[The opportunities of the minimally invasive approach for the cardiovascular and thoracic surgery]. / Apport de l'approche moins invasive en chirurgie cardiovasculaire et thoracique.

There is a continuous growth in the incidence of cardiovascular and thoracic diseases, especially related to the increased life expectancy. Moreover, the quality and efficacy of care for these pathologies are progressing constantly. The evolution of surgery prompts us to develop less aggressive (minimally invasive), although technically more complex, treatment or diagnostic techniques. Pathologies, which until now required heavy surgeries, are managed today in a less invasive way and become therefore accessible to patients even if they are older or in a poor general condition. In this article, we present our experience in the development of the minimal invasive procedures in cardiovascular and thoracic surgery.

Les pathologies cardiovasculaires et thoraciques, au sens large, sont de plus en plus fréquentes, vu l'augmentation de l'espérance de vie, mais elles sont aussi de mieux en mieux prises en charge. En effet, l'évolution de la chirurgie nous incite à développer des techniques de traitement ou de diagnostic moins agressives (mini-invasives) quoique techniquement plus complexes. Des pathologies qui nécessitaient, jusqu'à présent, des chirurgies lourdes se prennent en charge, aujourd'hui, de manière moins invasive et deviennent donc accessibles à des patients en moins bon état général ou de plus en plus âgés. Nous présentons ici notre expérience dans le développement de l'approche mini-invasive en chirurgie cardiovasculaire et thoracique.

[Heart transplantation, indications and results at the University Hospital of Liege]. / La transplantation cardiaque : indications actuelles et résultats de l'expérience liégeoise.

Heart transplantation remains undoubtedly the most effective treatment for end-stage heart failure, whatever its cause. Last decade has witnessed significant improvements in terms of morbidity and mortality following heart transplant. The 5-year survival rate is now beyond 70 %. However, the shortage of potential donors limits its use and requires strict criteria before listing a candidate for heart transplantation. Herein, we present a review of current indications and results of the heart transplantation program at the University hospital of Liège.

La transplantation cardiaque demeure, à ce jour sans conteste, le traitement de choix de l'insuffisance cardiaque terminale, quelle qu'en soit l'origine. La dernière décennie a été marquée par une amélioration significative des résultats de la transplantation cardiaque tant en termes de mortalité que de morbidité. La survie globale à 5 ans dépasse maintenant 70 %. Cependant, la pénurie d'organes limite malheureusement son emploi et impose des critères de sélection rigoureux des potentiels candidats. Une revue des indications actuelles ainsi qu'un aperçu des résultats de la transplantation cardiaque au CHU de Liège sont présentés.

[Minimally invasive aortic valve replacement through right anterior minithoracotomy: early experience at the University Hospital of Liege]. / Chirurgie valvulaire aortique mini-invasive vidéo-assistée par thoracotomie. Expérience initiale liégeoise.

Aortic valve replacement is nowadays a safe procedure with low morbidity and mortality. However, the evolution of surgery requires the development of less invasive techniques. Aortic valve replacement through a right mini-thoracotomy, technically more complicated, offers a lower rate of complications including less postoperative pain and less blood loss and transfusion, with a faster recovery. We report our early experience of aortic valve replacement through a right anterior mini-thoracotomy.

La chirurgie de remplacement valvulaire aortique offre toujours d'excellents résultats avec une morbidité et une mortalité faibles. Cependant, l'évolution de la chirurgie nous incite à développer des techniques mini-invasives. La mini-thoracotomie antérieure droite, pour la chirurgie de remplacement de la valve aortique, techniquement plus complexe, offre de nombreux avantages. Cette technique assure une réduction des pertes sanguines et des douleurs postopératoires, une meilleure fonction respiratoire, un rétablissement plus rapide (durée de séjour hospitalier plus court) et un bénéfice esthétique. Nous rapportons ici notre expérience initiale de remplacement valvulaire aortique par mini-thoracotomie antérieure droite.

[AORTOENTERIC FISTULA, A POOR PROGNOSIS FINDING]. / LE CAS CLINIQUE DU MOIS. La fistule aorto-digestive, un diagnostic de mauvais augure.

We report the case of a patient admitted with upper gastrointestinal bleeding. The CT scan revealed an aorto-duodenal fistula. This case highlights the progression of radiological imaging in parallel with the clinical course. We take this opportunity to write a brief literature review mainly focused on the description and diagnostic modalities of aortoenteric fistulas.

[Surgical fixation in flail chest : a local first encouraging experience]. / Fixation chirurgicale d'un volet thoracique : à propos d'une première procédure encourageante (cas clinique).

We report the case of a young woman who suffered from a severe traffic accident with major thoracic trauma consisting of hemopneumothorax and flail chest. At day 5 of mechanical ventilation, a surgical reduction and fixation of the fractured ribs were performed; the patient was liberated from mechanical ventilation the next day and discharged from the intensive care unit two days later. The success of this local first case incites us to further a similar approach in such challenging trauma cases.

Nous rapportons le cas d'une jeune patiente victime d'un accident grave de la circulation avec un traumatisme thoracique sévère ayant entraîné un hémopneumothorax et un volet thoracique. Au 5ème jour de ventilation invasive, une réduction et une fixation chirurgicales du volet thoracique furent réalisées. La patiente fut sevrée de la ventilation invasive le lendemain et transférée en salle de soins banalisés deux jours plus tard. Le succès de cette première thérapeutique nous incite à la proposer à l'avenir dans des situations similaires.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]. / Le cas clinique du mois. Les endofuites, une complication spécifique du traitement endovasculaire des pathologies aortiques.

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

[Type A intramural hematoma of aorta: An undervalued clinical entity]. / Hématome intramural aortique de type A : une entité clinique sous-évaluée.

Intramural hematoma of the ascending aorta occurs after rupture of the vasa vasorum. Previously considered as a first step of acute aortic dissection, it was later defined as a separate entity that may or may not lead to arterial dissection. The debate about the most appropriate treatment for a 69-year-old patient with intramural hematoma of the ascending aorta, led to this extensive review of the literature demonstrating that intramural hematoma type A is a life-threatening condition requiring urgent surgical support.

Potential benefits of laparoscopic aorto-bifemoral bypass surgery.

BACKGROUND: This series aims to prove the positive impact of laparoscopic approach in aortofemoral bypass grafting. METHODS: It concerns a retrospective non randomized study comparing 58 consecutive patients treated with laparoscopic procedure (n = 30) and with a standard open procedure (n = 28) in a single center. The different operating times, the complications and the follow-up of these two groups are compared RESULTS: The demographics and angiographic data of the two groups were comparable. Operating time was longer in the laparoscopic group. However, we noticed a significant shorter hospitalisation stay (p < 0.0001) after the laparoscopic procedure with a mean 5.1 days. There was no significant difference of morbidity. CONCLUSION: We suggest that the trans-peritoneal approach is the best way in laparoscopic procedure in term of exposure and ergonomics. Laparoscopic aortofemoral bypass grafting is feasible, safe and effective. Shortening of operating time is observed as surgeon's experience grows.

[Clinical value of cardiac resynchronization therapy in patients with congestive heart failure]. / Resynchronisation ventriculaire dans la décompensation cardiaque réfractaire.

Besides major progress in the pharmacologic treatment of severe chronic heart failure, cardiac resynchronization therapy (CRT) has developped over the last ten years. We report the follow-up of the 36 first patients with a CRT device implanted from July 2000 to November 2002 at the CHR de la Citadelle Hospital in Liege. After a mean follow up of 6 months, no death was observed. The functional benefit of resynchronization is validated by a significant improvement in the NYHA class, an increase in the walking distance measured by the six minute walk test from 268 +/- 103 to 342 +/- 106 meters (p < 0.004) and by a not significant rise in the VO2 max (from 11.1 +/- 2.8 to 14 +/- 10 ml/kg/min; P=0.1). The quality of life, assessed by the Minnesota-Living-In-CHF score, improves from 49 +/- 20 to 35 +/- 22 after the six month follow-up (P=0.02) The echocardiogram also shows a better left ventricular ejection fraction at six months, from 24 +/- 7% to 31 +/- 7% (P<0.05). Based on a better NYHA functional class, responders (n=24; 71%) and non responders (n=10; 29%) were compared; a correlation between the functional class change and the improvement of the ejection fraction was documented, but not with the reduction in QRS width. Our registry, with the potential pitfalls of a monocentric prospective study, confirms the feasability, safety and efficacy of CRT in severe chrbnic heart failure uncompletely corrected pharmocalogically. It remains however approximately 30% of non responding patients, in whom the current clinical studies should help identify the right criteria to predict and discriminate responders.

Takayasu's arteritis.

This paper reviews the literature of Takayasu's arteritis (T.A.). The concept of this disease has evolved considerably over the past decades. T.A. was first described by Mikito Takayasu in 1908, and was thought to be restricted to south-east Asia. But due to the increasing reports from all over the world, it is well established that T.A. has world-wide distribution. Clinical presentation varies according to the location of the arterial lesions. In Europe brachiocephalic trunk lesions prevail and are best managed by an arterial reconstruction. Historical background, epidemiology, etiology, pathology, clinical findings, diagnosis, classification, treatment and long-term prognosis are discussed.

[Role of carotid surgery in the prevention of cerebral infarction]. / Rôle de la chirurgie carotidienne dans la prévention de l'infarctus cérébral.

A significant part of transient or permanent cerebral ischemic attacks (CIA) are due to arterio-arterial emboli issued from carotid plaques. Surgery for carotid disobstruction aims to take out emboligenic plaques by endarterectomy (associated to angioplasty or not). The adversaries of surgical treatment sustain two main assertions: 1. carotid stenoses are not very dangerous, because the definitive thromboses they create are easily compensated by the development of collaterals, so that the risk for stroke is low. 2. this low and late risk of spontaneous carotid thrombosis is not greater than the immediate one following carotid surgery. Those objections have been encountered in randomized North American studies (Nascet & Veterans) that have been published in 1991 and 1993. They show the usefulness of correctly done surgical correction as well as for symptomatic as asymptomatic stenoses. So do we it, presenting the results of our series (2.282 procedures in 1.868 patients). The results of our series show a low combined morbidity-mortality rate (1.7%), and a yearly stroke of 1.4%.

Abdominal aortic aneurysms in octogenarians.

The decision on whether to operate or not abdominal aortic aneurysms (AAA) in elderly depends on the relative risk of the operation versus the natural course of the unoperated AAA. From January 1984 to December 996, 138 patients, aged 80 years and older, were referred to our department for an aneurysm of 40 mm or more (transverse diameter) of the infrarenal abdominal aorta (95 asymptomatic, 15 painful, and 28 ruptured AAA). For 58 patients with asymptomatic AAA, operation was denied at referral because of transverse diameter less than 50 mm (n = 21), patient refusal (n = 10) or unacceptable operative risk or poor general condition (n = 27). Thirty-four of these observed AAA were ultimately operated after a mean delay of 41 months because of aneurysm enlargement (n = 15), aneurysm tenderness (n = 6) or rupture (n = 13). Overall, 52 patients had immediate (n = 37) or delayed (n = 15) elective repair of their AAA, with an in-hospital mortality of 5.7%. Urgent operation was done for 21 patients with a painful AAA. Six patients died at hospital (28% mortality rate). Emergent surgery was applied to 41 patients with ruptured AAA (including 13 AAA who ruptured during surveillance). The operative mortality in this subgroup attained 68%. Follow-up for the 77 survivors and the 24 non-operative patients averaged 43 months. The 5-year survival (operative mortality included) is 47% for electively operated patients, 30% for urgently and 20% for emergently operated patients. For comparison, the 5-year survival of an age and sex matched Belgian population is 63%. For the 24 medically followed AAA, the 5-year survival was 33%. In six cases, the cause of death was rupture of the AAA. Of the 58 patients for whom operation was initially not considered, 19 (33%) presented AAA rupture (13 operated in emergency and 6 who never came to surgery). The operative outcome of AAA repair in octogenarians is less favourable than in the younger age group (3.6% mortality after elective repair, 44% after operation for AAA rupture, according to our institution data). The authors conclude that AAA surgery should not be denied to octogenarians on the basis of advanced age alone. They recommend a straightforward surgery for otherwise healthy octogenarians with AAA of 50 mm diameter, surveillance up to 60 mm for high-risk patients and no surgery for unfit, bedridden or demented patients.

Kinking of the internal carotid artery: clinical significance and surgical management.

The authors report on 62 surgical corrections for kinking of the internal carotid artery during a 13-year period (1980-1993). This represents 2.8% of all carotid operative procedures (n = 2188) in the same period. It always concerned a significant (< 60 degrees) angulation of a redundant internal carotid artery, that in all but 3 cases was associated with atherosclerotic involvement of the carotid bifurcation. The indication to surgery included transient hemispheric or ocular ischaemia in 25.5% of cases, a regressive neurologic deficit in 8%, a minor stroke in 3%, a stroke in evolution in 11%, and non-lateralized cerebral ischaemia in 21%. In 19 patients (31%) it concerned an asymptomatic high degree stenosis. The surgical technique consisted in carotid transposition-reimplantation after eversion endarterectomy in 37 cases, in posterior transverse plication with patch angioplasty in 20 cases, and in segmental excision with venous interposition graft in 5 cases. There was one postoperative death. The morbidity include one ipsilateral non-fatal stroke and 3 transient ischaemic attacks. A complete long-term follow-up (mean duration 3.4 years) is available for 57 patients. The late incidence of stroke is 1.5% per year. The 5-year survival attains 67%. These long-term results are comparable to the outcome of standard endarterectomy in the same institution. The authors discuss the indication, techniques, and outcome of surgical correction of kinked internal carotid artery. They recommend a shortening procedure, often associated with endarterectomy for severely kinked vessels (angulation 60 degrees or less), symptomatic or not.

Carotid surgery in octogenarians: is it worthwhile?

Controversy surrounds the role of carotid endarterectomy in octogenarians. Although the prognosis of severe degree carotid stenosis is more ominous in the elderly, operative risk seems more important in the aged. To evaluate the presumed detrimental effect of advanced age on the mortality-morbidity of carotid endarterectomy, the authors reviewed their common experience with carotid surgery in patients aged 80 years or more. From 1980 to 1994, 129 octogenarians were operated on for occlusive carotid artery disease in two university hospitals. The data for these patients, 80 years of age and older (group 1) are compared to these for a large middle age group (less than 80 years) (group 2) operated by the same surgeons during that period. The baseline characteristics of both groups were similar, except for smoking, diabetes and previous myocardial revascularization, more prevalent in the younger age group. In the elderly group prophylactic surgery for asymptomatic stenosis was done in 36%, versus 40% of the middle aged patients, and for stroke in evolution in 8% versus 4% (p < 0.05). The perioperative stroke rate was 0.8% in the group older than 80 years, compared to 1.2% for non octogenarians (NS). The operative mortality was similar for both age groups (2.3 and 1.5 respectively). The long-term results gave a similar outlook for both age groups. The 5-year stroke-free rate reached 89% for group 1 versus 91% for group 2. The 5-year survival rate, however, was less for the elderly patients (47% versus 77%, mean follow-up periods of 30 and 49 months). These results suggest that carotid endarterectomy can be safely done in elderly patients, with a similar risk/benefit ratio as for the younger patients. Advanced age, by itself, is not to be considered as contraindication to carotid surgery.

[Amazing epic of blood transfusion...]. / L'étonnante épopée de la transfusion sanguine....

On the occasion of the 100th anniversary of the discovery of blood groups by Karl Landsteiner, the author makes a historical note on the amazing history of the blood transfusion from the origin to the beginning of the XXth century.

[Endovascular treatment of supra-aortic stenosing lesions]. / Traitement endovasculaire des lésions sténosantes des troncs supra-aortiques.

After a description of the endovascular procedure for the treatment of supra-aortic trunks lesions, the author, through an international review of the literature, analyses the feasibility and the results of this recent surgical technique in comparison to conventional surgery.

[History of medicine. It's been 150 years since Horace Wells disappeared]. / Histoire de la médecine. Il y a 150 ans disparaissait Horace Wells.

On the occasion of the 150th anniversary of Horace Wells's death, the author makes a historical note about the discovery of the general anesthesia by inhalation.

[History of medicine. The Collegium Medicorum Leodiensium....]. / Histoire de la médecine. Le collegium medicorum leodiensium....

Three hundred years ago, the Collegium Medicorum Leodiensium was founded under the authority of His Majesty the Prince Bishop Joseph- Clemet of bavaria. On the occasion of this anniversary, the author a chronological account and a description of the characteristics of the old medical colleges in Liége (Belgium) from the Middle-Ages up to the early nineteenth century.

[Iohan Georg Fuchs...an oculist and itinerant surgeon of the 18th century]. / A propos d'un certain Iohan Georg Fuchs....

After the recent discovery of an antique engraving representing Iohan Georg Fuchs, the author provides some information about this unknown physician who practiced eye surgery in the Principality of Liège.

[About some "anatomic anthroponyms"]. / A propos de quelques "anthroponymes anatomiques".

Daily in our practice we use terms of anatomy. Some of these terms are directly linked to the name of their discoverer. Very often, we ignore or have forgotten the history of these anatomists. The author, with a short repertory refreshes our memory.