Biomedical subjects
Publications and source records attributed to D Savioz.
The discovery of a cystic image in the mesentery is a difficult diagnostic and therapeutic problem. We report the case of a 25-year-old female with a mesenteric lymphangioma, which was resected after careful consideration. The complications due to the expansion of this benign tumour are reviewed, and the surgical indications discussed.
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We determined the kinetics of cooling in multiple organ procurement for the kidney in a pig model. A biometric analysis by regression enables us to define the factors which influence the rate of temperature decrease: weight of the donor, average rate of perfusion and difference of temperature between the rectal temperature and the temperature of the perfusion solution at initiation of cooling. The description of the temperature as a function of time follows an exponential model of the type T(t) = T0. e(dt) where d is the rate of decrease. The rate of decrease varies according to the above factors. The cellular viability ratio (CVR), was correlated to the rate of cooling. The mean CVR was 91% (SD 4.95) when the rate of cooling was more than 1 degrees C/min. This was compared to 75% (SD 11.17) when the rate was less than 1 degrees C/min (p = 0.023). Our experience leads us to believe that the average cooling rate is frequently too low (<1 degrees C/min). This model can be used to predict and control the kinetics of cooling and may help to define the best way of cooling for future xenotransplantation.
PURPOSE OF THE STUDY: Retrospective evaluation of conventional mediastinoscopy in the preoperative staging of primary lung cancer. METHODS: Between 1978 and March 1997, 117 consecutive patients underwent conventional mediastinoscopy in the preoperative staging of primary lung cancer, after imaging had shown mediastinal lymph nodes larger than 1.5 cm. RESULTS: In 8 instances no material was found at mediastinoscopy, in 38 the lymph nodes showed no tumorous infiltration, and in 71 the lymph nodes were metastatic. 48 patients underwent thoracotomy in the same stage, with resection achieved in 41. Contraindications for thoracotomy (in 69) were N2 (45) or N3 (11) disease adn/or small cell lung cancer (18). Mediastinal lymphadenectomy was performed in 26 of the 41 patients who underwent lung resection; half of those with negative nodes at mediastinoscopy had in fact N2 disease, with involvement of 2 areas of more in half. There were no deaths due to mediastinoscopy but 4 complications. CONCLUSIONS: A favorable mediastinoscopy is not synonymous with resectable disease, nor does it exclude N2 disease; it does however serve to avoid unnecessary thoracotomies in more than half of cases.
10% of chronic pancreatitis (CP) cases are complicated by splenic vein thrombosis (SVT) which is responsible for upper digestive haemorrhages. To improve our approach to treatment we reviewed 30 cases of SVT associated with CP treated in our centre from 1985 to 1995. 14 patients were treated conservatively. Six of them were refused for surgery due to extension of splenic vein thrombosis into the portal vein. Two patients without extrinsic compression of the vein were treated with anticoagulants. 16 patients were treated by surgery with low morbidity and without mortality. The standard treatment in fourteen cases was splenopancreatectomy. The average follow-up of seven years shows that these patients have preserved their body mass index (BMI). The results suggest that early surgical intervention is beneficial in preventing progression of SVT to the portomesenteric vein.
Pseudocysts of the pancreas may require drainage or resection during their evolution. External drainage can be considered as a treatment of first resort with low related morbidity. It also offers a means of treating patients with major contraindications for surgery. In our experience, however, only 55% of external drainages prove successful. Therefore, surgical treatment, even at the cost of low-rate morbidity, remains the only final treatment for complications linked to pseudocysts of the pancreas. In the long term, however, these results depend on the etiology of the pseudocysts.
Rubber band ligation is a well established treatment of internal second-degree hemorrhoids. Up to now, the long-term results (> 5 years) of this method have not been assessed. The aim of this study was to determine the long-term success rate of rubber band ligation in patients with a first episode of second-degree hemorrhoids not responding to medical treatment (local cream with laxative). A total of 92 patients who were treated between 1979 and 1997 for second-degree hemorrhoids responded to a questionnaire. The need for complementary conservative (sclerotherapy, cryotherapy or rubber band ligation) or surgical treatment was considered indicative of relapse. The collected data were analyzed according to the Kaplan-Meier method. The average follow-up time was 5.6 years. There were 21 patients who suffered a relapse. The probability of successful treatment was 0.77 (range: 0.67-0.88) after 5 years and 0.68 (range: 0.5-0.86) after 10.6 years. We conclude that rubber band ligation represent an efficient long-term treatment for second-degree hemorrhoids. Approximately two thirds of the patients are cured after 5 years and more than a half after 10 years.
OBJECTIVE: To assess the relationship between postoperative infective complications and the CD4 count. DESIGN: Retrospective and biometric study. SETTING: Two university hospitals, Switzerland. SUBJECT: 40 HIV-positive patients who had had CD4 counts done during the three months before operation. INTERVENTIONS: Clean and contaminated gastrointestinal and orthopaedic procedures. MAIN OUTCOME MEASURE: Postoperative infective complications. RESULTS: 15 patients developed postoperative infective complications (38%), 6 of which (40%) were HIV-related. CD4 cell count, as well as the type of operation (contaminated or clean), influenced the infective complication rate. The risk of infective complications after a contaminated procedure when the CD4 count was below 200 mm3 was more than 50%. In clean operations, even when the CD4 cell count was close to 0, the rate of infective complications was never as high as 50%. Patients with a CD4 cell count of 500 or more have a similar rate of infective complications as HIV seronegative patients. CONCLUSION: Indications for operation in HIV-positive patients must take into account the CD4 cell count and the type of operation.
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INTRODUCTION: evaluation of the clinical and radiological criteria for laparotomy in intestinal lacerations after a blunt abdominal trauma. Determination of the different radiological signs from the CT scan and the sensitivity of this examination in the diagnosis of intestinal lacerations. DESIGN: retrospective study. MATERIAL AND METHOD: we selected all patients operated for intestinal laceration caused by a blunt abdominal trauma during the period of 1986 to 1995. The clinical and radiological criteria for laparotomy in these patients were determined. Correlation of the radiological signs from the CT-Scan and the surgical findings was used to determine the sensitivity of the CT-scan. We distinguished patients who had an abdominal CT-scan from those patients for which no CT was done.
After external cardiac massage, 3-8% of patients present potentially dangerous liver lacerations. Here we discuss the case of a patient who presented a major haemodynamic instability following external cardiac massage and thrombolytic therapy. Falsely attributed to a cardiac complication, this was actually consecutive to a hepatic haemorrhage originating from liver lacerations caused by the cardiac massage. Haemodynamic stability was obtained by reestablishing blood volume and coagulation factors. Following this the patient evolved favorably. We discuss the importance of evoking the possible existence of abdominal lacerations after external cardiac massage and the therapeutic attitude which must be adopted towards these, particularly in the light of thrombolytic therapy used in interventional cardiology and its effect on these complications.
OBJECTIVE: To review patients who presented lesions of the pancreas following blunt abdominal trauma, in order to determine which elements contributed to or on the contrary delayed the diagnosis. Construction of a diagnostic procedure which could be followed in order to maximize the rapidity and efficency of treatment. DESIGN: Retrospective study. PATIENTS AND METHOD: Patients from 1985 to 1997 having suffered blunt trauma were studied. The lesions of the pancreas were classified according to Lucas. The grounds for indication and the information that the echography, the CT-Scan and the wirsungographie brought to the diagnosis was determined for each patient. Elements which delayed diagnosis were retrospectively evaluated. RESULTS: We treated 11 patients having suffered blunt abdominal trauma resulting in pancreatic damage. 7 patients were operated. Five had emergency laparotomies. Three of these were unable to reveal an existing rupture of the pancreatic duct. CONCLUSIONS: Surgical exploration is difficult and pancreatic lesions are frequently missed. The wirsungography done before or during the operation should, therefore, be more often used as a diagnostic tool.
The data of 62 adult patients with isolated blunt splenic trauma were retrospectively analysed to determine the value of a CT score-system in the choice of treatment: nonoperative treatment versus surgical management. 22 patients (35%) without hemodynamic instability presenting with pain localized in the left flank were primarily managed conservatively. 3 of them subsequently required splenectomy. 40 patients (65%) were operated immediately, 32 on the basis of clinical criteria and 8 on the basis of laboratory criteria. 45 patients with no initial haemodynamic disorders were investigated by abdominal CT-scan. Splenic injuries were retrospectively classified according to Resciniti's CT-scoring system. 13 patients had a splenic injury score > or = 5.5. All of them were operated, 11 early and 2 after failure of conservative management. According to our study this score > or = 5.5, which concerns 21% of our patients, can be considered to be an indication for surgery; in this case, a conservative approach should not be at tempted, even in the absence of immediate clinical and laboratory operative criteria.
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PURPOSE OF THE STUDY: We have retrospectively studied the results of arthroscopic removal of loose bodies in the elbow. The aim of the study was to determine if the etiology of the loose bodies could be considered as a criteria for technical difficulty and clinical prognosis. MATERIAL: 16 patients (11 men and 5 female) had an elbow arthroscopy for loose bodies removal. Their average age was 29.5 years (range: 16-49). The post-operative results were recorded in their medical files with an average follow-up of six months. METHODS: In each case we have determined the etiology of the intra-articular loose bodies. The results were analyzed according to technical difficulty and clinical outcome. RESULTS: The etiology of the loose bodies was 8 chondromatosis, 4 osteochondritis dissecans and 4 post-traumatic osteoarthritis. The removal of the loose bodies was possible in 13 cases. Three arthroscopies were interrupted because of arthritic joint space narrowing. Twelve patients with primary chondromatosis and osteochondritis dissecans were improved. We did not find any significant clinical improvement in osteoarthritic elbows. A correlation between the results and the etiologies could therefore be shown. DISCUSSION: In arthroscopic removal of elbow loose bodies, technical difficulties and clinical results are correlated to the etiology of the loose bodies and also to the statement of the osteochondral surfaces.
We have determined the kinetics of the cellular viability ratio (CVR), defined as the number of living cells over the total cell count, in pig kidneys using propidium iodide and fluorescein diacetate staining, as a function of time and preservation conditions. The kidneys were preserved in warm or cold ischemia in order to mimic the conditions of transplantation from non-heart-beating donors or multiple removal with optimal preservation of the graft, respectively. To determine the CVR, the cells were obtained by a fine-needle aspiration biopsy, which minimizes the damage to the graft. A biometric analysis by regression enabled the determination of the time dependence for warm ischemia (CVR(t) = 80.0 x e(-0.733-t)(+2.7/-0.36)) and for cold ischemia (CVR(t) = 80.0 x e(-0.022-t)(+1.57/-0.64)) with a confidence interval of 95%. These master curves allow us to predict, under the described conditions, the CVR after a given ischemia time. The half-life of the cells can be deduced from the time-dependent CVR(t), and is 0.64 hr (38 min) for warm ischemia and 21.4 hr for cold ischemia. Further, the CVR for a given kidney can be used to assess its condition at removal: if the CVR is below 48% at 2 hr after removal, one can conclude that the organ has suffered a period of warm ischemia.
A retrospective review was performed of the clinical features present in 17 patients who were human immunodeficiency virus (HIV) positive requiring a diagnostic or therapeutic procedure for suspected appendicitis. Patients who were acquired immune deficiency syndrome (AIDS) free (n = 11) and those with AIDS (n = 6) were compared. Ten of the 11 patients who were AIDS-free had appendicitis. The morbidity rate was 9 per cent, similar to that expected in seronegative patients, but the appendix perforation rate was 50 per cent. Only two of the six patients with AIDS had appendicitis. Three suffered from an HIV-related disease process. Computed tomography (CT) was performed in four of the six patients with AIDS, and was considered of diagnostic help in three. In patients with AIDS, the morbidity rate rose to 50 per cent. Surgical decision-making with regard to HIV-positive patients who were AIDS-free with suspected appendicitis should be similar to that for seronegative patients. For patients with AIDS, alternative diagnostic strategies, including preoperative CT, or possibly laparoscopy, should be considered.
The surgical treatment of chronic sprain of the distal radio-ulnar joint remains a difficult problem. Some authors have proposed a radio-ulnar stabilization procedure which involves some loss of mobility of the forearm. Other, more radical authors, have suggested partial or complete resection of the ulnar head. In this case, they restore mobility in prono-supination, but often with a loss of stability and discomfort or pain. Hui and Lindscheid modified a technique of tenodesis which had been previously proposed by Bunnell. They perfected a tenodesis based on the use of the flexor carpi ulnaris tendon. We feel that this procedure should ensure stability of the distal radio-ulnar joint, while preserving its mobility. We used this technique in 9 patients who were reviewed with a follow-up of 2.7 years. The authors obtained 2/3 of good and very good results. This procedure will be compared with other techniques currently used and differences of the results will be discussed. Unfortunately, few articles have been published on this subject.