Particularities of peripheral arterial disease managed in vascular surgery in the French West Indies.

BACKGROUND: Epidemiology of peripheral arterial disease is currently unknown in French West Indies (Antilles). AIMS AND METHODS: The aim of this study is to present peripheral arterial disease (PAD) occurring in the French West Indian subjects through the analysis of our database of vascular surgery. The study population included 754 patients (mean age 73 +/- 10 years), mostly from African descents. The main clinical presentation was critical limb ischemia (66%, including tissue loss in 48% of cases), followed by claudication (20%). The lesions affected the infragenicular arteries in 86% of cases, including 24% isolated to this level as well as 51% combined to femoro-popliteal lesions and only 7% of cases affecting the aorto-iliac level. RESULTS: Ankle-brachial index was at 0.57 +/- 0.13 and 0.34 +/- 0.22 (p<0.001) in patients with claudication and critical limb ischemia (CLI), respectively. The severity scores were significantly higher in claudicants with aorto-iliac disease and CLI patients with infragenicular lesions. Except for hypertension (85%) and obesity (19%), the other risk factors were differently distributed between the 2 groups. While in the CLI group, patients were older, with higher rates of female sex, diabetes (62% vs. 48%, p<0.001) and severe renal failure, claudicants were significantly younger, with higher rates of smokers among men (75% vs. 51%, p<0.001) and moderate dyslipidemia (52% vs. 36%, p<0.001). The association with carotid stenosis (12%) and ischemic heart disease (18%) were quite uncommon. Renal disease (glomerular filtration rate<60 ml/mn/1.73 m2) was present in 61% of cases. CONCLUSION: This study highlights clear differences regarding the presentation, localization and associations of PAD in the West Indies subjects managed in vascular surgery, especially with a severe infragenicular disease, even in claudicants. This study suggests the effect of a different distribution of risk factors as well as other ethnic and socio-economic factors.

Morbidity of percutaneous tube thoracostomy in trauma patients.

OBJECTIVES: This prospective study was designed to evaluate the complications of percutaneous tube thoracostomy (PTT) performed for chest trauma in our institution and to determine predictive factors. METHODS: One hundred and thirty-four primary PTTs were performed in 128 patients for blunt (83) and penetrating (45) chest traumas. Failure was defined as undrained hemothorax or pneumothorax, post-tube removal complications and empyema. Univariate and multivariate hazard analyses were used to assess the association between potential risk factors and complications. RESULTS: The overall complication rate was 25% including 30 (23%) failures and nine (7%) improper placement with iatrogenic injuries to the lung (n = 4) or subclavian vein (n = 1). Complications were managed with 18 repeat PTTs and ten early thoracotomies for clotted hemothorax (two), persistent air leak (two), fluid collection (three) or a combination (three) at a mean delay of 6.5 +/- 2.4 days. Failure of additional PTT required late decortication for empyema (three) or decortication (three) at a mean delay of 23 +/- 7 days. One patient died postoperatively, the only death directly related to PTT failure among the four (3.1%) deaths that occurred in this study. Hospital length of stay was significantly increased in patients with PTT failure (24 +/- 19 vs. 15 +/- 8 days in uncomplicated PTT, P = 0.004). By univariate analysis, polytraumatism (relative risk (RR) 2.7, P < 0.05), the need for assisted ventilation (RR 2.7, P = 0.003) and tube insertion by emergency physicians (RR 8.7, P < 0.0001) were significantly associated with increased incidence of complications in blunt trauma. Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P < 0.00001). CONCLUSIONS: PTT is associated with significant morbidity and extended hospitalizations, partly related to inappropriate training of all individuals dealing with trauma care. Additional training should be recommended and some conventional indications for PTT should be revised. A prospective study is currently in progress to evaluate the benefit of early videothoracoscopy in trauma and failure of primary PTT.

Injury of the pulmonary artery and its branches due to penetrating chest trauma.

This study describes the treatment of seven wounds involving the pulmonary artery or its main branches in six men (36 +/- 12 years). Injury was associated with hemoptysis or massive hemothorax in four patients, three of whom had arrest on the way to the operating room. The mean interval between injury and admittance and between injury and surgery was 18 +/- 8 min and 39 +/- 14 min, respectively. Wounds were located on the left pulmonary artery in two cases, right pulmonary artery in two cases, intermediate branch of the pulmonary artery in one case and right upper mediastinal branch of the pulmonary artery in two cases. Injuries involved penetration of only one side of the vessel in three cases, transfixion of two sides of the vessel in one case, and complete disruption of the vessel in three cases. Treatment required pneumonectomy in two cases presenting complex lesions involving both vessels and lung structures. In the remaining five cases, arterial repair was achieved by resection-anastomosis (n = 2) and lateral suture (n = 3). Our results show that isolated injuries of the pulmonary artery are amenable to surgical repair and have a good prognosis. Mortality appears to be high in patients presenting complex lesions involving vascular and pulmonary structures that require pneumonectomy to achieve hemostasis and in patients presenting associated cardiovascular lesions.

Infection of PTFE grafts used to create arteriovenous fistulas for hemodialysis access.

Between January 1993 and December 1994, we treated 19 patients for infection involving expanded polytetrafluoroethylene (ePTFE) grafts used to create arteriovenous fistulas (AVF) for hemodialysis. Manifestations included false aneurysm in nine cases, periprosthetic abscess in seven cases, and tunnel contamination in three cases. The port of entry was the puncture site or catheter in 63% of cases. The delay to onset of infection was significantly longer in patients with secondary graft infection than in those with postoperative graft infection (7.8 months vs. 1.8 months; p < 0.05). Primary treatment consisted of subtotal resection of all but the juxtaarterial segment of the graft in 12 cases, total resection by resection-anastomosis in 2 cases or ligation of the brachial artery in 2 cases, and conservative treatment with removal of only the infected segment in two cases. Creation of a replacement site was possible in 11 patients (group I) within a mean delay of 3 months (range 1-10 months). Replacement sites were created using another graft in nine cases and a native vein graft in two cases. In 7 patients (group II), creation of a replacement site was not possible due to either intractable infection or unavailability of a suitable native vein graft. The findings of this study support prompt creation of replacement sites after resection of infected prosthetic grafts. Priority should be given to native vein grafts or nonprosthetic alternatives.

[Computed tomography study of the sigmoid colon: discriminating diagnostic criteria and interobserver correlations]. / Exploration tomodensitométrique du côlon sigmoïde: critères diagnostiques discriminants et corrélations interobservateurs.

PURPOSE: To assess the value of pericolonic findings at CT in the evaluation of the sigmoid colon. MATERIALS AND METHODS: A total of 210 CT examinations were retrospectively reviewed by 3 blinded radiologists. Data was analyzed to determine the interobserver correlation and the value of pericolonic and colonic wall findings in diagnosis of sigmoid colon pathology. RESULTS: The interobserver correlation for pericolonic findings was equal to or superior to that for colonic wall findings. The presence of abnormal pericolonic fat was the most sensitive (88%) and specific (93%) sign to differentiate a diseased sigmoid colon from a normal one or from sigmoid diverticulosis. Wall-thickening was less sensitive (82%) and specific (76%). Findings suggesting malignancy over diverticulitis included acute zone of transition, focal fatty infiltration, and lymph nodes. Symmetrical and circumferential wall thickening, target-like enhancement, and local fatty proliferation were findings suggesting colitis over diverticulitis. Wall thickening more than 15 mm, involvement of 15 cm or less, asymmetrical involvement, acute zone of transition, and homogeneous or heterogeneous enhancement were findings suggesting malignancy over colitis. CONCLUSION: To render a diagnosis, the evaluation of the fat infiltration must prevail on the parietal thickening appreciation.

[Which is the best performing imaging method for demonstrating residual renal calculi?]. / Quelle est la méthode d'imagerie la plus performante pour mettre en évidence des calculs rénaux résiduels?

OBJECTIVES: To compare the results of plain abdominal films, tomography, ultrasonography and spiral computed tomography in the detection of residual stone fragments after extracorporeal lithotripsy or percutaneous nephrolithotomy. MATERIAL AND METHODS: Prospective study on 31 patients and 40 renal units comparing the results obtained by plain abdominal films, tomography, ultrasonography and spiral CT. RESULTS: This study demonstrates the superiority of spiral CT over the other examinations for detection of renal stones (sensitivity of 100% for spiral CT, 89.2% for tomography, 82.1% for plain abdominal films and 67.8% for ultrasonography), determination of their number (n = 68, 58, 60 and 27, respectively) and demonstration of millimetric stones (100%, 69.4%, 67.8% and 2.7%, respectively). CONCLUSION: Spiral CT is the method of renal stone imaging which provides the most reliable diagnosis of radiopaque, non radiopaque, millimetric or centimetric stones, regardless of local anatomical conditions.

Surgical management of critical limb ischaemia in the French West Indies.

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age +/- SEM: 73 +/- 15 yrs) admitted for critical limb ischaemia. 145 (84%) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisations were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14% in the "Amputation" group and 9% in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 of 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82%. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17%, p < 0.05; and 37 vs 13%, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56%), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.

[The role of percutaneous drainage in acute calculous cholecystitis. Apropos of 27 cases]. / Place du drainage percutané dans les cholécystites aiguës lithiasiques. A propos de 27 cas.

Surgery is the treatment of acute calculous cholecystitis. Mortality and morbidity are considerable for patients with anesthetic risk factors. In this context, ultrasound-guided percutaneous drainage seems to be a alternative to urgent surgery. The place of this technic and its results have not been determined with certainty. We report our experience of percutaneous drainage in acute calculous cholecystitis, based on a series of 27 patients treated between May 1992 and May 1996. A favorable course was observed after drainage in 26 patients, one patient was operated urgently for purulent peritonitis on D1. One drain migrated into the gallbladder and required cholecystenterostomy en D30. Seventeen patients underwent cholecystectomy after the acute episode. Surgery was contra-indicated in light patients: two presented recurrence of acute calculous cholecystitis and six remained asymptomatic. The aim of this study was to define the place of this technic in the treatment of acute calculous cholecystitis, and estimate the results in terms of mortality, morbidity and recurrence.

Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age +/- SEM: 73 +/- 15 yrs) admitted for critical limb ischaemia. 145 (84) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisations were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14in the [quot ]Amputation[quot ] group and 9in the [quot ]Revascularisation[quot ] group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 of 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17, p < 0.05; and 37 vs 13, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the [quot ]Revascularisation[quot ] group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the [quot ]Amputation[quot ] group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.

Fatty acid composition of phospholipids and neutral lipids from human diabetic small arteries and veins by a new TLC method.

It has been suggested that lipid peroxidation of polyunsaturated fatty acids (PUFA) may play a role in the pathogenesis of diabetic complications. To test this hypothesis, we aimed to compare PUFA composition of small arteries and veins (< 500 microm diameter) obtained from diabetic or non-diabetic Guadeloupean patients undergoing arterio-venous shunt surgery before renal dialysis. Small forearm subcutaneous vessels were analysed by a new TLC method which involved inclusion of vascular biopies directly in alveoles made in the TLC gel and lyophilization onto the plate. The TLC plate was then chromatographed and lipids were both extracted and eluted during this step. Fatty acid composition of phospholipid and neutral lipid fractions were determined. Similar fatty acid composition was obtained for arteries and veins from diabetic or non-diabetic subjects. In phospholipids from diabetic vessels, major changes consisted of a 20% decrease of arachidonic acid (20:4 n-6), a 40% decrease of its elongation product 22:4 n-6 and 30% increase of 18:2 n-6. In neutral lipids, 20:4 n-6 was also diminished by 60% whereas oleic acid increased by 15%. This loss of arachidonic acid in small diabetic vessels suggests impaired delta6-desaturase forming 20:4 n-6 or alternatively increased peroxide formation, in the vascular wall of small vessels in diabetic patients.

Infrapopliteal bypass for critical limb ischaemia. Early experience in the French West Indies.

From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with critical limb ischaemia (mean age, 71 years). Thirty-four patients (87%) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with atherosclerotic involvement of femoral and crural arteries. Outflow anastomotic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (< 3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10%, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3-35). Fourteen bypasses failed, 5 in the early period (8-30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72% (+/- 8) at 12 months and 61% (+/- 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75% vs 32% at 2 years- p < 0.01), respectively. Overall life-table limb salvage rates were 84% (+/- 7) and 76% (+/- 9) at 12 and 24 months, respectively. Seventy-eight per cent of patients with limb salvage were relieved of ischaemic symptoms, 57% regained the ability to ambulate with improved functional level and 85% of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities.

Acute mesenteric ischemia: diagnosis with contrast-enhanced CT.

PURPOSE: To evaluate the accuracy of dynamic, contrast material-enhanced computed tomography (CT) in the diagnosis of acute mesenteric ischemia. MATERIALS AND METHODS: Reviewers blinded to patient diagnoses retrospectively compared the CT scans in a study group with those in a control group. The study group comprised 39 consecutive patients (23 men, 16 women; aged 55-88 years) with surgically proved acute mesenteric ischemia. The control group comprised 24 patients (13 men, 11 women; aged 50-82 years) with suspected acute mesenteric ischemia that was disproved at surgery. RESULTS: For the diagnosis of acute mesenteric ischemia, each of the following findings had a specificity of more than 95% and a sensitivity of less than 30%: arterial or venous thrombosis, intramural gas, portal venous gas, focal lack of bowel-wall enhancement, and liver or splenic infarcts. When CT was used in the diagnosis of suspected acute mesenteric ischemia, the detection of at least one of these signs resulted in a sensitivity of 64% (25 of 39; confidence interval, 0.49, 0.79), a specificity of 92% (22 of 24; confidence interval, 0.81, 1.00), and an accuracy of 75% (47 of 63; confidence interval, 0.64, 0.86). CONCLUSION: Dynamic, contrast-enhanced CT is a valuable tool in the diagnosis of and determination of prognosis in acute mesenteric ischemia.

Infrapopliteal bypass for critical limb Ischaemia: early experience in the French West Indies

From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities.

What are the small bowel obstructions to operate and how to do it?

Small bowel obstruction is one of the main surgical emergencies. CT scan is today the best exam to detect occlusions requiring an urgent surgical procedure. It also specify the cause of the obstruction. Post-operative adhesions are the first etiology and justify 3.5%-5% of laparotomies in Western Countries. Recently, small bowel obstructions due to adhesions could be treated by a laparoscopic procedure. The authors report a series of 35 patients presenting an acute small bowel obstruction treated by laparoscopy. The laparoscopic procedure was successful in 70% of cases when occlusion was due to acute adhesions. Compared with open procedure, coelioscopy had an immediate benefit on intestinal mobility re-establishment and hospital stay. The morbidity was 4.5% with no mortality. CT has to be part of pre-operative check-up in front of a small bowel obstruction in order to propose a laparoscopic procedure when postoperative adhesions are suspected.

[Actinomycosis and non-Hodgkin's malignant lymphoma: fortuitous association?]. / Actinomycose et lymphome malin non hodgkinien: association fortuite?

Two cases of actinomycosis associated with non Hodgkin's lymphoma (NHL) are reported. In one case, low grade NHL was diagnosed many years after actinomycosis because of the persistence of abdominal lymphadenopathy in spite of antibiotic therapy. In the second case, hepatic metastasis were initially suspected until actinomycosis diagnosis was made by percutaneous liver biopsy under scanography. High grade NHL was diagnosed by laparotomy and liver biopsy performed 6 weeks after the onset of antibiotic therapy as no improvement in hepatic lesions was obtained. These two case reports outline the difficulties encountered in the diagnosis of actinomycosis and the indication of a repeat biopsy when actinomycosis does not respond to antimicrobial therapy because of the possibility of concomitant malignancy.