Gallstone ileus.

Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.

[Status of resection-anastomosis in emergency left-sided colon surgery]. / Place de la résection-anastomose en chirurgie colique gauche d'urgence.

Resection and primary anastomosis (RPA) in emergency left-side colon surgery is not universally performed because of anastomotic healing difficulties of unprepared, dilated, or inflamed colons. Ninety-three patients underwent emergency surgery for left-side colon disease. Sixty-three primary anastomoses were performed with a 16% mortality rate and a 6% incidence of anastomotic leakage. These results are similar to those reported in the literature, depending upon the pathology involved, and appear to justify resection and primary anastomosis in case of hemorrhage, trauma, and left-colonic obstruction. As for diverticular perforation with localized peritonitis, RPA can be attempted in some instances, if a protective stoma is added. Finally, in case of diffuse peritonitis, the Hartmann procedure still remains the safest method.

Sclerotherapy of rectal varices.

Rectal varices represent a rare condition even in cases of portal hypertension. A case of bleeding ano-rectal varices presenting as the first manifestation of portal hypertension is reported. Treatment by sclerotherapy was successful.

[Laparostomy in children]. / Die Laparostomie im Kindesalter.

Laparotomy means leaving the abdomen open after a laparotomy. This enables the surgeon to revise the abdominal cavity regularly and to check the efficacy of the drainage without repeated damages to the abdominal wall. In adults, this method is used in cases of abdominal pathology with necrotic or infectious pathogenesis. We describe the method of laparotomy in 3 cases of paediatric surgery. It was used in cases of postoperative peritonitis and we think that laparotomy may be used in these situations, especially because there are almost no sequelae.

Frequency of testicular atrophy following incarcerated hernia.

From 1977 to 1981, 40 infants and children were operated for incarcerated inguinal hernia, 35 boys and 5 girls. During this time, 903 hernias were cured. Follow-up examination has been possible with 32 boys, from 6 months to 5 years after surgery. Three have an irreversible lesion of the testis (2 atrophies, 1 orchiectomy), 4 a decrease of testicular volume, 1 has a bilateral retentio testis, 1 has a cryptorchidism on the non-operated contralateral side and 23 are normal. Risk factors of testicular lesions were studied with regard to age, duration of symptoms, reducIbility of hernia and to other clinical findings, and the follow-ups are evaluated with regard to macroscopic operative appearance of testicles. The group of infants less than 1 month of age with symptoms for more than 24 hours and with ileus is the highest risk group for testicular infarction at the time of incarceration of hernia.