Feasibility of perforator flaps in Day surgery. A retrospective study through a two-years' experience

BACKGROUND

Day surgery is developing and its popularity is increasing for a variety of reasons: economic constraints, changes in professional practices, a greater adhesion of the patient. In an era of progress in surgical procedures, pedicled-perforator flaps reducing donor site morbidity and avoiding micro-anastomosis could take their place in Day surgery if planned and managed by an experienced team.

METHODS

In the period January 2019 to January 2021, we performed perforator flaps for soft tissue coverage in ambulatory setting. The patients were included retrospectively and data were collected by reviewing the medical records. Major and minor complications were recorded.

RESULTS

The retrospective cohort included 32 surgical procedures in 32 patients. In all cases, perforator flaps were realized for resurfacing soft tissue defects consequent to oncodermatology surgery (84.3%), soft tissue sarcoma surgery (12.5%), invasive ductal breast carcinoma (3.1%). Major complications needing a surgical revision overcame 3/32 times (9.4%). In these cases, a failure requiring the drop off the flap overcame once. The average wound healing time was of 33 days (15-90) and the mean duration of follow-up was 9.6 months (1-22).

CONCLUSION

The low complication rate in our series suggests that this first experience on perforator flaps in outpatient surgery is promising in terms of safety and feasibility. Day surgery could be a practical option for this type of surgical procedures avoiding the conventional department's saturation and allowing the delivery of proper surgical cares.

Percutaneous infraclavicular subclavian vein catheters in paediatric cancer patients in comparison with critically ill children: a one-year experience from a Tunisian hospital

BACKGROUND

Paediatric cancer and critically ill patients frequently require central venous catheters for prolonged intravenous therapy. The aim of this study is to compare the difficulty of catheter insertion and the morbidity related to this procedure in these two populations and to investigate risk factors for complications.

METHODS

This prospective observational study was conducted at the Hedi Chaker University Hospital in Sfax, Tunisia, from July 2021 to July 2022. We included all patients aged three months to 14 years who required an infraclavicular subclavian vein catheterization. Patients were divided into two groups: Group 1 included children with malignancies; and Group 2 included critically ill paediatric patients. Then, we compared the demographic data, the difficulty of the catheterization procedure, and catheter-related complications. We also investigated risk factors for complications using a logistic regression model. The significance level was P<0.05.

RESULTS

We included 65 infants and children requiring central venous access, 28 of whom suffered from malignancies. The demographic parameters were comparable. However, the time for the procedure and the number of attempts were higher in the malignancy group with P<0.001. Central venous catheter complications were present 46.4% of the time in Group 1 compared to 21.6% in Group 2 (P=0.032). Malignancies were associated with an increased risk of complications (aOR = 2.95; 95%CI: 0.63-13.8).

CONCLUSIONS

This study showed increased difficulty and higher morbidity related to infraclavicular subclavian vein catheterization among infants and children suffering from cancer.

Airway management in a rare case of congenital palate teratoma with a cleft palate: A case report

Airway management in neonates is difficult because of the risk of rapid hypoxia. It presents a challenge even for an experienced anesthesiologist. Oral tumors in neonates can obstruct the airway or feeding problems in the newborn. Surgical excision is the treatment of choice but these tumors can seriously worsen the conditions of intubation. To surmount these difficulties, a particular multidisciplinary approach and special precautions are needed. We describe the airway management and precautions taken in the anesthesia for surgical removal of a case of large congenital palate teratoma associated with a wide cleft palate in a 25-day-old girl. Impossible intubation was predicted on magnetic resonance imaging. The difficult airway management cart as well as an otorhinolaryngologist skilled in performing emergency tracheostomies in neonates were available. The patient was intubated by conventional laryngoscopy under sevoflurane inhalation anesthesia. The tumor was successfully resected. This case poses a challenge for managing the airway because of the possibility of obstruction of the airway and the difficulty of the airway that radiological exams have allowed us. So, a multidisciplinary team effort is needed for successful neonatal airway management.

Management of COVID-19-Associated Guillain-Barré Syndrome in a Full-Term Pregnant Woman: A Case Report

Guillain-Barré syndrome (GBS) can occur after viral infections. Its occurrence after COVID-19 infection in the peripartum period is a very rare co-occurrence. Therefore, there are no guidelines for the management of these patients. We report the case of a 32-year-old pregnant woman who developed COVID-19-associated GBS with aspiration pneumonia, motor weakness, and ascending paralysis at 39 weeks of gestation. Preoperative plasmatic exchange (plasmapheresis) and oxygen support were very effective and allowed for a rapid recovery within five days. Because of foetal distress during labor, the patient had a caesarean section under spinal anaesthesia with no maternal complications or adverse foetal outcomes.

Predictors of perioperative respiratory adverse events among children with upper respiratory tract infection undergoing pediatric ambulatory ilioinguinal surgery: a prospective observational research

Objectives

Anesthesia for children with an upper respiratory tract infection (URI) has an increased risk of perioperative respiratory adverse events (PRAEs) that may be predicted according to the COLDS score. The aims of this study were to evaluate the validity of the COLDS score in children undergoing ilioinguinal ambulatory surgery with mild to moderate URI and to investigate new predictors of PRAEs.

Methods

This was a prospective observational study including children aged 1–5 years with mild to moderate symptoms of URI who were proposed for ambulatory ilioinguinal surgery. The anesthesia protocol was standardized. Patients were divided into two groups according to the incidence of PRAEs. Multivariate logistic regression was performed to assess predictors for PRAEs.

Results

In this observational study, 216 children were included. The incidence of PRAEs was 21%. Predictors of PRAEs were respiratory comorbidities (adjusted OR (aOR)=6.3, 95% CI 1.19 to 33.2; p=0.003), patients postponed before 15 days (aOR=4.3, 95% CI 0.83 to 22.4; p=0.029), passive smoking (aOR=5.31, 95% CI 2.07 to 13.6; p=0.001), and COLDS score of >10 (aOR=3.7, 95% CI 0.2 to 53.4; p=0.036).

Conclusions

Even in ambulatory surgery, the COLDS score was effective in predicting the risks of PRAEs. Passive smoking and previous comorbidities were the main predictors of PRAEs in our population. It seems that children with severe URI should be postponed to receive surgery for more than 15 days.

Complications and its risk factors of percutaneous subclavian vein catheters in pediatric patients: enhancing the outcomes of a university hospital in a low-income and middle-income country

Objective

Assessing central venous catheter-related complications with regular feedback and investigating risk factors are mandatory to enhance outcomes. The aim of this study is to assess our experience in the management of pediatric subclavian vein catheters (SVCs) and to investigate the main risk factors for complications.

Methods

In this prospective observational study, we included children aged 3 months to 14 years who underwent infraclavicular subclavian vein catheterization consecutively using the anatomic landmark technique. Patients were divided into two groups: group 1 included complicated catheters and group 2 included non-complicated catheters. The management protocol was standardized for all patients. After comparing the two groups, univariate and multivariate logistic regression were used to investigate the risk factors for complications.

Results

In this study, we included 134 pediatric patients. The rate of complications was 32.8%. The main complications were central line-associated bloodstream infection (63.6%), bleeding and/or hematoma (22.7%), mechanical complications (13.6%), and vein thrombosis (13.6%). After adjustment for confounding factors, predictors of catheter-related complications were difficult insertion procedure (adjusted odds ratio (aOR)=9.4; 95% confidential interval (CI): 2.32 to 38.4), thrombocytopenia (aOR=4.43; 95% CI: 1.16 to 16.86), comorbidities (aOR=2.93; 95% CI: 0.58 to 14.7), and neutropenia (aOR=5.45; 95% CI: 2.29 to 13.0).

Conclusions

High rates of complications were associated with difficult catheter placement and patients with comorbidities and severe thrombocytopenia. To reduce catheter-related morbidity, we suggest an ultrasound-guided approach, a multidisciplinary teaching program to improve nursing skills, and the use of less invasive devices for patients with cancer.

Improvement of Broviac catheter-related outcomes after the implementation of a quality management system: A before-and-after prospective observational study

Background: Because of the high rates of Broviac catheter complications, we started an urgent quality process to reduce this morbidity. The aim is to assess the efficiency of the main actions we have taken in enhancing our practice and improving Broviac outcomes. Methods: We included all neonates and young infants requiring surgical central venous access using a Broviac tunneled catheter. We compared the catheters’ outcomes before and after the implementation of a quality program based on a nurse teaching program, patient selection, and catheter management multidisciplinary protocol. The significance threshold was set at p<0.05. Results: We included 94 patients: 51 in the protocol group and 43 in the control group. The complication rate was reduced from 60.3% to 25.5% with p=0.001. The lifetime of the catheter was improved from 11.3 ± 4.3 days to 19.1 ± 9 days with p=0.007. The catheter infection was reduced from 65.3% to 46.1% with p≤0.001. Conclusion: This quality improvement project shows the utility of a quality assurance program based on careful indications and patient selection, a nursing teaching program, and a multidisciplinary catheter management protocol, in reducing Broviac catheter-related morbidity.

Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg and clonidine 1μg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.

Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery: A randomized controlled trial

INTRODUCTION

Subarachnoid morphine is widely used for pain relief in enhanced recovery program after cesarean section in spite of its side effects. However, the role of TAP block is still controversial. The aim of our study was to compare the impact of these analgesic techniques (subarachnoid morphine and TAP block) on enhanced recovery after cesarean section.

MATERIALS AND METHODS

In this randomized controlled trial, we included patients scheduled for cesarean delivery under spinal anesthesia. Patients were randomized in two groups. Group I: received spinal anesthesia with 100μg of subarachnoid morphine. Group II: received spinal anesthesia without subarachnoid morphine followed by an ultrasound-guided TAP block. We assessed the time required for mobilization, for re-establishment of gastrointestinal transit and for breast-feeding.

RESULTS

TAP block allowed earlier postoperative mobilization. Time required for getting up was significantly lower in group II (9.4h versus 6.9h; P=0.024) as well as time required for walking (12.4h versus 7.4h; P=0.001). TAP block allowed earlier re-establishment of gastrointestinal transit (11.2h in group I versus 8.1h in group II; P<0.001).

CONCLUSIONS

TAP block seems to be suitable with enhanced recovery programs.

Near-infrared spectrometry in pregnancy: progress and perspectives, a review of literature

Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of in vivo oxygenation in selected tissues. It has been used primarily as a research tool for several years, but it is seeing wider application in the clinical arena all over the world. It was recently used to monitor brain circulation in cardiac surgery, carotid endarteriectomy, neurosurgery and robotic surgery. According to the few studies used NIRS in pregnancy, it may be helpful to assess the impact of severe forms of preeclampsia on brain circulation, to evaluate the efficacy of different treatments. It may also be used during cesarean section to detect earlier sudden complications. The evaluation of placental function via abdominal maternal approach to detect fetal growth restriction is a new field of application of NIRS.

[Hyperemesis gravidarum with severe electrolyte disorders: report of a case]

L'hyperemesis gravidarum s'accompagne habituellement d'une perte de poids, d'une acétonurie et de troubles hydro-électrolytiques comme il peut également s'accompagner d'anomalies du bilan hépatique. Nous rapportons un cas de vomissements gravidiques à 10 semaines d'aménorrhée non traité et vu tardivement avec des troubles ioniques sévères associés à des répercussions cliniques dans un contexte de cytolyse, de cholestase et d'insuffisance rénale aigue. Ce cas a bien répondu au traitement médical.

Percutaneous closure of Ostium secundum atrial septal defect using amplatzer occlusion device

AIM

To report our clinical experience with transcatheter closure of ostium secundum atrial septal defects (OS ASDs) using Amplatzer septal occluder.

METHODS

It's a retrospective study conducted between October 2005 and April 2010 and involving 34 patients. The procedures were conducted in the hemodynamic laboratory under general anesthesia with transthoracic (TTE) and transoesophageal echocardiographic (TEE) monitoring. Clinical and echocardiography assessments of the patients were conducted within 24 hours post procedure and several months after the procedure.

RESULTS

From the 34 patients, 28 (82%) were females. The middle age was 27.5 years. The mean ASD diameter was 19.4 mm by TTE; 18.1 mm [12-38] by TEE, and 23.4 by angiography. The average size of the implanted devices was 23.2 mm ranging from 10 to 34 mm.The final success rate of the procedure was 90.9% (30/33). One patient was excluded from transcatheter occlusion and three patients (8,6%) had complications including two prosthesis migrations and one large residual shunting. A total of 4 patients (11,7%) underwent surgery. No major complication (thromboembolic events, obstruction of intracardiac structures, cardiac perforation, device embolization and endocarditis) or death has occurred during follow-up and all devices were securely anchored without any persistent residual shunts.

CONCLUSION

Compared to previous data of the literature, percutaneous closure of OS ASDs using Amplatzer device appears safe and effective according to our experience of the cardiology department of Hedi Chaker Hospital.

Antepartum detection of macrosomic fetus: the effect of misdiagnosis

AIM

To determine the effect of misdiagnosis of macrosomia on maternal and perinatal outcomes.

METHODS

We conducted a retrospective study ,between January 2007 and December 2008 of women (n = 464) who delivered singleton neonates with actual birth weight over 4000g and in whom fetal weight was estimated, by both methods :sonographic and clinical, up to 3 days before delivery.Statistical comparisons were made between patients in whom fetal macrosomia was predicted : «prediction » group (n=336)and those in whom it was not « non prediction »group (n=128) for outcome variables.

RESULTS

The cesarean delivery was performed in 35.9% in « non predicted » group, and in 35.7% in the « predicted » group.The difference was not statistically significant. Failure to detect macrosomia was associated with higher rates of maternal and fetal complications in the group « non predicted » compared with the group « predicted » :perineal trauma,post partum hemorrhage, 5- minute Apgar scores less than 7, and shoulder dystocia, mostly related to the higher rate of surgical vaginal deliveries.

CONCLUSIONS

The misdiagnosis of fetal macrosomia substantially did not modify the cesarean section rate but leads to increase the maternal and neonatal complications.

[Prospective study of 45 cases of disseminated intravascular coagulation]

BACKGROUND

Disseminated intravascular coagulation (DIC) in obstetric disorders is a severe complication.

AIM

To study the frequency and means of diagnosis of DIC and the therapeutic care and maternal morbidity induced.

METHODS

Monocentric, prospective and descriptive study about 45 cases of intravascular coagulation in an obstetrical service collected at the University Hospital of Obstetrics and Gynecology Hedi Chaker of Sfax over a period ranging from June 2007 to June 2010. All the pregnant patients who have given birth beyond 28 weeks and have presented a DIC were selected for this study.

RESULTS

The mean age of patients was 31.4 years. The mean parity was 2.6. The main diseases during pregnancy were: severe preeclampsia (22.2%), diabetes (28.8%), intrauterine fetal death (17.7%), previa placenta (8.8%). The main causes of DIC were: uterine atony (44.4%), abruptio placenta (22.2%), Hellp syndrome (11.1%) and uterine rupture (6, 6%). The lowest rate of platelets was 21000/mm3. The fibrinogen level was <0.5 g in 40% of cases. Despite reanimation and transfusion with blood products, surgical treatment was necessary in 77.7% of cases. All the patients were transferred in intensive care unit with an average stay of about three days. No maternal death was reported.

CONCLUSION

DIC is a frequent complication of many obstetrical diseases. The treatment is urgent. It requires first to the cause and the shock by massive transfusions of packed red blood cells, fresh frozen plasma, and platelets, associated with antifibrinolytic drugs, if necessary.

[Emergency peripartum hysterectomy: indications and prognosis]

AIM

Detect the risk factors, indications and maternal morbidity of haemostatic hysterectomy.

METHODS

A retrospective study of 46 women who had haemostatic hysterectomy between 2005 and 2009.

RESULTS

The mean age was 33.3 years. The mean parity was 3.5. 35% of patients had a previous cesarean section. The mode of delivery was: vaginal delivery (47.8%), cesarean delivery (52.2 %). The hysterectomy was subtotal in 39 cases (85%). The indications of haemostatic hysterectomy was: uterine inertia (44%), disseminated intravascular coagulation (26%), placenta accreta (8.7%), Placenta praevia (13%), uterine rupture (8.7%).Three patients were dead. Five patients had a depression. Six patients had a dyspareunia. Five patients had a decrease of sexual desire.

CONCLUSION

Haemostatic hysterectomy is a mutilating surgery giving an irreversible infertility. The development of arterial embolization avoid the appeal to this surgery.

[Ligation of internal iliac arteries for severe hemorrhage in obstetric]

AIM

To assess the efficiency of arteries ligation in intractable obstetrical hemorrhage.

METHODS

Prospective study which concerned 53 patients who underwent internal iliac arteries ligation for persistent and severe obstetrical hemorrhage from January 2007 to June 2010.

RESULTS

The average age of patients was 29.3 years. The mean parity was 2.2. Main etiology of hemorrhage were: uterine atony (62.2%), abruptio placentae (15.1%). Coagulation disorders and hypovolemic shock were observed respectively in 20.7 % and 37.7%. Blood transfusion was performed in all cases. Internal iliac arteries ligation allowed hemorrhage control in 90.5 % of cases. In five cases a hysterectomy was necessary to control bleeding.. No peroperative complication were observed.

CONCLUSION

Internal iliac arteries ligation is a prerequisite treatment of severe postpartum hemorrhage. It is a good alternative to arterial embolization.

[Obstetrical prognosis following ligation of hypogastric arteries]

BACKGROUND

Ligation of hypogastric arteries is a conservative surgical treatment in cases of postpartum hemorrhage.

AIM

To study the fertility and pregnancies outcome in women who required hypogastric artery ligation for severe post-partum haemorrhage in our hospital.

METHODS

The fertility and pregnancy outcome parameters were retrieved from medical files and telephone interviews

RESULTS

34 patients required hypogastric ligation on this period. 39 pregnancies were observed with 30 term deliveries, 1 ectopic pregnancies and 8 miscarriages. Two patients had infertility and pregnancy was obtained in less than 10 months most once desired.Pregnancy outcome was normal. 73,3% of deliveries were by caesarean.

CONCLUSION

Hypogastric artery ligation for post-partum haemorrhage is not responsible for secondary infertility. Following pregnancies do not suffer complications from the ligation.

Liver cystic echinococcosis: which cysts are correlated with false negative indirect passive hemagglutination (IHA)?

BACKGROUND

It's generally agreed that calcified liver cystic Echinococcosis (CE) is associated with negative serology; the influence of other cystic features on serologic result remains unclear. The aim of this study is to determine predictive factors of negative indirect passive hemagglutination (IHA) in liver CE.

METHODS

119 patients operated on for liver CE, had preoperative IHA. Correlation was studied between serological result and sex, age of patient and number (single vs multiple), size, ultrasonic type (unilocular, multivesicular, degenerative) and intrabiliary rupture of cyst.

RESULTS

IHA sensitivity was 74.8%. Univaried analysis showed that false negative serology was correlated with age <10 or >20 years (p < 0.01), single cyst (p < 0.006), cystic size <9 cm (p < 0.03) and unilocular or degenerative cyst in comparison with multivesicular type (p < 0.01 and p < 0.03 respectively).

IN CONCLUSION

in liver CE, cystic predictive factors of false negative IHA are single cyst, unilocular or degenerative type and size inferior to 9 cm.

Répercussions maternelles et néonatales de l'anesthésie générale par rémifentanil pour césarienne programmée

OBJECTIVE

Opioids are routinely omitted at the induction of general anesthesia for Caesarean delivery because of the risks of respiratory neonatal depression. The short-acting opioid remifentanil may afford advantages at the induction and surgical stimulation, without subsequent neonatal depression.

PATIENTS AND METHODS

In this double-blinded study, 40 at term women undergoing elective Caesarean section and requiring general anaesthesia were allocated randomly to receive either remifentanil (0,5 microg/kg) at the induction of anaesthesia (G1, n=20) or placebo (G2, n=20). Induction of anaesthesia was performed with propofol 2 mg/kg and succinylcholine 1 mg/kg. Anaesthesia was maintained with nitrous oxide in oxygen (50/50%, v/v), propofol (100 microg/kg/min), remifentanil (0.2 microg/kg/min) and atracurium. Neonates were assessed by using Apgar scores, possible respiratory depression, with or without ventilation in the mask or intubation and umbilical cord blood gas (artery: UA and vein: UV). Values are expressed as mean values +/-SD. Pearson's Chi squared and t-test were used for statistical analysis P<0.05 was considered significant.

RESULTS

Maternal systolic pressure, mean pressure and heart rate were significantly higher in G1 at induction. Apgar scores, heart and respiratory rate were similar between groups. Seven episodes of respiratory depressions were noted (3 in G1, 4 in G2). Five neonates required only brief assisted ventilation by face-mask (2 in G1, 3 in G2).

CONCLUSION

Remifentanil (0.5 microg/kg) at the induction of anaesthesia in elective Caesarean section under general anaesthesia can be used without subsequent neonatal depression. However, we believe that further research is necessary to extrapolate these results to a pregnancy carrying an acutely distressed foetus.

The effects of drainage with a Redon versus a conventional drain on postoperative pain and blood loss after valve replacements

AIM

The aim of this study was to assess the influence of drainage with a Redon drain versus a conventional drain on postoperative pain and blood loss after valve replacements.

METHODS

After approval by the local Ethics Committee and written informed consent, 30 patients, 20-60 years of age, scheduled for first elective valve replacement were included. After standardized anaesthetic regimens, cardiopulmonary bypass and coagulation therapy procedures and at the end of the operation, the patients were randomly assigned to 1 of 2 groups: (GI, n=15): drainage with 4 Redon drains; (GII, n=15): drainage with 2 conventional drains. Postoperative pain intensity at rest (VAS-R), during coughing and mobilization (VAS-M) in bed was independently evaluated using a visual analogue scale (VAS 100 mm) at 6 hourly intervals until 48 h after admission to the ICU (Ho). All patients received 2 g of paracetamol after obtaining the VAS score (8 g/24 h). No other analgesic agents were used. All patients were submitted to 2D echocardiography to verify the presence of pericardial effusion 24 h after surgery. Values are expressed as means. Pearson's chi squared and ANOVA (for repeated measurements) were used for statistical analysis. P<0.05 was considered significant.

RESULTS

There was no statistically significant difference in the mean postoperative VAS-R and VAS-M, and in the mean postoperative total blood drainage 822.3 ml in GI, versus 704.3 ml in GII. Non pericardial effusion was found, and we did not see side-effects in any of the patients.

CONCLUSIONS

We have shown that drainage with a Redon drains versus a conventional drain does not influence postoperative pain intensity and blood loss after valve replacements.

[A programmed autologous transfusion. A study of 47 patients]

From December 1994 to January 2002, 44 among the 47 patients proposed have been integrated in the protocol of programed autologous transfusion. 18 patients were belonged to the male sex and 26 others belonged to the female one. The average age was 53.2 years (range 15-82 years old). 39 among the patients admitted in the protocol had an orthopaedic pathology. The protocol has associated the teams of surgery, of anesthesia and of transfusion and has occurred in the respect of the regulation (circular 91/2000). The blood taking have led to a significant modification of the hemoglobin rate (average decrease of 2 g/100 ml), of hematocrit (average decrease of 6.1%) and of the rate of platelets (average increase of 29,324 platelets/mm3). On the other hand, a transfusional complement by the concentrated homologous red corpuscles was necessary for 2 patients (2/40).

[Retroperitoneal schwannoma. Case report]

Retroperitoneal schwannoma is a rare tumor originating in the neural sheath. We report the case of a 48 year-old women. She had a ten year history of lumbal pain. The abdominal sonography had revealed a left retroperitoneal tumor that compresses the left renal cavities. The abdominal CT scan visualized a 56 mm, homogenous, well demarcated, retroperitoneal mass with a low attenuation. This mass with multiple enhanced septa is separated from the left adrenal gland. The diagnosis of a cystic lymphangioma is made. We perform surgical exeresis of the tumor by a left lumbal laparotomy. The pathology examination concludes in an altered schwannoma with Antoni B patterns. Retroperitoneal schwannoma is a primary neural benign tumor with a good prognosis. The management is surgical.

[Thoracic aortic aneurysm complicating pseudo-coarctation]

INTRODUCTION

The aneurysm of the descending aorta complicating a pseudocoarctation, itself due to a congenital elongation with kinking of the aorta is a rare entity.

OBSERVATION

We report a case of aortic aneurysm discovered in a 72 years old woman without notable antecedents, which was referred for recurrent bronchitis. The X-ray showed a calcified opacity of the upper mediastinum, 5 cm of large. A thoracic CT-scan evoked the presence of a circulating sacciform aneurysm with calcified walls, developing on the final part of the aortic arch, which was with abnormally ascending way going up to the cervico-thoracic orifice and carrying out an aspect of aortic kinking. The assessment was complemented by a RMI as well as an aortic opacification. A thoracic scintigraphy showed an hypoperfusion of the left lung. The remainder of the cardiac assessment was normal. The patient was operated under femoro-femoral extracorporeal circulation through a left posterolateral thoracotomy of the 4th intercostal space. The examination showed a 7 cm diameter calcified aneurysm of the descending thoracic aorta complicating a tight stenosis in connection with an elongation and a kinking. The upper section of the aorta was shifted towards the pleural dome. The aortic section above aneurism was of normal size whereas the lower section was dilated. The aneurism was excised and a prosthetic graft was carried out. The surgery follow-up was marked by an hemodynamic stability, without neurological deficit. A ventilatory assistance was necessary during 5 days. Currently with 8 months follow-up, the patient goes well.

COMMENTS

A prosthetic replacement in front of this type of aneurism is legitimate given the risk of the occurrence of complications secondary to the pseudocoarctation (arterial hypertension, aortic insufficiency) or to the aneurism itself, dissection or compression of vicinity (pulmonary artery).