The posterior approach to the low and mid-rectum is a good and anatomical way to treat high fistulas' problems, perirectal tumors and villous adenoma. It is also possible to treat by this method some rectal adenocarcinomas in special situations and in high-risk patients. A good evaluation of the disease if possible by rectal endosonography, has to be done. Coccygectomy is necessary but the transsphincteric route is not mandatory and has never been used here. 9 cases are reported with relatively good results.
After surgical correction, hiatus hernia recurs in 5--15%. Papers dealing with these recurrences are rare. Among 140 hiatus hernias operated in our service, quite a few had some residual symptoms such as intermittent dysphagia, epigastric pain and flatulence. Three of them had to be reoperated on for a recurrence. In this paper 20 patients operated for recurrent hiatus hernia are reviewed. Some factors predispose to recurrence: inadequate initial operation, stage 3--4 oesophagitis, kyphosis, very broad hiatal orifice at initial operation. When the cases reoperated upon are reviewed some of them are not improved. Most of these patients have psychosomatic problems or are under psychiatric treatment. This is why a patient coming for a recurrent hiatus hernia should be investigated thoroughly. Psychosomatic cases are as bad an indication for a second operation as they probably were for the first one. When reoperation has been decided, several procedures can be used. The choice depends on what was done at the first operation, on the radiological, endoscopic and peroperative findings. In the majority of the cases, an abdominal approach can be used, but occasionally a thoracic or thoraco-abdominal route is preferable. Associated vagotomy does not improve the results and adds its own morbidity.
Traumatic lesions of the pancreas are rare (3-12% of abdominal trauma). In Central Europe most of them are due to blunt trauma. We reviewed the series from four university and one central hospitals in Switzerland over a period of ten to twenty years. Among these 75 cases, 84% were consecutive to blunt trauma. All the cases with an open injury were operated on rapidly. 15 patients with blunt trauma were treated conservatively. Out of the 58 operated patients, 20 had a caudal resection, 3 a pancreatico-jejunal anastomosis and 1 a duodeno-pancreatectomy. The others were drained. Nine patients died, 5 of them as a direct consequence of the pancreatic lesions. The morbidity was high (48%). After an open abdominal trauma, or when the patient remains unstable after blunt trauma an emergency laparotomy should be undertaken. It can lead to damage control surgery as a first step when the general and local conditions are bad. When the patient is hemodynamicaly stable, a conservative approach should be considered. The best diagnostic tools are repeated CT-scan and amylasemia. A differed operation is indicated only if the general and local condition deteriorate.
This is a retrospective study of 47 near total and 30 total thyroidectomies for multinodular goiter, Graves' disease and thyroid cancer. Complications are rare: one permanent recurrent nerve palsy out of 154 nerves at risk, one definitive hypoparathyroidism. For a benign pathology, the former bilateral sub-total thyroidectomy should be replaced by a near-total thyroidectomy which leaves one unilateral thyroid remnant the size of a cherry. Using this technique, we did not observe any recurrence. Among 42 patients controlled after more than one year 1/3 have a normal thyroid function. Systematic substitution is not indicated. Thyroxine should be used only if hypothyroidism develops after the operation or if an increase of the thyroid remnant is demonstrated. Thyroid cancer should be treated by total thyroidectomy, except for noninvasive papillary cancer without node metastasis for which a total lobectomy is sufficient.
We report here the case of a 55 year old female that underwent surgery for a well differentiated squamous cell carcinoma of the esophagus (middle third). Four months after surgery, she complains of neck pain, for which she is prescribed non steroidal antiinflammatory drugs (NSAID). A CT-scan and a Barium swallow are then normal. After three weeks of treatment, the patient is admitted on emergency to the Intensive Care Unit for a resuscitation hematemesis and atrial fibrillation with a fast ventricular response. The symptoms are stabilized after the transfusion of a few packed red blood cells. A few hours later, however, a massive hematemesis recurs and the patient dies despite intense resuscitation measures. Autopsy reveals three gastric ulcers, one of which had perforated through the cardiac left ventricular wall.
