Herniation through the foramen of Winslow. Report of two cases

PURPOSE

Two clinical cases of internal herniation through the foramen of Winslow are presented. The first case concerns herniation of the cecum and ascending colon. In the second patient, the ileum was herniated through the foramen epiploicum.

METHODS

Preoperative assessment of clinical and radiologic findings suggested diagnosis.

RESULTS

Final diagnosis was only made at laparotomy. Reduction of hernia could be performed by pulse traction, and no signs of intestinal necrosis were seen.

CONCLUSION

Herniation through the foramen of Winslow should be taken into account when making a differential diagnosis for upper gastrointestinal tract obstruction.

Life-threatening hemorrhagic diathesis due to disseminated intravascular coagulation during elective brain tumor surgery

Disseminated intravascular coagulation (DIC) is an extremely rare complication during elective brain tumor surgery. We report the case of a life-threatening intraoperative hemorrhagic diathesis due to a fulminating DIC during the removal of a grade III parietooccipital astrocytoma in a patient with a history of three pulmonary embolisms. Intraoperatively, the patient required 13 U of blood, 9 U of fresh-frozen plasma, and 5.45 L of colloids and crystalloids (total volume infused during the procedure: 12.5 L). Bleeding persisted for 24 h and required further blood component therapy. Laboratory data support the diagnosis of DIC: decreased fibrinogen and platelet count, prolonged thrombin and prothrombin times, and the presence of fibrin monomers. With aggressive and swift treatment of the DIC, the patient survived with transient neurological worsening.

Simulation of appendicitis by tumor-like lesion of cecum

Four cases are presented in which an initial diagnosis of appendicitis was made. At laparotomy, a cecal lesion simulating a tumour was found. Pathological examination showed inflammatory granulomatous tumour against foreign body, non specific ulcer, diverticulitis and acute solitary diverticulitis. When malignancy is excluded, hemicolectomy is not necessarily the best treatment and we propose conservative management for these patients.

[Appendicular mucocele. Report of 2 cases]

We report two cases of mucocele of the appendix produced by a cystadenocarcinoma, with pseudomyxoma peritonei in one. The treatment consisted in appendectomy with partial resection of the caecum, for the first patient. It consisted in wide resection and in local chemotherapy for the second.

[Autoplasties of evisceration on total flap-skin-graft (author's transl)]

The cure of major uncomplicated evisceration can be satisfactorily obtained by the method of autoplastic total skin-flap according to Seror and Stoppa. In 69 patients it yielded a significant success rate of 80% so that its use can be largely extended especially as it is an easy and benign procedure.

[Non-parasitic solitary cysts of the liver (author's transl)]

Three cases of solitary benign livercysts are reported. The first one (250 cm3) was incidentally discovered during a cholecystectomy for lithiasis and was located in the vicinity of a hamartoma. The second one was enormous (4800 cm3), inflamed, adherent and displacing the nearby organs. The third one contained 3,600 cm3. The literature of this rather rare entity was reviewed and the symptomatology, clinical findings, laboratory results, liver scintigraphy, selective arteriography and especially the coaxial computer tomography scan which by itself just almost reveals the diagnosis, are discussed in function of our findings. The etiology of these tumors and their possible association with a hamartoma is discussed. A classification of kystic livertumors is proposed. The treatment of choice is a kystectomy and the prognosis is good.

[A major visceral anomaly from malrotation of the primitive digestive tube (author's transl)]

Report of a case of major anomaly of the primitive digestive tube. Due to gastric malrotation the stomach was located to the right, behind the right lobe of the liver and the duodenum ran upward and to the left, passing behind the major biliary tract (mirror image of the normal gastroduodenal structure). The small intestine having undergone a normal rotation, the splenic flexure did not exist, while the ileum and colon gave an image of inversed "Mesenterium commune" (absence of the transverse colon, the ascending colon to the right and all the small intestine reassembled to the left). The patient, who presented with a choledocholithiasis underwent an Oddian sphincterotomy in an unusual position.

[Assessment of the methods of drainage associated with truncular vagotomy]

The authors analyse 398 cases of truncular vagotomy by the abdominal route. They study the method of associated gastric emptying, the immediate and long-term results. They conclude that truncular vagotomy is a very satisfactory operation, that pyloroplasty is a good means of ensuring gastric emptying after vagotomy, and pyloroplasty according to Murat, or Judd-Lagrot, are the most recommended. Judd-Lagrot's operation is mainly indicated in acute cases of perforation or hemorrhage.

[Reflexions on carcinomas of the extra-hepatic bile ducts]

The authors present 12 cases of true malignant ampulloma and 23 cases of carcinoma of the biliary tract (MBT). They analyze frequency, symptomatology, pathology, radiology, treatment and results. They stress that decreasing malignancy is in the following order: cancer of the MBT, cancer of the gallbladder, and ampulloma. The latter is the least lethal with the most long-term cures. As to cancer of the MBT no cure is to be expected, but palliative surgery (resection or tumor by-pass) will bring temporary cure; consequently this should always be tried when possible despite the high operative mortality.