[Single-lobe Caroli's disease. Anatomoclinical aspects. Diagnostic and therapeutic procedure. Apropos of 3 personal cases and 101 cases in the literature]. / La maladie de Caroli unilobaire. Aspects anatomocliniques. Démarche diagnostique et thérapeutique. A propos de 3 observations personnelles et de 101 observations de la littérature.

On the basis of 3 personal cases of single-lobe Caroli's disease and of 101 cases in the literature, the authors have observed that biliary-type pain was the most constant presenting symptom (85%), in association with fever (72%), while angiocholitis was observed in only 44% of all cases. The preoperative diagnosis of the disease and of the hepatic and extrahepatic lesions is aided by the noninvasive techniques of morphological exploration such as ultrasound and computed tomography, which must be proposed in first intention as they clearly demonstrate the cystic nature of the intrahepatic lesions, the associated biliary lesions [choledochal cyst (30%), lithiasis (37%)]. However, the cystobiliary communication and the definition of the type of biliary dilatation can be demonstrated only by transhepatic percutaneous cholangiography, endoscopic retrograde cholangiography, the injection of a contrast medium with biliary elimination, and quite often by intraoperative cholangiography only. The 4 types of single-lobe Caroli's disease distinguished by the authors, ie: type I: racemose biliary dilatation, type II: digitiform biliary dilatation, type III: large cystic biliary dilatation, type IV: choledochal cyst associated to the intrahepatic biliary disease, require a particular surgical treatment, which must also take account of the operative risks and of all the associated lesions (lithiasis, choledochal cyst, congenital hepatic fibrosis (5 cases), neoplastic degeneration (8 cases)]. External biliary bypass no longer has any use for treatment as it constantly fails. First-intention hepatic resection is the ideal treatment is all anatomical forms of single-lobe Caroli's disease as it treats all the hepatic lesions with no mortality. It is therefore indicated whenever the general conditions do not produce an excessive risk, when the controlateral liver is normal and when resection will not injure the bile duct of the remaining liver. If an associated choledochal cyst is present, it must be resected at the same time. Hepatic resection also is the best second surgery to propose when the other methods have failed. Hepaticojejunal anastomosis is the therapeutic solution every time hepatic resection cannot be performed.

[Idiopathic segmental infarction of the greater omentum]. / Infarcissement segmentaire idiopathique du grand épiploon.

Segmental infarction of the omentum is a rare disease, with about 150 published cases, and an unusual cause of "pseudoacute" abdomen. The preoperative diagnosis is difficult because of the rarity and lack of specificity of the syndrome, and it is established after laparotomy, with a few exceptions. The authors report on a personal case and emphasize the importance of systematic exploration in spite of the "innocence" of the organ initially involved, and they describe the few signs that are nontheless suggestive of this provocative and puzzling entity.

[Results of distraction by way of external metacarporadial fixation in fracture of the distal end of the radius. Apropos of 97 cases]. / Résultats de la distraction par fixateur externe métacarporadial dans les fractures de l'extrémité distale du radius. A propos de 97 cas.

104 fractures cases were treated over 5 years using this method, which is reserved for the most critical cases (less than one fourth the total number of fractures of the distal end of the radius); 97 of those were reviewed by an impartial observer. The technique consists in distractive reduction, maintained by a small external holding device interconnecting two pins inside the radius and two pins in the 2nd metacarpal bone. Usually, the device is removed after 45 days. Subjective results were rated "very good" in 62.8% of cases, while post-mobilization, radiological and overall findings rated likewise in 61.8%, 40.2% and 63.9% of cases, respectively. Half the patients presented secondary displacement, which although usually minimal, did necessitate in 6 cases a new reduction (using the same device). Algodystrophy occurred in 17 cases and constituted the main source of complications. It increased in frequency proportionally to the degree of distraction applied. At long term, important finger stiffness persisted only in 3 cases. Thus, the quality of results obtained makes external fixator distraction a choice therapeutic method in hard-to-manage fractures.

[Osteosynthesis of articular fractures of the heelbone using a reconstruction plate]. / Ostéosynthèse des fractures articulaires du calcanéum par plaque de reconstruction.

The authors describe in detail this technique which employs a reconstruction plate which can be moulded in all directions. The plate, fashioned in a stereotyped way extemporaneously or even during the pre-operative period, perfectly fits the lateral surface of the calcaneus, curves behind the tuberosity and descends in front to the junction of the lateral and inferior surfaces of the greater apophysis. With its screws anchored in the sustentaculum tali, it supports the previously reduced thalamic body which is itself fixed to the sustentaculum by screws, thereby avoiding further slippage. The very solid union thus obtained allows early weight bearing. This technique allows logical treatment of all types of fractures. Numerous technical details provide surgical guidelines for these technically difficult fractures. The operating protocol may thus be used by all operators. There are plans to market a pre-moulded plate which would further simplify the procedure. Currently, 55 fractures have been treated by this technique. The median interval to weight bearing was 7 days and 6 weeks to walking without crutches (45 cases). The functional results in 34 cases with sufficient follow-up (16 Months) showed 71% satisfactory results (very good, good or quite good), 21% mediocre and 8% poor results.

[Hydatid cysts of the liver appearing late (10 to 22 years) after surgical treatment of pulmonary hydatidosis. Physiopathologic problems]. / Les kystes hydatiques du foie de révélation tardive (10 à 22 ans) après traitement chirurgical d'une hydatidose pulmonaire. Problèmes physiopathologiques.

The very late observation of an hydatid cyst of the liver, after clinical or fortuitous signs (intraoperative, ultrasound, CT) is a highly underestimated possibility. From 4 cases of hydatid cysts of the liver which were removed 10 to 22 year after a pulmonary hydatidosis, any possibility of parasitic reinfestation during this time being excluded, the authors propose a physiopathological explanation to an often very long clinical latency period of the liver hydatidosis. Indeed the pulmonary location of the hydatid disease means that the hepatic filter did not properly operate or was bypassed, but it does not exclude a simultaneous intrahepatic graft. The literature study shows a 4 to 8.4% rate of concomitant liver-lung location according to the statistical data provided by thoracic and digestive surgery departments. The percentage reaches 25% when ultrasounds and abdominal computed tomography are systematically used. The rapid growth of the hydatid cyst in the lung can be explained by the low resistance of the lung parenchyma and vasculo-bronchial structure to the intracystic pressure, whereas in the liver, the hydatid cyst growing is stopped by a dense parenchyma and the hepatobiliary capsules. When fissuring or large opening in the biliary tract occurs the intracystic pressure drops, the pericyst becomes sclerotic, calcified. The combination of these different factors all the more contributes to the cyst involution since it presents a central topography.

[Peritoneal mesothelioma]. / Mésothéliome péritonéal.

On the basis of 5 personal cases with illustrations and a review of the literature, the authors emphasize the clinicopathological features of peritoneal mesotheliomas, rare primary tumors for which the histological diagnosis is often difficult. The classical evidence by contact with asbestos fibers is obtained in every second case only. The tumor is often associated with a pleural lesion. Ultrasound and CT currently aid in the diagnosis, usually in a context of extensive ascites. The prognosis is poor. For technical reasons, surgical exeresis most often remains partial in the diffuse forms. Chemotherapy is rarely effective.

[Cutaneous closure of peritonitis]. / Fermeture cutanée des péritonites.

The authors report results of prospective study about skin closure of peritonitis. Two groups are compared: Group A: continuous suture + suction drain VS Group B: simple suture at wide intervals of 4 cm. 93 patients have been included with a mean age of 53.2 +/- 23.9 and just before surgery randomized. Two groups are homogeneous. The postoperative parietal complications were respectively 12% in group A versus, 29% group B. There is a significant difference of 5% in favor of group A. Because the little size of groups, the authors conclude that closure of the skin peritonitis with "continuous suture" is not forbidden. This procedure doesn't increase morbidity.

[Supra- and intercondylar fractures of the distal humerus in adults. Apropos of 28 osteosynthesis]. / Fractures sus et inter-condyliennes de l'extrémité distale de l'humérus chez l'adulte. A propos de 28 ostéosynthèses.

The authors report their experience of the surgical fixation of supra- and intercondylar fractures over a 13 year period. Twenty eight cases were reviewed with a mean follow-up of 3 years and 85% good and very good results. Postoperative complications were related to defective fixation and inappropriate material. The 4 poor or tolerable results involved compound and comminutive fractures in the context of polytrauma or complicated by sepsis. Amongst the various plates used, A0 3.5 plates (strong and mouldable) provided satisfactory fixation with the possibility of early physical rehabilitation (between 3 and 21 days).

[Hemihepatectomy]. / Hémihépatectomie.

Controlled right hemi-hepatectomy is a major operation reserved for primary or secondary malignant tumours, a few very large benign tumour and, more rarely, rupture of the right lobe of the liver. The surgical technique of hemi-hepatectomy respects several general rules concerning positioning of the patient, the surgical incision, haemostasis of the various pedicles, biliary stasis and drainage. Six technical variants are discussed together with their advantages and disadvantages and respective indications according to the size, nature and situation of the lesion in relation to the glissonian and hepato-caval pedicles. On the basis of this very detailed basic technique, tactical modalities according to the features of the lesion are proposed: extra or intra-hepatic control of the pedicles, initial or terminal opening of the median fissure, initial or terminal mobilisation of the right hemi-liver, total vascular exclusion. Controlled left hemi-hepatectomy is a less complicated technique which can be performed according to tactical variant identical to those described for right hemi-hepatectomy, but total vascular exclusion is rarely essential.

[Ovarian metastases of digestive cancers. Diagnostic and therapeutic management]. / Métastases ovariennes des cancers digestifs. Démarches diagnostiques et thérapeutiques.

Although ovarian metastasis of digestive cancers were well known since more 80 years, the management of ovaries is still discussed. The authors reviewed 112 cases of digestive tumors in female patients operated between 1973 and 1987, excluding the peritoneal carcinomatosis, and report 7 cases of ovarian metastasis. The primary carcinoma was gastric (2 cases) colonic (2 cases) appendicular (1 case) small bowel (1 case) and biliary tract (1 case). Because the severe prognosis and the frequent revealing and isolated feature of the ovarian metastases the authors review the literature in order to propose recommendations regarding the diagnosis and treatment according to the localisation, the grading of the primary tumor particularly in non menopausal patients. When the primary tumor is a mucinous signet-ring carcinoma with spread to the serosa and a gross abnormality of an ovary is discovered the oophorectomy should be performed. In every cases an immediate histological examination is absolutely necessary. Clinical and sonographic findings are included in the operative staging and the follow up of patients operated for a digestive adenocarcinoma. Especially if the ovarian tumor is bilateral a complete digestive check-up including appendix and biliary tract is necessary.

[Obstruction of the extrahepatic bile ducts by tumor debris and/or clots in primary cancer of the liver. Diagnostic and therapeutic problems. Apropos of 9 personal cases and review of the literature]. / Obstruction des voies biliaires extra-hépatiques par débris tumoraux et/ou caillots dans les cancers primitifs du foie. Problémes diagnostiques et thérapeutiques. A propos de neuf observations personnelles et revue de la littérature.

The onset of jaundice in patients with primary liver cancer is sometimes caused by intra ductal biliary system tumor casts, free floating debris or hemobilia. The diagnosis of this complication is now possible by E.R.C.P. or P.T.C. We report 9 cases of unrecognized primary liver tumor revealed by intra biliary system migration of tumor casts or free floating debris. In three patients the diagnosis was operative, but for the last six cases the E.R.C.P. data in addition with U.S., C.A.T. Scan and/or hepatic angiography were helpful in determining the nature of the hepatic and biliary changes, the operability (size, location, extent). A curative surgery was not indicated in our 8 operated patients: liver resection and biliary decompression. With the palliative procedures, bilio enteric by pass (2 cases) T tube (1 case) trans hepatic uni or bilateral tubes. The survey was not longer than 11 months. Three patients died in post operative course. Only 56 patients among 117 observations of the literature have been operated: 10 liver resections including the main hepatic junction in two cases were performed with one hospital death, two patients were alive over 2 years with recurrence and three patients were disease free with a follow up less than one year. The operative mortality with palliative procedures was 34.4%; the one-two years survival was 23%; the two longest survivors lived 41 and 61 months.

[Construction of a plaster collar]. / Réalisation de la minerve plâtrée.

A fairly simple but strictly controlled method is described for constructing a plaster collar. After a brief description of the apparatus, meticulous details are given of each technical step leading to the production of a light, perfectly molded and well tolerated apparatus. The collar is usually constructed with the patient sitting, under slight traction and with webbing straps to obtain immobilization in the exact position required. The shoulders are lowered to a maximum by making the patient hold weights. The cephalic part is first molded and then integrated solidly into the thoracic part (breastplate and backplate). A perfectly constructed apparatus provides excellent immobilization.

[Surgical possibilities in the treatment of hepatic metastases]. / Les possibilités chirurgicales dans le traitement des métastases hépatiques.

314 patients with liver metastases were admitted to the Department of Surgery. University of Angers, from 1963 to 1983. The primary sites include tumors of the colon and rectum (129 patients), pancreas (74 patients), stomach (51 patients), extrahepatic bile ducts (38 patients), esophagus (7 patients), small intestine (4 patients), ovaries (4 patients), kidney (3 patients) and 4 malignant melanomas. Surgical management of liver metastases was hepatectomy (23 cases) or wedge resection (4 cases) when metastases were solitary or multiple but unilateral, selective (2 patients), total (4 patients), temporary (4 patients), desarterialization or regional intraarterial chimiotherapy (12 patients) were performed for non resectable metastases. Most of the resections (22 cases) were done for apparently solitary metastases from colorectal cancer, while a palliative treatment was utilized for some hypervascular deposits from renal, ovarian and endocrine primary tumors. The operative mortality rate was 4 per cent (2 of 49 patients): one right, and one left hepatectomies. Nine patients survived more than 2 years after liver resection, two lived more than 4 years; the longest survival (62 months) occurred after plurisegmentectomies for carcinoid metastases. The results of palliative surgery were deceptive, 14 patients died within one year, 2 patients survived 2 years, and 1 patient had a 68 months survival after liver desarterialization for carcinoid metastases. We conclude that an agressive surgical approach in the treatment of solitary or multiple resectable liver metastases is based upon several tenets. The primary tumor, when the site is the colon or the rectum preferendly must be well differentiated, Dukes B class, especially with no evidence of extrahepatic metastases.(ABSTRACT TRUNCATED AT 250 WORDS)