Persistent left superior vena cava in cardiac congenital surgery

La persistance d'une veine cave supérieure gauche (VCSG) est une entité relativement fréquente dans le cadre des malformations cardiaques congénitales. Le but de cette étude est d'analyser à quel moment le diagnostic de la persistance de la VCSG est effectué, à quel moment le diagnostic des éventuelles anomalies du sinus coronarien associées est effectué, et de l'impact global de la persistance d'une VCSG sur la mortalité et la morbidité des patients après chirurgie cardiaque pour une malformation cardiaque congénitale. Analyse rétrospective d'une cohorte d'enfants ayant subi une chirurgie cardiaque avec circulation extracorporelle pour une malformation cardiaque congénitale. Trois-cent septante et un patients ont été inclus dans l'étude avec un âge médian de 2.75 ans (IQR 0.65-6.63). Parmi eux, 47 patients présentaient une persistance de la VCSG (12.7%), et cette persistance de la VCSG a été identifiée par échocardiographie dans le cadre du bilan préopératoire chez 39 patients (83%). Trois patients (6.4%) présentant une persistance de la VCSG, ont développé après chirurgie cardiaque, une obstruction significative de la voie d'entrée du ventricule gauche qui a aboutit à un débit cardiaque anormal ou à une hypertension pulmonaire secondaire. Chez huit patients (17%), la persistance de la VCSG, était associée à un défaut partiel ou total de fermeture du sinus coronarien et dans deux cas (4%) à une atrésie de l'ostium du sinus coronarien. La durée de la ventilation mécanique était plus courte de façon significative dans le groupe contrôle (1.2 vs. 3.0 jours, p = 0.004), tandis que la durée de séjour aux soins intensifs ne différait pas. La mortalité était significativement moins élevée dans le groupe contrôle que dans le groupe de patient avec persistance de la VCSG (2.5 vs. 10.6 %, p = 0.004). Les résultats de cette étude montrent que la persistance de la VCSG en association avec une malformation cardiaque congénitale augmente le risque de mortalité chez les enfants qui subissent une chirurgie cardiaque avec circulation extracorporelle. La mise en évidence d'une persistance de la VCSG et des anomalies associées, s'impose pour éviter des complications pendant et après une chirurgie cardiaque.

Childhood epilepsy with neuropsychological regression and continuous spike waves during sleep: epilepsy surgery in a young adult.

We describe the case of a man with a history of complex partial seizures and severe language, cognitive and behavioural regression during early childhood (3.5 years), who underwent epilepsy surgery at the age of 25 years. His early epilepsy had clinical and electroencephalogram features of the syndromes of epilepsy with continuous spike waves during sleep and acquired epileptic aphasia (Landau-Kleffner syndrome), which we considered initially to be of idiopathic origin. Seizures recurred at 19 years and presurgical investigations at 25 years showed a lateral frontal epileptic focus with spread to Broca's area and the frontal orbital regions. Histopathology revealed a focal cortical dysplasia, not visible on magnetic resonance imaging. The prolonged but reversible early regression and the residual neuropsychological disorders during adulthood were probably the result of an active left frontal epilepsy, which interfered with language and behaviour during development. Our findings raise the question of the role of focal cortical dysplasia as an aetiology in the syndromes of epilepsy with continuous spike waves during sleep and acquired epileptic aphasia.

Should Koos grade I vestibular schwannomas be treated early with gamma knife surgery? A subgroup analysis in a series of 190 consecutive patients.

INTRODUCTION: Gamma knife surgery (GKS) for vestibular schwannomas (VS) has a long-term clinical and scientific track record. After a period of de-escalation of dose prescription, results show a high rate of tumor control with improvement of clinical outcome (less than 1% facial palsy, 50-70% hearing preservation). Régis et al. (J Neurosurg 2013;119 Suppl.:105-11) suggested recently that proactive GKS management in intracanalicular tumors is better than a « wait and see » strategy when hearing is still useful at the time of diagnosis. MATERIALS AND METHODS: Based on these previous findings, we prospectively analyzed 190 vestibular schwannomas (VS), treated with GKS as first intention over a period of 4 years (2010-2014). We concentrated on patient, tumor and dosimetric characteristics. Special attention was given on the dose to the cochlea and its impact in maintaining serviceable hearing. RESULTS: The mean follow-up period was 1.3years (range 0.6-3.6). Preoperative serviceable hearing was present in 63.11% patients. The mean maximal diameter was 15.1mm (range 5-29.5). The size and volume of the tumor corresponded to Koos grade I, II, III and IV in 15.9%, 34.8%, 45.4% and 3.8% of the cases, respectively. The mean target volume was 1.24cm(3) (0.017-7.8). The mean prescription isodose volume was 1.6 cc (0.032-8.5). The mean marginal dose was 12Gy (11-12). The mean maximal dose received by the cochlea in patients with GR class 1 and 2 was 4.1Gy (1.5-7.6). Our preliminary neuroradiological follow-up shows 97% tumor control, with 45% shrinkage. Patients presenting with GR class 1 and class 2 at baseline retained serviceable hearing in 85% of cases. Among the patients with a follow-up of at least one year, those with Koos I tumors had the highest probability to maintain identical level of hearing after GKS. CONCLUSION: Our preliminary data suggest that Koos I patients should be treated early with GKS, before tumor growth and/or hearing deterioration, as they have the highest probability of hearing preservation.

Hidradenitis suppurativa of the groin treated by radical excision and defect closure by medial thigh lift: aesthetic surgery meets reconstructive surgery.

INTRODUCTION: Hidradenitis suppurativa of the groin is a chronic, relapsing inflammatory disease of the skin and subcutaneous tissues. Radical surgical excision is the treatment of choice. Often split-skin grafting or wound healing by secondary intention are used for defect closure, sometimes with disfiguring results. We describe our experience with radical excision of localised inguinal hidradenitis suppurativa and immediate defect closure with a medial thigh lift. PATIENTS AND METHODS: Our hospital database was searched for all patients presenting to our institution for surgical treatment of hidradenitis suppurativa between 2001 and 2006. Only patients with hidradenitis confined to the groin were included. Exclusion criteria were simple abscess incisions, recurrence after previous grafting or flap surgery and extension of the disease outside the groin and presence of clinical signs of infection at the time of surgery. We documented patient demographics, sizes of defects, complications, time of follow-up, recurrences and patient satisfaction. RESULTS: A total of 8 patients with localised inguinal hidradenitis suppurativa were identified and 15 thigh lifts were performed. Defect size assessed on pathologic examination of the excised specimens averaged 15.9 cm x 4.3 cm x 1.3 cm (length x width x depth). All wounds but one healed primarily. Functional and aesthetic results were satisfactory. No major complications and no irritations of the genital area were observed. No recurrences were observed either. CONCLUSION: We propose the medial thigh lift to be considered for immediate defect closure after radical excision of localised inguinal hidradenitis suppurativa provided that no perifocal signs of infection are present after debridement.

Bilan préopératoire en chirurgie viscérale [Preoperative assessment in visceral surgery]

The purpose of preoperative assessment is to evaluate the patient's health status, to address known or unidentified co-morbidities and to perform adequate complementary exams if necessary. On the other hand, it allows to prepare and protect the patient in order to reduce perioperative risk. The assessment consists of patient's history and physical examination, both focusing on cardiovascular and respiratory assessment. Complementary exams have to be chosen selectively depending on the patient's risk factors and the type of surgery. They are indicated if their result leads to a potential patient's benefit only, either by a modification in anesthetic and/or surgical management or by introduction of a pharmacological strategy, adequate and maximal if necessary, especially for cardioprotection.

Body taping for contour surgery.

BACKGROUND: Preoperative marking is of primary importance in body contouring and when precise simulation of skin excisions is difficult. Because the "cut as you go" principle can be delicate, especially in patients after massive weight loss, a simple and quick method is needed for preoperative planning. We suggest an approach that helps visualize the optimal skin incision lines and simulates the postoperative result by body taping. METHODS: Twelve patients who underwent abdominal contouring, including classic and vertical abdominoplasties as well as dog ear and scar revision, were prospectively analyzed. The skin to be excised was preoperatively folded, taped, and then marked. The area marked was measured and compared with the actual intraoperatively resected area and the postoperative result was evaluated after 1 year by the patients and three surgeons. RESULTS: With body taping, an 83% congruence between the preoperative planning and the surgery was obtained and only two patients had additional skin resected. No wound dehiscence and flap necrosis occurred and patients as well as surgeons scored the final body contour positively. CONCLUSION: Body taping is a simple, quick, and economic method for planning contour surgery with high accuracy as demonstrated by the low rate of intraoperative changes of the planned resection and low complication rate.

Complications of different ventilation strategies in endoscopic laryngeal surgery: a 10-year review.

BACKGROUND: Spontaneous ventilation, mechanical controlled ventilation, apneic intermittent ventilation, and jet ventilation are commonly used during interventional suspension microlaryngoscopy. The aim of this study was to investigate specific complications of each technique, with special emphasis on transtracheal and transglottal jet ventilation. METHODS: The authors performed a retrospective single-institution analysis of a case series of 1,093 microlaryngoscopies performed in 661 patients between January 1994 and January 2004. Data were collected from two separate prospective databases. Feasibility and complications encountered with each technique of ventilation were analyzed as main outcome measures. RESULTS: During 1,093 suspension microlaryngoscopies, ventilation was supplied by mechanical controlled ventilation via small endotracheal tubes (n = 200), intermittent apneic ventilation (n = 159), transtracheal jet ventilation (n = 265), or transglottal jet ventilation (n = 469). Twenty-nine minor and 4 major complications occurred. Seventy-five percent of the patients with major events had an American Society of Anesthesiologists physical status classification of III. Five laryngospasms were observed with apneic intermittent ventilation. All other 24 complications (including 7 barotrauma) occurred during jet ventilation. Transtracheal jet ventilation was associated with a significantly higher complication rate than transglottal jet ventilation (P < 0.0001; odds ratio, 4.3 [95% confidence interval, 1.9-10.0]). All severe complications were related to barotraumas resulting from airway outflow obstruction during jet ventilation, most often laryngospasms. CONCLUSIONS: The use of a transtracheal cannula was the major independent risk factor for complications during jet ventilation for interventional microlaryngoscopy. The anesthetist's vigilance in clinically detecting and preventing outflow airway obstruction remains the best prevention of barotrauma during subglottic jet ventilation.

Chirurgie du pied et de la cheville rhumatoïdes [Surgery of the rheumatoid foot and ankle]

Surgery of the rheumatoid foot and ankle Initial presentation of rheumatoid arthritis (RA) will be foot and ankle symptoms in 20% of cases. Eventually, 50-90% of patients will develop foot and ankle alterations. Typical deformities of the forefoot include hallux valgus and dorso-lateral dislocation of the lesser metatarso-phalangeal joints. RA involvement of the hindfoot frequently leads to plano-valgus deformity. Approximately 20% of surgery performed for RA is done at the foot and ankle. Early surgery is efficient against pain and deformity. Patient's satisfaction rate after surgery is high despite a slight higher complication rate compared to conventional foot and ankle surgery.

Levosimendan as rescue therapy after surgery for congenital heart disease

Objectives: Levosimendan, a calcium-sensitizing agent has been reported as useful for the management of patients with low cardiac output state. We report here our experience, safety and efficacy of use of levosimendan as rescue therapy after surgery for congenital heart disease. Methods: Retrospective cohort study on patients necessitating levosimendan therapy for post operative low cardiac output or severe post operative systolic and diastolic dysfunction. Twelve patients with a mean age of 2.1 years (range 7 days - 14 years old) received levosimendan. Type of surgery: 3 arterial switch, 3 correction of complete abnormal pulmonary venous return, 3 closure of VSD and correction of aortic coarctation, 3 Tetralogy of Fallot, one correction of truncus arteriosus and one palliation for single ventricle. The mean time of ECC was 203 +/- 81min. Ten patients received levosimendan for low cardiac output not responding to conventional therapy in these cases (milrinone, dopamine and noradrenaline) in the first 6 hours following entry in the ICU and 3 patients received levosimendan 3-4 days after surgery for severe systolic and diastolic dysfunction. Levosimendan was given as a drip for 24-48 hours at the dose of 0.1-0.2 mcg/ kg/min, without loading dose. Results: Significant changes were noted on mean plasmatic lactate (3.3 +/- 1.7mmole/L vs 1.8 +/-0.6mmole/L, p+0.01), mean central venous saturation (55 +/- 11% vs 68 +/- 10%, p+0.01) and mean arterio-venous difference in CO2 (9.6 +/- 4.9mmHg vs 6.7 +/- 2.1mmHg, p+0.05) for values before and at the end of levosimendan administration. There was no significant changes on heart rate, systolic pressure or central venous pressure. No adverse effect was observed. Conclusion: Levosimendan, used as rescue therapy after surgery for congenital heart disease, is safe and improves cardiac output as demonstrated with improvement of parameters commonly used clinically.

Total and segmental liver volume variations: implications for liver surgery.

BACKGROUND: Liver remnant volumes after major hepatic resection and graft volumes for liver transplantation correlate with surgical outcome. The relative contributions of the hepatic segments to total liver volume (TLV) are not well established. METHODS: TLV and hepatic segment volumes were measured with computed tomography (CT) in 102 patients without liver disease who underwent CT for conditions unrelated to the liver or biliary tree. RESULTS: TLV ranged from 911 to 2729 cm(3). On average, the right liver (segments V, VI, VII, and VIII) contributed approximately two thirds of TLV (997+/-279 cm(3)), and the left liver (segments II, III and IV) contributed approximately one third of TLV (493+/-127 cm(3)). Bisegment II+III (left lateral section) contributed about half the volume of the left liver (242+/-79 cm(3)), or 16% of TLV. Liver volumes varied significantly between patients--the right liver varied from 49% to 82% of TLV, the left liver, 17% to 49% of TLV, and bisegment II+III (left lateral section) 5% to 27% of TLV. Bisegment II+III contributed less than 20% of TLV in more than 75% of patients and the left liver contributed 25% or less of TLV in more than 10% of patients. DISCUSSION: There is clinically significant interpatient variation in hepatic volumes. Therefore, in the absence of appreciable hypertrophy, we recommend routine measurement of the future liver remnant before extended right hepatectomy (right trisectionectomy) and in selected patients before right hepatectomy if a small left liver is anticipated.

Recovery of rotators strength after latarjet surgery.

The purposes of this study were to prospectively determine changes in rotator cuff strength before and after surgical shoulder stabilization by Bristow-Latarjet procedure and to better estimate time needed for rotator cuff strength recovery. 20 patients with recurrent anterior posttraumatic shoulder dislocation underwent internal (IR) and external (ER) rotator isokinetic evaluation before and 3, 6 and 21 months after Bristow-Latarjet surgery. In a seated position with 45° of shoulder abduction in the scapular plane, both shoulders were evaluated concentrically with a Con-Trex® isokinetic dynamometer at 180°∙s - 1, 120°∙s - 1 and 60°∙s - 1. 3 months post-surgery, IR and ER strength of the operated shoulder were significantly lower than before surgery ( - 28±20% for IR, - 17±17% for ER) (P<0.05). At 6 and 21 months post-surgery, IR and ER strength were comparable to strength before surgery; strength recovery is seen at 6 months post-surgery with long-term maintenance at 21 months. Given the weakness 3 months post-surgery, return to sports (including overhead and contact sports) should be discussed, and 6 months post-surgery may be a better point for an athlete to resume practicing sports. Isokinetic rotator cuff strength evaluation appears to be relevant in helping to determine the need of continuing strength rehabilitation. Pre-surgical evaluation contributes to the relevance of later comparisons.

Management of Pharyngeal Fistulas After Anterior Cervical Spine Surgery: A Treatment Algorithm for Severe Complications.

STUDY DESIGN:: Retrospective database- query to identify all anterior spinal approaches. OBJECTIVES:: To assess all patients with pharyngo-cutaneous fistulas after anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA:: Patients treated in University of Heidelberg Spine Medical Center, Spinal Cord Injury Unit and Department of Otolaryngology (Germany), between 2005 and 2011 with the diagnosis of pharyngo-cutaneous fistulas. METHODS:: We conducted a retrospective study on 5 patients between 2005 and 2011 with PCF after ACSS, their therapy management and outcome according to radiologic data and patient charts. RESULTS:: Upon presentation 4 patients were paraplegic. 2 had PCF arising from one piriform sinus, two patients from the posterior pharyngeal wall and piriform sinus combined and one patient only from the posterior pharyngeal wall. 2 had previous unsuccessful surgical repair elsewhere and 1 had prior radiation therapy. In 3 patients speech and swallowing could be completely restored, 2 patients died. Both were paraplegic. The patients needed an average of 2-3 procedures for complete functional recovery consisting of primary closure with various vascularised regional flaps and refining laser procedures supplemented with negative pressure wound therapy where needed. CONCLUSION:: Based on our experience we are able to provide a treatment algorithm that indicates that chronic as opposed to acute fistulas require a primary surgical closure combined with a vascularised flap that should be accompanied by the immediate application of a negative pressure wound therapy. We also conclude that particularly in paraplegic patients suffering this complication the risk for a fatal outcome is substantial.

A new poly(ortho ester)-based drug delivery system as an adjunct treatment in filtering surgery.

PURPOSE: Pharmacologic modulation of wound healing after glaucoma filtering surgery remains a major clinical challenge in ophthalmology. Poly(ortho ester) (POE) is a bioerodible and biocompatible viscous polymer potentially useful as a sustained drug delivery system that allows the frequency of intraocular injections to be reduced. The purpose of this study was to determine the efficacy of POE containing a precise amount of 5-fluorouracil (5-FU) in an experimental model of filtering surgery in the rabbit. METHODS: Trabeculectomy was performed in pigmented rabbit eyes. An ointmentlike formulation of POE containing 1% wt/wt 5-FU was injected subconjunctivally at the site of surgery, during the procedure. Intraocular pressure (IOP), bleb persistence, and ocular inflammatory reaction were monitored until postoperative day 30. Quantitative analysis of 5-FU was performed in the anterior chamber. Histologic analysis was used to assess the appearance of the filtering fistula and the polymer's biocompatibility. RESULTS: The decrease in IOP from baseline and the persistence of the filtering bleb were significantly more marked in the 5-FU-treated eyes during postoperative days 9 through 28. Corneal toxicity triggered by 5-FU was significantly lower in the group that received 5-FU in POE compared with a 5-FU tamponade. Histopathologic evaluation showed that POE was well tolerated, and no fibrosis occurred in eyes treated with POE containing 5-FU. CONCLUSIONS: In this rabbit model of trabeculectomy, the formulation based on POE and containing a precise amount of 5-FU reduced IOP and prolonged bleb persistence in a way similar to the conventional method of a 5-FU tamponade, while significantly reducing 5-FU toxicity.

Apport de l'utltrasonographie dans la chirurgie d'épargne du rein et du testicule [Benefits of ultrasonography in kidney and testicular-sparing surgery].

Renal and testicular cancers account for 4% and 1% of all malignancies, respectively. Their prevalence has increased over the past years and is related to the widespread use of medical imaging and the incidental findings of small asymptomatic tumors on computed tomography scanners and ultrasounds examinations. The urologist faces the dilemma of overtreating benign asymptomatic lesions with radical surgery. Therefore, organ-sparing surgery was developed. Recent studies have shown that recurrence rates are often similar between organ-sparing and radical surgery for small kidney or testicular tumors. However, the risk of positive surgical margins consecutive to organ-sparing surgery remains a matter of debate. This article discusses the role of ex-vivo peroperative ultrasonography in predicting negative surgical margins during kidney- and testicular-sparing surgery.

Concurrent or sequential adjuvant letrozole and radiotherapy after conservative surgery for early-stage breast cancer (CO-HO-RT): a phase 2 randomised trial.

BACKGROUND: Letrozole radiosensitises breast cancer cells in vitro. In clinical settings, no data exist for the combination of letrozole and radiotherapy. We assessed concurrent and sequential radiotherapy and letrozole in the adjuvant setting. METHODS: This phase 2 randomised trial was undertaken in two centres in France and one in Switzerland between Jan 12, 2005, and Feb 21, 2007. 150 postmenopausal women with early-stage breast cancer were randomly assigned after conserving surgery to either concurrent radiotherapy and letrozole (n=75) or sequential radiotherapy and letrozole (n=75). Randomisation was open label with a minimisation technique, stratified by investigational centres, chemotherapy (yes vs no), radiation boost (yes vs no), and value of radiation-induced lymphocyte apoptosis (< or = 16% vs >16%). Whole breast was irradiated to a total dose of 50 Gy in 25 fractions over 5 weeks. In the case of supraclavicular and internal mammary node irradiation, the dose was 44-50 Gy. Letrozole was administered orally once daily at a dose of 2.5 mg for 5 years (beginning 3 weeks pre-radiotherapy in the concomitant group, and 3 weeks post-radiotherapy in the sequential group). The primary endpoint was the occurrence of acute (during and within 6 weeks of radiotherapy) and late (within 2 years) radiation-induced grade 2 or worse toxic effects of the skin. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00208273. FINDINGS: All patients were analysed apart from one in the concurrent group who withdrew consent before any treatment. During radiotherapy and within the first 12 weeks after radiotherapy, 31 patients in the concurrent group and 31 in the sequential group had any grade 2 or worse skin-related toxicity. The most common skin-related adverse event was dermatitis: four patients in the concurrent group and six in the sequential group had grade 3 acute skin dermatitis during radiotherapy. At a median follow-up of 26 months (range 3-40), two patients in each group had grade 2 or worse late effects (both radiation-induced subcutaneous fibrosis). INTERPRETATION: Letrozole can be safely delivered shortly after surgery and concomitantly with radiotherapy. Long-term follow-up is needed to investigate cardiac side-effects and cancer-specific outcomes. FUNDING: Novartis Oncology France.