Surgical management of retro-rectal tumors in the adult.

Retrorectal tumors (RRT), whether benign or malignant in nature, are rare in adults and often asymptomatic. While diagnosis is based on clinical findings, differential diagnosis depends mainly on magnetic resonance imaging (MRI). MRI provides guidance for surgical management, the first-line treatment of choice. Four surgical approaches are described: abdominal, perineal, posterior and abdomino-sacral.. This review of major reported series has made it possible to specify the indications for each surgical approach, as well as the advantages, disadvantages and complications of each one. The choice of surgical approach is determined by the nature of the RRT, its anatomical position relative to the middle of the third sacral vertebra (S3) and the presence or absence of invasion of the neighboring organs, the pelvis or sacral vertebrae. The abdominal route is chosen for tumors situated above the middle of S3, whether benign or malignant, but without invasion of neighboring organs. The perineal route is indicated for benign RRT situated below the middle of S3. The posterior route is chosen for tumors located below the middle of S3, and allows an associated resection of sacral segments in case of tumor invasion. The combined abdomino-sacral route is indicated for RRT above the middle of S3, when there is an invasion of a pelvic organ or a sacral vertebra. Intra- and post-operative complications are mainly hemorrhagic, neurological and infectious. The long-term prognosis is usually favorable, but varies according to the nature of the RRT and its management.

[Water-electrolyte abnormalities during pregnancy: maternal and fetal complications (about a case)]. / Troubles hydroélectrolytiques pendant la grossesse: complications maternelles et foetales (à propos d'un cas).

Water-electrolyte abnormalities while pregnancy or for infant are very serious. We present a case of a woman at 26 weeks who had gestation pernicious vomiting that led to major extracellular dehydration, water intoxication and acute renal insufficiency. The etiology was a volvulus on common mesentery. Hyperemesis disappeared thanks to surgical treatment. The mother and her fetus would later present serious complications due to the water-electrolyte imbalance correction. The fetus suffered from cerebral hemorrhage and subdural hematoma subordinate to brain edema resorption. The mother presented centropontine myelinolysis. The treatment of electrolyte abnormalities during pregnancy could lead to serious complications for the mother and fatal for the foetus.

[Bilateral post-traumatic adrenal hemorrhage. Report of a case with acute adrenal insufficiency]. / Hémorragie surrénalienne bilatérale post-traumatique. A propos d'un cas avec insuffisance surrénale aiguë.

Bilateral adrenal haemorrhage of traumatic origin is rarely observed or possibly missed in severely multi-traumatised patients. It can lead to a potentially fatal adrenal shock. Its emergency diagnosis is made by imaging techniques, usually by CT-scan. Early substitution therapy has to be done. This complication emphasizes the importance of an immediate abdominal morphological exploration in multi-traumatized patients when this is feasible.

[Results of laparoscopic hernioplasty. A study of 401 cases in 318 patients]. / Résultats des hernioplasties coelioscopiques. Etude de 401 cas chez 318 patients.

STUDY AIM: The aim of this retrospective study was to report a series of laparoscopic hernioplasty performed in two surgical centers, and to evaluate the results with a mean follow-up of 31 months. PATIENTS AND METHODS: From January 1992 to January 1997, 318 patients with 401 inguinal hernias were operated on through laparoscopy by six senior surgeons and six junior surgeons. There were 302 men and 16 women (mean age: 53 years). The operation was performed through an extra-peritoneal approach (TEP) in 298 hernias, a trans-abdomino-preperitoneal approach (TAPP) in 62 hernias, and an intra-abdominal approach (IPOM) in 41 hernias. RESULTS: Conversion into open surgery was necessary in 7% of the patients. There was no postoperative death. The postoperative morbidity rate was 10%. The average hospital stay was three days. With a 1 to 5 year follow-up, 4% of the 94% of the patients who answered the questionnaire showed a recurrence (3% in the extra-peritoneal group; 4% in the trans abdomino-preperitoneal group; 10% in the intra-abdominal group). CONCLUSION: Laparoscopic hernioplasty seems as efficient as traditional hernoplasty with the advantages of mini-invasive surgery. The extra-peritoneal approach was preferred and performed in most cases of this series. The intra-peritoneal approach was abandoned.

[What place for endoscopic sphincterotomy in treatment of acute pancreatitis?]. / Quelle place pour la sphinctérotomie endoscopique dans le traitement des pancréatites aiguës?

STUDY AIM: A prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis. PATIENTS AND METHODS: Among 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiological reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a "control group". RESULTS: The mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P = 0.1) (NS) and the morbidity rate 25% versus 32% (P > or = 0.1) (NS). CONCLUSION: These results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.

[Colonic pseudo-obstruction caused by digestive amyloidosis in a chronic hemodialyzed patient. Apropos of a case]. / Pseudo-obstruction colique par amylose digestive chez l'hémodialysé chronique. A propos d'un cas.

A case of intestinal pseudo-obstruction by amyloidosis, occurring after 20 years of dialysis in a 72-year-old woman is reported. Although acute intestinal complications of intestinal amyloidosis, such as ischemia, colonic obstruction or haemorrhage are well known, colonic pseudo-obstruction is more unusual. It gradually results in, it carries out an intestinal obstruction with colonic and gastric distension. The diffuse topography of amyloid deposits throughout the gastrointestinal tract carries a poor prognosis and surgery cannot be curative.

[Vital prognosis in acute pancreatitis. Study of 5 clinicobiological indices]. / Pronostic vital dans la pancréatite aiguë. Etude de 5 indices clinico-biologiques.

The values of the Acute Physiology and Chronic Health Enquiry (Apache II) and the Simplified Acute Physiology Scores (SAPS) were compared with Ranson and Imrie scores to predict death after acute pancreatitis. Fifty-five (ten deaths) patients were evaluated. Patients who died had a mean score greater than those who survived. The accuracy of all scores was similar after 48 hours. The ICU (Intensive Care Unit) available at the time of admission may facilitate the early selection of patients for appropriate management.

[Celioscopic appendectomy. Results in 137 consecutive patients]. / Appendicectomie coelioscopique. Résultats chez 137 malades consécutifs.

Between September 1990 and August 1992, laparoscopic appendicectomy was attempted in 137 patients: 98 females and 39 males (sex-ratio: 2.5:1) with a mean age of 31 years (range: 15-85). The patients were operated on by 9 surgeons. Laparoscopic appendicectomy was possible in 120 patients (87.6%). In 19 patients the procedure was converted into open surgery. The main causes of unsuccessful laparoscopic procedures were: retrocaecal appendix (n = 5) and injury of appendiceal artery (n = 4). The rate of unsuccessful procedures was 31% in retrocaecal appendix and 9.4% in the other cases (P < 0.02). In exclusively laparoscopic procedures, the mean operating time was 63 (2.9) minutes. It was 49 (3) minutes for experienced surgeons and 69 (3.3) for other surgeons (P < 0.05). Histological examination of the appendix revealed inflammatory signs in 97 specimens (71%). There were no wound infections after successful laparoscopic appedicectomy. One female patient developed an abscess in the pouch of Douglas. The median postoperative hospital stay was 3 days (range: 1-16). These results suggest that laparoscopic appendicectomy is a safe technique, with low morbidity allowing short postoperative hospital stay.

[Chylous ascites caused by retroperitoneal neoplastic obstruction of lymphatic vessels. Treatment by peritoneo-jugular shunt. A case]. / Ascite chyleuse par obstruction lymphatique néoplasique rétropéritonéale. Traitement par dérivation péritonéo-jugulaire. Une observation.

A case of chylous ascites due to retroperitoneal tumoral compression is reported. Following failure of a medical treatment which consisted of paracentesis and medium-chain triglyceride (MCT) diet, the ascites dried up after installation of a peritoneum-jugular vein shunt valve. This operation is seldom performed in patients with chylous ascites since the medical treatment with paracenteses, MCT diet or even total parenteral nutrition succeeds in drying the effusion in almost 50 percent of the cases, notably those with postoperative lesion.

Percutaneous surgery of biliary cyst: a case report.

Biliary cysts are uncommon and often asymptomatic. Once symptoms occur, treatment is needed. Though percutaneous drainage is possible, the recurrence rate is high. Open drainage is associated with the morbidity of laparotomy. We report a case of laparoscopic treatment of a large biliary cyst.

[Cost of the surgical treatment of inguinal hernias]. / Coût du traitement chirurgical des hernies de l'aine.

The hospital stay of 100 patients admitted to hospital in 1988 for surgical repair of inguinal and crural hernias was analysed. Fifty-three per cent of patients were over the age of 60 years and more than one half of them has a medical history. There was no mortality and only a single serious complication. The mean hospital stay was 7.6 days, influenced by the age of the patients. The complementary investigations only constituted a small proportion of the cost of the hospital stay. The authors conclude on the necessity for further reduce the length of hospital stay (principal cost factor) and even propose day admission, although this alternative can only be proposed to a minority of patients.