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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 Nous rapportons un cas de fistule arterioportale mesenterique inferieure postchirurgicale. Les fistules arterioportales representent une pathologie rare. La semiologie est dominee par une hypertension portale et des signes cliniques lies au shunt, c'est-a-dire une ischemie d'aval. Le traitement de choix de ces fistules est l'embolisation. La chirurgie est neanmoins toujours possible par ligature ou excision de la fistule ; la vascularisation etant assuree par l'arcade de Riolan et les arteres hypogastriques a retro.

Resume But de l’etude : La chirurgie laparoscopique du foie en est encore a ses debuts. Le but de cette etude etait de rapporter une serie de tumeurs solides et kystiques du foie traitees par voie laparoscopique. Patients et methodes : Entre avril 1991 et decembre 1999, 32 patients porteurs de lesions hepatiques ont ete operes par voie cœlioscopique. Il s’agissait de 15 patients ayant des lesions kystiques non parasitaires (kystes biliaires volumineux [ n = 11], polykystoses [ n = 4]), et de 17 patients ayant 18 tumeurs solides : hyperplasie nodulaire focale ( n = 8), angiome ( n = 6), adenome ( n = 2), metastase d’un cancer colique gauche ( n = 1) et carcinome hepatocellulaire ( n = 1). Quinze fenestrations simples ou multiples et 18 exereses hepatiques ont ete realisees par laparoscopie : une hepatectomie droite, cinq lobectomies gauches, deux sous-segmentectomies IVb, une segmentectomie III et neuf tumorectomies. Resultats : Une conversion a ete necessaire (3 %) en fin d’intervention (lobectomie gauche pour carcinome hepatocellulaire) pour confirmer la marge de securite au niveau de la tranche de section. Le diametre moyen des tumeurs solides etait de 6,5 cm et celui des lesions kystiques solitaires de 15,7 cm. La duree operatoire moyenne des exereses hepatiques a ete de 232 minutes. La mortalite postoperatoire a ete nulle. La morbidite a comporte dans chaque groupe un cas d’occlusion de l’intestin grele par hernie interne au niveau d’un orifice de trocart survenue a j5 et a j7, ayant necessite dans les deux cas une resection intestinale segmentaire. La duree moyenne de sejour postoperatoire a ete de 5,6 jours dans les tumeurs solides et de 7,5 jours dans les lesions kystiques. Dans le groupe des lesions kystiques, le taux de recidive etait de 50 % apres un suivi moyen de 5,5 mois. Conclusion : La chirurgie laparoscopique du foie semble realisable en toute securite mais necessite au prealable une experience de la chirurgie hepatique classique et une parfaite maitrise de la chirurgie cœlioscopique. Seules les lesions de siege anterieur, qu’il s’agisse de tumeurs benignes symptomatiques ou atypiques, de kystes, ou de polykystoses de type I, peuvent etre traitees par l’abord laparoscopique. Pour les lesions malignes, les indications restent a preciser.

Resume But de l'etude : La rupture spontanee d'un carcinome hepatocellulaire (CHC) est un accident grave entrainant un hemoperitoine abondant mettant en jeu le pronostic vital. Le but de ce travail etait de rapporter une serie retrospective de 22 cas observes dans le meme centre. Patients et methodes : De 1978 a 1998, 22 patients (18 hommes et quatre femmes, âge moyen : 63 ans, extremes : 18–83 ans) ont ete traites pour un CHC rompu sur foie cirrhotique dans 17 cas, et sur foie sain dans cinq cas. Dans 14 cas, le diagnostic d'hemoperitoine aigu a conduit a une laparotomie en urgence. Le siege de la rupture predominait au niveau du lobe gauche (huit cas). L'operation realisee a consiste en une lobectomie gauche ( n = 7), une hepatectomie droite ( n = 2), une exerese tumorale ( n = 4), une ligature de l'artere hepatique ( n = 5), et une hemostase directe ( n = 4). Resultats : La mortalite postoperatoire globale a ete de 45,4 % ( n = 10). Sur les 12 survivants, neuf sont decedes dans un delai de 6 a 29 mois. Trois patients etaient vivants au moment de la realisation de ce travail avec un recul de 32, 40 et 66 mois. Conclusion : La rupture aigue d'un CHC impose le plus souvent une intervention en urgence avec une mortalite elevee. La resection tumorale est le procede le plus efficace mais n'est pas toujours realisable en urgence. La fissuration permet de realiser des examens complementaires et une eventuelle embolisation arterielle preoperatoire avec des resultats immediats meilleurs.

An 80-year-old woman with sigmoid diverticula was treated by corticosteroid for Horton disease. She presented abdominal pain, and abdominal mass in left iliac fossa. Radiological examinations revealed a colo-jejunal fistula. At laparotomy it was a giant diverticulum of colon sigmoid with fistula in the jejunum. The pathogeny of giant diverticulum and the role of corticosteroid are discussed.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

Resume Les auteurs rapportent une observation d’agenesie du foie droit. Cette anomalie rare a ete suspectee en postoperatoire sur des anomalies du cholangiogramme peroperatoire au decours d’une cholecystectomie et diagnostiquee par une tomodensitometrie abdominale. Cette anomalie congenitale peut etre associee a une pathologie des voies biliaires, une hypertension portale et d’autres anomalies congenitales.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

An 80-year-old woman with sigmoïd diverticula was treated by corticosteroid for Horton disease. She presented abdominal pain, and abdominal mass in left iliac fossa. Radiological examinations revealed a colo-jejunal fistula. At laparotomy it was a giant diverticulum of colon sigmoid with fistula in the jejunum. The pathogeny of giant diverticulum and the role of corticosteroid are discussed.

The authors report a case of right liver atrophy. This rare anomaly was suspected during post-operative period on abnormalities of cholangiogram. This biliary tract anomaly was diagnosed by CT scan. This congenital abnormality may be associated with biliary tract abnormalities, portal hypertension and other congenital abnormalities.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

The authors take interest in the portal aneurysm about the observation of a 52 year-old woman with an echographic lesion in the head of the pancreas. Radiological examination was done with abdominal CT and MRI. Because of no accurate diagnosis, an explorative laparotomy was done and showed an aneurysm at the junction of the portal and superior mesenteric veins. These lesions are rare: they can be acquired particularly with underlying hepatocellular diseases and portal hypertension; they can be congenital due to an incomplete obliteration of the right vitelline vein. If asymptomatic, only a close surveillance must be proposed.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.

Laparoscopic liver surgery is still in its early stages. The aim of this study was to report our experience in the laparoscopic management of solid and cystic liver tumours.From April 1991 to December 1999, 32 patients with various lesions of the liver underwent laparoscopic liver surgery. One group of patients presented with cysts (n = 15) (11 giant solitary cysts and 4 polycystic liver diseases) and one group of patients presented with solid tumours (n = 18): focal nodular hyperplasia (n = 8), haemangioma (n = 6), adenoma (n = 2), isolated metastasis from a colonic cancer (n = 1) and hepatocellular carcinoma (n = 1). Fifteen cyst fenestrations and eighteen liver resections were performed via a laparoscopic approach including 1 right lobectomy, 5 left lateral segmentectomies, 2 subsegmentectomies IVb, 1 segmentectomy III and 9 non-anatomical resections.Conversion to laparotomy was performed in one case (3%) at the end of the operation (patient who had successfully undergone left lateral segmentectomy for hepatocellular carcinoma) to check the resection margins and surgical transection had been performed in healthy parenchyma. Mean diameter of solid tumours was 6.5 cm and 15.7 cm for solitary cysts. The mean operating time for hepatic resections was 232 minutes. There was no postoperative mortality. Complications occurred in one case for each group and consisted in intestinal stricture through a port site requiring intestinal resection. Mean postoperative hospital stay was 5.6 days for solid tumours and 7.5 days for cystic lesions. In the group of cystic lesions, the recurrence rate was 50% with a 5.5-months follow-up.Laparoscopic liver surgery can be safely performed, but requires a good experience in open hepatic surgery and laparoscopic surgery. The laparoscopic approach is indicated in patients with symptomatic or atypical benign solid tumour, giant solitary cyst and polycystic liver disease, located anteriorly on the liver. Indications for malignant lesions have not been clearly defined and require further information.

A case of a 27-year-old female patient presenting with bilateral agenesis of the thyroid gland and a benign euthyroid adenoma of the isthmus and the pyramidal lobe is reported. The patient had for several years been followed for a cystic nodule that was presumed to have developed from the left thyroid lobe, having recently increased in size. Scintigraphic and echographic studies evoked the absence of right lobe. Direct examination at cervicotomy found hypoplasia of the two lobes. This report highlights the similarity of this rare anomaly to widely known hemiagenesis.

Spontaneous rupture of hepatocellular carcinoma (HCC) causing massive hemoperitoneum is a critical and life threatening complication. The study aim was to report a retrospective series of 22 cases observed in the same centre.From 1978 to 1998, 22 patients (18 males and four females, mean age: 63 years, range: 18-83) were treated for ruptured H.C.C involving a cirrhotic liver in 17 cases and a normal liver in five cases. In 14 cases, the diagnosis of acute hemoperitoneum indicated an immediate laparotomy. The site of rupture was predominant in the left lobe (eight cases). The surgical treatment was: left lobectomy (n = 7), right hepatectomy (n = 2), excision (n = 4), hepatic artery ligation (n = 5), direct hemostasis (n = 4).Postoperative mortality was 45.4%. Among the 12 survivors, nine died within a delay of 6 to 29 months. Three patients were still alive at the time of this study at 32, 40 and 66 months.Acute rupture of HCC requires emergency procedures with a high risk of mortality. Curative operation with hepatic resection is the most effective procedure but is not often feasible because of the spreading of the tumor or/and the cirrhosis. The ligation of hepatic artery seems to be an alternative procedure to obtain an immediate hemostasis. Fissuration allows performance of complementary explorations and possibly preoperative arterial embolization with better immediate results.

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.