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Resume Les troubles digestifs du sportif sont des evenements tres frequemment rencontres dans les activites d’endurance et engendrent une auto medication non negligeable. Les mecanismes physiopathologiques sont complexes car intriques les uns aux autres en faisant intervenir trois principaux facteurs (ischemique, moteur et mecanique) mais aussi de nombreux parametres personnels et/ou environnementaux. L’ischemie est consideree comme le facteur le plus grave. Les cas publies a ce jour sont cependant limites avec un pronostic rapidement favorable lorsqu’ils sont pris en charge rapidement. La prevention de ces troubles digestifs doit etre personnalisee. Elle repose essentiellement sur un entrainement adapte a l’effort attendu et des mesures nutritionnelles. Le recours a la pharmacopee est possible mais limite et se base principalement sur les pansements digestifs et protecteurs gastriques.

We report the case of a 42-year-old woman, who was admitted with an acute subarachnoid cerebral haemorrhage, due to the rupture of an end-basilar artery aneurysm. Two other aneurysms were found: one on the sylvian artery and the other on the extracranial vertebral artery. The management of these types of aneurysms is reported as well as a review of extracranial vertebral aneurysm treatment reported in the literature.

Resume Le developpement de la pratique sportive est un fait de societe. La participation croissante aux epreuves de masse (marathon, cyclosportive …) et le developpement de recents concepts (epreuves combinees telles que le triathlon, raid nature …) ont engendre l’apparition d’une symptomatologie digestive consideree comme « nouvelle », specifiquement liee a l’effort. Touchant les sportifs de tout niveau de performance, du simple amateur a l’athlete de haut niveau, cette entite fut initialement retrouvee dans les sports extremes et d’endurance. Relates de maniere anecdotique (Philipides decedant a Athenes en 490 av. J.-C. d’un hypothetique coup de chaleur ou Derek Clayton vomissant a l’issue de sa victoire au marathon d’Anvers en 1969), les exemples ne manquent pas et se sont multiplies « en direct » a la faveur des nombreuses retransmissions d’evenements sportifs (hospitalisation du triathlete Mark Allen lors de sa victoire a Hawaii [1988] pour « crampes epigastriques », abandon d’Oscar Sevilla, cycliste espagnol pour les memes raisons, dans la seizieme etape du Tour de France 2002, retrait de Roland Garros pour « troubles digestifs » de Pete Sampras et Mary Pierce en 1997, etc.). Malgre la difficulte d’evaluer la prevalence exacte de ces troubles digestifs, il semblerait qu’ils puissent toucher jusqu’au quart des participants des epreuves d’endurance. Les symptomes sont decrits en fonction de la localisation de l’atteinte (manifestations œsogastriques ou coliques) et du degre de gravite represente essentiellement par les manifestations hemorragiques (melena, rectorragies). L’atteinte hepatique ne saurait cependant etre oubliee, representee essentiellement par l’hyperthermie d’effort et les hepatites virales. Source au minimum de contre-performance pour l’athlete (de 5 a 15 % des causes d’abandon en competition), ils peuvent presenter certains criteres de gravite et engager le pronostic vital, necessitant alors une prise en charge medicale rapide avec une frequence d’hospitalisation de 0,1 %.

The liver is a vital organ and plays a central role in energy exchange, protein synthesis as well as the elimination of waste products from the body. Acute and chronic injury may disturb a variety of liver functions to different degrees. Over the last three decades, the effects of physical activity and competitive sport on the liver have been described by various investigators. These include viral hepatitis and drug-induced liver disorders. Herein, we review acute and chronic liver diseases potentially caused by sport. Team physicians, trainers and others, responsible for the health of athletes, should be familiar with the risk factors, clinical features, and consequences of liver diseases that occur in sports.

The infectious or inflammatory nature of an aortitis is difficult to assert because the microbiological results are often negative. The development of an aneurysm under treatment is rare, but requires a change in the therapeutic strategy and the etiologic diagnosis needs to be discussed again.We report the case of a 69-year-old woman treated by corticotherapy for an aortitis thought to be inflammatory, who required emergency surgery when a dissected aneurysm appeared. The peroperative samples were positive to Streptococcus pneumoniae using polymerase chain reaction and allowed a change of the diagnosis. The patient evolved favorably under antibiotic therapy.The decision to treat an aortitis by corticotherapy must be made with caution even if the microbiological tests are negative.

In order to evaluate the results of carotid endarterectomy with closure using a polyurethane patch, a multicentre prospective study of 252 patients (263 interventions) undergoing this operation was performed between November 1996 and August 2001.One hundred and seventy-one men and 81 women with a mean age of 70 years were studied. Fifty-five percent of the patients had neurological symptoms. The degree of carotid stenosis evaluated using the European carotid surgery trialist's collaborative group (ECST) criteria was greater than or equal to 70% in 95% of cases.The combined mortality-morbidity operation rate (CMMR) was 2% (1 death from cerebrovascular haemorrhage on Day 3, 1 non-regressive cerebrovascular accident (CVA), 3 regressive CVAs). The patients had follow-up clinical examinations and Doppler ultrasound scans for 2 years. Fifteen patients died during follow-up, 8 of these patients died from heart-related causes and 2 patients died from CVA. Four patients presented with CVAs ipsilateral or contralateral to the endarterectomy. Two false aseptic aneurysms and 1 false septic aneurysm required further surgery. Three asymptomatic carotid occlusions occurred during follow-up. The rate of restenosis greater than 50% was 1.2% at 6 months, 2.3% at 1 year and 5.3% at 2 years.These results confirm the value of po-lyurethane patch closure of carotid endarterectomy.

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 accuracy and reproducibility of a new magnetic resonance cholangiopancreatography sequence (MRCP), using long echo time and "single shot" acquisition (providing high-contrast thick slices: 20 mm or more), in the morphological analysis of the biliary tree and pancreatic ducts.Fifty four patients with biliary and/or pancreatic disease were investigated with MRCP "single shot" thick slices. Biliary ducts were explored with MRCP "single shot", coronal and oblique coronal 20 mm thick slices on a 256 x 256 matrix. Natives pictures were reviewed by three independent radiologists, from three different institutions. MRCP results were compared with reference examinations in 54 cases (direct biligraphy methods: 54, CT scan: 11, endoscopic ultrasonography: 6, surgery: 6).For detection of bile duct dilatation, the agreement of MRCP "single shot" thick slices was more than 96% (Kappa0.92) and the inter-observer agreement was excellent (Kappa=0.92). For detection of biliary tree and/or pancreatic duct obstruction, MRCP "single shot" thick slice sensitivity was above 89% and specificity was 75%. The malignant nature of the lesions was determined with a sensitivity of 100% and a specificity of 92%. MRCP "single shot" thick slices could not differentiate pancreatic carcinomas from distal main bile duct cholangiocarcinomas. MRCP "single shot" thick slices did not detect small stones ( 3 mm) of the common bile duct.The excellent sensitivity, specificity and inter-observer agreement of MRCP "single shot" thick slices can be used to limit invasive imaging methods in the diagnosis of extrahepatic cholestasis.

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.

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.

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.

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.

Listeria monocytogenes arterial infections are uncommon and usually occur on aneurysms of previously operated arteries, classically in very young and very old or immunodepressed subjects. Peroperative samples for bacteriology should always be taken as antibiotics generally used in vascular surgery are ineffective against listeria. We report a case of a patient who underwent emergency surgery. Bacteriologic analysis of the thrombus revealed listeria inoculation which was eradicated by adapted antibiotic treatment.

The difficult insertion of a right subclavian catheter in a 63-year-old patient resulted in a pseudoaneurysm of the brachiocephalic artery requiring a resection-suture. The preventive measures of that complication are reminded.

In long occlusions of the superficial femoral artery, possibilities of revascularization depend on the patency of the above-knee popliteal artery. In case of occlusion of the above-knee popliteal artery, the distal anastomosis is to be performed at the below-knee level or more distally; in this situation, studies demonstrate a clearcut superiority of venous bypasses over prosthetic bypasses. Patency of the above-knee popliteal artery allows to perform a shorter bypass avoiding to cross the knee joint; given comparable results between venous and prosthetic above-knee bypasses in certain series, several authors advocated the preferential, if not systematic use of prosthetic materials at this level; this attitude having the advantage of preserving the saphenous vein for later coronary or distal grafting. A critical analysis of studies advocating this therapeutic option reveals that results of prosthetic and venous above-knee bypasses are equivalent in only very restrictive clinical situations (claudication, good runoff) and for follow up less than 3 years; beyond this follow up, the use of a prosthesis increases the number of secondary procedures necessary for maintaining or restoring patency and for this reason increases slightly the overall mortality owing to the operative mortality associated with each reoperation. Apart from rare cases represented by fragile and high-risk patients, whose lifespan is likely to be short and in whom a quicker operation is advisable, indications of the use of prosthetic grafts depend on the limits of the use of the saphenous vein generated by a poor quality or an insufficient diameter.

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.

The causes of digital necrosis are so diverse that it should be considered not as a surgical but as a medical emergency. In women, digital necrosis first suggests connective tissue disease, and especially Progressive Systemic Sclerosis. In men the causes are more diverse. In this retrospective study, we have tried to identify and categorize the cause of digital necrosis in patients without Progressive Systemic Sclerosis. The medical files of all patients admitted from 1/1/89 to 1/1/93 for digital necrosis were retrospectively reviewed. All patients with Progressive Systemic Sclerosis, either diagnosed at that time or know before, were excluded. All 45 patients in the study had an evaluation of coagulation, vascular risk factors, a cardiac examination and nailfold capillary microscopy, as well as tests for antinuclear antibodies, and cryoglobulinaemia. Other tests were done according to the clinical presentation. Upper limb angiography was done 26 times.there were 10 women and 35 men, mean age 53 years (24-85 years). In the women, the following diagnosis were found: atherosclerosis 1, paraneoplastic syndrome 1, one thrombocythemia, and 6 connective tissue diseases (one dermatopolymyositis, 1 essential cryoglobulinaemia, 2 lupus erythematous and two suspected secondary Raynaud's phenomenon. Twelve men had arterial diseases: 6 thromboangiitis obliterans and 6 obliterans atherosclerosis. Seven times, the cause was local: 5 hammer's syndromes, 2 thoracic outlet syndrome. In the other patients, the causes were extremely diverse: cardiac embolism (4), primary antiphospholipid syndrome (3), polyarteritis nodosa (1), leprosy seroconversion (1), connective tissue disease (3). In 4 patients (3 of whom were smokers) no cause was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Saphenous vein bypass is the optimal operation for arterial reconstruction in the subinguinal region. There has been no demonstrated advantage to using a devalvulated saphenous vein in situ rather than an inverted dissected vein. Prosthetic bypass may be preferred over saphenous bypass with a veinor = 4 mm if the lower anastomosis is situated on the upper popliteal artery, if the life expectancy is short or if on the contrary the downstream bed is normal. Permeability after percutaneous transluminal angioplasty does not last as long as after bypass surgery for obliterations, but the operation is less aggressive and does not compromise a subsequent procedure. The best indications are short stenoses in patients with a long walking distance in whom surgery would be excessive. Angiography or ultrasound angioscopy after a bypass procedure or endoluminal dilatation can check the technical quality of the operation and help improve permeability duration. Adjuvant treatment such as a venous patch on a prosthetic anastomosis or various drugs are highly important in improving the duration of permeability. A prospectively planned follow-up should be an integral part of arterial reconstruction surgery in order to identify subsequent stenoses and programme their treatment before occlusion occurs.

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.

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.

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.

Two patients with non functioning silent kidney on excretory urography and renal artery occlusion on angiography, underwent renal artery revascularization without severe hypertension or renal failure. Angiographic appearance of collateral circulation, histologic evidence of intact viable glomeruli and a normal sized kidney are necessary for successful results. Renal blood flow was restored in the two patients but one had slight return of function and the other patient showed no evidence of improvement. Both patients presented criteria for revascularization. The first case was a minor success on the renal scintigraphy. The return of renal function did not occur in the second case because of preexisting renal pathology. We therefore recommend histologic examination before every renal artery revascularization for chronic occlusion.

The role of genetically determined immune attack and blood pressure in graft rejection-induced arterial wall injury and response was assessed by studying the compliance and changes in wall structure of aortic isografts and allografts in normotensive (Wistar-Kyoto [WKY]) and hypertensive (spontaneously hypertensive [SHR]) rats. Six groups of 8-week-old rats were compared: sham-operated in both strains, isografts, and allografts between the two strains (SHR aortas grafted in WKYs, designated SWs; WKY aortas grafted in SHRs, designated WSs; isografts in SHRs, designated SSs; and isografts in WKYs, designated WWs). Each arterial graft was studied 8 weeks after transplantation for volume and compliance (pressures of 75-175 mm Hg) under basal conditions. The amounts of collagen, elastin, and nuclei in the media and intima of the walls of control and grafted aortas were quantified morphometrically. Isografts and controls had the same mechanical characteristics under basal conditions: the arterial volume and arterial compliance of hypertensive rats were lower than those of normotensive rats (p less than 0.001). Allografts had a greater initial volume (p less than 0.001) and a lower compliance (p less than 0.001) than did isografts. Allografts in SHRs (SSs) were initially dilated, whereas allografted WKYs (WWs) were not. There was intimal proliferation in hypertensive isografts (14 +/- 0.77 microns) and in both types of allografts (WS, 69 +/- 1.55 microns; SW, 44 +/- 1.81 microns); nucleus density was higher in hypertensive allografts (WS) than in normotensive allografts (SW); and collagen density was also higher in SW than in WS allografts. Allografts had decreased medial thickness and decreased smooth muscle cell density.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.