Pancréatectomies sous laparoscopie : une série de 22 patients

Introduction. - Laparoscopic pancreatic surgery underwent many changes in the last few years. Current indications include staging laparoscopy for pancreatic neoplasms, palliative treatment of non-resectable tumors, and pseudocysts drainage. Pancreatic tail resection or pancreatic enucleation have also been reported, but are currently under investigation. We report our experience in this domain.Material and methods. - Retrospective study of patients who had a pancreatic tail resection or pancreatic enucleation, in a single institution.Results. - From November 1993 to June 2002, a laparoscopic pancreatic resection was attempted in 22 patients. Nineteen patients were operated by laparoscopy (86%), two patients had conversion to laparotomy (9%), and one had conversion to a “hand-assisted” technique (4%). There was 17 left pancreatectomies and five enucleations. Median operating time was 4.1 hours (range 1.6 to 6.6 hours). There were no deaths in the first 30 post-operative days. Global morbidity rate was 31.8% (N =7), including four pancreatic fistulas (18%), one superficial phlebitis, one prolonged ileus, and one peri-pancreatic fluid collection. Median hospital stay was six days (1 to 26 days).Conclusion. - Pancreatic tail resections and enucleations are feasible by laparoscopy, with a mortality and morbidity rate similar to open surgery. The potential advantages of laparoscopy (reduced post-operative pain, hospital stay and recovery time) should be balanced with a potential increase in pancreatic fistula rate. That risk should be addressed before laparoscopy is generalized for pancreatic resections.     

Intérêt du monitoring électrophysiologique au cours d’une chirurgie éveillée en neurochirurgie

Brain tumor surgery is at risk when lesions are located in eloquent areas. The interindividual anatomo-functional variability of the central nervous system implies that brain surgery within eloquent regions may induce neurological sequelae. Brain mapping using intraoperative direct electrical stimulation in awake patients has been for long validated as the standard for functional brain mapping. Direct electrical stimulation inducing a local transient electrical and functional disorganization is considered positive if the task performed by the patient is disturbed. The brain area stimulated is then considered as essential for the function tested. However, the exactitude of the information provided by this technique is cautious because the actual impact of cortical direct electrical stimulation is not known. Indeed, the possibility of false negative (insufficient intensity of the stimulation due to the heterogeneity of excitability threshold of different cortical areas) or false positive (current spread, interregional signal propagation responsible for remote effects, which make difficult the interpretation of positive or negative behavioural effects) constitute a limitation of this technique. To improve the sensitivity and specificity of this technique, we used an electrocorticographic recording system allowing a real time visualization of the local. We provide here evidence that direct cortical stimulation combined with electrocorticographic recording could be useful to detect remote after discharge and to adjust stimulation parameters. In addition this technique offers new perspective to better assess connectivity of cerebral networks.     

Facteurs de risque de pose de sonde gastrique en chirurgie colorectale programmée,dans le cadre d’un programme de réhabilitation postopératoire : une analyse multivariée

Objective

Nasogastric tube placement (NTP) is no more systematically recommended in patients scheduled for elective colorectal surgery but could be necessary in case of postoperative vomiting. The aim of this study was to determine independent risk factors for NTP after colorectal surgery.

Patients and methods

We performed an observational study including 290 patients scheduled for elective colorectal surgery included in an enhanced recovery programme: immunonutrition, thoracic epidural analgesia, antiemetic prophylaxis, respiratory physiotherapy, absence of NT and drainage, forced mobilization and oral nutrition. The main outcome was the occurrence of vomiting requiring NTP. Univariate analysis included: age, sex, BMI, American Society of Anesthesiologist Physical Status Classification System (ASA), duration of surgery, epidural analgesia, and mobilization, intraoperative fluid, temperature, laparotomy, use of droperidol, parenteral nutrition, stoma, diabetes, hypertension or coronary disease, COPD, type of surgery. A logistic regression was performed to determine independent risk factors of NTP.

Results

Among the 290 patients included, 277 were analyzed. The incidence of NTP was 10.5% (95%CI [7.4–14.6%]). Univariate analysis documented BMI, low temperature in PACU (< 35 °C), ASA scores, duration of surgery and epidural analgesia, rectal and sigmoid resections, diabetes, transfusion, no use of droperidol, duration of mobilization, conversion to laparotomy. Three independent risk factors were associated with NTP: temperature in SSPI < 35.5 °C (OR: 14.49; IC95% [4.52–45.45], P < 0.0001), BMI < 21 kg/m² (8.40; [1.99–35.71], P = 0.0038) and lack of postoperative droperidol administration (3.37 [1.02–11.39], P = 0.04).

Conclusions

After colorectal surgery tolerance to rapid oral feeding is impaired by denutrition and postoperative hypothermia. The combined used of postoperative droperidol should also be considered to avoid postoperative NTP.