Retroperitoneal laparoscopic bilateral lumbar sympathectomy.

The first retroperitoneal lumbar sympathectomy was performed in 1924 by Julio Diez. The classic procedure for sympathectomy is open surgery. We report a unilateral laparoscopic retroperitoneal approach to perform bilateral lumbar sympathectomy. This approach was performed for a 43-year-old man with distal arterial occlusive disease and no indication for direct revascularization. His predominant symptoms were intermittent claudication at 100 metres and cold legs. The patient was placed in a left lateral decubitus position. The optical system was placed first in an intra-abdominal position to check that the trocars were well positioned in the retroperitoneal space. The dissection of retroperitoneum was performed by CO2 insufflation. The inferior vena cava was reclined and the right sympathetic chain was individualized. Two ganglia (L3-L4) were removed by bipolar electro-coagulation. The aorta was isolated on a vessel loop and careful anterior traction allowed a retro-aortic pre-vertebral approach between the lumbar vessels. The left sympathetic chain was dissected. Two ganglia (L3-L4) were removed by bipolar electro-coagulation.

Totally retroperitoneal laparoscopic aortobifemoral bypass.

The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.

Isolated supradiaphragmatic descending thoracic aorta stenosis in a Takayasu's disease: surgical cure.

A 21-year-old male patient presented with a typical middle aortic syndrome. Echography disclosed a severe narrowing of the lower thoracic aorta with parietal thickening. The isolated character of the lesion was confirmed by magnetic resonance imaging and aortography. The surgical cure was realized by a Dacron bypass between the upper thoracic descending aorta and the juxta-diaphragmatic thoracic aorta. Aortic biopsy confirmed Takayasu's disease. Postoperative course was uneventful with normalized blood pressure. The therapeutic options, surgery versus percutaneous dilatation and stent, are discussed.

Atherosclerotic popliteal aneurysms. Report of one ruptured popliteal aneurysm. Survey and analysis of the literature.

The commonest complication of an atherosclerotic popliteal aneurysm is thrombosis but we report a case in which rupture occurred. It is generally accepted in the management of the popliteal aneurysm, that a prophylactic surgical repair is the treatment of choice. Of all available graft materials, the autogenous saphenous vein remains the best material for arterial reconstruction. In the case reported, excision of a ruptured popliteal aneurysm with end to end anastomosis was performed. The signs and symptoms of popliteal aneurysm are discussed and the literature is reviewed.

Aneurysm of the descending thoracic aorta in a young woman.

The diagnosis of a thoracic aortic aneurysm in an otherwise healthy young woman is a very rare occurrence. The Authors report the case of a woman aged twenty-two in whom such an aneurysm was discovered the day after delivery. Physical signs and radiological documents are presented and early surgical treatment is described. The Authors made a survey of the world literature and emphasize the abnormally high incidence of aneurysms in women of child-bearing age. Etiopathological factors are detailed.

[Mercury strain gauge plethysmography. A noninvasive exploration method for monitoring the efficacy of treatment of deep venous thrombosis]. / La pléthysmographie a jauge de mercure. Méthode d'exploration non invasive monitorant l'efficacité du traitement de la thrombose veineuse profonde.

The plethysmographic tracings of a patient presenting a deep venous thrombosis, give information about the functional evolution of the affected limb. The plethysmographic parameters which are used to estimate the efficacy of the treatment of the deep venous thrombosis are: the venous capacitance, the venous outflow and the venous pressure. These values are always compared with the contralateral limb. The decision to stop an anticoagulant treatment is made after observing an increase of the venous capacitance and outflow and, simultaneously, a decrease of the venous pressure. During the last three years, we have followed up 200 patients with this method. It allows a rational therapeutic management which is based on the objective monitoring of the functional potentialities of the venous system.

Continuous monitoring by microprocessor from the operating room to the intensive care unit.

The "Chronicler" is made up of a microcomputer (the CPU is a Motorola 6809), an alphanumeric-graphic display with keyboard and a printer. The system is connected to several physiological signal monitors and in our application to a mechanical ventilator under electronic control. It collects every 5 seconds - or at each breathing cycle if required - all the data supplied by the various measuring devices including those in the mechanical ventilator. The time basis for displaying and storing the data is a multiple of the data acquisition time basis; it is selected interactively by the user during operation. Up to five raw analog curves (f.i. capnogram, pulmonary artery pressure curve) can be displayed and their morphology can then be examined. Manual data are entered or retrieved at any time. The system was designed by Dr. Demeester's team in order to help the anesthesiologist during and after anesthesia. Clinical use of the system by our staff has convinced us that indeed it is of great help in the control of general anesthesia: this results from the very clear and efficient presentation of the data both as numbers and curves; an alarm program under interactive control of the user makes surveillance still easier; furthermore the use of the system is simple and convenient. Finally, when surgery is over, a standard report is automatically printed; it is equivalent to a manually written anesthesia report. The data are stored on floppy disks and can be processed later for retrospective analysis in order to investigate, for instance, the influence of surgical maneuvers and of drugs on physiological parameters. The "Chronicler" is thus a tool for dynamic monitoring during anesthesia; it is also a powerful tool for clinical and physiological research.

[Vascular injuries: vascular syndromes and their clinical diagnosis]. / Traumatismes vasculaires: les syndromes vasculaires et leur diagnostic clinique.

The authors present a short review of vascular trauma and their clinical signs. The diagnosis of traumatic vascular lesions is rather obvious in most cases, but it may also be uneasy in a lot of other cases. The frequency and the localization of vascular trauma is mentioned relating to publications about series; no part of the body seems to be safe for arterial and/or venous complications. Not infrequently does it concern polytraumatic patients, which show bone, nerve, lung and abdominal lesions, etc. Haemorrhage and shock are frequent clinical signs. Tissular ischemia is found in 70 to 90% of the vascular lesions of the limbs, which on their own represent 75 to 90% of all vascular trauma. It is often necessary to use angiography to determine the extent of the lesions before surgical intervention.

Dunbar's syndrome.

The authors report the case of a 70-year-old female patient presenting with nausea, epigastric pain, anorexia and a loss of weight. An aortography showed a compression of the celiac trunk. The patient became asymptomatic and her clinical condition improved after surgical release of the celiac trunk by section of the arcuate ligament of the diaphragm. A preliminary attempt at percutaneous transluminal angioplasty proved unsuccessful.

Inflammatory aneurysms of the abdominal aorta. Review of 7 cases.

Seven cases of inflammatory aneurysm of the abdominal aorta were reviewed. The authors discuss the different diagnostic modalities (ESR, CT-scan, IVU) and some peroperative technical details in the surgical approach to this pathology in order to lessen blood loss and prevent aorto-enteric fistulous complications.

Rupture of infected superficial femoral artery aneurysm. A case report.

A case of misdiagnosed infected superficial femoral artery aneurysm is presented. It was initially misdiagnosed as thrombophlebitis. Surgical excision and repair with a saphenous vein interposition graft was performed. The diagnosis of this disease is difficult because there is a lack of signs and symptoms. Staphylococcus aureus and enterobacter are the two most common organisms responsible for infected peripheral aneurysms. Surgery is the standard treatment: ligation, drainage and resection with or without arterial reconstruction depending upon the aneurysm localization.

[A case of arteriopathy due to ergot intoxication. Revue of the literature (author's transl)]. / Artériopathie par intoxication à l'ergot. A propos d'un cas. Revue de la littérature.

The authors present a case of ergot intoxication with ischemia from arterial lesions in all four limbs. Angiograms are presented. The treatment comprises interruption of ergotamine and a bilateral lumbar sympathectomy. Etiology, clinical picture, angiologic characters and the different treatments are described after a revue of the literature.

[Spontaneous aortocaval fistulization caused by rupture of an abdominal aortic aneurysm: apropos of 3 case reports]. / Fistulisation aorto-cave spontanée par rupture d'un anévrisme de l'aorte abdominale: à propos de 3 observations.

During the last six years, the authors treated 44 patients for a ruptured abdominal aneurysm. Three of these patients had a spontaneous aorto-caval fistula and their clinical cases are described. The special diagnostical and therapeutical features of this rare complication are emphasized.

[Vascular complications in a case of hemolytic anemia due to pyruvate kinase deficiency]. / Complications vasculaires dans un cas d'anémie hémolytique par déficit en pyruvate kinase.

A rare case of congenital non-spherocytic hemolytic anemia due to pyruvate kinase deficiency is reported. Of particular interest is the never before in the literature mentioned complication of migratory phlebitis and acute thrombosis of the left lower limb associated with trophic changes of the foot. Arteriography disclosed thrombosis of all three calf arteries. The patient was treated by lumbar sympathectomy combined with streptokinase fibrinolysis and resulted in healing of the trophic changes. The distal location of the vascular lesions made direct vascular reconstruction illusory. Fogarty thrombectomy is not indicated either due to the thrombotic nature of the lesions in association with thrombocytosis.

[Management of mycotic aneurysms. Apropos of 3 cases]. / Attitudes thérapeutiques dans les anévrysmes mycotiques. A propos de trois cas.

The diagnosis of mycotic aneurysms remains rather difficult. When a mycotic aneurysm is found, two therapeutic measures should be taken without delay: on the one hand an antibiotherapy which is started preoperatively and continued at least six weeks postoperatively, and on the other hand a surgical intervention. In this review, the authors present three types of operations: ligation and excision of the aneurysmal mass, restoration of the arterial tree with a venous graft or extra-anatomical bypass with prosthetic material.

Ascending aorta syphilitic aneurysm presenting as a dystrophic disease.

A 37-year-old female originating from Central Africa presented with cardiac failure, aortic insufficiency and aortic root dilatation of supposed dystrophic origin. Left coronary ostial dilatation and dense adhesions between the aorta and the pulmonary trunk at operation were the only unusual features. However, pathological examination evoked a syphilitic disease and serology confirmed luetic infection. The diagnosis and the therapeutic approach are discussed. Syphilitic aneurysms belong to the protohistory of vascular surgery, but, in the antibiotherapy era, tracking a syphilitic aneurysm is like fishing for coelacanth. When this pathology mimics a dystrophic aneurysm, diagnosis and therapeutic attitude becomes hazardous and justifies the present report.

Primary mediastinal tumors.

Primary mediastinal tumours (PMT) are rare, they include many different histological types, but lymphomas, thymomas and neurological tumours make up most of these tumours. Their symptomatology is often poor and they are in many cases discovered by routine thoracic radiography. Diagnosis mainly relies on medical imagery and on biopsy by mediastinoscopy or by CT-Scan controlled needle puncture. The treatment depends on the histological type (radiotherapy, chemotherapy, surgery). Median sternotomy is preferred to tackle anterior and middle mediastinum PMT, since it offers a large operative field and is more comfortable for the patient than classic thoracotomy, which will be reserved to tackle posterior mediastinum PMT.

Variant form of popliteal artery entrapment syndrome.

A forty-six-year-old, non smoker, patient presented with an intermittent claudication of the right calf, clinically compatible with a low popliteal artery obliteration. Arteriography showed an irregular intercondylar popliteal artery and oblitered low popliteal and anterior tibial arteries. Surgical posterior access showed a faulty insertion of the mediate gastrocnemius caput responsible for popliteal artery entrapment syndrome and for aneurysmal dilatation of the popliteal artery above compression. As far as we know, this form of popliteal artery entrapment syndrome has not been published yet.

[Physiopathology of bedsores]. / Physiopathologie des escarres.

Pressure is the primary pathogenic factor in the development of decubitus ulcers. Other major factors are shearing forces, friction and moisture. Significant intrinsic risk factors are immobility, age-related diseases, nutritional status, medications and smoking. The morbidity and mortality related to the complications of pressure sores are quite significant. Prevention is essential and is best achieved by identification of high risk patients. The therapeutic approach is based on the grade of pressure ulcer.