[Anatomic study of the location of the thoracoacromial pedicle. Application to the pectoralis major musculocutaneous flap]

AIM OF THE STUDY

The thoracoacromial pedicle is the major pedicle of the pectoralis major flap which is still frequently used in cervicofacial loss of substances reconstruction. The classical landmark of this pedicle is the intersection between the acromioxyphoid line and the medioclavicular line. The aim of this study was to determine the exact location of the pedicle compared to the classical landmark in case of narrow pectoralis major flap.

PATIENTS AND METHOD

Twenty-one pectoralis major pedicles have been dissected from 12 fresh cadavers. For each dissection have been determined: the medial or lateral situation of the pedicle compared to the intersection of the medioclavicular line and the acromioxyphoid line and the distance between these two points, the angle between the real axis of the pedicle and the acromioxyphoid line.

RESULTS

The pedicle was lateral to the acromioxyphoid line in 19 cases, in close contact to the lateral border of the muscle.

CONCLUSION

A narrow pectoralis major flap has to be harvested between the acromioxyphoid line and the lateral border of the pectoralis major.

Réalités et perspectives des allotransplantations laryngées

Laryngeal stenosis or amputation for tumor definitely impairs laryngeal functions with negative impact on quality of life. Experimental laryngeal transplantation has been carried out for nearly 40 years hoping that human transplantation would become feasible in the near future. Nearly 10 years ago, a 40 years old man with a long-standing history of recalcitrant laryngeal stenosis, benefited from a vascularized laryngeal allotransplantation. Speech and deglutition resumed quickly making of this first attempt a success. Although a tracheostomy canula and immunosuppressive regimen are still necessary, this man enjoyed a tremendous improvement in this quality of life. Cumulated experiences tend to demonstrate that laryngeal transplantation in human is not only feasible, but may represents the only chance for rehabilitation of number of laryngeal cripple. Induction of a functional tolerance may allow the necessary evaluation of laryngeal allotransplantation in humans.

Does percutaneous endoscopic gastrostomy prevent gastro-oesophageal reflux during the enteral feeding of elderly patients?

Percutaneous endoscopic gastrostomy (PEG) is reported to be a safe method for enteral feeding, although its ability to prevent gastro-oesophageal reflux (GOR) during enteral feeding remains controversial. In 12 elderly patients fed enterally to avoid the risk of tracheal aspiration, we have compared two 24-h oesophageal pH profiles, one recorded when enteral feeding was delivered at first via a nasogastric tube (NGT), and the other via a PEG. The second recording was always performed at least 8 days after gastrostomy placement. Enteral nutrition consisted of 500 ml of a polymeric diet delivered 3 times a day at 08:00, 13:00 and 18:00. After gastrostomy placement, enteral feeding was associated with a pathological acid reflux in 8 out of 12 patients. In all of these 8 patients, GOR was mostly related to a high number of reflux episodes. In 4 out of 8 patients, GOR occurred only during the 3 h following the administration of the nutritive diet. In 4 of the patients, GOR did not occur any more after removal of the NGT, whilst gastrostomy placement was followed by GOR in 5 patients. GOR during enteral feeding via PEG is common in elderly subjects. We have shown that a chronological relationship existed in some patients between the endoscopic procedure and the onset of a pathological GOR.

Increase in cyclooxygenase-2 and nitric oxide-synthase-2 mRNAs in pouchitis without modification of inducible isoenzyme heme-oxygenase-1

OBJECTIVES

The pathophysiology of pouchitis occurring after ileal pouch-anal anastomosis remains controversial. Prostaglandins and nitric oxide synthesized in excess by cyclooxygenase-2 and nitric oxide synthase-2 are thought to be involved in the inflammatory process. Because heme oxygenase-1, by its antioxidant properties, could modulate inflammatory reaction, we analyzed mRNAs of the three enzymes (cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1) in patients with ileal pouch-anal anastomosis.

METHODS

Endoscopic biopsies were obtained in eight patients with normal ileal pouch-anal anastomosis, in eight patients with pouchitis, and in normal ileum of six healthy subjects. A relative quantitative RT-PCR was performed to determine the levels of cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1 mRNAs.

RESULTS

Cyclooxygenase-2 and nitric oxide synthase-2 mRNAs were increased both in normal ileal pouch-anal anastomosis and in pouchitis, compared with healthy subjects. Pouchitis disease activity index was correlated with mRNA levels of cyclooxygenase-2 (r = 0.71; p < 0.01) and nitric oxide synthase-2 (r = 0.51; p < 0.05). Heme oxygenase-1 mRNA levels were not significantly different in patients versus healthy subjects.

CONCLUSIONS

The increase in cyclooxygenase-2 and nitric oxide synthase-2 mRNA levels both in pouchitis and normal ileal pouch-anal anastomosis demonstrates that a latent inflammatory process occurs in the ileal pouch mucosa. This inflammatory process was not found to be associated with an induction of heme oxygenase mRNA, a possible regulator of the inflammatory response.

Prothrombotic inherited abnormalities other than factor V Leiden mutation do not play a role in venous thrombosis in inflammatory bowel disease

OBJECTIVES

Because the incidence of thromboembolism is increased in patients with inflammatory bowel disease, we attempted to assess the role of prothrombotic inherited coagulation abnormalities in the development of thrombosis.

METHODS

Four populations were compared: 15 patients with inflammatory bowel disease and a previous venous thrombosis, 58 control patients with inflammatory bowel disease but without thrombosis, 110 patients without inflammatory bowel disease but with previous deep venous thrombosis, and 84 healthy subjects. Inherited and acquired risk factors of venous thrombosis, e.g., factor V Leiden and prothrombin 20210A mutations, C677T methylenetetrahydrofolate reductase polymorphism, a polymorphism located in exon 13 of factor V gene, inflammatory and hypercoagulability markers were studied in each population.

RESULTS

In the study, 14.3% of thrombotic patients with inflammatory bowel disease had factor V Leiden mutation versus 0% of control patients with inflammatory bowel disease (p = 0.04), 15.5% of thrombotic patients without inflammatory bowel disease (NS) and 3.6% of the healthy controls. A total of 14% of thrombotic patients with inflammatory bowel disease and 11.8% of thrombotic patients without inflammatory bowel disease carried prothrombin 20210A mutation, compared to 1.7% of control patients with inflammatory bowel disease; however, the difference was just below significance. Other inherited coagulation abnormalities were not statistically significantly different among the four populations.

CONCLUSIONS

Our study confirms that factor V Leiden mutation increases the risk for thrombotic events but is not more frequent in patients with inflammatory bowel disease. Our results do not support the role of other thrombotic risk factors.

[T3 and T4 cancer of the oral cavity, surgical treatment with oral tongue resection]

Amputation of the oral tongue is required to treat T3 and T4 bilateral tumors of the anterior two third of the tongue with or without extension to the floor of the mouth. This partial glossectomy was performed initially for 27 patients and as salvage therapy for 35 patients with recurrent diseases. The reconstruction required a flap in all cases, including 8 microvascular free flaps. Two months after surgery, two third of patients had a satisfactory swallowing hability. The functional results were worst for patients operated after radiotherapy. Actuarial survival rates were 37.5% and 22.1% at 3 and 5 years respectively. The survival rate of patients who had surgery as primary modality of treatment was significantly better as compared with those who had radiotherapy before surgery (p=0,018). This surgery offers a perfect control of tumors of the anterior floor and oral tongue and good rehabilitation provided by the conservation of the posterior tongue.

How do fiber-supplemented formulas affect antroduodenal motility during enteral nutrition? A comparative study between mixed and insoluble fibers

BACKGROUND

Fiber supplementation during enteral nutrition has been recommended, but the effect of soluble compared with insoluble fiber supplements on antroduodenal motility is unknown.

OBJECTIVE

The objective of this study was to compare antroduodenal motor patterns in 8 healthy volunteers during and after gastric infusion of 3 different diets: a fiber-free diet, an insoluble-fiber diet, and a mixed-fiber diet (50% soluble fiber and 50% insoluble fiber).

DESIGN

Manometric studies with the 3 different diets (2100 kJ) were performed in random order. Antroduodenal motility was monitored continuously for 6 h by using a pneumohydraulic system to calculate the number, amplitude, and duration of the pressure waves; the area under the curve (AUC); and the percentage of time occupied by motor activity before, during, and after each type of infusion. Variations in antral areas were measured by ultrasonography.

RESULTS

The gastric motor response was significantly higher, whatever the diet, in the distal antral recording site than in the 2 more proximal sites. In the proximal but not the distal antrum, the number of waves, the AUC, and the percentage of time occupied by motor activity were higher (P: < 0.04) with the mixed-fiber than with the insoluble-fiber diet. No significant differences in variations of antral area were observed among the 3 diets. In the duodenum, motor variables were not significantly different among the 3 diets.

CONCLUSIONS

A gastric infusion induced a greater motor response in the distal than in the proximal antrum. A mixed-fiber diet was associated with significantly greater proximal antral motility than was an insoluble-fiber diet. There was no significant difference among the 3 formulas in duodenal motor variables or in variations in antral area as measured by ultrasound.

[3-dimensional computed tomography with model preparation before mandibular reconstruction]

Extended mandibular defects resulting from cancer resection are amenable to reconstruction with a free vascularized bone graft transplantation. Between 1992 and 1995, 12 patients were enrolled in a protocol including a preoperative 3D-CT used to develop a custom-made acrylic model of the mandible. Besides contributing to the assessment of tumor extension, 3D-CT helps determine the adequate limits of mandibular resection. 3D-CT has the advantage of providing the surgeon with a more familiar image of the mandible and the mandibular model, allowing better and quicker conformation of the bone flap. The graft can be shaped at the donor site before cutting its vascular pedicle, resulting in a shorter period of ischemia. This series demonstrated that preoperative mandibular modeling with 3D-CT helps improve functional and cosmetic results in mandibular reconstruction.

[Gallbladder involvement in Crohn disease]

We report the case of a young woman with Crohn's disease involving the entire digestive tract and with associated lesions of the liver, pancreas and gallbladder. This latter lesion led to acute cholecystitis which required cholecystectomy. The histo-pathological examination showed granulomas with multinucleated giant cells in the lamina propria. This observation illustrates a severe and extended form of Crohn's disease involving the entire digestive tract as well as the liver, the pancreas and the gallbladder.

Does chronic supplementation of the diet with dietary fibre extracted from pea or carrot affect colonic motility in man?

The aim of the present study was to assess, in healthy volunteers and under physiological conditions, the acceptability, clinical tolerance and effects on colonic motility of chronic supplementation of the usual diet with new dietary fibre sources. Three studies were carried out, one after a period of habitual diet, and two after randomized 3-week periods of supplementation with fibre extracted either from pea hulls or carrots, added to the meals as a fine powder. The 24 h motility was recorded on an unprepared colon at five levels to determine the initiation site and the number of high amplitude propagated contractions (HAPC) and to quantify motor activity every 30 min, particularly in the two periods following lunch and breakfast. With the habitual diet the motility pattern was an irregular alternation of quiescence and sporadic non-propagated contractions. HAPC always started from the ascending colon and occurred mainly after breakfast. With either type of fibre the 24 h motor profiles, the 24 h variations and the number of HAPC were not significantly modified but a more distal initiation of HAPC was found. The colonic postprandial motor response was more diffuse after dietary enrichment with carrot fibre than after enrichment with pea-hull fibre. In healthy volunteers the long-term addition of fibre extracted from pea hulls and carrots to the usual diet was easy and well-tolerated without clinical side-effects, but with limited colonic motor effects. However, the more distal initiation of HAPC observed could be deleterious.

[Effect of lipid intake in meals on the duodenojejunal and sigmoid motor responses in healthy volunteers]

OBJECTIVES

In man, fat induces a fed motor pattern in the small bowel and stimulates colonic motility. With a pure lipid meal, these motor effects are dose-related. However, animal studies have suggested that the motor effects of fat are reduced when lipids are mixed with proteins and carbohydrates. Our aim was to study in healthy volunteers the duodeno-jejunal and sigmoid motor responses after two 750-kcal meals, one containing 28%, the other 58% lipids.

METHODS

Combined duodeno-jejunal and sigmoid manometric sessions were performed in each volunteer during 3 hours after each test meal. Meal was always given 30 minutes after the occurrence of a phase III in the duodenum. The order of the two studies was randomly assigned with a minimal interval of 8 days between the two studies. The number of waves and the area under curve were calculated both on the overall and on each of the 6 successive half hours of the recording period.

RESULTS

Phases III were interrupted at least for 3 hours by both types of meals in each volunteer. The overall duodeno-jejunal motor response was not different after the two meals and, in all cases, a progressive decrease of the motor parameters with time was demonstrated. A lower response in the duodeno-jejunum during the first postprandial hour and a delayed onset of the maximal motor activity were observed with the high fat meal. In the sigmoid, a motor response to food was observed in all volunteers without any quantitative difference between the low and high fat meals.

CONCLUSION

A two-fold increase of the lipid fraction of a meal does not enhance the duodeno-jejunal and sigmoid motor responses to food. At variance, it reduces the first hour motor response and delays the peak of maximal activity in the duodeno-jejunum. Our data confirm that the specific motor effects of fat are modified by their combination with proteins and carbohydrates.

Prognosis of patients with nonmalignant chronic intestinal failure receiving long-term home parenteral nutrition

BACKGROUND/AIMS

Long-term survival of patients with intestinal failure requiring home parenteral nutrition (HPN) has been only partly shown. Therefore, we described the survival of these patients and explored prognosis factors.

METHODS

Two hundred seventeen noncancer non-acquired immunodeficiency syndrome adult patients presenting with chronic intestinal failure enrolled from January 1980 to December 1989 in approved HPN programs in Belgium and France; prognosis factors of survival were explored using multivariate analysis. Data were updated in March 1991; not one of the patients was lost to follow-up.

RESULTS

Seventy-three patients died during the survey, and the mortality rate related to HPN complications accounted for 11% of deaths. Probabilities of survival at 1, 3, and 5 years were 91%, 70%, and 62%, respectively. Three independent variables were associated with a decreased risk of death: age of patients younger than 40 years, start of HPN after 1987, and absence of chronic intestinal obstruction. In patients younger than 60 years of age included after 1983 with a very short bowel, who could represent suitable candidates for small bowel transplantation, the 2-year survival rate was 90%, a prognosis that compared favorably with recent reports of survival after small bowel transplantation.

CONCLUSIONS

HPN prognosis compares favorably with recent reports of survival after small bowel transplantation.

Endoscopic injection of adrenaline for severe peptic ulcer haemorrhage in high surgical risk patients

Endoscopic adrenaline-hypertonic injection was attempted in 40 patients admitted for oesophagogastroduodenal ulcer haemorrhage unresponsive to conventional medical treatment and presenting with severe underlying disease or advanced age (less than 80 years). The results were compared with our own historical controls (43 patients) treated by conventional therapy, meeting the same inclusion criteria. Permanent haemostasis was achieved in 32 patients in the injection group and 30 in the control group (NS) but emergency surgery was less frequent in the injection group (2 vs 25, p less than 0.001). Blood transfusion requirements were less in the injection group (8.5 +/- 6.2 vs 10.2 +/- 5.4, p less than 0.05) but length of hospital stay was not really different (15.7 days +/- 9.3 vs 20.9 +/- 14.4). Unfortunately, mortality was not reduced in the injection group (14/40 vs 17/43). Two lethal complications attributable to injection treatment occurred. This treatment could represent an alternative to conventional haemostatic treatment in high surgical risk patients with severe clinical bleeding, avoiding emergency surgery. In spite of the fact that we selected high-risk patients, endoscopic treatment was not able to lower the mortality (about 37%). Due to severe unpredictable side effects and potential risks of long-term massive rebleeding, this treatment should be performed electively in patients with severe clinical bleeding, as first line treatment when surgical risk factors exist or immediately before surgery in low risk patients.

[Prolonged home enteral feeding]

Home enteral nutrition (HEN) is a method that will develop as an alternative to hospitalization. It is indicated mainly in patients who would normally be kept in neurology, ENT, gastroenterology, oncology, paediatrics or geriatrics hospital departments. The technicalities of HEN, such as route, periodicity and modalities of administration and choice of the diet, must be adjusted to the patient's condition and to the foreseeable duration of the procedure. HEN is best organized by a team of hospital specialists who will educate the patient prior to his discharge and follow him up at home in cooperation with the family doctor and district nurse. The extent of financial assistance provided by health insurance organizations is currently under evaluation.

[Diarrhea in intestinal inflammatory diseases]

Diarrhoea is a frequent symptom in ulcerative colitis (UC) and Crohn's disease (CD) which it often reveals. Its clinical features, course, physiopathology and treatment are different in these two diseases. UC is accompanied by an imperative, blood-stained, diurnal and often noctural diarrhoea the intensity of which fluctuates with the course of the disease, usually regressing under medical treatment but capable of becoming severe. This diarrhoea is due to several physiopathological mechanisms such as loss of colonic absorption function, exudative enteropathy and disorders of motility. Contrary to the lesions of UC, those of CD involve the whole digestive tract; they are multisegmental, ileal, colonic, ileocolonic or diffuse. Diarrhoea takes different forms depending on the site and evolutive stage of the lesions: malabsorption of bile salts and/or fatty acids in ileal lesions or after surgical resections, bacterial proliferation above stenoses, intestinal shunts due to internal fistulae, reduced absorbing area, exudative enteropathy and motor disorders in colonic lesions. In UC, treatment of the diarrhoea is that of exacerbations: systemic or topical corticosteroids or 5-aminosalicylic acid. In CD, side by side whit the maintenance treatment of the disease with anti-inflammatory drugs, the symptomatic treatments of diarrhoea play an important role and must be tailored to the responsible physiopathological mechanisms; some patients need artificial feeding.

[Severe diarrhea caused by Ticlid associated with disorders of small intestine motility]

Ticlopidine is a potent inhibitor of platelet aggregation whose mechanism of action remains unknown. It might act through an increase of intraplatelet PGE1 and PGD2. Benign diarrhea is the most common side effect during ticlopidine treatment. We report four cases of severe chronic diarrhea with fecal incontinence in patients treated by ticlopidine. In two patients manometric recording of jejunal motility was performed. Abnormal motility patterns were observed in both cases: bursts of 3-11 propagated contractions occurring every 2 min and migrating at a rate of 0.6 cm/s, preceded and followed by a brief period of quiescence. Migrating motor complexes and a low percentage of time of quiescence were noted on both recordings. These disorders in intestinal motility may play a role in the pathogenesis of diarrhea observed with ticlopidine.

[Mandibular reconstruction employing a costomyocutaneous flap of pectoralis major. Anatomical and technical aspects and viability of graft (author's transl)]

Costomyocutaneous flaps of pectoralis major were employed for reconstruction of the mandible. The various unconventional procedures for mandibular reconstruction reported in the published literature are reviewed, a critical analysis conducted of the different tests of viability of the graft employed, anatomical and technical aspects discussed, and results presented. This flap is suggested as being an excellent method for reconstruction after interrupted pelvimandibulectomy or mandibulectomy involving the skin.

[Preventive treatment in caustic stenosis of the oesophagus (author's transl)]

The authors review the varioux forms of treatment used experimentally and clinically in an attempt to prevent oesophageal stenosis following ingestion of caustic substances. Corticosteroid therapy is still used by certain authors though its effectiveness is far from obvious. However, promising results have been obtained experimentally using substances such as amino-nitriles, which alter the properties of newly formed collagen.

[Experimental model for the study of caustic stenoses of the oesophagus. Trial of d-penicillamine (author's transl)]

The aim of this article is above all to describe a new experimental protocol of caustic stenosis of the oesophagus in the rat, a protocol leading to regular stanoic scarring and offering and experimental model for the trial of anti-collagen substances. Initial research with d-penicillamine appears to offer encouraging results which justify its continuation.