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.

Lumboscopy is an endoscopic surgical technique providing direct visualization of the retroperitoneal space from the kidney hilium to the iliac bifurcation. We report our 10-year experience with this technique used to diagnose masses in the retroperitoneal space. This method is not very invasive and the morbidity is low. The sensitivity is greater than needle biopsy under CT guidance.

The purpose of this study was to evaluate the load and the release of antibiotics obtained with an implant made of a macroporous beta tricalcium phosphate ceramic (beta-TCP). Two parameters have been assessed: macroporosity and external shape (beads and parallelepipeds). In vitro, the ceramic beads were soaked in a Vancomycin-aqueous-solution, and the load of the antibiotic was then evaluated: it was 9.3% of the weight of the 40%-porosity beads and 4.6% of the weight of the 20%-porosity beads. The release has been evaluated by elution in phosphate-buffered-saline (PBS). With a 20% porosity, 12 beads (6.3 mm, 279 +/- 38 mg) demonstrated a short an massive release which ended within the 32 first hours. On the opposite, the release was sustained until the third week for the 40%-porosity beads (6.9 mm, 353 +/- 25 mg), while only one third of the load was released during the first 24 hours. A macroporosity of 40% of the ceramic could allow a deep incorporation of the antibiotic in the beads and thus decrease the rate of release. The in vivo study compared the bone concentrations of antibiotics obtained after implantations of either parallelepipedical or spherical devices in the distal femurs of 14 sheep. The bone concentrations of Gentamicin obtained with parallelepipeds until the end of the third week were from 5 to 10 times the minimum inhibitory concentration of this antibiotic for staphylococci. On the opposite, beads achieved only low concentrations of Vancomycin and nearly no detectable Gentamicin in the bone. We hypothesize a negative effect of the fibrous tissue which fills the gaps between the beads, and which could impair the diffusion of the antibiotics into the bone.

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.

Ependymomas and astrocytomas are the most frequent spinal cord tumors. They have the same clinical expression and the only treatment is surgery. We report the experience of two neurochurgical teams working in Lyon and Brussels with 171 operated patients, focusing on therapeutic strategies. Spinal cord ependymomas usually present as circumscribed benin tumors, complete exeresis is the best strategy. Long-term follow-up in 40 patients who were not given adjuvant radiotherapy showed no recurrence and satisfactory functional results. Astrocytomas are classically less well circumscribed but when exeresis is macroscopically complete, results are comparable with those of ependymomas as was found in 22 patients with long-term follow-up. Inversely, for infiltrating astrocytomas, pathology is usually malignant and prognosis is unfavorable despite radiotherapy or chemotherapy.

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.