[Localized acute intestinal ischemia caused by an atheromatous embolus following aortography].
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Biomedical subjects
Publications and source records attributed to F Bacourt.
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The first reported case of a left iliac arteriovenous fistula from rupture of an aseptic atheromatous aneurysm is described. The fistula occurred proximally to a primary iliac vein thrombosis which explains the clinical picture observed of very severe "blue" phlebitis and the absence of any cardiac complications. The fistula was treated by the endo-aneurysmal approach and arterial continuity re-established with a prosthesis. The postoperative result was excellent.
Sipple's syndrome in three members of the same family (three successive generations) is reported, confirming that this syndrome is hereditary and transmitted in an autosomal and dominant way. Whereas pheochromocytoma was clinically detectable, medullary thyroïd carcinoma could only be detected in two cases by systematic search for high levels of calcitonin before and after stimulation. In 6 other siblings, thyroïd carcinoma was eliminated in view of negative stimulation tests. HLA groups were studied, but definite conclusions as to the interest of these data in Sipple's syndrome cannot be drawn from 10 few cases. Persistingly high levels of calcitonin after surgery is known to be of severe prognosis; in the present cases, the very short delay after surgery did not allow definite conclusion, since, according to some authors, several months are necessary to allow a return to normal levels.
Three types of aorto-intestinal fistula may be associated with gastrointestinal bleeding: primary fistulae from an aneurysm, secondary fistulae related to an aorto-prosthetic anastomosis and paraprosthetic fistulae by intraduodenal protrusion of a graft. The prevalence of secondary and paraprosthetic fistulae increases with more widespread vascular surgery. Only if the diagnosis is always borne in mind in a patient with an aneurysm or an aortic prosthesis makes it possible to recognise an aorto-intestinal fistula in time. Upper GI series and endoscopy are more useful in reaching a diagnosis than arteriography but signs must be sought in the third and fourth parts of the duodenum. The lesion may even be missed on surgical exploration, being concealed before separation of the aorta and duodenum. Infection and the underlying general medical condition are factors in the gravity of the operative prognosis. One of our three patients treated surgically was saved by the insertion of an extra-anatomic bypass. The prognosis in paraprosthetic fistulae, the possible precursor stage of a secondary aorto-digestive fistula, is more favourable.
An unusual course for subclavian-femoral bypass was made by tunnelisation underneath the abdominal wall rather than the skin in an elderly patient with a huge incurable incisional hernia which required the wearing of an abdominal support belt. The prosthesis passed behind the sternum and the deep surface of the abdominal wall when the belt was worn.
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The authors report the clinical and laboratory results of 65 orthotopic allotransplantations of the liver in the pig. The operative mortality (8 cases) was nil in the last 23 transplantations. Vascular filling without blood transfusion, blood alkalinisation and precautions to avoid hypothermia, seem essential to reduce early mortality. The various causes of secondary mortality are studied, using certain preventive measures. Thus, deaths due to gallbladder or hepatic ischemia have become rare by conserving end-to-end anastomosis on the hepatic artery and taking certain precautions. The grafts were rejected only in incompatible pigs in the SLA system, but were not rare in this group (13/43) and sufficient to cause death in one case out of two. Gastric ulcers were frequent, even after vagotomy, but vagotomy protects fairly well against ulcer hemorrhage. However, ulcers almost always accompany a disease which is alone sufficient to cause death. Cholangitis appears less frequent after cholecysto-jejunal anastomosis on an excluded omega loop. The mortality from extra-hepatic causes was severe (12 cases), in particular due to mechanical complications at the level of the small intestine. Laboratory analyses showed a definite rise in SGOT transaminase levels and, above all, alkaline prosphatase levels in cases of rejection compared with cases of biliary obstruction or hepatic necrosis.
The two cases reported here show intestinal obstruction may occur by coagulation of lymph around the loops. They permit us to better understand the physiopathology of blockage of the lymph vessels whether congenital as in the first case or traumatic as in the second case. Traumatic rupture of the cisterns chyli is exceptional. The histological lesions observed on clamped biopsies show clearly the pathology of protein-losing enteropathy.
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Two cases of common carotid stenosis as a late complication of radiotherapy are reported. One of them was treated by subclavian-carotid by-pass. Delayed lesions of medium and large arteries after radiotherapy are reviewed, with emphasis on the neck vessels--and the surgical possibilities.
Fibrosis of the intestinal lymphatic vessels, produced in one case by tuberculosis and, in the other, by appendicitis and peritonitis, caused blockage of the main lymphatic vessels causing, clinically, a protein-losing enteropathy similar to that noted in congenital lymphatic diseases of childhood. In the laboratory, there was noted a fall in serum protein, lipid and cholesterol. A fat absorption test was very abnormal showing a flat curve. During laparotomy, there was discovered on the small intestine, the same layout of lymph vessels, resembling a lace network, as that observed in congenital malformations. Intestinal lymphography showed considerable stasis of the opaque substance and absence of injection of the lymph vessels in the mesentery.
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