Colonic perforation due to colonoscopy: a retrospective study of 48 cases.

BACKGROUND AND STUDY AIMS: The aim of this retrospective study was to analyze data on the treatment of 48 cases of colonic perforation, with a view to defining the criteria for choosing between medical and surgical treatment. PATIENTS AND METHODS: A questionnaire requesting information about complications of colonoscopy and their treatment was sent out to four hospital gastroenterological and surgical units. RESULTS: From January 1979 to December 1993, we reviewed the records of 48 cases of colonic perforation following colonoscopy (24 perforations occurred after diagnostic colonoscopy and 24 after therapeutic colonoscopy). Diagnosis of perforation was delayed in 42% of the patients, with a mean delay of two days (range 0.5-7 days). The treatment was surgical in 35 cases, including eight in which previous medical treatment had been unsuccessful. The perforation was in the sigmoid colon in 74% of the surgical population. Operations were carried out using two procedures, including colostomy, in the case of 20 patients (57%). Colostomy closure was performed in 12 patients (60%) with no mortalities. Surgical mortality occurred in five patients (14%), in four cases due to preexisting medical diseases. Medical treatment was attempted in 21 cases, and was successful in 13, mainly in cases in which perforation had occurred after therapeutic colonoscopy (12 patients). CONCLUSION: The choice of the right type of treatment for colonoscopic perforation seems to depend on the size of the lesion. Surgical treatment is appropriate when the perforation has occurred during diagnostic colonoscopy, since the lesion in this case is usually a large colonic laceration, whereas nonsurgical treatment seems to be justified after polypectomy, as long as there is rapid clinical improvement.

[Primary anorectal malignant melanomas. 2 cases]. / Mélanomes malins ano-rectaux primitifs. 2 observations.

Two cases of primary ano-rectal melanoma are reported. Primary melanoma of the anorectum is an uncommon and highly malignant disease (the survival rate is about 7 to 12 percent at 5 years). The tumour may be difficult to diagnose when it is not pigmented (16 to 53 percent of the cases). At histological examination the diagnosis is impossible in 30 percent of the cases. It is facilitated after local excision by immune markers (vimentin, PS 100, HMB 45 immunostaining). Radical abdominal perineal resection may cure patients with less than 2 mm wide lesions. The few cases of long term survival have resulted from radical surgery. For larger lesions staged IV or V by Breslow's method conservative local approach by excision achieves local palliation. Radiation is a palliative therapy in extensive tumours. Combined chemotherapy with fotemustine and dacarbazine may be attempted in case of metastatic spread.

[Enteral nutrition in patients with chronic obstructive bronchopathy treated by artificial ventilation. Effect of conventional feeding on anthropometric and biochemical parameters]. / Nutrition entérale chez le bronchopathe chronique obstructif soumis à une ventilation artificielle. Influence d'une alimentation conventionnelle sur les paramètres anthropométriques et biochimiques.

The influence of conventional gastric tube feeding on anthropometric and biochemical parameters was studied prospectively during 12 months in 14 patients with chronic obstructive lung disease put on mechanical ventilation for respiratory failure. The anthropometric parameters were: body weight, tricipital skin fold, brachial and brachial muscle circumferences. The biochemical parameters included albumin, transferrin, retinol binding protein, transthyretin, acid alpha-1-glycoprotein, C-reactive protein, fibronectin and amino acids in blood, and 3-methylhistidine in urine. Measurements were performed on inclusion, then every 3 days until D15. After 15 days of a nutrition bringing 28.8 +/- 8.9 calories/kg/day and 13.9 +/- 2.2 grams of nitrogen per day, no improvement in anthropometric parameters was observed. On D0, comparisons with healthy controls showed that visceral serum proteins levels were significantly lower and inflammatory proteins levels significantly higher (P < 0.05); the levels of protein metabolism markers were higher, but not significantly, and those of the principal glucose-forming amino acids were significantly lower (P < 0.01). On D15, comparisons with the initial values showed that the values of retinol binding protein and transthyretin were increased (P < 0.05 and 0.01 respectively), whereas the values of the other visceral proteins were little modified; yet their concentrations remained significantly lower than those found in controls, except for the retinol binding protein. Inflammatory proteins levels were high, with a significant (P = 0.05) difference for the acid alpha-1-glycoprotein, and the patients remained in slight catabolism while their nitrogen balance was positive. These results should encourage to carry out studies on the qualitative composition of artificial nutrition in order to optimize its effectiveness in the treatment of these patients.

[Nonsecreting or so-called malignant adrenocortical tumors. Contribution of immunohistochemistry]. / Les corticosurrénalomes malins non sécrétants ou prétendus tels. Apport de l'immunohistochimie.

The authors mention two cases of adreno cortical carcinoma treated by surgery. They insist upon complete hormonal exploration in order to assert the characteristic non functioning of these growths. An immuno histo clinical examination of the operated part could complement these biological explorations. The existence of a hormonal secretion brought to light by this method can simplify future biological supervision and establish a reason to apply systematically a complementary treatment of OP'DDD or Ketoconazole. A literary precis is prepared.

[Prolonged survival in retroperitoneal liposarcoma. Apropos of a case with 27 years' survival. Prognostic value of the histological type and role of repeat surgery]. / Survie prolongée des liposarcomes rétropéritonéaux. A propos d'une observation ayant vingt-sept ans de survie. Valeur pronostique du type histologique et place de la chirurgie itérative.

The authors report a case of differentiated myxoid liposarcoma with a survival of 27 years as a result of repeated resections. They emphasise the value of a precise study of the histological type and grade: well differentiated and/or myxoid forms of liposarcomas appear to have a more favourable long term prognosis. This prognosis justifies repeated operations. The post-operative follow-up by computed tomography ensures earlier detection of recurrences. The time of re-operation depends on the volume of the tumour, the rate of growth, the possibilities of resection and the request for relief by the patient.

[Left internal paraduodenal hernia: a case in a young adult]. / Hernie interne paraduodénale gauche: une observation chez l'adulte jeune.

The authors report the case of a left paraduodenal hernia which involved almost the entire small intestine in a 15 year old girl who presented with recurrence episodes of acute abdominal pain associated with König's syndrome. Radiologic examination (plain film of the abdomen and upper GI series with small bowel follow-through) was suspicious, but did not establish the diagnosis due to unfamiliarity with the radiologic appearance of the condition. The roentgenograms are shown as well as the intraoperative findings. Anatomic, pathophysiologic, clinical, and radiologic characteristics are reviewed.

[Duodenal varices. Review of the literature apropos of a case]. / Les varices duodénales. Revue de la littérature à propos d'une observation.

The authors report a case of digestive hemorrhage secondary to isolated duodenal varicosities, in a patient with ethylic cirrhosis. The diagnosis done through optical fibroscope was confirmed by arteriography. The evolution was unfavorable. Lesions were corroborated by autopsy. A review of the literature is done, about the 22 cases already published. With the help of these cases to authors stress the points that can lead to the good diagnosis and what therapeutical management should be done.

Small bowel deposition of crystals associated with the use of clofazimine (Lamprene) in the treatment of prurigo nodularis.

A 46-year-old woman with widespread prurigo nodularis was treated with 300 mg clofazimine a day for six months. Ten months after stopping the drug she complained of weight loss and gastrointestinal side effects which were shortly improved by a gluten-free diet, but relapsed one year later. At laparotomy, all tissues were stained bright orange-yellow, and histological examination showed crystals deposited in the chorion of intestinal villi and in the mesenteric lymph nodes.

[Exudative enteropathy caused by clofazimine: apropos of a case]. / Entéropathie exsudative à la clofazimine: à propos d'une observation.

The authors report a case of a forty-six year old woman suffering from generalized prurigo nodularis. This dermatosis was associated with a cellular immunodeficiency; therefore a clofazimine therapy 300 mg/a day was instituted for six months. Ten months after the cessation of the clofazimine therapy, there appeared a malabsorption syndrome that was temporarily improved by gluten--free diet the real etiology was only ascertained during laparotomy, when masses of crystals in the small intestine mucosa as well as in mesenteric lymph nodes were observed. Therefore when it is necessary to prescribe clofazimine to take advantage of become its immunoregulating properties, it must always become in mind that an intestinal complication may ensue: this is well recognized in articles appearing in journals devoted to leprosy.

[Cystohepatic ducts. Surgical problems and review of the literature. About 10 operated cases (author's transl)]. / Les canaux cysto-hépatiques. Incidences chirurgicales et revue de la littérature. A propos de dix cas opérés.

The authors are reporting 10 cases of operated cystohepatic ducts. In each case there is a unic duct, leading five times in the gallbladder, and once in the cystic duct. In 8 cases this abnormality was shown intraoperatively. In 2 cases the diagnosis was only given during the surgical procedure, when a fistulography was performed. In one case it was necessary to reoperate. In four cases during the cholecystectomy we had to ligate the cystohepatic duct. In order to argue these cases, a literature review was done: 42 cases were found. The ligation of a cystohepatic duct is in most cases without consequences. the different ways of restoration are studied when large ducts are found. The best treatment of such an abnormality seems to be an anterograde cholecystectomy associated to a systematic drainage of the gallbladder region.

[Primary closure and healing of the perineal wound in abdomino-perineal resection of the rectum for carcinoma (author's transl)]. / La fermeture primitive du périnée après amputation abdomino-périnéale du rectum pour cancer. Technique. Résultats.

The results of primary perineal closure after rectal resection for cancer are reported, about a series of 105 patients male and female; to whom this technique was systematically applied. The healing of the wound was primarily obtained in 77.2% of the cases (82.3% in males, 72.2% in females). 86% of the patients left the hospital completely healed within 30 post operative days. The authors stress the influence of the environment on the result and also discuss the practical conditions of the primary suture: hemostasis, fecal contamination, peritonisation, enlarging followed with ablation of the genital tract in women.

[Enteropathy due to clofazimine treatment. A case report with an ultrastructural study]. / Entéropathie à la clofazimine. Une observation avec étude ultrastructurale.

The authors report a case of enteropathy due to clofazimine treatment for prurigo nodularis. The drug usually restricted to the treatment of leprosy has sometime been given to patients suffering from skin diseases because of its assumed anti-inflammatory effects. When high dosage of clofazimine treatment is carried on during a long period, and drug accumulates in the tissues and precipitates as a solid. This crystal storage in the lamina propria of the jejunal mucosa and in the mesenteric lymph nodes accounts for an enteropathy, sometime severe but slowly regressing after drug withdrawal. The electron microscopic study shows the prints of these crystals in autophagic vacuoles of histiocytes.

[Colorectal anastomotic stricture : transanal resection using the E.E.A. autostapler (author's transl)]. / Résection trans-anale à la pince E.E.A. d'une sténose anastomotique colo-rectale.

Anastomotic stricture is an unusual complication of the colo-rectal surgery ; this can be very difficult to manage, particularly in low anastomosis. About one case successfully treated, the authors suggest an original non operative treatment : a resection with simultaneous anastomosis only performed through a transanal approach, with upper coloscopic control.