Biomedical subjects
Publications and source records attributed to B Gayet.
The authors present a case of massive bleeding from duodenal varices documented by selective portography and successfully controlled by percutaneous embolization.
Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 23 patients with histologically proven hepatic cirrhosis. All but two patients were classified as Child's class A and all but three had a prothrombin time over 60% of normal values. Twenty-two esophagogastrostomies were performed through a separate abdominal and right thoracic approach in 15 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Six patients died after operation (26%) as a result of anastomotic leakage in two patients, hepatorenal in three patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (65%), and when associated with hepatorenal syndrome there was a significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection where the above criteria are met. This strict selection allows one to anticipate a lower mortality rate.
This study concerns a series of 355 carcinomas of the thoracic esophagus treated over a six-year period. 5 points of the pre operative work up are discussed: total endoscopy, respiratory and hepatic function as most of the patients were heavy smokers and alcoholics, nutritional status and C.T. scan in order to precise the preoperative nutrition value and the true correlation between surgical and CT scan findings. As far as curative resection is concerned, the indications of cervical and intra-thoracic anastomoses and of phi en bloc- posterior mediastinectomy versus blunt dissection are discussed. The mortality rate in this series of 135 curative resections was 8 p. cent due to pulmonary infection and to fistulas. The late results are studied according to the Japanese classification. The overall five-year actuarial survival is 19 p. cent, and 30 p. cent for the group of curative resection in stage 0, 1 and II.
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Five currently used procedures of gastric esophagoplasty were done in 5 groups of 14 embalmed human cadavers. These procedures were: whole gastric intrathoracic transposition (Kirschner's procedure) isoperistaltic gastric cone (Akiyama's procedure) isoperistaltic gastric tube (Rutkowski's or Lortat-Jacob's procedure); isoperistaltic gastric tube with resection of the lesser curvature; anisoperistaltic gastric tube with intrahilar splenectomy (Gavriliu's, Heimlich's procedure). Gastric morphometry and ascinding vascularization ability and quality of the vascular network were assessed. Injection of plastic dye was used to evaluate the vascularization of the grafts. In 13 out of 14 grafts, whole gastric transposition extended above the sternal notch, for a mean distance of 7.7 +/- 4.9 cm. This basic performance was significantly correlated to the dimensions of the greater and lesser curvatures and to the cardioxiphoid, sternal and hyosternal distances. Absent or poor injection of the distal arterial network, over a mean distance of 3.6 +/- 0.8 cm, was seen in all 14 grafts. Study of the isoperistaltic gastric cone demonstrated that the graft extended above the sternal notch in all 14 cases. The mean distance of the graft segment above the sternal notch was 5.0 +/- 3.0 cm. This basic performance showed a significant correlation only with the dimensions of the greater and lesser curvatures. Absent or poor injection of the distal arterial network of the gastric cones was seen in 9/14 cases, the mean length of the devascularized segment being 1.3 +/- 1.3 cm. Subsequent to resection of the distal zone showing poor vascularization, 13 out of the 14 isoperistaltic cones still extended above the sternal notch. The mean length of the segment above the sternal notch was 3.7 +/- 2.6 cm. All 14 isoperistaltic gastric tubes (without resection of the lesser curvature) extended above the sternal notch. The mean length of the segment above the notch was 15.1 +/- 7.1 cm. This basic performance showed a statistically significant correlation only with the minimum pylorodiaphragmatic distance subsequent to extensive Kocher's manoeuver. Of these 14 gastric tubes, 9 showed poor or no vascularization of their distal arterial network. The mean length of the poorly injected segment was 8.0 +/- 1.8 cm. Subsequent to resection of the poorly vascularized territory, 12/14 grafts were still found to extend above the sternal notch. The mean length of the segment above the sternal notch was 7.1 +/- 6.9 cm.(ABSTRACT TRUNCATED AT 400 WORDS)
The authors report two new cases of splenic epidermoid cyst. They stress the importance of sonography and the need for thorough examination of the surgical specimen for establishing the diagnosis. They also discuss several etiological hypotheses. Although uncommon, the possibility of an epidermoid cyst must always be considered once the echinococcal nature of the cyst has been ruled out, in all cases of splenic cysts in children or young adults.
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Connection between the left hepatic veins and inferior diaphragmatic veins were studied after injection in 20 embalmed cadavers. An unusual (5%) variant is described in which the left diaphragmatic vein replaces the left posterior hepatic vein and drains sub-segmental branches. Simple methods to recognize this abnormality are described. In such cases, it is recommended, when dividing the left triangular ligament, to sever the left inferior diaphragmatic vein between two ligatures and to work behind it.
The authors report on three cases of benign neurogenic tumors of the duodenum, two of which degenerated. They discuss the difficulties involved in diagnosis and treatment. In one case, the tumor was simply excised. In the two cases of malignant tumors, the excision was wider because of extensions to the liver or colon. Postoperative chemotherapy was applied in both cases, but to little effect as the two patients died within two years of the operation.
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A retrospective study was undertaken of abdominal echography in mode B with manual scanning in assessing the spread of 102 carcinomas pf the oesophagus. This showed echography to be reliable in the diagnosis of hepatic metastases (accuracy of method = 93%), ineffective in detecting coeliac lymph node involvement and specific in the recognition of fatty infiltration and steatofibrosis of the liver. However, with regard to hepatic metastases, the existence of false positives and false negatives, even few in number, was such that echography could not influence final decisions as to treatment. The authors feel that histopathological proof in doubtful cases by cytological puncture using a fine needle would avoid false positives and thus give echography its full value.
Always severe and increasingly frequent carcinoma of the thoracic oesophagus now ranks among the most worrying malignancies. However, the authors' experience concur with recent publications to demonstrate that an a priori pessimistic attitude is no longer justified. The considerable progress achieved in pre- and post-operative care and surgical techniques has reduced to 10% the operative mortality rate and has made surgery the best prospect of comfortable and, possibly, prolonged survival. Radiotherapy and chemotherapy still have a place in the treatment, either alone when surgery is contra-indicated or combined with surgical excision.
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