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Biliary cysts are frequent hepatic manifestations. They are benign, single or multiple congenital lesions, with a female predominance. In more than half the cases, they remain asymptomatic; fortuitously detected during abdominal investigations, they are observable either by imaging (ultrasonography, CT scanning, MRI), either by surgery (laparoscopy or laparotomy). However, they may evolve and induce various complications: congestive attacks, intracystic hemorrhage, ruptures, infection, compression of the surrounding intra- or extrahepatic tissues. Treatment is indicated only in case of complication or pain. Although laparoscopic resection of the dome is the most frequently used treatment for about twelve years, the recurrence rate remains high. Besides, other therapeutic means exist, such as surgery (cystectomy, hepatic resection, hepatic transplantation) or non-surgical treatments (percutaneous radiological drainage, intracystic injection of sclerotic substances). All these methods have to be carefully discussed before selection, owing to various associated advantages, disadvantages and results.

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 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.

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 : L’evaluation de la gravite potentielle de la pancreatite aigue (PA) est determinante pour l’optimisation des soins. Le but de cette etude prospective etait de comparer l’efficacite des scores de gravite generalistes dans la PA, et celle des differents scores specifiques de la PA, dans le but de simplifier la realisation d’un pronostic precoce. Patients et methodes : Quatre-vingt sept patients hospitalises dans le meme hopital pour PA ont ete inclus dans cette etude. Pour chaque malade, les scores de Ranson et de l’equipe de Glasgow ont ete calcules, ainsi que l’IGS 1, l’IGS 2 et l’Apache II. Les scores radiologiques de Hill et de Balthazar ont egalement ete calcules quand la TDM a ete realisee precocement (80 % des cas). Chacun des scores a ete correle avec la gravite, la morbidite et la mortalite, et sa valeur predictive globale evaluee par l’aire sous la courbe ROC. Resultats : Dans cette serie, la mortalite globale a ete de 8 %, le taux de PA graves de 29 %, le taux de morbidite de 40 %. Tous les scores testes etaient significativement correles a la mortalite. La valeur pronostique de ces differents scores etait globalement equivalente dans la prediction de la mortalite, les valeurs de l’aire sous la courbe ROC variant de 0,77 a 0,84. Conclusion : Cette etude prouve que l’IGS 2, comme l’IGS 1 et l’Apache 2, ont une efficacite equivalente a celle des scores de Ranson et Imrie dans la pancreatite aigue. L’utilisation de scores specifiques ne semble plus justifiee dans la pancreatite aigue.

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.

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

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.

Resume Les metastases intrathyroidiennes sont sous estimees en pratique car elles sont pour la majorite « silencieuses ». L'origine renale represente plus de 50 % des cas dans les series cliniques. Nous rapportons deux observations de localisations metastatiques thyroidiennes d'origines renales survenues, trois ans et huit ans, apres la cure du foyer primitif. La notion de neoplasie dans les antecedents doit faire evoquer le diagnostic de metastases devant tout nodule thyroidien. La cytologie par ponction a l'aiguille fine ne fait pas l'unanimite. Enfin, la survenue des metastases essentiellement sur des terrains de dystrophie thyroidienne meriterait d'effectuer des etudes plus poussees.

We describe a case of ruptured mesenteric artery branch aneurysm. Since it is characterized by nonspecific clinical manifestations, aneurysm in this uncommon location is usually diagnosed following complications. Definitive diagnosis requires Doppler ultrasound followed by arteriography. The purpose of this report is to describe the pitfalls of diagnosis and define an appropriate management strategy. Unlike abdominal aortic aneurysm, isolated aneurysms of the superior mesenteric artery (SMA) branches are rare. Most cases are diagnosed after the occurrence of complications. Early diagnosis would be useful, since the natural course can be tragic without timely treatment. In this report, we describe one case of ruptured mesenteric artery branch aneurysm and review the literature for relevant data on the circumstances of discovery, methods of investigation, and appropriate management of these lesions.

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.

We report the case of a patient who underwent splenectomy for spontaneous rupture of the spleen due to splenic metastasis. Pathologic examination revealed diffuse infiltration by carcinoma. Chest X-ray revealed a right lung superior lobe tumor, related to poorly differentiated carcinoma. Total splenectomy is a good option for diagnosis and treatment of splenic metastases.

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.

We herein report a case of axillary localization of supernumerary breast. It is a matter of axillary bilateral masses mistaken as lipoma at clinical examination and ultrasonography. We here explain this confusion between lipoma and supernumerary breast. The aim of this work is to specify clinical characters of an axillary mass that must lead to suspect a supernumerary breast.

But: Elaborer une technique chirurgicale dans les peritonites par perforation diverticulaire sigmoidienne permettant, dans un second temps operatoire, un retablissement de continuite systematique et precoce par une technique associant la celioscopie et l’endoscopie. Patients et Methodes: Entre decembre 2001 et mai 2002, 5 patients ont ete admis en urgence pour peritonite sur perforation diverticulaire sigmoidienne. Le premier temps operatoire consistait a realiser une sigmoidectomie par laparotomie avec anastomose colorectale latero terminale a muqueuse fermee protegee par une colostomie en fosse iliaque gauche. Le second temps operatoire, precoce chez les 5 patients, consistait a retablir la continuite par l’action conjuguee de la celioscopie et de la coloscopie. Un controle endoscopique de l’anastomose etait realise a 1 an. Resultats: Le retablissement de continuite a ete systematique chez les 5 patients sans recours a la laparotomie. Le delai entre l’intervention initiale et le retablissement etait de 55 ± 23 jours. La duree de l’intervention de retablissement etait de 65 ± 7 min. La duree d’hospitalisation apres le retablissement etait de 6,5 ± 2 jours. Aucune complication post operatoire et aucun deces n’ont ete observes. La coloscopie a un an ne decelait aucune stenose anastomotique. Conclusion: La technique chirurgicale que nous avons developpee permet d’eviter les inconvenients de la technique de Hartmann classique (pourcentage eleve de colostomie definitive, delai de retablissement de continuite superieur a quatre mois, difficultes a dissequer le moignon rectal restant lors du retablissement de continuite) mais egalement ceux de l’anastomose colorectale protegee (necessite de conditions locales satisfaisantes, risque de fistule anastomotique ou de dehiscence post operatoire). Par ailleurs, cette technique a ses propres avantages: retablissement de continuite precoce, protection de l’anastomose vis a vis de la contamination fecale par le maintien d’une interface muqueuse, duree d’hospitalisation plus courte lors du retablissement de continuite, absence de stenose tardive de l’anastomose, controle endoscopique de la longueur du moignon colique.

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.

A 16-year-old male riding as a passenger on a personal watercraft fell behind the jet nozzle while jumping waves. An unusual rectal injury caused by the accident and resulting in the death of the patient is presented. The surgical management and postoperative course is discussed. Attention is drawn to the need for adequate protective clothes for all passengers of personal watercraft and to the necessity of a complete examination for correct diagnosis and treatment.

Background/Purpose. Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. Methods. From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 ± 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). Results. There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 ± 2.7 units. The mean operative length was 280 ± 60 min and the mean hospital stay was 12.8 ± 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. Conclusions. In our experience with major liver resections, vascular clamping is not necessary.

Damage control laparotomy is a new approach to the more severe abdominal traumas. It stems from a better understanding of the physiopathology of the haemorragic shock.A national retrospective study from 27 centers about 109 trauma patients who underwent a damage control procedure between January 1990 and December 2001, is analysed. Surgical procedures included 97 hepatic packing, 10 abdominal packing, 4 exclusive skin closure, 1 open laparotomy technique and 3 digestive stapplings.The mortality rate is 42%. Eleven abdominal compartment syndromes have occurred with 7 decompressive laparomy (4 deaths).This study is based on the largest series of damage control laparotomy published in France. Results in terms of mortality and morbidity are similar to those of published studies from the USA.

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

A role for laparoscopy in the management of selected trauma patients is now possible. We report a case of a patient with a stab wound and a bowel perforation who underwent diagnostic and laparoscopic treatment.

The thyroid metastasis are under estimated in clinical practice because they are in the vast majority of cases "silent". Over than 50% of clinically apparent metastatic lesions are due to kidney carcinomas. We report two cases of thyroid metastasis from clear-cell renal carcinoma occurred 3 years and 8 years after nephrectomies. The previous history of any type of carcinoma should suggest a possibility of metastasis for every thyroid nodules. Fine-needle aspiration cytology is recommended by some authors. Finally, clear-cell carcinoma metastases seem to have a propensity to occur in abnormal thyroid tissue and further study could be interesting.

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.

Fibrin sealant is widely used to achieve complete hemostasis in many fields of surgery. A retrospective review of the surgical management of 81 patients with thyroid diseases between 1992 and 1998 was undertaken to determine if drainage after thyroid surgery could be safely avoided and substituted by fibrin sealing before closure of the wound. Complications were few and resulted in one patient with hoarseness, four minor oedemas and one case of unexplained fever during 48 h. The subjective discomfort from the collar incision was unusual and aesthetic healing was obtained in most of the cases (93.8%). These results suggest that the application of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure and perhaps that prophylactic drainage is unnecessary.

The authors report an experimental study in the rabbit with a new composite non absorbable mesh in Polyethylene Terephtalate-Polyurethane used for incisional hernia repair in intraperitoneal positioning. This new mesh has one permeable side in polyethylene terephtalate for rapid tissue fixation and another side in polyruethane, hydrophob in order to avoid cell penetration. Eighteen rabbits were operated. A wound was created in aponeurose, muscle and peritoneal abdominal wall. The mesh was placed in intraperitoneal positioning and was taken off at 4, 9 and 13 months for histologic examination and electronic microscopical examination. Tolerance, adhesion, tissular reaction and neoperitoneum formation have been studied. All the meshes were well integrated and without sepsis. In 18% of cases small and monocclusive intraperitoneal adhesions were found. This new composite mesh in intraperitoneal positioning gave good results at medium-term in the rabbit. It's an attractive alternative for incision hernias repair with intraperitoneal mesh.

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.

Objective To evaluate the feasibility and outcome of laparoscopic hepatectomy in patients with solid liver tumors. Summary background data Although the laparoscopic approach has become popular in the surgical field, the value of laparoscopy in liver surgery is unknown. Methods Fifteen patients with solid liver tumors underwent 16 consecutive laparoscopic resections at the authors' institution between 1994 and 1999. Indications were symptomatic hemangioma, focal nodular hyperplasia, liver cell adenoma, isolated metastasis from a colon cancer, and hepatocellular carcinoma. The laparoscopic procedure was performed using four to seven ports (four 10-mm, two 5-mm, and one 12-mm). Results One patient underwent a major hepatic resection (right lobectomy); the others underwent minor hepatic resections (left lateral segmentectomies, IVb subsegmentectomies, segmentectomy, and nonanatomical excisions). The laparoscopic procedure was uneventful in 15 patients; one patient required conversion to open laparotomy because of inadequate free surgical margins. Conclusion Laparoscopic surgery of the liver is feasible. The use of this new technical approach offers many advantages but requires extensive experience in hepatobiliary surgery and laparoscopic skills. The authors' experience suggests that laparoscopic procedures should be reserved for benign tumors in selected cases. Its application must be verified by further studies.

Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission.Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve.Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death.Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.

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.

To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject.From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required.There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results.Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.

The management of blunt hepatic trauma has been modified by the development of conservative methods. Risks and pitfalls of this new approach must be determined.From January 1985 to September, 1998, 130 patients with blunt hepatic trauma were treated by the same team. Among them, 38 patients were referred from another centre (21 already having undergone operations). Eighty patients (61%) had an initial non operative management and 50 patients (39%) underwent emergency laparotomy. Perihepatic packing was performed in 24 patients, hepatic sutures in 22, limited hepatic resection in six, and major hepatectomy in two patients only.There were three deaths in the non operative management group (mortality rate: 3.5%) and 11 patients required a secondary laparotomy: four for haemorrhage, one for enteric injury, two for acute pancreatitis, one for bile leakage, one for subphrenic abscess, one for acute cholecystitis. There were 14 deaths in the emergency laparotomy group (mortality rate: 28%), including four intraoperative deaths due to haemorrhage and two due to abdominal compartment syndrome.In the nonoperative management group a close clinical survey of the patient is necessary and a secondary laparotomy often indicated. In the operative management group, early packing requires reintervention if the patient is unstable. Alternative means of temporary closure may allow coverage without tension in order to avoid the abdominal compartment syndrome.

With extended indications for renal transplantation and increasing survival, it can be expected that atherosclerotic vascular disease in the post-transplant patient will become more frequent. The authors report a case of a ruptured abdominal aortic aneurysm in a renal transplant recipient. A temporary axillo-femoral shunt was used to maintain perfusion of the renal graft during aortic cross-clamping. They review the literature and discuss the available methods for preserving renal function.

The authors report morphometric mensurations from axial features on CT scan of twenty eight cases of normal pancreas. A review of the literature corroborates the value of anatomic correlations of computerized axial tomography in the morphometric study of the pancreas.

The authors report three cases of primary adenocarcinoma, two concerning the duodenum and the third concerning the duodenojejunal junction. These rare tumours are characterized by polymorphic and non specific clinical signs. Diagnosis is suspected by upper gastrointestinal fibroscopy and barium swallow, and confirmed by biopsies. Prognosis varies according to histological differentiation and lymph node extension. Whipples operation is the sole curative procedure in the absence of local lymph node involvement. Cases of extensive invasion are managed by bilio-digestive by-pass.

We report the case of a patient who underwent splenectomy for spontaneous rupture of the spleen due to splenic metastasis. Pathologic examination revealed diffuse infiltration by carcinoma. Chest X-ray revealed a right lung superior lobe tumor, related to poorly differentiated carcinoma. Total splenectomy is a good option for diagnosis and treatment of splenic metastases.

Resume Les auteurs rapportent ici un cas de localisation axillaire de seins surnumeraires. Il s’agit de masses axillaires bilaterales diagnostiquees comme des lipomes a l’examen clinique et a l’echographie. Ce travail explique la possible confusion entre seins surnumeraires et lipomes. L’objectif en est de preciser les caracteres cliniques et echographiques d’une masse axillaire devant orienter vers un sein surnumeraire.

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.

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