The anatomical situation of the duodenum and the pancreas, in human adult, deep and retroperitoneal, proceeds from its development in the posterior meso of the anterior primitive intestine. Foetal evolution of bowel is the result of unequal growth of its segments and abdominal constraqint of pressure. We have dissected 17 human foetus (7 1/2 at 33 weeks) and collected observations concerning rotation and developement of the human embryo. Anatomicals and foetal observations revealed a dorsal peritoneal fusion of duodenum and pancreas between 10 and 12 weeks. The fused peritoneal layers disappear and suodenum and pancreas comes to lie retroperitoneally. The head of the pancreas with duodenum and the tail of the pancreas have an independant evolution of fixation. Tha attachment of duodenum and head of the pancreas progress from the sagittal plan to the inferior duodenal flexure, in a triangular surface. Secondary, the superior duodenal flexure is fixed. The tail of the pancreas fuses from the sagittal plan to the left. The anatomical situatoin of the pancreas, in human adult, elucidates spreading of pancreatis necrosis in the extra-peritoneal space, retro and sub peritoneal, and in the vascular sheaths. Secondar infection of pancreatis necrosis is indeed the cause of mortality. Drainage, surgical or percutaneous, should be considered as surgical anatomy (Authors' summary).

Les perforations de l'oesophage sont rares mais de frequence croissante devant la multiplication des gestes fibroscopiques diagnostiques et therapeutiques. Nous rapportons une serie de 10 nouveaux cas toutes causes confondues. L'existence d'une population de patients inhomogene et d'etiologies differentes rend difficile toute tactique therapeutique codifiee. Cependant il nous parait necessaire d'entreprendre un geste chirurgical sans delai qui devra etre le plus simple (suture simple et drainage direct) et si possible avant qu'apparaissent des manifestations septiques. L'amelioration du pronostic passe par les progres des techniques de reanimation et en particulier de l'antibiotherapie.

Background. Cathepsin D is a widely distributed lysosomal acidic endopeptidase. It is an estrogen-regulated protein that is a prognostic factor in breast cancer. The aim of this study was to measure cathepsin D concentrations in thyroid tissues and to correlate these concentrations with clinical and pathologic parameters.Methods. Cathepsin D and thyroglobulin concentrations were measured in the cytosol of normal thyroid tissues (n = 14), benign nodules (n = 6), and thyroid carcinomas (n = 32) with an immunoradiometric assay. Statistical analysis was based on the Kruskal-Wallis and Wilcoxon tests and on the Spearman rank correlation coefficient.Results. The mean level of cathepsin D, expressed as picomoles per milligram protein minus throglobulin, was higher in the 32 carcinomas, 29.1 +/- 15.5, than in the 14 normal thyroid tissues, 8.4 +/- 2.5 (p < 0.001) or in the 6 benign nodules, 11.2 +/- 7.3 (p = 0.003). Cathepsin D concentrations correlated with tumor size; Spearman rank correlation coefficient was r(s) = 0.44 (p = 0.012). No significant difference was found regarding histologic type. Cathepsin D concentrations were inversely correlated with the thyroglobulin level in the tumor; Spearman rank correlation coefficient was r(s) = -0.60 (p < 0.001).Conclusions. Cathepsin D concentration is higher in thyroid carcinoma than in normal thyroid tissue, Increased cathepsin D concentrations correlate with thyroid tumor size but not with histologic type. Further studies should be done to confirm the potential prognostic value of cathepsin D in patients with thyroid carcinomas.

Introduction : le caractere fortuit ou non de l'association cancer thyroidien et thyroidite reste tres controverse. Methodes : etude retrospective portant sur 1063 goitres operes entre le 1.1.92 et le 31.12.94, dont 83 thyroidites histologiquement affirmees (7,8%). L'indication operatoire reposait toujours sur la presence de nodules cliniques et echographiques, froids en scintigraphie. Resultats : parmi ces 83 cas, l'association a un cancer thyroidien etait retrouvee 16 fois (19,3%). Il s'agissait de 14 femmes et 2 hommes, d'âge moyen 42 ans (extremes de 12 a 71 ans). Des signes compressifs etaient presents dans 5 cas. Le nodule etait unique 9 fois. Le cancer etait multifocal 5 fois (31%). Il s'agissait de cancers papillaires (14 cas), vesiculaire (1 cas), ou medullaire (1 cas). Discussion : si le caractere fortuit de cette association est le plus souvent evoque dans la litterature, nous retrouvons toutefois un pourcentage nettement plus eleve de cancers parmi nos thyroidites (19,3%) que parmi la population de goitres nodulaires operes (7,5%). Ce chiffre est a rapprocher de la frequence des cancers occultes dans les series autopsiques (13% pour l'equipe d'Ann Arbor), ce qui suggere la realite du caractere fortuit de l'association thyroidite-cancer. Conclusion : si l'association thyroidite-cancer est peut-etre fortuite, cette eventualite est relativement frequente et justifie l'intervention chirurgicale devant la survenue d'un ou de plusieurs nodules au sein d'une glande thyroide siege d'une thyroidite.

La maladie gelatineuse du peritoine est une accumulation de substance mucoide dans le peritoine. La tumeur initiale est le plus souvent appendiculaire ou ovarienne. La pathogenie de la maladie reste encore mal expliquee. Nous rapportons trois nouveaux cas dont deux ont une survie superieure a 15 ans. Les modes de revelation cliniques peuvent etre tantot aigus (appendicite aigue, torsion de kystes de l'ovaire), tantot progressifs. Le traitement est avant tout chirurgical avec exerese large des lesions. La place des traitements complementaires reste a evaluer.

Introduction : le caractere fortuit ou non de l'association cancer thyroidien et thyroidite reste tres controverse. Methodes : etude retrospective portant sur 1063 goitres operes entre le 1.1.92 et le 31.12.94, dont 83 thyroidites histologiquement affirmees (7,8%). L'indication operatoire reposait toujours sur la presence de nodules cliniques et echographiques, froids en scintigraphie. Resultats : parmi ces 83 cas, l'association a un cancer thyroidien etait retrouvee 16 fois (19,3%). Il s'agissait de 14 femmes et 2 hommes, d'âge moyen 42 ans (extremes de 12 a 71 ans). Des signes compressifs etaient presents dans 5 cas. Le nodule etait unique 9 fois. Le cancer etait multifocal 5 fois (31%). Il s'agissait de cancers papillaires (14 cas), vesiculaire (1 cas), ou medullaire (1 cas). Discussion : si le caractere fortuit de cette association est le plus souvent evoque dans la litterature, nous retrouvons toutefois un pourcentage nettement plus eleve de cancers parmi nos thyroidites (19,3%) que parmi la population de goitres nodulaires operes (7,5%). Ce chiffre est a rapprocher de la frequence des cancers occultes dans les series autopsiques (13% pour l'equipe d'Ann Arbor), ce qui suggere la realite du caractere fortuit de l'association thyroidite-cancer. Conclusion : si l'association thyroidite-cancer est peut-etre fortuite, cette eventualite est relativement frequente et justifie l'intervention chirurgicale devant la survenue d'un ou de plusieurs nodules au sein d'une glande thyroide siege d'une thyroidite.

Negative initial cervicotomy for primary hyperparathyroidism can be due to one of two reasons: first, one gland has not been found: it was an missing adenoma on an ectopic gland. Secondly, four normal glands were found: a missing adenoma arising in a supernumerary and ectopic gland. Successful parathyroid surgery depends the on surgeon's experience, his knowledge of parathyroid gland embryology, and his perseverance to find the pathologic gland. After an unsuccessful cervicotomy, the necessity for reoperation must be discussed. Before reexploration, diagnosis of hyperparathyroidism must be reviewed, the operative notes and pathologic report of the previous operation must be studied, and localization studies must be performed in order to define the cervical or mediastinal surgical approach.

Surgery is usually indicated in elderly patients with acute lithiasic cholecystitis although single antibiotics are often used for patients over 75 with complex medical histories and major visceral lesions. In our series of 45 patients, no new biliary pathology was seen in 26 (57.8%) after a mean follow-up of 40 months. In 15 patients, acute cholecystitis recurred and in 4 a stone found in the common bile duct. No deaths were associated with biliary pathology. While antibiotics appear to have an immediate beneficial effect, medium and long term results are mediocre. Percutaneous cholecystectomie however would be a satisfactory technique for external drainage even though mortality related to other pathologies is high.

It is important to recognize exceptional vascular events in celiosurgery because of their gravity. Most occur during pneumoperitoneal manoeuvres using a Palmer needle and rarely at the insertion of the first trocar. We performed a tomodensitometric study in 200 subjects free of abdominal pathology in order to determine the distance from the umbilicus to the aortic bifurcation, their projection over the spine and the superficial relations of the large vessels to the cutaneous umbilical cover. Generally, the projections of the umbilicus, and also the aortic bifurcation, lie over L4. The distance between the skin and the large retroperitoneal vesses is generally equal to one-third of the antero-posterior abdominal diameter. In thin subjects with a flat abdomen however, this distance may be smaller, even less than 3 cm. These findings emphasize the importance of "safety" manoeuvres during celiosurgery, especially during the learning period.