Chirurgie; memoires de l'Academie de chirurgie最新文献

The development of implantable electric assist systems for the left ventricle cannot be used in all patients. Approximately one-third of them who could benefit from circulatory support while waiting for transplantation also require a supporting system for the right ventricle. In addition, the small number of available donor organs means that only those patients with the best prognosis can be transplanted. From January 1993 to December 1995, 36 patients (33 men, 3 women) mean age 41 years (range 19-60) were treated with a total artificial heart system, CardioWest at the La Pitié Hospital in Paris and at the Laennec Hospital in Nantes, France. Heart assist lasted 1 to 138 days (mean 31 days). Indications were terminal heart failure due to dilated (n = 21) or ischemic (n = 11) cardiomyopathy and 4 high-risk indications (chronic rejection, primary failure, hereditary heart disease, polyvalve disease). Twenty-two of these patients (61.1%) were transplanted. By using strict selection criteria, the total artificial heart CardioWest was able to maintain satisfactory hemodynamic conditions until transplantation without compromising the small number of donor organs available. The total artificial heart is the best system available for total circulatory support in case of dual ventricular failure. The risk of infection is low and the rate of thrombo-embolic events is reduced when care is taken in controlling coagulation, allowing long-term support. Independently of the experience of the different teams, CardioWest is the only device currently available allowing total heart support; its use is justified in particular when other assist devices are unsuccessful.

The aim of this prospective study was to evaluate objectively the effects of a laparoscopic posterior fundoplication on the pressure and length of the lower oesophageal sphincter (LOS) and to compare these results to those of a group of patient who underwent the same technique through a laparotomy. Fourty six patients were included in the laparoscopic group and 48 in the open group. Intraoperative manometry was performed using the same material before and after the posterior fundoplication (after evacuating the pneumoperitoneum). Criteria of assessment were the increases in pressure and length of the LOS. The two groups were comparable regarding age, rate of hiatal hernia, and stage of the oesophagitis. In the laparoscopic group, the mean pressure of LOS (mmHg) increased from 10.1 +/- 3.8 to 35.2 +/- 12 after the fundoplication (that is 3.5 times) and the length of LOS (cm) increased from 3.4 +/- 0.8 to 4.8 +/- 0.8 (that is 1.4 times). In the open group the increase was for the pressure and length respectively 3.3 times and 1.5 times the initial values. Thus by performing the same procedure we obtained the same effects on the pressure and length of the LOS. The effectiveness of laparoscopic posterior fundoplication should be similar to that of the open procedure.

Encouraging results of alternative techniques used for liver transplantation in children (liver reduction) and the persistent lack of a sufficient number of cadaver donors has favored the development of living related donor liver transplantation. This program, which began after a long preparative period concerning the ethical questions involved, has included 32 children during the first 30 months. Results have been excellent. All children who underwent elective transplantations (n = 18) are still living. Among the 14 patients whose condition required hospitalization before transplantation, 86% have survived. Vascular complications and graft loss due to primary dysfunction or chronic rejection have been reduced, but 22% of the patients have biliary stenosis. In the donors, there has been no severe complication or sequelae. Use of related living donor livers has increased the number of grafts available for children on the waiting list for cadaver livers. The resulting gain in waiting time has also reduced the risk of death before transplantation. In our experience, the combination of the two transplantation programs using living donors and cadaver livers has had a positive impact on global management of children referred for liver transplantation, whatever the option chosen by the parents.

We report eight cases of cystic lesions of the adrenal glands. Benign cysts or pseudocysts are the predominant tumors of the adrenal glands. However, neither tumor size, gross aspect, presence of calcified walls, color, cyst contents nor routine laboratory tests can exclude a malignant or hormone secreting lesion. We discuss the role of therapeutics, transparietal puncture and simple radiographic surveillance in the management of patients with cystic tumors of the adrenal glands. Surgery is often indicated or recommended.

We describe a novel autoplasty method we developed for primary inguinal hernia repair and report our results in nearly 150 operations. The method is based on novel principles: priority given to an individual stato-dynamic conception of the inguinal region; effect on physiological defense mechanisms of the inguinal canal; absence of tension on the sutures by autoplastic repair.

Laparoscopic hysterectomy performed for benign uterine lesions without prolapse is becoming more and more popular. This surgical route has some of the advantages of the vaginal route and could avoid numerous abdominal hysterectomies. Our experience shows that most of abdominal or laparoscopic hysterectomies could be done using the vaginal route which is for us the reference. One question about laparoscopic hysterectomy is: can we perform this technique to avoid abdominal hysterectomy when the vaginal route looks impossible? To answer this question, we retrospectively studied 171 hysterectomies. The laparoscopic hysterectomy rate should not reasonably exceed 10 to 15%, yet is much higher for the promotors of this technique of which advantages compared with vaginal hysterectomy are not clearly demonstrated.

Unlabelled: We report 2 similar cases of severe injury of the dorsum of the hand, both treated in emergency.

First case: A 37-year-old right handed male truck driver was admitted with a complex severe injury of the dorsum of his right hand following a traffic accident. He had a combined large defect involving skin, tendons and bone. A complex reconstruction was performed using a massive iliac crest allograft, a tendon graft and a free serratus anterior flap in a one stage procedure, eight hours after the injury. A skin graft was done later. Two years later the functional and esthetic results are good.

Second case: A 37-year-old woman was admitted with a severe injury of the dorsum of her right hand following a traffic accident. She had a large combined defect involving skin, tendon and bone. A complex reconstruction was carried out using a large iliac crest autograft, a multiple tendon graft and a free latissimus dorsi flap, in one stage 6 hours after the trauma. Eight months later the functional result is partial but useful for the daily activities of the patient.

Clinical manifestations, clinical course and therapeutic schemes were studied in 37 patients with a surgical indication for biliary cysts of the liver observed in a surgery unit over 25 years. Cyst size varied from 2 to 30 cm and was greater than 10 cm in 12 cases. Yellowish-clear contents were observed in 23 cases and purulent or hemorrhagic contents in 3 each. Twenty-three patients were asymptomatic, 14 had pain and/or complications (hemorrhage 3, infection 3, compression 3, rupture 1). Therapy was abstention in 7 cases, puncture in 5, resection of the protruding dome in 17, complete exeresis in 5, and hepatectomy in 3. There were no deaths and morbidity reached 7%. Biliary cysts of the liver can be discovered fortuitously at surgery or imagery or in patients with abdominal pain, an abdominal mass or complications including compression, intraperitoneal rupture, intracystic hemorrhage, hemobilia, acute infection, torsion, cancerization. Diagnosis requires sonography and computed tomography. Therapeutic indications are: abstention for small asymptomatic cysts. For voluminous cysts, with complications or confirmed during a supramesocolic operation, the risk of recurrence or aggravation of the complications excludes puncture or injection of a sclerosing agent. Wide resection of the protruding part of the cyst with histology resection can be performed although prospective assessment is needed. Cystectomy is not indicated if there is a diagnostic doubt. Hepatectomy is an exceptional indication retained for patients with uncontrolable hemorrhage, intra-cystic tumors or voluminous cysts destroying the lobe.