[Obligatory surgery after endoscopic sphincterotomy for the treatment of stones in the common bile duct]. / Chirurgie de nécessité après échec de la sphinctérotomie endoscopique dans le traitement des lithiases de la voie biliaire principale.

Endoscopic sphincterotomy is the treatment of choice for stones in the common bile duct in patients with a high operative risk. However, when this modality is insufficient or fails, these patients need to be operated. The authors have operated 14 patients under these conditions. In addition to the cholecystectomy performed in 9 patients who still retained their gallbladder, the common bile duct was cleared in 3 cases and drained by means of choledochoduodenal anastomoses in 10 cases. Three patients developed complications and one of them died. Endoscopy and surgery appear to be complementary in this indication. Sphincterotomy should be proposed as first-line treatment as, even in the case of incomplete disobstruction, it enables high-risk patients to be operated under better conditions.

Surgery for carcinoma of the colon in people aged 75 years and older.

From January 1976 to June 1986, 154 patients (75 men and 79 women) who were 75 years of age or older were admitted for the surgical treatment of a colonic cancer. The mean age was 80.7 years. Patients were divided into two groups: 66 patients, between 75 and 80 years of age, were in Group I; 88 patients, 80 years of age and older, were in Group II. One hundred and forty-three patients (93%) were operated on and a resection was carried out in 125 patients (87%). The overall post-operative mortality rate was 12% (Group I: 5%; Group II: 17%; p less than 0.02). The actuarial survival rate of patients operated on was 32 +/- 8% at 3 years and 26 +/- 8% at 5 years (Group I: 37%; Group II: 17%). In both groups the survival rate was closely related to the extent of the disease according to Dukes classification. These results suggest that in the 75-80 year group age alone should no longer be considered a major risk factor for immediate surgical outcome. In patients aged 80 and older, the results are worse but it is not advanced age per se which influences mortality, rather the physiologic status of the patient.

[A case of sacrococcygeal chordoma]. / Un cas de chordome sacrococcygien.

The authors describe a case of sacrococcygeal chordoma which was detected in a 49-year old male subject in the course of a clinical examination. Bone X-rays and CT-scans confirmed the diagnosis of sacral tumor, and radical excision was performed via combined abdominal and sacral approach. The chief characteristics of these rare tumors are further discussed, with particular focus on the therapeutical problems arising in relation with the fact that surgical removal, alone, can prevent tumor recurrences.

Surgical treatment of Graves' disease.

Seven men and 81 women were operated on for Graves' disease. Their median age was 33 years. Eleven patients underwent a bilateral subtotal lobectomy; 77 patients underwent a complete lobectomy with contralateral partial lobectomy. Forty-seven patients were treated before 1981. In these patients, the weight of the thyroid remnant was estimated empirically between 5 and 12 g. In the 41 patients treated since 1981, the remnant weight was estimated at 5 g by comparative weighing. There were no postoperative deaths. Functional results were established in 83 patients with an average follow-up of 50 months (range 12 to 156 months), with control of vocal cord mobility demonstrated by indirect laryngoscopy in 66 patients. Hormonal determinations were carried out in 74 patients. There were no cases of permanent hypoparathyroidism. Three patients (4.5 percent) had unilateral vocal cord dysfunction. Twelve patients (14.5 percent) had clinical and biologic hypothyroidism, which occurred within 1 year postoperatively in 11 cases. Seven patients (8.3 percent) had latent hypothyroidism only discovered by hormonal determinations. Fifteen patients (17.8 percent) had recurrent hyperthyroidism, 6 of whom were diagnosed by hormonal determinations. The actuarial recurrence rate increased progressively up to the sixth postoperative year. The only predictive factor for recurrence was the type of operation. Patients who underwent a bilateral subtotal lobectomy had more recurrences than patients who underwent a complete lobectomy with partial contralateral lobectomy (p less than 0.01). These results suggest that patients should be followed closely for many years and should undergo hormonal determinations regularly, as some recurrences can occur 5 years or more after operation with very few symptoms.

[Basedow's disease: recurrence after surgical treatment. Study of a series of 88 patients]. / Maladie de Basedow: récidives après traitement chirurgical. Etude d'une série de 88 malades.

A homogeneous series of 88 patients with a history of surgery for Basedow's disease was studied retrospectively to evaluate long term recurrences. A total of 88 cases were reviewed after a follow up of a median of 50 months (range 1 to 13 years), and hormone assays were carried out in 74 cases. Surgical complications were minor: no mortality, no definitive hypoparathyroidism, 45% unilateral recurrent nerve palsies and 14.3% definitive hypothyroidism occurring during the first year. Fifteen patients had one or several recurrences of hyperthyroidism. The actuarial recurrence rate at 5 years was 17%, the risk increasing progressively up to the sixth year. The type of operation was the only predictive factor of recurrence surveillance of these patients should be prolonged and involve regular hormone assays, since 6 of the 15 recurrences were poorly symptomatic.

Carcinoma of the cardia and proximal third of the stomach. Results of surgical treatment in 91 consecutive patients.

In the present retrospective study, 79 percent of the patients were men with a median age of 65.5 years. Of 91 patients, 84 were surgically explored. Excision of the tumor was carried out in 57 patients (63 percent) and was curative in 28 cases and palliative in 29 cases. Curative resection included proximal gastrectomy in 5 patients and total gastrectomy in 23 patients, which was extended to the spleen and distal pancreas in 18 patients. Lymph node metastases were found in 67 percent of the patients treated by resection. According to the TNM classification, 18 percent of the patients undergoing resection had stage I tumor, 28 percent had stage II tumor, 40 percent had stage III tumor, and 14 percent had stage IV tumor. The postoperative mortality rate was 16 percent for the entire series, 21 percent for patients undergoing palliative resection, and only 4 percent for patients undergoing curative resection. Three patients had an obvious anastomotic leak, one of whom died. Median survival time was 5 months for patients who had exploration only, 6 months for patients who had palliative resection, and 36 months for patients who had potentially curative resection. The 5 year actuarial survival rate was 20 percent for patients having resection and 40 percent for patients having curative resection. Survival was closely related to tumor stage. These results indicate that total gastrectomy with complete abdominal lymph node dissection can give comparatively good long-term results when performed for cure. Nevertheless, only one of three patients in this series could have a potentially curative resection. The only way to increase the curative resection rate and to improve survival is to detect the cancer at an early stage.

[Anterior sacral meningocele. Report on 2 cases treated by the abdominal approach]. / Méningocèle sacrée antérieure. Présentation de 2 cas traités par voie abdominale.

Anterior sacral meningocele is a rare affection (150 cases published) that is frequently misdiagnosed with resulting inappropriate, always dangerous treatment. Diagnosis should however be simple to establish on the finding of a fluid hypogastric mass attached to the sacrum with associated radiologic anomalies of the sacrum. Two cases are reviewed and diagnostic and surgical therapy features discussed.

[Spontaneous rupture of the liver in pregnancy. Case study and review of the literature]. / La rupture "spontanée" du foie au cours de la grossesse. Etude d'un cas et revue de la littérature.

The authors report a case of "spontaneous" rupture of the liver in a woman of 35 years of age. This occurred immediately after post-partum eclampsia. It was not possible to obtain complete haemostasis using absorbable haemostatic compresses along the convexity of the liver. Complete cessation of bleeding only occurred after the operation when posterior pituitary abstracts had been transfused. The patient died 53 days after the initial procedure from a high gastro-intestinal haemorrhage. A study of the literature shows that this rare condition is most probably a complication of toxaemia of pregnancy but the physio-pathology of these liver lesions is ill-understood. The clinical picture is in two phases--the first corresponds to the formation of a sub-capsular haematoma and the second to the intra-peritoneal rupture of this haematoma. The prognosis for this condition is poor, the maternal mortality ranging from 56%-75%. The prognosis is linked to the speed with which the diagnosis is made and surgical intervention is carried out. This should be done before the capsule of the liver ruptures. Haemostasis is nearly always best obtained by using haemostatic compression with packs but haemostasis is not always adequate, particularly if there are several lesions in both lobes of the liver. This case history shows that using posterior pituitary abstracts in transfusion can be helpful.

[Cancers of the colon. Results of surgical treatment. Presentation of a series of 234 patients]. / Les cancers du côlon. Résultats du traitement chirurgical. Présentation d'une série de 234 malades.

This report is a retrospective analysis of the results of surgical treatment in 234 consecutive cases of adenocarcinoma of the colon; 56.4 p. 100 of patients were male with a mean age of 66. Sixty per cent of the carcinoma were situated in the sigmoid. Carcinoma was complicated in 26.1 p. 100 of cases. The tumor was confined to the bowel wall in 14.3 p. 100 of cases (stage A), involved the serosa in 36.3 p. 100 of cases (stage B), lymph nodes in 25.5 p. 100 of cases (stage C), and distal organs in 23.8 p. 100 of cases (stage D). Global operative mortality was 10 p. 100. Obvious anastomotic leakages occurred in two patients with one death. The overall five year survival rate was 35 p. 100. The stage-by-stage 5-year survival rates depended mainly on the differentiation and on the extension of the tumor: 59.2 p. 100 in patients with stage A lesions, 54.8 p. 100 in those with stage B lesions, 30.2 p. 100 in those with stage C lesions, 3.9 p. 100 in those with stage D lesions. On the other hand, survival was not significantly related to the duration of symptoms. This suggests that early diagnosis of symptomatic disease does not guarantee a better prognosis. This can only be achieved by prevention of the disease.