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All patients with gallstone ileus admitted to our institution between 1985 and 1995, were retrospectively analysed, to determine, whether a one stage procedure (removal of impacted gallstone, fistula repair and cholecystectomy) is a more valid option than enterotomy. There were 10 patients (8 women, 2 men) in the study group (age range: 63-86 ans), representing 3.7% of small bowel obstruction and 1.4% of patients who underwent biliary surgery during the same period. Bowel occlusion was present in 8 patients and a correct preoperative diagnosis was made in only 2 cases (20%). Eight patients had a one-stage procedure, with no mortality but complications occurred in 2 cases. Enterotomy was the only surgical treatment in 2 cases, with no morbidity. During follow-up period, one patient died 3 years after enterotomy from a biliary complication. We believe that a one-step procedure, is a valid option and should be undertaken to prevent future recurrence, later biliary complications and reoperations in these elderly patients, who have serious concomitant diseases.

Atheromatous aneurysmal degeneration of a venous bypass graft is a rare and late event after venous bypass grafting. We report the case of a 49-year-old man in whom a large aneurysm of a saphenous graft implanted 10 years earlier ruptured to the skin. Amputation was required. Graft degeneration can lead to complications which may be life or limb-threatening due to graft rupture, graft thrombosis or distal embolization. Close follow-up after arterial reconstruction using a vein graft is therefore highly warranted for early detection and correction of any abnormalities before onset of complications.

Objectives: We assessed preoperative diagnosis of appendicitis and perforations in elderly patients in our unit to determine whether the overall higher rate of appendectomy in France (3 to 4 times higher than in anglo-saxon countries) has an effect., Methods: We analyzed retrospectively the cases of all patients over 70 years of age who undervent appendectomy for histologically confirmed appendicitis between February 1, 1990 and 31 January 1995., Results: There were 20 patients (15 women 5 men) in the study group (age range 70-89 years). The site of abdominal pain was atypical in 10 cases (50%) and acute bowel occlusion occurred in 9 (45%). The diagnosis of appendicitis was made before surgery in 10 patients; surgery was performed within 24 hours of admission in only 8. The high rate of perforations (70%) was not correlated with age. Complications occurred in 70% of the cases and were related to perforation (p < 0.02) and an American Society of Anesthesia (ASA) score > 2 (p < 0.05)., Conclusion: Acute appendicitis in the elderly patient is a serious condition. The atypical nature of the clinical presentation in half of the patients often requires computed tomography or laparoscopy for diagnosis.

Objectives: Yersinia enterocolitica infection is a rare cause of intestinal intussusception, especially in adults. We report here a case in a 29-year-old man and review the literature on diagnosis and therapy., Case Report: A 29-year-old man presented with a 2-week history of diarrhea and weight loss. Ultrasonography revealed acute intestinal intussusception localized at the site of enlarged mesenteric nodes. At laparostomy, intestinal resection was not required. Histology examination of the mesenteric nodes showed follicular hyperplasia. Serology was positive for Yersinia enterocolitica. Outcome was favorable after treatment with tetracycline for 15 days., Discussion: Yersinia enterocolitica are Gram negative bacilli that grow at low temperature. Food contamination is the most frequent source of infection in man, usually in children. Clinical manifestations include gastroenteritis or pseudoappendicular syndrome. Intestinal intussusception is rare. Operative reduction by taxis is generally sufficient. Histology examination of the lymph nodes excludes lymphoma. The diagnosis is confirmed by serology. A 10 to 15-day antibiotic regimen is needed.

Pain in the right iliac fossa in a patient infected with HIV raises several questions which can mislead or delay diagnosis leading to increased morbidity and mortality. We report 3 cases selected because of the difficulties encountered in diagnosis or treatment and review the literature on the topic in an attempt to develop a management strategy for such patients.

Objective: The aim of this study was to determine the applicability and short-term results as well as the indications for laparoscopic surgery in acute occlusion of the small bowel., Methods: From May to September 1995, 9 consecutive patients (8 females, 1 male, mean age 54.4 years, range 27-82), hospitalized for acute occlusion of the small bowel were included in an evaluation of laparoscopic cure. Patients were divided into two groups according to the presence (n = 5) or absence (n = 4) of a past history of medial laparotomy., Results: Laparoscopic surgery was used in all patients with no complications. In the group with a past history of laparotomy, the procedures were more difficult and the duration of the procedure was longer (220 +/- 74 min versus 104 +/- 11) (p < 0.01). The advantages of laparoscopic surgery were decreased post-operative pain and shorter duration of ileus and hospitalization., Conclusion: Laparoscopic treatment of acute occlusion of the bowel is possible. The procedure should probably be reserved for patient without a past history of medial laparotomy. A long-term study is required to assess the risk of recurrence.

Implantable central venous catheters are routinely introduced in the subclavian or jugular veins. In some cases such as thrombosis or infection, this localization must be avoided. In these circumstances, the inferior vena cava is used. The catheter can be inserted into the inferior vena cava via the right genital vein. Surgery is performed under general or loco-regional anesthesia. The right genital vein is approached using a MacBurney incision. The retroperitoneum is entered and the right genital vein is cannulated. The catheter tip is placed at the limit between the inferior vena cava and the right atrium. The port is placed in a subcutaneous pocket in the lower part of the thorax. In cases where the right genital vein is too narrow to allow catheterization, it is easy to proceed through the same incision and puncture the inferior vena cava.

A mucocele of the appendix was complicated by appendicular volvulus. The CT-scan findings suggested the diagnosis which was confirmed at laparoscopy. This case illustrates the contribution of laparoscopy in diagnosis and treatment of mucoceles of the appendix.

Objectives: Determine whether laparoscopic surgery for painful syndromes of the right iliac fossa in young women can reduce the number of unnecessary appendectomies and shorten hospital stay., Methods: Thirty-two women (age range 15-43 years) who were admitted consecutively for "acute appendicitis" were included in a prospective study based on laparoscopic surgery for diagnosis and treatment., Results: There were 14 cases of acute appendicitis (all confirmed histologically), 16 cases involving extra-appendicular tissues (mainly salpingitis, n = 7) and 2 cases in which no cause was found. Two unnecessary appendectomies were performed and only one laparoscopy had to be converted to an open procedure. Mean post-operative hospitalization was 3.43 days. These findings demonstrate that laparoscopic surgery effectively reduces the rate of unnecessary appendectomies and probably the duration of hospitalization. Laparoscopic surgery should be more widely used for young women presenting with appendicular syndromes.

Recurrent hydatic cyst of the psoas is an exceptional disease in France but should not be missed in patients coming from endemic areas. A case report and a review of the literature on the aetiopathology, diagnosis and therapy are presented. Abdominal pelvic CT scan should give the diagnosis. Surgical treatment is indicated, with complete exeresis to avoid early relapse.

Supracoeliac occlusion of the aorta was performed in two patients with visceral and vascular lesions due to blunt abdominal trauma. In both cases, aortic occlusion was required due to peroperative hypovolaemic shock. The first case was a 30-year-old man hospitalized for blunt thoracic and abdominal trauma. Haemodynamic parameters were unstable at admission with initial blood pressure at 85/45 mmHg. Physical examination indicated a haemoperitonium which was confirmed echographically. At laparotomy, among other injuries, the right supra-hepatologic vein and two posterior veins draining the segment VII were severed. Despite suture and haemostatic procedures, hypovolaemic shock occurred with systolic pressure at 40 mmHg. In the second case, haemoperitonium was also confirmed echographically in a 28-year-old man hospitalized for blunt frontal abdominal trauma. Blood pressure was 70/45 mmHg at admission and emergency laparotomy revealed major avulsion of the left lobe of the liver and lesions to the sub-renal vena cava and the left renal vein in addition to major injury to the pancreas and the stomach. While the supra-coeliac aorta was being prepared, persistent bleeding led to shock with a systolic pressure of 45 mmHg. In both cases, the supracoeliac artery was clamped, for 30 and 35 minutes respectively, making it possible to re-establish satisfactory haemodynamic conditions and allowing favourable outcome. These observations demonstrate that per-operative occlusion of the supracoeliac aorta performed as a salvage manoeuvre in cases of hypovolaemic shock can be an effective means of re-establishing a precarious haemodynamic situation. The technique is simple and rapid and few complications have been reported.

The french board of qualification in general surgery examines requests from physicians who have neither a University French diplome of surgery, nor a similar diplome of a country of the European Community. From 1989 to 1991, 184 requests were submitted to the board, coming from military surgeons (n = 18), residents of university hospitals (n = 37) or general hospitals (n = 10) or from other physicians (n = 119). These latters originate mainly from non European foreign countries, and are naturalized as French citizens afterwards. The board gave 54 favourable recommendations (29%), ranging from 100% for military surgeons, to 8% for other physicians who had not been resident. Out of these requests, 18 were applied by physicians who were appointed as staff surgeon, usually in small public hospitals. Rather to appoint physicians without any surgical qualification to artificially provide jobs it would be cheaper for the care insurance system, and more secure for the patients, to close or transform hospitals which cannot find qualified surgeons. However, it is a difficult political challenge as, in France, mayors are systematically President of the administrative board of the public hospital.

Crohn's disease (CD) is a chronic pan-enteric inflammatory disease of unknown etiology. Although treatment of CD of small intestine is at present principally medical, in the majority of cases surgical intervention is unavoidable, essentially to treat complications such as occlusion, intra- and/or extra-abdominal abscess, certain fistulae, intraperitoneal perforation, profuse hemorrhage and neoplastic degeneration. Surgery may also be indicated during acute episodes of corticotherapy resistant CD, and as a valid alternative to only partially effective long term corticoid treatment of an active chronic disease. Experience has shown that surgery should be as conservative as possible, "stricturoplasty" being the treatment of choice for stenotic lesions. Postoperative follow-up conditions have still to be formulated because of the marked variations in manifestations of recurrence of the disease.

We report about one case of cholecystoduodenal fistula complicated by antropyloric lithiasic obstruction, which was treated surgically with gastrotomy and extraction of the calculus, in an 82-year-old woman. This case represents an anatomic variant of Bouveret's syndrome, which is classically defined as a duodenal lithiasic obstruction. On the basis of this case, the authors discuss the diagnostic and possibly therapeutic merits of digestive endoscopy and define the main clinical, anatomical and evolutive characteristics of this unfrequent complication of biliary lithiasis.

From 1984 to 1990, 60 patients underwent emergent surgery for a neoplastic obstruction of the left colon. We performed 19 colostomies without initial exeresis and 41 immediate tumoral resections. In the latter group, five subtotal colectomies (S.T.C.) were performed, including four with immediate mechanical anastomosis. Two patients had synchronous cancers and three had pre-perforating cecal lesions. Three patients had an associated general peritonitis. Three of the patients treated with STC died. These were these patients with general peritonitis, two of whom also had hepatic metastases. The data found in the literature on neoplastic obstructions of the left colon treated with STC with immediate anastomosis (227 cases are published) show an overall mortality rate of 8.4% with 24% morbidity, a complication of the anastomosis occurring in 4.5% of all cases.

The authors describe a case of mycotic aneurysm of the popliteal artery secondary to Campylobacter jejuni-derived infectious endocarditis treated by excision and in situ femoro tibial venous bypass, and take the opportunity to review 14 literature cases of infectious aneurysm of popliteal artery. This diagnosis is most frequently evoked by the development in an infectious setting of a throbbing inflammatory mass in the popliteal fossa. Management is aimed at controlling the infection and insuring proper distal vascularization. Eradication of the infection rests with the excision of the aneurysm and adequate antibiotherapy for at least 6 weeks. Distal vascularization is best provided (2 cases) by extra-anatomical bypass. However, in situ bypassing (9) is possible provided apyrexia and negative blood cultures have been obtained by preoperative antibiotherapy. The material used must be a venous autograft, whenever possible.

Rapid digestive irrigation makes it possible to remove all the blood contained in the intestine of the cirrhotic suffering from a gastrointestinal haemorrhage. With this procedure, used 62 times during 110 haemorrhages occurring in 57 patients with portal hypertension due to cirrhosis, there was statistically significant prevention (p is less than 0.001) against complications of post-haemorrhagic encephalopathy, but there was no action where neurological and psychiatric problems had already developed. The excellent tolerance of mannitol in a concentration of 100 mg/l, and in particular the absence of any untoward effects on water and electrolyte balance, made it possible to reduce fluid intake to 2000 ml in 2 hours without diminishing its effectiveness, the technique thus being simple and easy to apply.

Variations in serum enzyme levels were studied in 50 patients suffering from various types of neoplasm, 25 of whom had hepatic metastases. In the absence of any associated hepato-biliary or pancreatic disorder, gamma-glutamyl-transpeptidase would appear to be a reliable test in 96 % of cases. It represents a factor of assessment which merits a place in the prognostic study of all types of neoplasia.

Perforation of the abdominal esophagus is not exceptional, either after endoscopy of the esophagus or after surgery of hiatus hernia. The clinical symptoms are not always clear especially during surgery. Immediate diagnosis is however essential for any delay in treatment causes the mortality to rise from 15% to more than 60% for repairs carried out under septic conditions. The best surgical attitude is difficult to determine under these conditions.

Two types of pre-operative skin preparation were compared in a prospective randomized study conducted on 100 patients undergoing elective surgery: 51 patients were shaven (group I) and 49 were prepared with a depilatory agent. In all cases skin preparation was performed on the eve of the operation. Bacterial density, measured immediately before surgery by application of a contact agar preparation was 493 +/- 928 CFU in group I and 386 +/- 670 CFU in group II (NS). Bacterial density was less than 25 CFU in a significantly greater number of group II patients (P less than 0.01). On the second postoperative day, the number of scars without any sign of sepsis was significantly greater in group II patients (P less than 0.05). In addition, the depilatory agent proved bactericidal against 3 pathogenic strains (S. aureus, Pseudomonas aeruginosa and E. coli). Depilation with a chemical agent seems to be a satisfactory method of pre-operative skin preparation. It is more rapid than shaving, it can be applied to areas not easily accessible to razors, and it can often be carried out by the patient himself.

The efficacy of Noxythiolin in solution for peritoneal toilet during operation on 48 patients with acute generalized peritonitis was evaluated. The trial was prospective, with random selection of patients who were divided into two groups with identical backgrounds, initial affections, and therapies applied. No significant differences were noted in prognosis, bacteriological findings or subsequent course in the survivors in the two groups. The only favorable effect noted in the group treated with Noxythiolin was the frequency with which further operations had to be performed, but the difference was nos significant. Though the use of peritoneal antiseptics isjustified when positive bacteriological test are reported, the determining element in peritoneal toilet appears to be the volume of liquid employed, independently of its composition.

In the technique described, anastomosis is started with a GIA mechanical stapler then completed with a TA stapler followed by resection of the segment involved. We prefer this technique to other mechanical procedures (triangulation, circular anastomosis) in all colectomies which do not require lower colorectal anastomosis. It is simple, economical and solves problems of incongruence. Finally--and this is the most important point in surgery of the colon--it considerably shortens the septic operative stages.

The authors report a clinical study of 101 cases of continuous digestive suture and an experiment comparing intestinal healing after continuous and interrupted sutures. A certain discrepancy exists between the excellent clinical results and the pathological and microscopic findings with continuous sutures, and in particular the presence of pseudo-diverticular pouches in 20% of cases developing at the expense of a mucosal evagination within the suture. If carefully performed, continuous suture seems excellent, preventing by its watertightness, the onset of early fistula.

This is a rare condition, often presenting late as a result of compression of adjacent organs, as demonstrated by radiological examinations. Laparoscopy reveals only hepatic hypertrophy whilst the intrahepatic lesion is seen on isotope scan, its irregular appearance sometimes leading to confusion with metastatic disease. Study by scanner confirms its cystic nature. This dysembryoplasic nature of this lesion is now generally accepted, its origins lying in the vestiges of the hepatic ducts. Resection of the overling dome is the usual treatment of exteriorised biliary cysts. The evacuation of large central cysts may be associated with haemorrhagic complications as a result of decompression, which explains the need for slow evacuation or even the preference sometimes expressed for excision at the outset, in particular in the case of a left-sided lesion.