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Metastase surranelienne : survie apres chirurgie d’exerese M. Kapella, D. Genet, B. Pech de Laclause, S. Durand-Fontanier, M. Lachachi, A. Fabre, D. Valleix,B. Descottes But : Determiner la survie apres chirurgie d’une metastase surrenalienne apparue au cours de l’evolution des cancers extra surrenaliens. Patients et methodes : Etude retrospective descriptive de 1995 a 2005. Etaient inclus les patients presentant une metastase surrenalienne apparue au cours d’une neoplasie primitive. Pour chaque patient etaient colliges l’âge de survenue, la neoplasie primitive, les circonstances de decouverte clinique, les examens complementaires contributifs, le type de metastase unique ou multiple, synchrone ou asynchrone de la neoplasie primitive, le delai d’apparition, la prise en charge et la survie en mois. La survie a ete estimee par la methode de Kaplan-Meier. Resultats : Seize patients ont ete inclus, 10 hommes et 6 femmes, l’âge moyen etait de 55,5 ans (25 a 74 ans). Aucun signe clinique ne revelait la metastase surrenalienne. Le scanner mettait en evidence la metastase surrenalienne dans 12 cas et dans 4 cas c’etait le TEP scan. La neoplasie initiale etait dans 6 cas un carcinome pulmonaire, dans 3 cas un carcinome renal, dans 2 cas un melanome, dans 2 cas un carcinome colorectal, dans 1 cas un carcinome œsophagien, dans 1 cas un carcinome pancreatique, dans 1 cas un lymphome B. Dans 9 cas la metastase surrenalienne etait associee a d’autres localisations metastatiques, dans 7 cas elle etait unique. Le delai d’apparition variait de 9 mois a 11 ans. Une chirurgie radicale a ete realisee dans 5 cas, une metastasectomie dans 10 cas et une biopsie seule dans un cas. La survie cumulee moyenne etait de 12 mois avec des extremes de 2 a 120 mois. Elle etait en moyenne de 8 mois lorsque la decouverte de la metastase etait synchrone au diagnostic de la lesion primitive. Conclusion : La mediane de survie apres l’apparition d’une metastase surrenalienne a ete de 12 mois. Lorsque la decouverte de la metastase etait synchrone au diagnostic de la lesion primitive la survie moyenne etait de 8 mois. La prise en charge chirurgicale depend de la neoplasie primitive et de son evolution metastatique globale.

Resume Le caecum est, en frequence, la deuxieme partie du colon concernee par le volvulus apres le sigmoide et avant l’angle gauche et le colon transverse. Cette affection survient sur des caecums anormalement mobiles. Le mecanisme du volvulus est la torsion ou la bascule. Le tableau clinique est celui d’une occlusion intestinale aigue par strangulation. La radiographie de l’abdomen sans preparation permet de poser le diagnostic dans plus de la moitie des cas. Elle montre le caecum distendu, donnant l’image en « grain de cafe » ou en « goutte de larme », associee a des niveaux hydro-aeriques de l’intestin grele, et a une absence d’air dans le colon. Le lavement aux produits hydrosolubles montre une opacification colique totale, et une absence d’opacification caecale, avec un arret du produit en « bec d’oiseau ». Le scanner montre une image pathognomonique que l’on nomme le « tourbillon » caecal. Le traitement vise a reduire le volvulus et a traiter les complications evolutives. La resection ileo-caeco-colique est la meilleure option therapeutique. Les caeco-colopexies peuvent dans de rares cas constituer une alternative therapeutique chez les sujets âges, ou sur terrain debilite et en l’absence de necrose.

The cecum is the second most common site of colonic volvulus after the sigmoid. The mechanism is torsion or hyperflexion of the enlarged, poorly-fixed, and hypermobile cecum. It presents clinically as an acute bowel obstruction with strangulation. Diagnosis can be made by plain abdominal X-ray in more than half the cases on the basis of cecal distention (with a classical "teardrop" or "comma" appearance), proximal small bowel distention with air-fluid levels, and a gasless distal colon. Barium enema shows lack of filling of the cecum, often with a "beaked" termination of the column of contrast. CT images are pathognomonic when they reveal a cecal "vortex". After surgical reduction of the torsion, ileo-cecal resection is usually the best therapeutic alternative. Cecopexy may be aDDrouriate in older and debilitated Datients if there is no concomitant cecal necrosis.

A retrospective study of 134 total gastrectomies performed between 1982 and 1992 was conducted with regular follow-up. There were 96 males and 38 women (mean age 66.66 years, range 27-82). The indication for total gastrectomy was malignant tumour (n = 115), mostly adenocarcinoma (79.1%, 91/115) with 7 cases of stump degeneration after partial gastrectomy (5.2%) and benign lesions (n = 19), mostly gastric ulcers. Gastrectomy was associated with node dissection in 53 cancer cases (47.8% 53/115) and dissection of neighbouring organs in 16 patients. Y anastomosis with circular mechanical suture was performed in 78 cases (62.9%) with pre-stapling in 30 (38.5%). Operative mortality was 8.2% (11/134). The oesophagealjejunal disunion occurred in 7/133 patients (5.3%) including two fatal cases. Early reoperation was necessary in 10.5%. Long-term follow-up for 2 to 12 years in 119 patients gave the following data. For malignant tumours: 5-year survival rate 10.1% (n = 8), recurrence an anastomosis 6.3% (n = 5), distant recurrence 28.2% (n = 21). For all patients sequellae were: reflux oesophagitis 8.1% (n = 10), stenosis of the anastomosis 7.3% (n = 9) requiring late reoperation in 2. The quality of life was considered satisfactory by 28.57% (n = 8) and good in 39.29% (n = 11). These results were compared with those reported in the literature and led to the conclusion that the general view as to the gravity of gastrectomy should be reconsidered in light of the progress in viscerostapling.

The authors report a case of bulky retroperitoneal liposarcoma (6 kg) in a 42-year-old woman. This observation of liposarcoma is interesting in that diagnosis was incidental during check up for recent hypertension. The diagnosis was suggested by ultrasonography, essentially computed tomography and suspected by multiple subcutaneous lipomas. Treatment was exclusively surgical with complete tumor resection including the left adrenal gland. The authors review literature data of retroperitoneal liposarcoma. Because of frequent recurrency, follow-up of tumor resection must be made by CT scanning every six months. An aggressive surgical approach including adjacent organs if necessary and total excision of local recurrencies can improve long-term prognosis. Postoperative adjuvant radio- and/or chemotherapy does not effect survival.

There is an important fistula rate associated with the cervical anastomosis of oesophagoplasties. The authors report their experience with reinforcement of these anastomoses by adhesion using a fibrinogen based biological tissue glue. They propose that this technique be used in all high risk anastomoses, in particular, for those affecting a non peritonealized section of the digestive tract.

Two cases of schwannoma and leiomyoma of duodenum are reported. The semiology of the benign duodenal tumors are analysed. The treatment, in all cases surgical, depends on the site of the tumor.

One thousand case reports of patients treated in eleven French surgical departments for stones in the common bile duct between 1975 and 1982 were analyzed. One in three cases were asymptomatic and detected by peroperative radiology during treatment of a simple or complicated gallstone, most forms were painful, with jaundice in 9 p. cent, an angiocholitis in 12 p. cent, and biliary pancreatitis in 2 p. cent. The most reliable exploratory procedure for gallstones is ultrasound imaging, as positive results were obtained in 90 p. cent of cases, but it enabled the diagnosis of choledocholithiasis in only one out of five patients. Intravenous cholangiography is a useful diagnostic tod for painful forms (60 p. cent). The failure of these two methods to establish the diagnosis in forms complicated by jaundice, pancreatitis, or angiocholitis has to be compared with the good results (85 p. cent) observed with endoscopic retrograde cholangiography. Treatment was surgical in 99 p. cent of patients, peroperative radiology being performed in 95 p. cent of these cases and endoscopy in 30 p. cent. In one out of two cases a single large stone was present while multiple stones were present in 8 p. cent. A "ideal" choledochotomy was carried out in 77 patients (7,7 p. cent) without mortality. External biliary drainage in 702 cases resulted in a 1.7 p. cent mortality rate, this increasing to 8 p. cent after 192 biliodigestive shunt operations, and 7 p. cent after 146 sphincterotomies, including 18 under endoscopic control. Unrecognized lithiasis, detected during follow-up radiography two weeks after external biliary drainage, accounted for 2-8 p. cent of cases. Of the 30 patients with residual stones and open biliary pathways, 6 were treated by mechanical removal, 6 by endoscopic sphincterotomy, and the others by repeat surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective multicenter study involving 12 digestive surgery centers was conducted on 497 cases of colon obstruction. The most frequent cause of colon obstruction was colo-rectal cancer (71 p. cent of cases), but many other etiologies were involved, including 61 cases of torsion and 37 patients with occlusive sigmoiditis. Differential clinical and radiological features in each etiological group are discussed, the results of therapy undertaken analyzed, and a reasonable line of conduct proposed, adapted to each situation, with the objective of attempting to reduce mortality which still affects 25 p. cent of cases operated upon.

A case of cystic dilatation of the common bile duct is reported. Initially treated by Roux-Y cystojejunostomy, twenty five years after, the patient presented a cholecystitis. This patient was treated by cholecystectomy and a few months after by excision of the cyst with Roux-Y hepato-jejunostomy. This attitude is proposed to avoid the complications of the cystic dilatation of the common bile duct: secondary biliary cirrhosis, angiocholitis, and malignant degeneration.