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Summary Background Smoking induces complications in plastic surgery, in particular wound healing delays. Despite a 4-weeks’ abstinence asking before and after surgery, some patients denied or hid their consumption. The aim of this study was to evaluate the effectiveness of a cotininury detection test in terms of improvement in outcomes after an abdominoplasty. Material and methods This retrospective cohort study included patients who underwent an abdominoplasty with umbilical transposition and lipoaspiration. Current smokers were asked to stop smoking 4 weeks before and after surgery. After 2013, we performed a preoperative cotininury test for patients having abdominoplasty, with a cancellation of surgery in case of positive result. We analyzed the test's effectiveness on delayed healing and on other complications. Results Two hundred and thirty-five patients were included; 80 were tested and 21,3% had a positive test. There was significantly less delayed healing in the “screening” group than in the “no screening”: 20,3% versus 41,5% (P = 0,002). Alike, complications were significantly less frequent in the “screening” group than in the “no screening”: 18,1% versus 42,3% (P Conclusion The routine use of the cotininury test in preoperative abdominoplasties significantly reduces risk of delayed healing and other serious complications. It is an objective test, which is simple, quick and non-invasive. Smoking cessation must be at least 4 weeks before and after the surgery. Following medical advice to cease smoking by the surgeon and anesthetist, referral to an appropriate tobacco-addiction specialist clinic may be helpful for the patient who has difficulty stopping smoking.

Chylothorax is a rare cause of pleural effusion. The most common causes are iatrogenic or medical. We report an unusual and rare cause of bilateral chylothorax.A 73-year-old woman with no past history was admitted to the emergency department for sudden onset of dyspnoea. Chest X-ray and thoracic CT scan revealed large bilateral pleural effusions. Analysis of the fluid revealed a chylothorax. The patient was treated by chest tube drainage and a fat free (medium chain triglyceride) diet. This led to drying up of the effusions and rapid discharge. Complementary imaging examinations with chest-abdomen-pelvis CT, PET CT and pelvic MRI did not reveal any underlying cause. The final diagnosis was bilateral traumatic chylothorax caused by tearing of the thoracic duct during stretching exercises.Following a literature review, similar cases with the same clinical presentation were found. Combined treatment with thoracic drainage and medium chain triglyceride diet was effective in drying up the effusions. Our diagnosis was a diagnosis of exclusion. It is important to exclude a medical cause by thorough investigation.

To report the results of minimally invasive surgery in patients with stage I or II thymoma in the Masaoka classification. The reference technique is partial or complete thymectomy by sternotonomy.A retrospective single-center study of a prospective database including all cases of thymoma operated from April 2009 to February 2015 by minimally invasive techniques: either videosurgery (VATS) or robot-assisted surgery (RATS). The surgical technique, type of resection, length of hospital stay, postoperative complications and recurrences were analysed.Our series consisted of 22 patients (15 women and 7 men). The average age was 53 years. Myasthenia gravis was present in 12 patients. Eight patients were operated on by VATS and 14 patiens by RATS. There were no conversions to sternotomy and no perioperative deaths. The mean operating time was 92min for VATS and 137min for RATS (P0.001). The average hospital stay was 5 days. The mean weight of the specimen for the VATS group was 13.2 and 45.7mg for the RATS group. Twelve patients were classified Masaoka stage I and 10 were stage II. According to the WHO classification there were 7 patients type A, 5 type AB, 4 type B1, 4 type B2 4 and 2 type B3. As proposed by the Group ITMIG-IASLC in 2015 all patients corresponded to group I. The mean follow-up period was 36 months. We noted 3 major perioperative complications according to the Clavien-Dindo classification: one pneumonia, one phrenic nerve paralysis and one recurrent laryngeal nerve palsy. We observed one case of local recurrence at 22 months. Following surgery 4 patients were treated with radiotherapy and 2 patients with chemotherapy.The minimally invasive route is safe, relatively atraumatic and may be incorporated in the therapeutic arsenal for the treatment of Masaoka stage I and II thymoma as an alternative to conventional sternotomy. RATS and VATS are two minimally invasive techniques and the results in the short and medium term are acceptable. The clinical advantages of one over the other are sifficult to establish. RATS could handle larger and more complex lesions in view of the weight and size of the operating instrument.

Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume.Retrospective review of a single institution database. The program was launched after a 6-month preparation period.From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life.This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs.

BackgroundThe best way to manage generalized peritonitis complicating sigmoid diverticulitis is controversial. This randomized clinical trial involved a comparison of primary resection and suture, drainage with proximal colostomy followed by secondary resection.MethodsFrom January 1989 to December 1996, 105 patients of mean(s.d.) age 66(14) (range 32–91) years were randomized to undergo primary or secondary resection. The main endpoint was occurrence of generalized or localized postoperative peritonitis. The Mannheim Peritonitis Index score was calculated for each patient to check for comparability of groups.ResultsPostoperative peritonitis occurred less often after primary than secondary resection whether considering the first procedure only (one of 55 patients versus ten of 48; P < 0·01) or all procedures (one of 55 versus 12 of 48; P < 0·001). Likewise, early reoperation was performed less often following primary resection than secondary resection (two of 55 versus nine of 48 (P < 0·02) and two versus 11 (P < 0·01)), leading to a shorter median first hospital stay for patients having primary resection (15 days) than for those undergoing secondary resection (24 days) (P < 0·05). The mortality rate did not differ significantly with regard to operative policy (primary resection 24 per cent versus secondary resection 19 per cent) or type of peritonitis (faeculent 27 per cent versus purulent 19 per cent). No patient died following a second or third procedure.ConclusionPrimary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.

The aim of our study was to describe the motility in the limb, the duodenum, and the jejunum distal to the limb after Roux-en-Y hepaticojejunostomy in patients who remained asymptomatic postoperatively. Our objective was to obtain reference manometric recordings for interpretion of recordings in symptomatic patients.Manometric recordings were obtained in the Roux-en-Y limb in 13 patients 15.6 +/- 1.1 days postoperatively, using a probe inserted into the limb during surgery and coming out through the abdominal wall. The recording openings were positioned in the limb itself in eight patients, and also in the jejunum immediately distal to the limb in five patients. In four of eight patients, limb manometry was combined with duodenal manometry using a second probe introduced nasally.Phase IIIs were recorded in all 13 patients, either spontaneously or after trimebutine stimulation (100 mg i.v.). Phase IIIs occurred spontaneously in 12 patients. They always migrated throughout the Roux-en-Y limb, and were also most often observed in the distal jejunum; migration stopped in the distal jejunum in three of five patients. Phase IIIs in the limb occurred independently from duodenal phase IIIs. In the limbs, the duration of phase IIIs was longer (p0.02), and the migration slower than in the duodenum (p0.001) and in controls (p0.02). In nine of 13 patients, injection of trimebutine (100 mg i.v.) initiated phase III in the Roux limb or in the distal jejunum within 2 min. During the combined recordings, trimebutine initiated phase III simultaneously in the duodenum and in the limb. The response to meals in the limb was poorer than in controls. Interruption of phase IIIs was shorter, and the area under the postprandial curve was smaller (p0.01) for each postprandial half-h. Postprandial motility was poorer in the limb than in the distal small bowel (p0.01).In asymptomatic patients, interdigestive motility is present in the hepaticojejunostomy Roux-en-Y limb, but it is abnormal because of slow migration of phase IIIs. The second abnormality observed in the limb is a response to meals that is both short and of low amplitude.

Major lung resection using minimally invasive techniques - video-assisted thoracoscopic surgery (VATS) - was first described 20 years ago. However, its development has been slow in many countries because the value of this approach has been questioned. Different techniques and definitions of VATS are used and this can be confusing for physicians and surgeons. The benefit of minimally invasive thoracic surgery was not always apparent, while many surgeons pointed to suboptimal operative outcomes. Recently, technological advances (radiology, full HD monitor and new stapler devices) have improved VATS outcomes. The objectives of this review are to emphasize the accepted definition of VATS resection, outline the different techniques developed and their results including morbidity and mortality compared to conventional approaches. Minimally invasive thoracic surgery has not been proven to give superior survival (level one evidence) compared to thoracotomy. A slight advantage has been demonstrated for short-term outcomes. VATS is not a surgical revolution but rather an evolution of surgery. It should be considered together with the new medical environment including stereotactic radiotherapy and radiofrequency. VATS seems to be more accurate in the treatment of small lung lesions diagnosed with screening CT scan. In the academic field, VATS allows easier teaching and diffusion of techniques.

Deep venous thrombosis of the upper limb has become recently more common because of the increasing use of central venous catheters. Diagnosis is sometimes difficult. Main causes are pacemaker and central venous catheter related thrombosis. The thoracic outlet syndrome is a rare cause and requires a multidisciplinary diagnostic and therapeutic approach. A systematic research of a thrombophilic disorder is not recommended because of the weak therapeutic impact. Duration of anticoagulation is similar to lower limb deep venous thrombosis despite a lower rate of recurrence. Therapeutic alternatives recently developed include thrombolysis, angioplasty and vein stenting. To date, no randomized controlled studies have evaluated the efficacy and safety of the various treatments that have been proposed for upper limb deep venous thrombosis.

To evaluate the clinical results of laparoscopic cystogastrostomy and to determine the potential advantages of this new therapeutic option.This study concerned 12 patients presenting with pancreatic pseudocyst and operated on by laparoscopic cystogastrostomy between 1997 and 2002. There were five men and seven women with a median age of 46 years (range: 30-72). In ten patients, the pseudocyst developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients, the pseudocyst was associated with chronic pancreatitis. All the patients had a single cyst bulging into the posterior wall of the stomach and the median cyst diameter was 9 cm (range: 5-14).Endoluminal gastric laparoscopy was used in six patients and intraperitoneal transgastric laparoscopy in six patients. Conversion to open surgery was required in one patient because the cyst could not be correctly localised by laparoscopy. The median size of the cystogastrostomy was 3 cm (range: 2-5). In eight patients, necrotic debris were still present within the cyst. The median operative time was 90 min (range: 60-140) and the median postoperative hospital stay was 6 days (range: 4-24). No mortality was recorded and postoperative morbidity was limited to one haematoma of the rectus sheath on a port site. One patient was readmitted on the 20th postoperative day because of cyst infection due to partial closure of the cystogastrostomy and was treated by endoscopic placement of a stent. One patient was lost for follow-up 2 months after surgery. With a median clinical and radiological follow-up of 12 months (range: 6-36), no recurrence of pancreatic pseudocyst was observed.In this series, laparoscopic cystogastrostomy is associated with a low postoperative morbidity and an effective permanent result. Laparoscopy has two main advantages: an excellent control of haemostasis and the creation of a wide communication with debridement of the cyst contents thus minimizing the risk of infection or recurrence of the pseudocyst.

A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP).We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30-72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5-20).According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80-300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2-5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4-24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6-36), no recurrence of PP was observed.The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage.

Low grade pulmonary sarcomas are very rare tumours. We report the case of a low grade sarcoma of the lung occurring two years prior to the finding of a uterine primary.Complete surgical excision of a low grade pulmonary sarcoma was performed. The initial search for dissemination was negative. Two years later a follow-up scan discovered a uterine mass as well as a para-aortic shadow that proved to be the primary tumour (low grade uterine sarcoma) and a metastasis.This is the second case of a pulmonary metastasis discovered before a primary low grade uterine sarcoma. The first was found during the investigation of a pulmonary sarcoma. The main differential diagnosis to consider is metastatic leiomyosarcoma. In both cases their finding justifies the search for a uterine primary by immunohistochemical examination for oestrogen and progesterone receptors as well as pelvic ultrasound or even magnetic resonance imaging.

Among 8 patients with giant cell arteritis (GCA) (6 women, 2 men) whose clinical presentations were compatible with temporal arteritis (TA), 6 were followed for 37-105 (mean 74.9) months, one died shortly after treatment onset, and the last was asymptomatic (10 mg steroids/day) when lost to followup at 29 months. All 8 patients had bilateral leg claudication of recent onset; for 6 patients, this was the first symptom. All leg angiograms showed multiple, bilateral, long and smooth stenoses, thromboses, or both. Biopsies of diseased leg arteries from 4 patients provided histological proof of GCA; another case was histologically proven post mortem. Among the 5 patients who met at least 3 American College of Rheumatology criteria of GCA or TA, 3 without histologically documented leg GCA also had biopsy proven temporal GCA (n = 1), or headaches and claudication and angiographic inflammatory arteritis of the arms (n = 2). All patients received steroids; 3 had bypasses, one with endarterectomy. Five are asymptomatic after 24-100 months of steroids (mean 50.6). Revascularization was not successful; one amputation was necessary. Large artery involvement in GCA can affect the legs. Bilateral and rapidly progressive intermittent claudication of recent onset is the most common symptom, even in the absence of headaches or the presence of a silent inflammatory syndrome. Early diagnosis allows rapid initiation of steroid therapy, which is usually able to generate a sufficiently good response to avoid vascular surgery.

To assess the quality of life (QoL) of patients operated for gastroesophageal reflux disease (GERD).This prospective study included 82 consecutive patients submitted to antireflux surgery between October 1998 and January 1999. A new questionnaire was used to assess their QoL: the Gastrointestinal Quality of Life Index (GIQLI) that includes 36 items concerning 5 dimensions: symptoms, vitality, emotions, social relations and medical treatment. The series consisted of 44 men and 38 women with a mean age of 47 years (range: 18-78). QoL was assessed before and 6 months after surgery; the follow-up rate was 94% (77/82). The pre- and postoperative GIQLI scores of the study group and the GIQLY score of a control group of 110 healthy patients were compared.Before surgery, the GIQLI score (90 +/- 23) was greatly impaired compared to the score (123 +/- 13) observed in the control group (p0.001). After surgery, the GIQLI score (110 +/- 23) increased significantly (p0.001), but remained statistically lower than the score of the control group (p0.001). The postoperative score recorded in the symptoms dimension was lower than the control group score: 55 +/- 11 versus 66 +/- 6 (p0.001), while no significant difference was observed in the other 4 dimensions. Univariate statistical analysis revealed that the postoperative GIQLI score (y) was correlated with the preoperative GIQLI score (x) according to the formula: y = 0.43 x + 71 (p0.001) and the sex of the patients, as the postoperative GIQLI score was higher in male patients (115 +/- 19) than in female patients (103 +/- 23) (p0.02).The QoL of the patients was greatly improved after antireflux surgery, but remained lower than that of a control group of healthy subjects. Better patient selection should improve the results. In our series, male patients or patients with a high preoperative GIQLI score were the best candidates for antireflux surgery.

For more than 20 years it has been generally acknowledged that operation for inflammatory abdominal aortic aneurysm (IAAA) using the common in-lay-graft procedure will induce the regression of peri-aortic fibrosis. However in prospective studies, after a 2 years follow-up, no regression appeared in approximated 8% of the cases (table I). Moreover in some IAAA a corticosteroid treatment (CS) was prescribed and it produced a regression of fibrosis and therefore facilitated the operation. Nevertheless the usefulness of the CS remains debated. We report 4 new cases of IAAA with CS. Based on our cases and an analysis of the literature we conclude that when there is no urgency to operate (diameter inferior to 50 mm) CS is the best option in IAAA with either severe inflammation or ureter involvement. Due to the regression of the fibrosis it can facilitate the surgical procedure. However it needs to be conducted with an adequate dose and duration. Finally the CS is the only possibility when the inflammation persist following the treatment of the IAAA.

The aims of this study were to compare Roux-en-Y limb motor patterns after total or distal gastrectomy, and to identify possible motor differences between symptomatic and asymptomatic patients. The usefulness of preoperative recording was also investigated.Sixteen patients were enrolled in the study, 10 patients after total gastrectomy (TG group) and 6 patients after distal gastrectomy (DG group). In 6 of 10 patients in the TG group, recordings were obtained before and after operation. Manometric recordings in the limb lasted 6 hours in all patients, 3 hours during fasting, and 3 hours after a 750-kcal meal. An intravenous injection of trimebutine (100-mg i.v.) was systematically administered at the end of each recording session. Motor results of the patients were compared with those obtained in the intact jejunum of 20 healthy controls.After operation, when patients were compared with controls, phase III (ie, regular activity of the migrating motor complex) was more frequent and more often incompletely propagated (5 of 16 patients versus 1 of 20 controls, unadjusted p0.05) and was significantly slower (p0.01 versus controls). Intravenous trimebutine induced phase III in 12 of 16 patients within a mean of 8.8 +/- 1 (SEM) minutes, longer than in controls (delay2 minutes). The fed pattern was shorter than in controls in both TG and DG groups, and the postprandial area under the curve during successive 30-minute periods was reduced in the DG group compared with controls (p0.01). In patients investigated before gastrectomy, motor parameters were not different from those of controls. Surgery resulted in an increased number of phase IIIs and a decreased migration velocity (p0.01) of phase III, a longer delay in response after trimebutine (p0.0001), and a reduced postprandial motor response (p0.01). After the operation, 4 of 10 patients in the TG group and 5 of 6 patients in the DG group were symptomatic. Symptomatic patients had slower and more often incompletely propagated (p0.01) phase III compared with asymptomatic patients.Roux-en-Y limb reconstruction mainly disturbs phase III propagation and the motor response to a meal. Motor changes are more marked after DG than after TG. Disturbed phase III propagation is the main difference between symptomatic and asymptomatic patients. Successful induction of phase III with trimebutine after gastrectomy and Roux-en-Y reconstruction indicates maintenance of encephalinergic mechanisms.

Leiomyosarcomas are extremely rare tumors which develop from smooth muscle, usually in the esophagus and large vessels (inferior vena cava, pulmonary artery, and superior vena cava). In very rare cases, leiomyosarcomas develop from small vessels in the soft tissue of the mediastinum. Clinical expression of mediastinal leiomyosarcomas (dysphagia, dysphonia) is related to their large size and the subsequent compression of mediastinal structures. At pathology examination, the gross aspect is one of a single cell tumor. Microscopically, the tumor may be highly undifferentiated making it necessary to use specific immune markers (actin and desmin) or ultra-structural analysis to establish the diagnosis. Treatment of localized tumors is based on surgical excision, either alone or in combination with radiotherapy of the mediastinum. Chemotherapy, generally dexorubicin, is indicated in case of metastatic dissemination, but outcome remains uncertain. As for all soft tissue sarcomas, the prognosis of mediastinal leiomyosarcoma depends on the size of the tumor, its histological structure and its resectability.

Upper-extremity thrombosis appears to be more frequent today, comprising about 2% of all deep venous limb thrombosis. Its severity depends on the type of possible complications, i.e., pulmonary embolism and post-thrombotic sequelae. In this retrospective series, we investigated both the predisposing factors and the evolution of upper-extremity deep venous thrombosis.Forty-nine consecutive patients (24 men and 25 women, mean age 50.2 years) with upper extremity deep venous thrombosis documented by color Doppler ultrasonography (n = 47) or phlebography (n = 2) were included in the study.Clinical manifestations were mainly pain (81.6%) and edema (93.9%). Mean time between the onset of clinical signs and diagnosis was 7.2 days. Thrombosis involved humeral (26.5%), axillary (46.9%), subclavian (73.5%) and jugular (24.5%) veins. Causative factors were malignancies (32.7%), venous catheters (22.4%), deep venous thrombosis related to effort or thoracic outlet syndrome (22.5%) and thrombophilic states (8.2%). During the 6-month follow-up, six patients developed symptomatic pulmonary embolism (12.2%); one recurrence (2.2%) and 19 post-thrombotic sequelae such as residual edema (36.7%) were also observed. Initial therapy included heparin administration, principally subcutaneous low molecular weight heparins (n = 36/49).This series highlights the fact that upper-extremity deep venous thrombosis is mainly secondary to either malignancies or catheterization. Moreover, it confirms that color Doppler ultrasonography may be useful in the diagnosis of the disease and also underlines the high frequency of severe complications, i.e., pulmonary embolism and post-thrombotic sequelae. Finally, this study also demonstrates that low molecular weight heparins should be considered as the initial treatment of choice.

A 74-year-old woman was hospitalised for pleuro-pneumonia of the right base. The chest x-ray showed the presence of a right paratracheal opacity which persisted during the course of the infectious episode. A computed tomographic scan of the thorax showed a voluminous anterior mediastinal mass which compressed the trachea without invading it. Surgical excision enabled the ablation of a tumour which was haemorrhagic and the histological examination established a diagnosis of cystic parathyroid adenoma. At anytime did the patient present either clinical symptoms or biochemical signs suggesting primary hyperparathyroidism.

Endoscopic surgery has been used as a new procedure to simplify different surgical processes. The goal of this study was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. Between February 93 and November 95 we performed 35 lumbar sympathectomies using this technique. All patients were arteritic. The results were as follows: for 25% of the patients, conversion classical open technique was required; 6% complications (septic); 3% of the patients died. In comparing the various techniques of sympathectomy and sympatholysis, it would appear that the endoscopic technique produces fewer complications. However we believe that a learning period is necessary before this technique can be fully mastered.

Out of 15 patients operated on for a carotid stenosis 3 to 19 years after a cervical irradiation, 2 were treated by a subclavian-carotid by-pass, 3 by a common carotid-internal carotid by-pass, 10 by an endarterectomy (6 closed with a patch), 3 of these endarterectomy extended largely down on the common carotid. Although the surgical approach was often difficult through the sclerotic tissues and 8 times the scar of a lymphadenectomy, the removal of the atherosclerotic core was as easy as usual. We observed neither mishap in arterial and cutaneous healings nor post operative stenotic myointimal hyperplasia.

Spontaneous pneumothorax in HIV infected patients are mostly due to a sub-pleural necrotizing pneumonitis most often related to Pneumocystis carinii pneumonia. From our experience of nine patients and a review of the literature, we describe the clinical characteristics and therapeutic management and confirm the frequent failure of simple chest tube drainage and the high morbidity and mortality rate despite treatment. An aggressive stepped-care management of thoracoscopic talc poudrage as initial therapy should be evaluated.

Eleven thrombo aspirations were performed in ten patients with lower limb acute ischemia. Three were performed under local and 8 under general anesthesia. They were associated with 4 thrombectomies, 6 transluminal angioplasty procedures, 1 limb infusion, 1 treatment of a false aneurysm, 1 aponeurotomy, 1 angioscopy. Clinical and radiological success was achieved in 9 patients whereas there was one immediate failure requiring a popliteal distal bypass. Late partial rethrombosis requiring medical treatment occurred in one patient. Thrombo aspiration is a safe effective technique which can be combined with other endoluminal procedures in patients with acute lower limb ischemia.

A 42-year-old man was consulted because of a pain in his left leg. He was a highly trained biker since 20 years. The echo-Doppler and arteriography evidenced a stenosis, probably due to endofibrosis of the external iliac artery. In addition, it showed an aneurysm and an intimal dissection of this artery. The arteriography confirmed this diagnosis, and normal aspect of the other arteries. Neither conservative nor endovascular treatments were possible because of the anatomic lesions. We resected the external iliac artery and performed a by-pass with the great saphenous. The result at the 5th month was clinically good. The echo-Doppler control did not show any abnormality. The natural course of the endofibrosis of athletes is unknown, although stenosis, revealed by intermittent claudication is usually observed. Only a few cases of dissection and no aneurysmal degeneration have been described before.

Two cases of infra renal vena cava leiomyosarcoma are reported. Their locoregional extension resulted in a joint resection of the aorta and the vena cava. The follow-up of the two cases is of respectively 34 months and 32 months. We think that large resections are necessary, due to the microscopic characteristics of such tumors in order to try to improve the prognosis.

We report a case of spontaneous regression of a cystic adventicial disease of a popliteal artery in a 37 years old man. The peroperative resection of the adventicia give us the histologic confirmation of the diagnostic. The cyst's content may have gone through either in the peri-arterial space or through a communication with the articulation of the knee. For us, it seems to confirm the embryologic theory for the pathogenic of this disease.

Inflammatory aneurysms of the abdominal aorta raise particular problems, as they are often detected as a result of their complications. In the light of one case presenting with anuria, the authors discuss the various treatment options and the value of preoperative corticosteroids.

Only four cases of per-operative pulmonary embolus of parasites during surgery for hydatic cysts of the liver have been reported. Embolus usually occurs in patients who already have lung metastasis of hepatic cysts, suggesting a hepatic cyst in direct communication with the vena cava or suprahepatic vein. We report the first case which occurred in a patient in which there was no evidence of such communication.

Despite the low morbidity and mortality of laparoscopic cholecystectomy, trauma and infection have been reported. Such complications can produce a misleading clinical picture, as in two cases we observed. Case 1. A symptomatic 56-year-old female patient underwent laparoscopic cholecystectomy. During the operation, the gall bladder ruptured and the contents had to be aspirated from the abdominal cavity. The patient complained of hepatalgia 2 weeks after the operation, then was not seen again for more than 1 year when fever and hepatalgia did not respond to symptomatic treatment. An inter-hepato-renal collection (6 cm in diameter) was punctured under echography. Aspirate culture yielded Pseudomonas aeruginosa. Adapted antibiotic therapy was unsuccessful and surgery was required to empty the abscess then remove a fibrous conjunctive tissue formation. Case 2. A 55-year-old female patient with a history of complete remission after mammectomy for breast cancer underwent laparoscopic cholecystectomy in 1991. Two days after the operation, fever (39 degrees C) was accompanied by abdominal defence. Biliary peritonitis due to imperfect suture of the bile duct was repaired followed by peritoneal lavage-drainage. Per-operative blood samples revealed type 6 Pseudomonas aeruginosa. Despite adapted parenteral antibiotics, fever persisted at 39 degrees C and intense jaundice was observed. A second laparoscopy 14 days later showed inflammatory narrowing of the main bile duct which was drained into a small bowel loop. Eight days later computed tomography revealed multiple abscess in the liver. Transparietal cholangiography was performed and showed that the contrast medium entered the abscesses via the biliary canals. The state of sepsis persisted, jaundice worsened and hepatic encephalopathy developed with obnubilation and flapping tremor. After 1 month of general antibiotherapy, no improvement was seen on computed tomography images and needle biopsy of an abscess led to the identification of resistant type 6 P. aeruginosa. Antibiotics were adapted and administered iv with no clinical improvement. Selective catheterism of the hepatic artery via the femoral access was performed to allow intra-hepatic antibiotic delivery. Three weeks later clinical situation remained unchanged when acute respiratory distress highly suggestive of pulmonary embolism led to death. Autopsy was not performed. In both of these rare cases of infectious complications due to P. aeruginosa after laparoscopic cholecystectomy, the source of contamination remained unknown. Nosocomial infection was suspected.

Recklinghausen disease which usually appears by tumors of the nervous system peripheral and central can present anomalies of other systems, particularly vascular anomalies. The damage of renal arteries is well known. Intracerebral aneurysms are rare. Multiple intracerebral aneurysm has been reported in only four cases. We report a case of a patient presenting three intracerebral aneurysms. The patient died of a meningial haemorrhage. This leads us to search for intracerebral aneurysms in Recklinghausen's disease, specially in presence of arterial hypertension.

We report a case of cystic adventicial disease of the popliteal artery in a 67 years old man. The realisation of the intra arterial pressure measurements, and the peroperative echography permit to diagnose important associated lesions of the intimal part of the arterial wall.

Leiomyosarcomas of the lower vena cava are tumours whose prognosis is bad. The best survival opportunities consist of the widest possible exeresis. You will find below two cases that lead us to proceed to a joint exeresis of the aortic and vena cava bifurcation.

The technique of thoracic splanchnicectomy under video thoracoscopic control is described. This little aggressive surgical operation is indicated for very painful forms of pancreatic cancer and for some cases of chronic pancreatitis. It should relieve pain for a longer period than splanchnic nerve injection or radiotherapy.

In order to list the negative emergency laparotomies, the records of 24,494 laparotomies performed from 1950 to 1989 were examined. 211 negative laparotomies were performed over this 40 years period: 49 for abdominal trauma, 42 for supposed intestinal obstruction, 44 for supposed peritonitis or visceral infection, 46 for presumed early post-operative abdominal complications and 30 for gastrointestinal bleeding. Over these 4 decades, the emergency laparotomy rate and negative laparotomy rate remained stable despite changes in the diagnostic tools, in the age of the patients and the frequency of their diseases.

The authors report about one case of type I aortic dissection disclosed as bilateral lower limb ischemia. The rarity of this way of expression of dissections may result in a delay in diagnosis that can be highly pejorative in such diseases where mortality is high without surgical treatment. The timing and tactics of the surgery to be implemented between the cure of dissection and the removal of ischemia is discussed. Lastly the choice of the mode of arterial cannulation in a patient who had had an axillo-bifemoral bypass ten days earlier also makes this case interesting.

A case is reported of 60-year-old woman who developed transfusion refractoriness after having been transfused several times. This patient who had been transfused with 4 standard packed red cell packs (PRC) for a surgical repair of a hiatal hernia, required three further operations within two months for postoperative complications. After the first operation, she had developed anti-JK1 and anti-CW alloantibodies. Seven phenotype compatible PRC and five fresh frozen plasma (FFP) were transfused during the surgery carried out on day 32. Massive haemorrhage occurred during the fourth operation on day 48, and the patient was transfused with 31 phenotype compatible PRC, 21 fresh frozen plasma, 36 standard platelet concentrates (SPC), fibrinogen, factor VIII and anti-thrombin III. Postoperative disseminated intravascular coagulation occurred, with thrombocytopaenia (45 G.l-1). Major thrombocytopaenia persisted for 6 days (12 G.l-1 on day 52), after the other signs of intravascular coagulation had been corrected, and despite the transfusion of 40 SPC. Platelet counts progressively returned to normal (195 G.l-1 on day 56). An HLA alloimmunization was discovered, which may have been induced by leukocytes contaminating the transfused red blood cell and platelet concentrates. A fifth operation carrying a high risk of haemorrhage was therefore prepared by harvesting autologous platelet rich plasma two days before and on the morning of the operation. These were transfused intraoperatively, together with phenotyped and leukocyte-free PCR, thus avoiding massive and expensive homologous platelet transfusions. In patients with a high risk of HLA immunization (previous pregnancies, multiple transfusions), autotransfusion or leukocyte-poor blood products should be used.

We report two cases of renal vein thrombosis, unusual because of acute expression, right renal vein localization, absence of the usual renal or perirenal causes, surgical management and a never before reported etiology. In one case the thrombosis was secondary to primary antiphospholipid syndrome, in the other it was secondary to heparin associated thrombocythemia. In this case surgical management was performed during prostacyclin infusion.

Laparoscopic cholecystectomy (LC) emerges as an effective alternative to classical cholecystectomy, but its safety, benefits and indications still need to be clarified. From September 1989 to March 1991, 178 LC were performed by 8 surgeons in 2 hospitals, on 142 women and 36 men with a mean age of 48.2 years. The gall bladder wall was thin in 160 cases and thick in 18 cases (with 6 cases acute cholecystitis). We observed no deaths, 147 simple procedures with a hospital stay and drug requirement lower than with the usual cholecystectomy via laparotomy. But in 21 cases, the procedure needed a laparotomy, and in 10 cases complications occurred, requiring laparotomy in 6 cases. Our results suggest: a) LC is an improvement in the treatment of uncomplicated gallstones; b) a trained surgeon and extreme caution are required in complicated cholelithiasis; c) classical cholecystectomy is still useful in many circumstances.

The aim of this study was to describe the motor patterns found in two patients with recurrent cholangitis episodes after Roux-en-Y hepaticojejunostomy. In one patient, cholangitis was due to a stenosis of the anastomosis between the limb and the left intrahepatic bile duct, while motility of the limb, duodenum, and distal jejunum was normal. In the second patient, no anatomical explanation was found for cholangitis attacks. However, although the duodenal motor activity was normal, the motility of the limb and of the jejunum below the jejunojejunal anastomosis was grossly abnormal: permanent minute rhythm, phase IIIs absent or rare and slowly propagated, all motor abnormalities that could promote bacterial overgrowth in the limb. This stresses the interest in performing motor studies of the Roux-limb when cholangitis remains unexplained after Roux-en-Y hepaticojejunostomy.

Surgical thoracoscopy is performed with laparoscopic material and instrumentation and is not limited to the therapeutic applications of classical pleuroscopy such as thoracic sympathectomy or pleurectomy for pneumothorax. It is a simpler, more rapid technique which causes less tissue damage and appears to be more effective than the other transparietal techniques. It has been performed twice for sympathectomy and five times for recurrent pneumothorax with excellent results.

Endoscopic adrenaline-hypertonic injection was attempted in 40 patients admitted for oesophagogastroduodenal ulcer haemorrhage unresponsive to conventional medical treatment and presenting with severe underlying disease or advanced age (less than 80 years). The results were compared with our own historical controls (43 patients) treated by conventional therapy, meeting the same inclusion criteria. Permanent haemostasis was achieved in 32 patients in the injection group and 30 in the control group (NS) but emergency surgery was less frequent in the injection group (2 vs 25, p less than 0.001). Blood transfusion requirements were less in the injection group (8.5 +/- 6.2 vs 10.2 +/- 5.4, p less than 0.05) but length of hospital stay was not really different (15.7 days +/- 9.3 vs 20.9 +/- 14.4). Unfortunately, mortality was not reduced in the injection group (14/40 vs 17/43). Two lethal complications attributable to injection treatment occurred. This treatment could represent an alternative to conventional haemostatic treatment in high surgical risk patients with severe clinical bleeding, avoiding emergency surgery. In spite of the fact that we selected high-risk patients, endoscopic treatment was not able to lower the mortality (about 37%). Due to severe unpredictable side effects and potential risks of long-term massive rebleeding, this treatment should be performed electively in patients with severe clinical bleeding, as first line treatment when surgical risk factors exist or immediately before surgery in low risk patients.

Three cases of leiomyosarcoma of the inferior vena cava are reported. With the help of a review of the literature, the value of ultrasonography, computed tomography and cavography is recalled. Surgical possibilities and results are described together with the necessity of adjuvant treatments.

The results of infradiaphragmatic Collis' gastroplasty for the treatment of gastroesophageal reflux associated with acquired short brachyesophagus (Barrett's esophagus) were prospectively studied in 49 patients (50 operations). Clinical and endoscopic findings, and 3-hour postprandial pH measurement including Kaye's score were evaluated at short (3 to 8 months), medium (1 to 4 years), and long-term (more than 4 years) for all patients. Postoperative morbidity was 16 percent; there were 3 deaths (6 percent). Short term results, evaluated in 45 patients, were considered satisfactory in 30, poor (pyrosis and esophagitis) in 2, and incomplete (pyrosis without esophagitis in 2, dysphagia in 5, mild esophagitis in 6) in 13. Long term results (32 patients) were satisfactory in 24, poor in 5, and incomplete in 3 (pyrosis without esophagitis in one, gastric outlet disorder in 2). Long term pH measurements were obtained in 21 patients: 3 out of 6 patients with high scores had clinical or endoscopic signs of esophagitis. Analysis of late results showed that: a) satisfactory short term outcome was maintained in all but 2 patients (deterioration was observed in one patient 4 years later because of aggressive treatment for terminal bronchopulmonary carcinoma; the other was observed 5 years later after steroid therapy for aspergilloma with severe asthma); b) pH scores were variable in 11 patients. This variability and discordance of pH measurements was most likely due to the presence of acid secretion above the new esogastric junction, which was observed in half of the cases. We conclude that Collis' gastroplasty provided good results in Barrett's esophagus and might be compared to duodenal diversion in ulterior studies in this setting.

From 1975 to 1987, 68 patients were operated with repeated subinguinal bypass (SIB) following early or late thrombosis os an initial bypass graft; 10 were operated with a third SIB, 4 with a fourth SIB. The indication for the second SIB was acute ischemia in 15 cases and chronic ischemia in 53. The graft material used was venous in 21 cases, prosthetic in 29 cases and mixed in 53. The distal anastomosis was performed on the upper popliteal artery in 12 cases, the lower popliteal artery in 34 cases or an artery in leg in 22 cases. The actuarial permeability rate of 84 repeated SIBs, whatever the material, was 21.7% at 1 year (50.2% for venous grafts and 13.6% for prosthetic grafts). The limb preservation rate was 47.9% at 5 years. Operative mortality was about 1%. The analysis of the results suggests that the repeated SIB should be performed only: for limb salvage, if the downstream arterial bed is in good condition, with usable venous material. The risk of having to perform a thigh amputation rather than a leg amputation when attempting repeated SIB is of 13.9% only.

The aim of this study was to describe (during the fasting state in two patients the motor activity of the limb in Roux-en-Y hepatico-jejunostomy). In the two patients, the limb was created 15 years and 15 days prior to the study respectively. Recordings were performed with a low compliance pneumohydraulic system below the jejuno-jejunal anastomosis then in the limb. Motor studies in the limb were coupled with recordings carried out in the duodenum. In both patients, the regular occurrence of a typical phase III (PIII) activity was demonstrated in the limb whereas no retrograde or abnormal motor patterns were found. PIIIs in the limb were uncoordinated with duodenal PIIIs. Trimebutine, given intravenously, induced a typical PIII activity in the duodenum and the limb simultaneously. Spontaneous or trimebutine-induced PIIIs in the limb had a slower migration velocity (p less than 0.01) than duodenal PIIIs. Lastly, we were unable to record PIIIs in the distal jejunum below the jejuno-jejunal anastomosis despite the lack of associated abnormal motor patterns. This study demonstrates that a normally propagated PIII activity can be observed in the limb in Roux-en-Y hepatico-jejunostomy immediately or several years after the surgical procedure.

23 patients with obstruction of one or both main iliac arteries underwent one or more transluminal angioplasties by catheterization via the obstructed vessel. 26 iliac arteries were thus reopened. The length of obstructions varied from 1 to 10 cm. The majority of the obstructions were of recent onset whilst in 6 cases the presumed date was more than 6 months previously. In all cases potency was obtained with normal follow-up angiograms in 20 cases, and a residual though not hemodynamically significant stenosis in 6 cases. All patients were followed up by Doppler and in the majority of cases by venous digital angiography, with a follow-up at the present time of 6 months to 2 years. 2 patients underwent surgery because of reobstruction occurring 2 and 13 months after dilatation. Cumulative patency is 79% in 2 years, similar to results obtained by surgery. These results show that iliac angioplasty, a simple procedure, may avoid or delay surgery, and that it should be widely used in this precise anatomical indication.