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En 30 fiches, l’auteur propose un résumé des questions essentielles posées par la pratique comptable et leur exploitation financière.À la fin de chaque fiche, sont proposés de nombreux exercices dont la correction détaillée permet de vérifier ses connaissances.Cet ouvrage est utile à toute personne (étudiant, salarié, créateur d’entreprise, etc.) voulant s’initier et comprendre la technique comptable et la signification des principaux documents de synthèse (bilan, compte de résultats…).

Cet ouvrage traite de l’une des décisions les plus importantes dans la vie d’une entreprise ayant atteint une taille respectable : son introduction en bourse. Il s’agit d’un thème particulièrement intéressant et clivant dans la mesure où il conditionne le développement de la société concernée, mais où il donne lieu à des controverses acharnées. En effet, il arrive un moment où ses capitaux s’avérent insuffisants pour lui permettre d’assurer sa croissance. Il lui faut donc trouver des fonds supplémentaires. Elle dispose pour ce faire de plusieurs moyens, dont réaliser un prêt à très long terme, une augmentation de capital soit auprès de ses actionnaires historiques soit auprès de nouveaux actionnaires. C’est à cette question que cet ouvrage est consacré, en expliquant les avantages, les inconvénients et les risques de chacune des modalités envisageables.Écrit par deux spécialistes du financement d’entreprises, à la fois patriciens et théoriciens, ce sujet fait l’objet de changements constants au gré de l’évolution des pratiques financières. S’appuyant sur les dernières statistiques connues, il permet de comprendre l’enjeu pour une jeune entreprise ou pour une entreprise mature d’une cotation en bourse ou, même, parfois, pour l’ensemble de la population d’un pays.

24 fiches pour réviser l'essentiel de l'Histoire monétaire, bancaire et financière: les définitions à connaître, les erreurs à éviter, les points essentiels à retenir ; des exercices corrigés pour vérifier ses connaissances ; des repères bibliographiques pour aller plus loin ; 1 index.

The research in this thesis shows that enol carbamates react with hyper-reactive cysteine and serine residues within proteins. By equipping the scaffold with a reporter group, chemical probes can be obtained that label enzyme containing these residues. The reactivity of the scaffold can be tuned to increase the potency and to generate selectivity for proteins of interest.

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Fully polarimetric SAR gives valuable information on the nature of scattering mechanisms, which can be used for vehicle detection. This project aims at comparing the contrast between vehicles and background offered by different polarimetric features, at different wavelengths and under different orientation angles. The study is based on data acquired with DLR’s FSAR, in Oksbøl, Denmark, at X, S and L bands. This work can lead to further improvements in target detection by selecting individual features or a combination of features optimizing contrast between vehicles and their surroundings.

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Environ 6 % des naissances sont prématurées. Jusqu'au XXe siècle, la plupart de ces enfants décédaient. En effet, les bébés prématurés risquent plus de présenter des problèmes de développement que ceux nés à terme. Ces problèmes sont dus surtout à l'immaturité du système nerveux central et des poumons qui n'ont pu se développer complètement pendant la grossesse. Généralement, plus l'âge gestationnel est bas, plus les répercussions sont élevées. Actuellement, on assiste à un double phénomène. Malgré les progrès considérables de la médecine, la prématurité connaît un regain de fréquence. Pourquoi ? On sauve de plus en plus de bébés nés avec un très faible poids de naissance. Quelles en sont les conséquences ? Une prématurité légère a longtemps été considérée comme exempte de risques. Est-ce vraiment le cas ? Le présent ouvrage de vulgarisation éclairée s'adresse à tous les parents concernés qui attendent un nouveau-né "trop tôt" et à tous les soignants qui souhaitent mettre à jour leurs connaissances dans ce domaine. Le lecteur suit Yanis, un petit être qui va prendre forme dans le ventre de sa maman et vivre l'expérience d'une naissance prématurée avec son cortège de soins plus ou moins inquiétants, émouvants et parfois traumatisants. Les auteurs ont souhaité un abord qui mette en scène la vie, ses multiples facettes, sa richesse et ses espérances, sans oublier la souffrance de ceux qui prennent des chemins de traverse. Découvrez le chapitre 4 "Le retour à la maison" en lecture gratuite sur artelittera.com.

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Figure politique majeure de la IIIe République qu'il contribua à installer, Léon Say (1826-1896) fut aussi un homme d'idées soucieux d'inscrire ses convictions libérales dans la gestion courante des finances publiques. Commentateur de l'œuvre de Hume, Adam Smith et Turgot, collaborateur du Journal des économistes, auteur d'une bonne trentaine d'ouvrages d'économie sociale et dirigeant de l'Union libérale républicaine positionnée au centre gauche, ce protestant laïque, petit-fils du célèbre économiste Jean-Baptiste Say a en effet été à quatre reprises et pour une durée totale de cinq ans ministre des finances. Avant tout attaché à maintenir la stabilité fiscale, il fut en 1880 l'ambassadeur de France à Londres chargé de renégocier le Traité de libre échange franco-britannique avec Gladstone. Le libéralisme assumé de ce contemporain de Gambetta et de Jules Ferry lui a fait simultanément défendre la liberté du travail et combattre le travail des enfants ainsi que militer pour le repos hebdomadaire, ou encore s'opposer à l'impôt progressif sur le revenu et promouvoir le mouvement coopératif et mutualiste.

Les marchés financiers constituent aujourd'hui l'un des modes de financement des entreprises et des États et un mode de placement pour les épargnants. Cette 3e édition mise à jour permet de comprendre les mécanismes de la rencontre des besoins financiers et des capacités financières. Elle décrit d'une manière simple les différents titres financiers avec leurs principales caractéristiques, les marchés où ils s'échangent et la manière dont les participants peuvent se couvrir contre le risque essentiel des marchés financiers, la volatilité ou fluctuation du prix des titres.

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Religion de salut, le christianisme enseigne un monothéisme exclusif de toute autre croyance et engage ses fidèles à vivre selon la morale la plus rigoureuse. L'attente d'un bonheur céleste et de la fin des temps les détourne largement du monde. Par tous ces traits, les chrétiens sont étrangers à la civilisation gréco-romaine.En dépit d'un rejet par les élites et de dures persécutions, le christianisme s'impose jusqu'à devenir la religion officielle de l'Empire romain, puis de tous les royaumes qui se succèdent au moyen Âge en Europe occidentale. L'Église devient un acteur essentiel de la vie sociale. Elle contribue à aménager les sociétés en s'impliquant fortement dans l'exercice de l'autorité. Elle adopte le savoir antique et l'utilise pour élaborer ses propres conceptions. Elle bâtit et développe un art en empruntant à celui de tous les peuples. Cette naturalisation sociale et culturelle s'accomplit au prix d'une difficile adaptation, trop bien réussie peut-être. Or les Écritures, qui renvoient en permanence à l'idéal religieux primitif, inspirent une remise en cause fréquente de cet ordre. L'exercice du pouvoir, la hiérarchie sociale, les comportements humains, les modes de raisonnement sont successivement concernés. Réformer sans cesse induit un dynamisme qui se dément rarement. C'est cette histoire longue et complexe que le présent ouvrage retrace dans toute sa diversité. Jacques Paul est professeur à l'université de Provence Aix-Marseille I. Il est l'auteur chez Armand Colin de Histoire intellectuelle de l'Occident médiéval et de Culture et vie intellectuelle dans l'Occident médiéval. Le salut. L'Écriture sainte. L'Église. Le christianisme latin à la fin de l'Empire romain. Les chrétiens et l'Empire. Les chrétiens et les religions païennes. Du héros au saint. Les chrétiens et la culture antique. Ordre du monde et salut chrétien (500-1050). La christianisation des peuples barbares. L'expérience insulaire. Christianisme et Empire carolingien. L'Église entre l'E

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We present the SVOM (Space-based multi-band astronomical Variable Objects Monitor) mission that the Chinese National Space Agency and the French Space Agency have decided to jointly implement. SVOM has been designed to detect all known types of gamma-ray bursts (GRBs), to provide fast and reliable GRB positions, to measure the broadband spectral shape and temporal properties of the GRB prompt emission, and to quickly identify the optical/near-infrared afterglows of detected GRBs, including high-redshift ones. Scheduled to be in orbit in the second half of the present decade, the SVOM satellite will carry a very innovative scientific payload combining for the first time a wide field X- and gamma-ray coded mask imager for GRB real-time localizations to few arcmin, a non-imaging gamma-ray monitor, and two narrow-field instruments for the study of the GRB early afterglow emission in the X-ray and visible bands. The SVOM payload is complemented by ground-based instruments including a wide-field camera to catch the GRB prompt emission in the visible band and two robotic telescopes to measure the photometric properties of the early afterglow. A particular attention is paid to the GRB follow-up in facilitating the observation of the SVOM detected GRB by the largest ground based telescopes., Comment: 13 pages, 3 figures. To appear in a special issue of Comptes Rendus Physique "GRB studies in the SVOM era", Eds. F. Daigne, G. Dubus

Background. Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. Methods. A retrospective multicenter study was conducted in 4 European surgical centers concerning, their experiment with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof Of the MBC (defined as being BDC with MBC involvement subgroup). Results. From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). Conclusion. BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

According to recent analyses of the type-Ia supernova rate as a function of redshift, delayed and prompt type-Ia supernovae (SN Ia) should explode respectively in the Galactic bulge and in the nuclear bulge, a gas rich structure with ongoing star formation, located in the central region of the Milky Way. We estimate the rate of type-Ia supernovae in the Galactic bulge and nuclear bulge. We show that this rate is insufficient by an order of magnitude to explain by positron escape from type-Ia supernovae envelopes alone the large positron injection rate into the Galactic central region, as re-observed recently by the Spectrometer on INTEGRAL, which amounts to 1.25 10^{43} e+ s^{-1} and would require 0.5 SN Ia explosions per century., Comment: 5 pages, 3 figures. Accepted for publication in ESA SP-622 (Proceedings of the 6th INTEGRAL Workshop, Moscow, 2006 07 03-07)

Aims. We report the INTEGRAL/IBIS observations of the Coma Cluster in the hard X-ray/soft-ray domain. Methods. Since the Coma Cluster appears as an extended source, its global intensity and significance cannot be directly extracted with standard coded mask analysis. We used the method of imaging the extended sources with a coded mask telescope developed by Renaud et al. (2006). Results. The imaging capabilities and the sensitivity of the IBIS/ISGRI coded mask instrument allows us to identify for the first time the site of the emission above ~ 15 keV. We have studied the Coma Cluster morphology in the 18-30keV band and found that it follows the prediction based on X-ray observations.We also bring constraints on the non-thermal mechanism contribution at higher energies., Comment: 4 pages, 4 figures, Accepted for publication in A&A Letters

The bulk of the extragalactic background between 10 keV and 10 GeV is likely to be explained by the emission of Seyfert galaxies, type Ia supernovae, and blazars. However, as revealed by the INTEGRAL satellite, the bulge of our galaxy is an intense source of a 511 keV gamma-ray line, indicating the production of a large number of positrons that annihilate. The origin of the latter is debated, and they could be produced, in particular, by the (S- or P-wave) annihilation of light Dark Matter particles into e+e-. In any case, the cumulated effect of similar sources at all redshifts could lead to a new background of hard X-ray and soft gamma-ray photons. On the basis of the hierarchical model of galaxy formation, we compute analytically the SNIa contribution to the background, and add it to Seyfert and blazars emission models. We find that any extra contribution to this unresolved background at 511 keV should be lower than about 4 keV/cm^2/s/sr. We also estimate analytically the extragalactic background due to Dark Matter annihilation, increasing the accuracy of the earlier computations. Indeed, we take into account the large positron escape fraction from low mass dark matter halos, unable to confine a dense and magnetized interstellar medium. Our new background estimate turns out to be one order of magnitude lower, so that the hypothesis of a light Dark Matter candidate remains compatible with the observed extragalactic background for a wider range of particle masses and cross-sections., Comment: 10 pages, 8 figures, 1 table, accepted for publication in Physical Review D, improved with 4 new figures, 1 new table and 1 new part

The Ibis/Isgri imager on Integral detected for the first time a hard X-ray source, IGR J17456-2901, located within 1' of Sgr A* over the energy range 20-100 keV. Here we present the results of a detailed analysis of ~7 Ms of Integral observations of the GC. With an effective exposure of 4.7 Ms we have obtained more stringent positional constraints on this HE source and constructed its spectrum in the range 20-400 keV. Furthermore, by combining the Isgri spectrum with the total X-ray spectrum corresponding to the same physical region around SgrA* from XMM data, and collected during part of the Integral observations, we constructed and present the first accurate wide band HE spectrum for the central arcmins of the Galaxy. Our complete analysis of the emission properties of IGR shows that it is faint but persistent with no variability above 3 sigma contrary to what was alluded to in our first paper. This result, in conjunction with the spectral characteristics of the X-ray emission from this region, suggests that the source is most likely not point-like but, rather, that it is a compact, yet diffuse, non-thermal emission region. The centroid of IGR is estimated to be R.A.=17h45m42.5, decl.=-28deg59'28'', offset by 1' from the radio position of Sgr A* and with a positional uncertainty of 1'. Its 20-400 keV luminosity at 8 kpc is L=5.4x10^35 erg/sec. Very recently, Hess detected of a source of ~TeV g-rays also located within 1' of Sgr A*. We present arguments in favor of an interpretation according to which the photons detected by Integral and Hess arise from the same compact region of diffuse emission near the central BH and that the supernova remnant Sgr A East could play an important role as a contributor of very HE g-rays to the overall spectrum from this region., Comment: 14 pages, 11 figures, Accepted for publication in ApJ

Local failure after prostatectomy can arise in patients with cancer extending beyond the capsule. We did a randomised controlled trial to compare radical prostatectomy followed by immediate external irradiation with prostatectomy alone for patients with positive surgical margin or pT3 prostate cancer., Clinical Trial, Clinical Trial, Phase III, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, N.I.H. Extramural, Research Support, Non-U.S. Gov't, Research Support, U.S. Gov't, P.H.S., SCOPUS: ar.j, info:eu-repo/semantics/published

INTEGRAL/SPI has recently observed a strong and extended emission resulting from electron-positron annihilation located in the Galactic center region, consistent with the Galactic bulge geometry, without any counterpart at high gamma-ray energies, nor in the 1809 keV $^{26}$Al decay line. In order to explain the rate of positron injection in the Galactic bulge, estimated to more than 10$^{43}$ s$^{-1}$, the most commonly considered positron injection sources are type Ia supernovae. However, SN Ia rate estimations show that those sources fall short to explain the observed positron production rate, raising a challenging question about the nature of the Galactic positron source. In this context, a possible source of Galactic positrons could be supernova events of a new type, as the recently observed SN2003dh/GRB030329, an exploding Wolf-Rayet star (type Ic supernova) associated with a hypernova/gamma-ray burst; the question about the rate of this kind of events remains open, but could be problematically low. In this paper, we explore the possibility of positron production and escape by such an event in the framework of an asymmetric model, in which a huge amount of $^{56}$Ni is ejected in a cone with a very high velocity; the ejected material becomes quickly transparent to positrons, which spread out in the interstellar medium., Comment: 8 pages, 2 figures. To appear in the Proceedings of the 5th INTEGRAL Workshop: "The INTEGRAL Universe", February 16-20, 2004, Munich, Germany

An intriguing feature of extra dimensions is the possible production of Kaluza--Klein gravitons by nucleon-nucleon bremsstrahlung in the course of core collapse of massive stars, as pointed out by Hannestad and Raffelt. In this event Kaluza--Klein gravitons are copiously produced and a significant fraction of them remains trapped around the newly born neutron stars. They slowly decay into 2 gamma rays, making neutron stars gamma-ray sources. In this letter, we strengthen considerably the limits on the radius of compactification of extra-dimensions for small number $n$ of them, or alternatively the fundamental scale of quantum gravity, considering the gamma-ray emission of the whole population of neutron stars sitting in the Galactic bulge, instead of the closest member of this category. For $n=1$ the constraint on the compactification radius is $R<400\mu$m, overlapping with the distance ($180\mu$m) at which Newtons law is directly measured. In addition, for n=1 and n=2, the fundamental energy scale of quantum gravity is far beyond the collider technology. These results imply that if $n\lesssim4$ and if strong gravity is around a TeV, the compactification topology is to be more complex than that of a torus., Comment: 4 pages, minor changes to text, matches published version

Background. The prognostic relevance of a Japanese-like lymphadenectomy for gastric adenocarcinoma in Caucasian patients is not well established. Methods. Skeletonizing en-bloc gastrectomy (SEBG) (including removal of the stomach, excision of the potentially involved lymph nodes, and skeletonization of the main anatomic structures in the upper abdominal floor) was attempted in 216 consecutive patients with adenocarcinoma of the stomach. Gastrectomy was total in 143 patients, and subtotal in 72. One debilitated patient had a wedge resection of the gastric wall. Results. SEBG was performed in 160 patients (74%), whereas 56 patients (26%) had a palliative gastrectomy (PG) without lymph node dissection. The feasibility rate of SEBG was influenced significantly (P < 0.001) by the depth of wall penetration, so that it dropped from 97% in T1 tumors to 91%, 65%, and 17% in those classified T2, T3, and T4, respectively. The 5-year survival rate, including postoperative mortality (0.9%) was 48% for the whole series, 66% after SEBG, and 0% after PG. The 5-year survival rate after SEBG was related significantly to the lymph node involvement (NO, 75% vs N+, 54%; P = 0.008) and to its magnitude (N+, <5 metastatic lymph nodes, 62% versus N+, ≥5 metastatic lymph nodes, 39%; P = 0.018). Considering the fact that 9 patients died of an unrelated cause before the postoperative term of 5 years, the cancer-related survival rate 5 years after SEBG was 71% in the whole group of 160 patients. This survival rate was 82% in patients with normal lymph nodes, versus 56% in those with metastatic nodes (P < 0.001). Conclusion. SEBG was feasible in three-quarters of a population of Caucasian patients operated on for gastric adenocarcinoma. SEBG provided a chance for a longterm favorable outcome in three-quarters of patients with normal lymph nodes and in more than half of those with metastatic lymph nodes. These results are similar to those achieved after radical gastrectomy in Japanese p

It has been recently proposed that the observed 511 keV emission from the Galactic bulge could be the product of very light (1-100 MeV) annihilating dark matter particles. Other possible explanations for this signal are associated with stellar objects, such as hypernovae. In order to distinguish between annihilating light dark matter scenario and more conventional astrophysical sources for the bulge emission, we here propose the study of dwarf spheroidals such as Sagittarius. These galaxies have typical luminosities of $10^5 L_\odot$ but mass-to-light ratios of $\sim 100$. As there are comparatively few stars, the prospects for 511 keV emission from standard astrophysical scenarios are minimal. The dwarf spheroidals do, however, contain copious amounts of dark matter. INTEGRAL/SPI has observed the Sagittarius region. Analysis of this data for 511 keV emission will provide a test of MeV dark matter which can distinguish between annihilating dark matter and more standard astrophysics. The observation of such a signal from Sagittarius should be a ``smoking gun'' for MeV dark matter., Comment: 4 pages, no figures. Version accepted by Physical Review Letters

We briefly review the fundamentals of nuclear gamma-ray line astronomy (radioactive astronomy), focusing on its role to decipher the intimate physics of supernovae, either immediatly (via $^{56}Co)$ or after a time delay (via $^{44}Ti$). All kinds of supernovae can be in principle tested through their radioactivities and their associated gamma-ray lines. Dedicated to the spectroscopy and imaging of celestial sources in the 15 keV to 10 MeV band, the ESA scientific observatory INTEGRAL will open a golden age of nuclear astrophysics in Europe, Comment: Invited review, "Cosmic Evolution", meeting in honor of the 60th birthday of Jean Audouze and Jim Truran, to be published by World Scientific, 6 pages, 1 figure

We present a broad overview of the principal processes and astrophysical sites of gamma-ray line production and review the main pre-INTEGRAL satellite observations to set the stage to the next European era of gamma-ray line astronomy., Comment: 5 pages, 0 figures, in "International Nuclear Physics Conference, Paris, August 1998, to be published Elsevier Edt

Collection : Que sais-je ? ; 3360, Contient une table des matières, Avec mode texte

Collection : Que sais-je ? ; 3262, Contient une table des matières, Avec mode texte

info:eu-repo/semantics/published

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited disease that affects about 1 in 8000 individuals. Patients with FAP typically develop hundreds to thousands of adenomas or adenomatous polyps during their second and third decades of life. Although these benign tumours are not individually life-threatening, their large number virtually guarantees that some will progress to invasive carcinomas. Additionally, FAP patients often carry congenital retinal lesions and later develop other extracolonic manifestations, including osteomas, desmoids tumours, cysts of the skin, brain tumours and some other, rarer neoplastic formations. Throughout our different studies, the purpose was the prevention of colorectal cancer in aptients with FAP. In Part I, we emphasised the importance of including the patients and their families in a national register. The principal aim of a polyposis register is to imrpov the prognosis of FAP through family tracing, and through appropriate information, education and counselling of familu memebers at risk. This has a beneficial effect on the incidence of established colorectal cancer at diagnosis of FAP. Moreover, a register will ensure a regular follow-up of patients after surgery. A secondary aim is to provide a database for research and for national or international collaborative studies. To date, surgery is still the only effective prophylactic treatment of FAP to prevent cancerous degeneration, but the choice of a surgical procedure is controversial. In Part II, we showed that ileal pouch-anal anastomosis (IPAA) with endoanal mucosectomy offers the best prevention by removing all the diseased epithelium. In order to avoid urinary and sexual dysfunction in the often young and healthy patients with FAP, we advocate a dissection close to the rectal wall when performing the protectomy, to avoid injury of the pelvic autonomic nerves. Compared to ileorectal anastomosis (IRA), IPAA is a rather complex, technicall, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

The thesis addresses two main questions of major clinical importance regarding the surgical treatment of esophageal cancer: 1. What is the potential of esophagectomy including extensive thoraco-abdominal lymph node clearance to provide oesophageal cancer patients with long-term survival and cure? 2. What are the qualities of the stomach as an esophageal substitute after total or subtotal esophagectomy regarding surgical feasibility, technical complications, and alimentary comfort? In the introduction, we reviewed the current knowledge according to the world literature concerning, vasculature, innervation and mobility of the stomach which is required for a clear understanding of the to issued presently studied. The review of a personal series of 306 esophagectomies performed for malignancy showed that resection of the esophagus en-bloc with the loco-regional lymph nodes was technically feasible in 213 patients (70%). Five-year survival rate after radical esophagectomy was 70% for the 104 patients having no lymph node involvement (T1-T2-T3-N0) and 31% for the 109 patients having metastatic lymph nodes. (T1, T2, T3, N1). Five-year survival rates improved with increasing experience on the procedures over the years. Comparison of results obtained form 1984 to 1988 with those from 1989 to 1997 showed that the 5-year survival rate increased form 63.6% to 75.5% for patients classified N0 and from 17.5% to 39% for those classified N1. Replacement of the esophagus with the stomach is governed by anatomical constraints in relation to the shape, vascularisation and innervation of the organ, the distance to bridge between the abdomen and the neck, and the need for complete lymphatic clearance of the lesser curvature. We have compared the classic technique of gastric tubulisation with stapling resection of the lesser curvature to a personal technique in which the lesser curvature of the whole stomach is denuded for the purpose of gastric lengthening and l, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

La transplantation hépatique est actuellement reconnue comme la thérapeutique de choix dans le traitement des enfants atteints de maladie hépatique irréversible. La survie est possible dans plus de 80% des cas. Ces résultats furent obtenus grâce aux incessantes améliorations apportées aux soins de ces enfants, qui commencent tôt après le diagnostic de l’affection et se poursuivent ensuite tout au long de la surveillance du patient. La période périopératoire bien qu’étant la plus courte est aussi celle qui s’accompagne des plus importants changements physiologiques. Cette thèse s’intéresse à certains de ces évènements et présente notre expérience dans leur approche. Les techniques anesthésiques et chirurgicales sont s’abord présentées et illustrées par les améliorations observées durant les 450 premières transplantations réalisées par notre équipe, ensuite, nous décrivons l’approche que nous avons adoptée dans le cas particulier de l’enfant cirrhotique et hypoxémique, et finalement, nous démontrons de nouvelles théories concernant les mécanismes responsables des modifications hémodynamiques du patient cirrhotique. Nous avons montré que grâce à la mise en place de nouvelles stratégies et au développement d’innovations dans les techniques chirurgicales, nous pouvions réduire considérablement les besoins transfusionnels de ces patients ainsi que la fréquence de décès peropératoires. Auparavant, vu le risque opératoire trop important, nous nous trouvions devant l’obligation de récuser les enfants souffrant d’hypoxémie secondaire à leur cirrhose hépatique. De plus, la physiopathologie de cette complication chez l’enfant était peu connue. Nous avons étudié celle-ci en utilisant la méthode des gaz inertes et avons pu ainsi montrer que cette hypoxémie était principalement due à d’importantes inégalités du rapport ventilation/perfusion causées très probablement par une vasodilatation exagérée des capillaires pulmonaires. Nous avons aussi démontré la réversibili, Liver transplantation is now widely recognized in the management of children with end-stage liver disease. Survival rates are in excess of 80%. This has been achieved by continuous improvements of the care provided throughout the whole procedure, starting very early after diagnosis and going on during all the follow-up of these patients. The perioperative period probably represents the shorter period of this challenge though it is undoubtedly accompanied by the greater physiological stresses. This thesis reviews some of the complications of pediatric liver transplantation and our experience in their management. We will first present the improvements in anesthetic management observed during the first 450 liver transplantations performed by our team. In the first part, we then describe our approach in the particular case of the hypoxemic and cirrhotic child and finally, in the second part, we give new insights on the mechanisms involved in the hemodynamic modifications induced by liver disease. We have shown that the development of new surgical techniques and appropriate intraoperative strategies enabled us to dramatically decrease the blood requirements and the intraoperative mortality. Because of its prohibitive perioperative risks, hypoxemia in children was until recently considered as contraindication for liver transplantation and the physiopathology of this complication was poorly understood. We studied it with the use of the multiple inert gas elimination technique (MIGET), and showed this hypoxemia to be due to a severe intrapulmonary ventilation/perfusion mismatch probably caused by intrapulmonary vascular dilatations. We demonstrated that theses modifications were fully reversible after liver transplantation, for which hypoxemia can therefore no longer be viewed as a contraindication. The pulmonary vasodilatation is part of the more general hyperdynamic circulation, which is a well-known complication of cirrhosis. Many vasodilators have been su, Thèse d'agrégation de l'enseignement supérieur (faculté de médecine) -- UCL, 1997

Organ transplantation and laparoscopic surgery are clearly the two most recent revolutions in actual surgical practice. Laparoscopic surgery really started in 1987, when Philippe MOURET performed the first laparoscopic cholecystectomy (LC) in France. The concept of laparoscopic surgery is to create o working space by insufflating an inert gas (CO2) within the peritoneal cavity. The surgical procedure is performed though a variable number of “key-holes” by using special introduction tubes (trocars) and instruments. The operation is assessed on a video-screen via a camera connected to a rigid fiberoptic (the laparoscope). This procedure is performed on a “closed abdomen” in comparison to open surgery through a laparotomy, and for this reason has at times been called “Nintendo surgery”. Several advantages have been advocated, such as reduced postoperative pain and pulmonary dysfunction, lower stress response to surgery, shorter postoperative hospital stay, earlier return to normal activities and esthetic benefit (3-5). Based on the suggestion than laparoscopic surgery is “minimally-invasive surgery”, LC had a rapid wide spread diffusion among general surgeons all over the world and the approach has been applied to an increasing number of pathologies. According to MEDLINE, 256 publications were dedicated to laparoscopic surgery in 1990. This number rose to 1,064 in 1992, 1,954 in 1994, and 1,415 from January to November 1996n thereby confirming the exposure enthusiasm for the techniques. Almost all types of gastro-intestinal operations have been performed laparoscopically : appendectomy, inguinal hernia repair, antireflux procedures, cardiomyotomy for esophageal achalasia, vagotomies, Billroth II gastrectomy, gastroenterostomy, esophagectomy, treatment of perforated peptic ulcer and small bowel obstruction, gastroplasty for morbid obesity, all types of colorectal resections, small bowel resection for Crohn’s disease … etc. In urology, nephrectomy, adrenalectom, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

Laparoscopic splenectomy has become an attractive treatment for patients with selected hematologic disorders. Almost 200 observations have been reported. The rate of conversion to laparotomy is 10% to 15%, and the complication rate is between 0% and 30%. Adequate selection of patients, preoperative administration of intravenous immunoglobulin in patients with idiopathic thrombocytopenic purpura, meticulous surgical techniques, and careful preoperative and intraoperative search for accessory spleen are critical factors for success in these patients. The procedure should be confined to expert laparoscopic surgeons with considerable experience in the management of hematologic diseases.

A Heller-Dor procedure was performed by laparotomy (group A: n = 8) or by laparoscopy (group B: n = 12) after failure of one to 17 sessions of intraluminal dilatations (n = 13) or as a primary treatment of oesophageal achalasia (n = 7). The oesophagomyotomy was extended over the thoracic oesophagus by thoracoscopy in two patients having vigorous achalasia. Injury to the oesophageal mucosa occurred in two group A patients who had previously been dilated. At follow-up (range: 1 to 113 months), 6 patients of group A (75%) and 10 of group B (83.3%) had no residual dysphagia. The four patients (group A : n = 2; group B : n = 2) who complained of heartburn prior to the operation were asymptomatic, only one group A patient developed symptoms of reflux, and oesophageal pi-I-monitoring was normal in the 6 group B patients investigated at follow-up. The laparoscopic approach reduces the magnitude of the operation, and the magnified overview permits precise dissection of the intraparietal adhesions which may develop after numerous sessions of dilatation.

Transplantation of a vascularized allograft in a host leads to acute rejection of the graft and elimination of the foreign antigen. This rejection process can be avoided by inhibition of the immune response. There are different ways in which one can overcome the immune response to an allotransplant: matching, nonspecific immunosuppression and specific transplantation tolerance. The matching is based on the fact that allotransplants are rejected because the recipient’s immune system recognizes on donor cells histocompatible antigens that are different from his own. If there are no such disparate antigens, such as in identical twins, then no rejection response occurs. The most important histocompatibility antigens are those of the Major Histocompatibility Complex (MHC); known in human beings as the Human Leukocyte Antigen (HLA) system. However, there are numerous other antigens capable of causing rejection, termed minor histocompatibility antigens. Matching to avoid or eliminate the immune response in conceivable in kidney or bone marrow transplants, since the time necessary to carry out tissue typing is available. Matching, however, is unrealistic in case of liver, heart or lung transplants, since the admissible ischemia time does not allow the achievement of tissue typing. The use of nonspecific immunosuppressive drugs represents the most practical means to avoid rejection. This therapy is accountable for the enormous success in the field of transplantation over the past three decades. Such a drug regimen, however, can produce major complications during the early as well as long-term follow-up such as infections, malignancies or drug-induced side-effects. Long term, the immunosuppressive regimen therefore may directly cause loss of patients ad cannot prevent chronic rejection, which is the second major cause of graft loss. Therefore, induction of specific transplantation tolerance still represents a major goal of modern transplantation immunology. Specific, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1995

Objective: Our goal was to assess the state of the portal vein in cirrhotic patients treated with a portacaval shunt associated with an arterialization of the portal vein. Materials and Methods: We reviewed the follow-up CT of 23 patients treated by portacaval shunt with arterialization of the portal vein. Results: Five patients demonstrated an aneurysm of the portal vein. Followup Studies revealed progression of the aneurysm and development of a mural thrombosis in four patients. The thrombosed portal vein was calcified in three patients. One patient demonstrated a dilatation of the saphenous vein graft in addition to the portal vein aneurysm. Only one of the five patients was symptomatic, presenting with ascites, dilatation of intrahepatic biliary ducts, and jaundice secondary to the compression of hilar structures by the huge portal vein. Conclusion: Aneurysm of the portal vein following portacaval shunt associated with arterialization of the portal vein is not a rare complication.

Two uncommon complications of en bloc resection of the oesophagus for cancer are reported: paraplegia, probably related to division of the right intercostal arteries at the thoraco-abdominal junction, and abundant weeping of lymphatic fluid originating from the retropancreatic area due to both the resection of the thoracic duct and a Kocher's manoeuvre that had been performed to facilitate gastric pull-up to the neck. The former strongly suggests that both right and left intercostal arteries should be maintained when performing an en bloc resection of the oesophagus and the latter that Kocher's manoeuvre should be avoided after ligation or resection of the thoracic duct whenever abundant retroperitoneal oedema is present at the time of the laparotomy made for the gastric mobilization.

SCOPUS: ar.j, info:eu-repo/semantics/published

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Contient une table des matières, Avec mode texte

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