[Esophageal perforation during nasogastric tube insertion in a patient with right-sided aortic arch and thoracic aorta. Pathophysiology and surgical implications]. / Perforation oesophagienne par sonde nasogastrique avec arc aortique droit et aorte descendante à droite. Physiopathologie et particularités chirurgicales.

Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly probably contributed to the complication and necessitated a modified approach to the surgical repair.

[Esophageal perforation during nasogastric tube insertion in a patient with right-sided aortic arch and thoracic aorta. Pathophysiology and surgical implications]. / Perforation oesophagienne par sonde nasogastrique avec arc aortique droit et aorte descendante à droite. Physiopathologie et particularités chirurgicales.

Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly probably contributed to the complication and necessitated a modified approach to the surgical repair.

Spinal cord stimulation in the treatment of non-reconstructable stable critical leg ischaemia: results of the European Peripheral Vascular Disease Outcome Study (SCS-EPOS).

OBJECTIVE: To determine the effect of spinal cord stimulation (SCS) on limb survival in patients with non-reconstructable critical leg ischaemia, and the value of patient selection on the basis of transcutaneous oxygen pressure (TcpO2) measurements and trial screening. DESIGN: A prospective, controlled, European multicentre study. METHODS: Non-reconstructable patients with stable critical leg ischaemia were divided into three groups. The SCS-Match group comprised patients with a baseline forefoot TcpO2 of < 30 mmHg and both sufficient pain relief and sufficient paraesthesia coverage (> 75%) after a test stimulation period of at least 72 h. If baseline TcpO2 was < 10 mmHg, the TcpO2 should have exceeded 20 mmHg after test stimulation. The SCS-Match group was compared with patients not meeting these criteria, who were treated either with SCS (SCS-No-Match) or without SCS (No-SCS). RESULTS: At baseline, the mean (+/- SD) supine TcpO2 was 14.9 +/- 8.3 mmHg in the SCS-Match group (n = 41), 11.3 +/- 13.3 mmHg in the SCS-No-Match group (n = 32) and 15.3 +/- 17.1 mmHg in the No-SCS group (n = 39). In the SCS-Match group a significant improvement in pain relief (p < 0.005) and TcpO2 (p < 0.001) was seen. After 12 months, cumulative limb survival of patients treated with SCS was significantly better than that of patients not treated with SCS (p < 0.03), and limb survival in the SCS-Match group was significantly higher (p < 0.03) than that in the SCS-No-Match and No-SCS groups (78, 55 and 45%, respectively). CONCLUSION: SCS treatment of non-reconstructable critical leg ischaemia provides a significantly better limb survival rate compared with conservative treatment. Patient selection based on TcpO2 and the results of trial screening further increase the probability of limb survival after SCS therapy.

The best TcpO(2) parameters to predict the efficacy of spinal cord stimulation to improve limb salvage in patients with inoperable critical leg ischemia.

AIM: Spinal cord stimulation (SCS) is available as an alternative therapy for patients suffering from inoperable critical limb ischemia (CLI). Selection of patients is essential to achieve the best treatment effect. For this purpose transcutaneous oxygen (TcpO(2)) measurements have frequently been applied. So far, it is unclear which TcpO(2) parameters serve this purpose best. METHODS: Studies in which inoperable CLI patients were treated with conservative treatment with or without SCS, and in whom various TcpO(2) measurements were performed before and during treatment were pooled to investigate which TcpO(2) parameter(s) were best to detect patients who benefit most from SCS treatment as to limb salvage. RESULTS: TcpO(2) in the supine position increased significantly (p<0.001) in patients after a short period of SCS treatment (from 9 to 22 mmHg), but not in those treated conservatively (from 7 to 7 mmHg). Baseline supine TcpO(2) (using a cut-off value of 10 mmHg), the baseline sitting-supine TcpO(2) difference (cut-off value: 17 mmHg), and the difference in TcpO(2) before and after test stimulation (cut-off value: 4 mmHg) were related to a significantly increased limb salvage. SCS patients with a sitting-supine TcpO(2) difference of >17 mmHg had a 1-year limb salvage of 83% vs 68% in the whole SCS-treated group irrespective of TcpO(2) selection. CONCLUSION: The TcpO(2) parameters mentioned above are capable of detecting the effect of SCS treatment. Selection using (a combination of) TcpO(2) measurements substantially improves limb salvage of patients treated with SCS for inoperable CLI.

The LGM Vena-Tech caval filter: results of a multicenter study.

Caval filters have proved essential to the progress being made in the prevention of recurrent pulmonary embolism. A prospective multicenter study was conducted to evaluate the efficacy and possible complications relating to the LGM Vena-Tech percutaneous caval filter, which has been used in Europe since 1989. A total of 222 patients who had undergone LGM Vena-Tech filter placement between September 1989 and December 1991 were included in this study. Two hundred twenty caval filters were positioned via the percutaneous route: 154 of them via the jugular or subclavian vein and 66 via the femoral vein. Two filters could not be implanted. The in-hospital mortality rate was 1.7% (four patients), which included one patient who died of intraoperative recurrent pulmonary embolism. Mean follow-up was 15 months. Forty-one patients died during follow-up (actuarial survival 65.4% +/- 6% at 30 months). There were five cases of recurrent pulmonary embolism (cumulative freedom from pulmonary embolism 93.2% +/- 3.8% at 30 months). Ten patients had thrombosis of the inferior vena cava (actuarial caval patency 94% +/- 3.6% at 30 months). Eight filters (3.6%) migrated over distances that were less than the height of one vertebra. Shifting did not lead to any cases of thrombosis or recurrent pulmonary embolism. Ten filters tilted between 15 and 25 degrees in relation to the inferior vena cava axis. Recurrent pulmonary embolism never occurred concurrently with filter tilting. The LGM Vena-Tech caval filter ensures satisfactory prevention of pulmonary embolism with a low rate of complications. However, because its long-term fate is not known, its use should be restricted to cases in which heparin treatment has failed or is contraindicated.

[Inverted papilloma of the nose and paranasal sinuses. Retrospective study of 18 cases]. / Papillomes inversés naso-sinusiens. Etude rétrospective portant sur 18 cas.

The authors report about 18 cases of inverted papillomas treated between 1981 and 1991. The average age of the patients is 51 years, with a marked male predominance. The average follow-up is of 4 years. The most often noted revealing sign is unilateral nasal obstruction. A history of polypectomy and nasosinual surgery is found in 45% of the cases in our series. The treatment was surgical in all cases, including 4 De Lima's procedures, 11 procedures through a paralateronasal approach, 2 ethmoidectomies through an endonasal approach, and 1 degloving for a septal lesion. Endonasal surgery was performed for two limited tumors, for which the diagnosis of inverted papilloma never could be made preoperatively. The recurrence rate observed in our series is 5%. Out of 18 patients, 4 presented with a malignant change, either at once (2 cases) or some time after the primary exeresis of the inverted papilloma (2 cases). In the light of the results, and after analyzing the literature, the authors reassert the necessity of radical exeresis for inverted papilloma. Rhinosinual endoscopy must remain a diagnostic means and never is an indication of exeresis of inverted papilloma. The authors emphasize the difficulty of the histological diagnosis and set forth the various problems arising from the malignant degeneration of inverted papillomas. Recent discoveries on viral etiopathogenesis and on the oncogenic potential of the type-16 papilloma virus may allow characterizing the evolutive and prognostic features of inverted papillomas in the future.

[Prevention of nosocomial infections at a cardiovascular surgery unit: therapeutic tactics, efficacy and results]. / Prévention des infections nosocomiales dans un service de chirurgie cardio-vasculaire: tactiques thérapeutiques, efficacité, résultats.

The experience of prevention of nosocomial infections inside a cardiovascular surgical unit leads to insist, among the various tactics, on the quality and the mode of disinfection of the operating room and the intensive care unit, in particular, the technics of air and surface processing (by Anios) of sterilizing water (by Hyconium B and Filtranios), of sterilized respirators (by Formobloc). Quality and efficiency are bacteriologically controlled. The good results, obtained for 3 years, testify of the efficiency of such technics. However some architectural and structural drawbacks can jeopardize a strict compliance towards prevention of nosocomial infections.

[Malignant venous tumors of the limbs. Apropos of 6 cases]. / Les tumeurs veineuses malignes des membres. A propos de 6 observations.

The authors report six personal cases of malignant venous tumours of the limbs, tumour pathology of the inferior vena cava being excluded from this study. Diagnostic features are described together with the various therapeutic possibilities. This discussion forms the basis of a review of the worldwide literature, but stresses two problems which determine the prognosis: that of diagnosis, which in the majority of cases is very late, and that of their prognosis, which remains somber because of their tendency to metastasize by blood-borne spread and that of locoregional recurrences. Finally, the authors suggest a three stage classification, taking into account not only macroscopic pathological features but also the results of the various special investigations which have led to the diagnosis. Prognostic correlation based upon the features involved in this classification is entirely satisfactory.

[Thoracic complications caused by catheterization of the superior vena cava system]. / Complications thoraciques secondaires au cathétérisme du systéme cave supérieur.

The authors report on 8 observations of respiratory complications, following catheterization of the superior caval system. They mention its clinical features, the seriousness of its development and the diagnostic procedure. The symptomatic treatment is based on the evacuation of the extravasation and the withdrawal of the catheter. Sometimes there has to be recourse to surgery. Finally, the authors emphasize the need for prevention of such typically iatrogenous complications.

Aortoseptal approach for optimal resection of diffuse subvalvular aortic stenosis.

The results of conventional operative resection of diffuse subaortic stenosis (tunnel subaortic stenosis and diffuse idiopathic hypertrophic subaortic stenosis) have been less than satisfactory. A new approach using the concept of aortoventriculoplasty was designed to allow adequate surgical resection of a diffuse subvalvular aortic stenosis. The aorta, the right ventricle, and the septum are incised in the same way as during aortoventriculoplasty , with the aortic anulus being divided carefully across the commissure between the left and right aortic cusps. The septotomy is extended beyond the limits of the stenosis, and fibrous and/or muscular tissue is removed from each edge of the septal incision. After adequate widening of the subvalvular area, the various incisions are closed and the aortic valve is reconstructed. This aortoseptal approach was studied experimentally in the dog and then carried out on two patients, both of whom had excellent hemodynamic and functional results. The aortoseptal approach may be the procedure of choice in the treatment of diffuse stenoses limited to the subvalvular area, whereas other procedures ( aortoventriculoplasty , and apico-aortic valved conduit) should be used when the valvular and/or supravalvular levels are involved.

[Our experience with interaxillary shunts. Apropos of 39 shunts. Technic, results, indications]. / Notre expérience sur les pontages inter-axillaires. A propos de 39 pontages. Technique, résultats, indications.

The technique used and the results obtained in 39 patients with chronic obstructive subclavian artery lesions treated by interaxillary shunts are described and the literature reviewed. The indications for this therapy appear to be well defined and to apply mainly to elderly patients, to those with evidence of return flow after carotid-subclavian bypass, and to those with upper limb ischemia from post-vertebral lesions. This type of shunt is effective, is simple to perform and possesses minimal morbidity.

[Our experience with surgery of chronic obstructive lesions of the subclavian artery. Apropos of 94 procedures. Critical analysis of our results]. / Notre expérience dans la chirurgie des lésions obstructives chroniques de l'artère sous-clavière. A propos de 94 interventions. Analyse critique de nos résultats.

Patient characteristics, types of lesion, routes of approach and techniques employed are discussed in relation to 94 cases of surgical treatment for chronic obstruction of the subclavian artery. The most frequently (60% of cases) used procedure was an extrathoracic by-pass operation, thrombo-endarterectomy being performed in 25%, réimplantations in 10%, and aortic by-pass implants in 6% of cases. Immediate and 30-day follow-up results are presented, and failures critically analyzed with regard to their relation to vascular or neurological complications, and those linked to the approach route. Conclusions to be drawn from these unsuccessful cases are exposed, as well as current tendencies in respect of indications for surgery in these lesions.

[Iliocaval venous thrombosis. Clinical and paraclinical aspects and therapeutic approach, apropos of 58 cases]. / Les thromboses veineuses ilio-caves. Aspects cliniques, paracliniques et approche thérapeutique à propos de 58 cas.

The authors report 58 cases of ilio-femoral and ilio-caval thrombosis and emphasise the considerable contribution of two vascular function tests: Doppler and occlusion rheoplethysmography, which now compensate for clinical deficiencies. Nevertheless, phlebography remains essential in defining management which is based upon age, general condition, and the site and type of thrombosis (floating or adherent clot). An outline therapeutic approach is suggested on the basis of these data.

[Surgical treatment of subvalvular aortic obstructions. A new approach]. / Cure chirurgicale des obstacles sous-valvulaires aortiques. Voie d'abord nouvelle.

Approaching the region below the aortic valve is notoriously difficult. The new technique described, derived from the Konno-Restan technique, provides wide exposure of the infra-aortic canal through the right ventricle, the aorta and the septum. Experiments on animals have shown that it entails no risk of heart damage. This technique was used on one patient with sub-aortic fibromuscular tunnel with excellent post-operative results.

[Treatment of dissecting aneurysms of renal artery. Report of four cases (author's transl)]. / Le traitement des anévrismes disséquants de l'artère rénale. A propos de quatre cas.

The localized dissection of visceral arteries, renal arteries in particular, is less frequent than the extension forward the visceral arteries of aneurysms of the abdominal aorta which are well known. Reporting on four cases within their own personal experience, the authors present their commentaries and insist upon the necessity of early diagnosis which, thanks to an adapted surgical treatment, permits protection of these patients from the complications inherent in this reno-vascular pathology.

[Dorsal peridural analgesia in thoracic traumatisms (author's transl)]. / Analgésie péridurale dorsale en traumatologie thoracique.

Prolonged dorsal peridural analgesia is technically easy to achieve: after puncture in the middle of the metameric segment to be anaesthetized, an extradural catheter is inserted and graded doses of bupivacaine are injected. The method provides a valuable contribution to the management of thoracic traumas and is indicated for multiple fractures of the ribs, intolerable pains and flaioe chest. It reduces the incidence of bronchopulmonary complications due to accumulated secretions and of hypoxia from impaired gas exchanges or enlarged physiological dead space. It helps to overcome the acute stage of chest injury, prevents or limits its pernicious effects and shortens the patients' stay in hospital.