Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

SUMMARY: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

[Is laparoscopic cholecystectomy effective and reliable in acute cholecystitis? Results of a prospective study of 221 pathologically documented cases]. / La cholécystectomie coelioscopique est-elle performante et fiable en cas de cholécystite aiguë? Resultats d'une étude prospective portant sur 221 cas vérifiés histologiquement.

From December 1989 to May 1995, a prospective study of laparoscopic cholecystectomy was carried out in our department, in order to assess the reliability and safety of this method in the case of acute cholecystitis. During this period, 1453 patients underwent laparoscopic cholecystectomy. Acute cholecystitis was diagnosed in 280 patients, based on clinical history and macroscopic lesions. Only 221 cases (15%) were included in the study after positive histology was obtained (M: 86; F: 135). The mean age was 62 years (20-90). Sixty-two patients (28%) were classified as ASA III and IV. The mean interval between the first symptoms and the operation was 9.9 days (1-53). The mean operating time was 130 minutes (45-420). Conversion to an open procedure was necessary in 22 cases (10%). The operative mortality was 0.9% (2 ASA IV patients) and the overall morbidity was 13.5%. A bile duct injury occurred in 0.4% of cases (1/221). In conclusion, laparoscopic cholecystectomy for acute cholecystitis is a safe procedure, when performed by operators experienced in laparoscopic surgery.

Laparoscopy for management of nontraumatic acute abdomen.

The diagnostic and therapeutic influence of laparoscopy has been studied in 255 patients presenting with nontraumatic acute abdominal pain. Laparoscopy provided a correct diagnosis in 93% (236 of 255) of the cases, the others requiring a laparotomy. An erroneous preoperative diagnosis was corrected by laparoscopy in 50 patients (20%), which called for a change of treatment in 25 patients (10%). Seventy-three percent (186 of 255) of acute abdominal conditions were treated exclusively by laparoscopy, 23% (58 of 255) by conventional surgery, and 4% (11 of 255) by laparoscopically assisted surgery. Mortality was 2% (5 of 247) and morbidity 11% (28 of 247). We conclude that laparoscopy is a valuable tool for the general surgeon facing a patient with an acute abdomen.

[Laparoscopic cholecystectomy in the elderly patient]. / Cholécystectomie coelioscopique chez le sujet âgé.

Biliary surgery in the elderly is associated with a high morbidity and mortality rate. The aim of this prospective study is to determine the complications or benefits of laparoscopic cholecystectomy in patients over 75. From December 1989 to July 1992, 60 women and 15 men, all aged over 75, underwent laparoscopic cholecystectomy. 32 (43%) were at high surgical risk. In one half of cases, complications were present (30 cases of acute cholecystitis and 13 cases of choledocolithiasis). 10 underwent endoscopic sphincterotomy preoperatively and 4 patients with common bile duct stones were treated by laparoscopy during the same operating time. Eight conversions were necessary because of inflammatory process. The global morbidity rate was 10.6%. Local complications were: 1 wound abscess, 1 wound dehiscence, 2 biliary leaks and 2 cases of bleeding at puncture sites. The general complications concerned the respiratory tract except for one case of urinary tract infection. The mortality rate was zero. Laparoscopic cholecystectomy seems to be better tolerated than laparotomy. It allows curative treatment of gallstones, complicated or not, with a low morbidity rate.

[Value of celioscopy in non-traumatic acute abdomen]. / Intérêt de la coelioscopie dans les abdomens aigus non traumatiques.

The diagnostic and therapeutic value of laparoscopy in emergency was studied in 314 patients presenting with non-traumatic acute abdomen. Laparoscopy gave a correct and complete diagnosis of the underlying disease in 92% (290/314) of cases. An erroneous preoperative diagnosis was corrected by laparoscopy in 18% (58/314) of cases. This implied a change of the therapeutic strategy in 9% (27/314). Seventy five per cent (234/314) of patients were exclusively treated by laparoscopy, 22% (68/314) by laparotomy and 3% (11/314) by laparoscopically assisted surgery. Mortality was 2.5% (8/314) and morbidity 9% (29/314). In conclusion, laparoscopy is a valuable diagnostic tool for the surgeon in the context of acute abdomen and is an interesting therapeutic alternative in selected cases. However, it requires extensive experience in laparoscopic techniques.

[Bilateral ureteral amyloidosis manifested by anuria]. / Amyloïdose uretérale bilatérale révélée par une anurie.

Ureteral amyloidosis is an uncommon disease. It usually presents as an ureteral stenosis and resembles ureteral malignancy. The lesion consists of localized amyloidosis, containing lambda light chains, the etiology of which remains unknown. Ureteral calcifications have been suggested to be pathognomonic. When the diagnosis of ureteral amyloidosis is considered preoperatively, a renal-sparing surgery must be planned. We observed a case of bilateral ureteral amyloidosis presenting with anuria; the patient was treated with conservative surgery and colchicine. The renal function improved without recurrence and remained stable after 5 years of follow-up.

[Fatal myocardiopathy due to adriamycin in spite of a reportedly non-dangerous cumulative dose]. / A propos d'une myocardiopathie mortelle à l'adriamycine malgré une dose cumulative réputée non dangereuse.

We report a case that illustrates the risk of major, irreversible heart failure despite theoretically safe cumulative doses of adriamycin. We discuss risk factors for cardiotoxicity, predictive methods among which echocardiography is the most useful, and preventive measures. Data are still lacking concerning long term consequences on cardiac function. Until less cardiotoxic adriamycin derivatives become available, modifications in the treatment regimen can be proposed, including a tolerance test, lower doses approximating 20 mg per week instead of 60 mg every three weeks, and administration by continuous infusion through a deep catheter or a pump as cardiotoxicity seems more dependent on drug level peaks than on total dose. These measures should reduce the hazards of adriamycin, a drug that also has potent antimitotic properties.

[Anatomo-pathological diagnosis of neonatal malformations of the urinary tract. II. Excreto-urinary tract malformations]. / Diagnostic anatomo-pathologique des malformations néo-natales de l'appareil urinaire. II. Malformations des voies excréto-urinaires.

Congenital anomalies of the urinary tract are of great pathological importance and account for about 10.9 per cent of all fetal and neonatal autopsies. This paper reports 17 cases of such lesions compiled from 156 consecutive autopsies of newborn infants performed during 33 months at C.H.R. de Bordeaux. Each malformation is discussed, using embryological classification. These lesions can occur independently but usually they are associated with other organ abnormalities. Whenever, an hereditary syndrome must be seek after. In a first part, we have presented the anomalies of the kidney proper. In a second part, we shall present the anomalies of the excretory apparatus, bladder, and urethra.

[Anatomo-pathologic diagnosis of neonatal malformations of the urinary tract. 1: Malformations of the kidney parenchyma]. / Diagnostic anatomo-pathologique des malformations néo-natales de l'appareil urinaire. 1re partie: Malformations du parenchyme rénal.

Congenital anomalies of the urinary tract are of great pathological importance and account for about 10,9 per cent of all fetal and neonatal autopsies. This paper reports 17 cases of such lesions compiled from 156 consecutive autopsies of newborn infants performed during 33 months at C.H.R. de Bordeaux (France). Each malformation is discussed, using embryological classification. These lesions can occur independently but usually they are associated with other organ abnormalities. Whenever, an hereditary syndrome must be seek after. In a first part, we present the anomalies of the kidney proper. In a second part, we shall present the anomalies of the excretory apparatus, bladder and urethra.

[Primary carcinoid of the larynx]. / Carcinoïde primitif du larynx.

Primary carcinoid of the larynx is an extremely rare neoplasm. Only seven cases could be traced in the literature so far. The authors report another case in a 71 year-old male patient. Gross examination revealed a large ulcerated tumor of the right part of the supraglottic larynx. Microscopically, the tumor was composed of nests and sheets of relatively uniform cells with round nuclei. A Grimelius stain showed positively stained granules in the cytoplasm of the cells. One cervical lymph node presented little metastatic foci of the tumor cells. A review of the medical literature showed that all laryngeal carcinoid were pathologically malignant and the treatment of choice is the surgical excision.

[Upper tract urothelial tumors following bladder tumors. Report of seven cases (author's transl)]. / Tumeurs des voies excrétrices hautes survenant après tumeur de vessie. Sept observations.

Among 138 new cases of bladder tumours treated between 1974-1979, 7 patients developed an upper urinary tract urothelial tumor, 2 after prostatocystectomy, 2 after radical irradiation curing the bladder disease, and 4 after multiple trans-urethral procedures. Four patients had a nephro-ureterectomy out of the 7 cases 3 died of their tumor, 2 before any procedure, and 4 are alive, 1 with diffuse metastatic disease.

[Abrikossof tumor in the esophagus]. / Tumeur d'Abrikossof à localisation oesophagienne.

Among the benign tumours of the oesophagus, the discovery of an Abrikossof tumour is exceptional. Although modern methods of investigation now permit recognition of this tumour and suspect its benign nature, only histology permits one to determine its precise nature, either by biopsy or by frozen section. Histogenetically, the schwann cell and histiocytic theories are not completely incompatible to the extent that they are considered from the point of view of general pathology, where there is evidence in favour of the mesoectodermic origin of the granular cell myoblastomas. In all cases, surgical excision is necessary. This resection of the myoblastoma permits a permanent cure.

[Organ culture of human skin using dermis from cadavers]. / Culture organotypique de peau humaine sur derme de cadavre.

An original method for organ culture of human skin epithelial cells using as a support human skin grafts obtained from the Human tissue Band of "C.H.R. de Bordeaux" is described. Methods and results of this technic which seems to represent a forward step relative to traditional practices are exposed.