101. Gastrectomie de nécessité

Zusammenfassung Nach dem Prinzip gastrectomie de nécessité wird der Magen nur dann vollständig entfernt, wenn der Abstand des Tumors zum oesophago-gastralen Übergang keine sichere Resektion im Gesunden erlaubt. Für dieses Prinzip spricht, dass eine grössere Patientengruppe (ca. 20%) von den Vorteilen einer Teilresektion -sie betreffen v. a. den Ernährungszustand und somit Lebensqualität und körpereigene Tumorabwehr - profitieren kann. Gegen dieses Prinzip spricht, dass beim Vorliegen eines diffusen Carcinoms die Gefahr eines lokalen intragastralen Rezidivs erhöht ist.     

Tumeurs malignes de l'ampoule de Vater. Résultats de l'exérèse radicale. Étude de 39 cas

Study aimFrom 1971 to 1995, 39 patients underwent curative resection of a malignant tumor of the ampulla of Vater. The aim of this retrospective study was to report long-term results and to determine factors influencing survival in these patients.Patients and methodsData was collected from patient record analysis, correspondence with patients, their family or general physician. Kaplan-Meier method was used to compare survival data by the log-rank test. Multivariate analysis evaluated the impact of each variable on survival. Values with a P value of 0.05 or less were considered statistically significant.ResultsResection consisted of pylorus preserving pancreaticoduodenectomy (n = 21) or pancreatico-duodenectomy associated with an antrectomy (n = 18). Overall mortality rate after resection was 10% (n = 4). General and specific morbidity rates were 71% and 2.5%. During the course of the follow-up (completeness: 100%) mean survival was 80 months (median: 37 months, range: 6–227 months). Five-year survival rate was 35%. Factors favorably influencing long-term outcome were exposed protruding and well differentiated tumors (P = 0.03, P = 0.01, respectively) and negative lymph node status (P = 0.0001). Prognosis was poorer if tumor was extended into the pancreas (P= 0.04). Among proposed histoprognostic classifications (classifications of Martin, Talbot, Shiraï, Yamaguchi), an excellent correlation was obtained only with TNM classification (P = 0.0001).ConclusionResults of the present study suggest that prolonged survival can be obtained following radical resection of a malignant tumor of the ampulla of Vater, especially for exposed protruding and well differentiated tumors, without extension into the pancreas or lymph node metastasis. TNM classification provides an excellent predictive value and should be used more systematically.     

Douleur postopératoire. Spécificités de l'enfant de moins de 5 ans,néonatologie exclue

For many years, postoperative pain has been undertreated in children less than 5 years old in comparison to adults. The assessment of pain is indeed difficult in this range of age, and only the scales of hetero-evaluation are used. The guidelines for treatment are similar as in adults: systematic administration, balanced analgesia, evaluation of pain and potential adverse effects. Non opioid analgesics used are mainly paracetamol, niflumic acid and ibuprofen. Morphine remains the drug of choice among opioids; however the risk of respiratory depression in higher in infants less than 3 months old. Nalbuphine is also widely used in paediatrics. In addition, regional anaesthesia, either in single shot for minor surgery, or in continuous administration through epidural catheter for major surgery, has changed the management of postoperative pain in paediatrics.     

Tumeur de Klatskin. Étude de 15 cas réséqués

Study aimKlatskin tumors are rare. Prognosis is still poor, and long term survival can be expected only after surgery, which is the treatment of choice. The aim of this study is to report the results of 15 resected cases and, by analysis of the literature, to emphasize the progress of the surgical treatment in hilar cholangiocarcinoma.Patients and methodsBetween 1990 and 1998, 27 patients affected by Klatskin tumor were observed. Eight women and seven men underwent surgical resection. The mean age was 59 years. Thirteen patients (48%) had curative resection (7 hilar resection (HR), 5 HR combined with partial hepatectomy (PH) and 1 HR+PH with portal vein resection). Two patients had palliative resection and surgical drainage.ResultsOne in-hospital death occurred right after hepatectomy with portal vein resection (6.6%). Postoperative morbidity was 40%. Patients were regularly followed. Ten patients died and 5 were alive at the time of this study. The 1, 2 and 3-year survival after a curative resection was 84%, 54% and 34%. The median survival was 28.5 months. Lymph node involvement did not show a statistically significant difference on median survival between the positive group and the negative group (26.2 vs 29.8 months) because of the small number of patients. Survival after hilar resection at 1, 2, 3, and 5 years was 100%, 57.1%, 28.6% and 0%. Four out of the 6 patients who underwent hilar resection combined with partial hepatectomy were still alive 1, 23, 29, 38 months after resection. Hepatectomy increased mortality (16% vs 0%). Palliative biliary resection and surgical drainage were successfully performed in 2 patients.ConclusionAggressive surgical treatment of Klatskin tumor can improve the survival of patients. Careful preoperative management has to be carried out by a multidisciplinary approach including surgeons, hepatologists, radiologists and pathologists. Hepatic resection including the caudate lobe is often performed in order to obtain microscopic tumor-free margins and curative resection (R0). Biliary drainage and treatment of cholangitis is mandatory before surgery in order to improve the surgical outcome. Surgical treatment is characterized by high technical difficulties, and better results can be achieved by hepatobiliary surgical teams.     

Ostéoporose fracturaire révélatrice du syndrome de Cushing. Deux observations. Revue de la littérature

Osteoporotic fractures at presentation of Cushing's disease. Two case reports and a literature review. Osteoporosis is a common complication of Cushing's disease/syndrome. Fractures can be the presenting manifestation. We report two cases and review 28 others from the literature. Clinical, laboratory, and absorptiometry data are reviewed; the vertebras and ribs were the most common fracture sites, and osteoporosis reversal after treatment varied with age, gender, and symptom duration. The pathophysiology, which remains controversial, is discussed. A search for Cushing's disease/syndrome should be part of the routine evaluation of osteoporosis in children and adults, particularly men.     

Propositions de réflexion à partir de l’article de Cyril Desjeux sur les modalités de coopération entre personnes valides et handicapées. Commentaire.

In this short article, we provide a commentary on Cyril Desjeux’ article (“Care” made for disabled persons: What are the ethical and power issues?). We return here to several questions raised by his article. The first concerns the various ways of qualifying an act as “help”, “care” or “cure”, the tensions that can result from this process, and the issues raised by these qualifications for the actors. In particular, we insist on the relationship between this process of qualification and professional issues, as it can challenge the boundary between medical and non-medical professions. Secondly, we situate the debates addressed by Cyril Desjeux in recent developments concerning the status of sick and disabled people, the promotion of their autonomy and their participation in decisions that concern them. We draw the reader's attention to the unexpected and potential negative effects of the willingness to involve disabled people, when this will turns into a normative directive. Finally, we emphasize the originality of Cyril Desjeux’ article in Alter journal. It presents “research-in-action” that goes beyond the strict academic framework.     

Chirurgie vidéopariétoscopique de la paroi abdominale. Étude de 15 cas

AimThe aim of videoparietoscopic surgery is to repair an abdominal wall weakness or defect without affecting the overlying skin, mainly for cosmetic reasons, and especially in young women.Patients and methodA supra-pubic or umbilical approach was used, depending on the site of the lesion to be repaired. A 10 mm trocar with a sponge mandrin was placed in contact with the aponeurosis. After an initial dissociation of the cellular tissue, progressive insufflation with CO₂ produced extensive detachment of the cutaneous plane upwards and laterally. Using one or two 5 mm trocars, the aponeurotic plane was progressively freed and the pathological zones were identified and repaired with standard endoparietal sutures or with percutaneous sutures using a Reverdin needle.Fifteen patients (14 females, one male) with a mean age of 30 years (19–36), were treated by parietoscopy for a diastasis of the reclus abdominis (five cases), an eventration (three cases) or an epigastric or linea alba hernia (seven cases).ResultsA conversion to a classical technique was necessary in one man with a diastasis of the rectus abdominis, due to fibrous tissue which did not allow a subcutaneous plane of detachment to be obtained. Successful repair was possible in 14 cases. The mean operating time was 1 h 20 min; the mean duration of hospitalisation was 2 days (1–3). There was no mortality or morbidity. With a mean 18-month follow-up (range: 4–40), cosmetic and functional results were excellent.ConclusionAbdominal videoparietoscopy allows repair of minor parietal pathologies while preserving the overlying skin. It is indicated for cosmetic reasons in young women with normal skin overlying a localised abdominal wall defect or weakness.     

Angiomyolipome Rénal et Sclérose Tubéreuse de Bourneville: Revue de la Littérature à Propos de Deux Cas.

Objectif  

La sclérose tubéreuse de Bourneville est une affection héréditaire caractérisée par le développement de tumeurs bénignes à type d’hamartomes au niveau de la peau, du rein, du cou, du cerveau et de l’oeil. Le but de rapporter nos deux observations est de rappeler les différentes caractéristiques de cette pathologie.     

Thromboses veineuses mésentériques. Facteurs de risque,traitement et évolution. Analyse de 18 observations

Eighteen patients with an acute thrombosis of the splanchnic veins were reviewed. Most of apparently idiopathic cases of splanchnic vein thrombosis are related to an increased coagulation related to a congenital or acquired defect of haemostasis. The aim of this study was to assess the effects of a new and effective treatment. Nine male and 9 female patients (range of age : 19 to 81 years) experienced a mesenteric venous thrombosis. There were 14 mesenteric vein thromboses with infarction, two transient mesenteric venous ischaemias without bowel infarction and two acute thromboses of the splanchinc veins without bowel ischaemia. A coagulopathy was detected in seven patients : oral contraception, protein C (PC) or antithrombin III (AT III) congenital deficiencies, acquired deficiency of AT III, PC and protein S (PS), polycythaemia in the post-partum period and primary myeloproliferative disorder. No coagulopathy was associated with thrombosis in eight cases : mesenteric haematoma, splenomegaly, cirrhosis, appendicectomy, cholescytectomy, chronic heart failure, treatment with beta-adrenergic receptor antagonist and digitalis, stenosis of the portal anastomosis after liver transplantation. Twelve patients required surgery : eight intestinal bowel resections with immediate anastomosis, four resections without immediate anatomosis. Only one patient underwent a second look for a repeat bowel resection. No death occurred in the early postoperative period and 17 out of 18 patients were alive after 12 years. An oral anticoagulant therapy was undertaken from two months to seven years. However, three patients suffered a recurrent thrombosis. Two of them required a long-term anticoagulation. Six patients experienced a portal hypertension and oral anticoagulants were discontinued in three of them because of bleeding oesophageal varices. Six patients were treated only by unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by oral anticoagulants. After laparotomy, two were only treated with UFH without any bowel resection, as mesenteric venous ischaemia was too extensive. These observations suggest that the choice between an appropriate medical or surgical treatment is important and must be discussed. Since 1989, the therapeutic choice has been modified by ultrasonography and contrast enhanced computed tomographic scan which confirmes diagnosis, allows to follow up and check the effects of anticoagulation and to choose the time for surgery. When the diagnosis is established and the patient's risk is low, the anticoagulant therapy is decided. UFH is administered by continuous infusion at the average dose of 500 IU · kg⁻¹ · d⁻¹ to obtain an antifactor Xa activity between 0.3 and 0.6 antiXa IU mL⁻¹. When the diagnosis is uncertain and the patient's risk is high, a laparotomy is required. During surgery, UFH must be delivered at a low dose of 100–150 IU · kg⁻¹ · d⁻¹ and progressively increased to obtain the same antifactor Xa activity in two three days. Congenital or acquired AT III or PC deficiencies should be treated by appropriate concentrates. Duration of treatment with oral anticoagulants is not determined and has to be discussed. A 6-month therapy with an INR of 2.0 to 3.0 seems to be reasonable when no coagulopathy is associated with splanchnic venous thrombosis. A long term anticoagulation must be discussed when a coagulopathy is associated with a splanchnic venous thrombosis.     

Données cliniques et E. E. G. de l'introduction d'Amytal sodium dans la circulation encéphalique,concernant l'état de conscience

Résumé On a étudié, en tenant compte exclusivement des modifications de l'état de la conscience et du contrôle EEG, l'action de l'A. S. sur le S. N. C. par l'introduction intracarotidienne (uni- et bilatérale) et vertébrale chez l'homme. Seulement avec injection bilatérale d'A. S. dans la carotide on a pu constater une abolition complète de la conscience, tandis que l'injection unilatérale dans la carotide donnait lieu seulement à une modeste réduction de la vigilance et qu'aucun trouble de la conscience ne pouvait être observé avec injection intravertébrale.Ces résultats semblent confirmer les données cliniques et expérimentales de la littérature à ce sujet, soulignant en outre l'importance de l'intégrité du cortex cérébral au moins d'un côté pour le maintien de la conscience.L'absence de troubles de la conscience après injection d'Amytal dans l'A. vertébrale est discutée à la lumière des conceptions de la neurophysiologie actuelle.

---

Summary The action of sodium amytal on the central nervous system in man when injected into the carotid arteries (unilaterally and bilaterally), or into the vertebral artery, has been studied. The effects of the sodium amytal were judged entirely by changes in the state of consciousness combined with EEG control. After bilateral intracarotid injection of sodium amytal one could observe loss of consciousness; unilateral intracarotid injection gave rise merely to slight diminution of alertness; whilst after intravertebral injection there was no observable change in the level of consciousness.These results seem to confirm the clinical and experimental facts in the literature of this subject; moreover they underline the importance of the integrity of the cerebral cortex at least as one feature essential for the maintenance of the conscious state.The lack of disturbance of consciousness after the intravertebral injection of amytal is discussed in the light of current neurophysiological concepts.

---

Zusammenfassung Die Autoren berichten über die Wirkungen von Amytal sodium auf das Zentralnervensystem des Menschen, nach ein- und doppelseitiger Injektion in die Carotiden und die A. vertebralis. Dabei wurden ausschließlich die Veränderungen der Bewußtseinslage und des EEG's analysiert.Nur wenn Amytal sodium doppelseitig in die Carotiden injiziert wird, kann man einen völligen Bewußtseinsverlust feststellen; die einseitige Injektion in eine Carotis bewirkt nur eine mäßige Minderung der Reaktionsbereitschaft (vigilance); und nach Injektion in die A. vertebralis tritt überhaupt keine Störung des Bewußtseins auf.Diese Ergebnisse scheinen diejenigen klinischen und experimentellen Berichte des Schrifttums zu bestätigen, welche die Bedeutung des Intaktseins der Hirnrinde zumindest einer Seite für das Erhaltenbleiben des Bewußtseins unterstreichen.Das Fehlen von Bewußtseinsstörungen nach Injektion von Amytal in die A. vertebralis wird im Zusammenhang mit den derzeitigen neurophysiologischen Vorstellungen diskutiert.

---

Resumen En el hombre han sido estudiados, teniendo en cuenta exclusivamente las modificaciones del estado de conciencia y con control EEG, la acción del Amytal sódico sobre el sistema nervioso central inyectado intracarotideamente (uni- y bilateralmente) y vertebralmente. Solamente con la inyección bilateral de Amytal sódico en las carótidas pudo constatarse la abolición completa de la conciencia, mientras que la inyección unilateral de la carótida solo daba lugar a una modesta reducción del estado vigil y que ningún trastorno de la conciencia pudo ser observado con la inyección intravertebral.Estos resultados parecen confirmar los hallazgos clinicos y experimentales de la literatura sobre este tema, subrayando por otra parte la importancia de la integridad de la corteza cerebral, al menos de un lado, para el mantenimiento de la conciencia,La ausencia de trastornos de la conciencia después de la inyección de Amytal en la arteria vertebral se discute basandose en las nuevas concepciones neurofisiológicas actuales.

---

Riassunto È stata studiata l'azione sul S. N. C. dell'Amytal Sodium somministrato per via intracarotidea (uni- e bilaterale) e vertebrale nell'uomo, tenendo conto esclusivamente delle modificazioni dello stato di coscienza e sotto controllo EEG. Soltanto con l'iniezione bilaterale d'A. S. nella carotide si è potuto constatare una abolizione completa della coscienza mentre l'iniezione unilaterale nella carotide ha dato luogo solo ad una modesta riduzione della vigilanza. Nessuna modificazione dello stato di conscienza è stata osservata con l'iniezione intravertebrale.I risultati sembrano confermare i dati clinici e sperimentali della letteratura sull'argomento, evidenziando inoltre l'importanza dell'integrità della corteccia cerebrale, per lo meno di un emisfero, per il mantenimento della coscienza.L'assenza di alterazioni della coscienza dopo l'iniezione d'A. S. nell'arteria vertebrale viene discussa al lume dei concetti neurofisiologici correnti.

     

Administration continue de médicaments au pousse-seringue. Présentation d'un logiciel de calcul posologique

Intensive therapy includes continuous delivery of drugs with infusion pump. This article describes an infusion rate computing programme using a Macintosh micro-computer and the Hyper-Card® 2 software. The latter permits the classification of data onto cards collected in stacks. The card that is displayed when the programme is launched shows fifteen buttons assigned to various drugs. Click upon a button opens the corresponding card which displays the presentation of the drug and suggests a dilution. The next step associates input of patient's weight into the appropriate field and a click on the main button. A display then indicates for various standard dosages, the corresponding rate of infusion in mL · h⁻¹ and the daily consumption of the drug. In order to avoid causal or voluntary changes of the setting, soft securities have been inserted in the programme.     

Arthrose pisi-pyramidale. À propos de 13 cas et révision de la littérature

Piso-triquetral osteoarthritis (OA) is an infrequent cause of ulnar wrist compartment pain. Specific clinical manoeuvres may help for diagnosis. If this aetiology is suspected, a 30° oblique wrist X-ray in supination and sometimes a CT scan with transverse cuts should be performed demonstrating a joint narrowing and osteophytes formation. The FCU-pisiform biomechanical unit transfers the wrist flexion forces. A series of 13 cases of piso-triquetral OA is presented in 12 patients (six females and six men) treated between 1990 and 1997. Mean age was 52,7 year. Pain at resisted motion in flexion and ulnar deviation and strength decrease was always present at clinical examination. Subperiosteal pisiform excision has been constantly performed. Continuity of FCU insertions and its distal ligamentous extensions has been preserved. Mean F-up was 18,1 months (3–57). Pain has disappeared in seven cases and significantly decreased in five. NSD was present in one case. Range of motion and strength was normal in all cases. Ulnar nerve paresthesias has always disappeared. The pisiform bone is not a sesamoid: a true joint with the triquetrum exists.From the phylogenetic point of view, three theories have been proposed: (a) in some species, pisiform is fused with adjacent bones or metacarpals; (b) pisiform is a remnant of a polydactyly hand; (c) pisiform is a remnant of the carpal central row.     

Pseudarthrose congénitale de l’avant-bras. À propos de deux cas et revue de la littérature

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.     

Étude thérapeutique prospective randomisée des entorses latérale de la cheville. Apport de l’échographie

In case of a lateral sprain of the ankle, the clinician has to estimate its gravity and to propose the most adapted treatment. The contribution of the ultrasounds in our series determines the type and the number of worn-out bundles. It also informs about the articular effusion and so contributes to the diagnosis of less frequent hurts involving the lower tibio-fibular joint, the medio-tarsal joint, the sinus tarsi.The purpose of this prospective and randomized work is to compare at three months the clinical result of the functional treatment alone versus orthopaedic treatment associated to a functional treatment. An echography is practiced in the middle and at the end of processing to check the ligamentary healing of the ligaments.In the third month, no recurrence was reported. It was not highlighted by significant difference as regards: the pain in the initial site or somewhere else, the anterolateral sensibility, the subjective instability, the sensation of disturbance, and the insecurity in the running. An objective instability was not found in our series.We suggest for any severe lateral ankle sprain to confirm the lesional balance sheet by an ultrasound, which according to the hurts ligament isolated or associated to prescribe the type of fixed immobilization, the duration of the treatment, to individualize the reeducation and to plan the incapacity. The followed by the ligament healing and by the lesional recovery is assured by repetitive ultrasounds