Prediction of pre-eclampsia by uterine artery Doppler imaging: relationship to gestational age at delivery and small-for-gestational age.

OBJECTIVES: To determine the relationship between pre-eclampsia, small-for-gestational age (SGA) and gestational age at delivery, and the effect of this relationship on the prediction of pre-eclampsia by uterine artery Doppler imaging. METHODS: This was a multicenter prospective Doppler study of the uterine artery at 22-24 weeks of gestation in unselected women with singleton pregnancies. RESULTS: In the 30,639 pregnancies examined, the median uterine artery pulsatility index (PI) was 1.0 and the 95(th) centile was 1.58. In 614 (2%) cases the woman developed pre-eclampsia and in this group there was an inverse significant association between the gestational age at delivery and prevalence of SGA (r = - 0.99, P < 0.0001), and between the gestational at delivery and mean uterine artery PI (r = - 0.51, P < 0.0001) and prevalence of mean uterine artery PI above the 95(th) centile (r = - 0.99, P < 0.0001). The mean uterine artery PI was above the 95(th) centile in 77.2% of women who developed pre-eclampsia requiring delivery before 34 weeks, in 35.9% of those delivering at 34-37 weeks and in 21.9% of those delivering after 37 weeks. The respective percentages were 82.3%, 46.9% and 28.8% for those with pre-eclampsia and SGA, and 43.8%, 21.2% and 8.4% for those with SGA but without pre-eclampsia. CONCLUSIONS: Pre-eclampsia requiring early delivery is more likely to be associated with SGA than less severe pre-eclampsia in women who deliver at term. Doppler ultrasound assessment of the uterine arteries is more effective in identifying pre-eclampsia requiring preterm than term delivery.

[Primary T-cell lymphoma of the common bile duct]. / Lymphome T primitif de la voie biliaire principale.

Involvement of the gastrointestinal tract is frequently reported among the extranodal sites of non-Hodgkin's lymphoma, but primary lymphoma of the common bile duct is extremely rare. We report the case of a 29-year-old man who presented with obstructive jaundice, leading to the diagnosis of high-grade primary non Hodgkin's T-cell lymphoma, originating from the extrahepatic biliary tract, and confirmed by endosonography and magnetic resonance cholangiography. This patient was treated by sequential chemotherapy without resection and remained in complete remission after one year.

A refined approach to the repair of postcholecystectomy bile duct strictures.

OBJECTIVE: To assess the results of a refined approach to repair of postcholecystectomy bile duct strictures. DESIGN: An 11-year retrospective review of patients who had surgical repair of bile duct strictures developing late after cholecystectomy. SETTING: A major university teaching hospital in France. PATIENTS AND INTERVENTIONS: During an 11-year period from 1987 to 1997, 22 patients (mean [+/-SD] age, 55+/-15 years) were operated on for bile duct strictures after cholecystectomy (11 after laparoscopic surgery and 11 after open surgery). Thirteen (59%) of the 22 patients had previous repair. Most patients had episodic cholangitis (14 patients [64%]) and biochemical evidence of cholestasis (20 patients [91%]). There were 5 Bismuth type 1 strictures; 4, type 2; 7, type 3; 5, type 4; and 1, type 5. The average (+/-SD) time from initial surgery to repair was 6.3+/-9.6 years. Intraoperative cholangiography was used to plan the repair in 18 patients (82%). Fifteen patients (68%) were repaired with high Hepp-Couinaud hepaticojejunostomies. The last 4 patients had the hilum exteriorized by the posterior approach to improve access. RESULTS: There was 1 intraoperative complication (bleeding) and 4 postoperative complications (biloma, fistula, and 2 cholangitis). There were no deaths; mean (+/-SD) length of stay was 12.8+/-5.8 days; and mean (+/-SD) follow-up was 4.8+/-3.3 years (range, 1-10.7 years). Three patients were reoperated on, 1 with an obstructed Roux-en-Y limb and the 2 others for incisional hernias. Eighteen patients remain well, 3 had sporadic recurrent cholangitis after surgery that resolved spontaneously, and 1 patient remains unwell requiring antibiotics to control cholangitis. CONCLUSIONS: Hepp-Couinaud hepaticojejunostomy without stenting remains a reliable repair of postcholecystectomy strictures. Intraoperative cholangiography and exteriorizing the hilum by the posterior approach are useful adjuncts to this technique.

Gastric bypass for malignant esophagotracheal fistula: a series of 21 cases.

OBJECTIVE: Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. METHODS: Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2). RESULTS: Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. CONCLUSION: The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.

Retrosternal bypass operation for unresectable squamous cell cancer of the esophagus.

BACKGROUND: A palliative bypass operation may be beneficial when severe dysphagia or tracheoesophageal fistula occurs after radiochemotherapy for unresectable tumor of the esophagus. METHODS: Thirty-two patients with an unresectable tumor of the esophagus underwent a palliative retrosternal gastric (29) or colonic (3) bypass operation with ligature of the lower esophagus (3) or drainage (27). Tracheoesophageal fistula was present at operation in 20 (62.5%), including 8 after radiochemotherapy. RESULTS: The overall operative mortality rate was 34.4%: 45% with tracheoesophageal fistula and 16.6% without (p < 0.01). Median intensive care and hospitalization times were 5 and 19 days, respectively. Median postoperative survival was 6 months (range, 53 to 492 days). Complications in 21 survivors were lung infections (seven), cervical fistulas (eight), and failure of the esophageal suture (two); 19 patients resumed oral nutrition, and quality of life was excellent in 6. All eight cervical fistulas regressed favorably. Postoperative radiotherapy or chemotherapy did not improve survival. CONCLUSIONS: Despite the high operative mortality rate, bypass operation can provide good palliation and allow subsequent radiochemotherapy in selected patients with an unresectable tumor of the esophagus.

[200 first hepatic transplantation at the Rennes University Hospital]. / Les 200 premières transplantations hépatiques du C.H.U. de Rennes.

UNLABELLED: From 21st of april 1978 to 1st september 1994, 200 liver transplantations in 172 patients were performed in the Medical Center of University of Rennes. Three patients had a liver and kidney transplant. 26 patients received a second transplant (13%) and 2 patients a third transplant (1%). There were 110 males and 62 females with a mean age of 43.7 years (range 17 months-66 years). The indications of transplantations were the following: 22 fulminant hepatitis (12%), 104 cirrhosis (60.5%), including 41 alcoholic cirrhosis (24%), 21 post-hepatitis B cirrhosis (12.2%), 24 post-hepatitis C cirrhosis (14%), 6 autoimmune cirrhosis, 7 primary biliary cirrhosis (4%), 21 non A non B cirrhosis (12.9%), 3 undetermined cirrhosis. Thirty one patients had a liver transplantation for cancer. The other indications were 5 sclerosing cholangitis and 2 atresia of the biliary tract. 45% of the patients had an uneventful postoperative course. In hospital mortality rate is related to the indication and Child Pugh classification in cirrhotic patients. The vascular surgical complications were 8.5%, biliary complications 6.1%, intra-abdominal infection 9.2%, intra-abdominal bleeding 5.5%. The rate of reoperation was 18.5%. 23 re-transplantations were performed in emergency and 6 electively (one from outside). The overall survival of patients from 1978 to 1994, including the patients before cyclosporine era, the use of extracorporeal circulation, the preservation with Wisconsin solutions and with main indications for cancer was 69% at 1 year and 59% at 5 years. After 1988, the overall patient survival was 75% at 1 year and 70% at 5 years. The graft and patient survival is mainly related to the indications. In fulminant and subfulminant hepatitis, the quality of the graft was preferred as often as possible. The actuarial graft survival at 1 year, 3 years and 5 years was respectively 75%, 70.45% and 70.45%. The actuarial patient survival was 77.3%, 72.5% and 72.5%. In liver transplantation for cancer, the actuarial patient survival at 1 year, 3 years and 5 years is respectively 55%, 32% and 23.5%. 5 patients are alive and well at 5 years, including a patient who underwent a Cluster operation for Klatskin tumor. In post-hepatitis cirrhosis, the patient actuarial survival at 1 year, 3 years and 5 years was 79%, 76.5% and 76.5% and in alcoholic cirrhosis 75%, 72% and 72%. The actuarial survival is closely related to Child Pugh Classification (at one year Child A 87%, Child B 72.4%, Child C 58%). CONCLUSION: in this series of the first 200 liver transplants at the University of Rennes Medical Center, graft and patient survival depends on the evolution of the surgical technic but it is also closely related to the indication. In fulminant hepatitis, the quality of the graft (without incompatible graft, if possible) should permit to avoid retransplantation and to obtain results closely to the elective transplantation. Liver transplantation for cancer should be restricted. In cirrhosis, results are depending upon Child Pugh classification. The conclusions of Paris consensus conference should be followed. The limited number of donor livers call for the "priorization" (T.E. Starzl) favoring those patients who will benefit most, i.e., patients with the most serious conditions and the poorest short term vital prognosis.