[Abdominal management of rectocele and elytrocele: place of the laparoscopic approach]. / Traitement des rectocèles et des élytrocèles par voie abdominale: apport de la laparoscopie.

AIM OF THE STUDY: To report the results of abdominal promontory rectopexy and douglassectomy in the management of rectocele and enterocele. PATIENTS AND METHODS: Between 1992 and 2002, 72 patients were operated by one colorectal surgeon. Laparotomy was used in 37 cases between 1992 and 2001 and the laparoscopic approach in 35 cases from 1995 to 2002. Promontory rectal fixation required only one mesh secured between the anterolateral right side of the rectum and the lumbosacral ligament. The same mesh was used to fix the vagina or the cervix. Combined therapeutic or prophylactic urinary interventions are frequent in the series. RESULTS: The follow-up was more than one year in 63 patients with a mean value of 58 months with no patient lost. Recurrence of posterior vaginal prolapse was noted in only two cases. Dyschesia and urinary incontinence were improved respectively in 80 and 70% of the cases and a significant improvement in anal incontinence was observed in 95% of the patients. CONCLUSION: The abdominal way allows a suitable treatment in patients with advanced stage rectocele and enterocele and evidence of pelvic organ prolapse. The laparoscopic approach is superior in terms of morbidity and functional results.

[Magnetic resonance study of complex anal fistulae. Preliminary results apropos of 28 cases]. / Exploration par résonance magnétique des fistules anales complexes. Résultats préliminaires à propos de vingt-huit cas.

PURPOSE: To evaluate the use of Magnetic Resonance Imaging (MRI) for the treatment of problematical anal fistulas and follow-up of cases treated by long-term seton drainage with two or three-stage fistulotomy. METHOD: prospective study on 24 patients with surgical treatment between July 1993 and March 1995 selected for MRI among 100 anal suppurations according to following criteria: high trans-sphincteric or supra-sphincteric fistula with one or more previous definitive attempts at treatment (15), and/or severe anal or rectal fibrosis (11). Patients with Crohn's disease were not included. For 14 of these patients who had a long-term seton drainage, MRI tried to assess the quality of the surgical drainage and the course of residual abscess. RESULTS: the overall accuracy of MRI for visualization of internal opening, primary and secondary tract was 84% when compared with surgical data. The sensitivity and specificity were 100% for the detection of horse shoe fistulous tracts (8). For the 14 patients followed by MRI, only one false positive was noted and in 5 cases the results of MRI modified the previous staged procedure (prolonged seton drainage or new excision). For the 20 patients treated for more than 6 months, the mean follow-up was 18 months and median was 14 months. Only one recurrence was noted with no loss of follow-up. CONCLUSION: this study confirms the high degree of accuracy of MRI for mapping of high complex fistula in ano. MRI is very helpful for the survey of healing in cases treated with seton drainage and two or three stage fistulotomy to preserve continence.

[Mammary microcalcifications: is there a consensus on interpretation and management?]. / Les microcalcifications mammaires: existe-t-il un consensus sur l'interprétation et la conduite à tenir?

Twenty two view mammograms without magnification, with microcalcifications corresponding to non palpable breast lesions, were submitted to 23 experienced observers, either gynaecologists or radiologists. These mammograms consisted of 10 malignant lesions and 10 benign lesions; all of them underwent surgical procedures. The microcalcifications were graded and categorized into one of the four groups: malignant; suspect; slightly suspect; benign. One of the four options was proposed: biopsy; mammogram within 3 months; mammogram within 6 months; mammogram within a year. Twelve observers out of 23 have referred to a classification. The mammograms were assessed according to a consensus. The validity of that diagnostic test was studied in various clinical situations and the lack of homogeneity of the responses was quantified. In the trade-off situation between sensitivity and specificity (suspect or malignant considered as positive), sensitivity is 50% and specificity is 70%. Moreover, the responses are not homogeneous at all and this lack of homogeneity is found to be statistically significant, greater than by chance alone. The diagnosis of cancer is more frequently put forward by the radiologists. This study explains the low predictive value of non palpable microcalcifications undergoing surgical procedures: from 11.5 to 44% in the literature. Similarly, there is no agreement on the frequency of the follow-up for these microcalcifications when they do not lead to surgical procedures.