Bile duct cysts in adults: a multi-institutional retrospective study. French Associations for Surgical Research.

OBJECTIVE: To review the features of adult patients undergoing surgery for bile duct cysts, focusing on the anatomy of the biliary tree as well as the long-term outcome. SUMMARY BACKGROUND DATA: Bile duct cysts (BDCs) are uncommon in Western countries, and the majority of reported cases originate from Asia. Japanese authors have emphasized the frequent association of extra- and intrahepatic bile duct dilatations, but grading of patients based on Todani's classification is often hindered by the absence of an accurate definition of types IC and IVA cysts. Moreover, despite the increasing use of extrahepatic cyst excision, little is known about the long-term outcome in patients with intrahepatic bile duct involvement. METHODS: Forty-two adult patients with BDC were treated between 1980 and 1992 in 17 institutions of the French Associations for Surgical Research. Clinical presentation, radiologic presurgical evaluation, and surgical procedures were analyzed. The long-term postsurgical outcome was derived from patient charts, attending physicians, or direct patient contact. RESULTS: Twelve patients (30%) had recurrent abdominal pain or jaundice from childhood. Seven (17%) had undergone prior cystenterostomy. Twenty-one (50%) had a Todani-type IVA cyst with extra- and intrahepatic bile duct involvement. Of these, nine had segmental, exclusively left-sided intrahepatic bile duct dilatation. Biliary carcinoma was encountered in five patients (12%). Extrahepatic cyst excision with a Roux-en-Y hepaticojejunostomy was performed in 34 patients with type I or IV cysts. The overall operative mortality rate was 2.4%. Long-term results were clearly correlated with cyst type: during a mean follow-up of 8.4 years, 11 of 12 patients (92%) treated by cyst excision for type I cyst remained free of symptoms, whereas 31% of patients who underwent surgery for type IV cyst had episodic or severe cholangitis with intrahepatic stones. CONCLUSIONS: In patients with BDC, particular attention must be given to the associated intrahepatic bile duct dilatations. We propose a modification of Todani's classification to distinguish cystic, segmental, and fusiform dilatations of the intrahepatic biliary tree in type IV cysts. In patients with segmental left intrahepatic cystic dilatations, combined left liver lobectomy and extrahepatic cyst excision is suggested to decrease late postsurgical biliary complications.

[Diagnostic strategy of abdominal contusions in adults]. / Stratégie diagnostique dans les contusions abdominales de l'adulte.

Diagnosis of a deep visceral lesion in an adult following abdominal contusion is almost always difficult as the abdominal signs are late or masked by associated lesions. All of the controlled studies agree on the superiority of peritoneal puncture-lavage over ultrasonography or CT scan in the diagnosis of haemoperitoneum. The diagnostic performance of computed tomography in the identification of lesions of solid organs is very much better than that of ultrasonography. The diagnosis of an isolated lesion of a hollow viscus has benefited from progress in imaging to a much lesser degree and peritoneal puncture-lavage with leukocyte count remains the key examination. The diagnostic strategy must be based on the patient's clinical condition and on this hierarchy of complementary investigations.

[Retrograde cholangiopancreatography and endoscopic sphincterotomy for biliary lithiasis. Prospective evaluation in surgical circle]. / Cholangio-pancréatographie rétrograde et sphinctérotomie endoscopique pour lithiase biliaire. Evaluation prospective en milieu chirurgical.

Between January 1982 and 1987, 772 consecutive endoscopic retrograde cholangiopancreatographic examinations (ERCP) were performed in 673 consecutive patients suspected of having biliary tract lithiasis (mean age: 62.1 +/- 18.2 years). Two hundred and thirty-two were emergency procedures (30%). Endoscopic sphincterotomy was performed for common bile duct stones (CBDS) in 257 cases (38.0%), of whom 143 (55.6%) had undergone previous cholecystectomy. In 17.2% of cases, ERCP was either a complete (7.8%) or partial (9.4%) failure. In 124 patients for whom microlithiasis was not identified by sonography and who underwent operation, sensitivity and specificity of ERCP was 70% and 87%, respectively. Of 266 patients in whom ES was attempted, 96.6% were achieved and the common bile duct was cleared of stones in 72% of cases. Nineteen percent of patients required two or more attempts at extraction. After ERCP without ES, mortality and morbidity rates were 0.96 and 3.6% respectively. After ES, complications followed in 12.1% of patients and 3.9% died. Mortality and morbidity directly related to ES were 3.1% and 11.3% respectively. The most common complications after ERCP were acute cholangitis and pancreatitis, whereas after ES, acute cholangitis was the most common complication, followed by hemorrhage and duodenocholechocal perforations. These complications occurred independently of age and previous cholecystectomy but was closely related to stone clearance (P < 0.05). Seventy-one patients (10.5%) required operation. Twenty-nine patients underwent emergency surgery for complications with a mortality rate of 17%. Forty-two patients underwent elective surgery for retained CBDS after ES without any mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraperitoneal resorbable mesh in the prevention of postoperative wound dehiscence. A comparative study]. / Le treillis résorbable intra-péritonéal dans la prévention des éviscérations post-opératoires. Une étude comparative.

The purpose of this study was to compare efficiency of polyamide mesh externally applied to the skin and intraperitoneal resorbable mesh of polyglactine 910, for the prevention of wound dehiscence. Two consecutive and homogenous groups of 100 patients, operated by the same surgical team and presenting one or more risk factors of evisceration, were retrospectively compared. Use of intraperitoneal polyglactine mesh, significantly reduced rate of wound dehiscence (4% vs 13%), lowered frequency of reoperation in eviscerated patients (25% vs 61%), but did not improve prognosis of this complication (50% mortality). Potential effect of resorbable mesh on late fascial disruption remains controversial.

[Adenocarcinoma of the appendix. A multicenter study from AURC]. / Adénocarcinomes de l'appendice. Une etude multicentrique de l'AURC.

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Diagnosis was never suspected preoperatively. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients. One patient with an obstructing tumor and peritoneal involvement died postoperatively. Estimated survival rate was 46% at five years. Probability of survival was unrelated to the histologic tumor type but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. In patients with pseudomyxoma peritonei, long-term survival was obtained by repeated laparotomy with resection of mucinous material. Our results indicate that, in good risk patients, right hemicolectomy performed as first or second operation, provides better results than appendectomy alone.

Adenocarcinoma of the appendix.

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients studied. Survival was unrelated to the histologic tumor type, but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. Long-term survival was obtained by repeat laparotomy with resection of mucinous material in patients with pseudomyxoma peritonei.

[Rupture of the abdominal wall in highway accident victims wearing seat-belts]. / Ruptures pariétales abdominales chez les accidentés de la route porteurs d'une ceinture de sécurité.

Rupture of the rectus abdominis muscle represents one of the rare specific lesions due to seat-belts. Two cases are presented which illustrate diagnostic difficulties and the value of the warning provided by these lesions, which are very frequently associated with severe contusion of the small intestine or colon.

[Tolerance and short-term results of the systematic laparotomy-chemotherapy-radiotherapy sequence in Hodgkin's disease in adults]. / Tolérance et résultats à court terme de la séquence: laparotomie systématique-chimothérapie-radiothérapie dans la maladie de Hodgkin chez l'adulte (25 cas).

Twenty five cases of Hodgkin disease were treated by chemotherapy and radiotherapy after staging laparotomy. The safety and the utility of staging laparotomy are discussed. Staging laparotomy seems to be usefull in stage II with involvement of at least three lymphatic territories and in stage III.

[Eosinophil ileitis (author's transl)]. / Les iléites à éosinophiles.

Eosinophilic ileitis is observed mainly in three coastal areas: Holland, Japan and Brittany. It presents in the form of a parietal inflammation, stenosing the intestinal lumen or a sessile tumour of limited volume. The symptoms are generally those of appendicitis but a past history of allergy and the discovery of eosinophilia greater than 10 p. cent may lead to the diagnosis of eosinophilic granuloma which only histology can confirm. Surgical treatment consists of segmental resection of the small intestine. The pathogenesis of the granuloma, which was for long attributed to the presence in the wall of the intestine of ascaris larvae, is at present debated. Are there non-parasitic eosinophilic granulomas? The case reported here is perhaps an example.

[Experimental findings in liver perfusion measurements using an ultransonic Doppler flowmeter]. / Experimentelle Befunde der Leberdurchblutungsmessung mittels eines Ultraschall-Doppler-Flussmessgerätes.

1. The ultrasonic doubling method of bloodflow measurement is an experimental easily practicable and very exactly recording measurement arrangement. By this method data of other methods were extended and ensured. 2. Early inquested finding is attested that after inhibition of portal vein bloodflow and after portocaval anastomosis an increased arterial perfusion of liver through a. hepatica is following. Increasing bloodflow of a. hepatica is independent of cardiac output. 3. After diminution of arterial perfusion by occlusion of a. hepatica no increased portal bloodflow is following. 4. It is to suppose an "intrahepatic regulation of liver bloodflow". It seems economical that the perfusion part of the a. hepatica with her higher oxygen content is increasing when the general perfusion is decreasing by diminished portal bloodflow or diminished blood pressure. So far it is impossible to interpret whether this accomodation is based on a difficult "auto-regulation" or is originated pressure passive from the flow together of two systems are staying under different pressure.

[Wirsung's duct and chronic pancreatitis. Changes in the morphology of the pancreatic ducts after pancreatic duct shunts. 23 cases followed-up]. / Canal de Wirsung et pancréatite chronique. evolution de la morphologie des voies canalaires aprés dérivations wirsungo-digestives

The authors study in chronic pancreatitis the morphology of Wirsung's duct in 31 patients who had undergone repeated operations, 23 of them were submitted in a first stage to an anastomosis between the pancreatic duct and the digestive tract. The main causes of failure were obstructions of the anastomosis, biliary complications and continuation of the pancreatic disease. The difference in prognosis between pancreatitis with a dilated pancreatic duct, and those with a filiform duct, is perhaps due to lesions of different histological appearance and course. The best results were obtained in patients able to give up alcohol and in whom it was possible to carry out a broader anastomosis on a dilated and unobstructed pancreatic duct.

[Intracystic hemorrhages of pancreatic pseudocysts]. / Les hémorragies intra-kystiques des pseudo-kystes pancréatiques

The authors report ten personal cases and review the literature on 99 other cases, and study primary intra-cystic hemorrhage or post-operative hemorrhage, occurring during the course of pancreatic pseudo-cysts. These hemorrhagic pseudo-cysts are very often associated with chronic pancreatitis; they may rupture into a hollow viscus, the peritoneal cavity or into Wirsung's duct. Arteriography and duodenoscopy with retrograde pancreatography, should permit one to reduce the frequency of these latent, undiagnosed forms until surgical operation has been carried out. Even more dangerous, post-operative bleeding often represents a recurrence of primary intra-cystic hemorrhage which has been undiagnosed or neglected. Surgical treatment should give a greater place to operations of excision which simultaneously treat false cyst, the responsible vascular lesion and the chronic casual pancreatitis.