Tuberculose du calcanéus révélée par une fistule cutanée de la cheville

The isolated tuberculosis of the calcaneus is an unusual entity of osteoarticular tuberculosis. Because of the low index of suspicion and the insidious course, it is usually diagnosed late. The occurrence of cutaneous fistula may constitute a mode of revelation. The multi-drug anti-tubercular treatment is always effective. We present a case of calcaneus tuberculosis revealed by cutaneous fistula of the ankle.     

Traitement vidéolaparoscopique des hernies hiatales par roulement

Study aimThe aim of this prospective study was to report the results of videolaparoscopic repair in a series of ten patients with paraesophageal hernia.Patients and methodsFrom January 1982 to September 1998, ten patients (three men and seven women, mean age: 68 years [range: 42–87]) were operated on for paraesophageal hernia. An intrathoracic gastric volvulus was present in four patients, a severe anemia in four and two were asymptomatic. All interventions were performed laparoscopically and included sac resection, crura closure and realization of a posterior gastric valve on 270 degrees.ResultsThere was one irruption of gastric juice in the bronchial tree at the beginning of the anesthesia which required assisted ventilation for 3 days. The mean follow-up was 17.5 months (range: 3–50). There was no postoperative diarrhea and no gas bloat syndrome. Eight patients complained of postoperative dysphagia which disappeared within 6 weeks, except in one patient with esophageal motility disorder postoperatively discovered. None of the patients had postoperative gastroesophageal reflux. A chest X-ray performed after 1 year detected no hernia recurrence in seven patients. There was no recurrent anemia after 6 months.ConclusionThe videolaparoscopic repair of paraesophageal hernias is feasible without any technical difficulties even in aged patients with precarious physical conditions. The results are good with a mean follow-up of 17.5 months.     

La pancréatectomie pour cancer avec résection des vaisseaux rétropancréatiques est-elle justifiée?

Aim of the studyTumoural invasion of the retropancreatic vessels and particularly of the superior mésentéricoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection.Patients and methodTwenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients.ResultsTumoural invasion was historically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%.ConclusionSegmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy.On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.     

Traitement des sténoses et des oblitérations iliaques par angioplastie transluminale

PurposePercutaneous transluminal angioplasty (PTA) has an established and valuable role in the treatment of iliac stenoses and occlusions. The use of stents may improve the results of PTA. The aim of this study is to report our surgical experience of iliac angioplasty over the past 5 years.Patients and methodsFrom January 1993 to October 1997, 201 iliac PTA were performed in 175 patients, at the level of the common iliac artery (n = 111 ) and external iliac artery (n = 90). In 26 cases, two iliac lesions were treated simultaneously. There were 188 stenoses and 13 chronic occlusions. During PTA, 55 stents were used, because of unsatisfactory results (dissection, residual stenosis) or in case of total occlusion, in the common iliac artery in 35 cases and in the external iliac artery in 20 cases. In 15 cases (8.6%), a femoro-popliteal bypass was associated to the iliac PTA, because of multilevel occlusive disease.ResultsThere were no early deaths. There were seven initial failures. The initial success rate was 96%. The clinical follow-up has been achieved in 163 patients, (range: 3 to 48 months, mean: 28 months). The primary patency rates were 84%, 79% and 63% respectively at 1, 2, and 4 years. The secondary patency rates were 87%, 85% and 73% respectively at 1, 2, and 4 years.ConclusionPTA is a good procedure for aortoiliac disease. Selective use of stents may improve early results of PTA; however, routine use of stents cannot be recommended.     

Traitement par lavage articulaire des atteintes récidivantes du genou au cours des arthrites juvéniles idiopathiques (AJI)

Objective. – To retrospectively evaluate the benefits of knee joint lavage with intraarticular glucocorticoid injection in patients who have juvenile idiopathic arthritis with knee involvement unresponsive to repeated intraarticular glucocorticoid injections.Patients. – Seventeen knees in 10 children (eight girls and two boys) were treated from 1997 to 2000. Mean age was 14 years 9 months and the mean disease duration was 7.2 years. The diagnoses were juvenile oligoarthritis (n = 6, including 2 with extended disease), systemic arthritis (n = 2), juvenile spondyloarthropathy (n = 1), and juvenile dermatomyositis (n = 1). Repeated intraarticular triamcinolone hexacetonide injections had been performed in all the patients, the mean number of injections being 2.2/patient within the last 30 months. Plain radiographs were normal in six of the eight patients. Mean erythrocyte sedimentation rate was 21.7 mm/h and mean C-reactive protein level was 20.6 mg/l. Joint fluid was obtained from 10 knees and had a mean cell count of 12,660/mm³. Second-line therapy was with methotrexate alone or combined with cyclosporine or azathioprine. Oral glucocorticoids and/or nonsteroidal antiinflammatory drugs were used for symptom relief.Treatment procedure. – Lavage was performed under strict aseptic conditions with simple analgesia, on a day-hospital basis. After aspiration of the joint, lavage was performed with saline, and a delayed-action glucocorticoid was injected. The knee joint was immobilized in the extended position for 48 h. Efficacy criteria were the presence of effusion, presence of pain, and the presence of a systemic treatment-sparing effect.Results. – Freedom from effusion and pain was noted in all 17 knees after 1 month, in eight (47%) knees after 6 months, and in seven (41%) knees after 12 months. The patients with the long lasting improvements had systemic polyarthritis. After joint lavage, second-line treatment was reduced in two patients and the oral glucocorticoid therapy was stopped in the other two. None of the variables studied (age, sex, disease duration, inflammatory syndrome, or joint fluid cytology) predicted a good response. No adverse effects were recorded.Conclusion. – These preliminary results show that joint lavage with glucocorticoid injection is safe in children. The improvements were modest, but the patients had a history of arthritis refractory to multiple triamcinolone hexacetonide injections. Thus, joint lavage may have a place in the treatment pyramid just before synovectomy.