[Eulogy of Paul Pialoux (1914-1996)].
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France↗
Biomedical subjects
J Natali
Publications and source records attributed to J Natali.
[Forensic medical implications of vascular injuries in orthopedic surgery].
The vascular risk in orthopedic surgery results from the close relation between bones and vessel-nerve bundles, the use of sharp cutting and perforating instruments and, in hip surgery, the use of cement. The two main prognosis factors are early diagnosis and the time of treatment. Here we review risks by localizations. For spinal surgery, the great vessels may be damaged by discetomy and can lead to intraperitoneal bleeding and death or arteriovenous fistulization. In the scapular area, pin migrations after surgery involving the clavicle can lead to bleeding or false aneurysms of the subclavian artery. When surgery is performed for thoraco-brachial outlet syndromes, arterial damage is less frequent than nerve damage which can lead to death (one case reported) or severe sequelae. Hip surgery can damage the iliac or femoral vessels with severe sequelae after total hip replacement. Two cases of death related to femoral neck fracture and anticoagulant treatment are reported. Two other cases of lesions to the femoral artery with severe sequelae after treatment of diaphyseal fractures of the femur are also reported. In the knee area, consequences of surgery can be particularly severe, especially unrecognized damage or incorrect treatment of the popliteal artery after osteoarticular injuries, or iatrogenic lesions after knee surgery. Finally two cases of tibial artery lesions are reported. In most of these cases, medicolegal consequences were confirmed by court judgements.
Blood Vessels↗
[Forensic medical implications of vascular injuries and accidents related to the practice of conventional vascular surgery].
Three areas are covered: neck surgery, thoracic aorta and abdominal aorta surgery. In neck surgery, cerebral vascular events can occur after endarterectomy of the carotid artery or after resection of carotid loops. These accidents are also seen after locoregional anesthesia in carotid surgery. Cases of hemorrhage or cerebral vascular events after chemodectomy are also reported. In thoracic aorta surgery, three cases of paraplegia after exeresis are reported. In abdominal aorta surgery, a case of non operation for aneurysm of the aorta led to legal procedures as did a case of an infected prosthesis. Legal procedures are rare after surgery of the lower limb arteries, despite the frequency of this surgery, but the observations reported demonstrate that amputations may follow an unfavorable course. Focus is increasingly being put on the need to inform the patient before surgery.
Accidents↗
[Forensic medical implications of vascular injuries and accidents related to the practice of conventional general surgery].
We recall a certain number of cases in our experience after cure of a hernia. Cases include damage to the iliac arteries and veins after appendicectomy (the case is still in court 25 years after the accident), hemorrhage after hysterectomy, damage to the iliac artery due to a Pfannensteel incision, lesion of the axillary artery during lymph node curettage, and hemorrhage during attempted appendicectomy.
Accidents↗
[Forensic medical implications of vascular injuries in the course of video-endoscopic surgery].
We report 21 case files. Seven concerned gynecology laparoscopy with 3 deaths and 4 severe sequelae. Five cases involved laparoscopic appendicectomy with 1 death and 4 severe sequelae. In 3 cases complications during conventional appendicectomy were treated laparoscopically. Three cases concerned post-operative complications and finally, 6 cases of laparoscopic cholecystectomy are reported, including 4 fatal cases. Three-fourths of these cases occurred after 1990 and the fatal cases were usually related to bleeding caused by the inflation trocar, emphasizing the importance of strict safety measures, especially control of intraabdominal pressure and verification of ligatures. These case-files demonstrate that severe vascular events can occur in all laparoscopic procedures. In most of the cases, the surgeon was not unexperienced but rather well trained in this type of surgery. Practicians using this technique must have training in vascular surgery or at least operate within structures allowing immediate relay by a vascular surgeon.
Adult↗
[Forensic medical implications in the course of sclerotherapy of varicose veins].
Complications are exceptional compared to the number of sclerosis treatments performed. We report 58 case-files with medico-legal implications. Intraarterial injections are by far the most severe complications: we observed 40 such cases with the following consequences: 7 major amputations including 2 above the knee and 5 below the knee, 6 minor peripheral amputations of one or more toes, 27 severe sequelae, mainly due to retraction of the triceps sural muscle. This type of accident occurs more readily after attempted sclerosis of the lesser saphenous vein "crosse", although other localizations can be involved: inguinal area by sclerosis of the greater saphenous vein "crosse", the lower third of the leg with direct injection into the anterior or posterior tibial artery or its branches. Subcutaneous injections of the sclerosis agent produce either simple inflammatory reactions or skin necrosis. Neurological disorders can be observed by direct damage to the nerve. Sensorial complications may occur by lesion of a cutaneous branch of the popliteal sciatic nerve. Other cases involve motor disorders. Pulmonary thromboembolic events (4 cases) appear to be exception when modern criteria for the diagnosis of phlebitis are used. General allergic and anaphylactic reactions are very rare and often related to overdose. The same is true for toxic reactions. One case of septicemia occurred after incision of post-sclerosis clots. From a medicolegal point of view, the responsibility of the practician is usually confirmed for severe accidents (intraarterial injections) leading to trophic disorders. For necrosis or limited eschars, the question is debated.
Accidents↗
[Forensic medical implications of vascular punctures and catheterization and radiologic procedures with diagnostic or therapeutic purpose].
Whatever the aim of the procedure, puncture of a vessel can lead to local complications. Access to the artery carries a risk of hemorrhage, occlusion, stenosis, arteriovenous fistulization or pseudo-aneurysm. The same types of complications can occur in veins. Other complications include skin necrosis due to extravasation of the contrast medium, perforation of the superior vena cava after insertion of an infusion catheter and the risk of pericardial effusion. General complications occur immediately, usually caused by contrast media, or late. There are different examples of secondary legal procedures following punctures involving, with the exception of radiology cases, intraarterial injection at the elbow, perforation of the right atrium by a jugular catheter and acute ischemia of the foot after catheterization of the pedial artery. Legal procedures after radiological procedures were discussed in more detail. The personal experience of the authors and others concerns accidents occurring after arteriography, angioplasty or embolization. Finally, two legal cases after treatment for impotency are analyzed. We focus on a certain number of rules on patient information, preangiography consultation, participation of an anesthetist, careful post-operative follow-up and operation report. Finally, the possibility of radiation-induced arteriopathy is demonstrated by one case reported here.
Angiography↗
[Forensic medical implications of lymph node and lymphatic injuries].
Three cases of injuries to lymph nodes are reported; the main sequela was lymphedema. One case occurred after node curettage and two after varicose vein surgery.
Adult↗
[Forensic medical implications of anticoagulant treatments].
Several types of accidents related to anticoagulant treatment can lead to legal procedures, including: thromboembolic post-operative complications associated with lack of anticoagulant prophylaxis and leading to sequelae or death; severe hemorrhagic or thromboembolic accidents attributed to poor management of anticoagulant therapy; complications with sequelae or death resulting from heparin-induced thrombopenia, either with standard or low-molecular weight heparin and associated with poor surveillance of platelet counts. The exceptional nature of accidents leading to legal procedures (24 legal cases in Pr Natali's experience) and the small number of other cases reported should not lead to underestimating the importance of precise rules for anticoagulation treatments. In 7 cases, there was no anticoagulant prophylaxis after surgery. Recent consensus conferences have proposed a definition of small, moderate or high risk of thrombosis as a function of patient status and surgical procedure. Expert working groups have defined the operated patients for which pharmacological anti-coagulation is necessary. In 19 other cases, management of the treatment protocol was insufficient leading to severe hemorrhage with sequelae, severe thromboembolism, or late diagnosis of heparin-induced thrombocytopenia because of insufficient surveillance of platelet counts. Recent advances in laboratory tests for the diagnosis of heparin-induced thrombocytopenia should be emphasized. To these case reports can be added other observations in a small number of complaints resulting from unadvisable treatment combinations, poor surveillance of a thromboembolic event or dangerous invasive exploration.
Adult↗
[Legal aspects of vascular injuries and their forensic medical sequelae].
The questions which an expert opinion should answer are presented in the first part of this article: evaluation of the physical or functional handicap, evaluation of the occupational handicap, analysis of any cause and effect between the trauma and the arterial injury. Four criteria are studied: the former status of the patient, the nature of the injury, the time of onset of the signs or delay to onset of disorders, and certain diagnosis. The second part of the article concerns the general methodology used in vascular injuries. In the third part professional responsibility is discussed-three conditions, and all three, are necessary for malpractice to be retained: 1) Prejudice or harm to the patient, 2) Error committed by the practitioner, 3) A causal relationship between the error and the verified harm. The four levels of medical responsibility are recalled: penal, civil, administrative and ordinal. Finally the physician's management of vascular injuries can also lead to legal pursuits.
Blood Vessels↗
[Surgery of carotid stenosis and prevention of cerebral infarction].
In 1983, the author, relating his personal experience, as well as those of other authors, presented a critical analysis of indications and results of surgical treatment for carotid artery stenosis in order to prevent stroke. The actual experience of the author is based on for 142 patients operated on from 1st January 1982 to 31st December 1986. This study includes 32 stage 0 (asymptomatic) patients, 95 stage I (transient) patients, and 15 stage IIIa (slight deficit) patients. The immediate mortality rate has been 2.1% with a rate of severe morbidity of 1.4%. The 5 year survival rate has been 72.3% decreasing fairly regularly from 90% for the first year. The conclusions of this study and other published at the same time in the literature were that there was a category of high-risk patients with over 70% stenosis, especially those with an history of transient ischemic attack. But unfortunately no randomized work was available for supporting these conclusions. Lately, two randomized studies have been published, the first one in Europe called ECST (European Carotid Surgery Trial), and the second one in North America called NASCET (North American Symptomatic Endarterectomy Trial). The European Trial based on 2,518 patients showed that for 778 patients with a carotid stenosis between 70% and 99% and a history of a transient ischemic attack the cumulative risk of any ipsilateral stroke at 3 years was 10.3% for the surgical group and 16.8% for the medical group. The North American Trial is still more accurate. For 659 patients in the same conditions, the risk of any ipsilateral stroke at 2 years is 9% for the surgical group and 26% for the medical group. Those two studies make clear that carotid endarterectomy significatively lowers the risk of severe or lethal cerebral stroke in the patient group with a stenosis of ICA higher than 70% and a TIA. Nevertheless, there is no modification of the total mortality, of whose the first cause is coronary disease. Other studies are in progress in order to appreciate the results of surgery for stenosis between 30% and 69% and for asymptomatic patients.
Adult↗
Jacques Oudot and his contribution to surgery of the aortic bifurcation.
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Animals↗
[Rupture of abdominal aorta aneurysms. Study of 92 cases operated on over a ten year period (1980-1989)].
From January 1980 to December 1989, 92 ruptured abdominal aortic aneurysms (AAA) were operated upon in emergency at our institution. During the same period, 747 AAA were operated in election or in the absence of rupture. The mean age of patients was 72.8 +/- 9.1 (52-95). There were 81 men and 11 women. Etiology of the AAA was common degenerative in all cases except in one case of aortic dissection and one case of infectious aneurysm. 27 (29.3%) patients presented antecedents of bronchopathy, 31 (33.7%) antecedents of hypertension and 36 (39.1%) antecedents of coronary heart disease. All patients were operated upon under general anesthesia, in two (2.1%) cases through a thoraco-abdominal exposure, in one case through a lombotomy, in one case, using exclusion and an extra anatomic bypass and through a midline transperitoneal laparotomy in all 88 (96.9%) other cases. The mean diameter of the AAA was 9 +/- 3.9 (4-25) cm. The rupture was intra-peritoneal in 26 (28.3%) cases, intra caval in 5 (5.4%) cases, intra duodenal in 2 (2.2%) cases and retro peritoneal in all the other 59 (64.1%) cases. The aorta was cross clamped above the renal arteries in 15 (16.3%) cases, under the renal arteries in 48 (52.2%) cases and at both levels in 29 (31.5%) cases. Surgical treatment consisted in an aorto-aortic tubular graft in 45 (48.9%) cases, a bifurcated aortic graft in 32 (34.8%) cases, an exclusion with extra anatomic bypass in one (1%) case and could not be completed before the death of the patient in 14 (15.3%) cases. There were 56 (60.9%) deaths, 27 (29.4%) in the per operative and 29 (31.5%) in the post operative periods after a mean time of 5.7 +/- 9.2 (0-36) days. The cause of the death was hemorrhage in 25 (44.4) cases, cardiac complications in 28 (50%) cases, renal insufficiency in 1 (2%) case, pulmonary complications in 1 (2%) case and septic complications in one (2%) case. During the period of the present study, rupture of an AAA remained, in our institution as in other institutions an often fatal condition. This condition could probably be avoided with a policy of early detection and surgical treatment.
Aged↗
[Long term results of surgery of aortic aneurysms].
During 10 years, between 01.01.80 and 01.12.89, 838 patients have been operated on consequently for a A.A.A. in the vascular surgery department of the Hospital Pitié-Salpêtrière (Paris). Post-operative death was 7.3% (51 patients) among 692 operated on without emergency and 41.7% (60 patients) among 146 patients operated on emergency. The study was undertaken with the 727 surviving patients (86.8%) for the long term follow-up. Only 25 patients (3.4%) were lost out, so 702 patients (96.6%) had complete recalls even to their late death until the fourth trimester 1990. Total deaths, were 172 patients, (24.5%) out of the 702 patients in the follow-up. 60 patients (34.9%) died from cancer, 52 patients (30.2%) from heart disease, 21 patients (12.2%) from C.V.A. (cerebro-vascular-accident), 8 (4.6%) from rupture of aneurysm, 6 (3.6%) from renal insufficiency, 5 (2.9%) from prosthesis infection, 10 (5.8%) died from known reasons, 10 (5.8%) from unknown reasons. All these results were studied according to the "actuarial method" and the conclusions were as follow. The actual survival rate at 5 years was 72.1% +/- 5.6% and the average annual death rate was 5.8%. The factors which have influenced the late death are: a) Patients age: survival rate at 5 years and average annual death rate were significantly different whether the patients were less or more than 70 at the time of surgery. b) Surgical circonstances: late survival was significatively less with patients operated on emergency. c) Cerebro-vascular insufficiency. The average annual rates from cardio-vascular and cerebro-vascular accident were significatively more important in patients which previously had cerebro-vascular insufficiency. This work shows out that cardiac death are slightly overcame by cancer, but these two factors represent almost 2/3 (65.1%) of late death. So it should be important for prevention of late death to screen for lung and E.N.T. cancers. Some authors have proposed for prevention of coronarian accidents extensive use of coronarography and myocardial revascularisation. We prefer more acute screening than aggressive methods for patients with coronary problem who had surgery for A.A.A. and specially when they are less than 70 at surgical time.
Adult↗
[Complications of sclerosing injections of varices of the external saphenous vein].
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Humans↗
Training of vascular surgeons in France: ten years of the French College of Vascular Surgery.
The French College of Vascular Surgeons serves several functions including the organization of vascular surgery training nationwide, overseeing the practical aspects of institutional training, providing motivation for trainees by creating final exams, and bringing surgeons together to update their knowledge. This article details the results of their programs, the demographic changes in vascular surgical practice over the last ten years, and the problems to be solved in the near future. These challenges include: maintenance of autonomy in the surgical world, enlargement of the fields of action, clarification of indications for vascular procedures, demographic control, and recognition of training programs on the wider, European level.
Certification↗
[Carotid surgery for ophthalmic manifestations. Early and late results].
Two hundred and twelve cases of carotid surgery performed on patients presenting ipsilateral ischemic monophthalmic symptoms were retrospectively studied (OPH group). Among these, 125 had presented isolated ophthalmic pre-operative symptoms (OPHEX group) and 87 both ophthalmic and encephalic ischemic symptoms (OPHNEX group). During the same period, 702 cases of isolated carotid surgery were performed upon atherosclerotic patients without ipsilateral ischemic monophthalmic pre-operative symptoms (NOPH group). Among the cases of this latter group, 147 were performed upon asymptomatic patients (ASY group). 514 had presented isolated encephalic pre-operative symptoms (ENC group) and 41 had presented contralateral ischemic symptoms. The OPHNEX group presented a significantly increased peri-operative mortality and morbidity rate compared to the OPHNEX group (peri-operative deaths, lethal strokes, cardiac peri-operative morbidity) and compared to the ENC group than in the ASY group. The OPHNEX group presented a significantly increased long term mortality and morbidity rate compared to the OPHEX group (lethal strokes, all deaths). In the follow up, the OPH group presented, compared to the NOPH group, lower rates of non lethal stroke but higher rates of ophthalmic ischemic events (ipsi or contralateral) and higher rates of cardiac deaths. OPHEX, OPHNEX, ASY, ENC and NOPH groups presented significant differences as regards the general cardio-vascular and metabolic context, the macroscopy of carotid lesions operated upon, the topography and diffusion of other atherosclerotic lesions.
Aged↗
[Iatrogenic vascular lesions].
We have observed during a period of 24 years, 277 vascular iatrogenic injuries. An analytic study has revealed the prominent following etiologies; Injections, perfusions, catheterisms and arteriographies: 121 cas; Orthopedic surgery: 69 cas; General surgery: 14 cas; Surgery and sclerosis of varicose veins: 71 cas. The author analyse the various aspects of these lesions, most of them are due to imperfect technique or professional error. A special attention is given to the 82 very serious cases, seen in emergency with more of 50% of bad results. Vascular risk is not frequent, but it exist in very numerous medico-surgical procedures. Early recognition and early correction of the vascular lesions reduce the incidence and the gravity of complications.
Adolescent↗