Intra-hepatic arterio-venous fistula after penetrating liver injury.

Arterio-portal fistula occurs relatively frequently after liver trauma; its treatment is well codified. We present here in the case of a patient with an intraparenchymal fistula between a hepatic artery branch and the right hepatic vein. Embolization via interventional radiology was considered at high risk. However, hepatic necrosis developed, leading to the performance of a right lobectomy. The literature on this type of arterio-venous fistula is scanty making it difficult to propose specific management recommendations.

Herniation of the broad ligament And the other side?

INTRODUCTION: Broad ligament herniation is a very uncommon cause of small bowel obstruction. Surgery permits reduction of the hernia and closure of the defect to prevent recurrence. PRESENTATION OF CASE: We report a rare case of a 35 year old woman admitted in our hospital for recurrence of a small-bowel obstruction, secondary to internal hernia. The patient underwent intestinal resection in 2018 for herniated left broad ligament of the uterus strangulated. This time, the computed tomography revealed a double junctional syndrome with ileal dilation localized in right side of uterus. Emergency surgery confirmed internal hernia with passage of ileal loops through the right broad ligament. After reduction of the hernia, closure of the defect was performed to prevent recurrence. For the first time, a check of other classic abdominal hernias was carried out. DISCUSSION: Internal hernias are responsible for less than 5% of mechanical bowel obstruction. Broad ligament hernias represent only 4-7% of these hernias. The diagnosis is often delayed, because of its rarity and lack of surgical history. Surgery confirms the diagnosis, treats the occlusion and prevents recurrence. The presence of several internal hernias has never been studied and no recommendation has been made on this topic. CONCLUSION: This case demonstrate the importance of a systematic exploration of other internal abdominal hernias during the surgery, especially a contralateral broad ligament hernia.

Elevated human chorionic gonadotrophin without pregnancy: A case of gallbladder carcinoma.

We report a rare case of primary gallbladder adenocarcinoma producing human chorionic gonadotropin (HCG) in a 31-year-old woman. The patient was first misdiagnosed and monitored for an extra-uterine pregnancy. The most frequent cause of elevated serum HCG is pregnancy but elevated HCG can also be a marker of others pathologies like tumors. It is of utmost importance to keep in mind all the possible causes of elevated serum HCG. Once pregnancy has been ruled out, complementary exams should be performed to seek a tumor, especially since tumors producing HCG can be particularly aggressive.

[Penile metastasis of recto-sigmoid adenocarcinoma. Apropos of a case]. / Métastase pénienne d'un adénocarcinome recto-sigmoïdien . A propos d'un cas.

Metastases to the penis from rectocolic adenocarcinoma are extremely uncommon with 50 cases reported; the diagnosis is often delayed and the prognosis is very poor. The choice between an aggressive surgical approach and a palliative treatment is difficult, but surgery seems to give the best results in limited penile lesions. The authors report a case of metastatic involvement of the penis by a recurrent rectocolic adenocarcinoma in a 42 year old patient. A MR scan was performed before surgical treatment of both lesions.

Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome. Vena cava replacement under veno-venous bypass and liver hypothermic perfusion.

We report the first case of leiomyosarcoma of the middle and upper part of the vena cava successfully treated by surgical resection, complete vena cava replacement and disobliteration of the hepatic veins under veno-venous bypass and liver hypothermic perfusion as described in "ex situ, in vivo liver surgery".

Laparoscopic cholecystectomy in complicated cholelithiasis.

From January 1990 to December 1992, 129 patients presenting complicated cholelithiasis were included in a prospective study to assess the feasibility and efficiency of laparoscopic cholecystectomy. There were 84 females (65%) and 45 males (35%). Mean age was 60 years (range from 23 to 88). There were 90 acute cholecystitis (70%), 14 empyema (11%), 14 cholecystitis on scleroatrophic gallbladder (11%), and 11 mucocele (9%) cases. Laparoscopic cholecystectomy has been successfully performed in 106 cases (82%) (group I). In this group of patients, morbidity and mortality were 4.7% and 0.9% (n = 1), respectively. Mean hospital stay was 4.7 days after uneventful postoperative course. Two patients required reoperation for complications (1.8%). Twenty-three patients (18%) required enforced conversion to laparotomy after unsuccessful laparoscopic procedure (group II). Mean hospital stay was significantly higher in group II (10.8 days, P = 0.0001). There was no difference between the two groups according to sex, previous surgery, or indications. Laparoscopic cholecystectomy may be attempted and successfully realized in complicated cholelithiasis without morbidity increase. Main advantages of this procedure are a shorter hospital stay and a better recovery period.

Carcinosarcoma of the gallbladder. A case report and review of the literature.

We report a carcinosarcoma (CS) of the gallbladder in an 83-year-old woman. Ultrasonography found an enlarged gallbladder with thickened walls, a 3-cm gallstone, and a polypoid mass in the fundus. Pathological examination revealed neoplastic tissue composed of sarcomatous and glandular components. Twelve months later, the patient is alive. We review 24 other cases in the literature to outline the characteristics of this tumor.

[Resection anastomosis of the small intestine by celioscopy in swine. Comparative experimental study between manual and mechanical anastomosis]. / Résection anastomose de l'intestin grêle par coelioscopie chez le porc. Etude expérimentale comparative entre anastomose mécanique et manuelle.

Laparoscopic intestinal anastomosis is not very reliable and needs to be evaluate in an experimental model in animals before being performed in man. The purpose of this study was to evaluate the feasibility, efficacy and safety of manual anastomosis comparatively to the standard stapling suture. Twenty female pigs weighing 20 +/- 5 kg. were used for this study. A 5 cm ileal segment resection was performed under laparoscopy. The animals were assigned to 2 groups. Group I: 10 animals underwent end-to-end hand-swen anastomosis with Polyglactin 910, dec 1.5. Group II: 10 animals underwent side-to-side anastomosis using the Endo stapler. Operating time and anastomosis time were compared using the Mann-Whitney test for statistical analysis. On the 15th postoperative day, the animals were sacrificed and the anastomoses were evaluated. There was no operating death in the 2 groups. The operative time was significantly longer in group I than in group II (p < 0.01), with 180 +/- 40 min vs 49 +/- 25 min respectively. This difference was due to the anastomosis time of 130 +/- 40 min vs 16 +/- 6 min respectively (p < 0.01). There was 1 postoperative death related to fistula and peritonitis in group I and none in group II. The post-operative follow-ing showed 5 anastomotic leakages (4 in group I and 1 in group II) and 2 relative stenoses in group I. This study shows the simplicity and rapidity of performing stapling intestinal anastomosis under laparoscopy. Hand-sewn anastomosis is technically more difficult to perform under laparoscopy and requires a greater experience.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery.

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

Colorectal carcinoma in patients aged 75 years and more: factors influencing short and long-term operative mortality.

A review of 238 patients aged over 75 years and operated on for colorectal cancer was undertaken to analyse factors influencing short and long-term operative mortality. Operative mortality in the first postoperative month was 13% (n = 31) and 17% (n = 35) in the first year. Four factors influenced significantly postoperative mortality in the first month: postoperative complications (p = 0.0001) related to medical complications (p = 0.0001), emergency surgery (p = 0.007), type of anesthesia (p = 0.01). Mortality during the first year (excluding patients who died in the first month) was higher in females (p = 0.05), in patients subjected to emergency operation (p = 0.004), in patients with preexisting, cerebrovascular accident (p = 0.04) and in patients with Dukes C staging (p = 0.0001). A multivariate analysis with Cox's model revealed 3 prognostic factors: Dukes staging (p = 0.0001), medical complications in the postoperative period (p = 0.0001) and type of anesthesia (p = 0.0009). Age as an isolated factor is not a contraindication to colorectal surgery in elderly patients presenting colonic or rectal carcinoma. Prognosis in elderly patients is first correlated to the control of postoperative mortality undergoing until the first year and then to the cancer itself.

[Celioscopic cholecystectomy in simple and complicated cholelithiasis. Apropos of 392 cases]. / Cholécystectomie coelioscopique dans la lithiase vésiculaire simple et compliquée.

In a study including 392 patients we compared two groups of patients according to the indication for laparoscopic cholecystectomy: group I: 293 patients treated for simple cholelithiasis (n = 291) or gallbladder polyps (n = 2). Group II: 99 patients operated for complicated cholelithiasis. For each patient, 14 pre, intra and postoperative parameters were analysed and compared. Mean operative time was 80 minutes. Primary and secondary laparotomies were necessary in 5.8% and 1.3% of cases respectively. Biliary injury was the most frequent complication (1.3%). Mean hospital stay was 4.5 days. In terms of mean age, operative time, intraoperative incidents and complications, and primary laparotomy. There was a significant difference between the two groups (p less than 0.001). There were 4 secondary laparotomies in group II and one in group I. These results suggests that laparoscopic cholecystectomy is a safe technique with a low mortality rate (0.25%). The comparative study proves that this technique, first indicated for simple cholelithiasis, is also applicable to the majority of complicated cholelithiasis.

[Heterotopic hepatic transplantation. Apropos of a case treated in the terminal stage of decompensated alcoholic cirrhosis]. / Transplantation hépatique hétérotopique. A propos d'un cas réalisé pour une cirrhose éthylique décompensée au stade terminal.

Heterotopic liver transplantation is an exceptional indication for acute or chronic liver disease. The authors report a case of auxiliary liver transplantation performed for end-stage alcoholic cirrhosis. The patient was contra-indicated for orthotopic transplantation because of poor general and nutritional status. The HLT was indicated because of intractable ascites, liver insufficiency and chronic encephalopathy. The operation was performed according to the technique described by Fortner. Liver function tests returned to normal within 3 days and the only postoperative complication were gastro-intestinal bleeding due to CMV viral infection. Liver function was assessed by HIDA scintigram which showed blood intake by the graft and atrophy of the native liver. The patient was discharged after 3 months. The follow-up is 17 months. At the 15th month control, liver CT showed multiple hypodense nodules biopsied and corresponding to metastasis from a probable pancreatic carcinoma. ERCP and morphologic explorations did not show the primary tumor. The authors discuss the indications of HLT, the rules of successful performance of HLT and the problem of the graft involvement by metastases.

[Ileal pouch in the treatment of ulcerative rectocolitis and familial polyposis. Analysis of morbidity in a series of 30 cases]. / Réservoirs iléaux dans le traitement de la rectocolite ulcéro-hémorragique et de la polypose rectocolique familiale. Analyse de morbidité sur une série de trente cas.

Between 1984 and 1989, 30 patients underwent total coloproctectomy with J ileal pouch and ileo-anal anastomosis. They corresponded to 29 cases of ulcerative colitis and one case of familial polyposis. The authors report their own experience and the related morbidity and functional results. There were 23% fistulae, 6.6% pouchitis, 10% stenoses, 8.7% pelvic abscesses, 10% bowel obstructions, 6.6% fistulae after ileostomy closure. Only one pouch had to be removed for severe pouchitis. Functional results were partly related to post-operative complications: 50% of patients had normal continence, 57% at least 6 stools per day, 81% had one stool per night, 15% had soiling. Morbidity is discussed for the various types of complications.