Reconstruction vaginale par sigmoïdoplastie pour aplasie utérovaginale : Technique chirurgicale et avantages

Construction of a neo-vagina by sigmoidocolpoplasty has been effective in the treatment of vaginal aplasia, a condition most commonly seen with the Mayer Rokitansky Syndrome. This article describes the surgical technique and principal complications, and reviews the literature to compare this technique with other methods of repair, particularly the Davydov technique.     

Traitement d'une anémie aiguë post-traumatique par érythropoïétine humaine recombinante chez un témoin de Jéhovah

A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.8 g·dL⁻¹ and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g·dL⁻¹ and haematocrit to 33%. Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.     

Evaluation de la qualité du sang recueilli et traité par cell saver en cours de césarienne

Objectives

To determine the quality of blood salvaged and processed during Caesarean section with a cell-saver.

Study design

Laboratory study.

Patients

The study included 20 patients of ASA physical class 1 or 2 undergoing a scheduled Caesarean section.

Methods

A separate suction device was used from the beginning of surgery until the delivery of the fetus, to remove most of the amniotic fluid coming from the surgical field. Thereafter using an Haemolite 2Plus^™ (Haemonetics), the blood was separated and washed with 2 L of normal saline solution. Blood quality was assessed through detection of fetal cells and measuring out of alpha-fetal-protein, tissue factor. A Kleihauer test was also performed.

Results

Cell-saver processing removed most of alpha-fetalprotein and tissue factor while fetal cells were rarely seen. The Kleihauer test could not be performed because of haemolized blood samples. However, the results were very heterogeneous and after washing some salvaged units contained very high concentrations of alpha-fetal-protein or tissue factor.

Conclusions

These preliminary results show that intra-operative autologous transfusion is not fully safe during Caesarean sections. In addition, there is an immunological risk if a significant part of fetal red blood cells are reinfused into maternal circulation. Therefore, additional studies are needed to better assess this risk.     

Eléments du diagnostic des pneumopathies acquises sous ventilation mécanique

Ventilator-associated pneumonias (VAP) are the most frequent nosocomial lung infections. Histological diagnosis is the standard for reference.A diagnosis of VAP can be considered in presence of fever or hypothermia, hyperleucocytosis or leucopenia, worsening of blood gases, and new radiological infiltrate. Their diagnostioal value is dependent on the number of included manifestations.A clinical pulmonary infection score (CPIS) has been produced and compared with histological data.Bacteriological data are essential for an adapted antibiotherapy.The blind non-protected specimen brush is inexpensive and reliable: at levels of 10⁴ and 10⁶ CFU·mL⁻¹, the sensitivity and specificity reach 80%.The double-protected catheter is a sensitive and specific test at the level of 10³ CFU·mL⁻¹. At present its accuracy has only been compared with bronchial brushing.The culture of a 20 mL mini-broncho-alveolar lavage (same material) is specific (80%) but not sensitive enough (< 70%) at the level of 10³ CFU·mL⁻¹.The culture of the protected telescopic brush is the most expensive test. It does not carry a risk of contamination, but does not detect a significant amount of VAP even at a level below 10³ CFU·mL⁻¹. Due to its high specificity it is used as the reference test in numerous studies.The endoscopic broncho-alveolar lavage provides a rapid diagnosis. Although not protected, it carries a low risk of false positives. It also allows the diagnosis of non-bacterial or atypical bacterial lung infections.The diagnosis can also be obtained with lung biopsy which hower carries a risk in case of mechanical ventilation, whatever the technique.Except for the protected double catheter, a direct examination has been advocated, for the differentiation between infection and colonization and the improvement of the performances of the simple culture of the broncho-alveolar lavage (search for intra-cellular bacteria).     

Épiploolastie de couverture des vaisseaux au cours d’une duodénopancréatectomie céphalique : technique modifiée

Introduction

In 1994, a technique of omental flap development and interposition to cover the celiac and mesenteric vessels was described. Its aim was to isolate the pancreatic anastomosis from the vessels dissected during pancreaticoduodenectomy (PD) and thereby to reduce the consequences of postoperative pancreatic fistula – particularly the risk of postoperative bleeding.

Technique

We describe this technique adding a simple modification consisting of passage of the pancreatic remnant through an omental window before completion of the pancreaticodigestive anastomosis.

Results

Sixty-four patients underwent PD using an omental flap to cover the celiomesenteric vessels. No postoperative deaths occurred. The rate of PF was 23% and the rate of postoperative hemorrhage was 3% (two patients). No complications related to the omental flap were observed. All postoperative hemorrhages originated from the transected surface of the pancreatic remnant and were successfully treated by transgastrotomy simple suture.

Conclusion

This simple technique has no specific morbidity; it isolates the celiac and mesenteric vessels from the pancreatic anastomosis and therefore may reduce the risk of severe postoperative bleeding after PD.