Ileal MALT lymphoma causing massive gastrointestinal haemorrhage revealed on computed tomography angiography.

Primary MALT lymphomas affecting the ileum are rare, and their presentation with massive haemorrhage exceptional. This report describes such a case. The patient presented with melaena and haemodynamic instability, but normal upper gastrointestinal endoscopy. Subsequent imaging with multi-detector row computed tomography angiography both localised the bleeding source to the ileum and identified the underlying tumour, resulting in considerably earlier introduction of appropriate management. The patient made an excellent recovery and remains in remission.

Right ventricular function early after total or standard orthotopic heart transplantation.

Right ventricular failure after orthotopic heart transplantation (OHT) is classically related to preoperative pulmonary hypertension. However, the role of the enlarged atria in right ventricular dysfunction after OHT remains unclear. For that purpose, the right ventricular function in the first 2 days after OHT was compared in two groups of transplant recipients: 11 patients who underwent standard OHT (group I) and 9 patients who underwent total OHT, which consisted of total excision of both the left and right atria and OHT of an intact donor heart with its atria as well as its ventricle (group II). Right ventricular ejection fraction, cardiac index, and right-sided pressures were recorded at baseline and 4, 8, 12, 24, and 48 hours after OHT using a Swan-Ganz catheter with a rapid-response thermistor. Right ventricular function parameters did not differ between groups; they were characterized by a decrease in right ventricular ejection fraction and an increase in right ventricular end-diastolic volume index whereas cardiac index and right-sided pressures remained normal or slightly increased. Ischemic time (177 +/- 41 minutes in group I versus 178 +/- 39 minutes in group II) and preoperative pulmonary vascular resistance (1.9 +/- 0.7 Wood units in group I versus 3.0 +/- 1.5 Wood units in group II) were not different between groups. These results suggest that the anatomic and physiologic advantages offered by the modified technique of OHT had no clinical relevance in this group of patients with low preoperative pulmonary vascular resistances when compared with a group of patients who underwent transplantation with the standard technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and late outcome after elective cardiac surgery in patients with cirrhosis.

BACKGROUND: A prospective study was performed to evaluate the early and late outcome after elective cardiac surgery in patients with cirrhosis. METHODS: All patients who underwent elective cardiac surgery between 1995 and 1997, and were suspected of having a history of cirrhosis, were followed in the intensive care unit (ICU), during hospitalization and after hospital discharge. All patients received high doses of aprotinin during surgery. RESULTS: Ten patients of Child-Pugh class A and 2 patients of Child-Pugh class B were studied. All patients had signs of portal hypertension, and 11 of 12 patients had thrombocytopenia. In the first 24 h after operation, the median chest tube output was 810 mL (range 350 to 1,500 mL). Median ICU and hospital stays were 3 and 15 days, respectively (range 2 to 10 and 7 to 36 days, respectively). Seven patients experienced postoperative morbidity and 7 patients had significant complications after their hospital discharge. One death occurred in the ICU. Two deaths occurred after hospital discharge and were related to further hepatic damage. CONCLUSIONS: These results suggest that, in patients with mild or moderate cirrhosis, the incidence of significant complications was high after elective cardiac surgery, increasing the length of stay in ICU and overall hospitalization time and compromising the health status, even well after the operation.

[Cardiac surgery under extracorporeal circulation in patients with chronic renal insufficiency. Apropos of 4 cases and review of the literature]. / Chirurgie cardiaque sous circulation extra-corporelle chez les insuffisants rénaux chroniques. A propos de 4 observations et revue de la littérature.

Four cases of cardiac valve replacement in patients with chronic renal failure are reported. The problem of surgery under cardiopulmonary bypass in these patients are discussed with respect to 36 other previously reported cases. Of this lot of 40 cases, 33 (82,5 p.100) underwent valve replacement (21 aortic, 9 mitral, 1 mitral and aortic, and 2 unspecified), 26 (79 p.100) for valvular lesions due to infective endocarditis. Coronary revascularisation was performed in 6 cases (15 p.100) and pericardectomy in 1 case. Operative mortality was within acceptable limits (4 deaths) ; the overall mortality was 10 cases. Valvular lesions due to endocarditis were the main cause of death (9 cases). A session of haemodialysis is performed 12 hours preoperatively. Post-operative care is directed to the control of the fluid balance, the neutralisation of metabolic acidosis with alkaline fluids (sodium lactate) and the correction of hyperkalaemia by kayexalate. In addition, dialysis is required between the 24 th post-operative hour and the 3 rd day. The main indications for cardiac surgery under cardiopulmonary bypass in patients with renal failure are valve replacement for infective endocarditis where the operative decision should be made early on, and aorto-coronary bypass grafting, the selection criteria for which should be very strict.

[Cardiac transplantation at the University Hospital Center of Nantes. 2 years' experience]. / Transplantation cardiaque au CHU de Nantes. Deux ans d'expérience.

Between March, 1985 and April, 1987, 25 orthotopic heart transplantations were performed in 20 men and 5 women aged from 17 to 58 years (mean 42 years) on account of cardiomyopathy (n = 15), ischaemic heart disease (n = 6) or miscellaneous lesions (n = 4). The immunosuppressive treatment consisted of antilymphocyte serum and corticosteroids during 10 days; cyclosporine was introduced on the 7th day and continued thereafter in association with low-dose corticosteroid therapy. Endomyocardial biopsies were performed. Acute rejection, responsible for 2 deaths (one on the 10th day, the other in the 10th week), usually occurred within the first 3 months. Infections were frequent and often serious, resulting in one death in the 7th week. One out of patients had to be treated for arterial hypertension, and 3 patients presented with renal impairment (blood creatinine over 200 mumoles/l). The actuarial survival rate at 2 years is 84 p. 100. More than one-half of the patients have resumed social and occupational activities.

[Heart-lung transplantation and cystic fibrosis. Indications and results]. / Transplantation cardiopulmonaire et mucoviscidose. Indications et résultats.

BACKGROUND: Heart lung transplantation for++ cystic fibrosis is now performed in patients with severe lung disease but the experience is still scarce with the exception of some specialized centers. PATIENTS AND METHODS: Twenty-one patients underwent heart-lung transplantation between September 1989 and November 1994 in our institution, with a high standard of reliability in tracheal anastomosis and with a low incidence of hospital mortality (5%). RESULTS: The actuarial patient survival is 90.2% (95% confidence interval, 70 to 97%) at 1 year and 75.7% (95% confidence interval, 51 to 90%) at 3 and 4 years. The mean forced expiratory volume in 1 second (FEV1) increases from 20.1% predicted preoperatively to 76.1%. CONCLUSION: Despite the presence of airway pathogens, these results confirm that heart-lung transplantation for cystic fibrosis leads to a pronounced improvement in lung function and good rehabilitation after surgery. The two main obstacles are the shortage of donor organs and the possibility of late deterioration in lung function with a progressive airflow obstruction.

[Comparison of amoxicillin and cefamandole in the prevention of bronchopulmonary infections in pulmonary surgery. A randomized double-blind study]. / Comparaison de l'amoxicilline et du céfamandole pour la prévention des infections broncho-pulmonaires en chirurgie pulmonaire. Etude randomisée, en double-aveugle.

Antibiotic prophylaxis is currently recommended in clean-contamined surgery (type II of Altemeier classification). Pulmonary surgery belongs to this type. This prospective randomized and controlled study was designed to compare amoxicillin and cefamandole for prevention of pleural and bronchopulmonary infections after pulmonary resections. It included 256 patients, admitted between October 1st 1989 and July 1st 1991, for elective thoracotomy and probable pulmonary resection. The patients were allocated into two groups, group A (amoxicillin) and group C (cefamandole). The first intravenous antibiotic injection took place immediately after induction of anaesthesia (1 g of amoxicillin or 1.5 g of cefamandole). Postoperative injections were performed every 6 hours during 36 hours (i.e. a total of 6 injections). Infection was defined by the association of general signs including hyperthermia (> 38 degrees C), hyperleucocytosis (> 12,000/mm3), and local signs such as bronchitis (B), pneumonia (P), empyema (E), wound sepsis (W) and non thoracic infection (S). Follow-up included the hospital stay and a period of eight months after surgery for possible rehospitalisation for infection. Respiratory infections (bronchitis n = 35, pneumonia n = 5, empyema n = 2) occurred in 18% of the total population. No difference was seen between the two groups concerning the type of infection and the repartition of infection in relation to the type of pulmonary surgery. The causative bacterial organisms were Haemophilus influenzae (n = 4), Streptococcus pneumoniae (n = 2), Escherichia coli (n = 1), anaerobic bacteria (n = 1). Multiple bacteria were found in one case. The empyema and wound sepsis occurred in the amoxicillin group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute renal failure after extracorporeal circulation with aortic counterpulsation in surgically treated patients]. / Insuffisance rénale aiguë après circulation extracorporelle chez des opérés avec contrepulsion aortique.

In a series of 604 adults operated on for cardiac surgery with cardiopulmonary bypass (CPB), 21 (3.5%) underwent circulatory assistance by intra-aortic balloon pump (IABP); in 5 of them (24%), acute renal failure (ARF) was observed. ARF occurred in only 26 (4.4%) of the other patients who did not require IABP. Evolution of ARF and its factors were therefore investigated in those patients having received IABP. ARF was defined as serum blood urea nitrogen (BUN) greater than or equal to 16 mmol X 1(-1), urinary urea/BUN less than 10, creatinine clearance less than 40 ml X min-1 X 1.73 m-2. Some perioperative features were compared between patients with postoperative ARF and those without ARF. ARF occurred in the 5 patients with IABP during, or immediately after, weaning from IABP. ARF was more frequent in patients operated on for mechanical complications of myocardial infarction with a significant more severe haemodynamic status. They had significantly longer CPB and aortic clamping times. The prognosis depended on the cardiac failure and not on the ARF. In patients with mechanical complications of infarction, early IABP seemed to be the predominant preventive measure. Other therapeutic implications are suggested, particularly the use of dopamine (1 to 3 micrograms X kg-1 X min-1) because of its renal vasodilating action which can contribute to the maintenance of urinary flow.

[Heart surgery with extracorporeal circulation in hemodialyzed patients with renal insufficiency]. / Chirurgie cardiaque sous circulation extra-corporelle chez des insuffisants rénaux hémodialysés.

The authors report 4 valvular replacements under cardiopulmonary bypass in chronic hemodialysis-dependent patients. The peri-operative management was the same in every case. The recent improvements of intensive care medicine amend this protocol. Considering the analysis of data from the literature and the results of our 4 valvular replacements these operations and coronary artery-bypass graft, can be scheduled with an acceptable risk in these patients. Because of the hemodynamic improvement secondary to the cardiac operation, which allows a better tolerance of hemodialysis, this surgery must not be delayed.

[Incidence and prognosis of acute renal failure after cardiac surgery with extracorporeal circulation]. / Fréquence et pronostic des insuffisances rénales aiguës après chirurgie cardiaque avec circulation extra-corporelle.

Acute renal failure occurred in 21 patients after 311 cardiac operations with cardiopulmonary bypass in adults (6,75%). It was non oliguric in 20 cases. It is related to per and postoperative hemodynamic depression. Patients operated for valvular replacement seemed most at risk if severe cardiac failure existed with or without preoperative renal dysfunction. Similarly those operated upon for mechanical complications of myocardial infarction were often affected. The prognosis depends on the degree of cardiac failure. Strict patient selection, myocardial protection during bypass and measures to increase low cardiac output are recommended. Intra-aortic balloon pump for patients with myocardial infarction and dopamine in the early postoperative period seem helpful.

[Infections in surgery under extracorporeal circulation. Results of 3 years of antibioprophylaxis]. / Infections en chirurgie sous circulation extra-corporelle. Bilan de 3 ans d'antibioprophylaxie.

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.

[Inotropic and vasopressive drugs during anesthesia and critical care. Current data]. / Inotropes et vasopresseurs en anesthésie-réanimation. Actualités.

Recent therapeutic advances in inotropic drugs and vasipressors uses allow a reappraisal of their indications during the perioperative period. Non-catecholamines vasopressors, ephedrine and phenylephrine, are particularly suitable for treatment of abrupt peroperative arterial hypotensions as observed during induction of general and medullar anesthesias. Cardiac arrest, peroperative anaphylactoid and toxic accidents are treated with epinephrine. In non-cardiac surgery, circulatory insufficiency is usually due to a peripherical origin. Cardiogenic failure occurs in rare cases mainly in vascular surgery. Therefore dopamine remains the first amine to be used in non-cardiac surgery in conjunction with volume expansion. A cardiogenic factor is responsible for most of low-cardiac output syndromes observed after cardiopulmonary bypass for cardiac surgery. However, hypovolemia may be involved and could be undiagnosed. For these reasons, dobutamine is used because of its rapid half-life of elimination and its potent effects. Inodilators (enoximone, amrinone and milrinone) ans nex dopaminergic compound (dopexamine) are powerful vasodilators agents to be introduced with care when association of amines and current vasodilators have failed. Finally, arterial pressure has to be maintained with norepinephrine after dopamine failure. Epinephrine remains last chance.

[Accidents and complications seen during anesthesia and postoperative recovery in coronary surgery]. / Incidents et accidents observés lors de l'anesthésie-réanimation en chirurgie coronaire.

One hundred and six cases of myocardial revascularisation ECC performed during 1976 and 1977 were reviewed in order to assess the accidents and complications seen in surgery of this type. The course of the operation, and above all during the pre-ECC phase, was felt to be marked above all by hypertensive crises. During the immediate postoperative phase the picture was dominated by haemodynamic problems. Moderate left ventricular failure was common and responded rapidly to restoration of water and electrolyte and blood volume balance. Sympathomimetic amines were also used as necessary. Severe low output states were seen in only 8.5 per cent of cases. Analysis of factors interfering with the operation showed that the prior myocardial state had the most influence on the postoperative course.

[A new case of epidermolysis bullosa dystrophica in a fifteen years old girl operated upon for pulmonary stenosis with a cardiopulmonary bypass (author's transl)]. / Epidermolyse bulleuse congénitale (dystrophique polydysplasique). Problèmes anesthésiques pour la chirurgie avec circulation extra-corporelle.

The authors encountered technical difficulties for the endotracheal intubation but neither laryngeal damage nor serious oropharyngeal lesions occurred after this intubation. The general evolution was favourable without specific trouble (cutaneous or infectious). The risk of intubation was reexamined from the recent literature. It is generally believed that there is a tendency for the skin to become more resistant to the formation of bullae as the afflicted children grow older. So, when another disease sets vital prognosis in action, major surgical operations can be performed and more especially as the average length of life is now increasing for these patients.

Mitral valve replacement with St Jude Medical prosthesis. Incidence of thromboembolic events in 349 patients.

This study reports incidence of thromboembolic episodes in a series of 349 patients where the St. Jude Medical (SJM) valve was implanted in the mitral position (252 isolated mitral, 91 mitral and aortic, 4 triple valve and 2 mitral and tricuspid valve replacements). The mean follow up was 28 months (range 6 to 57 months) which represents 784 patient-years. Overall operative mortality was 15 patients (4.3%). There were no valve-related deaths. Late post-operative prosthetic thrombosis occurred in 3 poorly anticoagulated patients (0.4% patient-years). A further 4 patients had a thromboembolic episode (0.5% patient-years). The overall frequency of thromboembolic episodes was 0.9 events per 100 patient-years. Per- and post-operative anticoagulation methods are described. The frequency of thromboembolism was studied with respect to the performance of SJM valve analyzed by echocardiography regardless the positioning of the prosthesis in the mitral ring. Our experience indicates that the SJM valve offers an excellent alternative in the choice of mechanical valve.