[Secondary surgeries in craniosynostosis and faciocraniosynostosis]. / Chirurgie secondaire des craniosténoses et faciocraniosténoses.

Secondary surgeries for single craniosynostosis surgeries are mainly esthetic refinements rather than functional indications. However, cranioplasties for bone defects correction or insufficient corrections may be undertaken. Management of syndromic craniosynostoses usually requires multiple surgical interventions, the sequence of which might vary per the genetic mutation. It is commonplace to start with posterior vault expansion before age 6 months, then treat cerebellar tonsillar herniation by the age of twelve months, and delay fronto-facial monobloc advancement until at least 18-24 months of age. Ventricular shunting is preferably avoided or delayed. Failure to respect these guidelines can significantly complicate the subsequent management. Primary fronto-orbital advancement or early facial osteotomy type Le Fort3, may compromise the subsequent fronto-facial monobloc advancement. However, this salvage secondary monobloc may be undertaken in some instances despite previous anterior osteotomies with a higher morbidity.

Lactate kinetics in severe COPD. Implications of an abnormal aminopyrine breath test.

The ability of the 13C aminopyrine breath test (APBT) to reflect hepatocellular metabolic capacity and therefore to predict lactate removal following incremental exercise in male COPD patients was evaluated. Two previous patients with COPD who had histories of heavy alcohol intake but no overt liver disease showed prolonged lactate elevation following exercise. The possibility of subclinical hepatic disease affecting lactate removal was considered. No patient in the present study had clinical evidence of liver disease. Four of 9 patients had an abnormal APBT (mean 5.0% cumulative dose 13CO2 excreted over 2 h). Patients with a normal APBT (group 1) and with an abnormal APBT (group 2) were compared. The groups did not differ in age or severity of lung disease. An incremental exercise test was performed and lactate samples were collected before, during, and for 90 min following exercise. Exercise parameters (work rate, duration, VO2max, VEmax, and peak lactate) did not differ between groups. Comparing group 1 with group 2 mean values, the time to recover to resting lactate values (Trecov 45 vs 76 min, respectively, p less than 0.005) and the time required for lactate level to return to the normal range (Tnorm 35 vs 65 min, respectively, p less than 0.005) were statistically different. Furthermore, the 2-h excretion of 13CO2 was inversely correlated with both Trecov (r = -0.76, p less than 0.05) and Tnorm (r = -0.79, p less than 0.05). We conclude that subclinical derangement of hepatocellular capacity, as determined by APBT, may adversely affect lactate removal following exercise.