An unusual epithelial pleomorphic giant cell tumour of the pancreas with osteoclast-type cells.

A case of giant cell tumour of the pancreas with a mixture of pleomorphic giant cells and osteoclast-like cells is described. This association is rare and its histogenesis has been debated. The presence of a small differentiated adenocarcinomatous area at the periphery of the tumour indicates an epithelial origin. Moreover, some pleomorphic cells were positive for keratin (KL1). The osteoclast-like cells strongly expressed CD68 (a marker of histiomonocytic lineage) and did not show proliferative activity. They probably correspond to an unusual reaction of the stroma. Their clinical importance in this type of tumour remains unknown.

Wich remain the surgical indications in chronic duodenal and gastric ulcers?

A ulcera duodenal pode ter indicacao cirurgica em diferentes circunstancias, na dependencia da doenca em si, do paciente, da localizacao da ulcera, de seus efeitos fisiopatologicos e de doencas concomitantes, mas o tratamento clinico e o de eleicao. As ulceras gastricas podem ser conduzidas de maneiras diferentes-o tratamento cirurgico e preferido pelo risco de malignizacao: 1,5 a 10 por cento. A nao-cicatrizacao ao final de 3 meses de tratamento clinico bem conduzido, indica a operacao, pois alem do problema da malignizacao, a localizacao da ulcera nas vizinhancas da arteria gastrica esquerda aumenta o risco de sangramento. Enfim, na presenca de ulceras gastricas ou duodenais, o tratamento clinico e a cirurgia devem ser complementares. A decisao pela operacao deve ser conscenciosa e sua conducao deve ser adaptada a cada paciente, respeitando ate mesmo seu tipo de personalidade.

[Giant cell tumors of the pancreas. Clinical presentation]. / Tumeurs à cellules géantes du pancréas. Présentation clinique.

The authors report the case of a large tumor located at the tail of pancreas. Despite extensive surgery and absence of synchronous metastasis, death occurred after a short period of survival. The authors stress the lack of major clinical features of carcinoma of left pancreas and outline the high malignancy of giant cell type.

[Hemorrhagic ulcer of the bulb. Plea for gastric resection]. / Les ulcères hémorragiques du bulbe. Plaidoyer en faveur de la résection gastrique.

Bleeding remains on of the most fearsome complications of duodenal ulcer disease. It is, as if H2 Blockers, while never curing the ulcer, were in fact promoting its most severe forms, i.e., posterior huge ulcers, the control of which has to be a gastric resection. On the basis of a short but consecutive serie of 10 patients, the authors plead in favor of the exclusion of the ulcer from the digestive tract, using the wheeling off procedure to close the duodenal stump.

["Wheeling-off" of the duodenum in gastric resection in hemorrhagic duodenal ulcer]. / Déjantement du duodénum dans la résection gastrique pour ulcère duodénal hémorragique.

Truncal vagotomy associated with antrectomy is required in the treatment of terebrant and haemorrhagic ulcers of the first duodenum. The main problem lies in the closure of the duodenal stump. The "wheeling-off" procedure is a reliable technique which consist of separating the duodenum from the pancreas by carrying out dissection into the posterior wall of the duodenum, between its two muscular layers. Closure is obtained by means of a stappler. This procedure was performed in 23 patients without leakage or recurrent bleeding.

[Current concepts of the treatment of cholelithiasis in aged patients]. / Conceptions actuelles du traitement de la lithiase biliaire chez le sujet âgé.

Biliary lithiasis in elder patients is characterized by the physical defects usually present--therefore surgery is less mandated than endoscopic procedures or extra corporeal lithotripsy. However, if surgery is undertaken, then it should be carried out as completely as possible. In this paper, the authors emphasize the special aspects of its indications and technics--for more than any where else this surgery required perfection.

A multicentric study of netilmicin once daily versus thrice daily in patients with appendicitis and other intra-abdominal infections.

This multicentric, randomized, double-blind trial compared the efficacy and safety of netilmicin, 4.5 mg/kg od and 1.5 mg/kg tid, in patients with intra-abdominal infections. Of 114 patients enrolled, 57 patients (mean age 40.3 years) in the od group and 55 (mean age 36.8 years) in the tid group were evaluated for efficacy; 58 and 56 patients in corresponding groups were evaluated for safety. Among those evaluated for efficacy were 12 od-treated and 11 tid-treated patients with documented septicaemia, and 32 and 30 patients of respective groups with polymicrobial infections. Initially, 86 and 81 netilmicin-susceptible causative microorganisms were isolated in corresponding groups. Of these pathogens, 55% in the od group and 62% in the tid group were Escherichia coli. Daily dosage of netilmicin ranged from 3.70 to 4.71 mg/kg (mean 4.50) for the od group and from 3.06 to 4.76 mg/kg (mean 4.46) for the tid group. Duration of netilmicin therapy ranged from six to 13 days (mean 8.7 days) for od-treated patients and from seven to 16 days (mean 8.8 days) for tid-treated patients. Concomitant metronidazole was administered to 41 patients of the od group and 34 of the tid group; one patient in the tid group received clindamycin. Clinical and bacteriological responses were assessed, and peak and trough serum netilmicin levels were measured periodically, during therapy. Laboratory tests, including determinations of serum creatinine and blood urea nitrogen values, were performed throughout the trial. A clinical cure was achieved in 57/57 od-treated patients and 54/55 tid-treated patients; treatment failed in one tid-treated patient (1/55). In od and tid groups, 86/86 and 80/81 netilmicin-susceptible pathogens initially isolated were considered to be eliminated, respectively; one isolate (Esch. coli) persisted in the tid group. Mean peak serum netilmicin concentration in the od group was approximately two-fold greater than that in the tid group; mean trough serum netilmicin concentrations were similar for the two groups. Adverse reactions were limited to mild pain at the site of netilmicin administration in several patients in each treatment group. Netilmicin od and tid (alone or in combination with metronidazole) were similarly efficacious in the treatment of patients with appendicitis and other intra-abdominal infections caused by netilmicin-susceptible pathogens. Both dosage regimens of netilmicin were safe and well tolerated.

[What are the surgical indications for non-complicated duodenal and gastric ulcers?]. / Que reste-t-il des indications opératoires dans les ulcéres duodénal et gastrique non compliqués?

Taking into account recent medical progress and on the basis of their own experience, the authors define the up-to-date surgical management of non-complicated duodenal and gastric ulcers. Chronic duodenal ulcers still remain to be submitted to surgery in case of resistance to different types of medical drugs, in case of concomitant disease requiring a specific treatment contraindicated in ulcer disease, in case of patients refusing drugs or developing side-effects, and last, in posteriorly localized or bleeding ulcers. In these situations proximal gastric vagotomy (P.G.V.) still remains the best procedure owing to its low mortality (less than 0.5%) and morbidity rates, and its very satisfactory functional results. The recurrence risk, estimated between 10 to 15%, might burden the long-term results. But in a high percentage of cases it is related to technical inefficiencies. It has to be recalled that only 30% of these patients will undergo reoperation. But it should be emphasized that prepyloric ulcers are a poor indication for P.G.V. and should be submitted to truncular vagotomy with antrectomy. In gastric ulcers, the surgical treatment is mandated whenever endoscopic signs don't disappear under medical treatment or if biopsies remain suspicious. The most satisfying procedure is a gastric resection always involving the lesion and followed by a gastroduodenal anastomosis according to Péan-Billroth I.

[Gastroduodenal ulcer. New therapy and new clinical practice?]. / Das Gastroduodenalulkus. Neue Therapie und neue Praxis?

Duodenal, prepyloric, and gastric ulcers are based on different pathophysiological processes. The achievements obtained from therapeutic medication, using H2-blockers, have reduced indications for surgical treatment, primarily for duodenal ulcer. Surgery has continued to be required for failure of medicamentous therapy, recurrence, development of intercurrent diseases calling for corticoid or anti-coagulant treatment, patients above 55 years of age with haemorrhage, occurrence of severe side effects, and, occasionally, for economic reasons. Optional methods are left-side selective vagotomy for duodenal ulcer, antrectomy with bilateral subdiaphragmatic vagotomy for prepyloric ulcer, and hemigastrectomy with gastroduodenal anastomosis for gastric ulcer.

[Injuries of the spleen: conservative treatment or exeresis?]. / Les traumatismes de la rate. Traitement conservateur ou exérèse?

The authors report their experience with splenic preservation in a series of 36 patients. 77 patients with splenic injury were seen during the period from 1982 to 1987. In 41 cases splenectomy had to be carried out. This was for splenic contusions secondary to road traffic accidents in 36 cases and iatrogenic per-operative lesions in 5 cases. Intra-omental splenic autotransplantation was performed in 4 cases. In 36 other patients, the spleen was able to be preserved. Hemostasis was fairly obtained using infra-red photocoagulation (24 cases), splenorrhaphy (8 cases), surrounding the spleen with a resorbable mesh (3 cases) or by partial splenectomy (1 case). Only 1 case of transient and moderate secondary hemorrhage was seen and did not require further surgery. The authors define the legitimacy of splenic preservation and its indications and also stress its limitations. They insist on the following contraindications: preexisting splenic disease, subject on anticoagulants, labile blood pressure, multiple intra-abdominal lesions, presence of intra-peritoneal infection, severe cranio-encephalic lesions, age over 70 years. Study of this series shows that conservative treatment is most often justified for splenic trauma. Nevertheless, in view of the real but rare risk of OPSI, it is better to have a correct splenectomy than an incorrectly preserved spleen.

[Surgery of the left colon]. / La chirurgie du côlon gauche.

Some basic technical principles make the left colon surgery as safe as possible. The authors recall the surgical anatomy and the vascularization of the left colon and describe the technic of a left hemicolectomy, of the Hartmann procedure with restoration of the intestinal continuity and the closure of a lateral colostomy. Mastering these technics should help to face and resolve any urgent or regular pathological pattern of the left colon.

[Long-term recurrence and complications of 300 supra-selective vagotomies for simple chronic duodenal ulcer]. / Récidives à long terme et complications de 300 vagotomies supra-sélectives pour ulcère duodénal chronique simple.

Three hundred H.S.V. for chronic duodenal ulcer, performed between 1972 and 1982, are reviewed. A thorough analysis of intra and post-operative complications points out that only ulcer recurrence still set problems. These concern their definition, frequency, diagnosis and treatment. The personal experience of the authors leads them, in case of failure of the medical treatment with and endoscopically proved ulcer--what happened in 6 patients of 17 (35,8%)--to prefer gastric resection to re-vagotomies, the performance of which is often difficult and the results uncertain.

[Results of a French survey on the use of surgical staplers in gastrointestinal surgery]. / Ergebnisse einer französischen Umfrage über die Anwendung von chirurgischen Klammerinstrumenten in der Gastrointestinalchirurgie.

Results of an inquiry in 40 French hospitals (28 universities and 12 private clinics). With 2 exceptions, all questioned surgeons use stapler instruments in oesophagus, stomach and colon rectal surgery. 50% of the surgeons noticed the same percentage of fistulae by stapler as by hand suturing and the severity of these leakages was more or less identical in both series. As contraindications for using stapler machines oedema of the visceral wall, small size of the lumen, important visceral distension and insufficient practice with such instruments, were mentioned.