[Eugene Koebèrlé (1828-1915), founder of modern surgery]. / Eugène Koeberlé (1828-1915), père de la chirurgie moderne.

Eugène Koeberlé, surgeon and anatomist gained international renown due to his outstanding ability in resection of ovary cysts and in hysterectomy. He was one of the first to perform these operations successfully. He was a pioneer in asepsis and pre- and postoperative care. He also invented many surgical instruments, among them an efficient hemostatic forceps.

[Complicated colonic diverticulosis. Changes in treatment and results over 22 years]. / Diverticulose colique compliquée. Evolution du traitement et des résultats en 22 ans.

OBJECTIVES: The aim of this study was to analyse the clinical course, surgical strategy and results in patients with complicated colonic diverticular disease. METHODS: We retrospectively compared two groups of patients who underwent surgery for complicated colonic diverticulosis from 1970 to 1984 (Group A, n = 94, mean age 60 years, 49 males, 45 females) and from 1985 to 1992 (Group B, n = 76, mean age 63.5, 32 males, 44 females). RESULTS: Patients in the two groups were comparable; only the rate of peritonitis (20 vs 8%) was different (p < 0.05). The most frequent operations in Group A were colostomy-drainage (43%) and Hartman's procedure (26%) in emergency situations and resection with immediate anastomosis (63%) or resection-anastomosis with diverting stomy (19%) in elective cases. In Group B, surgical strategy led to a different pattern of operations, 4 and 56% in emergency, and 94 and 2% in elective surgery, respectively. Overall mortality was 11%, with 17% and 4% in Groups A and B respectively (p < 0.01). This major drop in mortality was particularly important in emergency cases (31 vs 4%; p < 0.02). Morbidity in emergency surgery fell from 21 to 4% (P < 0.0006). Interrupting the use of colostomy-drainage was a major factor in reducing mortality followed by a sharp fall in mortality after Hartmann's procedure (28.5 vs 0%). CONCLUSION: The marked improvement in results between the two groups was mainly due to preferring resections of pathological colonic segments over colostomy-drainage.

[Cancer of the rectum: clinical and therapeutic aspects. What changes occurred during the last 2 decades?]. / Le cancer du rectum: aspects cliniques et thérapeutiques. Quels changements au cours des deux dernières décennies?

This retrospective study of 440 cases of cancer of rectum was done over a period of 2 decades (1970-1993) which was divided in 3 periods (1970-79, 1980-89, 1990-93) and a comparative analysis was done with respect to clinical features, histo-pathology, treatment and results. At least one predisposing lesion (polyp, villous tumour) was noted in 26.7%, 41.5% and 41.5% respectively. The topographic distribution was unchanged in all three periods. The Dukes staging showed increase in stage A with 1.9%, 9.8% and 10% respectively and decrease in stage D with 26.1%, 20.2% and 16% respectively. The operability rate was 92.3%, 94% and 96.5% respectively, resectability rate was 80%, 91.3%, 94% and 96.5% respectively, resectability rate was 80%, 91.3% and 95.9% and curative resection rate was 83.3%, 86% and 88.2% respectively. Amongst the operations done, abdomino-perineal resection was done in 55.8%, 39.5% and 7.2%; anterior resection was done in 5.5%, 36.6% and 81.4%; thus these two curves crossed in 1985. Hartmann's procedure was done in 11%, 8.7% and 4.1%. The radiotherapy was given in 6.9%, 23.9% and 75.8% respectively. Overall hospital mortality rate was 5.8% which showed progressive decrease in the 3 groups with 13.8%, 1.24% and 2% respectively. The principal factors influencing the mortality rate were the emergency presentation the type and the palliative type of operation. Overall early complication rate was 42% which showed progressive decrease in the 3 groups with 64.8%, 37% and 21% respectively. Rate of local recurrence was 17.2% which was related to the topography of the tumour, Dukes staging, type of operation, margin of resection and preoperative radiotherapy. 5 year survival rate was 43% which in relation to the curative or palliative nature of the operation and the Dukes staging. The expected progress in terms of survival depended on surgery in early stages of disease and use of radiotherapy and chemotherapy.

[The surgical therapy of liver trauma]. / La terapia chirurgica dei traumi epatici.

The different therapeutic patterns of liver trauma are presented; they should be chosen on the basis of both clinical assessment, particularly looking for hemodynamic impairment and associated bowel lesions, and CT scan data. Surgical abstention should be considered for a great number of blunt liver trauma; open or severe blunt trauma should be preferably treated by elective hemostasis and biliostasis, with only rare use of hepatic resection "à la demande", on partially sectioned or devitalized tissues. Cavo-suprahepatic wounds remain the most important technical problem and continue to worse the prognosis in liver trauma.

[Hemorrhagic ulcer of the bulb. Plea for gastric resection]. / Les ulcères hémorragiques du bulbe. Plaidoyer en faveur de la résection gastrique.

Bleeding remains on of the most fearsome complications of duodenal ulcer disease. It is, as if H2 Blockers, while never curing the ulcer, were in fact promoting its most severe forms, i.e., posterior huge ulcers, the control of which has to be a gastric resection. On the basis of a short but consecutive serie of 10 patients, the authors plead in favor of the exclusion of the ulcer from the digestive tract, using the wheeling off procedure to close the duodenal stump.

[Outpatient surgery. Why? How?]. / La chirurgie ambulatoire. Pourquoi? Comment?

One day surgery--defined by the fact that the patient enters the clinic in the morning and returns at home late in the afternoon--requires the observation of a whole of criteria which are absolutely necessary to guarantee the highest security as possible. At first an outstanding collaboration with the anesthetist is mandatory. Material conditions of its practice should'nt be neglected. Rooms and medical staff have to be appropriate. Indications of its performance are large but depend of the experience of the surgeon. Limits are ruled by the general status of the patient and also by his social conditions and his surroundings, not to forget an excellent collaboration with the general practitioner. Economic advantages seem obvious but have to be calculated. It is above all necessary to persuade the public hospital administrations and the social Security structures, of the interest and the advantages of one day surgery.

[How much general surgery does the specialist surgeon need? French considerations?]. / Wieviel Allgemeinchirurgie braucht der Teilgebietschirurg? Französische Uberlegungen?

General surgery is the basis of surgery and the prerequisite for any type of surgical intervention. General surgery is also the coordinating factor for all those patients whose state of health, requires the attendance of several specialists. Four conditions are mandatory for optimal training: 1. Criteria for admission 2. Duration of training: 4 years of basic surgical training with 2-3 more years for specialization 3. Criteria for the standardization among the training centres (hospital accreditation system) 4. Quality control: at the end of the 1st year control of manual ability and after 4 years theoretical, clinical and practical examinations. These points are discussed and defended.

[Severe acute intestinal hemorrhage. Value of investigation tests]. / Hémorragies intestinales aiguës graves. Valeur des examens complémentaires.

Episodes of intestinal bleeding likely to endanger vital functions require detailed etiological and topographical examination before surgical intervention. Forty-two cases of serious haemorrhage of the lower digestive system in adults were studied retrospectively. The origin of the bleeding was localized preoperatively in 37 cases (88%). Four exploratory laparotomies were carried out after etiological examination including at least digestive arteriography. Hence it was always possible to localize the source of bleeding. We found it convenient to establish the order of the complementary pretherapeutic tests by taking into account two symptoms, acute active bleeding (AAB) and haemorrhage with acute anemia (HAA).

[Criteria for selection and contra-indications of ambulatory surgery]. / Critères de sélection et contre-indications de la chirurgie en ambulatoire.

Ambulatory surgery means to us the scheduled surgery and investigations carried out under various modes of anaesthesia in patients who are admitted in the morning and discharged in the evening. Now the strictness and guarantees required and the essential conditions of safety and efficiency can only be achieved if a number of selection criteria and contraindications are complied with. The authors first study the lesions for which ambulatory treatment is possible, as well as the criteria regarding both the patient and the attending physician responsible for the follow-up at home. Since a close co-operation between the anaesthesist and the surgeon proves to be essential, the criteria of anaesthesia must also be dealt with. The contraindications are connected to the type of surgery, to the type of anaesthesia, to the patient, to the patient's circle, to the medical team, and finally to the equipment and organization of the unit in which ambulatory surgery is performed. These many aspects of the problem are analyzed and discussed.

[Current concepts of the treatment of cholelithiasis in aged patients]. / Conceptions actuelles du traitement de la lithiase biliaire chez le sujet âgé.

Biliary lithiasis in elder patients is characterized by the physical defects usually present--therefore surgery is less mandated than endoscopic procedures or extra corporeal lithotripsy. However, if surgery is undertaken, then it should be carried out as completely as possible. In this paper, the authors emphasize the special aspects of its indications and technics--for more than any where else this surgery required perfection.

[The development of surgical therapeutic concepts of acute severe pancreatitis]. / Evolution des conceptions thérapeutiques chirurgicales des pancréatites aiguës graves.

The actual surgical concepts concerning the treatment of acute pancreatitis are described. Owing to sonography and above all to computed tomography, constantly compared with clinical data, the surgical decisions can be more easily conducted. In acute pancreatitis of biliary origin, endoscopic sphincterotomy is mandatory in a great number of cases, followed by complete de-obstruction of the common bile duct. That procedure has the advantage of reducing notably mortality and morbidity. In idiopathic pancreatitis, 4 therapeutic behaviours which correspond to 4 different clinical types, are to be faced: --or after 5 to 6 days, division of the left hypochondrium with performing of a meticulous cleaning, followed by a large drainage lavage, --if all reanimation measures have failed, earlier surgery, often of the last chance, consisting in necrosectomy as extended as necessary, --in right away appearing pancreatic phlegmon, a very large drainage, --or, a more expecting attitude in cases in which resorption of the necrotic spots appears to be very slow on CT-Scan, but without any clinical abnormality. Figures support these concepts and prove their warranty.

[Perforations of the colon. Apropos of 74 cases]. / Les perforations du côlon. A propos de 74 cas.

74 colic perforations were surgically handled between 1975 and 1988. Among the non-traumatic perforations, which represent 74% of this series, 39 cases (71%) complicated the course of acute diverticulitis, 9 cases (15%) were due to cancers and 7 cases (13%) were of miscellaneous origin. Traumatic perforations (26%) were iatrogenically induced in 84% (16 cases). In 78% the perforation was located in the sigmoid or recto-sigmoid. The treatment consisted in performing either a diverting colostomy (30 cases--40%) or a colic resection (44 cases--60%) with or without immediate anastomosis (respectively 10 cases--13.5% and 34 cases--46%). The overall mortality was 10.8%, which referred to etiology, turns to be 15% (3/19 cases) in traumatic perforations, 13% (5/39 cases) in diverticulitis and 0% in cancer. Related to treatment, mortality reached 23% for derivation and drainage procedure and 2% for resection. Post-operative complications were respectively 10% and 47%. Among post operative complications (22 cases--29%) 11 patients were reoperated on with an additional mortality of 18%. These results give strong evidence to the reliability and value of urgent colic resection in perforated colon and enhance the necessity of undelayed operation.