An 18-cm-large renal arteriovenous fistula treated by nephrectomy.

Idiopathic renal arteriovenous fistulas are extremely rare. They are believed to occur as the result of congenital renal artery aneurysm that erodes into an adjacent vein. We report a case of a 48-year-old man in whom we discovered fortuitously a painless mass of the right flank. Computed tomography revealed a huge renal artery aneurysm with giant arteriovenous fistula in the absence of any clinical stigmata. Given the size of the fistula and the partial destruction of the renal parenchyma, nephrectomy was successfully performed.

[Emboligenous hydatid cyst of the right heart]. / Kyste hydatique emboligène du coeur droit.

The cardiac location of the echinococcosis is rare. It is associated with complications potentially severe. Indeed, the break inside the cardiac chambers with pulmonary embolism is the inevitable complication of the echinococcosis of the right heart. Between January 1992 and January 2006, five patients were operated in the department of cardiac surgery of Sousse (Tunisia) for an emboligenous hydatid cyst of the right heart. The average age is of 30 years with extremes from 18 to 65 years. The cardio-pulmonary bypass is the technique of choice. We regretted a single death in immediate postoperative period. All the patients were controlled with an average recession of 36 months. A single late death was noticed. No recurrence was observed.

Bronchioloalveolar lung carcinoma: results of surgical treatment and prognostic factors.

STUDY DESIGN: To determine the long-term results after surgical treatment of bronchioloalveolar lung carcinoma (BALC) and to identify prognostic factors. PATIENTS AND METHODS: A retrospective study of 70 patients (49 men, 21 women), mean age 61+/-10 years, was carried out. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. All the diagnosed BALC cases were reviewed and were classified into histologic types: mucinous, nonmucinous (including fibrotic center), and mixed tumors. Univariate and multivariate analyses were carried out. RESULTS: The nodular or tumoral type was identified in 42 patients, pneumonic in 21, and diffuse in seven. Histologically, there were 36 mucinous, 25 nonmucinous, and nine mixed tumors. Resection was complete in 61 instances (87%) and incomplete in five. The 5-year survival rate was 34% in patients with curative resections. Five prognostic factors were identified by univariate analysis, but in multivariate analysis, only three factors remained significant: the absence of symptoms, the TNM stage, and completeness of resection. Thirty-six patients with curative resection (59%) developed recurrences (in the lung in 26 patients; mediastinal lymph nodes, four; distant metastases, nine). The frequency of recurrence was significantly greater in patients with pneumonic-type BALC than in nodular or tumoral types (p<0.01), and pulmonary recurrences were significantly more frequent in pneumonic than in tumoral types (p<0.02). CONCLUSIONS: This study confirmed that the overall prognosis of BALC is not significantly different from that of the other non-small cell lung cancers. We found that the lungs are the predominant site of recurrence in BALC, especially in the pneumonic types. The complete surgical resection of localized BALC offers the best chances of long-term survival.

[Radioclinical profile of cardiopericardial hydatid: report of 17 cases]. / Profil radioclinique du kyste hydatique cardiopéricardique: à propos de 17 cas.

Hydatid cysts concerning the heart are rare, accounting for 0.5 to 2% of all hydatic sites. The risk of serious complications in this location makes rapid diagnosis and surgical treatment essential. The aim of our study is to clarify the role of imaging in the diagnosis of the disease and to propose an adequate strategy. We report on 17 patients who underwent surgery for cardiopericardial hydatid cyst in the cardiovascular and thoracic unit of Sahloul hospital in Sousse from January 1988 to December 1998. Clinical investigation included in all cases chest X ray, ECG and ultrasonography (US). A computed tomography (CT) scan was performed in 14 cases, magnetic resonance imaging in three cases, transesophageal US in five cases, and coronary angiography in fsix cases. Examination for other hydatic sites was realized in all cases, and brain CT was performed in four cases. The hydatid cyst was variably localized in the left ventricle wall (five cases), the right ventricle (five cases), the pericardium (five cases), the interventricular septum (four cases), the right auricle (one case) and the left auricle (one case). The existence of other cardiac hydatid sites was found in 12 cases. All patients underwent surgery. Outcome was favorable in 14 cases, with a mean of 3 years and 5 months survey. Three patients died. The combination US-CT scan allowed a precise topographical inventory, reducing the need for MRI to the complicated cases and to the rare cases of inconclusive results by US-CT scan.

[Comparison of extrapleural and intrapleural analgesia with bupivacaine after thoracotomy]. / Comparaison de l'analgésie extrapleurale et interpleurale par bupivacaïne après thoracotomie.

OBJECTIVE: To compare the analgesic and the ventilatory effects as well as blood concentrations of bupivacaine, administered either in the extrapleural or interpleural space after posterolateral thoracotomy. STUDY DESIGN: Randomized clinical trial. PATIENTS: Twenty ASA class I and II patients, scheduled for elective thoracic surgery were randomly allocated either in the IP group (catheter inserted into the interpleural space) or the EP group (catheter inserted in extrapleural position, paravertebrally above the posterior parietal pleura). METHODS: In the catheter, inserted at the Th4 level at the end of the surgical procedure, 20 mL of 0.5% bupivacaine were injected after full recovery from anaesthesia, with the thoracic drains clamped for 30 min. The injection was repeated every six hours. Pain was evaluated after a deep inspiration with a visual analog scale (VAS), before and 1.3 and 6 hours after the injection. Analgesia was considered as effective if the VAS score at the end of the first hour was less than 30 mm. Otherwise 0.1 mg.kg-1 of morphine was administered subcutaneously. The forced vital capacity (FVC) and the forced expiratory volume one second (FEV1) were measured preoperatively and on 1st (D1) and 2nd postoperative Day (D2). Blood samples for measurements of plasma bupivacaine concentrations were obtained at 5, 10, 20, 30, 60, 90, 120, 150, 180 and 250 min respectively after the first injection. RESULTS: Bupivacaine provided a more rapid, deep and prolonged analgesia by extrapleural than by interpleural route. Analgesia was effective in 9 patients in EP group vs 4 patients in IP group (P < 0.05). Morphine requirements were 4 +/- 8 mg in EP group vs 17 +/- 10 mg in the IP group (P < 0.05). The FVC and FEV1 values were similarly decreased on D1, but recovery was better in EP group on D2 (P < 0.05). Bupivacaine peak concentrations in plasma were lower in EP group (0.86 +/- 0.42 microgram.mL-1) than in IP group (1.63 +/- 1.44 micrograms.mL-1), however the difference was not significant. CONCLUSIONS: Extrapleural administration of bupivacaine provides better analgesia as the anaesthetic agent comes in closer contact with intercostal nerves and with lower risk of loss of agent through the pleural drainage. Therefore its use is recommended preferentially over the interpleural route for analgesia after posterolateral thoracotomy.

[Early surgery in patients with native valve endocarditis]. / Chirurgie de l'endocardite sur valves natives à la phase active.

Between January 1990 and December 2006, 93 patients with infective endocarditis on native valves were operated in the active phase of the disease. The average age of our patients was 32 years with a male ascendancy. The causal heart disorder was found in 89 % of the cases, dominated by rheumatoid arthritis. The germ in cause was isolated in 52.6 % of the cases. The operative indication was hemodynamic in 29 cases, infectious in nine cases, mixed in 29 cases and embolic in 26 cases. The average operating delay was of 13 days with regard to the beginning of the antibiotic treatment. We realized a valvular aortic replacement at 32 patients with reconstruction of the ring in six cases, a valvular mitral replacement at 29 patients, a mitroaortic replacement at 21 patients, a reconstructive mitral surgery in nine cases, a valvular tricuspid replacement in one case and a reconstructive tricuspid surgery in one case. The early mortality was 13 %. The follow-up was 89 % with an average recession of 3.1 years and a late mortality of 5 %. The aim of this study is to analyze the immediate and late results of the surgery of infective endocarditis in the active phase and to bring to light the prognostic factors of mortality.

[Coronary artery fistula: case report and review of the literature]. / Fistule coronaire : rapport d'un cas opéré et revue de la littérature.

The coronary fistula is a rare abnormality making communicate a coronary artery with a cardiac cavity or a great vessel, so bypassing the myocardial capillary network. The majority of these fistulas are congenital but can nevertheless arise after a cardiac surgery. The right coronary artery and the left anterior descending coronary artery are mostly concerned. The circumflex coronary artery is rarely involved. The most frequent site of drainage is the right ventricle. We report the case of a 2-year-old child, brought by his parents for dyspnoea of effort. The diagnosis of coronary fistula was confirmed by the coronary angiography which showed an aneurysmal circumflex artery, draining into the right ventricle. The intervention was led under cardiopulmonary bypass. We proceeded to the longitudinal opening of the aneurysm then to the blindness of the fistula. The postoperative course was simple.

[Surgery of 56 patients having a partial atrioventricular septal defect]. / Chirurgie du canal atrioventriculaire partiel : résultats à court et à moyen terme à propos de 56 patients opérés.

Between January 1991 and December 2006, 56 patients having a partial atrioventricular septal defect (AVSD) were operated. The purpose of this retrospective study is to analyze the immediate and long-term results of the surgery by granting of the importance to two main problems which are the disturbances of the rhythm and the conduction and the residual mitral regurgitation (MR). The mean age of our patients is of 10 and a half years with a net feminine ascendancy. Ninety-three percent of the patients were in regular sinus rhythm. No case of complete atrioventricular block (AVB) was noted. The MR was of grade I in 28.5% of the cases, grade II in 60% of the cases and grade III and IV in 7.5% of the cases. The MR was mild in 4% of the cases. The correction was made under cardiopulmonary bypass (CPB) and consisted of a suture of the mitral cleft in most of the cases with lock of the ostium primum by a patch of pericardium. The perioperative mortality was 1,8% of the cases. The disturbances of the rhythm and the conduction were noted in 34% of the cases. All the patients were controlled with a mean follow-up of six years and seven months. The secondary mortality was nil. The MR, at mid-term follow-up, was mild in 78% of the cases. The partial AVSD is a congenital heart disease, the spontaneous evolution of which can be burdened by complications, notably the disturbances of the rhythm and the conduction, as well as the heart failure. This justifies a premature surgical repair.