[Malignant duodenal fistulae of colonic origin (clinical case)]. / Fistules malignes duodénales d'origine colique. (Cas clinique).

Duodenocolonic fistulas created by invasive cancer of the colon are rarely reported in the literature and their frequency is probably underestimated. We report 4 cases together with the problems encountered and therapeutic approaches used.

Original oblique sections of the retroperitoneum: radio-anatomic basis.

The authors present oblique sections of the retroperitoneum adapted to the morphology of each patient, which affects both the liver and the organisation of the retroperitoneum. This original method involve two incidences for studying the left and right retroperitoneum separately with vertical sectional planes. The authors postulate that the orientation of the retroperitoneal viscera depends on the degree of hepatic development, so these incidences are chosen with reference to axial sections of the portal bifurcation and the middle hepatic v.: the two vascular landmarks of the liver. Anatomic and radiologic studies confirm the reliability of these landmarks and their easy application in modern imaging. Such new data improve our understanding of the classical topographic anatomy of the retroperitoneum. These oblique sections promote the radiologic study of the portal and systemic vessels, renal pedicles, suprarenal glands and pancreas.

Large inferior right hepatic vein. Clinical implications.

The right middle and inferior hepatic vv. are very frequent, indeed constant, but usually of small caliber. The presence of an extra-wide right inferior hepatic v., usually solitary, produces a variation in the venous drainage of the right lobe of the liver. The right inferior hepatic vv. reaching or exceeding a caliber of 0.5 cm were investigated in 125 anatomic liver specimens: 70 injection-corrosion specimens, 32 formolised livers and frontal or frontal-oblique sections of the trunk made in 23 cadavers. The incidence of such vv. was estimated at 9% in the injection-corrosion specimens, 13% in the sections and 16% in the formolised livers. The incidence of these vv. in the literature varies from 10% to 24% according to the method used to demonstrate them. Usually, there is a balance between the right superior and inferior hepatic vv. Rarely, the right inferior hepatic v. predominates compared with the right superior hepatic v. The position of an extra-wide right inferior hepatic v. is constant, close to the visceral aspect of the liver. Its appropriate territory is segment VI, but it may encroach somewhat on adjacent segments. Clinically, the existence of an extrawide right inferior hepatic v. as detected by MRI and, especially, located by intraoperative ultrasonography, allows performance of a subtotal hepatectomy leaving only segment VI. In certain pathologic conditions, thanks to the development of anastomoses between the hepatic vv., an extra-wide right inferior hepatic v. may contribute to a compensatory circulation towards the right atrium.

[Synthetic prostheses used in surgery to repair abdominal wall defects (excluding groin hernias). Characteristics, in situ behaviour and applications]. / Les prothèses synthétiques dans la chirurgie réparatrice de la paroi abdominale (hernies de l'aine exceptées). Caractéristiques, comportement in situ et applications.

This study is an updating on synthetic prostheses used today to repair incisional hernias, eviscerations and abdominal wall defects due to a severe infection or a parietal excision of malignant tumours. The present prostheses are the fruits of the constantly developing plastic industry. Their characteristics and types (mesh or patch), together with the materials they are made of, are studied taking this development into account. The tissular reactions caused by prostheses are different depending on whether the material they are made of is an absorbable one or not. Published data on animal experimentation are largely used in this part of the study. A significant part is also allocated to the pathobiology of prostheses infection on which is based prevention of risk infection in the surgical practice. A synthetic prostheses has to be chosen depending on its characteristics and the tissular reactions it generates. In a septic environment, only absorbable prostheses can be used without risk. As for incisional hernias, which allows the authors to refer to their own expérience, the choice also depends on both the surgeon's own conception of the treatment and its purpose. The defect recovery after parietal excision of malignant tumours is eased by the use of a synthetic prostheses. In the future, synthetic prostheses will be even more used than today in the repair of abdominal wall. A present, the materials they are made of keep on being developed.

Magnetic resonance imaging of the liver by oblique sections.

The authors have applied magnetic resonance imaging (MRI) to the anatomic study of the liver by comparing cadaveric sections with those obtained with MRI. This study deals with sections oblique in relation to a sagittal or frontal plane, whose orientation is determined from landmarks visible on transverse sections. Oblique sections were made in 10 cadavers using an original method. First, adjacent transverse sections were made of the frozen trunk and two landmarks were located in these sections: the course of the middle hepatic v. and the direction of the division of the portal venous trunk. The transverse sections were then stacked and the block so reconstituted was refrozen and then cut in adjacent oblique sections oriented either along the plane of the middle hepatic v. (sagittal oblique sections) or along the plane of division of the portal venous trunk (frontal oblique sections). Oblique MRI sections were made in 15 healthy volunteers, mainly based on the same venous landmarks but sometimes on other landmarks visible on the transverse sections. Oblique MRI sections can be made in the plane of any anatomic structure located in the transverse sections in order to define its position. Sections based on identical landmarks differently oriented in different subjects allow for definition of the individual anatomy of the liver investigated. The frontal oblique sections clearly show the course of the trunk of the portal v. and the junctions of the hepatic vv. with the inferior vena cava. The sagittal oblique sections are particularly useful for investigating the thinnest part of the left side of the liver and also the caudate lobe.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal direct entry of the umbilical vein into the right atrium: antenatal detection, embryologic aspects.

Abnormal direct umbilical venous return into the right atrium was detected at obstetric ultrasonography in a 23 week fetus. This was an isolated anomaly; the growth of the fetus and size of the liver were normal, and the child was normal on examination at birth. Exclusion of the umbilico-placental circulation brought about closure of the umbilical vein. Growth and development of the child were normal 6 months after birth. Five other cases of abnormal umbilical venous entry into the right atrium have been reported in the literature, but associated with severe malformations, with situs ambiguous and heterotaxy. These cases have been grouped under the heading: persistence of the right umbilical vein. In view of recent findings relating to the organogenesis of the veins of the human liver, it seems preferable to label this anomaly: direct umbilical venous return into the right atrium.

Drainage of the scalp by the superficial temporal vein: surgical implications.

The arrangement of the veins of the scalp is not well-known. The drainage of the scalp by the superficial temporal v. was studied in 68 specimens dissected from unembalmed cadavers. After prolonged contraflow irrigation, the whole of the venous network drained by the trunk of the superficial temporal v. was injected from either side with latex. Depending on the method chosen to demonstrate the venous network, whether by direct observation or corrosion, the latex was stained with Evans' blue or with Latexol. The superficial temporal a. was also prepared by injection-corrosion in 16 cases. The diameter of the trunk of the superficial temporal v. in its preauricular portion was estimated as between 1.1 and 1.6 mm. Nine different types, classified by frequency, were recognised in the arrangement of the affluents of the superficial temporal v. In every case there was a main parietotemporal collector continued as the trunk of the superficial temporal v. The affluents joining the main collector varied in number (from 8 to 1) and in arrangement. Their anastomoses with the veins adjacent to the superficial temporal v. were numerous. The density of the secondary branches varied greatly with individuals. They were sometimes totally absent, particularly in the fronto-temporal region. Usually, the main collector was of sufficient caliber for microsurgical use and its course followed that of the parietal branch of the superficial temporal a., but in 4% of cases the main collector was too narrow to be so used and in 8% of cases its course did not follow that of the parietal branch of the superficial temporal a.(ABSTRACT TRUNCATED AT 250 WORDS)

[Conservative attitude in the treatment of closed injuries of the liver]. / Attitudes conservatrices dans le traitement des traumatismes fermés du foie.

Progress made in surgical treatment of blunt hepatic trauma (BHT) are numerous. Some procedures are sophisticated, but the best results seem to be due to conservative trends. These conservative trends are observed on one hand during the laparotomy with limited hepatectomies, and peri-hepatic packing, on the other hand in non operative management (NOM). Among 55 patients treated over a 10 years period for BHT, NOM. (18 cases) is reported: incidence of NOM increased along the period (from 3 cases on 35, to 15 cases on 20). No deaths and no complications were observed. Secondary exploration was required in three patients: no one was objectively useful. Detection of hemoperitoneum greater than 500 cc and initial blood hypotension (if well corrected by resuscitation) do not exclude this NOM.

The cystohepatic ducts: surgical implications.

The cystohepatic ducts (CHDs) drain the entirety of a hepatic territory of variable extent into the cystic duct or gallbladder (cholecystohepatic ducts). Certain very rare patterns of the CHDs constitute anomalies but as a rule a CHD represents one of the numerous variants of division of the extrahepatic bile-ducts. Their existence is explained by the normal anatomic development of the bile-ducts. They are usually discovered during peroperative cholangiography performed during cholecystectomy for gallstones. Their actual incidence is small: 1-2% of cases. A CHD was found by the authors on 12 occasions in a total of 1410 cholecystectomies (0.9%). The CHDs are always bile ducts of the right lobe of the liver and may drain a subsegment or segment, a sector or, exceptionally, the whole of the right lobe of the liver. Peroperative cholangiography does not always allow distinction of the CHDs from other and equally rare variants of division of the extrahepatic bile-ducts, whose existence carries the same practical implications. The existence of the CHDs is unpredictable. Their position renders them particularly vulnerable during cholecystectomy and the seriousness of an accidental injury of a CHD depends on the extent of the hepatic territory it drains. Strict observance of the rules of biliary surgery and routine peroperative cholangiography should preserve the integrity of CHDs draining an extensive hepatic territory.

[The repair of recurrent postoperative incisional hernias. Objectives and therapeutic indications (68 cases)]. / La cure des éventrations abdominales post-opératoires récidivées. Objectif et indications thérapeutiques (68 cas).

Among 327 surgical repairs of incisional hernias done between 1974 and 1989, 68 repairs (21%) were performed because of a primary treatment failure. Failed primary attempts of cure had been unique in 71%, and multiple in 29% of cases; their procedure had been essentially suture or herniorrhaphy. Site of recurrent incisional hernia (R.I.H.), was midline or lateral incision in respectively 84% and 16% of cases. Size of R.I.H. was considered as large in two third of cases. Operation was performed electively in majority of cases (93%). More than half of the patients were "prepared" by preoperative pneumoperitoneum and/or weight reducing regimen. Mersilene* mesh was used in 81% of cases. Results of treatment of R.I.H. are reported, depending on procedure. Among 55 cures by use of Mersilene* mesh, 1 patient died (from myocardial infarction), and 5 recurrences occurred, 4 of which from sepsis. Study of complications and failures suggests: 1) careful attention to indications, 2) advantages of a large size Mersilene* mesh, 3) attention to preoperative treatment, especially weight loss regimen and progressive pneumoperitoneum.

The supernumerary muscles of the leg: a report of two cases.

Two cases of supernumerary muscles of the leg reported, which were both inserted on the sides of the calcaneus. The accessory soleus m., adductor of the fore-foot, is a variation of the triceps surae which through hypertrophy on the medial side of the leg can become particularly problematic in athletes. The fourth peroneal m. abductor of the fore-foot, is considered to increase the stability of the ankle and is asymptomatic.

[Variations of division of the extrahepatic bile ducts: significance and origin, surgical implications]. / Les variations de division des voies biliares extrahépatiques: Signification et origine, conséquences chirurgicales.

As opposed to congenital anomalies, the anatomical variations, as well as the modal type, are issued from a normal morphological development. The variations of division of extra-hepatic biliary ducts are very frequent. They are clearly explained by the sequence of embryological development in man, and also by compared anatomy. Lots of variations occur, some of them being more frequently encountered than others during cholecystectomy for gallbladder lithiasis. A cysto-hepatic duct draining a large hepatic territory is the most dangerous variation. As a matter of fact, it can look as if the junction between the cystic duct and the common biliary duct was of the modal type. In surgical practice, the dissection of cystic duct must never go over the right side of the common biliary duct in order for it never to be injured. Radiological exploration of biliary tree during cholecystectomy for gallbladder lithiasis has to be routine, in order to discover the obviously unpredictable individual variations of division of extra-hepatic biliary ducts.

Functional anatomy of the liver of the human fetus: applications to ultrasonography.

The anatomy of the liver of the human fetus was established on the basis of cadaveric techniques, but its study has been transformed by obstetric ultrasonography. This work is based on a personal study of the normal morphology of the liver of the human fetus and on a review of the current literature, particularly with regards to vascularization. The liver is the digestive organ whose rudiments appear earliest and which develops most rapidly. The development of the liver and its functional segmentation are determined by the oxygenated blood flow in the umbilical vein. The extent of each hepatic territory depends on the quantity of umbilical flow, which determines its development and ensures its function. The fetal liver occupies a very large proportion of the abdominal cavity. It is a vascular organ, closely moulded to the walls of the abdominal cavity and the viscera in contact with it. The left liver is a little more bulky than the right liver and is developed mainly transversely. The morphology of the normal fetal liver appears quite uniform. The intrahepatic umbilical vein and the venous axis prolonging it to the right have a remarkably constant arrangement, well demonstrated by ultrasonography. An assessment of the anatomic features of the afferent veins, the ductus venosus and the efferent veins gives some idea of the conditions of the intrahepatic venous circulation in the human fetus that remain to be demonstrated. At birth, ligature of the umbilical v. brings about a sudden change in the hepatic circulation, resulting in temporary morphologic and functional modifications in the liver.(ABSTRACT TRUNCATED AT 250 WORDS)

The femoral artery and flexion of the hip joint.

The behavior of the femoral a. when the hip joint passes from the position of extension to the position of flexion at 90 degrees was studied in 13 cadavers, using several methods: anatomic sections, arteriographies or vascular casts. The modifications of the direction and shape of the femoral a. were assessed in the frontal and sagittal planes. They result from a movement combining flexion and torsion of the femoral a. on its axis at 2 different points in its course. The change of direction of the artery in the sagittal plane is the most obvious modification. It corresponds to the displacement and to the inversion of an angle of 45 degrees on the course of the artery. This angle is situated below the level of the inguinal ligament when the hip joint is in extension and above the sartorius m. when it is flexed to 90 degrees. If these modifications are produced in a similar manner in the living subject, they would seem to correspond to the best possible functional adaptation of the femoral a. They may be involved in the genesis of prosthetic aneurysms.

Magnetic resonance imaging of the liver by frontal (coronal) sections.

In general, frontal sections of the liver in magnetic resonance imaging are used less than sections passing through other planes of space. Frontal sections of the trunk in magnetic resonance imaging involving the liver, performed in over 80 patients for various reasons, were compared with frontal sections of the trunk made in 10 cadavers. A general schema was established of the anatomy of the liver studied in the frontal plane. Frontal sections in magnetic resonance imaging make it possible to form a very good estimate of the structure and size of the liver, and to recognize individual variations. They clearly show certain inferior relations of the liver. In particular, frontal sections in magnetic resonance imaging make it possible to identify most of the main veins of the liver, the main lobar veins and branches of the portal vein, and to properly study the entire retrohepatic portion of the inferior vena cava. Some of the vascular images were found almost constantly in the sections of the various subjects. The right lobe of the liver is more accessible to such study than the left by reason of its structure and its venous arrangements. Frontal sections of the liver in magnetic resonance imaging constitute a preferential method for studying the anatomy of the liver. Together with transverse sections, they make it possible to specify the site and venous relations of a pathologic process within the liver, with a view to hepatectomy.

Anatomical basis of rectus abdominis myo-cutaneous flaps.

The recent development of myo-cutaneous flaps and their use in plastic and reconstructive surgery prompted the authors to have a particular interest in musculo-cutaneous flaps of the rectus abdominis. From their personal studies and from a review of the literature, they consider the anatomical bases for these flaps and the different methods proposed for their construction. Finally they indicate their vast area of application which is essentially related to the wide range over which they can act.

A general review of anomalies of hepatic morphology and their clinical implications.

Anomalies of hepatic morphology, as opposed to anatomical variations, are rare. Nevertheless, knowledge of such anomalies is important since they do not always remain clinically latent. Four case studies of different types of anomalies encountered in surgical practice in the adult are reported herein. A general review of hepatic anomalies can be divided into two categories, i.e. anomalies due to defective development and anomalies due to excessive development of the liver. Such disturbances are sometimes associated with malformations of other structures, especially the diaphragm and suspensory apparatus of the liver. Defective development of the left lobe of the liver can lead to gastric volvulus. Conservely, defective development of the right lobe either remains clinically latent or leads to portal hypertension. Anomalies related to excessive development of the liver lead to formation of accessory lobes annexed to the liver. Despite their diversity of shape, size and location, such accessory lobes have common features allowing them to be considered as an entity. In most cases the accessory lobe is found in the infra-hepatic position. Riedel's lobe is the best known example of a sessile accessory lobe. Accessory lobes may also stimulate tumor. In cases where the accessory lobe has a pedicle, torsion is a common event leading to discovery of the abnormal mass. The origin of the anomalies of hepatic morphology occurring in the course of organogenesis remains to be elucidated. The use of ultrasonography should now allow identification of such anomalies prior to the occurrence of an acute complication and in the future to possibly detect them in the fetus.

[Verifying the function of hepaticojejunostomies by scintigraphy of the bile ducts]. / Contrôle du fonctionnement des hépatico-jéjunostomies par la scintigraphie des voies biliaires.

Thirty six hepatobiliary scintigraphies with 99mTc-Dimethyl IDA were performed in thirty patients with an hepaticojejunostomy one month to ten years after surgery. Twenty patients underwent surgery for biliary disease and ten for duodenal or pancreatic disease. In most cases (twenty three), the radionuclide study has been systematically performed to assess the scintigraphic pattern of a normal hepaticojejunostomy. In seven cases this pattern was abnormal. Four times the biliary enteric anastomosis was involved. Three times it showed an abnormal liver morphology. After an hepaticojejunostomy, hepatobiliary scintigraphy seems to be the only examination providing dynamic information for the biliary enteric anastomosis and the intestinal loop. But it sometimes is difficult to analyse in all cases, it must be the screening test in patients when symptoms occur after hepaticojejunostomy; but a percutaneous transhepatic cholangiogram cannot always be avoided.