[Nipple areola complex conservation in immediate breast reconstruction: prospective study of 66 cases]. / Conservation aréolo-mamelonnaire en reconstruction mammaire immédiate: étude prospective de 66 cas.

OBJECTIVE OF THE STUDY: Our objective is to define a sub-group of patients in whom skin-sparing mastectomy with immediate reconstruction and preservation of the nipple-areola complex is technically and oncologically feasible without increasing the risk of complications and local recurrence. PATIENTS AND METHODS: Between September 1999 and December 2005, 66 patients presenting an in situ and/or invasive breast carcinoma justifying a mastectomy underwent immediate breast reconstruction preserving the skin and nipple-areolar complex. RESULTS: After a median follow-up of 37 months, definitive conservation of the nipple-areolar complex with good esthetic results was achieved in 71% of the cases. CONCLUSION: This preliminary study provides encouraging results in a selected patient population but requires a longer term follow-up in order to draw definitive conclusions on the oncological safety preserving the nipple-areolar complex.

Free flap reconstruction in the treatment of tumors involving the hard palate.

AIM: To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. PATIENTS AND METHODS: Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. RESULTS: Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. CONCLUSIONS: Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.

[The development of operating tables]. / L'épopée des tables d'opérations.

Operating tables evolved in several stages. The most dynamic period was situated between 1860 and 1920: the surgeons of numerous countries were conscious of the necessity of specific tables for surgery. Introduction of anaesthesia in 1846 and asepsis in 1870 have strongly allowed this development.

Alcohol and congenital heart defects: an experimental study in mice.

Pregnant mice were exposed to a single dose of alcohol (0.03 ml of 25% alcohol X g-1 mouse) or two doses (2 X 0.015 ml of 25% alcohol X g-1 mouse) 4 h apart, by intraperitoneal injection or by gavage, on days 7, 8, 9 or 10 of gestation. The mice were killed on the day before term and the fetuses examined for heart defects. Alcohol exposure on day 8, 9 or 10 of gestation caused a high incidence of ventricular septal defects (60%, 75% and 15% respectively). Defects of both the membranous and muscular parts of the septum were seen as well as more complex ventricular septal defects involving the great vessels. Day 7 was resistant to the induction of heart defects. This study has demonstrated that a relatively short exposure to high doses of alcohol during pregnancy in mice can cause congenital heart defects. This has important implications both as a possible cause of congenital heart anomalies in humans and for the counselling of mothers of affected children.

Comparison of the cytotoxicity of clinically relevant cobalt-chromium and alumina ceramic wear particles in vitro.

Concern over polyethylene wear particle induced aseptic loosening of metal-on-polyethylene hip prostheses has led to renewed interest in alternative materials such as metal-on-metal and alumina ceramic-on-alumina ceramic for total hip replacement. This study compared the effects of clinically relevant cobalt-chromium and alumina ceramic wear particles on the viability of U937 histiocytes and L929 fibroblasts in vitro. Clinically relevant cobalt-chromium wear particles were generated using a flat pin-on-plate tribometer. The mean size of the clinically relevant metal particles was 29.5+/-6.3 nm (range 5-200 nm). Clinically relevant alumina ceramic particles were generated in the Leeds MkII anatomical hip simulator from a Mittelmieier prosthesis using micro-separation motion. This produced particles with a bimodal size distribution. The majority (98%) of the clinically relevant alumina ceramic wear debris was 5-20 nm in size. The cytotoxicity of the clinically relevant wear particles was compared to commercially available cobalt-chromium (9.87 microm+/-5.67) and alumina ceramic (0.503+/-0.19 microm) particles. The effects of the particles on the cells over a 5 day period at different particle volume (microm(3)) to cell number ratios were tested and viability determined using ATP-Lite(TM). Clinically relevant cobalt-chromium particles 50 and 5 microm(3) per cell reduced the viability of U937 cells by 97% and 42% and reduced the viability of L929 cells by 95% and 73%, respectively. At 50 microm(3) per cell, the clinically relevant ceramic particles reduced U937 cell viability by 18%. None of the other concentrations of the clinically relevant particles were toxic. The commercial cobalt-chromium and alumina particles did not affect the viability of either the U937 histiocytes or the L929 fibroblasts.Thus at equivalent particle volumes the clinically relevant cobalt-chromium particles were more toxic then the alumina ceramic particles. This study has emphasised the fact that the nature, size and volume of particles are important in assessing biological effects of wear debris on cells in vitro.

Reconstruction with free jejunal autograft after circumferential pharyngolaryngectomy: eighty-three cases.

The free jejunal autograft (FJA) has become a common procedure for pharyngeal reconstruction after circumferential pharyngolaryngectomy. In order to evaluate the postoperative outcome and the functional and carcinologic results, we retrospectively reviewed 83 cases of reconstruction with FJA. Fifty-one patients had received no prior radiotherapy, and 25 had received prior radiotherapy for their hypopharyngeal tumor or for another previous primary. Seven patients underwent a secondary reconstruction. In the postoperative course, there were 2 postoperative deaths, 4 graft failures (5%), and 11 salivary fistulas. The median time to removal of the nasogastric tube was 16 days, and to discharge, 23 days. Forty-eight patients received postoperative radiotherapy, with good tolerance. At 1 year postoperatively, 98% of the patients were able to eat a solid or soft diet. The postoperative radiotherapy did not impair the quality of the functional results in a long-term assessment. The vocal results were disappointing. The 3-year survival rate was 40%. The main carcinologic failures (45 patients) were locoregional recurrences (20 patients) and metastasis, which was the cause of death in 34% of the cases. It seems clear that FJA allows one-stage reconstruction and good swallowing rehabilitation, tolerates postoperative radiotherapy, and increases the quality of life in these patients with a poor prognosis.

The internal cavoatrial derivation for temporary vascular exclusion of the liver in the dog.

Vascular exclusion of the liver by clamping the hepatic pedicle and inserting an internal cavoatrial shunt allows bloodless hepatic surgery to be performed. The internal cavoatrial shunt performed on 30 dogs was studied to define its optimal hemodynamic characteristics. The internal diameter should measure half the caliber of the inferior vena cava and the total surface of the holes allowing blood flow to the shunt must be three times the internal caliber of the shunt. The aortic clamping associated with the clamping of the hepatic pedicle and the insertion of the internal cavoatrial shunt considerably diminishes the arterial blood pressure variations resulting from the splanchnic stasis. Administration of methylprednisolone (30 mg/kg) at the beginning of the experiment also plays a role in preventing alterations in the small intestine.

Analysis of debris from brushing the femoral canal with a plastic brush--a potential cause of loosening in total hip replacement.

The generation of submicrometre sized polyethylene particles has been shown to be one of the major causes of osteolysis, loosening and failure of total replacement joints. It has been reported that intramedullary brushing of the femoral canal with polymer brushes prior to total hip arthroplasty results in the release of polymer particles into the femoral canal. The aim of this study was to isolate and characterize these particles on the basis of morphology and size and to determine whether these particles may play a role in osteolysis and loosening of the total hip prostheses. It was found that the majority of the particles shed by the polymer brushes were submicrometre in size and were similar in morphology to UHMWPE wear particles isolated from periprosthetic tissues. In addition, the majority of the particles released by the brushes were in the biologically active size range (0.1-10 microns), and may contribute to osteolysis and loosening of hip prostheses.

[The advent of surgical gloves]. / L'épopée des gants chirurgicaux.

The advent of surgical gloves had a double evolution. Evolution of the material: cecum of a sheep, cotton, silk, leather, rubber. Originally introduced to protect theatre staff's hands from corrosive solutions, subsequent use was to protect the patient from contamination by theatre staff. Many surgeons contributed to the evolution of the surgical gloves. The use of gloves was truly part of an evolutionary process than a discovery. The turning of surgical gloves is now incontestable, and their use more and more important. Surgical gloves must secure a crossing protections between surgeon and patient.

[Vascular microsurgery and progress of free flap surgery]. / La microchirurgie vasculaire et l'essor des transplants libres.

In 1960 Jacobson and Suarez realized and described the first vascular microanastomosis. They introduced microsurgical operating technique, improved instrumentation and operating microscope. Many improvements were tried: vascular intubation, laser, biological glue, microvascular anastomotic system, non transfixing microstaples. After expert's report, these techniques have shown many drawbacks and have not supplanted the manual anastomosis. The failure rate was 6.6% in a review of 9,503 cases from the literature. The rate of vascular thrombosis decreased when subcutaneous heparin was administered in the post-operative period. Microvascular surgery has become an important method for reconstructing complex surgical defects by using free vascularized transplants. The majority of free flaps were applied to the reconstruction of defects resulting from tumor ablation or trauma. The recipient sites were mainly distributed to the head and neck and to the limbs. Reconstruction of an irradiated recipient site is a significant predictor of failure. The vascular microsurgery using thread and needle requires a strict training with an important invested time.

[Mesenteric venous thrombosis complicating acute appendicitis]. / Thrombose veineuse mésentérique compliquant une appendicite aiguë.

Common primary surgical sources of thrombophlebitis of the mesenteric vein are diverticulitis and appendicitis. This is an acute ascending infection with septic thrombophlebitis. C.T. imaging can diagnose this complication at an early stage. Broad spectrum antibiotic therapy and heparin should be started. Surgery is performed electively to eradicate the primary inflammatory process. Early detections of septic ascending pylephlebitis and adequate treatment have decreased the mortality rate. We report a clinical case of thrombophlebitis of the mesenteric vein in acute appendicitis.

[Small bowel perforations after blunt abdominal trauma: evaluation with computed tomographic scan and laparoscopy]. / Perforations du grêle par traumatisme fermé de l'abdomen: évaluation par le scanner abdominal et la laparoscopie.

Small bowel perforations are the consequences of violent blunt abdominal trauma. Diagnosis of small bowel perforation is suspected in case of acute pain associated with peritoneal signs (tenderness, followed by rigidity). Computed tomographic scan performed in emergency is often specific, showing intraperitoneal fluid without visible solid organ injury, bowel wall thickening, bowel wall discontinuity, extraluminal gas or small pneumoperitoneum. Explorative laparoscopy confirms the diagnosis of blunt bowel injuries and allows usually its treatment. We report herein two cases where we have chosen this strategy.

[U-shaped free jejunum transplant]. / Le transplant libre de jéjunum en U.

Reconstruction of the oro and hypopharynx has specific difficulties due to their wide diameters. Seven patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngolaryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop. This transplant allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially at the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue, and avoided nasal reflux. The best indications are large resections involving the oropharynx.

[Prefabricated free transplants. Experimentation]. / Les transplants libres préfabriqués. Expérimentation.

The principle of prefabricated transplants consists in the manufacturing of compound transplants complete with a vascular pedicle containing an artery, a vein, a muscle and its nerve, some cell tissue, bone tissue, cartilage, periosteum and innerved skin. This transplant is constructed and modeled in accordance with its intended use, around the preselected vascular pedicle, whence the term prefabricated. Neovascularization revascularizes these different structures. The free transplants together with their vasculonervous pedicles are excised five weeks after manufacture and then transplanted to the recipient site. Experimentally, we grafted 15 free prefabricated transplants in Wistar rats. One failure was observed due to thrombosis of the anastomoses. Experimental data from macroscopic, arteriographic, microangiographic, and histological examinations, with injection of a staining material, show that neovascularization develops at the level of the transplant. The emphasis is on creating free transplants selectively using various tissues and selected vascular pedicles. These transplants constitute a useful prospective alternative for very elaborate reconstructive surgery.

[Vascularization of the larynx. Update of classical anatomic data from an anatomical study of 100 subjects]. / La vascularisation du larynx. Révision des données anatomiques classiques à partir d'une étude anatomique de 100 sujets.

The study was conducted after arterial and venous neoprene latex injection to 100 fresh subjects. Three laryngeal arteries are constant: superior, inferior and posterior. The superior laryngeal artery is of variable origin: in 84% of cases it arises from superior thyroid artery. Anastomoses between the three laryngeal pedicles and the muscle territories supplied by the arteries are described. Vascularization of cartilages is according to a precise plan and cricothyroid and cricoarytenoid joints are the site of constant arterial anatomoses. Origin of superior laryngeal artery fluctuates due to sliding phenomena. The notion of a neurovascular pedicle is fundamental: it is formed by the neural crest derivation and the corresponding artery, that is to say the artery and nerve of a branchial arch. This is to be compared with the notion of pure musculocutaneous and glandular pedicles. The larynx is a junctional zone between 4th and 6th branchial arches and is integrated with the cervicocephalic system of aortic arches.

[Laryngeal nerves. A histomorphometric and cartographic study]. / Les nerfs laryngés. Etude histomorphométrique et cartographie.

Major difficulties in laryngeal reconstruction are due to laryngeal nerves. A study was conducted of 100 larynges from fresh subjects after vascular injection. Vascularization of superior laryngeal nerves is derived essentially from superior laryngeal and ascending pharyngeal arteries. Inferior laryngeal nerves obtain their vascular supply from inferior thyroid and main carotid arteries. Histomorphometric study of laryngeal nerves used semi-automatic techniques: microscope, numerical table, computer, printer. The number of fibers per nerve varied between 511 and 2.244, the number of nerve fasculi between 3 and 14, and the diameter of myelinated fibers between 2 and 12 micron. Fibers of left inferior laryngeal nerve had a mean diameter (8.9 to 10.2) greater than those of right inferior laryngeal nerve (5.1 to 5.2 micron). Nerve tissue represented 60% to 66% of total. The left recurrent was longer than right nerve but had larger fibers providing more rapid conduction. Cartography of laryngeal nerves from 2 mm serial sections confirmed their plexis structure, this study providing new and objective precisions on laryngeal nerve structure.

[Reconstruction with free jejunal graft after total circular pharyngolaryngectomy. 73 cases]. / Reconstruction par transplant libre de jéjunum après pharyngolaryngectomie totale circulaire. Soixante-treize cas.

Among the various procedures of pharyngeal reconstruction after circumferential pharyngolaryngectomy, the free jejunal autograft (FJA) has become a common one. We retrospectively reviewed 73 cases of reconstruction with FJA after resection for advanced hypopharyngeal carcinomas (70 primary reconstructions, 3 secondary reconstructions). Postoperative outcome, functional and carcinologic results were studied. There were 1 postoperative death, medical complications in 19 patients, 4 graft failures (5.5%), 11 salivary fistulas. The nasogastric tube was removed before the 15th day in more than a half of the patients. One year postoperatively all the evaluable patients were able to take an oral diet (solid or soft diet for 97% of them). The postoperative radiotherapy was well tolerated. Cancer developed further in 33 patients (13 local and/or nodal recurrences, 13 isolated metastasis, 7 second primaries). The overall survival rate was 44.8% at three years. It seems clear that FJA allows good functional results and increases the quality of life in such patients with poor prognosis.

[Free bone flaps in esthetic and functional rehabilitation after segmental mandibulectomy. Apropos of 38 cases]. / Apport des lambeaux libres osseux dans la réhabilitation esthétique et fonctionnelle après mandibulectomie interruptrice. A propos de 38 cas.

Development of microvascular free tissue transfers gives the surgeon the opportunity to realise complex reconstructions after segmental mandibular resections for tumor. We reviewed 38 cases of oromandibular reconstruction using various free bone grafts (25 fibula, 7 scapular, 3 iliac and 3 forearm free flaps). The mandibular defect was anterior in 24 cases, lateral in 9 cases and subtotal in 5 cases. In the post-operative course there were two total flap losses. Long-term esthetic results were excellent or good for 82% of the patients, 81% were able to eat a solid or a soft diet. The causes of esthetic or functional failures were studied as well as the specific interest of each donor site. The use of free bone flaps improved cosmetic and functional rehabilitation in cases of anterior mandibular defects. The secondary reconstructions or reconstructions of lateral bony defects were more disappointing. The free fibula flap allows reconstruction of wide bony defects. Scapular flap or forearm flap are indicated for smaller bony defects and in patients with severe peripheral vascular disease.

[Choice of the 3d portion of the jejunum for reconstruction of the pharynx in circular pharyngolaryngectomies. Indications and advantages]. / Le choix du troisième jéjunum comme procédé de reconstitution du pharynx dans les pharyngo-laryngectomies circulaires. Indications et avantages.

Many procedures are used for reconstruction of a pharyngeal gutter after circular pharyngolaryngectomy, interrupter of digestive continuity. The operation chosen was used of third part of jejunum for reconstruction, and its indications and limitations are described. The choice was based on anatomic data from dissection of 100 cadavers and values for different measurements performed (length of transplant, height of mesentery, caliber and length of vessels), and more particularly on constancy and reliability of vascularization of this digestive segment. To these advantages are added bacteriologic, technical, histologic and physiologic reasons. Results are analyzed of 11 operations carried out in the same department, from among a larger group comprising now 45 cases. Postoperative course was usually uncomplicated with rapid restoration of deglutition (a mean of 11.77 days in 9 of the 11 cases). Preoperative radiotherapy is not a contraindication and postoperative radiotherapy should be given routinely as a complement to surgery. It is usually well tolerated and transplant necrosis is not provoked. Nevertheless, the seriousness of this type of lesion is underlined by the high incidence of carcinologic failures, with an elevated risk of local and regional recurrence and of distant metastases.

[Carcinoma of the hypopharynx: reconstruction of the pharyngo-esophageal tract after circular pharyngectomy by the transplantation of a U-shaped jejunal loop to the neck]. / Carcinoma dell'ipofaringe: ricostruzione del tratto faringo-esofageo dopo faringo-laringectomia circolare mediante trapianto di ansa digiunale ad U al collo.

Reconstruction of the oro- and hypopharynx has specific difficulties duo to their wide diameters. Thirteen patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngo-laryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop and allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue and avoided nasal reflux. Best indication are large resections involving the oropharynx.