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

Multivisceral and orthotopic liver/small bowel transplantations have been performed to treat patients with intestinal failure associated with liver failure induced by parenteral nutrition. The aim of this experimental study was to determine the experimental liver-small bowel harvesting and transplantation technique that achieves the best compromise between liver and intestine ischemia times in pigs. Initial portal revascularization of the liver which reduces the hepatic warm ischemia time after cold ischemia preparation of the graft immersed in lactated ringer's solution at 4 degrees C, reduce the risk of primary non function of the graft.

Aneurysms of splanchnic arteries represent an uncommon but important vascular disease, which many times presents itself as clinical emergency and often results in death. 11 patients with splanchnic aneurysms were treated in our Department during the last 15 years. These aneurysms were located in 5 cases in splenic artery, 4 cases in hepatic artery, 1 case in celiac axis and 1 case in right gastroepiploic artery. Surgical treatment of these aneurysms was successful in all but one patient (he died from rupture of a hepatic artery aneurysm). Giving an overall mortality similar to that reported in the literature. The treatment of these aneurysms is discussed, while literature about this uncommon disease is reviewed.

Among the mandibular tumours, the secondary malignant tumours are uncommon. We relate 7 cases observed between 1977 and 1995. Two cases have revealed the original cancer (rectum, prostate). The five other cases were discovered during the evolution of the original cancer (colon, lung, kidney, thyroid, breast). These 7 mandibular metastases were isolated. The treatment included a mandibular resection in 6 cases. In one of these cases, the reconstruction was performed with a free vascularized fibular transplant with success. Among the seven cases, two patients are alive, at the present time, with a mean follow-up of 3 years. This justifies a curative treatment.

Posterior fundoplasty, is an antireflux procedure we introduced in 1966 after experimental laboratory trials and published in 1969. To data, we have operated more than 2,000 cas. Although we now also use laparoscopic procedures, the present study reports our experience with 1499 patients who underwent the conventional procedure and who have been followed for 4 to 30 years. Mortality has been nil and mean failure rate was 9.6%. One important feature of this technique is the low incidence of undesirable effects: 3.66% dysphagia (none required dilatation), 3.94% impossibility to vomit, and 4.94% difficulties in belching. This study establishes comparisons between this group of 1499 patients and another group of 68 patients who underwent the original Nissen procedure performed under laparoscopy by the same surgeon and followed for a similar period. Such a larger personal series followed for 30 years is rare in the medical literature.

Progressive technological developments have permitted clinical use of the wearable Baxter-Novacor left ventricular assist system. The system allows total bypass of the left ventricular function, and recovery of and adequate circulation in patients in cardiogenic shock. Since the first clinical use, in March 1993, eight patients about to die have been supported with a cardiac transplantation. This experience suggests that an an acceptable answer to the problem of organ shortage is now available.

Over the last decade, we have seen considerable progress both in medical treatment of acute and chronic heart failure and in circulatory assist systems, including the first used aorta counter-pulse system. More sophisticated systems have been developed with specific indications recognized by specialized teams. However, in the treatment of chronic heart failure, whether caused by idiopathic dilated cardiomyopathies or ischemic heart disease (frequently improved with coronary revascularization), the nature of the disease in patients hospitalized in intensive care units has greatly changed. There is a net tendency towards hospitalizing older patients who may no longer be reasonable candidates for transplantation. The option of circulatory assist is thus undoubtedly reasonable for these patients due to the lack of a sufficient number of donor organs.

The great vessels have long been considered as the limiting point for exeresis of abdominal tumors. We report eleven retroperitoneal tumors which led to more or less extensive vascular involvement. There were two benign tumors (neurofibroma, angiolymphoid tumor), 6 primary malignant tumors (liposarcoma, schwannosarcoma, corticoadrenal carcinoma, leiomyosarcoma of the inferior vena cava, leiomyosarcoma of the aorta, hemangiopericytoma) and 3 secondary malignant tumors (melanosarcoma, papillary cystadenocarcinoma, malignant germ cell tumor). Vascular surgery included mobilisation of the aorta or vena cava or total replacement with a prosthesis. There were no major complications and organ resection was limited to that required by tumor invasion. Despite a macroscopically satisfactory resection slice in all cases, local recurrence of malignant tumors was the rule leading to short term mortality (mean survival 30 months for primary sarcomas and 35 days for secondary forms). The therapeutic decision after careful CT and MRI word-up requires a discussion between the radiology, surgery and oncology teams. When the great vessels are involved, advice from a vascular surgeon should be acquired.

Axillary lymphadenectomy is part of breast cancer treatment. It has two aims: prognosis and treatment. The high morbidity rate of conventional lymphadenectomy is unacceptable in conservative treatment of small tumors. Therefore we developed a new technique combining liposuction and endoscopic picking. So we are able to perform a conservative axillary lymphadenectomy with the same efficiency for prognosis and treatment with a near to zero morbidity. We report here our experience of 72 cases in endoscopic lymphadenectomy.