[Implantable doppler probe for microsurgical free flap monitoring in cervico-facial reconstructive surgery]. / Le micro-doppler implantable dans la surveillance des lambeaux microanastomosés en chirurgie reconstructrice cervico-faciale.

AIM OF THE STUDY: The use of free flaps in head and neck reconstructive surgery requires postoperative monitoring, usually by conventional clinical tests. Nevertheless, clinical testing is not applicable to buried free flaps that are more frequently used in the head and neck area. The purpose of this study was to describe the use and to evaluate the implantable doppler system in this setting. PATIENTS AND METHOD: Among 162 patients who underwent free flap reconstruction in our department, between June 2008 and October 2012, 23 patients had postoperative monitoring using implantable doppler system. Probe placement, monitoring parameters and postoperative course was analyzed. RESULTS: Our series included 15 forearm free flaps, seven fibular flaps and one scapular flap. Indications for reconstruction were following the removal of a malignant tumor in 18 cases, a benign tumor in two cases and an osteoradionecrosis in three cases. Free flap monitoring by conventional clinical tests was not possible in 19 patients. Doppler signal was detected continuously during seven days in 82% of cases. A loss of signal was observed in three cases. Surgical exploration was required in one patient. CONCLUSION: Implantable doppler for free flap monitoring is a safe, reliable and efficient technique and cost is reasonable. The use of implantable doppler system seems particularly useful in head and neck reconstruction for buried free flaps, which are not accessible to conventional clinical tests.

Controlling the interparticle distance in a 2D molecule-nanoparticle network.

Mechanically controllable break junctions allow for an impressive level of control over the distance between two electrodes, but lack stability at room temperature. On the other hand, two-dimensional (2D) networks of nanoparticles bridged by molecules form a stable device structure for investigating molecular conductance properties. Here, we combine both techniques to create a robust platform for molecular charge transport with control over the inter-electrode distance on the picometer scale. The resistance change due to bending of our structures is dependent on the molecular species present between the nanoparticles.

Transition voltage spectroscopy and the nature of vacuum tunneling.

Transition voltage spectroscopy (TVS) has been proposed as a tool to analyze charge transport through molecular junctions. We extend TVS to Au-vacuum-Au junctions and study the distance dependence of the transition voltage V(t)(d) for clean electrodes in cryogenic vacuum. On the one hand, this allows us to provide an important reference for V(t)(d) measurements on molecular junctions. On the other hand, we show that TVS forms a simple and powerful test for vacuum tunneling models.

[Mandibular reconstruction with fibula free flap. Experience of virtual reconstruction using Osirix®, a free and open source software for medical imagery]. / Reconstruction mandibulaire par lambeau microanastomosé de fibula. Modélisation radiologique préopératoire par le logiciel Osirix(®).

The techniques of free tissue transfers are mainly used for mandibular reconstruction by specialized surgical teams. This type of reconstruction is mostly realized in matters of head and neck cancers affecting mandibular bone and requiring a wide surgical resection and interruption of the mandible. To decrease the duration of the operation, surgical procedure involves generally two teams, one devoted to cancer resection and the other one to raise the fibular flap and making the reconstruction. For a better preparation of this surgical procedure, we propose here the use of a medical imaging software enabling mandibular reconstructions in three dimensions using the CT-scan done during the initial disease-staging checkup. The software used is Osirix®, developed since 2004 by a team of radiologists from Geneva and UCLA, working on Apple® computers and downloadable free of charge in its basic version. We report here our experience of this software in 17 patients, with a preoperative modelling in three dimensions of the mandible, of the segment of mandible to be removed. It also forecasts the numbers of fragments of fibula needed and the location of osteotomies.

[Anatomic study of the location of the thoracoacromial pedicle. Application to the pectoralis major musculocutaneous flap]. / Etude anatomique de la localisation du pédicule thoracoacromial. Intérêt dans les lambeaux musculocutanés de grand pectoral.

AIM OF THE STUDY: The thoracoacromial pedicle is the major pedicle of the pectoralis major flap which is still frequently used in cervicofacial loss of substances reconstruction. The classical landmark of this pedicle is the intersection between the acromioxyphoid line and the medioclavicular line. The aim of this study was to determine the exact location of the pedicle compared to the classical landmark in case of narrow pectoralis major flap. PATIENTS AND METHOD: Twenty-one pectoralis major pedicles have been dissected from 12 fresh cadavers. For each dissection have been determined: the medial or lateral situation of the pedicle compared to the intersection of the medioclavicular line and the acromioxyphoid line and the distance between these two points, the angle between the real axis of the pedicle and the acromioxyphoid line. RESULTS: The pedicle was lateral to the acromioxyphoid line in 19 cases, in close contact to the lateral border of the muscle. CONCLUSION: A narrow pectoralis major flap has to be harvested between the acromioxyphoid line and the lateral border of the pectoralis major.

[Past and future of human laryngeal allotransplantation]. / Réalités et perspectives des allotransplantations laryngées.

Laryngeal stenosis or amputation for tumor definitely impairs laryngeal functions with negative impact on quality of life. Experimental laryngeal transplantation has been carried out for nearly 40 years hoping that human transplantation would become feasible in the near future. Nearly 10 years ago, a 40 years old man with a long-standing history of recalcitrant laryngeal stenosis, benefited from a vascularized laryngeal allotransplantation. Speech and deglutition resumed quickly making of this first attempt a success. Although a tracheostomy canula and immunosuppressive regimen are still necessary, this man enjoyed a tremendous improvement in this quality of life. Cumulated experiences tend to demonstrate that laryngeal transplantation in human is not only feasible, but may represents the only chance for rehabilitation of number of laryngeal cripple. Induction of a functional tolerance may allow the necessary evaluation of laryngeal allotransplantation in humans.

La gastronómía endoscópica percutánea en pacientes con trastornos deglutorios de origen neurológico. Resultados de un estudio prospectivo multicéntrico internacional / Percutaneous endoscopic gastrostomy in patients with neurological diseases. Results of a prospective multicenter and international study

AIM: To determine prospectively the long-term evolution of patients with neurological diseases after insertion of percutaneous endoscopic gastrostomy (PEG). METHODS: 109 PEG were performed in 99 consecutive patients (49 females, 50 males), mean age 75 years (range: 20-97 years) as an alternative to a nasogastric tube. Patients were enterally fed because of chronic neurological swallowing difficulties: cerebrovascular disease 38, dementia 27, disordered swallowing mechanisms in elderly patients 10, motor neurona disease and multiple sclerosis 10, neuro-surgical disease 6, Parkinson's disease 3, brain tumor 3, neo-natal encephalopathy 1, HIV encephalopathy 1. The procedure took place in a dedicated endoscopy room. In all cases, prophylatic antibiotics were given and the PEG tube was inserted by the "pull" technique. RESULTS: PEG insertion was technically succesful in all cases. After PEG insertion, all patients were subsequently discharged to local nursing home facilities. 85/99 patients were long-term followed-up on an outpatient basis, 25% of them were followed for more than a year. The mean follow-up time was 3 months (range: 1-24 months). The most frequent complication were minor: local wound infection 6, ostomy leakage 8, silicon degradation 16, leading to the removal of the PEG and the placement of a new PEG tubes in 10 cases. Two major complications were observed : one gastric perforation and death 2 months after the PEG placement and one gastrocolic fistula. No aspiration pneumonia was reported. In one patient, PEG was removed after recuperation of a normal swallowing. All patients had a nutritional improvement. A total of 11 deaths occurred during the follow-up, related to the neurological disorder in 10/11 cases. Nursing home team, patient's physicians and patient's families found PEG manipulations easier than naso-gastric tube. CONCLUSION: Our study suggests that PEG is a method of choice for enteral feeding of patients with chronic neurological disorders. PEG is well-tolerated, leading to an improvement in nutritional status and offering good facilities for home nursing.

La gastronómía endoscópica percutánea en pacientes con trastornos deglutorios de origen neurológico. Resultados de un estudio prospectivo multicéntrico internacional / Percutaneous endoscopic gastrostomy in patients with neurological diseases. Results of a prospective multicenter and international study

AIM: To determine prospectively the long-term evolution of patients with neurological diseases after insertion of percutaneous endoscopic gastrostomy (PEG). METHODS: 109 PEG were performed in 99 consecutive patients (49 females, 50 males), mean age 75 years (range: 20-97 years) as an alternative to a nasogastric tube. Patients were enterally fed because of chronic neurological swallowing difficulties: cerebrovascular disease 38, dementia 27, disordered swallowing mechanisms in elderly patients 10, motor neurona disease and multiple sclerosis 10, neuro-surgical disease 6, Parkinsons disease 3, brain tumor 3, neo-natal encephalopathy 1, HIV encephalopathy 1. The procedure took place in a dedicated endoscopy room. In all cases, prophylatic antibiotics were given and the PEG tube was inserted by the "pull" technique. RESULTS: PEG insertion was technically succesful in all cases. After PEG insertion, all patients were subsequently discharged to local nursing home facilities. 85/99 patients were long-term followed-up on an outpatient basis, 25% of them were followed for more than a year. The mean follow-up time was 3 months (range: 1-24 months). The most frequent complication were minor: local wound infection 6, ostomy leakage 8, silicon degradation 16, leading to the removal of the PEG and the placement of a new PEG tubes in 10 cases. Two major complications were observed : one gastric perforation and death 2 months after the PEG placement and one gastrocolic fistula. No aspiration pneumonia was reported. In one patient, PEG was removed after recuperation of a normal swallowing. All patients had a nutritional improvement. A total of 11 deaths occurred during the follow-up, related to the neurological disorder in 10/11 cases. Nursing home team, patients physicians and patients families found PEG manipulations easier than naso-gastric tube. CONCLUSION: Our study suggests that PEG is a method of choice for enteral feeding of patients with chronic neurological disorders. PEG is well-tolerated, leading to an improvement in nutritional status and offering good facilities for home nursing. (AU)

[Plastic surgery procedures in the treatment of mediastinitis in adult]. / Rôle de la chirurgie plastique dans la prise en charge des médiastinites aiguës de l'adulte.

Closed vacuum drainage is becoming the standard technique in most early postoperative mediastinitis, open wound treatment being only necessary in case of failure of the previous technique or in high grade mediastinitis. The reconstruction technique to be chosen depends on both resulting wound presentation after debridement and thorax morphology. Mediastinal dead space obliteration is a "sine qua non" for success often requiring multiple flap transposition. Since 1983, reconstructive procedures were carried out in 205 patients, of them 95 had bilateral pectoralis major turn-over transposition flaps on internal pedicules, following internal mammary artery coronary revascularisation in 45. Trapezius and latissimus dorsi were the next most used flaps. Transposition of the omentum although especially well suited for torpid wounds was to often precluded by bad abdominal risk factors. Conservative closed drainage salvaged by reconstructive procedures when necessary has greatly improved both survival and functional outcome of these patients.

Prognostic value of mandibular involvement in oral cavity cancers.

OBJECTIVES: The aim of the study was to determine, in a homogeneous population, the prognostic impact of mandibular involvement in oral cancers. STUDY DESIGN: Retrospective study of 117 patients with T4 squamous cell carcinoma of the oral cavity treated by surgery and radiotherapy in the ENT Department of Bichat-Claude Bernard Hospital. All patients had histologically confirmed mandibular involvement. Patients with partial involvement of the mandible underwent rim mandibulectomy (RM) and those with extensive invasion underwent segmental mandibulectomy (SM). METHODS: The local failure rate and the overall survival curves were calculated with respect to type of mandibulectomy. The causes of death were analysed. RESULTS: The surgery was conservative in 55 cases (47%) and segmental in 62 patients (53%). The degree of mandibular involvement did not influence the local failure rate (29% and 25% in the RM and SM groups, respectively). On the other hand, it strongly influenced vital outcome, as five-year survival was only 25.4% after segmental mandibulectomy, compared to 40% after rim mandibulectomy. The metastases and the second primary tumors were more frequent in the SM group. CONCLUSION: The degree of mandibular invasion influenced the survival rate of patients with squamous cell carcinoma of the oral cavity but this difference is not due to local failure.

Efficacy of antibiotic-lock technique with teicoplanin in staphylococcus epidermidis catheter-related sepsis during long-term parenteral nutrition.

BACKGROUND: The antibiotic-lock technique has been suggested to treat catheter-related sepsis in parenteral nutrition and to avoid catheter removal. METHODS: To determine the incidence of catheter-related sepsis, the bacteria involved, and the efficacy of the antibiotic-lock technique with teicoplanin, all patients (n = 263) undergoing parenteral nutrition from January 1997 to December 1999 in one center, with patients at the hospital (n = 209) and at home (54) were retrospectively studied. The antibiotic-lock technique with teicoplanin was systematically used in all suspected infections and maintained in staphylococcus epidermidis (SE) infections. RESULTS: A total of 21 of 263 patients had 34 infections (0.11/patient per year): 12 of 209 hospitalized and 9 of 54 home patients. A total of 10 of 34 infections were due to non-SE, and the catheter was immediately removed. The other 24 of 34 infections were due to SE; in 5 of 24, the catheter was removed after 48 hours of the antibiotic-lock technique because of persistent fever or thrombosis. A total of 5 of 12 patients had 2 or more infections on the same catheter. The antibiotic-lock technique prevented short-term catheter removal in these cases, but a second infection occurred within a median of 50 days. In 4 of 5 cases, a third infection occurred in a mean delay of 90 days so that the catheter was removed. In 3 of 5 patients, bacteria was analyzed with pulsed field gel electrophoresis, which showed that recurrent infections were due to the same strain in all cases. CONCLUSIONS: In this study, the incidence of catheter-related sepsis was low and mostly related to SE. Our results do not support the use of the teicoplanin antibiotic-lock technique in SE infections.

[Diagnostic value of needle biopsy and frozen section histological examination in the surgery of primary parotid tumors]. / Valeur diagnostique de la cytoponction et de l'examen histologique extemporané dans les tumeurs parotidiennes primitives opérées.

The necessity of fine-needle aspiration biopsy (FNAB) in the diagnosis and treatment of parotid gland lesions is still controversial. We examined the accuracy of cytology and histology in a review of 128 parotid gland tumors who underwent surgery with FNAB, n = 102 and/or frozen section examination (FS), n = 94. The diagnostic sensibility and specificity for malignant or benign lesions was respectively 81.5% and 97.5% for FNAB and 75% and 100% for FS as compared with definite histology (110 tumors were benign and 18 malignant). Insufficient material for FNAB evaluation was found in 12 patients mainly with small tumors (p = 0.043) or with tumors located in the deep process of the parotid gland (p = 0.029). Surgery was inappropriate (superficial lobe resection for malignant tumor) because of 4 false negative FS diagnoses. FNAB offers valuable information in the diagnosis of nonsurgical lesions and permits to avoid FS if FNAB identify a benign lesion. FS remains mandatory if FNAB evaluation is not possible or suggests a neoplastic tumor.

Increase in cyclooxygenase-2 and nitric oxide-synthase-2 mRNAs in pouchitis without modification of inducible isoenzyme heme-oxygenase-1.

OBJECTIVES: The pathophysiology of pouchitis occurring after ileal pouch-anal anastomosis remains controversial. Prostaglandins and nitric oxide synthesized in excess by cyclooxygenase-2 and nitric oxide synthase-2 are thought to be involved in the inflammatory process. Because heme oxygenase-1, by its antioxidant properties, could modulate inflammatory reaction, we analyzed mRNAs of the three enzymes (cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1) in patients with ileal pouch-anal anastomosis. METHODS: Endoscopic biopsies were obtained in eight patients with normal ileal pouch-anal anastomosis, in eight patients with pouchitis, and in normal ileum of six healthy subjects. A relative quantitative RT-PCR was performed to determine the levels of cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1 mRNAs. RESULTS: Cyclooxygenase-2 and nitric oxide synthase-2 mRNAs were increased both in normal ileal pouch-anal anastomosis and in pouchitis, compared with healthy subjects. Pouchitis disease activity index was correlated with mRNA levels of cyclooxygenase-2 (r = 0.71; p < 0.01) and nitric oxide synthase-2 (r = 0.51; p < 0.05). Heme oxygenase-1 mRNA levels were not significantly different in patients versus healthy subjects. CONCLUSIONS: The increase in cyclooxygenase-2 and nitric oxide synthase-2 mRNA levels both in pouchitis and normal ileal pouch-anal anastomosis demonstrates that a latent inflammatory process occurs in the ileal pouch mucosa. This inflammatory process was not found to be associated with an induction of heme oxygenase mRNA, a possible regulator of the inflammatory response.

Clinical, social and rehabilitation status of long-term home parenteral nutrition patients: results of a European multicentre survey.

BACKGROUND: Home parenteral nutrition (HPN) is a lifesaving treatment in patients with intestinal failure. Dependency of nutritional support becomes permanent for the majority of patients who had received HPN for at least 2 years. The alternative to long term HPN in selected patients is intestinal transplantation. AIMS: To study some of the clinical, social and rehabilitation aspects of long-term HPN treatment. METHODS: A survey was performed in nine European HPN centres. The questionnaire covered epidemiologic data, underlying diseases, intestinal anatomy, nutritional support and status, marital status, rehospitalization rate, HPN complications, rehabilitation score, drugs use, coexistent diseases and interest in intestinal transplantation. For some items, data were collected within 12 months prior to the evaluation. RESULTS: This survey included 228 patients with a median age of 49 years. The median duration of HPN was 7 years (range 2--24 years). Short bowel length less than 100 cm was reported in 65% of patients with a predominance of end-jejunostomy or jejuno-colonic anastomosis. Global subjective nutritional status was normal in 79% of the patients, who were supplied with a mean number of 5.6 bags of parenteral nutrition weekly. Rehospitalizations within the 12 months prior to evaluation accounted for a mean period of 23 days and were due to HPN complications in half of the cases. Catheter-related sepsis was the most frequent HPN-complication. Bone metabolism disorders, which seemed to be more common than liver diseases, were directly related to HPN duration. One-third of the HPN patients was regularly consuming analgesics or opiates. HPN impair complete rehabilitation status but may improve the status of patients who had a very low rehabilitation score before starting HPN. An interest of intestinal transplantation was noted in only 10% of medical teams and in 8% of HPN patients. CONCLUSIONS: This study is the largest European survey on long-term HPN patients with long standing or permanent intestinal failure. Data enlighten clinical, social and rehabilitation aspects of patients who could face the option of intestinal transplantation in the future.

[Supraglottic laryngectomy with arytenoidectomy]. / Laryngectomie supra-glottique avec aryténoïdectomie.

Relearning to swallow is frequently difficult after supraglottic laryngectomy requiring arytenoid cartilage resection. We propose a surgical procedure in which a local flap is used to close the pharyngeal defect without approximating the laryngeal remnants and the base of tongue. The procedure opens the median raphe and cuts the hyoid bone along the midline. The strap muscles, the perichondrium from the thyroid cartilage and thyroid lobe on the ispilateral side to the tumor are retracted laterally to be used to close the mucosal defect. Sixty-eight patients with T1-T3 carcinomas of the laryngeal margin with extension to an arytenoid in all cases and limited extension to the medial wall and/or anterior angle pyriform fossa in 33 underwent this surgical procedure. Only 5 patients had local recurrence and 8 a lymph node recurrence. Visceral metastases occurred in 21 patients (33%) and second primary tumors were diagnosed at the time of surgery or during follow-up in 19 patients (28%). Three and 5-year actuarial survival rates were 57 and 51%, respectively. Despite post operative radiotherapy, functional success was obtained in 50 patients (75%). This technique provided good tumor control and a high rate of satisfactory functional results in patients with tumors of lateral margin extended to one arytenoid.

Prothrombotic inherited abnormalities other than factor V Leiden mutation do not play a role in venous thrombosis in inflammatory bowel disease.

OBJECTIVES: Because the incidence of thromboembolism is increased in patients with inflammatory bowel disease, we attempted to assess the role of prothrombotic inherited coagulation abnormalities in the development of thrombosis. METHODS: Four populations were compared: 15 patients with inflammatory bowel disease and a previous venous thrombosis, 58 control patients with inflammatory bowel disease but without thrombosis, 110 patients without inflammatory bowel disease but with previous deep venous thrombosis, and 84 healthy subjects. Inherited and acquired risk factors of venous thrombosis, e.g., factor V Leiden and prothrombin 20210A mutations, C677T methylenetetrahydrofolate reductase polymorphism, a polymorphism located in exon 13 of factor V gene, inflammatory and hypercoagulability markers were studied in each population. RESULTS: In the study, 14.3% of thrombotic patients with inflammatory bowel disease had factor V Leiden mutation versus 0% of control patients with inflammatory bowel disease (p = 0.04), 15.5% of thrombotic patients without inflammatory bowel disease (NS) and 3.6% of the healthy controls. A total of 14% of thrombotic patients with inflammatory bowel disease and 11.8% of thrombotic patients without inflammatory bowel disease carried prothrombin 20210A mutation, compared to 1.7% of control patients with inflammatory bowel disease; however, the difference was just below significance. Other inherited coagulation abnormalities were not statistically significantly different among the four populations. CONCLUSIONS: Our study confirms that factor V Leiden mutation increases the risk for thrombotic events but is not more frequent in patients with inflammatory bowel disease. Our results do not support the role of other thrombotic risk factors.

[T3 and T4 cancer of the oral cavity, surgical treatment with oral tongue resection]. / Cancers T3 et T4 de la cavité buccale, traitement chirurgical par amputation de la langue mobile.

Amputation of the oral tongue is required to treat T3 and T4 bilateral tumors of the anterior two third of the tongue with or without extension to the floor of the mouth. This partial glossectomy was performed initially for 27 patients and as salvage therapy for 35 patients with recurrent diseases. The reconstruction required a flap in all cases, including 8 microvascular free flaps. Two months after surgery, two third of patients had a satisfactory swallowing hability. The functional results were worst for patients operated after radiotherapy. Actuarial survival rates were 37.5% and 22.1% at 3 and 5 years respectively. The survival rate of patients who had surgery as primary modality of treatment was significantly better as compared with those who had radiotherapy before surgery (p=0,018). This surgery offers a perfect control of tumors of the anterior floor and oral tongue and good rehabilitation provided by the conservation of the posterior tongue.

Prognostic value of lymph node involvement in oral cancers: a study of 137 cases.

OBJECTIVE: The aim of this study was to assess the prognostic value of lymph node involvement in patients with squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective study of 137 patients with T4 squamous cell carcinoma of the oral cavity treated by surgery and radiotherapy (84 N0, 23 N1, 16 N2,14 N3). Twenty-three patients in the N0 group had a history of surgery or radiotherapy. One hundred fourteen patients underwent limited or radical neck dissection unilaterally or bilaterally. METHODS: The histological charts were reviewed and correlated with preoperative lymph node clinical stage. The local failure rate and the overall survival curves were calculated with respect to clinical and histological stages. The causes of death were analyzed. RESULTS: No evidence of lymph node metastasis was found in 47.4% of cases (54 of 114 patients). Among the node-positive (N+) patients, 39 had rupture of the lymph node capsule (R+). In the N0 group, 27.8% of patients were N+. Regional control rates after surgery and radiotherapy were 95% at 1 year and 85.4% at 5 years. The local failure rates were 6% in N0, 8.7% in N1, 31.2% in N2, 51.7% in N3, 9% in node-negative (N-), and 29% in N+R+ patients. The overall survival rates at 3 and 5 years were, respectively, 44.7% and 34.8% in the N0 group, 37.7% and 37.7% (same rate at 3 and 5 years) in the N1 group, and 31.2% and 15.8% in the N2 group. None of the patients in the N3 group survived beyond 2 years. The overall survival rates at 5 years were 42.8% and 17.5% in the N- and N+ groups, respectively. CONCLUSIONS: In patients with locally advanced tumors (T4), clinical nodal status and histological nodal invasion were key prognostic factors. The presence of occult metastases in the N0 group justifies routine neck dissection.