Utilisation des lambeaux libres dans la prise en charge des plaies chroniques

International audienceINTRODUCTION:Chronic wounds represent a major health challenge with no current standardized surgical treatment. The use of free flaps is little discussed in the literature, with a supposed propensity to failure given unfavorable local conditions and land often debility. We present here the analysis of our monocentric experience of the use of free flaps in the curative treatment of chronic wounds.PATIENTS ET METHODS:We performed a retrospective monocentric study over 18 years of all free flaps used for the treatment of a chronic wound between January 2001 and September 2016. Several criteria were evaluated on patients, wounds, free flaps used and immediate to late outcomes.RESULTS:Ninety-one patients were included (sex ratio M/F: 3.55) with an average age of 41.6±16 years. Wounds were localized to the leg in 92.3% of cases and 58% of patients had initial osteomyelitis. The flaps used were predominantly muscle flaps (61.6%). The flaps survival rate was 92.3%. With a mean follow-up of 50 months, the reconstructive failure rate was 20.9%. The presence of a chronic osteomyelitis is the only statistically significant factor of reconstruction failure (P=0.0169) with a risk of failure multiplied by 5.CONCLUSION:Our study demonstrates that the reliability of free flaps in the treatment of chronic wounds is comparable, regardless of the time since the initial cutaneous lesion, to that existing in the treatment of acute wounds or in the reconstruction after oncological excision. The presence of a chronic osteomyelitis, however, represents a major risk of reconstruction failure by increasing 5 times the risk of failure. Recent changes in the integumentary reconstruction paradigm of the lower limb will undoubtedly allow in the next few years to establish more rationally the place of muscle free flaps in the therapeutic armamentarium of chronic wounds

Challenging TIPS in Liver Transplant Recipients: The Pull-Through Technique to Address Piggyback Anastomosis

The hepatic vein access during transjugular intrahepatic portosystemic shunt (TIPS) can be challenging in liver transplant recipient patients, especially when piggyback anastomosis was performed. We described a modified technique and reviewed the clinical outcomes of TIPS in transplanted patients. From 2015 to 2016, 8 patients with history of liver transplantation using a three-hepatic vein piggyback technique for venous anastomosis underwent a TIPS in our institution. Indications were refractory ascites (n = 7) or variceal bleeding (n = 1). When the hepatic vein access failed via the standard jugular route, a pull-through technique was used: After puncturing the right hepatic vein under ultrasound guidance, a guidewire and a vascular sheath were advanced, then the guidewire was snared in the inferior vena cava and retrieved though the jugular access, and the hepatic vein was catheterized along the guidewire. The safety and technical success rates of this technique and the clinical outcomes of the study population were retrospectively assessed. Seven of 8 patients (87.5%) required the pull-through technique to access a hepatic vein. No complications of the percutaneous access of the hepatic vein were found at the one-day and one-month ultrasound Doppler examinations. Among 7 patients who had refractory ascites, 3 had complete resolution of ascites (43%), and one had moderate improvement. One patient with refractory infected ascites on severe graft failure and one with massive bleeding died soon after the procedure. A pull-through technique following percutaneous puncture of a hepatic vein is a safe technique for performing a TIPS in liver transplant recipients with piggyback anastomosis complicated by acute hepatic vein angulation

Intra arterial treatment of hepatocellular carcinoma: Comparison of MELD score variations between radio-embolization and chemo-embolization

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