Biomedical subjects
Publications and source records attributed to J Leborgne.
The authors report a case of spleno-gonadal fusion in which the advantage of an angiographic study permitted, for the first time, an analysis of the vascularization of this malformation. The embryologic study explains the malformations associated with the continuous type of spleno-gonadal fusion.
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Intraoperative cholangiograms were studied in 250 patients. Analysis of the data obtained led to the establishment of a protocol for intraoperative cholangiography aimed at identification of anatomical anomalies and variations. Diagnosis of the latter must be achieved in order to avoid possible intraoperative complications. The common hepatic duct was formed by the junction of the right and left hepatic ducts in 52% of the cases studied. Absence of convergence of the posterior and anterior rami of the right hepatic duct was found in 30% of cases. Anatomical variations of the right sectorial duct system were seen in 12% of cases. Conversely, variations of the left sectorial duct system were rarely seen (2% of cases). Careful examination of the intraoperative cholangiograms led us to suspect certain anatomical variations in close to 1% of cases. These variations included abnormal hepatocystic duct, which if undiagnosed could lead to choleperitoneum or inadvertent ligation of the right hepatic duct. An abnormal hepatocystic duct terminating on the gall bladder was found in one patient. Study of the origin of the common bile duct allowed us to define the mode of termination of the cystic duct (on the right margin of the common hepatic duct in 80% of cases) and to identify a short choledochus in 2% of cases. Finally, variations of the duodenal termination of the common bile duct were studied and reflux into the pancreatic duct was seen in 27% of cases. However, the pathological significance of such reflux was rarely found.
The authors describe the anatomical basis of splenorenal anastomosis via the retroperitoneal approach. This technique can be used in cases where the transperitoneal approach is contraindicated.
Between 1970 and 1983, 30 children have been treated for a liver trauma. 16 were from 5 to 10 years old. 6 had solitary hepatic lesions and 24 had visceral or polytraumatic associated lesions. All but one were operated and 27 underwent an emergency laparotomy. Superficial tears and subcapsular hematoma were found in 11 cases while penetrating wounds (14), vascular injuries (3) and ruptures (2) represent 2/3 of the whole lesions. In five cases, hepatectomy was necessary. Half of the 6 deaths result of a vascular injury, the others of the associated lesions. We have a resolutely surgical behavior when collapse or polyvisceral lesions are patent, while in isolated blunt injury a single clinical and echographic follow up is justified. A CT scan is necessary when a penetrating wound is suspected completed with an angiography.
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Hemorrhage from Wirsung's canal complicated chronic pancreatitis in 4 patients. Excision (2 cephalic and 1 corporeocaudal) in 3 cases provided successful results, the 4th patient dying from intraperitoneal rupture of the false cyst responsible for the hemorrhage, during recurrence of the latter after simple ligature. A literature review indicated pancreatic disease, mainly chronic, as the cause in 76.5% of the 64 cases documented. Diagnosis is difficult from clinical findings, and is dependent mainly on results of endoscopy and particularly retrograde catheterization of the papilla, while arteriography is essential for confirmation of the diagnosis and the site of the lesion, and for assisting choice of therapy. When a chronic pancreatitis exists, the only logical attitude is selective excision, mortality being minimal (5%). Embolization could be a valid method for ensuring hemostasis temporarily to allow delayed radical surgery.
Urgent surgical operation to treat massive hemmorrhage of colorectal origin was necessary in 12 patients: --colon diverticulosis: 7 cases, --cecal angiodysplasia: 1 case, --pancreatocolic fistula: 1 case, --ischemic colitis: 2 cases, --post-radiation therapy rectitis: 1 case. Lesions exclused from discussion in this report and provoking hemorrhage were colorectal tumors, chronic inflammatsry colitis, rectosigmoid angiomatosis, and post-traumatic or iatrogenic lesions. After a definition of massive hemmorrhage based on pre-operative transfusional requirements, the exploratory procedures necessary for localization of the site of the hemorrhage or for detecting a right colon angiodysplasia are discussed. Bimesenteric arteriography represents the exploration of choice, but its usefulness is limited in patients with several risk factors and an average age of 70 years. The respective values of a barium enema and peroperative endoscopy in this particular context are also discussed. Elective surgery should be performed only when the exact site of bleeding has been determined or when an angiodysplasia is present. Particular problems arise when treating diffuse colon diverticulosis hemorrhage, and that provoked by the association of an angiodysplasia and a diverticulosis, as well as hemorrhagic lesions that may require emergency therapy in much rarer affections: ischemic colitis, pancreatocolic fistula, iliosigmoidal fistula, colorectal varices, colon and rectal ulcers, and colorectal radiolesions.
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Intraoperative autotransfusion was used in 15 patients undergoing peripheral vascular, porta-caval and liver surgery. This technique is blood saving in these indications. The most important physiopathological consequence is disseminated intravascular coagulation, whatever anticoagulation protocol is used. Low-dose heparin continuously administered is considered.
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