[Patient with homozygous sickle cell disease and free flap surgery: Ensuring the success of the procedure]. / Drépanocytose homozygote et nécessité d'une réparation par lambeau libre : comment assurer la réussite du projet thérapeutique.

Sickle cell anaemia is rare in France but frequent in Africa, leading to rigid, sickle-like shape red blood cells which bind together blocking microcirculation under certain circumstances. The vaso-occlusive crisis is the most frequent clinical manifestation especially in case of homozygous disease. Sickle cells disease is therefore usually considerated as a contraindication to microsurgery, however sometimes, a free flap procedure is mandatory. We here report the case of a 47-year-old man suffering with homozygous sickle cell anaemia and needing an antebrachial free flap procedure for a tongue reconstruction. The postoperative course was unremarkable apart from a delayed healing which is common in this particular localization. A review of the litterature allows to list the precautions to be taken to ensure a microsurgical procedure with this medical background. The preoperative examination has to assess usual sickle cell disease comorbidities such as kidney failure, heart failure or pulmonary hypertension. All the events leading to either low output syndrome, hypoxia, hypothermia, or a stress caused by uncontrolled pain should be avoided per- and postoperatively. With an optimum medical care, microsurgery is possible even in patients suffering with sickle cells anaemia. This case is rare in France but will become frequent in Africa with the improvement of the healthcare system, allowing to give all patients the best medical care.

Safety of percutaneous internal jugular catheterization in cancer patients: prospective observational study.

PURPOSE: To determine predictors for failure and early complications of percutaneous internal jugular catheterization (IJC) in cancer patients. METHODS: Six hundred and thirty consecutive cancer patients who required central venous catheterization were included in a prospective observational study. The rates of failure (defined as the intervention of a second physician and/or failure at initial insertion site) and of early complications were prospectively ascertained. Logistic regression analysis estimated odds ratio (OR) and 95% confidence intervals (95% CI) for independent predictors for failure and early complications of percutaneous IJC. RESULTS: The failure rate was 6.7%, and the early complication rate was 6.7%. In multivariate analysis, left-side initial catheterization (p<0.01), prior catheterization at the same site (p=0.001) and physician inexperience (p<0.0001) were independently associated with failure. Placement requiring more than one needle pass (p<0.01 for two and p<0.0001 for three and more) and absence of fluoroscopy (p<0.0001) were independently associated with early complications. CONCLUSIONS: Percutaneous IJC is a valid option in the central venous catheterization of cancer patients due to its reliability and safety. Skilled physicians must manage difficult placements. If placement requires more than one needle pass or is made without fluoroscopy, patients must be carefully followed for potential complications.