Prospective randomized study of carbon-impregnated polytetrafluoroethylene grafts for below-knee popliteal and distal bypass: results at 2 years. The Association Universitaire de Recherche en Chirurgie.

The purpose of this prospective randomized multicenter study is to compare patency for a new carbon-impregnated polytetrafluoroethylene (PTFE) graft and standard PTFE grafts. One hundred and sixty patients presenting severe chronic ischemia of the lower extremity were recruited at 17 centers of the French Association Universitaire de Recherche en Chirurgie. Eighty-one carbon-impregnated graft and 79 standard grafts were implanted. The procedure consisted of below-knee femoropopliteal bypass in 83 cases and femorodistal bypass in 77 cases. The minimum duration of the follow-up period was 2 years. Twenty-four patients died during the study. The actuarial primary patency rate, actuarial secondary patency rate, and limb salvage rate were 45%, 53%, and 57% respectively in the carbon-impregnated PTFE group and 35%, 36%, and 47% respectively in the standard PTFE group. The carbon-impregnated graft appeared to achieve better patency than the standard graft but the difference was not statistically significant. Since there was no difference up to 12 months, the study will be continued to determine if further follow-up confirms these findings. In this study we also assessed factors contributing to patency of below-knee prosthetic bypass grafts. Only two factors had a significant influence on patency, i.e., ankle/arm pressure difference greater than 0.25 as opposed to ankle/arm pressure difference less than 0.25 (p < 0.01) and below-knee femoropopliteal bypass as opposed to femorodistal bypass (p < 0.001).

Primary hyperparathyroidism in multiple endocrine neoplasia type IIa: retrospective French multicentric study. Groupe d'Etude des Tumeurs á Calcitonine (GETC, French Calcitonin Tumors Study Group), French Association of Endocrine Surgeons.

Primary hyperparathyroidism (PHPT) in multiple endocrine neoplasia (MEN) type IIa is rare, occurring in 20% to 30% of the patients. The aim of this study was to evaluate clinical findings, surgical therapy, and outcome for 56 patients affected by PHPT among 249 MEN-IIa patients collected from 84 families assembled by the Groupe d'Etude des Tumeurs á Calcitonine (GETC, French Calcitonin Tumors Study Group). This retrospective study was based on cases registered by the GETC (20 participating centers) from 1969 to 1994. Characteristics of PHPT in 56 patients (31 women, 25 men) with MEN-IIa were reviewed. All but two underwent cervicotomy. The median age at diagnosis was 37.6 years. PHPT was found concomitantly with medullary thyroid carcinoma (MTC) or pheochromocytoma in 43 patients (77%). PHPT was asymptomatic in 68% of the patients. Serum calcium levels ranged from 2.20 to 3.70 mmol/L (median 2.82 mmol/L; normal 2. 10-2.60 mmol/L). The number of parathyroid glands removed at surgery was 0 (n = 2), 1 (n = 24), 2 (n = 5), > 2 (n = 12), 4 (n = 11). Pathology (initial surgery) consisted of 24 adenomas, 4 double adenomas, and 25 hyperplasia. Cure after initial surgery was obtained in 89%, including a 22% incidence of hypoparathyroidism. There were 6 cases (11%) with persistent PHPT. With a mean follow-up of 6.4 years, five patients (9%) had recurrent PHPT. The results indicate that MEN-IIa-related PHPT is generally associated with mild, often asymptomatic hypercalcemia. Despite recurrences encountered 5 to 15 years after the first cervicotomy, resection of only macroscopically enlarged glands generally appears sufficient. Subtotal or total parathyroidectomy with autotransplantation is associated with a high rate of hypoparathyroidism.

Arteries from human beings are less infectible by Staphylococcus aureus than polytetrafluoroethylene in an aortic dog model.

PURPOSE: Treatment of aortoiliac prosthetic graft infections includes the removal of the infected material and repeat revascularization if necessary. The risk of infection of the graft material used for the repeat revascularization has been the drawback of its use in situ except with autografts. Good results were obtained in this setting by use of in situ arterial allografts. The purpose of our study was to compare in vivo the infectibility of arteries used as allografts to the infectibility of commercially available prostheses. METHODS: Twelve dogs underwent thoracoabdominal aortic bypass with use of either an artery from a human being (n=6) or an expanded polytetrafluoroethylene (ePTFE) graft (n=6). One month later, bacteremia was produced with Staphylococcus aureus. One week after bacterial challenge, the animals were killed to recover the grafts. Each graft then underwent bacterial study. RESULTS: None of the arterial grafts grew bacteria, whereas four of the six ePTFE grafts (p < 0.05) did. In addition, none of the fragments of the arterial grafts grew bacteria, whereas 24 of the 60 ePTFE fragments (p < 0.01) did. CONCLUSION: Nonautologous arteries are less infectible than ePTFE in vivo. This decreased infectibility makes the arterial allograft an appealing material when revascularization must be performed in a contaminated field.

The value of lymph node dissection in hereditary medullary thyroid carcinoma: a retrospective, European, multicentre study.

Clinical data of 139 patients with hereditary medullary thyroid carcinoma (HMTC) from nine european centres surgically treated from 1980 to 1991 were reviewed retrospectively to analyse the value of systematic versus selective lymphadenectomy (LA). Biochemical cure rate was significantly higher in patients who underwent LA compared to patients who did not. In nodal-positive HMTC, systematic LA compared to selective LA improved biochemical cure in small but not large tumours. In nodal-negative HMTC, systematic LA compared to selective LA could not improve biochemical cure in either small or large primary tumours. To prevent local recurrences with the risk of increased surgical and tumour-related morbidity, systematic LA should be performed in all HMTC patients regardless of the primary tumour stage. However, an improvement of biochemical cure by systematic LA seems to be possible only in nodal-positive small primary tumours without distant metastases.

Treatment of vascular graft infection by in situ replacement with a rifampin-bonded gelatin-sealed Dacron graft.

PURPOSE: The purpose of this study was to treat an established prosthetic vascular graft infection by in situ replacement with a rifampin-bonded gelatin-sealed Dacron graft in an animal model. METHODS: The infrarenal aorta of 18 dogs was replaced with a gelatin-sealed graft contaminated in vitro by soaking it in a solution with Staphylococcus epidermidis. One week later, animals were randomized into three groups. In group I (control, (n = 6), the dogs did not undergo repeat operations. The dogs in groups II and III underwent repeat operation. In these animals the infected grafts were removed for bacteriologic analysis and replaced in situ with one of two types of grafts: group II (n = 6) received an untreated, gelatin-sealed graft; group III (n = 6) received a rifampin-bonded, gelatin-sealed graft. Antibiotic bonding was obtained by soaking grafts for 15 minutes in a 60 mg/ml saline solution of rifampin at 37 degrees C. All 18 dogs received no systemic adjunct antibiotic therapy. Control grafts and replacement grafts were removed 4 weeks after the initial implantation for bacteriologic analysis. When harvested, all the grafts were cut into two fragments, and quantitative bacterial cultures were obtained from all the fragments. Results were expressed as colony-forming units (CFU)/cm2 of graft material. RESULTS: All 18 initially implanted grafts and all the untreated replacement grafts were grossly infected at the time of removal, whereas all the rifampin-bonded replacement grafts had normal incorporation. None of the rifampin-bonded grafts grew bacteria, whereas all the initially implanted and all the untreated replacement grafts were infected (p < 0.01). Bacterial counts from the infected fragments were similar in control grafts (2.6 +/- 1.9 x 10(6) CFU/cm2), in initially implanted grafts of groups II (9 +/- 1.1 x 10(5) CFU/cm2) and III (1.3 +/- 1.5 x 10(6) CFU/cm2), and in untreated replacement grafts of group II (1.7 +/- 2.5 x 10(6) CFU/cm2). Blood culture results and culture results of liver, spleen, kidney, and lung specimens at the time of sacrifice were negative. CONCLUSION: This study demonstrates that rifampin-bonded gelatin-sealed Dacron grafts are resistant to infection when used for in situ replacement of an infected graft in the dog.

[Ruptured hypogastric aneurysm presenting as a sciatic paralysis. Case report and review of the literature]. / Anévrysme rompu de l'artère hypogastrique révélé par une paralysie sciatique. Un cas et revue de la littérature.

A rupture of a hypogastric aneurysm presenting as a sciatic nerve compression is reported. The diagnosis was delayed as the lumbar spine CT Scan was normal. The aneurysm was visualized with a CT Scan of the pelvis, it was located in the front of the sacrum and continued through the greater sciatic foramen. After aneurysmorrhaphy the pain disappeared but the paralysis wasn't improved. 28 cases of ruptured hypogastric aneurysm have been collected by reviewing the literature, eight of them have simulated nerve compression.

[Prevention of false routes in vein strippers]. / Prévention des fausses routes du stripper.

It is possible for the stripper to go in a wrong direction during a stripping. This phenomenon occurs in two cases: it can go out of the lumen of the vein which is to strip (mainly perforations) or penetrate into another vein. The prevention of perforations depends on the quality of the stripper and that of the movement linked to various operations whose aim is to make its penetration easier when it "stumbles". The prevention of penetrations in another vein depends on the quality of the pre-operative cartography achieved by echo-Doppler under per-operative technical precautions.

[Thirty years of axillofemoral bypass]. / Le pontage axillo-fémoral trente ans après.

Improvement in axillary-femoral bypass (AFB) surgery thirty years after its first use results mainly from progress in prosthetic material, particularly external reinforcement cuffs. Indications for use remain those of aorto-iliac surgery in patients at high general or local risk. However, since the primary permeability rate was fairly poor prior to the appearance of non reinforced prostheses, the use of AFB was replaced by other techniques, notably endoluminal procedures. At the same time, contraindications to aorto-iliac surgery were reduced because of the improved global care of these patients and the possibility of treatment in situ of aortic infections. However, the excellent results of the most recent series using only strengthened prosthesis have stimulated renewed interest in AFB, which should always be evoked as a possibility in patients at risk for aorto-iliac surgery.

[Injuries to the abdominal aorta during laparoscopy]. / Plaies de l'aorte abdominale au cours des laparoscopies.

Member surgeons of the Société de Chirurgie vasculaire de Langue française participated in a survey concerning traumatic injury to the aorta and retrospectively reported nine cases of injury occurring during laparoscopic operations. Six had occurred in 1991 when video-laparoscopic surgery was becoming widespread. The laparoscopy had been indicated as a diagnostic procedure in 4 cases and for curative treatment in 5. Gynaecology disease were involved in 4 cases and digestive diseases in 5. Injury was reported near the aortic bifurcation or at the origin of the common right iliac artery. Concomitant injury to the small intestine (1 case) and to the mesentery (n = 3) were also reported. No venous injury was observed. Haemodynamic collapsus was the presenting sign and occurred early in 6 cases and late in 2. In 1 case, the haemorrhage occurred during the laparoscopic procedure itself and in another blood loss was visualized through the needle. An unsuccessful and unneeded procedure had been performed before the diagnosis in 4 cases: on splenectomy, two mesenteric dissections and one subcostal laparotomy after cholecystectomy. In all cases, the vascular surgeon had been called in by the operating surgeon and most often operated via the xypho-pubien route. After clamping the aorta, the vascular lesions was sutured. There was one death, directly related to late diagnosis. The frequency of injury to the abdominal aorta found in the literature and the difficulties in diagnosis was recalled. Mortality has been reported to vary between 13 and 23%. Such complications demonstrate the need for a rigorous technique but do not counterindicate the continued use of laparoscopic procedures.

Axillobifemoral bypass and aortic exclusion for vascular septic lesions: a multicenter retrospective study of 98 cases. French University Association for Research in Surgery.

Ninety-eight patients with aortic infection or aortoenteric fistula were treated by axillobifemoral bypasses and aortic exclusion by 22 surgical teams. Early mortality was 24%. Primary patency at two and five years was 62% and 55%, respectively. Actuarial primary patency at two and five years was 82% and 65%, respectively. The actuarial rate of limb salvage at two and five years was 90% and 82%, respectively. Eight aortic stumps ruptured in less than eight months, postoperatively. Two of these ruptures were treated with success. Infection of the axillobifemoral bypasses was observed in seven cases, six of which were treated successfully. Eight patients had axillary complications, all treated successfully without upper limb sequelae. In eight cases, the axillobifemoral bypass was replaced by a thoracic aortic bypass. Early mortality was higher after emergency operation (30%) than after elective operation (14%). Mortality after cure of primary infection (7%) was lower than after secondary infection (27%). The rate of infection in polytetrafluoroethylene axillobifemoral bypass (3%) was lower than in Dacron axillobifemoral bypass (13%). The rate of occlusion of polytetrafluoroethylene axillobifemoral bypass and Dacron axillobifemoral bypass was identical. The rate of occlusion in ringed reinforced grafts was lower (9%) than in the nonreinforced grafts (22%). The rate of occlusion was significantly higher after ablation of graft for occlusive lesions (38%) than after graft for aneurysms (7.9%) (p less than 0.01).

[Compression of the left renal artery by the diaphragm]. / Compression de l'artère rénale gauche par le diaphragme.

Investigation of hypertension in a 21 year old man detected the presence of stenosis of the left renal artery. The arteriographic appearance of this stenosis, associated with the presence of stenosis of the celiac trunk of identical morphology, was suggestive of extrinsic pressure by the diaphragm and excluded endoluminal dilatation. Section of the left diaphragmatic crus released the renal artery and celiac trunk with complete recovery from the hypertension.

[Isolated proximal revascularization for double aorto-iliac and femoral lesions]. / Revascularisation proximale isolée dans les lésions à double étage aorto-iliaque et fémoral.

From 1980 to 1990, 101 limbs were revascularized at the upper level only in 67 patients, while they presented with associated aortoiliac and femoral obstructive lesions. The symptoms disappeared after aortofemoral revascularization in 94% of the limbs operated on for claudication and 80% of those operated on for critic ischemia. Surgery of the deep femoral artery was associated in 51% of all cases. The average time lapse is 58 months. No complementary revascularization was needed in the cases of claudication. Out of the patients operated on for critic ischemia, upper revascularization was insufficient in 8 cases. Two of the operated patients were cured after secondary downstream revascularization (4%). Three operated patients still presented with intermittent claudication (6%), and 3 were amputed due to acute iliac obstruction seen at an advanced stage. As no reliable predictive test is available, we find it justified to carry out only upper revascularisation in most cases and to decide on the need for secondary downstream extension according to the clinical outcome. However, simultaneous revascularization at both levels is required in case of extensive involvement of the deep femoral artery, such as observed in only 5 of the patients operated during the same period.

Prevention of vascular graft infection by rifampin bonding to a gelatin-sealed Dacron graft.

This study examines the efficacy of rifampin bonding to a gelatin-sealed knitted Dacron graft to prevent perioperative bacteremic vascular graft infection. Antibiotic bonding was obtained by soaking grafts for 15 minutes in a 1 mg/ml saline solution of rifampin at 37 degrees C. Nineteen dogs had thoracoabdominal aortic bypass: seven (group I) received a rifampin treated graft; six (group II) received an untreated gelatin-coated graft; and six (group III) received an uncoated Dacron graft. Two days later bacteremic challenge was produced by rapid intravenous injection of 5 x 10(5) colony forming units of methicillin resistant Staphylococcus aureus. Grafts were harvested five days after this challenge and cut into 10 fragments, each submitted to bacterial counts. Results were expressed as CFU/cm2 of graft material. In group I, no graft was infected, whereas all grafts in groups II and III were infected (p less than 0.05). Median bacterial counts from the infected fragments (median +/- SD) were similar in groups II (2.5 x 10(5) CFU/cm2) and III (4 x 10(4) CFU/cm2). Blood cultures at time of sacrifice were negative in all dogs in group I and positive in five of six dogs in groups II and III. Cultures of liver, spleen, kidney, and lung specimens were always negative in group I and positive in 22 of 24 specimens in group II and 23 of 24 specimens in group III. Soaking a gelatin-sealed Dacron graft in rifampin solution evidently prevents early bacteremic graft infection and secondary foci of infection in this model.

Antibiotic prophylaxis of late bacteremic vascular graft infection in a dog model.

This study was undertaken to determine the efficacy of a single-dose antibiotic injection to prevent late bacteremic vascular graft infection. Twelve dogs had thoracoabdominal aortic bypass with expanded polytetrafluoroethylene grafts. One month later, a bacteremic challenge was produced by rapid intravenous injection of 5 x 10(8) Staphylococcus aureus. Dogs were treated by pairs, each dog of a pair being randomly assigned to receive either 0.5 g ceftriaxone (group I, n = 6) or saline (group II, n = 6), intramuscularly, 90 minutes before challenge. Grafts were harvested seven days after bacteremic challenge. They were cut into 10 fragments, each of which were submitted to bacterial counts. Results of bacterial counts were expressed as colony forming units per square centimeter of graft segment. The overall infection rates were zero of six grafts in group I and four of six in group II (p less than 0.05). In group I, none of the 60 graft fragments were found to be culture positive (p greater than 0.01). Bacterial counts from the 24 infected fragments were highly variable, ranging from 12 colony forming units/cm2 to 64 x 10(3) colony forming units/cm2. Serial quantitative blood cultures revealed a similar decrease of bacteremia in both groups with 2.4 +/- 0.9 x 10(2) (group I) and 1.2 +/- 0.9 x 10(2) (group II) colony forming units/ml at three hours. Mean ceftriaxone serum level was 26 +/- 18 mg/L at the time of bacteremic challenge. These data suggest that a single dose of ceftriaxone given before bacteremic challenge is sufficient to prevent late bacteremic vascular graft infection in this model.(ABSTRACT TRUNCATED AT 250 WORDS)