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

The easy performance and the efficiency of these repairs should make the surgeon attentive to some related drawbacks, which can scarcely appear when reoperating on the bladder or the prostate, also on the iliac vessels. The encountered difficulties are related to the scar sclerosis much or less extensive and/or effective, invading the Retzius and/or the Bogros' spaces. The authors report their intraoperative and anatomical findings. They propose the following solutions: (1) when the cleavage of the Retzius' space is impossible (for bladder or prostate surgery): a subperiosteal retropubic cleavage, either isolated or combined with a transperitoneal approach. (2) When the cleavage of the Bogros' space is impossible (for a surgery on the iliac vessels): a transperitoneal approach; but the prevention of the perivascular sclerosis after the use of large prostheses relies on the easy preservation of the funicular sheath, able to protect the iliac vessels, providing no slit has been done on the mesh prosthesis.

We present a series of 125 cases of centromedullary fixation with a flexible locked nail of unstable cortical bone fractures of the tibia in which we studied healing conditions in order to identify parameters which would predict the rate of consolidation. One hundred ten fractures followed more than 6 months were included in the statistical analysis. For 94 fractures, primary consolidation was achieved in a mean 11 weeks. Fractures situated in the lower portion of the tibia healed the fastest (10 weeks). However, opening the fracture site and comminutive fractures did not affect the rate of healing except for proximal fractures and for fractures with a gap exceeding 10 cm. These two parameters, width of the bone gap (whether trauma induced or iatrogenic) and proximal localization of the fracture were the cause of the cases with long periods of non-consolidation (14.5%). The speed of peripheral osteogenesis is considered to be accelerated with the flexible nail as seen in our 94 cases where no conversion was necessary. This method provides a mean 1 month gain over consolidation times compared with locked nailing where the distal locking probably increases the rigidity of the system.

Background: In an earlier study, we demonstrated that benign prostatic hyperplasia (BPH) was associated with significantly higher urine levels of prostate-specific antigen (PSA) than in prostate cancer (PC). These early results led to the present study: we assessed, in patients undergoing a prostate biopsy, the clinical value of the PSA serum/urine ratio (PSA S/U) in patients for the differential diagnosis of PC, particularly when the pre-biopsy serum level of PSA lies between 4.0 and 10.0 ng/ml.

Methods: All patients without an indwelling drain who underwent transrectal echoguided biopsy were prospectively included in this study from November 1994 to December 1995. All serum and urine PSA measurements were done by the same laboratory using a Tandem R kit (Hybritech). Blood and urine samples were obtained during the 24 hour period prior to surgery during which all urethral or rectal manipulation was avoided.

Results: We studied 130 patients with BPH (n = 73) or PC (n = 57). The PSA serum levels and the PSA S/U were significantly different between the BPH and the PC groups. In the subgroup of 50 patients with a serum PSA level in the 4-10 ng/ml range, the difference between the BPH and PC patients was not significantly different except for the PSA S/U ratio. Receiver operating characteristic (ROC) curves showed that the diagnostic power of PSA S/U was greater than serum PSA.

Conclusion: These results suggest that the PSA S/U ratio could be useful to distinguish between BPH and PC, particularly when diagnosis is uncertain in patients whose serum PSA is in the 4.0-10.0 ng/ml range.

A qualitative study of risk was performed on 4 forensic files and on accidents published in the literature (1,609 cases). The surgeon may be charged with the responsibility of specific complications involving the oeso-cardial-tuberosity junction including perforation of the esophagus (13 cases), perforation of the stomach (8 cases) and necrosis of the Nissen valve by ischemia after section of the short vessels of the lesser curvature (2 cases). Sudden migration into the mediastinum or the left pleural space may occur after laparoscopic surgery (23 cases). As for all surgery, it is the surgeon's responsibility to provide adequate means for the indicated procedure and to perform the operation and follow-up. Since this is a new technique, the severity of judgements increases with the notion of special risk and aggravated risk.

The modern techniques of treatment of the hallux valgus are founded on the biomechanic and permit to give again a good function of the big toe. The authors prefer the osseous methods and specially the phalangeal and metatarsal osteotomies. It is necessary also to do a lateral release of the metatarsophalangeal joint and an exostosectomy. The late results are good.

Twenty-five patients with stenosis of the abdominal aorta were observed during the last twenty years. The etiology was a congenital malformation in 20 patients (80%) and an inflammatory aortitis in five (20%). All patients had associated lesions of the renal artery(ies) and 10 had lesions of the digestive arteries, especially of the superior mesenteric artery. All patients had arterial hypertension but none complained of circulatory impairment in the lower limbs or in the digestive area. Aorto-aortic by-pass was performed in six patients. The lesions of the renal artery(ies) (37 kidneys at risk) were treated by nephrectomy in three cases and vascular repair in 34 cases. Four reconstructions of the superior mesenteric artery were carried out simultaneously. There was no postoperative mortality in the current series. After surgery, arterial hypertension was cured in 83.3% of the patients and improved in 12.5%; only one patient was unchanged. In three patients, deterioration of the repair of the renal artery led to repeat surgery. Aortic repair is to be performed in tight stenoses only (pressure gradient > 30 mmHg) and as near to the puberty age as possible.

Cholangiocarcinoma is the second most frequent malignant tumor, after hepatocarcinoma, of the liver; it is diagnosed in approximately 10% of the cases. This retrospective study reviewed follow-up in 50 patients with intrahepatic cholangiocarcinoma treated from June 1979 through February 1993. Among these 50 patients, 32 underwent liver resection and 18 had a liver transplantation. After resection, the median survival was 13.9 months. Tumor stage was seen to have an effect on the Kaplan-Meier plots although the differences were not significant. Four patients died from tumor recurrence more than five years after curative resection, 4 patients are living today. After transplantation, the median survival was 5 months. Among the 18 patients, 1 recipient who had a stage II tumor is currently living 42 months after transplantation with no evidence of recurrence. Despite the high degree of malignancy of intrahepatic cholangiocarcinoma, a certain number of patients do benefit from liver resection, justifying this aggressive surgical approach. Inversely, transplantation does not appear to be an exceptional therapeutic alternative. In the future, cholangiocarcinomas will require multimodal therapeutics.