Chirurgie最新文献

The necrosis of the ligamentum teres hepatis is a very rare and unrecognized pathology. Two cases only were reported in the literature. The presence of generalized or epigastric peritoneal signs, simulates acute cholecystitis or perforated pyloric ulcer. The diagnosis could be suggested by ultrasonography and CT scan of the abdomen revealing a hyperechogenic and hypodense focal lesion at the junction of the segments III and IV of the liver, associated with inflammatory signs and/or collection along the ligamentum teres. The etiology of this necrosis remains unclear, although in this case report, a ligament infection with E. Coli, Enterococcus and Klebsiella pneumoniae was observed. However, the primum movens of the infection is unknown. The proposed treatment is resection of the ligament from umbilicus up to the liver, associated with systemic antibiotherapy, because of the possible risk of propagation of the infection to the portal vein.

A 49 years old man in good physical condition suffering from abdominal pain in the right hypochondrium was hospitalized and CT scan revealed an hemoperitoneum, an enlargement of the liver and a rupture of an heterogenous spleen. The patient was operated on and spleen removed. Pathological examination of the spleen concluded to a splenic cavernous hemangioma. In the postoperative course, an increase of liver nodules occurred within two weeks. A localized splenic angiosarcoma was recognized by reexamination of the specimen. The patient treated by chemotherapy was still alive after 5 months. Prognosis of splenic angiosarcoma is very poor; there is no curative treatment.

Study aim

We have previously demonstrated that anti-LFA-1 monoclonal antibody (mAb) can efficiently protect against rejection of small bowel allograft in a mouse model. The aim of the present work was to determine, in the same model, the optimum conditions for utilisation of anti-LFA-1 mAb and the effects of calcineurin-dependent drugs on the immunosuppression induced by anti-LFA-1 mAb treatment.

Materials and methods

Foetal small intestines of C57Bl/6 (H-2^b) mice were transplanted into adult C3H/He (H-2^k) mice. Recipients were treated with anti-LFA-1 mAb alone (with or without day-1 injection), or combined to cyclosporin (20 mg · kg⁻¹ · j⁻¹ for 14 days), or to tacrolimus (1 mg · kg⁻¹ · j⁻¹ from day 0 to day 7). Biopsies were performed after engraftment from day 5 to day 30.

Results

Administration of anti-LFA-1 mAb alone is sufficient to induce significant prolongation of intestinal allograft survival, provided that the treatment starts one day before engraftment. This tolerogenic effect is reversed by the transitory administration of tacrolimus (p = 0,008).

Conclusion

Treatment with anti-LFA-1 mAb has to be started before the allogeneic response has begun. Calcineurin-dependent drugs can modulate the tolerogenic effect induced by anti-LFA-1. A transgenic mice model should give precise details about underlying mechanisms of these interactions, before a possible utilisation of anti-LFA-1 mAb in intestinal transplantation in humans.

Purpose of the study

The purpose of this retrospective study is to demonstrate the advantages of early surgical operation for patients suffering from Duchenne muscular dystrophy scoliosis.

Patients and methods

Since 1992, 37 patients suffering from Duchenne muscular dystrophy were operated on for scoliosis. Mean age was 12 years. Vital capacity was 62 ± 17% and left ventricular ejection fraction 55 ± 7%. Insertion of flexible vertebral instrumentation included a pedicular screwing system in the lumbo-sacral area and transversal attachments with steel threads at the thoracic level. A sub-laminar fastening was placed at L1. Bone bank arthrodesis was performed only at lumbo-sacral level, in order to maintain flexibility in the thoracic part of the assembly and to enable growth.

Results

Assisted ventilation was necessary in three children during 1.5 month. Superficial sepsis was treated locally with an antibiotherapy without the removal of material in four patients. There was one stem rupture two years after operation, caused by a road traffic accident. No further procedure was necessary for technical reasons. There was no death during the longest follow-up period among the first 24 patients (mean follow-up: 57 months). In the frontal plane, the preoperative Cobb angle, which was 19°, was brought to 5.2° at the postoperative stage, and 9.5% at the latest measurement, i.e., a loss of angular correction of 4.3°. In the sagittal plane, there were physiological curvatures. Pelvic balancing was correct and results have held over time. Vital capacity was reduced by 3.6% per year.

Conclusion

These results encourage early operation on these patients in order to avoid anaesthetic, peri- and postoperative complications. Likewise, giving support to minor curves reduces mechanical constraints during the first postoperative years. The absence of thoracic arthrodesis enables growth of about 5 cm when patients are operated on at about the age of 12 years. Stabilization of the myopath's spine enables the child to remain in an upright sitting position. The assembly's thoracic suppleness enables an increase in the range of movement in the upper limbs. It seems appropriate to operate on such patients when they cease walking, around the age of 12 years. Cardiorespiratory function and life expectancy are not improved, but most patients and families are very satisfied by the comfort brought about by the surgical operation.

Brain abscess after insertion of skull traction is a rare and serious complication. Its development is secondary to superficial infection. Adequate preventive measures have to be taken: proper sterile dressing and daily care. Signs of local irritation are not always synonymous with skull migration. When gradual loosening of the skull occurs, especially associated with superficial infection, the pins must not be tightened. The more appropriate management is to investigate for penetration of the inner cranial cave. When in doubt, repositioning the pins may be necessary, as well as establishing an aggressive treatment against cutaneous infection.