[Thoracoscopic bypass from the descending thoracic aorta to the femoral artery. Experimental study and clinical application]. / Pontage thoracoscopique entre l'aorte thoracique descendante et l'artère fémorale. Etude expérimentale et application clinique.

OBJECTIVE: Descending thoracic aorta to femoral artery bypass (DTAFB) has demonstrated usefulness in the treatment of aorto-iliac occlusive disease but related morbidity and mortality are not negligible. We wanted to determine the feasibility of thoracoscopic DTAFB and to report our clinical experience. MATERIAL AND METHODS: An experimental study was performed on 8 pigs in helicoidal position under general anesthesia with right selective ventilation ). Three trocars were inserted and the descending aorta was dissected ). After tunnelisation of a 6 mm graft, a lateral aortic anastomosis was thoracoscopically performed ) then femoral anastomoses were made. At the end of the procedure, an angiogram and then an autopsy were performed ). Subsequently, three patients were operated, two for thrombosis of a previous aortobifémoral bypass and one for infrarenal aortic hypoplasia. Dissection and graft tunnelisation were performed thoracoscopically ). Then, the aortic anastomosis ) was constructed through a left lateral minithoracotomy (10 cm). RESULTS: One pig died during surgery of acute lung oedema due to the difficulties of selective ventilation. Excluding this case, the average times of surgery and of dissection were respectively 246 (205-325) and 68 minutes (50-90). The average aortic clamping and anastomosing times were 135 (105-220) and 120 minutes (80-210) ). Three aortic tears were noted; one was repaired. Angiogram was normal 5 times; one pig had a minor stenosis and a leak, and another one had a leak. All the anastomoses were patent without stenosis at autopsy; no organ lesion was found. In humans, the procedure was performed with simple postoperative course in 2 patients and a conversion (20 cm long thoracotomy) was necessary for the third due to poorly supported selective ventilation. CONCLUSION: Totally thoracoscopic DTAFB can be performed in pigs. In clinical practice, we recommend the use of a mini thoracotomy. This way, the aortic anastomosis can be performed with aortic clamping time under 30 minutes, reducing the risk of spinal cord ischemia. These results allow to propose mini invasive thoracoscopically assisted DTAFB for the patients for whom laparoscopic access of the abdominal aorta appears to be difficult (calcified aorta, hostile belly.).

[Laparoscopic transperitoneal replacement of the abdominal aorta with left renal artery reimplantation: experimental study on pigs]. / Remplacement laparoscopique transpéritonéal de l'aorte abdominale avec réimplantation de l'artère rénale gauche.

OBJECTIVE: To study the feasibility and the tolerance of a combined laparoscopic transperitoneal aortic and renal restoration performed on animals. METHODS: Six pigs (mean weight: 79.5 kg, range 73-86) underwent laparoscopic replacement of the abdominal aorta using a 6-mm Dacron(R) graft, with direct reimplantation of the left renal artery. The study protocol was approved by the Advisory committee of Animal Ethics. The animal was placed supine on the operative table with a pillow under the lumbar region in order to raise the aortic area. A first midline, 10-mm diameter trocar was placed under direct vision, 5 cm above the pubis and allowed the insufflation of a 12-mm Hg pneumoperitoneum. One 30 degrees optic was used during the intervention. The pig was then tilted to a 30 degrees Trendelenbourg's position and two other 10-mm trocars were introduced 5 cm medially to the right and left antero-superior iliac spines ). Four other 10-mm incisions were necessary for introduction of an intestinal retractor, a suction-irrigation device and two laparoscopic aortic clamps. RESULTS: The procedure was performed in all animals in a mean operative time of 320 min (292-366), including ): - a time for aortic and renal artery dissection of 104 min (90-120), - a supra-renal aortic clamping time of 221 min (180-276), - a time for confection of proximal and distal aorto-prosthetic anastomosis of respectively 59 min (40-75) and 64 min (50-80), - a time for the left renal artery reimplantation of 72 min (40-140). Average blood loss was 525 ml (250-1050), and the mean pre and postoperative hemoglobin and pH values were 9.9 g/dl (8.9-10.7) versus 9.4 g/dl (8.5-11.3) and 7.36 (7.31-7.38) versus 7.30 (7.21-7.43) respectively. An angiogram ) performed before the sacrifice of animals showed a wide patent anastomosis in 18 (56%) cases, a<50% stenosis in 4 cases (22%), a > 50% stenosis in 1 case (5%) and a thrombosis of the first three renal artery restorations (17%) probably due to insufficient intraoperative heparinization. CONCLUSION: This experimental study shows the feasibility of laparoscopic transperitoneal abdominal aortic restoration with re-implantation of the left renal artery (fig. et ). The techniques of arterial sutures must be improved in order to decrease aortic and renal clamping times.

[American pulmonary histoplasmosis. Prospective study with 232 soldiers after a 2-year assignment in Guiana]. / Histoplasmose pulmonaire americaine. Etude prospective chez 232 militaires ayant effectue un sejour de 2 ans en Guyane.

The purpose of this report is to describe the results of a prospective study on pulmonary histoplasmosis in French Guiana. Chest radiographs were performed in 232 French legionnaires returning from a two-year assignment in French Guiana. Further examinations were performed in a total of 8 subjects in whom chest radiographs demonstrated the presence of nodules in the lungs. No evidence of cancer or tuberculosis was found. Findings confirmed histoplasmomas in two cases and demonstrated probable histoplasmosis nodules in 6 cases including three involving calcified lesions. Five of these eight patients had been in high-risk rain forest environments. Pulmonary histoplasmosis should be considered as a possible diagnosis in subjects returning from endemic zones. Confirmation depends on a spectrum of findings. Calcified nodules require only radiographic surveillance with follow-up at six months. Non-calcified nodules require further investigation including CT-scan, bronchoscopy, and serological tests. Surgical biopsy may be necessary to achieve exact histological and mycological identification of the lesion and is recommended in smokers.

[An anterior mediastinal mass]. / Une masse médiastinale antérieure.

A 50-year-old man developed a bronchogenic cyst complicated by hemorrhage. A complete radiographic chest work-up provided a reliable diagnostic approach. Bronchogenic cysts are usually asymptomatic incidental discoveries. Chest ultrasonography confirms the cystic nature of the mediastinal mass. Computed tomography scan and especially magnetic resonance imaging further support the diagnosis and are helpful for guiding surgery. Surgery is required because of the unpredictable risk of hemorrhage, infection or enlargement.

[Laparoscopic replacement of the abdominal aorta. Experimental study in the pig]. / Remplacement laparoscopique de l'aorte abdominale. Etude expérimentale chez le porc.

BACKGROUND: Progress in abdominal laparoscopy led us to study end-to-end anastomoses performed laparoscopically. METHOD: An experimental protocol in 10 castrated male pigs weighing 74-95 kg was approved by the ethics committee. After conventional anesthesia, each animal was positioned in lateral decubitus and a retropneumoperitoneum was created. CO2 inflation was maintained at 14 mmHg for insertion of 3 trocars, 5 to 10 mm width. The entire infrarenal aorta was dissected and resected with insertion of a 6 mm dacron prosthesis. Postoperative arteriography was performed in all cases. The animal was sacrificed for direct examination. RESULTS: One animal died during anesthesia induction and the entire protocol was conducted in 9 animals. Mean operative time was 397 min (305-535 min) including a mean 123 min (65-150) for aortic dissection, 82 min (30-155) for proximal anastomosis and 70 min (45-105) for distal anastomosis. Total blood loss varied from 100 to 450 cc (mean 252 cc). Mean difference between pre- and postoperative hematocrits was 4% (0-6%). Among the 18 aortic anastomoses performed, arteriography showed one with moderate leakage and one anastomotic thrombus. Stenosis > 50% was found in 4 cases and < 50% in 4 cases. Analysis of the different operative parameters showed a learning curve with decreasing operative time and improved quality of the anastomoses. CONCLUSION: This study demonstrates the feasibility of aortic reconstruction via retroperitoneal laparoscopy in the animal. This procedure could be introduced in man.

[An unusual tumor of the mediastinum]. / Une tumeur du médiastin inhabituelle.

We report a case of dual parathyroid adenoma associated with an ectopic gland in the right latero-esophageal region of the mediastinum revealed by asymptomatic hypercalcemia. Because of this dual localization and the lack of MBI uptake on the mediastinal scintigram, thoracotomy was used as the first line approach instead of cervicotomy.

[Benign mediastinal opacity: Castleman disease, apropos of a case and review of the current literature]. / Une opacité médiastinale bénign. Maladie de Castleman, á propos d'une observation et revue récente de la littérature.

We report a case of fortuitously observed Castleman's disease. An mediastinal opacity was observed on the chest x-ray. At surgery, the apparently benign tumor was well individualized. Pathology reported Castleman's disease. Pathogenesis is unknown. Recent data on localized and more diffuse forms of this disease are presented. Diffuse forms occur more readily in immunodepressed patients.

[A tropical pulmonary nodule]. / Un nodule pulmonaire "tropical".

The authors report a case of american pulmonary histoplasmosis discovered by chance on a chest radiograph in a non immunocompromised patient, back from a stay in French Guyana. Confronted with the negativity of usual mycotic research, diagnosis has been made thanks to wedge excision by video-assisted thoracic surgery. The authors briefly sum up the recent facts regarding this imported infection, stressing the interest of a direct approach by surgical practices not very invasive that allow to eliminate with certainty neoplasm or tuberculosis.

[Firearm wounds of the lower urinary tract in men. Surgical management in emergency context]. / Les plaies par arme à feu du bas appareil urinaire chez l'homme. Prise en charge chirurgicale dans le contexte de l'urgence.

The lower urinary tract is injured in less than 1% of all firearm wounds in men. In war medicine, blast wounds occur in 75% of the cases while in civil medicine ballistic injuries are more frequent. When the bladder and the posterior urethra is involved, the projectile usually follows a path through the gluteal muscles and pelvis. A perineal genital path is usually found for injuries to the anterior urethra. This explains the frequency of associated vascular and colorectal lesions in pelvic wounds and genital injuries in perineal wounds. Bone and muscle injuries occur in both situations. A mental reconstruction of the projectile path is required for a precise diagnosis of the lesions, together with the clinical examination (urine outlet, miction impossible with or without bladder extension, urethral bleeding) and most importantly standard x-ray of the pelvis in search of bone lesions and the projectile. Urethrography should always be performed whenever the urethra is injured in all civil wounds. However, the final diagnosis of the lesions can only be made at surgery. Urology procedures, usually performed by polyvalent surgeons, should be simple, rapid and reliable. It is important to preserve urinary and genital functions in these young subjects usually under 30 years of age. Cystostomy and drainage is the strict minimum. In addition, depending on the infectious and hemodynamic status, conservative excision of damaged tissue is needed prior to primary closure. Wounds involving the bladder can be closed in 95% of the cases. Closure is simple for wounds involving the superior portion of the bladder. For deeper wounds involving the trigone endovesical suture is used after intubing the ureters. Ureteral drainage is mandatory when the bladder is highly damaged and cannot be closed. Urethro-prostato-membranous wounds should also be repaired to avoid inevitable fibrosis of fistulization. However, access to the apex of the prostate causes major bleeding and there is a risk of injuring the sphincter or erection nerves, particularly by surgeons inexperienced in urogenital surgery. When massive bleeding cannot be controlled by clamping the two hypogastrics, symphysiotomy, rather than symphysectomy, is recommended. In other cases, aligning the urethral extremities may be sufficient. Short wounds to the anterior urethra should be cleaned and the extremities spatulated and anastomosed on a guide when they can be closed. In other cases, a perineal or penile urethrostomy is created. Associated wounds involving the anus and rectum require colostomy, emptying the excluded rectum and wide pelvic-perineal drainage. An attempt should be made to repair the rectum or the sphincter. Genital lesions require early repair: tight suture of the albuginea of the cavernous bodies with or without a patch, preservation of viable testicular parenchyma and adnexal tissues (but orchidectomy is necessary in 50% of the cases).

[Treatment of caustic stenoses of the upper digestive tract]. / Traitement des sténoses caustiques du tractus digestif supérieur.

Stenosis of the upper digestive tract developed in 22 patients with stage IIB or stage III caustic burns due to massive ingestion of an alkaline substance in 18 cases and an acid substance in 4 cases is analysed. Emergency oesogastrectomy without thoracotomy was performed in emergency situations in 10 patients in whom mortality reached 30%. For the remaining 12 patients with minimal stage IIB lesions, a jejunostomy was opened for enteral nutrition. After three months, stenosis developed in 10 cases and required surgical treatment in 7 after failure of endoscopic dilatations. Surgery included retrosternal coloplasy with oesophagectomy for 3 patients. There were no deaths. Two patients with a stenosis of the cervical anastomosis were treated endoscopically. These results suggest that the use of the endoscope in the acute phase can help ascertain the best management technique and confirms that stage IIB stenosis can develop a tight stenosis in 50% of the cases. This situation requires surgical treatment in 70% of the cases.

Diagnosis by video-assisted thoracoscopy of traumatic pericardial rupture with delayed luxation of the heart: case report.

Isolated pericardial rupture is probably a frequently overlooked injury. We present a case of delayed heart herniation through a left pericardial tear resulting from blunt trauma. Diagnosis was achieved by video-assisted thoracoscopy, which was also helpful in the selection of the appropriate site and extent for the thoracotomy incision.

[Round pulmonary lesions after returning from French Guyana. Six cases of american pulmonary histoplasmosis]. / Image ronde pulmonaire au retour de Guyane française. A propos de six cas d'histoplasmose américaine pulmonaire.

From 1989 to 1994, 71 patients were hospitalized for diagnosis of round lung lesions including 49 servicemen under the age of 45 years who had been stationed in tropical areas. In 6 of these servicemen, the diagnosis was pulmonary histoplasmosis at the tertiary stage of histoplasmoma. All had done duty in French Guyana and were negative for human immunodeficiency virus. The subpleural lung opacity was the only lesion in 5 out of 6 patients and was calcified in 4 out of 6 patients. Since skin tests with histoplasmin and serologic testing for histoplasmosis failed to achieve definitive diagnosis, surgical biopsy was performed by conventional thoracotomy in 2 cases and video-assisted thoracic surgery in 4 cases. The specimens obtained confirmed diagnosis of histoplasmosis on mycologic criteria in 3 cases and on a combination of findings including compatible histologic evidence in 3 cases. Treatment consisted in surgical excision of the nodules, for which video-assisted thoracoscopic surgery proved to be an excellent technique because of its simplicity and rapidity.

Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy.

We prospectively analyzed the outcome of lobectomy in a cohort of 67 patients. Operative time, postoperative pain, pulmonary function, and early outcome were compared between the patients undergoing video-assisted techniques (n = 44) and those undergoing standard muscle-sparing procedures (n = 23). Pain was quantified daily throughout the first week using the visual analog scale. The forced expiratory volume in 1 second and the forced vital capacity were measured at days 2, 4, and 8 postoperatively. The operative time was significantly longer (p < 0.02) and the postoperative pain was significantly less (p < 0.006) in the group undergoing video-assisted procedures. Pain-related morbidity, the mean duration of air leaks, the duration of chest tube placement, and the hospital stay were all less in the video-assisted group, but the differences did not reach statistical significance. However, the impairment in pulmonary function and the overall morbidity were identical for the two groups. Based on our findings, we conclude that video-assisted minithoracotomy is a safe and reliable approach for performing lobectomies, and that the decreased postoperative pain associated with this minimally invasive approach does not result in preserved pulmonary function and significantly reduced morbidity when compared with a muscle-sparing thoracotomy.

Rupture of the thoracic trachea with a Sengstaken-Blakemore tube.

Tracheal rupture from within is uncommon and always iatrogenic. We report a case of a tracheal rupture following the use of a Sengstaken-Blakemore tube to control a gastroesophageal hemorrhage. Emergency surgical repair was required. Although complications associated with balloon tamponade are well-documented, no major tracheal injury has ever been reported.

[Video-assisted thoracic surgery. Current techniques and indications]. / La chirurgie thoracique vidéo-assistée. Techniques et indications actuelles.

Up til recently, thoracoscopy was essentially performed for diagnostic purposes, allowing biopsies of the pleura or peripheral lesions of the lung tissue. Indications with a therapeutic objective were less frequent, usually in cases of recurrent pneumothorax. The recent development of less aggressive, more surgical instruments has virtually "forced" the surgeon to use the thoracoscope. Video thoracoscopy surgery thus entered the therapeutic armenatum. Small access channels less than a centimeter in diameter are used for videothoracoscopy giving an indirect view on the screed of the thoracic contents. Under these conditions, thoracoscopic procedures are possible to treat pneumothorax and resect small pleural or parenchymatous tumours. Inversely, gross resections (lobectomy, pneumonectomy) are technically more complex and raise the nearly unsolvable problem of removing the surgical specimen. In fact, a mini-thoracotomy has been required in many cases, leading to the development of video-assisted thoracic surgery. This new surgical technique is performed via a small incision and is guided by optic probes connected to the video screen. The surgeon can thus follow the entire operation both directly via the mini-thoracotomy and indirectly on the screen. This new approach is an interesting compromise between conventional thoracic surgery and videothoracoscopy.

Major pulmonary resection by video assisted mini-thoracotomy. Initial experience in 35 patients.

Video-assisted thoracic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. From February to July 1993, 35 patients (25 male, 10 female; mean age = 60 years, range: 17-74) underwent a major pulmonary resection using a video-assisted technique: lobectomy (n = 30) or pneumonectomy (n = 5). Pathology disclosed bronchogenic carcinomas (n = 26), metastases (n = 3), and miscellaneous disorders (n = 6). All procedures required one 10.5 mm port for the video-camera, one 3.5 to 5 cm utility thoracotomy through which surgical instrumentation was inserted and the operative specimen removed, and one occasional supplementary 12 mm port. Lung resections were performed with separated dissection and division of each component of the pedicle. The mean operative time was 145 min (SD: +/- 17). There were two postoperative deaths (5.7%) that were not directly related to the technique. Seven patients (20%) experienced non-fatal complications. After lobectomy, the mean duration of chest tube placement was 7.3 days (SD: +/- 1.6). The mean hospital stay was 11 days (SD: +/- 3). All the patients experienced minor postoperative chest pain. We conclude that video-assisted lung resections are technically feasible without an increased risk.