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Biomedical subjects

A Pagé

Publications and source records attributed to A Pagé.

At least 19 recordsLinked to original sources
PubMed1998

[Diagnostic and therapeutic observations drawn from the surgical experiences of 108 traumatic ruptures of the descending thoracic aorta].

Traumatic rupture of the thoracic aorta should be suspected when automobile (62.9%), motorcycle (11.1%), ski-doo (2.7%), deltaplane (0.9%), or skiing accidents (0.9%), cause a sudden and rapid deceleration. It was also encountered with a vertical fall of 10 meters and more (4.6%), when a pedestrian was struck by a vehicle (4.6%) or the chest damaged by a high velocity flying object (4.6%). A lateral impact was found in 33% of injured patients and 52.7% were not wearing seat belts. Ruptured aorta was found as a single lesion in only 12% of the cases and among associated orthopedic lesions (63.8%) and abdominal injuries (28.7%), about 2/3 of them involved the left side of the body. The most reliable clinical sign of descending aortic rupture is the pseudo-coarctation syndrome found in 53% in the acute phase by simple pulse palpation and in 56% with blood pressure measurements. As soon as the diagnosis is suspected, associated hypertension present in 50% should be medically treated to avoid sudden exsanguination. Surgical repair should be undertaken with a perfusion technique which is an integral part of the ressuscitation procedure. A Gott shunt was used in 81 patients and a partial left heart bypass with a Bio-Medicus pump in 25 cases. This active atrioaortic bypass is physiologically superior. The pump flow (3727 +/- 612 ml/min.) is superior to the shunt flow (2833 +/- 576 ml/min.). Proximal pressure with the pump is better controlled (111 +/- 20 mmHg) than with the shunt (152 +/- 30 mmHg) and the mean distal pressure obtained with the pump is higher (81 +/- 19 mmHg) than with the shunt (64 +/- 22 mmHg). One case of paraplegia occured (0.9%) with an unfunctionnal Gott shunt. The survival rate is 95.4% (63/66 cases) in the acute phase and 100% (42/42 cases) in the chronic phase.

Accidental Falls↗
PubMed1996

[Popliteal aneurysm: surgical treatment is mandatory before complications occur].

Between 1972 and 1995, surgical repair was undertaken for 94 popliteal aneurysms diagnosed in 71 patients (69 men and 2 women) with a mean age of 66 years. Ninety-one femoropopliteal bypasses, 2 lumbar sympathectomies and one primary amputation were performed. Postoperative results of 28 elective bypasses performed for asymptomatic aneurysms (AA) were compared with 63 revascularisations needed for symptomatic aneurysms (SA) secondary to thrombosis (31%), embolization (30%), venous or nerve compression (13%), or rupture (2.1%). Occlusion of at least one tibial vessel was documented angiographically in 40% of the asymptomatic aneurysms and in 80% of the symptomatic aneurysms. No significant difference was observed between 5-year graft-patency of asymptomatic aneurysms (64%, mean followup 30 months +/- 37.2) and symptomatic aneurysms (50%, mean followup 39 months +/- 40.9). Furthermore, 5-year graft patency was not influenced by the number of patent tibial vessels in either of these populations. No statistically significant difference between these two groups was observed with respect to morbidity (AA: 10.7%, SA: 19%), or early reintervention (AA: 7.1%, SA: 9.5%). However, 12 secondary amputations were needed, all of which were performed after repair of a symptomatic aneurysm (19%, p < 0.05). No postoperative mortality was observed after an elective bypass while 3 patients (4.8%) with symptomatic aneurysms died after an emergency surgery. Ischemic symptoms persisted in 56% of patients who were initially symptomatic. Surgical correction should therefore be performed once the diagnosis of a popliteal aneurysm has been established in order to prevent amputation and late sequelae.

Adult↗
PubMed1996

[Development of circulatory support during 420 aneurysm resections of the descending thoracic aorta].

From July 1974 to January 1996, 420 aneurysms of the descending thoracic aorta were surgically treated at l'Hôpital du Sacré-Coeur de Montréal. Three principles were previously established and rigorously respected: 1) the preservation of distal body perfusion, 2) the briefest aortic cross-clamp time realizable (mean: 29.8 +/- 16 minutes overall, reduced to a mean of 24 +/- 6 minutes for the last 250 cases), 3) keep the aortic resection as short as possible in order to preserve as many intercostal arteries as possible (10 cm or less in 91.6% of the cases). In the first 380 cases, distal aortic circulation was supported with a 9 mm Gott shunt without using systemic heparinization. Average shunt flows from 300 ml/min, to 4900 ml/min. (mean: 2497 +/- 813 ml/min.), average proximal pressures from 80 to 200 mmHg (mean: 146 +/- 17 mmHg) and average distal pressures from 15 to 150 mmHg (mean: 64 +/- 19 mmHg) were recorded. In the last 40 cases, the distal circulation was supplied through the left heart assistance device Bio-Medicus using minimal systemic heparinization (0.5 mg/kg), (target ACT > 150 seconds). Average pump flows from 1800 ml/min to 5200 ml/min. (mean: 3340 +/- 866 ml/min.) were obtained. Average proximal pressures from 90 to 200 mmHg (mean: 118 +/- 19 mmHg) and average distal pressures from 58 to 180 mmHg (mean: 95 +/- 24 mmHg) were recorded. Overall hospital mortality is 11.9% (50/420 cases) and 9.9% when ruptured aneurysms are excluded. Paraplegia occurred in 2 patients (0.4%) and one was related to an unfunctional Gott shunt. Adverse anatomical conditions like a proximal aneurysm, degenerative changes of the aortic wall, a previous proximal graft replacement or the presence of coronary artery bypass grafts, a friable wall encountered with dissecting aneurysms and also an adverse physiological condition like a left ventricular dysfunction prompted us to modify the circulatory support by using the left heart bypass. Comparison of both methods of perfusion supported by statistical analysis regarding shunt and pump flows, proximal and distal perfusion pressures has showed the physiological superiority of the centrifugal pump that we have now routinely adopted.

Adolescent↗
PubMed1995

Aneurysms of the descending thoracic aorta: three hundred sixty-six consecutive cases resected without paraplegia.

PURPOSE: The aim of this study was to present a 20-year experience with a single method of passive distal perfusion during descending thoracic aortic aneurysm resection. METHODS: Aortic repair with a Dacron graft interposition was performed for 366 consecutive aneurysms located between the left subclavian artery and the crux of the diaphragm. The extent of aorta resected in 335 patients (91.5%) represented one third or less of the aortic length. A 9 mm Gott shunt was cannulated proximally into the ascending aorta (235 cases), the aortic arch (60 cases), the descending aorta (68 cases), or the left ventricle (3 cases) and inserted distally into the descending aorta (232 cases), the femoral artery (127 cases), or the abdominal aorta (7 cases). Shunt flows were recorded in 91 cases and varied from 1100 ml to 4900 ml/min, (mean 2526 ml/min). Distal pressure during shunting was measured in 62 patients. It varied from 15 to 120 mm Hg (mean 64.5 mm Hg). The aortic cross-clamp time varied from 8 to 124 minutes (mean 30 minutes). RESULTS: The hospital death rate was 12% overall and 9.9% (35/351) if ruptured aneurysms are excluded. Among 359 operating room survivors, neither immediate nor delayed ischemic spinal cord deficit occurred. Transient renal dysfunction occurred in nine patients (2.4%) and kidney failure in one (0.2%). Five deaths (1.3%) were shunt related. CONCLUSION: Distal perfusion with the 9 mm Gott shunt has proven to be an effective method to preserve spinal cord function. The limited extent of aorta resected and the brief aortic cross-clamp time may also be interactive factors of protection.

Adolescent↗
PubMed1994

[Palliative treatment of malignant effusions by thoracoscopy under video-assistance: morbidity and survival].

Survival after surgical palliation of patients with malignant pleural effusions is expected to be of several months. From a group of 75 patients operated by video-assisted thoracic surgery (VATS) from September 1991 through March 1993, twenty-two of 38 patients with malignant disease underwent palliative surgery and operative morbidity and length of survival were studied. Palliation consisted in 20 talc pleurodesis and 2 pericardial windows for malignant effusions. In the 16 other patients with malignancy, video-thoracoscopy was done for diagnostic purposes. Thirty-day operative mortality was 13.6% (3/22) and the rate of operative morbidity was 31.8% (7/22). The follow-up was complete for all patients with a mean length of 5 months (+/- sd 4 months). During the follow-up period, 14 of 19 (74%) patients, alive 30 days after the procedure, were deceased at a mean of 3.4 +/- 4 months (6 patients < 3 months) after the operation. In all, 9 of 22 patients (40%) survived less than 3 months (median survival 4 months). Operative morbidity and mortality of video-thoracoscopy are high in the palliative group and only 60% of patients survived more than 3 months. More stringent criteria for selection of patients for palliative endosurgery should be defined.

Adult↗
PubMed1993

[Video-assisted thoracoscopy and thoracic surgery: the first 50 patients].

We report our first full year of clinical experience with video assisted thoracic surgery. From September 1991 to October 1992, 50 patients were treated using endoscopic surgical techniques. There were 29 men and 21 women with a mean age of 48 years, ranging from 17 to 76 years. Drainage and talc poudrage of pleural effusions, with or without pleurodesis, was done in 18 patients (36%), blebectomies with pleurectomy or pleural abrasion was done in 11 patients (22%), and 7 patients (14%) underwent wedge resections of pulmonary lesions. Four other patients (8%) underwent resections or biopsies of mediastinal tumors, and 3 (6%) pericardial windows were done for cardiac tamponade. Finally, one chest wall biopsy and one empyema drainage were carried out, and 5 thoracoscopies were limited to the exploration of the chest. Complications occurred in 5 patients (10%). There was one mortality. Video-assisted thoracic surgery is efficacious in the treatment of various thoracic diseases and associated with satisfactory results in selected patients.

Adolescent↗
PubMed1991

Ambulatory mediastinoscopy and anterior mediastinotomy.

Ambulatory facilities are being used more and more for various diagnostic and therapeutic procedures. We report 158 consecutive mediastinoscopies and anterior mediastinotomies performed in an ambulatory setting from July 1981 to February 1990. There were 120 patients with a malignancy: 114 bronchogenic carcinomas, 4 lymphomas, 1 teratocarcinoma, and 1 carcinoma of the stomach. Thirty-eight patients had a benign condition, including sarcoidosis in 27 and miscellaneous diagnosis in 11. Twenty-two patients (14%) were admitted the same day: 9 for elective operation in view of bed availability, 8 for medical observation, and 5 for overnight admission for nonmedical reasons. Six nonfatal complications were encountered: hemoptysis (2), atrial fibrillation (1), pneumonia (1), mediastinal self-contained bleed (1), and tear of a pulmonary artery (1). There was no operative mortality. Overall, ambulatory mediastinoscopy and anterior mediastinotomy permitted a diagnosis in 47 patients (20%) and confirmed unresectable malignant disease in 29 patients, thus sparing unnecessary admission to a surgical ward in 76 (48%) of the 158 patients. Mediastinoscopy and anterior mediastinotomy can be safely performed in an ambulatory setting and do alleviate the need for hospitalization in a substantial number of patients.

Ambulatory Care↗
PubMed1991

Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult.

Bronchogenic cysts are closed sacs considered to be the result of an abnormal budding of the respiratory system. They are lined by ciliated epithelium and have focal areas of hyaline cartilage, smooth muscle, and bronchial glands within their walls. They are seldom seen in the adult, and most are thought to be asymptomatic and free of complications. During a 20-year period, 86 patients underwent resection of a bronchogenic cyst of the mediastinum (66 patients) and lung (20 patients). There were 47 women and 39 men whose ages ranged from 16 to 69 years. Seventy-two percent of patients (67% with mediastinal cysts and 90% with cysts of the lung) were symptomatic at the time of operation, and the majority had two or more symptoms. Despite extensive investigations, which in some cases included computed tomographic scanning (n = 12) and angiography (n = 22), a positive diagnosis was never made preoperatively even if it was suspected in 57% of patients. In nearly all patients, the operative approach was that of a posterolateral thoracotomy. All but two mediastinal bronchogenic cysts could be locally excised, but all bronchogenic cysts of the lung required pulmonary resection (lobectomy, 13; limited resection, 6; pneumonectomy, 1). Major operative difficulties were encountered in 35 patients, all of whom were symptomatic preoperatively. Thirty-three patients had a complicated cyst; the complications consisted of fistulization (n = 16), ulcerations of the cyst wall (n = 13), hemorrhage (n = 2), infection without fistulization (n = 1), and secondary bronchial atresia (n = 1). Overall, 82% of patients had a bronchogenic cyst that was either symptomatic or complicated or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

[Thoracotomy with muscle sparing].

Muscle sparing thoracotomy is suggested more frequently in recent literature. From March 1988 to February 1990, a muscle sparing technique was used in 77 (58%) of 132 consecutive thoracotomies. There were 50 men and 27 women, age varied from 23 to 81 years, with a mean of 58 years. Forty-four lobectomies, 10 pneumonectomies, 9 lung biopsies, 6 wedge resections, 6 bullectomies and 2 segmentectomies were performed. A horizontal incision was used in 47 (61%) patients and a vertical mid-axillary incision in 30 (39%). For optimal exposure, transection of the latissimus dorsi muscle was needed in 14 (30%) of the horizontal incisions. Inadvertent rib fracture occurred in 10 (13%) cases. Continuous epidural analgesia was added in 46 (60%) patients for an average of 40 hours. Mechanical ventilation in 14 (18%) patients for a mean duration of 22 hours and an average stay of 2 days in the ICU and 7 days in the hospital, were required. There was 1 (1.3%) hospital mortality, 4 (5%) patients developed a seroma that required aspiration. Muscle sparing thoracotomy can be used safely for most thoracic procedures and we believe it permits easier pain control and early preservation of full shoulder motion. However the operative field is more restricted. A horizontal incision, permitting section of the latissimus dorsi for better exposure should be used for hilar or invasive lesions.

Analgesics↗
PubMed1991

[Mediastinoscopy in ambulatory surgery: nine years' experience].

Ambulatory facilities are being used more and more for various diagnostic and therapeutic procedures. We report 183 consecutive mediastinoscopies and/or anterior mediastinotomies performed in an ambulatory setting from July 1981 to January 1991. There were 140 patients with a neoplasia: 131 bronchogenic carcinomas, 5 lymphomas, 2 carcinoid tumors, 1 teratocarcinoma, 1 carcinoma of the stomach. Forty-three patients had a benign condition, including 32 sarcoidosis and 11 miscellaneous diseases. Twenty-eight (15%) patients were admitted the same day: 12 for elective surgery in view of bed availability, 9 for medical observation, and 7 required overnight admission for non-medical reasons. Eight non-fatal complications were encountered: hemoptysis (2), atrial fibrillation (1), pneumonia (1), mediastinal self-contained bleed (1), tear of a pulmonary artery (1), temporary palsy of the recurrent laryngeal nerve (1) and wound infection (1). There was no operative mortality. Overall, ambulatory mediastinoscopy and anterior mediastinotomy permitted a diagnosis in 58 patients (29%), and confirmed unresectable malignant disease in 36 patients, thus sparing unnecessary admission to a surgical ward in 89 (49%) of the 183 patients. Mediastinoscopy and anterior mediastinotomy are safe in an ambulatory setting and alleviate the need for hospitalization in a substantial number of patients.

Adult↗
PubMed1991

[Use of the Gott shunt in the prosthetic replacement of the aortic arch].

Our previous experience in 272 consecutive cases of descending thoracic aortic aneurysms resected without paraplegia by using the 9 mm Gott shunt encouraged us to apply the same technique to more complex aortic surgery. Graft replacement of the transverse aortic arch with brachio-cephalic vessel reattachment was undertaken in 2 patients without the aid of extracorporeal circulation and without systemic heparinisation. Body perfusion was achieved with two 9 mm Gott shunts inserted between the ascending aorta and both femoral arteries. A 10 mm graft interposition between the shunts and the femoral arteries allowed for retrograde perfusion and distal leg irrigation. Blood supply to the brain was maintained with the cut halves of a 7 mm Gott shunt connected as side branches to one of the 9 mm shunts, allowing cannulation of the innominate ant the left carotid arteries. In 90 of the 272 patients treated for a descending aortic aneurysm, a mean shunt flow of 2526 ml/min. was recorded through the 9 mm Gott shunt and from there, we took for granted that the total cardiac output, in there 2 patients, could be propelled by using 2 shunts. During aortic cross clamping, there were no change in the filling pressure of either the right heart or the left heart, and no metabolic acidosis was observed. Both patients survived with normal physiological function of all organs including the brain and the spinal cord.

Anastomosis, Surgical↗
PubMed1991

Bronchial carcinoids: long-term prognostic factors.

Between 1962 and 1987 bronchial carcinoids were diagnosed in 41 patients (21 men, 20 women) at l'Hôpital du Sacré-Coeur and the Centre hospitalier Maisonneuve-Rosemont. The patients ranged in age from 19 to 73 years (mean 47 years). Fourteen of the 19 asymptomatic carcinoids were discovered on routine chest radiography. Twenty-two symptomatic patients presented with either pneumonia or hemoptysis. Tumours involved the right and left lungs equally. Thirty tumours were located centrally and 11 peripherally. Sensitivity of endoscopic biopsy specimens was 66%. No complications occurred during biopsy. Cytologic examination of sputum, lavage, brushing and transthoracic biopsy specimens was of no value in establishing the diagnosis. Thirty-seven patients underwent surgical resection: lobectomies (26, 3 with bronchoplasties), pneumonectomies (7), segmentectomies (2) and wedge resections (2). One patient (3%) died, and there was one major complication (3%) related to surgery. The mean follow-up was 8 years. The probability of survival was 97% +/- 3 at 5 years and 92% +/- 6 at 10 years. None of the 19 patients treated for a peripheral tumour died, but two patients who had centrally located tumours that exhibited transbronchial invasion and lymph-node metastasis died. No prognostic information could be gained from tumour size or type. A statistical association was found between transbronchial invasion and lymph-node metastasis. Bronchial carcinoids are low-grade malignant tumours. Resection should be conservative, but lymph-node involvement requires a more radical approach.

Adult↗
PubMed1989

Thromboembolism from undersized Dacron grafts in the descending thoracic aorta.

Three patients were referred to our institution for major thromboembolic complications secondary to the use of undersized Dacron grafts (14, 16, and 18 mm) in the descending thoracic aorta. The progressive accumulation of thrombotic material in the prosthesis caused recurrent coarctation in 1 patient and peripheral embolisms in the other 2. With a 9-mm Gott shunt providing distal perfusion, excision of the clotted graft and its replacement with a 22-mm Dacron prosthesis was successfully achieved in each patient.

Adult↗
PubMed1989

Intrapericardial trauma: surgical experience.

From 1975 to 1987, 19 patients (pts) were operated on for a traumatic lesion of the heart or of the ascending aorta. There were 15 males and four females with a mean age of 42 years. Twelve lesions (Group I) were penetrating and seven (Group II) blunt. Group I: Nine patients were in shock upon admission, including six with cardiac tamponade. Six pts were stabbed, three sustained a gunshot wound, and two were accidental victims of a pneumatic gun. In the last pt, with previous lung surgery and mediastinal shift, a chest tube lacerated the right ventricle; this pt died in the operating room (OR), for a mortality rate of 8.3% (1/12). Associated intrathoracic and intra-abdominal lesions were present, but did not influence the outcome. Group II: All pts were involved in motor vehicle accidents. Five pts were in shock, including two with cardiac tamponade. Three pts required extracorporeal circulation (ECC) for aortic valve replacement, tricuspid valve reconstruction, and replacement of the ascending aorta. In one case, a lacerated right ventricle could be repaired without ECC, but the pt died from low cardiac output. Three pts with a ruptured left ventricle were managed in the OR, and two pts exsanguinated for a mortality rate of 43% (3/7). Associated lesions were present and death was related to ventricular rupture. Intrapericardial lesions are relatively rare in our Canadian experience. High survival can be obtained in penetrating injuries, while blunt injuries are more complex and remain highly lethal. ECC should be available for definitive treatment.

Adult↗
PubMed1988

Surgery of the descending thoracic aorta: spinal cord protection with the Gott shunt.

From July, 1974, to July, 1987, surgical treatment of descending thoracic aortic aneurysms was performed in 173 patients at l'Hôpital du Sacré-Coeur de Montréal. The cause of the aneurysms was arteriosclerosis or medial degeneration in 83 patients, trauma in 50, dissection in 34, and a congenital malformation in 6. A single method of external shunting provided distal perfusion in all patients in the series. A 9-mm Gott aneurysm shunt was placed preferentially between the ascending aorta (67%) and the descending aorta (60%). Alternative sites of proximal cannulation (aortic arch, 9%; proximal descending aorta, 22%; left ventricle, 2%) and distal cannulation (abdominal aorta, 3%; left femoral artery, 37%) were chosen based on the location and the extent of the aortic aneurysm. No systemic heparinization was used. In the last 40 patients, a flowmeter adapted for use with the shunt allowed the recording of shunt flow (mean, 2,475 ml/min; range, 1,100 to 4,000 ml/min). Hospital mortality, including patients with ruptured aneurysms, was 15% (26/173). The mean aortic cross-clamp time was 37 minutes (range, 8 to 105 minutes). Of the 173 patients, 168 survived long enough to allow accurate clinical evaluation of the function of the spinal cord: no paraplegia or other spinal cord ischemic injury occurred. To date, our clinical experience has demonstrated the effectiveness of the 9-mm Gott shunt in preserving the functional integrity of the spinal cord during cross-clamping of the thoracic aorta.

Adult↗
PubMed1988

Total replacement of the transverse aortic arch with the Gott aneurysm shunt.

A new method of temporary external shunting for total replacement of the aortic arch is described. Its greatest advantage is that systemic heparinization is not required. In a 46-year-old man total body perfusion was achieved with two 9-mm Gott aneurysm shunts inserted between the ascending aorta and both femoral arteries. Blood supply to the brain was maintained with the cut halves of a 7-mm Gott shunt connected as side branches to one of the 9-mm shunts, allowing cannulation of both carotid arteries. The total cardiac output, measured at 4.7 L/min by the thermodilution technique through a Swan-Ganz catheter, was propelled through these preheparinized multibranch shunts. A flowmeter adapted on one of the 9-mm Gott shunts demonstrated a shunt flow of 2000 ml/min and it was deduced that the other 2700 ml of the total cardiac output was delivered by the other shunt. During the 29 minutes of cross-clamping, there was no change in the filling pressure of either the right heart (central venous pressure 5 cm H2O) or the left heart (pulmonary wedge pressure 8 mm Hg). Aortic continuity was reestablished with the interposition of a 34-mm tubular woven Dacron prosthesis, on which two 10-mm woven Dacron side branches were anastomosed to the innominate and left common carotid arteries. The patient had no neurologic deficit and had normal physiologic function of all other organs.

Anastomosis, Surgical↗
PubMed1987

Penetrating chest trauma: a 20-year experience.

From 1965 to 1985, 76 patients were admitted to Sacré-Coeur Hospital, Montreal, with a diagnosis of penetrating chest trauma (PCT). The majority were under the age of 30 years and almost two thirds suffered gunshot wounds. Sixty-seven (88.1%) sustained a lateral or thoracic (T) injury and in nine (11.8%) the lesion was central or mediastinal (M). In the first group (T), 53.7% were treated surgically with thoracotomy, laparotomy, and chest tube (CT) insertion or both; 46.2% were managed conservatively. In the second group (M) the pericardium or the heart was involved, eight patients (88.8%) were managed surgically without the use of extracorporeal circulation and one patient was observed only. Eight (11.9%) died in the thoracic group; all survived in the mediastinal group, for an overall mortality of 10.5%. Shock was associated with increased morbidity and mortality in the thoracic group (T) and infection was the most frequent complication for the entire group of patients under study. There has been a steady increase in the total number of PCT at our hospital during the last two decades suggesting an increase in crime and violence in our urban surroundings.

Adolescent↗