Œdème pulmonaire deux jours après une césarienne réglée

Two days after an elective Caesarean section, a 30-year-old woman suffered a pulmonary oedema. The diagnosis of cardiomyopathy was obtained with echocardiography, right heart catheterization and a myocardial biopsy. Peripartum cardiomyopathy is defined as a heart failure occurring in the last trimester of pregnancy or up to the third postpartum month and the lack of another etiology. The cause of myocarditis resulting in peripartum cardiomyopathy remains yet unknown. An immunosuppressive therapy can be associated with the treatment of the congestive heart failure.     

Œdème pulmonaire aigu grave après laryngospasme peranesthésique chez un nouveau-né

The authors report a case of severe acute pulmonary oedema secondary to a laryngeal spasm in a 3-week-old neonate, immediately after induction of anaesthesia with halothane. After emergency tracheal intubation, the infant experienced a severe, life-threatening pulmonary oedema requiring prolonged intensive care. Such a secondary time course is unusual. Usually pulmonary oedema has a favourable outcome after oxygen administration and maintenance of positive expiration pressure, except in the neonate.     

Montages chirurgicaux après exérèse totale du mésorectum pour cancer

Total mesorectal excision is one of the most important points in the surgical treatment of rectal cancer. Differents assemblies after surgical total mesorectal excision are described.     

Œdème aigu du poumon cardiogénique postopératoire après chimiothérapie par doxorubicine (adriamycine)

We describe a case of postoperative congestive heart failure in a young woman of physical class ASA 1, following breast cancer surgery. Preoperatively she had been treated with doxorubicin (Adriamycin^®) 450 mg·m⁻², total dose, associated with breast and ovarian radiotherapy. This association was probably the cause of postoperative heart failure. Twenty-four hours after surgery, a two-dimensional echocardiography showed a severe left ventricular dysfunction, whereas preoperative clinical assessment was unremarkable. Doxorubicin cardiotoxicity can be acute, subacute and delayed as in our case. Clinical assessment and ECG are not sensitive indicators of such cardiac damage. Preoperative echography is the technique of choice for the evaluation of the cardiac status of a patient treated with a high cumulative dose of doxorubicin and mediastinal irradiation.     

Les fractures du fémur de type II après prothèse de hanche

Ninety-seven patients type II were in this study. There were 35 male and 53 female patient, whose average age at revision was 74,5 year old. In this group the average time to fracture after arthroplasty was 6,2 (1–20) years. The fracture was spiral in most cases (82%), but some there were transverse (18%). Loosening of the prosthesis often occured with the transverse fracture (p=0,001). Loosening occured in 30% cases before the femoral fracture : it was rarely a major, but its duration was unknown. Three different methods of treatment were used in this study:

1. conservative treatment was used rarely, where there was a surgical risk in incomplete or undisplaced fracture. Treatment with traction involved a prolonged stay in hospital (two months average).
2. internal fixation without removal of the prosthesis was used in 44% cases. Fixation with plates in 93%. Other devices were screw and cerclage wire fixation.
3. 47,5% cases were revised with a long stem cemented prosthesis.

The most difficult was type II fracture associated with femoral loosening. The location of type II fracture may compromise the stability of prosthesis. Although there was 41% of cases whose prosthesis was not loose before fracture. In these cases, type II fracture has not compromised the stability of prosthesis: the spiral line could shape peri prosthetic mantle of cement. Healing of the fracture was obtained in most cases (97%). Thus, protetic loosening created by type II fracture has not prevented consolidation: these two events are statistically independant. The present retrospective study supports the employement of different treatment. Based on these findings, the following management of type II fracture could be recommended:

1. undisplaced or incomplete fracture in high risk patients, should be treated conservatively. If loosening of the prosthesis develops, revision of the arthroplasty can be done after fracture healing.
2. internal fixation without revision of the prosthesis should be employed if the prosthetic stem stability is not compromised.
3. revision of the arthroplasty should be done if loosening of the prosthesis developped before or during the type II fracture occured. Then, a long stem should be employed.

     

Conduite à tenir après résection endoscopique d’un polype dégénéré

Following endoscopic complete resection of a cancerous polyp, there is no surgical indication in case of intramucosal cancer. In the situation of sub-mucosal infiltrating cancer, 5 major histologic criteria are in favour of complementary surgery, whenever the patient’s status allows this option: the presence of lymphatic or vascular invasion, a grade III histology, sub-mucosal invasion > 1000 μM, and the absence of an at least 1 mm clear margin. The presence of budding (undifferentiated or aggressive tumor cell foci at the tumor margin) is a new criteria needing further validation. In the absence of these negative criteria, the endoscopic treatment can be considered as satisfying on a carcinologic point of view, knowing the very low risk of residual disease to be balanced with the surgical risk. Rectal cancers invading the submucosa could be at higher risk of recurrence than colon cancers.     

Place de la transplantectomie après échec de greffe rénale

The number of kidney-transplant patients that return to dialysis therapy after a failed kidney allograft is increasing sharply. These patients differ from patients treated with chronic dialysis, but who have never received a transplant; i.e., former transplanted patients display a higher risk of morbidity–mortality, particularly from cardiovascular and infectious complications. The management of immunosuppression has not been codified for patients with a failed kidney allograft: immunosuppressive therapy can be either abruptly stopped or progressively reduced. In addition, nephrectomy of the failed allograft is debatable. Some advocate this procedure only when there is intolerance, e.g., gross hematuria, local pain, or unexplained inflammatory syndrome. In contrast, others propose a systematic nephrectomy, mainly to reveal anti-HLA antibodies within peripheral blood that may have been adsorbed within the failed allograft, and are not detected, even using sensitive techniques. Prospective studies are warranted to answer these issues.     

Succès du traitement par paclitaxel d’une rechute viscérale d’un sarcome de Kaposi après transplantation rénale

We report the observation of a patient who presented with post-transplant Kaposi's sarcoma after a delay of eight months with a dual cutaneous and palatal localisation. The reduction in immunosuppressive treatment and the introduction of Rapamune® allowed good clinical progress initially with regression of the skin lesions. He subsequently presented later a skin relapse with visceral localisation. Chemotherapy was conducted based on weekly paclitaxel infusions allowing partial remission and maintenance of renal graft function with good clinical tolerance.     

Les récidives tardives de la maladie de Wegener. À propos d’un cas après 20 ans de rémission

Immunosuppressive drugs have transformed the prognosis of systemic Wegener’s granulomatosis. Nowadays, the main residual problem is illness relapses, for which management is largely undefined. We describe the case of a patient, aged 47 in 1977. The diagnosis of Wegener’s granulomatosis was made when faced with polyarthralgias, cutaneous vasculitis, rhinitis, dyspnea, hemoptysis and global decline of her physical condition. The treatment associated high-dose corticotherapy and intramuscular cyclophosphamide for one year. This treatment led to a complete remission. Twenty years later, the patient was hospitalized for reoccurrence of rhinitis, dyspnea and right knee effusion associated with biological inflammatory syndrome, renal insufficiency and antibodies against polymorphonuclear neutrophil cytoplasm, type c-ANCA. Chest CT-scan disclosed parenchymal infiltrates. Wegener relapse was diagnosed and the combination of three methylprednisolone perfusions followed by oral prednisone (1 mg/kg/d) and a monthly bolus of cyclophosphamide led to a new remission. Nevertheless, 4 months after beginning the treatment the patient died from an infectious complication (Pneumocystis carinii and aspergillosis). Relapses of Wegener’s granulomatosis are frequent and difficult to predict. Moreover, some cases occur very lately. The remarkable efficiency of cyclophosphamide to induce remission is however shaded by the high rate of relaps. Other drugs are studied to identify more efficient therapy, able to both induce remission and prevent relapses, but reliable data are still missing to determine the best therapeutic regimen.     

Modes d'utilisation d'une échelle de qualité de vie personnalisée dans une étude longitudinale chez des patients opérés d'une prothèse totale de hanche

Quality of life scales are being increasingly used to evaluate patients. The earliest scales were standardized questionnaire that did not necessarily provide an optimal evaluation of the quality of life of each individual patient. A number of personalized scales are now available, including the SEIQoL, in which the patients nominate the five quality of life areas most important to them. The SEIQoL has been validated. We tested the SEIQoL in patients treated by total hip arthroplasty, a procedure that is expected to improve quality of life. Objective. To compare two methods of administration of the SEIQoL several months after total hip arthroplasty. Methods. The SEIQoL was administered before and after the arthroplasty. During the postoperative test session, the SEIQoL was administered twice, once using the items nominated preoperatively and once after allowing the patient to repeat the nomination procedure. Results. With both methods, significant improvements in quality of life were demonstrated (P < 0.05). There was no significant difference between the two methods. Conclusion. Changing the items of the SEIQoL during prospective studies does not modify the overall quality of life score. Keeping the same items throughout the study is nevertheless warranted.