[Arterial surgery in complicated reconstruction].
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Arterial Occlusive Diseases↗
Biomedical subjects
M Merlini
Publications and source records attributed to M Merlini.
Evaluating a home palliative care service: development of indicators for a continuous quality improvement program.
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Evaluation Studies as Topic↗
Laparoscopic drainage of postoperative pelvic lymphocele.
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Adenocarcinoma↗
[Surgical treatment of malignant tumors with mono- or multivisceral involvement].
Abdominal malignant tumors with a mono- or multivisceral involvement have a poor prognosis. Surgery is the only treatment with a hope to be curative. Between January 1989 and December 1992, 30 patients (12 men, 18 women, mean age 67.9) with abdominal malignancy involving one or more adjacent organs were operated on at the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. The majority of the tumors originated from the colon and rectum. 64 organs were partially or totally resected. Every curative procedure consisted of an "en bloc" resection. 53% of the procedures were curative, 37% palliative and 10% explorative. Surgical morbidity reached 30% and hospital mortality 13% (one peroperative death). Surgery obtained a local control of the tumor in 75% of the cases. After curative procedures, local recurrence and secondary metastases appeared respectively in 25% and 19% of the cases. After a palliative operation, preoperative symptoms diminished or disappeared in 82% of the patients. Tumor curability essentially depends on invaded organs. Mobile organs can nearly always be excised. Non-mobile organs and retroperitoneum are resected much more difficultly. Surgical treatment of multiorgan malignancies is difficult. It involves a long and tenacious exploration before declaring the tumor non-resectable.
Abdominal Neoplasms↗
[Use of the deep femoral artery as the anastomotic site in proximal or distal bypass. Indications, technique, results of a series of 19 cases].
Atherosclerosis predominantly affects the ilio-superficial femoral axis, and tends to spare the deep femoral artery which can offer excellent outflow for proximal reconstructions for occlusive vascular disease of the lower limbs. Often symptoms are relieved and ischemic lesions can heal. The deep femoral artery can also provide good, pulsatile inflow for distal reconstructions when it is desirable to avoid the groin (either because of multiple previous dissections or because of infection). Occasionally two-level sequential bypasses to and from the deep femoral artery are required for multilevel disease where the groin is to be avoided. Over the past 4 years we have performed 190 arterial reconstructions (41 central, 125 distal and 24 sequential two-level procedures). 19 times the proximal, distal or intermediate anastomosis was on the deep femoral artery. Short- and long-term results were good in these difficult patients, with relief of symptoms or significant improvement in most patients. Two major (and no minor) amputations were ultimately required. Arterial reconstructions using the deep femoral artery cannot only salvage many limbs, but offer good symptomatic relief in patients who are not suitable for usual reconstructive procedures.
Aged↗
[Transluminal dilatation by surgeons. Technique, results and advantages].
From January 1990 to December 1992, 25 balloon angioplasties were performed in the Department of Surgery, La Chaux-de-Fonds, Switzerland. The indications were claudication in 19, and limb salvage in 6 patients. In 4 patients, the stenosis was dilated in association with a femoropopliteal bypass (2 patients) or an intraluminal stent (2 patients). The follow-up period ranged from 3 to 36 months with a cumulated patency rate of 81%. Percutaneous transluminal angioplasty for atherosclerotic lesions of the lower extremity is associated with a good success rate. Important variables influencing patency include indications, site and extent of lesion and whether the responsible lesion is stenotic or occlusive. The advent of endovascular surgery has transformed the landscape of vascular disease management. In so doing it has confused the border between the various medical specialties. The decision to use transluminal angioplasty, should be a joint decision between surgeon and radiologist, but transluminal angioplasty should be part of the vascular surgeon's armamentarium.
Angioplasty, Balloon↗
[Laparoscopy: obstacle or revolution in the development of surgery?].
Laparoscopy is a new fascinating technique. However, after the first wave of enthusiasm, laparoscopy currently raises different problems related with surgical training. A national survey concerning laparoscopy and its teaching was sent to every surgeon-in-chief, chief resident and resident of all Swiss teaching hospitals. Surgical training is nowadays an important problem in Switzerland. Our survey revealed that laparoscopy intensifies this problem: a specific training in laparoscopy is desired by all surgeons and has to take place in the Swiss Board of Surgery (FMH). A preliminary experience of conventional surgery is desirable. Then a laparoscopic training should start on experimental certified models and be applied progressively on patients in attendance with a trained surgeon.
Credentialing↗
[Treatment of irreducible hiatal hernia with reflux esophagitis by Collis-Niessen gastroplasty-fundoplication. Indications, technique, results of a series of 17 cases].
Hiatus hernia with reflux can be asymptomatic or can lead to severe, complicated esophagitis or even to metaplasia, dysplasia and carcinoma. Ideally all refluxing patients with esophagitis who are not easily and completely controlled with medical therapy should undergo anti-reflux surgery before complications such as ulcers, stricture or columnar metaplasia (Barrett's esophagus) occur. When esophagitis is long-lasting or severe, shortening of the esophagus is common. In such cases the esophagus must be "lengthened" before an anti-reflux procedure can be performed safely. This is the Collis gastroplasty. We have performed 17 Collis-Nissen procedures over 5 years for complicated gastroesophageal reflux disease (GERD). Results were good to excellent in 8 cases, satisfactory in 6 and poor in 3. We conclude that a complete preoperative workup with esophagoscopy (and biopsies), 24-hour pH monitoring and esophageal manometry must be performed in all patients with complicated GERD to allow the best operative procedure to be chosen (gastroplasty-fundoplication, resection or total duodenal diversion). The role of alkaline reflux is also discussed.
Aged↗
[Standardized hepatectomy. 18 cases operated in a peripheral hospital].
Hepatectomy has long been a formidable surgical procedure because the risk of hemorrhage it can involve. With a better understanding of hepatic anatomy, left hepatectomy, right hepatectomy and segmental hepatic resections have been standardized. Between January 1989 and December 1992, 18 hepatectomies were performed on 16 patients in the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. The mean age of the patients was 65. The surgical indications were: hepatic metastases 11 (61%); gallbladder or biliary duct neoplasm 4 (22%); hydatic cyst 3 (17%). 11 segmental resection, 3 left hepatectomies, 2 right hepatectomies, 2 pericystectomies were performed. Blood loss during these operations averaged 2800 ml. Surgical complications appeared in 6 cases (hemorrhage 1, postoperative effusion 4, sepsis 1). One patient died within 30 days (mortality 5%). Hepatectomy is nowadays a safe procedure. It can be performed in a general hospital with a trained surgical team and an efficient intensive care unit.
Adult↗
[How to reduce the number of negative appendectomies? A prospective two-center study of 120 patients].
A decisional protocol based on clinical findings and laboratory data was assessed prospectively in a consecutive series of 120 patients with suspected appendicitis over a 24-month period at 2 teaching hospitals. Using this protocol the high rate of negative appendectomy (31.5%) during the 2 years prior to the study was reduced to 22% without increasing morbidity or mortality. Ultrasound examination was poorly predictive in unclear cases. Laparoscopy was used to assess diagnosis in persistent symptoms.
Adolescent↗
High-sensitivity electrophoretic method for the detection of Bence Jones protein and for the study of proteinuria in unconcentrated urines.
The study of proteinuria, and especially the search for Bence Jones proteins (BJP), has almost always required urine concentration. We evaluated a high-sensitivity electrophoretic method using unconcentrated urine based on colloidal gold staining. The sensitivity for the detection of BJP is further enhanced by immunofixation. Sensitivity to BJP is better than 1 mg/L and, apart from the alpha-1 microglobulin, all the proteins relevant to the classification of proteinuria can be visualized with a sensitivity of approximatively 3 mg/L.
Bence Jones Protein↗
[Pain syndrome in the right iliac fossa and laparoscopy: routine appendectomy or not?].
Diagnostic laparoscopy is useful in the evaluation of patients with lower right quadrant pain when the diagnosis is uncertain. The object of this study was to determine whether a normal appendix should be routinely removed at laparoscopy. We have decided to do this in children, men under the age of 30 and women of childbearing age. However we do not perform appendectomy in men over the age of 30, women over 50 and in immunodeficient patients. This is a working hypothesis and is the basis of an on-going prospective study in our unit.
Abdominal Pain↗
[Flexible choledochoscopy: two years experience].
This study is a retrospective review of 258 procedures on the gallbladder and bile ducts (115 without and 143 with flexible choledochoscope). There were 14 bile duct explorations for stone removal without choledochoscopy and 16 with a flexible choledochoscope. Residual stones were found in 2/14 (14.2%) cases without and 1/16 (6.3%) case with choledochoscope. A review of the literature confirms that there are fewer residual bile duct stones following flexible choledochoscopy. There were no complications attributable to the procedure.
Cholelithiasis↗
[Storage of reports in endoscopic surgery].
A computer system, based on multimedia technology allowing informatic storing of endoscopic pictures, written summary of the case and personal oral commentary by the operating surgeon is presented. This system is time-sparing and does not require special training owing to a highly developed interface between the computer and the operator. The system is currently in clinical practice.
Compact Disks↗
[Simultaneous proximal and distal revascularization for arterial obstruction of the leg at two sites. Indications, techniques and results].
In chronic aortoiliac occlusive disease, 50 to 75% of the patients have further femoropopliteal lesions. The surgical treatment of these multilevel obstructions is sometimes controversial: the distal reconstruction can be performed at the time of the proximal one or deferred to a later date. It can be difficult to determine the hemodynamic importance of an iliac stenosis. Angiography is not a perfect predictor of the iliac segment hemodynamics because as it underestimates the severity of aorto-iliac stenoses when single plane views are taken. Direct measurement of the femoral pressure at angiography disclosing a gradient between brachial and femoral arteries indicates significant iliac stenosis. Intraarterial papaverine administration can also be of importance to determine critical stenoses. Despite proximal reconstruction, distal ischemia can persist if peripheral resistance is high. Distal revascularization can relieve ischemic symptoms, providing an adequate outflow bed. However some patients do not benefit from this two-level procedure because of a steal phenomenon in the intermediate vascular bed.
Aged↗
[In situ venous grafts. Indications, technique and results. Prospective study of 26 consecutive cases].
The in situ saphenous vein bypass has been introduced in our department since 1989. A total of 26 bypasses in 22 patients have been followed prospectively. Indications for revascularisation have been severe arterial insufficiency in 73% of the cases (stage III or IV). With the exception of one postoperative death (myocardial infarction), all the patients have recovered uneventfully, with a regression to stage I. No amputation has been necessary. Morbidity has been 30%, with mainly minor local complications. The primary patency rate is 83% at one year and 78% after 2 and 3 years, whereas the secondary patency rate is 91% at one year, and remains constant thereafter up to 3 years. Considering our results and those from the literature, we believe that the in situ technique is very valuable, especially for below-knee vascular reconstruction. Technical difficulties of the method are analysed.
Adult↗
[The 60 hour week in surgery: possible or impossible?].
The number of hours of work per week by doctors is the subject of great controversy in many countries. This has led to restrictive legislation in several states or countries (New York and Great Britain, for example) which is both cumbersome and restrictive. We have polled the Swiss surgeons (both trained and in training) in teaching hospitals on this subject with a questionnaire which also covered some other aspects of training. A majority wishes that the working week be limited (to 60 h/week). However a real limit of 60 h per 7 day week (including call duty) is not reasonable. Furthermore the other problems are considered to be more important by 84% of respondents. Thus the overall opinion is that there are too many surgeons training in a poorly structured system, both on a personal and institutional basis.
Attitude of Health Personnel↗
[Value of antral mucosectomy, selective proximal vagotomy and a combination of the 2 procedures in serum gastrin production and inhibition of stomach acid. An experimental study].
This experimental study was aimed at determining the volume and acidity produced by the normal stomach, following antral mucosectomy (MA), proximal selective vagotomy (VSP) and combination of both procedures. In 10 mongrel dogs, a double-lumen tube was placed in the stomach under general anesthesia. One of the lumen was rinsed with a constant flow and the other retrieved the gastric secretion. Gastric secretion and acidity were calculated every 10 minutes for 120 minutes. At 60 minutes, pentagastrin was injected. After these controls, a MA was carried out in half the animals and a VSP in the other half. 6 and 12 weeks postoperatively, the same controls were repeated. The dogs were then submitted to the operation of the other group. Following MA and pentagastrin stimulation, the gastric secretion (volume) is not modified with regard to the preoperative levels. On the other hand, after VSP, pentagastrin stimulation induces only a small volume response. The vagus thus seems to be involved in liquid secretion of the stomach. Following MA, pentagastrin stimulation lowers gastric pH at 6 weeks but not at 12 weeks postoperatively. Gastrin is known to have a trophic effect on the oxyntic mucosa. This effect disappears in a few weeks and explains these different figures. Following VSP, gastric acidity decreases and plasmatic gastrin increases. In this situation, pentagastrin directly acts on a trophic mucosa and produces the important lowering of the gastric pH. Finally, after MA, pentagastrin induces an increase in plasmatic gastrin. This effect seems to be mediated by central stimulation of the nuclei of the vagus nerve.
Animals↗