Lung cancer following previous extrapulmonary malignancy.

OBJECTIVE: Having demonstrated a poor prognosis of operable lung cancer in patients with previous head and neck malignancies, we intended to evaluate prognosis of lung cancer in patients with a history of extrapulmonary and extracervical malignancies. METHODS: The population of this study included 55 patients; these were 40 males and 15 females, with a mean age 64.4+/-8.6 years. The previous malignancy was considered tobacco-induced in 15 patients (kidney, two; bladder, ten; esophagus, three), hormone-dependant in 18 (breast, six; female genital, eight; prostate, four), and miscellaneous in 22 (leukemia, four; skin, seven; colon, 11). Following complete resection, 25 patients were classified stage I, 13 were stage II, and 17 were stage IIIA. RESULTS: There were two early perioperative deaths (3.6%), and three during the second month owing to cardiovascular complications. At the conclusion of the study (July 1st, 1997), 32 further patients had died (58.2%): 25 had progression of lung cancer, one had progression of previous malignancy, and six were without evidence of disease. Five-year survival (Kaplan-Meier) was estimated 47+/-10.2% in stage I (median 44 months), 30.8+/-15.6% in stage II (median 26 months), and 16. 7+/-9.9% in stage IIIA (median 17 months). When excluding five early perioperative deaths, 5-year survival was 51.1+/-10.6% in stage I (median 93 months), 33.3+/-16.7% in stage II (median 36.5 months), and 19.0+/-11.2% in stage IIIA (median 20.5 months). Comparing the three groups defined according to location of previous malignancy, there was no significant difference neither in stage distribution (chi(2)=1.326; P=0.857), nor in 5-year survival estimates: 38.9+/-12. 9% (median 27 months) after tobacco-induced malignancies, 38.9+/-11. 5% (median 24 months) following hormone-dependant malignancies, and 28.4+/-10.2% (median 28 months) following miscellaneous cancers (chi(2)=0.059; P=0.9707). CONCLUSIONS: In opposition to data collected in patients with previous head and neck cancer, survival estimates according to stage were contained within the universally accepted range no high risk group has been identified. Resection of lung cancer with curative intent is a fair option in patients with previous extrapulmonary malignancy.

Surgical treatment of a Budd-Chiari syndrome secondary to hepatic inferior vena cava agenesia.

We report the case of a surgically treated congenital Budd-Chiari syndrome related to agenesia of the retrohepatic inferior vena cava. The first symptoms of the disease were noticed in childhood. The increasing symptomatology led to propose, at the age of 30 years, first a percutaneous transluminal angioplasty which failed, because of the impossibility to recanalize the obstructed segment. Then a surgical procedure consisting of the implantation of ePTFE prosthesis between the right atria and the retrohepatic inferior vena cava was performed. The hepatic biopsy showed a centrolobular fibrosis and an old subglissonian infarction. The patient was improved, allowing him to recover a normal life. However, three years later, an angiographic evaluation performed because of a recurrence of a slight abdominal pain, showed a thrombosis of the bypass. An attempt at thrombolysis failed. Since the patient did not present major clinical and biological consequences we only proposed a surveillance and no endovascular procedure because of the fear of a pulmonary emboli. The purpose of this case report is to review the literature and discuss the etiopathology of congenital Budd-Chiari syndrome with regard to the different therapeutic options.

[Surgery for aneurysms of the subrenal abdominal aorta after the age of 70 years: survival and quality of life]. / La chirurgie des anévrismes de l'aorte abdominale sous-rénale après 70 ans: survie et qualité de vie.

The aim of this study was to assess results of surgery for aneurysms of the abdominal aorta in patients over 70 years of age. Survival and quality of life were used as assessment criteria. Files of 277 patients over 70 years of age who had undergone surgery for an aneurysm of the subrenal abdominal aorta between 1974 and 1992 were examined retrospectively. There were 246 men and 31 women of whom 230 were under 80 and 47 over 80 years of age. The operation was programmed in 145 cases and was an emergency procedure in 132 (45 ruptures and 87 painful fissurations). Perioperative mortality was 1.4% in programmed surgery and 19.7% in emergency surgery. Overall actuarial survival was 60.07% at 5 years and 26.04% at 10 years. Quality of life after the operation was unchanged in 56.1%, improved in 19.3% and worse in 24.6%. Surgery for aneurysm of the subrenal abdominal aorta is justified in patients over 70 years of age. It can provide satisfactory survival in good quality of life conditions.

[Extra-popliteal localizations of adventitial cysts. Review of the literature]. / Les localisations extra-poplitées des kystes adventitiels. Revue de la littérature.

Cystic adventitial disease is an uncommon vascular anomaly first described in 1947 in the external iliac artery. The preferential localization is the popliteal artery although other arteries and veins may also be involved though not always recognized. There have been 45 extra-popliteal localizations of adventitial cysts reported in the literature. Thirty cases involved an artery an 15 a vein. The iliofemoral axis, with 33 reported cases, is the preferential localization of these extra-popliteal adventitial cysts (including 22 arteries and 11 veins). All the other cases also involved a vessel near an articulation (knee, ankle, elbow, wrist). Despite a preferential popliteal arterial localization only one case involved the popliteal vein. The diagnosis is rarely made before surgery, probably because of the nonspecific clinical presentation. Ultrasonography should allow better recognition of these adventitial cysts, eliminating an aneurysm or a synovial cyst, and evidencing the localization of the cyst within the vessel wall.

[Carotid endarterectomy by eversion and reimplantation. Techniques and results]. / L'endartérectomie carotidienne par éversion et réimplantation. Techniques et résultats.

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

[Paraplegia secondary to surgery of the abdominal aorta]. / Les paraplégies secondaires à la chirurgie de l'aorte abdominale.

We report the case of an 84 year-old man who suffered of paraplegia after surgery of an abdominal aortic aneurysm. The neurologic status did not improve during 5 years of follow-up. This complication is rare in light of the review of the literature. It is more frequent after emergency (1.4%) and redux (19%) surgery than after elective surgery (1.1%). Its mechanisms are anatomic (occlusion of the Adamkievitz artery and of the pelvic collateral arteries) and hemodynamic mechanisms (thromboembolism, low systemic tension, long supra-renal clamping). Since pre-operative aortography to detect anatomic variations is not realistic, its only prevention remains maintenance of intra-operative hemodynamic, systemic heparinization, and preservation of the pelvic collateral circulation.

[Revascularization of the circumflex artery with mechanical stabilization: initial experience]. / Revascularisation du territoire coronarien circonflexe à coeur battant avec stabilisation mécanique: expérience initiale.

OBJECTIVES: To evaluate the short-term result of the coronary artery revascularization without cardiopulmonary bypass for triple vessel disease, including the circumflex territory performed on the stabilized beating heart. METHODS: Prospective study conducted on the first 35 consecutive patients with triple vessel disease operated upon without cardiopulmonary bypass by a single surgeon (RC) at the Montreal Heart Institute between October 1996 and March 1997. RESULTS: Mean age of patients was 64 +/-1.6 years and the majority were men (30). Most common risk factors were hypercholesterolemia (65%) and familial history (55%) of ischemic heart disease. Main surgical indication was unstable angina (74%) and mean preoperative left ventricular ejection fraction was 53 +/- 3%. Hundred and twelve bypass were constructed averaging 3.2 +/- 0.1 grafts/patients of which 39 were made on branches of the circumflex artery. Average ischemic time was 34.17 +/- 2.17 minutes. The internal thoracic artery, saphenous vein, and radial artery were used as a vascular conduit in 44, 67, and 1 occasions respectively. There was one operative mortality, and one non Q perioperative myocardial infarction (CK-MB: 89 U/L). No patient required aortic counterpulsation balloon assistance. The average postoperative CK-MB (U/L) were 12.2 +/- 1.9, 15.2 +/- 3.2, and 10.3 +/- 1.7 at 1, 24 and 48 hours respectively. During the post-operative period 26% (9) of the patients presented atrial fibrillation, 6.5% (2) early reexploration for bleeding, and 63% (22) did not require transfusion. Average stay in hospital was 6.1 +/- 45 days. Coronary grafts were angiographically assessed in the first 10 patients and at the postmortem exam in one and displayed a 100% patency with 93.5% (29/31) adequate runoff. CONCLUSION: Triple vessel coronary artery disease revascularization is feasible on the beating heart without cardiopulmonary bypass with excellent short-term clinical and angiographic results.

[Do pericardial strips (Peri-Strip) facilitate the follow-up after pulmonary surgery in emphysematous patients?]. / Les bandelettes de péricarde (Peri-Strip) facilitent-elles les suites après chirurgie pulmonaire chez le patient emphysémateux?

The aim of this study was to evaluate the contribution of bovine pericardial strips (Peri-Strip) to achieve aerostasis within emphysematous lungs. A preliminary evaluation included 15 patients (13 men and 2 women, mean age 57 years) with severe emphysema (mean FEV-1: 28.6 +/- 10.2% of predicted, mean RV: 18.4 +/- 41.3% of predicted). Two patients were on ventilator owing to acute respiratory failure. Indication for surgery was elective surgery for emphysema in 9 patients, emergency surgery for emphysema in 2, and resection for bronchogenic cancer in 4 patients. The various procedures included single aerostasis in 1, unilateral bullectomy in 6, bilateral volume reduction in 4, thoracoscopic wedge resection for peripheral cancer in 1 and lobectomy for cancer in 3 (2 of which underwent simultaneous bullectomy) Peri-Strip were used to buttress the staple lines at the base of bullae, on parenchymatous transsection lines, and on the borders of fissures. One patient who underwent emergency thoracotomy for single aerostasis died 8 days post-operatively due to multiple organ failure. Another patient developed pneumonia which resolved under treatment. Mean duration of air leaks was 5.6 days (0-21, median 8). Two patients required tube thoracotomy for residual effusions. Mean hospital stay was 17 days (6-53; median 16). We conclude that use of Peri-Strip offered a real benefit to 12 patients; no evidence of benefit was noted in 3 patients.

The impact of knee joint flexion on infrainguinal vascular grafts: an angiographic study.

OBJECTIVES: To characterise the morphologic behaviour of infrainguinal vascular grafts during flexion of the knee. DESIGN: A prospective angiographic study. MATERIALS AND METHODS: In 64 infrainguinal bypass grafts, intravenous digital subtraction angiography was performed within the first postoperative week. Frontal and lateral projection angiograms with the knee joint extended and with a 80-90 degrees flexion were taken. The distal anastomosis of the bypass was performed below-knee in 49 cases (18 in situ veins, 8 reversed veins with an anatomic course, 2 reversed veins with an extra-anatomic course, 4 composite grafts, 15 synthetic grafts with an anatomic course (14 polytetrafluoroethylene (ePTFE), 1 polyurethane), and two synthetic grafts with an extra-anatomic course. Fifteen ePTFE prostheses were implanted in the above-knee position. RESULTS: Out of 64 cases a total of 16 grafts showed stenotic kinking during flexion: two of the 18 in situ vein grafts, four of the 12 reversed vein grafts implanted with an anatomic course, one of the two reversed vein grafts implanted in an extra-anatomic site, eight of the 15 synthetic grafts crossing the knee, 0 of the two extra-anatomic ePTFE grafts, and one of the 15 cases of above-knee femoropopliteal ePTFE grafts. CONCLUSIONS: Stenotic kinking due to knee flexion can affect all kinds of bypass grafts including vein grafts placed anatomically and above-knee prostheses.

[Evaluation of a new technique of extracorporeal perfusion of the swine liver on a swine-primate model]. / Evaluation d'une nouvelle technique de perfusion extracorporelle de foie de porc sur un modèle porc-primate.

With the increasing success of liver transplantation there is an urgent need for developing an artificial liver support system to be used in patients with liver failure. An extracorporeal porcine liver perfusion machine was successfully tested in animals with experimental liver failure. Livers were flushed, removed from 35 kg pigs and placed in a heated sterile cassette. The portal vein and the hepatic artery of the graft were connected to the arterial system of the animals. The perfusion pressure of the hepatic artery was regulated via a pressure-flow computerized feed-back device. The venous flow was reinfused from the hepatic veins of the graft to the jugular vein of the animals. The experimental work consisted in two steps: 1. evaluation of clinical and biological consequences of liver perfusion in healthy animals (Group A = pigs, n = 3; group B = primates, n = 3); 2. evaluation of the efficiency of the liver perfusion in animals with ischemic liver failure (Groupe D = pigs, n = 6). The control group (Group C = pigs, n = 7) consisted of pigs with ischemic liver failure without hepatic support. No major clinical or biological adverse effects are reported in groups A and B excepted a thrombocytmia and a marked increase in serum transaminases levels in group B. Liver function as assessed by the bile flow was good in both groups. Comatose pigs with ischemic hepatic failure (group D) recovered a subnormal neurological status in five out of six cases. Serum ammoniemia level were significantly decreased (from 1076 +/- 163 to 255 +/- 32 umol/l). A decrease in serum bilirubine levels and an improvement in the coagulation profile were observed in the perfused animals. Pigs and primates tolerated the perfusion procedure well and beneficial effects were observed in perfused pigs with experimental liver failure.

Albumin-impregnated prosthetic graft for infrarenal aortic replacement: effects on the incidence and volume of perioperative blood transfusion.

We retrospectively reviewed 290 cases in which an albumin-impregnated polyester prosthetic graft was used for surgical management of aortic bifurcation disease between November 1987 and December 1990. The purpose of this review was to determine the incidence and volume of blood transfusion and to evaluate the rate of patency and the incidence of infection achieved using this type of prosthesis. The indication for surgery was abdominal aortic aneurysm (AAA) in 218 cases (190 elective procedures and 28 emergency procedures) and occlusive disease of the aortic bifurcation (ODAB) in 72 cases. Mean follow-up was 25.5 +/- 13.4 months (range: 1 and 50 months). The incidence of blood transfusion for elective AAA and ODAB surgery was 30.2% and 32.3% intraoperatively, 21.3% and 12.9% postoperatively, and 40.4% and 42.6% overall. The mean number of red cell packs transfused for elective AAA and ODAB surgery was respectively 1 and 0.8 intraoperatively, 0.4 and 0.6 postoperatively, and 1.4 and 1 overall. No immediate or late graft infection prosthesis was observed in any patient in this series. Primary and secondary patency was 95.5% and 97.5% at 6 months with no graft thrombosis during further follow-up. The fact that use of an impregnated graft in management of aortic bifurcation disease was accompanied by a high incidence and volume of blood transfusion suggests that these grafts do not reduce perioperative blood loss. Use of an impregnated prosthesis had no effect on the rate of patency and the incidence infection.

Longitudinal ruptures of polyester knitted vascular prostheses.

AIM: The purpose of the study was the characterization of a type of rupture occurring on warp-knitted polyester vascular prostheses. MATERIALS AND METHODS: We studied 20 cases of warp-knitted polyester vascular prostheses that were explanted from humans that showed a longitudinal rupture as a part of a collaborative retrieval program. All the prostheses were immediately fixed in a 10% formaldehyde solution after their explantation in the operating room. The clinical data of these cases were recorded. The explants were photographed, washed to eliminate the surrounding tissues, and photographed again. The ruptures were characterized with macroscopic examination, optical stereomicroscopy, and scanning electron microscopy. RESULTS: The mean duration of implantation of the prostheses was 16.0 +/- 3.3 years (range, 9-20.7 years). The prostheses were Cooley Double Velour (n = 15) and Microvel Double Velour (n = 5). There were 16 aortobifemoral bypass grafts, 1 aorto-biiliac, 1 aorto-aortic, 1 iliofemoral, and 1 axillobifemoral. The longitudinal ruptures occurred on two specific parts of the prostheses: the guide line (6 cases) and the remeshing line (11 cases). In three cases both lines were affected. Scanning electron microscopy showed major degradation of the trilobar filaments of the velour and gradual ruptures of the flat filaments of the remeshing and guide lines. CONCLUSIONS: In this study, we have identified a specific mechanism of late (9-20 years) longitudinal rupture of knitted polyester prostheses consisting of degradation of the polyester filaments along the remeshing and guide lines that run the length of the graft.

Impregnated polyester arterial prostheses: performance and prospects.

Impregnated polyester arterial prostheses have gained wide acceptance by most vascular surgery teams, probably because these prostheses are easy to use, without any preclotting. We offer here a synthesis of the main studies that have appraised the experimental and clinical performance of these prostheses, and we delineate their major prospects.

Influence of crimping textile polyester vascular prostheses on the fluid flow kinetics. Groupe Européen de Recherche sur les Prothèses appliquées à la Chirurgie Vasculaire.

OBJECTIVES: to characterise the impact of the crimping of polyester prostheses on the fluid flow kinetics. DESIGN: an experimental in vitro study. MATERIALS AND METHODS: we investigated four models of polyester vascular prostheses in a continuous laminar flow circuit. The flow velocity was 80 ml/s for all experiments. We studied two fluids of different viscosity within the circuit. The speed of the particles was measured by a laser Doppler anemometer 2 to 52 mm from the prosthetic interface. We first established a calibrated flow-velocity profile corresponding to the study of the support inside the circuit without any prosthesis. We measured the velocity profiles for each prosthesis corresponding to four crimp densities obtained by stretching the grafts. RESULTS: the crimping of PET textile prostheses led to a decrease of flow velocity especially closer to the prosthetic surface. The decrease of flow velocity was dependent on the model of prosthesis. This decrease of flow velocity is described by the following negative exponential law: DeltaV=a times b(-x)where (a) is the crimp density and (b) the fluid viscosity. CONCLUSIONS: flow velocity near a prosthetic surface is influenced by the morphology of the crimping. The impact of crimping on the flow velocity in a vascular prosthesis can be predicted by computer simulation models. This may provide the optimal shape of crimping for each prosthesis.