Subcutaneous emphysema and mediastinitis: unusual complications of tonsillectomy.

INTRODUCTION: Subcutaneous emphysema and mediastinitis are rarely reported complications of tonsillectomy. CASE REPORT: We describe two patients who developed subcutaneous emphysema, one of them with mediastinitis, within a few days after tonsillectomy. The diagnosis was based on the clinical presentation and confirmed by computed tomography (CT). For the patient without mediastinitis, the emphysema disappeared after a short period of reintubation and administration of antibiotics. For the patient with mediastinitis, surgical drainage of a cervico-mediastinal purulent collection was necessary to obtain healing. DISCUSSION: The events leading to subcutaneous emphysema and mediastinitis have not been entirely clarified. They probably include direct introduction of air into the neck via either the tonsillar bed or a laryngeal or pharyngeal wound caused by intubation. The clinical presentation, treatment and possible pathophysiology of subcutaneous emphysema and medisastinits are discussed. CONCLUSION: Emphysema and mediastinitis after tonsillectomy occur seldomly. If rapidly recognised and appropriately managed, mortality can be avoided.

Anatomy of the Hunter's canal and its role in the venous outlet syndrome of the lower limb.

BACKGROUND: The "Adductor canal syndrome" has been described as an unusual cause of acute arterial occlusion inside the Hunter's canal in young sportsmen. It may also produce a compressive neuropathy of the saphenous nerve. To our knowledge, femoral vein compression in the canal has never been reported. OBJECTIVE: To describe the anatomy, to propose a physiology of this canal, and to show that the femoral vein is much more exposed than the artery to compression inside this adductor hiatus, particularly at the outlet. MATERIAL AND METHODS: The whole adductor canal was exposed in 100 limbs for anatomical study following latex injection. A series of 200 phlebographies and 100 CT venograms were also analyzed. RESULTS: Anatomically, we found a musculotendinous band called the "vastoadductor membrane," which jointed the adductor tendon to the vastus medialis in all the cases. The femoral vein, located more posteriorly, was frequently narrowed at this level. This band can create a notch with a venous stenosis at the outlet of the Hunter's canal, usually located 12-14 cm above the femoral condyle. Two femoral valves constitute the landmark of the canal on the venograms: the lower is just below the outlet, 9 cm above the condyle. The second valve is 3 cm higher inside the canal.Functionally, the cadaveric simulations showed that the contraction of the adductor longus closes the hiatus, while the adductor magnus opens it. Our hypothesis is that Hunter's canal prevents femoropopliteal axis reflux by synchronizing with calf pump ejection during ambulation. CONCLUSION: Compression of the femoral vein inside the adductor's canal is an underestimated and misdiagnosed cause of postural stenosis of the femoral vein. Ultrasound investigation of both limbs in patients with chronic venous disease (CVD) should be systematically carried out at this precise level in order to prevent future occlusion and onset of acute deep vein thrombosis.

The origin of the azygos venous system, as deduced from an anatomical and radiological study employing a corrosion technique.

The aim of this study is not only to describe the origin of the human azygos venous system by performing a 3-D reconstruction of a CT scan but also to evaluate the value of the techniques employed in investigating the topographical anatomy of a venous system in the body. Following perfusion with saline to wash away the blood, we injected an ALTUFIX/MINIUM mixture into the azygos vein of a cadaver. The head and trunk were subsequently corroded with hydrochloric acid (HCl). A CT scan of the trunk was obtained both before and after corrosion. According to the spatial resolution of the CT scan, the thinnest identifiable detail was measurable as 0.5 mm. The vertebral lumbar venous system was described, specifying the nomenclature of the lumbar veins (the lumbar veins being designated according to the vertebral body along which they run). On the right side, the lumbar veins at L2 and at L3 formed the lateral root of the azygos vein. On the left side, the vein at L2 formed the reno-azygo-lumbar arch (of Lejars). The lumbar veins, and the origin of the azygos system, were described and compared with previous studies. The 3-D reconstruction showed the importance of veins associated with the posterior paravertebral muscles. This description poses the problem of the metamerisation of the veins, but further evidence is required. Comparisons of the CT scans, 3-D reconstructions, and the ALTUFIX models of the veins obtained from the corrosion technique allowed verification of the 3-D reconstruction and correction of the errors inherent in a computer reconstruction. It is concluded that the description, and understanding, of such a complex system as the vertebral venous system is more valid when the results obtained using different techniques are compared.

[Phlegmasia caerulea dolens . Acute venous stasis and ischemic phlebothrombosis]. / Les phlébites bleues. Stase veineuse aiguë et phlébothrombose ischémiante.

On the basis of the data of the literature and of 25 personal cases, the problem of phlegmasia caerulea is contemplated in its whole. Grégoire made an outstanding description of the condition in 1938; it was related to an arterial spasm, but later works showed the importance of the venous block and the secondary character of the arterial involvement. A severe form of venous thrombosis, phlegmasia caerulea dolens often occurs in elderly patients (11/25 in our series) or in persons in a poor general condition. The primary phenomenon is the occurrence, in various etiological circumstances, of an acute venous stasis giving rise to a number of phenomena, including extensive thrombosis and arterial involvement, which lead to irreversible lesions and to gangrene. Thus there is a first reversible phase of acute venous stasis with a still moderate arterial involvement, and a second phase of evolution with marketed ischemia, in which the tissular lesions can become irreversible. The necrosis results from the massive obliteration of the cutaneous venulae, not from the arterial failure. The old term of venous gangrene (Cruveilhier) points out to the mechanism and makes the practicioner aware of the extreme severity of any ischemic phlebitis, which can reach an irreversible stage within a few hours. The condition is therefore an emergency, and venous drainage must be re-established as quickly as possible in the limb, thus breaking the pathological cycle leading to irreversible lesions. In the simple venous stasis phase, a medical treatment may be attempted, but it must not be continued if it is not effective. Venous thrombectomy, a quick and safe procedure, therefore is the solution to choose either at once or after a short trial of medical treatment. Phlegmasia caerula certainly is the best indication for this procedure. If operated on time, the results are excellents: however, in very advanced cases with massive and total thrombosis of the venous system, amputation remains the only solution.

[Peroperative sclerosis]. / La sclérose per-opératoire.

Complete, rapid destruction of the insufficient surface network as a one-stage procedure constitutes the best method for prevention of trophic disorders and especially pigmentation. Marked, rapid regression is obtained when these have unfortunately become installed. Combined surgery and multiple peroperative injections of a sclerosant allows the exclusive use of a gently acting sclerosant, 66% glucose solution, which is particularly well tolerated.

[Nocardia otitidiscaviarum, cutaneous infection in a patient receiving long-term corticosteroid treatment]. / Nocardiose cutanée à Nocardia otitidiscaviarum chez un patient traité par corticothérapie au long cours.

A 62-year-old man, under long-term corticosteroid therapy for pigeon breeder's disease, was admitted to endocrinology disease department for cutaneous abscess on back, limbs and scalp. Culture of various bacteriological samples (cutaneous abscess, blood culture) isolated Nocardia otitidiscaviarum. The patient was treated by trimethoprime-sulfametoxazole during several weeks with abscess disappearance. Our laboratory quickly identificatied a bacteria belonging to the Nocardia genus, with simple technique, later confirmed by a specialized laboratory (Pr. Boiron Claude Bernard University Lyon I) with identification of Nocardia otitidiscaviarum. The proof of pulmonary nocardiosis could not be established despite the existente of several risk factors. Prognosis is poor for immunocompromised patients, but the secondary cutaneous dissemination phase presented a favourable evolution under antibiotic therapy.

[Superficial veins of the lower limbs]. / Les veines superficielles du membre inférieur.

This study, limited to the superficial veins of 123 limbs (108 normal and 15 suffering from frank varicose disease) and only vessels with a caliber of at least 2 mm, reveals a certain degree of constancy of anatomical pattern. The initial network is defined embryologically and subsequent haemodynamic phenomena model the final veins. In particular, the topography of the main perforating veins is relatively fixed. Due to their double antihypertensive valve and aspirating pump function while walking, these vessels drain into saphenous veins. They are beneficial when they return reflux into the deep vessels. Conversely, perforator incompetence contaminates the superficial network in the case of deep reflux. The perforating vessels also have a relatively fixed position in relation to other structures: the main saphenous collateral veins, their duplicated branches, their communicating veins and the main valves. This results in large junctions typically associating a saphenous valve, one or several collateral veins, one or several communicating veins, and one or several perforating veins. Typical examples are the garter junction for the long saphenous vein, and the junction of the tip of the calf for the short saphenous vein. Other haemodynamic levels are situated at various sites, particularly in the leg, reflecting the existence, in some cases, of symmetrical "mirror", medial and lateral perforating veins. Morphological analysis of 15 limbs with obvious varicose veins of the trunk of the long saphenous vein defined the routes of transmission of reflux to the leg. Finally, the authors present several technical considerations which they hope will be useful for Doppler operators and surgeons.

[Medial approach to the distal deep femoral artery]. / Abord médial de l'artère fémorale profonde distale.

By placing the thigh in external flexion-rotation the deep femoral artery can readily be approached downstream the first perforating artery. The medial route respects the inguinal lymph nodes, approximately follows the internal saphenous vein axis, provides wide exposure of the artery and offers a wide range of courses for different bypasses.

[The clavi-pectoral route]. / La voie clavi-pectorale.

The clavi-pectoral route provides a limited approach to the axillary vessels as they emerge from the costal-subclavian outlet. The incision is oblique, following the course of the axillary vein. The greater pectoral muscle is split parallel to its fibres, and the smaller pectoral muscle is merely retracted. Only one nerve is exposed: the medial pectoral nerve. The vessels are controlled on à length of 4 to 5 cm, enough for catheterization, thrombectomy or central implantation of an axillo-femoral prosthesis. A technical device improves exposure of the artery and ensures haemostasis. The same route can be used for wide anterior resection of the first rib, a necessary stage in venous obstruction clearance, surgery of the outlet syndrome and wide access to the first ganglia of the thoracic sympathetic cord.

[Medial approach to the anterior tibial artery]. / Abord médial de l'artère tibiale antérieure.

The medial, transmembranous route is a simple way of approaching the anterior tibial artery in its middle third. The limb is elevated, the leg flexed and the thigh placed in external rotation. The incision, which follows the course of the great saphenous vein, begins 10 cm above the tibial malleolus and is 10 cm long. The soleus and long flexor muscle of toes are gently disinserted, and the posterior tibial muscle is retracted to expose the interosseous membrane which is split, displaying the artery. The main indication of this technique is tibio-saphenous bypass in situ, but the bypass can be performed with the posterior tibial artery or the peroneal artery, using the same approach.

[Interprostatorectal dissection: value of Denonvilliers' fascia]. / Clivage inter-prostato-rectal: intérêt du fascia de Denonvilliers.

We demonstrate that the Denonvilliers' fascia is attached to the prostatic gland and suggests that it is of Wolffian origin. The dissection plane between prostate and rectum therefore lies between the fascia and the rectum.

[Hemostasis of the preprostatic veins in total cystoprostatectomy. Anatomical bases]. / Hémostase des veines préprostatiques dans la cystoprostatectomie totale. Bases anatomiques.

An anatomical study has enabled the authors to propose a diagrammatic description of pre-prostatic veins, the haemostasis of which is one of the difficult stages in total cystoprostatectomy for cancer. These veins are surrounded by the pubovesical ligaments but they are separated from the membranous urethra by a cleavage plane which can be used to control venous bleeding.

[Organ procurement from cardiac arrest donors: outcome of kidney grafts and recommendations]. / Prélèvements d'organes sur donneurs décédés à coeur arrêté: devenir des greffons rénaux, propositions.

OBJECTIVES: To compare literature data with results obtained with organs procured from donors who died from cardiac arrest and to make proposals for this mode of organ procurement in France. METHODS: Over the last 10 years, 10 organ donors (2%) among a series of 486 donors in a state of brain death, had died of cardiac arrest. The arrest were perfused with double-balloon catheters. The outcome of the subsequent kidney grafts was compared with data in the literature. RESULTS: Fifteen of the 18 kidneys from cardiac arrest donors were functioning 1 month after implantation compared with 17 of the 20 kidneys from braindeath donors with beating hearts. The rate of acute tubular necrosis was 55% in the cardiac arrest kidneys and 40% in the beating-heart kidneys. Serum creatinine at 1 yeart was 145 +/- 69 mumol/l 17 +/- 29 mumol/l respectively. DISCUSSION: These results and those reported in the literature demonstrate that kidney procurement from cardiac arrest donors is feasible. If intensive care and surgery units are well organized, this type of organ procurement could provide a larger number of organs for transplantation. Emergency teams must be available for preparing and transferring the organs.

[Functional and mechanical anatomy of arm elevation]. / Anatomie fonctionnelle et mécanique de l'élévation du bras.

Experimental work on the functional anatomy of the shoulder has involved a study of the conditions involved in elevation of the arm. Movements of the upper limb are organised round a very special alignment of the scapulo-humeral joint whose geometric features and exact position have been determined. The ligaments of the joint play a major role in the controlling the attainment of this alignment. The value of this alignment in the physiology of the shoulder is demonstrated. A new terminology of shoulder movement is suggested.

[Santorini's venous plexus]. / Le plexus veineux de Santorini.

This article provides an anatomical study of Santorini's venous plexus based on forty dissections. The authors present a sketch of the plexus and its housing and suggest surgical applications of this anatomic sketch.

[The inferior vena cava: anatomic and embryologic study of its malformations]. / La veine cave inférieure: étude anatomique et embryologique de ses malformations.

The authors recall the anatomy and embryology of the vena cava with particular emphasis on MacClure's embryological scheme which explains a number of anomalies of the vena cava and the renal veins.

[Surgical significance of Denonvillier's aponeurosis]. / Intérêt chirurgical de l'aponévrose de Denonvilliers.

This article provides a macroscopic and microscopic anatomical study of the structure of Denonvilliers' fascia, and suggests that it is embryologically connected with the anlage of the Wolffian duct, prostate and trigone.

[A double balloon catheter for the procurement of abdominal organs]. / Sonde à double ballonnet pour prélèvements d'organes abdominaux.

When harvesting kidneys, a double balloon catheter can be inserted either at the bedside if cardiac arrest occurs or in the operating room. This catheter reduces the time required for dissection of the aorta and decreases the amount of fluid needed to cool the organs.

[Harvesting multiple organs]. / Les prélèvements multiples.

The development of organ transplants is limited by the shortage of organs. The improvement of this situation depends on two factors: increased awareness by the general public that refraining from refusing the removal of organs from the body of a patient with brain death is the most modern form of solidarity; and increased awareness by the medical profession that removal of organs should be proposed for every patient with brain death and that adequate resuscitative techniques should be used to preserve the organs in these patients. When the decision to harvest organs is taken, the transplant specialists must decide whether an organ should be used or not. Advances have been made in preservation techniques but are still insufficient to allow a reduction in immunosuppression. The UW solution is a major advance for liver, kidney and pancreas transplants. During harvesting, the separation of the vascular pedicles requires a good knowledge of surgical anatomy. Furthermore, the needs of the other surgical groups should be taken into account and concessions made to allow the harvesting of the greatest possible number of organs and consequently the treatment of the largest number of patients awaiting organs.

[Role of endoscopy and vascular decompression in the treatment of hemifacial spasm]. / Place de l'endoscopie et de la décompression vasculaire dans le traitement du spasme de l'hémiface.

Although it has long been hypothesized that hemifacial spasm could arise from a conflict between the nerve and the artery, it is very difficult to distinguish between a normal arterial loop and a pathological conflict leading to facial symptoms. Several new elements would help in the definition of the cause and allow less traumatic treatment of idiopathic hemifacial spasm. They include magnetic resonance imagery with CISS sequences, limited retrosigmoid approach, endoscopy of the cerebellopontine angle and monitoring the facial nerve. In our experience with 20 cases, retrosigmoid approach with a combined surgical and endoscopic procedure has led to total involution of the spasms in 80% of the cases.