[Abdominal pain among elderly patients in the emergency department]. / Abdomen aigu chez la personne âgée aux urgences.

With the population ageing, each physician will increasingly be confronted with older patients, who often suffer from multiple ailments. In such population, abdominal pain, though a frequent complaint, can present a real challenge as history and clinical examination may be misleading. This symptom is however the fourth most frequent ground for consultation in the emergency department and is often a major consumer of time and money. It therefore seems essential to address each case of abdominal pain in the elderly with methodology and bearing in mind at all times that the usual clinical signs may be missing or deceiving. Diagnosis of nonspecific abdominal pain often marks the end of the consultation once the worst has been excluded.

Intraarterial thrombolysis and stent placement in the acute phase of blunt internal carotid artery trauma with subocclusive dissection and thromboembolic complication: case report and review of the literature.

The case of a patient with blunt traumatic internal carotid artery dissection associated with subocclusive stenosis and thromoboembolic complication is presented. The patient suffered fluctuant neurological abnormalities and several open and closed fractures of the left limb. The vascular lesion and its complication were successfully treated with intraarterial thrombolysis and stent placement during the acute phase, prior to the open surgical treatment of the fractures.

Late intestinal fistula formation after incisional hernia using intraperitoneal mesh.

Enteric fistulas are a rare but serious complication following the repair of an incisional hernia using a prosthesis. We report the case of a 52-year-old man who developed an enterocolocutaneus fistula after incisional hernia repair with intra-abdominal polyester mesh. This case shows that one may want to avoid placing the parietal prostheses in direct contact with intestinal loops.

Gastroscopic removal of an adjustable gastric band after partial intragastric migration.

BACKGROUND: Laparoscopic implantation of an adjustable gastric band is being performed widely. One potential complication is the transgastric migration of the band, that should be extracted. METHODS: The authors report a series of 182 patients, followed prospectively, October 1996 - April 2002, who had undergone insertion of the Swedish adjustable gastric band. All implantations had been completed by laparoscopy alone. RESULTS: There were no deaths. 15 complications were detected, of which 7 were intragastric migrations of the band (3.8%) at an average follow-up of 40 months. 6 were treated successfully by gastroscopy only, with a new cutter device and without complications. CONCLUSION: The endoscopic technique is beneficial even when the intraluminal migration is partial.

Meckel's diverticulum in adults: retrospective analysis of 119 cases and historical review.

OBJECTIVE: To publish our experience in the management of Meckel's diverticula in adults, and compare our results with those published elsewhere. DESIGN: Retrospective investigation of casenotes. SETTING: Multicentre study, Switzerland. SUBJECTS: 119 patients aged over 16 years who had Meckel's diverticula resected between 1980 and 1997. MAIN OUTCOME MEASURES: Assessment of the usefulness of various investigations and the criteria for removing asymptomatic diverticula. RESULTS: 67 diverticula (56%) were resected during laparotomy for another cause, and 52 (44%) for symptoms caused by the diverticula. In both groups the condition was more common in men, and most likely to present during the fourth decade. The most common investigation in the 52 symptomatic cases was a plain film of the abdomen (n = 47, 90%), and in none was a Meckel's diverticulum suggested as the cause of the symptoms. The success rates of other investigations were: small bowel enema 4/9, 99mTc scan 3/4, angiography 1/3, and computed tomography 1/14. No ultrasound scans were done. Our results compared favourably with those reported elsewhere, with no deaths in either group, 2 complications that required reoperation in the incidental group, and 1 in the symptomatic group. CONCLUSIONS: The criteria to be taken into account when deciding to resect an asymptomatic diverticulum are: male sex, age <40, ASA score, the operation being done, the size and position of the diverticulum, whether it is palpable, and whether there are other reasons for the patient's complaints.

[What should you tell your patient who has an inguinal hernia?]. / Que conseiller à votre patient porteur d'une hernie du pli de l'aine?

Surgery of the inguinal hernia has undergone rapid progress in a decade. Evaluation of new techniques, prothetic and laparoscopic, are often confusing. Comparison with classical surgery may seem difficult to the non surgeon. Though, the general practitioner keeps an important place in caring for patients with this particular pathology. The importance of economical repercussion involved by hernia pathology and knowledge of the different techniques at disposition and their outcome should allow him to objectively guide his patient who is more and more informed through the media and the web.

[Pelvic and acetabular fractures, long term results, retrospective study from Cadolles from 1977 to 1997]. / Fractures du bassin et du cotyle, résultats à long terme, étude rétrospective du collectif des Cadolles de 1977 à 1997.

From 1977 to 1997, 51 unstable pelvic and/or acetabular fractures were operated in our institution. We could control 35 after a mean postoperative period of nearly six years. The outcome was analysed considering several factors: pain, neurological and genito-urinary problems, gait, social life, Xrays and clinical findings. Our results match well with those of other series. Different evaluation scores used in the literature are compared and discussed.

[Helicobacter pylori and Meckel's diverticulum]. / Helicobacter pylori et diverticule de meckel.

One quarter of Meckel's diverticula are covered by ectopic gastric mucosa and many may present histological inflammatory changes. Helicobacter pylori grows preferentially on an acid ground but has been found in different parts of the gastrointestinal tract. A prior hypothesis of a pathogenic role for this bacterium in some of Meckel's diverticula with ectopic mucosa is not confirmed by this study covering 21 cases.

[Diagnosis of non-hernia groin masses]. / Diagnostic des voussures inguinocrurales non herniaires.

Hernia is the most frequent etiology of a groin mass except in 1 or 2% of cases. Seven cases of atypical groin masses were reported. The different etiologies of the masses were reminded, with useful investigative procedures. A precise history and a detailed physical examination are necessary to determine the most valuable exam in each patient.

Choledochocele demonstrated by computed tomographic cholangiography: report of a case.

Choledochocele is a rare cystic congenital malformation of the distal common bile duct, the precise pathogenesis of which remains unclear. It is usually diagnosed in adulthood after many examinations for unclear digestive symptoms, as in the patient whose case is described herein. Of all the diagnostic techniques available, endoscopic retrograde cholangiography (ERCP) seems to be the best; however, it is an invasive procedure associated with some morbidity. Spiral computed tomographic cholangiography with three-dimensional reconstruction is also an interesting screening technique. Malignant transformation of a choledochocele occurs very rarely, compared with other cystic malformations of the biliary tract. If a choledochocele is small and symptomatic, the lesion can be treated by endoscopic sphincterotomy, but larger cysts are more effectively removed by a surgical cystoduodenostomy. We present herein the case of a 25-year-old woman admitted to our hospital in March 1998 with upper right quadrant abdominal pain caused by a choledochocele, who was successfully treated by a cystoduodenostomy.

Utility and complications of permanent venous access devices (PVAD) in oncological treatments. Follow-up of 100 cases.

BACKGROUND: Permanent venous access devices (PVAD) are nowadays routinely implanted and used with some morbidity for the oncological treatments. The adequate timing of implantation based on the number of treatments, the survival rate and the complications has not yet been well estimated. METHODS: A hundred permanent venous access devices placed in oncological patients were followed-up prospectively. RESULTS: No mortality was seen due to the surgical act. A 11% morbidity rate was noted, largely due to infections, with 6 patients needing a second surgery. On average, 6 chemotherapy cycles were done after placing of the permanent venous access device. CONCLUSIONS: Due to these results and an average survival rate of 10.7 months, we suggest the placing of a permanent venous access device early in the management of oncological patients requiring chemotherapy cycles, so as to increase the comfort of the patient and to safeguard his peripheral venous system.

[Post-mortem evaluation following oncologic treatment of the functional and bacteriologic status of 25 permanent venous access devices]. / Evaluation post-mortem après traitement oncologique de l'état fonctionnel et bactériologique de 25 accès veineux permanents.

Permanent venous access devices allow long-term parenteral treatment under relatively safe and comfortable conditions. Nevertheless, this use is associated with some degree of (particularly infectious) morbidity. 25 permanent access devices were removed surgically in immediate autopsies and cultured. Some half were infected, with a clear prevalence (40%) for Staphylococcus coagulase negative. The results were related to clinical history and compared with the figures and conclusions of other studies. It is proposed that in certain situations cultures of native blood should be carried out more frequently through the permanent venous access, with a view to possible specific targeted antibiotic therapy associated with the heparinized lock.

The migrating spilled stone.

Two cases of late complications of laparoscopic cholecystectomy following parietal breach are reported. The escaped unretrievable infected lost gallstones behave subsequently like foreign bodies and migrate out of the peritoneal cavity. Two patients presented seven months and two years later with abscesses containing stones. Early recognition and effective surgical treatment are the only guarantee of success.

[A rare complication of permanent venous access: constriction, fracture and embolization of the catheter]. / Une complication rare des accès veineux permanents: laminage, fracture et embolisation du catheter.

The pinch off syndrome due to squeezing of the implanted catheter is a rare complication of permanent venous access devices (0.1 to 1% of the cases). The cause is a mechanical catheter's compression in the costo-clavicular space, when implanted too medially in the subclavian vein. In case of lack of venous reflux or injection difficulties, sometimes complicated by local pain, a radiological control must be obtained to demonstrate signs of compression or beginning of fracture. Significant damage to the system is shown be extravasation of radioopaque contrast medium. The suspicion of catheter damage justifies early replacement of the system to avoid right heart or pulmonary artery embolism. The electron microscopic scanning tends to prove that the catheter's rupture is caused by a fatigue process.

[Outcome of nonspecific right iliac fossa pain syndromes]. / Devenir des syndromes douloureux non spécifiques de la fosse iliaque droite.

One-third of all cases of abdominal pain and a quarter of cases of right iliac fossa pain urgently admitted to hospital leave hospital with no precise diagnosis. Based on a series of 400 patients hospitalised for right iliac fossa pain, comprising 107 cases with no identified aetiology, this prospective study was designed to assess the medium-term outcome of these patients, with or without surgical exploration. 67 cases were reviewed at five years. No major diagnosis was missed. Over this 5-year period, 30 patients (45%) experienced another episode of abdominal pain. Among the third of patients (21 cases, 31%) reviewed for another episode of right iliac fossa pain, 7 were readmitted to hospital, with 5 operations, for histologically confirmed acute appendicitis in 3 cases (5% of the series). The patient and his attending physician must be informed of the nonspecific diagnosis established during the first hospitalisation. There is no significant evidence to suggest a psychological component in the recurrent nature of the pain. Cancer must be formally excluded in patients over the age of 50. When surgical exploration is performed, nowadays by laparoscopy, appendicectomy is recommended. This procedure does not decrease the risk of recurrent pain, but confirms the real absence of histopathological abnormality and decreases the number of subsequent hospitalisations.

[Laparoscopic treatment of small bowel obstruction arising on adhesions]. / Traitement laparoscopique des occlusions du grêle sur brides.

OBJECTIVES: Determine the feasibility of laparoscopy, with the objective as well as the subjective benefits offered to patients, and the possible contra-indications of this type of surgery in the treatment of mechanical intestinal ileus. PATIENTS AND MATERIAL: This concerned 20 patients who came to the hospital with a picture of intestinal obstruction. All had a history of at least one abdominal operation. The diagnosis of mechanical occlusion due to band adhesions was presumed on the basis of the clinical and complementary examinations, particularly x-rays, and confirmed in the course of the operation. All patients were operated by laparoscopy after failure of non-invasive treatment. RESULTS: Results obtained are encouraging since 60% of the patients were successfully treated by laparoscopy alone. The patients' comfort and length of hospital stay are improved by laparoscopy. There is no relation between previous surgical history and the results of the technique. CONCLUSIONS: Most failures were due to the time interval between onset of symptoms and the operation. Early operation therefore seems to increase the chances of success.

[Should the posterior approach to the rectum be forgotten?]. / L'abord postérieur du rectum mérite-t-il d'être oublié?

The posterior approach to the low and mid-rectum is a good and anatomical way to treat high fistulas' problems, perirectal tumors and villous adenoma. It is also possible to treat by this method some rectal adenocarcinomas in special situations and in high-risk patients. A good evaluation of the disease if possible by rectal endosonography, has to be done. Coccygectomy is necessary but the transsphincteric route is not mandatory and has never been used here. 9 cases are reported with relatively good results.

[How to reduce the number of negative appendectomies? A prospective two-center study of 120 patients]. / Comment diminuer le nombre d'appendicectomies blanches? A propos d'une étude prospective bicentrique portant sur 120 patients.

A decisional protocol based on clinical findings and laboratory data was assessed prospectively in a consecutive series of 120 patients with suspected appendicitis over a 24-month period at 2 teaching hospitals. Using this protocol the high rate of negative appendectomy (31.5%) during the 2 years prior to the study was reduced to 22% without increasing morbidity or mortality. Ultrasound examination was poorly predictive in unclear cases. Laparoscopy was used to assess diagnosis in persistent symptoms.

[Is extracorporeal cholelithotripsy still justified as treatment in cholelithiasis?]. / La cholélithotripsie extra-corporelle est-elle encore justifiée comme traitement de la cholécystolithiase?

This prospective study evaluates the results of extracorporeal shock-wave piezoelectric lithotripsy in 52 patients, 41 with radiolucent and 11 with calcified shell gallstones. The fragmentation rate was above 90% and the complication rate 31%, with pain or intolerance to the adjuvant dissolution therapy in particular. At the end of the treatment, 7 cholecystectomies were carried out among the 31 patients in whom lithotripsy failed. After 18 months, the success rate was 23% and only 12 patients remained stone free. Nowadays, thanks to the new laparoscopic therapy, extracorporeal shock-wave lithotripsy is no longer judged appropriate, particularly in view of its poor cost-effectiveness and high recurrence ratio.