Protective subpleural blanketing of intrathoracic esogastric anastomosis after esophagectomy

Esophagectomy followed by intrathoracic anastomosis is threatened by leakage which may prove all the more serious that mediastinal contamination is extensive. In the technique presented, the esogastric anastomosis is slipped under the upper mediastinal pleura which is kept intact, after the azygos vein has been ligated and divided. This pleural ‘blanket' may act as an efficient barrier against potential digestive spillage into the mediastinu

Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considere

Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non‐cardiac surgery

The increasing number of patients with coronary artery disease undergoing major non‐cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long‐term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high‐risk period of 6 weeks, and an intermediate‐risk period of 3 months. A 3‐month minimum delay is therefore indicated before performing non‐cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta‐block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non‐cardiac surgery. Br J Anaesth 2002; 89: 747-5

Atomic transfers between implanted bioceramics and tissues in orthopaedics surgery

We study transfers of ions and debris from bioceramics implanted in bone sites. A contamination of surrounding tissues may play a major role in aseptic loosening of the implant. For these reasons, bioceramics require studies of biocompatibility and biofunctionality . So, in addition to in vitro studies of bioceramics, it is essential to implant them in vivo to know body reactions. We measured the concentration of mineral elements at different time intervals after implantation over a whole cross-section. We found a discontinuity of the mineral elements (Ca, P, Sr, Zn, Fe) at the interface between the implant and the receiver. The osseous attack is not global but, on the contrary, centripetal. Moreover, the fit of the concentration time course indicates that the kinetics of ossification is different for each atomic element and characterizes a distinct biological phenomeno

Contamination by metallic elements released from joint prostheses

When a metallic implant is in contact with human tissues, the organism reacts and a corrosion process starts. Consequently, we might observe liberation of metallic debris and wear. Our purpose is to measure the contamination and the migration of these metallic elements in the surrounding tissues of the implant. Two types of samples have been studied. First type is sample taken on post-mortem tissues around prostheses to study contamination gradients. Second type is sample taken on pathologic joints on periprosthetic capsular tissues in surgical conditions. These allow estimating contamination degree. The experiments were made on a Van de Graaff accelerator located at CERI (Centre d'Etude et de Recherche par Irradiation, Orl\'{e}ans, France). We measure elemental concentrations resulting from the contamination of the surface of each sample. Results are analysed in function of the pathology and the type of implants. According to the pathology and the location of the sampling, these measurements show a very heterogeneous contamination by metallic elements under particles and/or ionic species which can migrate through soft tissues by various mechanism

Properties of two biological glasses used as metallic prosthesis coatings and after an implantation in body

présentation faite par Y. Barbottea

Off‐pump coronary artery bypass surgery: physiology and anaesthetic management†

Increasing interest is being shown in beating heart (off‐pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high‐risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple‐vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating‐heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data. Br J Anaesth 2004; 92: 400-1