Internal hernias: anatomical basis and clinical relevance.

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

Negative influence of delayed surgery on survival after preoperative radiotherapy in rectal cancer.

OBJECTIVE: In Europe, until recently the standard treatment for locally advanced rectal cancer was preoperative radiotherapy (RT). The objective of this study was to evaluate the influence on survival of intervals between diagnosis and treatment. PATIENTS AND METHODS: The influence on survival of intervals between diagnosis and surgery (Dg-Surg), diagnosis and initiation of RT (Dg-Rad), and completion of RT and surgery (Rad-Surg) was evaluated in a retrospective series of patients treated with preoperative RT. Between 1991 and 1998, 102 patients received treatment with preoperative RT without concomitant chemotherapy at the René Gauducheau Cancer Center. Patients generally received 45 Gy (80%) in 25 fractions over 35 days for T2-T3-T4 N0-N1 M0 rectal adenocarcinoma located mainly (62.7%) in the lower third of the rectum (< or = 5 cm from anal margin). Thirty-five pN1 patients were treated with postoperative chemotherapy. Differences between survival were assessed by the log-rank test, and prognostic factors by the Cox test. RESULTS: Median time was 14.7 weeks for Dg-Surg, 4.6 weeks for Dg-Rad and 5.1 weeks for Rad-Surg. Median follow-up from diagnosis was 57.4 months. Five-year local relapse-free survival was 83.9%, metastasis-free survival 64% and overall survival 60.8%. No factor was predictive of tumour response to RT. Log-rank and multivariate analysis showed that overall survival was significantly influenced by lower-third tumours, pT, pN and Dg-Surg (poorer survival when > or = 16 weeks: OR = 2.59, P = 0.005). Metastasis-free survival correlated significantly with Dg-Surg (> or = 16 weeks: OR = 2.05, P = 0.05). CONCLUSION: An interval of more than 16 weeks between diagnosis and surgery may reduce overall survival of patients treated with preoperative RT for locally advanced rectal cancer. Surgery should be performed shortly after completion of RT for patients with no possibility of sphincter preservation, or a minimal risk of morbidity from an abdominoperineal excision.

Serum from achalasia patients alters neurochemical coding in the myenteric plexus and nitric oxide mediated motor response in normal human fundus.

BACKGROUND AND AIMS: Achalasia is a disease of unknown aetiology. An immune mechanism has been suggested on the basis of previous morphological observations. The objective of this study was to test whether the serum of achalasia patients could reproduce the phenotype and functional changes that occur with disease progression in an ex vivo human model. METHODS: Specimens of normal human fundus were maintained in culture in the presence of serum from patients with achalasia, gastro-oesophageal reflux disease (GORD), or healthy subjects (controls). Immunohistochemical detection of choline acetyltransferase (ChAT), neurone specific enolase (NSE), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), and substance P was carried out in whole mounts of gastric fundus myenteric plexus. In addition, the effects of achalasia serum on electrical field stimulation (EFS) induced contractions were measured in circular muscle preparations. RESULTS: Serum from achalasia patients did not affect the number of myenteric neurones. Tissues incubated with serum from achalasia patients showed a decrease in the proportion of NOS (-26% of NSE positive neurones; p=0.016) and VIP (-54%; p=0.09) neurones, and a concomitant increase in ChAT neurones (+16%; p<0.001) compared with controls. In contrast, GORD serum did not modify the phenotype of myenteric neurones. Area under the curve of EFS induced relaxations (abolished by N-nitro-L-arginine methyl ester) was significantly decreased following incubation with serum from achalasia patients compared with controls (-7.6 (2.6) v -14.5 (5.0); p=0.036). CONCLUSIONS: Serum from achalasia patients can induce phenotypic and functional changes which reproduce the characteristics of the disease. Further identification of putative seric factors and mechanisms involved could lead to the development of novel diagnostic and/or therapeutic strategies in achalasia.

Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study.

BACKGROUND: The preoperative diagnosis of adult intussusceptions (AIs) remains difficult, and the assessment of the radiological methods has been evaluated very little in the literature. The aim of this study was to evaluate the interest of the different imaging modalities for the preoperative diagnosis of AI and describe causes of AI. PATIENTS AND METHODS: Consecutive patients of 15 years and older with the postoperative diagnosis of intussusception from 1979 to 2004 were reviewed retrospectively for this multicentric study. Data concerning clinical considerations, morphological examinations, surgical procedure, histological conclusions, mortality rate and recurrence were analysed. RESULTS: Forty-four patients with documented intussusception were included. The mean age was 51 years (15-93 years). The preoperative diagnosis of intussusception was made in 52% of the cases. The sensitivities of the different radiological methods were abdominal ultrasounds (35%), upper gastrointestinal barium study (33%), abdominal computed tomography (CT) (58%) and barium enema (73%). An organic lesion was identified in 95% of the cases. There was 29 enteric and 15 colonic (including appendicular) intussusceptions. Thirty-seven percent of the enteric lesions were malignant, and a bit less than 50% of them were metastatic melanomas. The benign enteric lesions were Meckel's diverticulum and Peutz-Jeghers syndrome in half of the cases. Fifty-eight percent of the pure colonic lesions (excluding appendix) were malignant, and 85% of them were primary adenocarcinomas. The benign colonic lesions were lipomas in 80% of the cases. All patients, except one, had a surgical treatment, and 13 of them had a complete reduction of the intussusception before resection. The mortality rate was 16% and recurrence occurred in three patients; two of them had a Peutz-Jeghers syndrome. CONCLUSION: Intussusception rarely occurs in adults, but nearly half of their causes are malignant. The CT scan is a helpful examination for enteric intussusceptions whether barium enema seems to be the most performing method for colonic lesions. Surgery is the recommended treatment, with or without a primary reduction of the intussusception. During the surgical procedure, this reduction can lead to a more limited bowel resection.

Neurochemical coding of myenteric neurones in the human gastric fundus.

The major functions of the stomach are under the control of the enteric nervous system (ENS), but the neuronal circuits involved in this control are largely unknown in humans. Enteric neurones can be characterized by their neuromediator or marker content, i.e. by neurochemical coding. The purpose of this study was to characterize the presence and co-localization of neurotransmitters in myenteric neurones of the human gastric fundus. Choline acetyltransferase (ChAT), neurone-specific enolase (NSE), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), substance P (SP) were detected by immunohistochemical methods in whole mounts of gastric fundus myenteric plexus (seven patients). Antibodies against ChAT and NOS labelled the majority of myenteric neurones identified by NSE (57.2 +/- 5.6% and 40.8 +/- 4.5%, respectively; mean +/- SD). The proportions of VIP- and SP-immunoreactive neurones were significantly smaller, constituting 19.6 +/- 6.9% and 16.0 +/- 3.7%, respectively. Co-localization studies revealed five major populations representing over 75% of the myenteric neurones: ChAT/-, 30.1 +/- 6.1%; NOS/-, 24.2 +/- 4.4%; ChAT/SP/-, 8.3 +/- 3.1%; NOS/VIP/-, 7.2 +/- 6.0%; ChAT/VIP/-, 4.9 +/- 2.6. Some similarities are apparent in the neurochemical coding of myenteric neurones in the stomach and intestine of humans, and between the stomach of humans and animals, but striking differences exist. The precise functional role of the neurochemically identified classes of neurones remains to be determined.

[Tongue metastasis from esophageal adenocarcinoma. A case report]. / Métastase linguale d'un adénocarcinome de l'oesophage. A propos d'un cas.

Metastasis within the buccal cavity is a relatively uncommon finding observed in about 1% of malignant tumors in this region. Mandibular or maxillary bones are usually involved as well as soft tissues. Tongue involvement is rare. Secondary localizations arising from the esophagus are exceptional. These metastatic disseminations occur at advances stages. We report a case of tongue metastasis from an esophageal adenocarcinoma in a 73-year-old man who had undergone surgery for lower esophageal adenocarcinoma a few months earlier. The clinical presentation in this context was suggestive of a metastatic process confirmed at histology. Careful pathology examination is required to distinguish primary from secondary localizations and establish the diagnosis of metastasis.

Percutaneous ethanol injection vs. resection in patients with small single hepatocellular carcinoma: a retrospective case-control study with cost analysis.

BACKGROUND: Percutaneous ethanol injection and hepatic resection are the most widely used curative therapeutic options for patients with compensated liver disease and small hepatocellular carcinoma. AIM: To compare percutaneous ethanol injection and hepatic resection in a selected group of consecutive French patients with a single hepatocellular carcinoma, smaller than or equal to 50 mm, in terms of survival, recurrence rate of malignancy and direct costs. METHODS: The analysis of two contemporary cohorts of Child-Pugh A or B patients with a single hepatocellular carcinoma of < or = 50 mm treated by percutaneous ethanol injection (n=55) or hepatic resection (n=50). RESULTS: Long-term survival was not significantly different between the two groups when the size of hepatocellular carcinoma was less than 30 mm. However, the survival of patients with hepatocellular carcinoma larger than 30 mm was higher after hepatic resection than after percutaneous ethanol injection (P=0.044). The cumulative direct costs were significantly higher in patients treated by hepatic resection than in those treated by percutaneous ethanol injection regardless of the tumour size. The calculated costs per month of survival in patients treated with percutaneous ethanol injection and hepatic resection were 999 vs. 3865 euros, respectively (P < 0.001). CONCLUSIONS: Percutaneous ethanol injection is more cost effective than hepatic resection in patients with a single hepatocellular carcinoma smaller than 30 mm. However, in patients with a larger tumour, long-term survival is higher after hepatic resection.

[Techniques, indications and early results of splenic preservation during left pancreatectomy]. / Techniques, indications et résultats précoces de la conservation splénique dans les exérèses pancréatiques gauches.

STUDY AIM: Splenic preservation is rarely performed during left pancreatectomy. We compared retrospectively the early results of left pancreatectomy with and without splenic preservation to define the place of this procedure. PATIENTS AND METHODS: From 1979 to 1997, among 54 left pancreatectomies for another indication than adenocarcinoma, 13 were performed with and 41 without splenic preservation. The technique used for splenic preservation was prograde dissection of the left pancreas with (n = 4) and without (n = 9) preservation of both splenic artery and vein. The preoperative characteristics of the patients, peroperative data, postoperative morbidity and length of stay were compared. RESULTS: Mean operative time was longer with splenic preservation (262 +/- 67 min versus 215.6 +/- 59 min, p < 0.05), particularly in case of splenic vessels preservation (295 +/- 38 min, p < 0.02) whereas no difference was noted with splenic vessels ligation (240 +/- 76 min, p > 0.05). No mortality occurred. Prevalence of preoperative or postoperative haemorrhage, morbidity, or length of stay (intensive care unit and whole hospitalisation) did not differ with or without splenic preservation. Five patients developed pancreatic fistula without influence of splenic preservation: 1/13 (7.7%) versus 4/41 (9.7%); conversely, surgery following acute pancreatitis was associated with an higher risk of pancreatic fistula: 3/5 versus 2/49 (p < 0.005). No splenic necrosis occurred after splenic preservation. CONCLUSION: During left pancreatectomy, splenic preservation increases the operative duration (only in case of preservation of splenic vessels) but does not increase morbidity. This technique should be used whenever possible to allow long term immunological benefits of splenic preservation.

[Abnormal catheter mobility in a totally implantable venous access depending on the upright or supine position in an obese patient]. / Mobilité anormale d'un cathéter de chambre implantable selon la posture chez une patiente obèse.

The authors advise on an exceptional complication in a totally implantable venous access and give recommendations on how to avoid this problem. In an obese person, one week after the implantation of a totally implantable venous access, a chest X-ray showed that the catheter was too short. In the operative room, at the time of the second intervention, the radioscopy did not find this anomaly. The subcutaneous injection port was positioned too low. When the patient was in a supine position, the subcutaneous injection port was in the correct position but when she was in an upright position, the breast descended and pulled down the subcutaneous injection port and the catheter.

[Accessory cystic duct discovered by intraoperative cholangiography during cholecystectomy]. / Canal cystique accessoire découvert par cholangiographie peropératoire au cours d'une cholécystectomie.

The study aim was to report a rare biliary variation detected with an intraoperative cholangiography during a laparoscopic cholecystectomy. After the ligation of the cystic duct, the gallbladder was opacified via an accessory cystic duct flowing into a branch of the right hepatic duct. This accessory cystic duct was clipped and the postoperative course was uneventful.

[Complicated colonic diverticulosis. Results of surgical treatment between 1981 and 1998 in 370 patients]. / Les diverticuloses coliques compliquées. Résultats du traitement chirurgical entre 1981 et 1998 chez 370 patients.

AIM OF THE STUDY: The aim of this retrospective study was to analyze case reports of all the patients with complicated diverticular disease of the colon admitted in the same surgical center during an 18-year period and to report the postoperative results in patients operated on in emergency and in patients operated on electively. PATIENTS AND METHOD: From 1981 to 1998, 501 patients were admitted for complicated diverticular disease. There were 233 men and 268 women. Mean age was 66 years (range: 27-96). One hundred and thirty-one patients were only treated medically and 370 patients were operated on, either as an emergency (n = 211) or electively (n = 159). The complicated diverticular disease was located on the left colon in 362 cases and in the right colon in 8 cases. RESULTS: In the emergency group, 103 patients were operated on for pelvic (n = 24) and generalized purulent (n = 67) or stercoral (n = 12) peritonitis, mainly with Hartmann procedure (n = 80) with 14 postoperative deaths; 67 were operated on for pericolic abscess with 6 deaths, 19 for colonic obstruction with two deaths and 22 for profuse hemorrhage with 4 deaths. The overall postoperative mortality rate was 12.3%, and morbidity rate 38.7%. Intestinal continuity was restored in 74% and eventrations were present in 10%. In the elective group, there were two postoperative deaths in patients with a colic fistula (n = 30), no mortality and a 10.8% morbidity rate in the other patients (n = 129). CONCLUSION: This series of an 18-year duration emphasizes the severity of surgery for acute complications in diverticular disease of the colon and the advantages of elective surgery. Large progress in the management of peritonitis and pericolic abscesses has made possible the improvement of their prognosis.

Prognostic and immunohistochemical validation of the capella classification of pancreatic neuroendocrine tumours: an analysis of 82 sporadic cases.

AIMS: To study the clinical outcome of 82 cases of pancreatic neuroendocrine tumours classified according to the recent histological and prognostic classification of Capella. METHODS AND RESULTS: Eighty-two surgical cases of pancreatic neuroendocrine tumours were examined histologically with immunohistochemical staining of paraffin sections using streptavidin-biotin complex and application of antibodies against chromogranin A and 10 hormonal peptides. Classification in four groups correlated with long follow-up and outcome of these cases. Histological examination showed 30 group I, four group II, 41 group III and seven group IV tumours. Twenty-one (70%) of group I tumours were insulinomas, whereas 25% of group III tumours were glucagonomas and 25% were unclassified. Most group IV tumours were unclassified, showing no immunohistochemical staining with any of the 10 hormonal peptides tested. Outcome was clearly correlated with tumour group. Among the 14 patients who died of the disease, four had group IV and 10 group III tumours. Thus, unclassified asymptomatic tumours without immunohistochemical staining had a poorer prognosis than asymptomatic tumours with staining. CONCLUSION: This study validates the Capella classification as easy to apply and useful in predicting clinical outcome.

[Outcome in cervical recurrences of papillary or follicular thyroid cancer]. / Devenir des récidives cervicales de cancer papillaire ou vésiculaire de la thyroïde.

The aim of this study was to evaluate the treatment and outcome of patients with local recurrence (LR) of differentiated thyroid carcinoma. This retrospective study concerned patients treated between 1974 and 1990 for papillary or follicular thyroid cancer. Our patients had at least one LR. LR diagnosed within 6 months after thyroidectomy and patients with increased serum thyroglobulin levels were excluded. Thirty one patients (80% female) aged 15 to 84 years had at least one LR. LR was diagnosed 7 to 200 months after thyroidectomy (mean 63.7). There were 25 papillary and 6 follicular cancers. There were 1.5 LR per patient (range 1-6). LR were treated by radioiodine in 21 cases and by surgery in 22 cases. Among the 22 surgically treated patients, 7 had nodal recurrences, 7 had nodes and tumor, 3 had only tumor, 1 had recurrence in the remnant thyroid. After a mean follow-up of 75.8 months, 11 patients had distant metastases, 11 had died from their thyroid carcinoma (7 after metastases). Three of the 7 patients with nodal recurrence died. In one third of cases, LR announced distant metastases. Node recurrence had a poor prognosis.

Predictive factors for node involvement in papillary thyroid carcinoma. Univariate and multivariate analyses.

For patients with papillary thyroid carcinoma, lymph node involvement is a common complication, resulting in node dissection and its resulting morbidity. To determine means of limiting lymph node dissections, we attempted to define intra-operative criteria predictive of node metastasis and so identify the patients likely to benefit from this procedure. This retrospective study concerned 158 patients (118 female) treated between 1974 and 1996 for papillary thyroid carcinoma by total thyroidectomy associated with bilateral (central and lateral) (n = 119) or unilateral (n = 39) dissection. The following criteria were used to study the predictive value of node involvement: age, sex, tumour size, tumour site, uni- or multifocality, existence or not of a tumour capsule, existence or not of perithyroid involvement and presence or not of vascular invasion. 99 patients (63%) had node involvement. Four factors showed predictive value for node involvement in univariate analysis: vascular invasion (P = 0.02), male sex (P = 0.008), absence of a tumour capsule (P < 0.0001) and perithyroid involvement (P < 0.0001). Two factors were predictive in multivariate analysis: absence of a tumour capsule and perithyroid involvement. Our results enabled us to calculate the risk of node involvement for each patient as a function of the existence of a peritumoral capsule and/or perithyroid involvement and to determine the indication for dissection. When neither of these factors was present, the risk of node involvement was 38.3% and dissection was not considered essential. If both risk factors were found, the risk was 87.1% and dissection was considered necessary.

[Ischemic colitic in the elderly: predictive factors of gangrenous outcome]. / Colite ischémique du sujet âgé: facteurs prédictifs de l'évolution gangreneuse.

OBJECTIVE: To better characterize the presentation of gangrenous and non-gangrenous ischemic colitis in subjects older than 60 years, and to identify risk factors of gangrenous outcome. METHODS: Retrospective analysis of 80 cases of ischemic colitis (22 male, 58 female; mean age 76.9 +/- 8.7 years) with 64 and 16 non gangrenous and gangrenous forms, respectively. RESULTS: Hematochezia and diarrhea were significantly less prevalent in gangrenous colitis compared to the non-gangrenous group (31.2% vs 81.2%, P < 0.0001 and 6.2% vs 53.1%, P < 0.0001, respectively), whereas nausea and vomiting, and hyperleukcocytosis were significantly more frequent in the former group (50.0% vs 18.7%, P < 0.01 and 93.7% vs 62.5%, P < 0.02 respectively). Hypertension (P < 0.03), angina (P < 0.05), history of cancer (P < 0.03) and age older than 90 (P < 0.002) were risk factors for gangrenous outcome. After multivariate analysis, only two independent factors were identified, i.e.: hypertension and history of cancer. These factors predicted gangrenous course in 85% of cases. CONCLUSION: Patients older than 60 years suffering from ischemic colitis are at high risk of gangrenous course if they have hypertension or history of cancer.

Interleukin 1 and interleukin 1beta converting enzyme (caspase 1) expression in the human colonic epithelial barrier. Caspase 1 downregulation in colon cancer.

BACKGROUND: Interleukin (IL) 1beta converting enzyme (now known as caspase 1) is able to process pro-IL-1beta into its active form and is involved in proapoptotic signalling. AIMS: To characterise IL-1 and caspase 1 expression in human colonic epithelial cells. METHODS: Intracellular IL-1 content (IL-1alpha and IL-1beta) was measured by ELISA in freshly isolated human normal colonocytes. Caspase 1 expression was determined both at the mRNA level using in situ hybridisation and reverse transcription polymerase chain reaction, and at the protein level by immunoblotting experiments using antibodies specific for the proform of caspase 1 and for its cleavage forms. RESULTS: Low amounts of IL-1beta were found in nearly all preparations (92%), and IL-1alpha was detected in only 45% of human colonocyte preparations. The normal colonic epithelium strongly expressed caspase 1, both at the mRNA level and at the protein level in its latent form. In contrast, caspase 1 was not expressed in colon cancer (primary colonic adenocarcinomas and cancer cell lines). CONCLUSIONS: The demonstration that the human colonic epithelial barrier is able to express caspase 1 and its substrate IL-1beta reinforces the concept that, under certain conditions, the epithelium could trigger an inflammatory reaction. In addition, the finding that caspase 1 was downregulated in colonic adenocarcinomas supports the concept that disrupted apoptosis pathways may be involved in tumour formation and/or may confer resistance to treatment.

[Severe pancreaticoduodenal trauma: review of a series of 30 patients]. / Traumatismes fermés duodéno-pancréatiques sévères. A propos d'une série de 30 patients.

Retrospective study of a series of 30 patients (mean age: 25.5 years), including 8 children with severe duodenopancreatic trauma, treated over a period of 15 years. This series consisted of 14 cases of duodenal perforation, 3 cases of duodenal haematoma, 11 cases of isolated pancreatic lesions (including 5 isthmic ruptures) and 2 cases of associated duodenal and pancreatic lesions. Injuries were due to road accidents in 60% of cases. Eight patients were considered to have multiple injuries. Twelve patients required emergency surgery. Eighteen were observed in a surgical unit. Two duodenal haematomas were operated. Duodenal perforations were operated urgently in 8 cases and electively in 6 cases. The surgical procedure consisted of simple suture (n = 3), suture combined with diversion (n = 7), or resection-anastomosis (n = 4). Five patients with pancreatic contusion were operated, in a context of acute pancreatitis in four cases and for associated lesions in one case. Isthmic ruptures were treated by left pancreatic resection. This was a rare lesion (1.8 to 9% of organ lesions). Duodenal haematomas justify first-line medical treatment, while duodenal perforations must be operated. The presence of a lesion of the pancreatic duct frequently justifies pancreatic resection.

[Prognostic factors of survival without clinical recurrences in medullary thyroid carcinoma: apropos of 52 operated cases]. / Facteurs pronostiques de survie sans récidive clinique dans les cancers médullaires du corps thyroïde: à propos de 52 cas opérés.

The aim of this retrospective study on 52 operated medullary thyroid carcinoma (MTC) was to assess clinical and biochemical factors influencing survival without clinical recidive. There were 52% of familial cases. Mean age was 44 years (3 to 78 years) with 58% of women. The diagnostic was made prostoperatively in 38% of case (nodular specimen), when it was strongly suspected for 50% of patients before intervention (familial context, and/or preoperative Calcitonin (CT) levels, and/or mutation). The medial survival rate was 54 month (3 to 360 month). The absence of postoperative negativation of the CT (between 1 to 3 month) was meeting in 43% of case. Twenty one patients (42%) had presented one or several clinical relapse. At the end of the study, five patients were died in a postoperative time-limit of 22 to 110 month. The different parameters studed were: the sex, the age, the tumoral stage, the familial cases, the tum-oral size, the calcitonin levels normalisation in the three month postoperatively, and the local nodes extent. The 5-year survival rate was 90%, and the 10-year survival was 80%. The familial cases had a better pronostic than the sporadic (no death in the familial group versus 80% of 5-year survival rate in the sporadic cases). In univariate analysis, the good survival-factors without clinical recidive were: the stage I or II (p < 0,0001), the female sex (p = 0,02), the tumoral size under 10 mm (p < 0,02), the postoperative negativation of CT levels (p < 0, 0002), and the absence of cervical node extent (p < 0,0005). In multivariate analysis, only the postoperative negativation of CT-levels was a good survival-factor without clinical relapse (p < 0, 001).

[MR cholangiopancreatography in choledochal cysts]. / Cholangio-pancréatographie par IRM des kystes du cholédoque.

PURPOSE: To assess the value of MR cholangiopancreatography (MRCP) in the diagnosis and preoperative evaluation of choledochal cysts. MATERIAL AND METHODS: Five patients (aged between 6 days and 28 years) were investigated by MRCP, referred for ultrasonographic detection of a bile duct dilatation or a cystic structure, of antenatal diagnosis (1 case), for jaundice or abdominal pain (3 cases) or in late follow-up of a choledochal cyst surgery. Two endoscopic-ultrasonographic studies were performed. The five patients underwent surgery without preoperative biliary cholangiography. MRCP was performed using a HASTE sequence in frontal, oblique, axial planes (1,5 Tesla MR unit). RESULTS: MRCP allowed to confirm choledochal cyst, helps to specify the anatomical type (2 type I, 3 type II), detects choledocholithiasis (3 cases). Anatomic correlation was perfect. MRCP allowed to exclude gastrointestinal duplication. Anomalous junction of the pancreaticobiliary duct was found in one case. CONCLUSION: MRCP diagnoses choledochal cysts, specifies type, helps surgery and can avoid endoscopic retrograde cholangiography or endoscopic sonographic examinations especially for children. It may find an anomalous junction of the pancreaticobiliary duct.

[Surgical treatment of colonic cancer after 75 years of age. Study of a series of 240 patients]. / Traitement chirurgical des cancers coliques après 75 ans. Etude d'une série de 240 patients.

AIM OF THE STUDY: The aim of this retrospective study was to report the results of the surgical treatment for large bowel cancer in patients over 75 years of age. PATIENTS AND METHOD: From 1985 to 1996, 240 patients. 114 men and 126 women, aged 75 years or over (mean age: 82, range: 75 to 95 years) underwent surgical treatment for large bowel carcinoma. Tumors were located in the right colon (n = 120), left colon (n = 100), transverse colon (n = 5), or were multiple (n = 15). Clinical presentation was failure of general condition (25%), intestinal obstruction (20%), rectal bleeding (20%), abdominal pain (17%). ASA score was I (n = 1), II (n = 69), III (n = 134), or IV (n = 36). Emergency surgery was mandatory in 110 cases (43 urgent and 67 delayed procedures) and 130 patients underwent elective surgery. Surgical resection was performed in 221 cases, including 177 cases with curative intent (67%). Surgical procedures included right colectomy (n = 119), left colectomy (n = 59), transverse colectomy (n = 9) or subtotal colectomy (n = 31). Histopathological staging was Astler--Coller A (n = 8), B (n = 116), C (n = 54) et D (n = 62). RESULTS: The postoperative course was uneventful in 157 cases (65.4%). Medical complications occurred in 46 patients with 34 deaths; and surgical complications in 39 patients with 20 subsequent reoperations and 15 deaths. The overall postoperative mortality rate was 20.4% (n = 49). Postoperative mortality rate was higher after emergency operations (32.7% vs 10%), higher with the level of ASA grading (class II: 8.6%, Class III: 17.1%, Class IV: 38.8%), higher in patients over 90 years (37.4% vs. 19.1%) and in patients without surgical resection (42% vs 18.5%). Disease specific 5-year survival rate was 45% and did not differ when compared to patients younger than 75 years (42%, data not reported). CONCLUSIONS: Patients older than 75 years remain a high risk group, specially if operated on emergency. Nevertheless, age is not a limiting factor in the surgical treatment of colon cancer. Prognosis is mostly depending on ASA grading. Colectomy with curative intent has to be performed when possible.