[Endovascular treatment of isthmic aortic rupture: use of second generation stent grafts]. / Traitement endovasculaire des ruptures isthmiques de l'aorte chez le polytraumatisé: utilisation de stents de deuxième génération.

OBJECTIVE: Prospective analysis of endovascular management of traumatic isthmic rupture with second generation stent grafts. STUDY DESIGN: Prospective analysis and follow-up. PATIENTS: Ten consecutive multiple injured patients presenting an acute isthmic traumatic rupture who underwent an endovascular repair with second generation stent grafts. METHODS AND RESULTS: The aortic injury was diagnosed by spiral computed tomography scan. The appropriate time to repair was decided according to multidisciplinary decision after analysis of associated injuries status and mediastinal lesions evolution. Endovascular repair was successfully completed in all patients under general anaesthesia without requirement of haemodynamic manipulations. Despite a prolonged length of stay related to associated injuries, all patients were discharged from hospital without migration of devices or complication related to the endovascular procedure. After a 20 months follow-up (range 6 - 38 months), all patients were alive with a satisfactory CT scan analysis. CONCLUSION: The immediate availability of the second generation of stents-grafts allowed the endovascular treatment of isthmic rupture without haemodynamic manipulations or massive heparinization. The analysis of this selected series reinforces the interest of this non-invasive technique for anaesthetists especially in polytraumatized patients.

Inhaled nitric oxide and vasoconstrictors in acute respiratory distress syndrome.

It has been suggested that the increase in PO(2) observed with nitric oxide (NO) should be enhanced by the addition of a vasoconstrictor agent. The vasoconstrictor used in combination with NO should mimic or enhance hypoxic vasoconstriction. The aim of this study was to evaluate the respiratory and hemodynamic effects of norepinephrine (a nonspecific vasoconstrictor), almitrine bismesylate (a specific pulmonary vasoconstrictor), and inhaled NO, alone or together. During a 6-mo period, 16 patients presenting with ARDS were prospectively investigated. On inclusion, no patient was receiving cardiovasoactive drugs. The protocol consisted of seven consecutive phases: baseline, norepinephrine (in order to obtain a 3 mm Hg rise in mean pulmonary arterial pressure [Ppa]), almitrine bismesylate (16 micrograms/kg/min), inhaled NO (20 ppm delivered during inspiration), norepinephrine + inhaled NO, almitrine bismesylate + inhaled NO, almitrine bismesylate + norepinephrine + inhaled NO. General factorial analysis of variance showed that inhaled NO and almitrine bismesylate increased oxygenation (p < 0.0001). Norepinephrine had no effect on oxygenation. A synergistic effect between inhaled NO and almitrine bismesylate was found (p < 0.05), whereas norepinephrine did not affect the response to inhaled NO. Nitric oxide produced a significant decrease in Ppa and pulmonary vascular resistances (PVRI) (p < 0.0001). Both almitrine bismesylate and norepinephrine induced an increase in Ppa (p < 0.0001). Norepinephrine increased PVRI (p < 0.002), whereas almitrine bismesylate had no effect on PVRI. The present results support the hypothesis that a selective pulmonary vasoconstrictor enhances the increase in oxygenation induced by inhaled NO, whereas norepinephrine attenuates this effect.

Inhaled NO and almitrine bismesylate in patients with acute respiratory distress syndrome: effect of noradrenalin.

The combination of inhaled nitric oxide with almitrine bismesylate has been proposed for the management of acute respiratory distress syndrome in order to divert pulmonary blood flow away from poorly ventilated toward well-ventilated areas. The aims of this prospective and comparative study were to: 1) confirm the beneficial effects on oxygenation of this association; 2) evaluate the haemodynamic effects of this association; and 3) evaluate the influence of noradrenaline (a nonspecific vasoconstrictor) on the modification of gas exchange related to inhaled NO and/or almitrine bismesylate. Forty-one sedated paralysed and ventilated patients were investigated. Haemodynamic and blood gas measurements were performed in a fixed order: baseline; inhalation of NO for 30 min.; intravenous infusion of almitrine bismesylate; and concomitant administration of inhaled NO and almitrine bismesylate. Inhaled NO and almitrine bismesylate increased arterial oxygen tension (Pa,O2)/inspiratory oxygen fraction (FI,O2) (p<0.001). The association of inhaled NO with almitrine bismesylate resulted in a dramatic improvement in Pa,O2/FI,O2 (p<0.0001 versus almitrine bismesylate, p<0.05 versus inhaled NO). In patients receiving noradrenalin (n = 19), almitrine bismesylate had no effect on oxygenation. The present study confirmed that the combination of inhaled NO with almitrine bismesylate improved oxygenation, and demonstrated that almitrine bismesylate has no effect on oxygenation in patients receiving noradrenalin.

[Gastric esophagoplasty in the treatment of cancer of the esophagus]. / L'oesophagoplastie gastrique dans le traitement des cancers de l'oesophage.

Between March 1982 and December 1987, 112 patients with oesophageal cancer were treated by gastroplasty following oesophagectomy to restore gastrointestinal continuity. This technique was used in all oesophageal cancers regardless of their site, with the exception of paryngo-oesophageal and oesophago-cardio-fundal cancers. The overall mortality of 12.5% fell to below 6% during the last two years. The postoperative course was straightforward in 54.5% of cases. The most frequent complications were respiratory tract complications (19 cases of ARDS out of 112 patients, i.e. 17%) and fistulae at the oesophago-gastric anastomosis (9 cases out of 112, i.e. 8%). The secondary complications were dominated by anastomotic stenoses (19/98, i.e. 19.3%).

Reconstructive operations for esophagogastric corrosive lesions.

Corrosive esophagogastric lesions are common in Algeria and France. Within the past 14 years, our overall mortality has decreased to 6% as compared to 12% in the best results from elsewhere. This report describes our operative experience with 68 patients from 1974 to 1982. According to a prospective interdisciplinary program, lesions in 351 patients were staged by emergency esophagoscopic findings: Stage I, ulceration; Stage II, hemorrhage and ulceration; Stage III, mucosal necrosis, hemorrhage, and ulceration. Total parenteral nutrition or jejunal feeding was given to patients with Stage II lesions for 3 weeks and to those with Stage III lesions for 3 months before repeat esophagoscopy. Operations were required by 68 patients who had Stage III lesions and severe stenosis. Procedures done included 39 retrosternal colon interpositions, 11 partial or total gastrectomies, nine esophagogastrectomies, four esophagoenteral colonic bypasses, six esophagogastric colonic interpositions following partial gastric resection, and one gastrojejunostomy. Eleven of the cervical anastomoses were to the pharynx. There were no operative deaths and no anastomotic leaks. All patients have satisfactory nutrition and rehabilitation. Our operative experience in the preceding 5 years included an 11% mortality; improved results in the past 8 years are attributed to early and accurate staging, planned multidisciplinary management, good nutritional support, and better timing of operations. Stage III esophagogastric corrosive lesions may be treated within 4 to 5 months of injury with low mortality and good functional outcome.

[Leak-proof intrathoracic esophagogastric anastomosis]. / Anastomose oeso-gastrique continente intrathoracique.

The procedure described is intended for lesions of the middle or lower third of the oesophagus, when 5 cm at least of proximal thoracic oesophagus can be preserved. It involves the use of a gastric tube and is facilitated by mechanical sutures. A new fundus is created, together with a sleeve that protects the anastomosis against leakage.

Thermodilution cardiac output measurements by injection in pulmonary artery vs CVP catheter.

Thermodilution cardiac output (CO) measurements are compared after liquid injection in the pulmonary artery (PA) catheter and CVP catheter. No significant differences were found. When the proximal lumen opening of the PA catheter is clogged, CO measurements can still be obtained after injection in the CVP catheter.

[Chemoprevention with intravenous doxycycline in 40 cases of colonic esophagoplasty]. / Chimioprophylaxie par la doxycycline intra-veineuse au cours de 40 oesophagoplasties coliques.

Doxycycline was used to prevent infection in 40 patients undergoing oesophageal surgery (for carcinoma in 35 and for benign lesions in 5). Treatment began with induction of anaesthesia and continued in doses of at least 200 mg/day for a mean period of 10 days. Concentrations of the antibiotic were measured in the serum and colonic tissue of 20 patients, 2 hours on average after the first injection. Mean serum and tissue levels were 4.1 +/- 0.8 mcg.ml-1 and 2.9 +/- mcg.ml-1 respectively, with a tissue to serum ratio of 0.7. This ratio remained practically unchanged between the first and fourth hours post-injection. Doxycycline was successful in preventing post-operative infection in 75% of the cases. No infection due to anaerobic organisms was observed.