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

Mechanical circulatory support is required when cardiogenic shock is unresponsive to well conducted medical therapy. In this hemodynamic situation, when the patient's life is in danger, within hours, several questions should be answered quickly. These questions take into consideration the etiologies of cardiogenic shock and are related to the possibility of improvement of myocardial function, cardiac transplantation, the choice of uni- or biventricular support and surgical techniques of left ventricular assistance (left atrium to aorta or left ventricular apex to aorta). The follow-up of patients with circulatory support is complex. It requires to take into consideration hemodynamic, mechanical and hemobiological parameters as well as the peripheric organ function. We report in this article our clinical experience with eight patients that underwent circulatory support with Medos external ventricular assist device.

Modularity allows a large choice of implants, like the use of cementless acetabular cups inducing bone ingrowth. The length and direction of the neck may also be adapted to be new joint. Risks of modularity are: implant dissociation, restriction of joint mobility, and especially augmentation of metal debris as a potential source of polyethylene wear. It is then critical to play attention to implant design, material choice and planning of the arthroplasty.

The transvaginal sacrospinous fixation, called Richter operation was initially aimed to cure vaginal vault prolapse after hysterectomy. The results are as good as those of the abdominal promontory fixation with the well known advantages of the vaginal route. Indications way be extended to V3 U3 R3 prolapse and cure of elytrocele with good results in our practice. In few cases remnant cystocele may be a trouble some problem.

Thirty eight patients on chronic hemodialysis were operated on for treatment of complicated aortoiliac atherosclerosis: 31 had aneurysms and 7 had stenotic or obstructive lesions. The 35 male and three female patients ranged in age from 39 to 78 years (mean: 55.3). The duration of hemodialysis treatment before the operation ranged from one month to 22 years but 80% of the patients were operated on during the first five years following the beginning of maintenance hemodialysis. The surgical repairs consisted of long aorta to femoral artery prosthesis in obstructive lesions and of short prostheses in cases of aneurysms so as not to make more difficult subsequent renal transplantation. All patients were operated on from 6 to 18 hours after a dialysis. Hemodialysis was resumed on the day of surgery in few patients or later according to the level of kalemia. Postoperative mortality rate was 10.5% and morbidity 13.5%. Only seven patients underwent secondary renal transplantation. The long-term survival rate was 43% at five years and 11% at ten years. Late deaths were due to coronary artery disease or to worsening of arterial lesions in the lower limbs.

Detachment of the acetabular segment is the most important long-term problem with total hip prostheses. We analyzed long-term outcome in our first 48 acetabular reconstructions with cryopreserved allografts. Among the 48 hips operated on with this technique, 38 were reassessed after a mean follow-up of 7 years 3 months (range 5 years-9 years 6 months). Mean age of the population at surgery was 63 years. There were two predominant etiologies: sequelae of chronic hip luxation and primary osteoarthrosis of the hip. In 10 cases with massive destruction, the Müller ring was used to stabilize the allograft. Results were assessed at 6 months, 2 years, 4 years and at longest follow-up using the Merle d'Aubigné clinical assessment scale. For the radiographic assessment, the Ranawat criteria were used to evaluate the alignment of the reconstruction. Clinically, patient comfort was improved in all cases with significant pain relief. Radiologically, mean acetabular ascention was 5 mm and mean medialization was 3.5 mm. A rim was observed in 24 cases including 19 measuring less than 2 cm. Acetabular loosening was evidenced in the 5 other cases where the rim measured more than 2 mm. In 4 of these 5 cases, the acetabulum had migrated to a new setting. The radiographic image then remained unchanged. Analysis of our 38 first cases showed that bone allografts with cimented acetabulum, sometimes with a stabilizing ring, is one of the possible solutions for difficult acetabular reconstructions. However, after a 7 years 3 months follow-up, we have had five (13%) aseptic displacements including one case requiring reoperation. In the 33 stable joints (87%) with good results reconstruction has achieved a nearly perfect anatomic position, similar to first intention arthroplasty with the use of perfectly stabilized bone grafts with a maximal acetabular surface. Our follow-up is longer than most published in the literature. However, the migration rate of 13% it is still too short to draw any conclusion concerning the long-term outcome in our patients, despite their older age and reduced physical activity compared with primary hip arthroplasty patients.

Skin allografts are essential for survival in patients who have suffered major third degree burns over more than 50% of the body surface in order to maintain covering until autografts from less severely wounded areas can be performed or until keratinocyte cultures have grown. Allografts have thus been increasingly used for severe burn patients. It has been estimated that 150 m2 are grafted per year in France. Both fresh and frozen tissue can be used thanks to the organization of graft banks and safe storage.

Treatment of hepatocellular carcinoma has become multidisciplinary. Liver resection, when technically feasible, remains the procedure of choice for non cirrhotic patients. On the contrary, its indications are decreasing for cirrhotics with the emergence of interventional therapies and since selected patients with small tumors and sufficient life-expectancy have become candidates to liver transplantation. Better results have to be obtained by adjuvant therapies in order to decrease the propension of the hepatocellular carcinoma to recur inside the liver. Intraarterial injection of lipiodol iodine-131 seems to give encouraging results in reducing the local recurrence rate after liver resection.

We describe herein a new model of surgical approach of an early mammalian embryo. Indeed the developmental mechanisms of numerous congenital anomalies, such as bladder exstrophy, remain obscure, and progresses in their knowledge must be achieved to propose better treatments. But up to now all the successful reports in experimental models of early produced malformations concerned birds or batracians, whose development is very different from human. We used the rabbit. Twenty-five time matted does were operated at 12.5 days of gestation. Out of their 247 embryos, 99 underwent a surgical procedure. Forty-eight were injured in order to produce an exstrophy. In 18 cases, the embryo extruded from the uterine cavity and could not be reintegrated, and 2 sacs were found empty. The remaining 31 were only exteriorized. Nine additional does received intravenous teratogen at 12.5 days of gestation. In the group of operated embryos we obtained 6 full-term fetuses, one of whom had a cloacal exstrophy. No exstrophy was noted among the intact embryos, neither in the 87 fetuses submitted to the teratogen. We conclude that: it is possible to operate on an early mammalian embryo, and to obtain further growth until term and that the exstrophy we observed in one case resulted from the surgical specific procedure.

Therapeutic indications aimed at improving function in handicapped persons are difficult to establish as the expected result of a given technique may vary. We have developed a multidisiplinary approach for handicapped persons. Our assessment of this activity which has concerned 62 patients from October 1995 to October 1996 is promising and encourages us to continue this type of attitude. Forty-six of the 58 persons evaluated stated they were well satisfied or very well satisfied with the management of their case and outcome was worse in none of the patients.

We report 35 cases of laparoscopic repair after prosthesis surgery using the classic open technique (19 cases) or laparoscopic technique (16 cases). Most difficulties were observed after intraperitoneal laparoscopy. Hernia repair was preferentially intrapreperitoneal (31 cases). Post-operative morbidity was low with two cases of serohematic effusion treated by puncture. Mean hospital stay was 2.5 days. Patients returned to normal activity within 7 days but work stoppage in active patients depended more on patient motivation than the initial surgical procedure. There were no reiterative recurrences although follow-up is too short (mean 21.2 months) for definitive results.