[Carotid surgery without systematic preliminary angiography. 402 patients treated by surgery between 1986 and 1992]. / Chirurgie carotidienne sans angiographie préalable systématique. 402 patients opérés entre 1986 et 1992.

Ultrasonography of the carotid bifurcation is a high performance technique for the detection of carotids stenosis. Associated with Doppler and echography, ultrasonography offers a means of precisely evaluating atheromatous stenoses of the bifurcation. The degree of narrowing can be calculated from the pulsed Doppler recordings and colour echo-Doppler measurements, reducing the subjective interpretation factor (the operator-dependent nature of the exploration is no longer related to data collection). Most severe stenoses can be diagnosed with these techniques. The question now is whether carotid angiography is still necessary to establish the indication for surgical endarterectomy. We attempted to give an answer based on our prospective series of 402 endarterectomies of the carotid bifurcation performed between 1986 and 1992 without prior routine angiography. Arteriography was performed occasionally in the pre-operative work-up but was limited to cases in which the ultrasonography was judged insufficient. We observed a mortality of 0.25% and a morbidity of 0.5%. This diagnostic approach is justified by its lower cost and reduced risk due to arteriography. In addition, unidentified arterial lesions downstream have little or no effect on indications and outcome.

[Prevention of postoperative wound dehiscence. Comparative study of polyglactin 910 mesh and total reinforced extraperitoneal sutures]. / Prévention de l'éviscération post-opératoire. Etude comparative du treillis de polyglactine 910 et de points totaux extrapéritonéaux appuyés.

Postoperative wound dehiscence is a serious complication. Various surgical procedures have been proposed to prevent it but only few studies have compared their effectiveness. The authors report a retrospective study on 292 high risk patients operated between 1980 and 1988. These patients were divided in two groups according to the methods of abdominal wall support: 226 patients (group I) with total reinforced extraperitoneal sutures and 66 (group II) with a polyglactin 910 mesh. Preoperative risk factors, surgical pathology and the incisions performed were similar in the two groups. Only two parameters were different: the number of previous operations and emergency surgery which were more frequent in group II (p less than 0.05). Fourteen patients in group I developed postoperative wound dehiscence and none in group II (p = 0.02). Nine of these patients were reoperated with a mortality of 28.5%. The frequency of the other complications was similar in the two groups. Polyglactin 910 mesh was more effective than total reinforced extraperitoneal sutures in the prevention of post operative wound dehiscence justifying its use in high risk patients.

[Stage 1 and 2 cancers of the endometrium. Value of the combination of pelvic radiotherapy and curietherapy followed by a total hysterectomy without lymph node removal]. / Les cancers de l'endomètre stade 1 et 2. Intérêt de l'association radiothérapie pelvienne, curiethérapie suivie d'une hystérectomie totale sans curage ganglionnaire.

In a retrospective study of 108 patients with stage I-II EC, treated between 1976 and 1983 at CGFL (Dijon), we performed an analysis of the efficacy and tolerance of a treatment approach consisting of external and intracavitary pelvic irradiation followed, 6 weeks later, by hysterectomy without lymph node dissection. Forty-three patients underwent this treatment sequence (G1) and 65 patients (G2) were treated by other modalities (33 intracavitary irradiation and hysterectomy, 27 hysterectomy alone or followed by pelvic irradiation, 5 irradiation alone). The mean follow-up was seven years (5-12). The five year total actuarial survival rate was 82% for G1 and 74% for G2 (p = NS). The five-year disease-free survival probability was 80% for G1 and 67% for G2 (p less than 0.05). The post-therapy complications were 2% for G1 (one late post-irradiation complication) and 14% for G2 (one late post-irradiation complication and 6 post-surgical complications). Although G1 group has more pejorative clinical and histopathological features (72% T1b or T2 for G1 vs 42% for G2 (p less than 0.005) and 77% grade 2 or 3 for G1 vs 61% for G2 (p = 0.05], the efficacy and tolerance of EIH treatment sequence appear at least comparable to those of G2. These results redefine certain therapeutic aspects of stage I-II endometrial carcinoma which should be considered in future prospective approaches.

[The association of uterine lipoma and cancer of the endometrium. Diagnostic and etiopathogenic approach]. / Association lipome utérin et cancer de l'endomètre. Approche diagnostique et étiopathogénique.

Uterine lipoma (UL) is a rare tumor frequently presenting as leiomyolipoma. Even more uncommon is the association of UL and endometrial carcinoma (EC) for which only two cases have been reported. We present the case of a 73 years old female of French origin complaining of vaginal bleeding. Initial examination under general anesthesia found a 13 cm length uterine cavity with a large tumor located in the anterior wall. After curettage, the histopathologic analysis diagnosed a moderately differentiated adenocarcinoma of the endometrium. Patient work-up showed no evidence of extension outside the uterus (stage Ib). Treatment consisted of pelvic and iliac lymph node external irradiation with subsequent vaginal intracavitary irradiation followed, 6 weeks later, by total extra-fascial hysterectomy without lymph node dissection. Pathologic examination found a small EC with limited infiltration of the myometrium (stage Ia) associated with a 10 x 9 x 7 cm yellowish fibrolipoma type tumor without smooth muscle pattern. First described by Lobstein in 1816, UL are uncommon and casually diagnosed. The association with EC is rare and without evident relationship. Ultrasound (US) and computed tomographic (CT) appearances allow a diagnostic approach. US show a highly echogenic central tumor with a thin moderately echoic rim. CT appearance of UL is a central, well delimited fat-density tumor. The etiopathogenesis of UL is unclear, attributed to a possible leiomyoma evolution for Willen or a myometrial cell metaplasia for Brandfass.