Acute necroticohemorrhagic pancreatitis. Why, when and how to drain? Apropos of 106 cases

The heavy toll of necrotizing acute pancreatitis led the authors to start developing a new method of treatment in experimental and clinical conditions in 1979. This was aimed on one hand at creating a large channel for the centrifugal drainage of pancreatic or peri-pancreatic foci, and on the other hand at maintaining this draining channel during the first 5 weeks of acute evolution of the acute necrotizing pancreatitis in order to allow the permanent evacuation of purulent or necrotic fragments. From 1979 to 1989, 106 patients were treated with this method, ie. 71 men and 35 women with an average age of 47.9 years. 73 (74%) of these patients had been referred by other hospitals, and 64 only had been initially operated at Saint-Antoine hospital. All patients presented with extensive peripancreatic necrosis. The average Ranson score was 4.8 (not taking the fluid sequestration during the first few hours into account). Visceral failure was observed in 76% of the patients before surgery. The necrosis of the pancreatic gland was focal in 6 cases, extensive in 47 cases and total or subtotal in 25 cases. Out of the 70 CT studies, 64 showed a Ranson grade of E. All patients received enteral feeding on a jejunal site postoperatively. The mortality rate was 16%. The stay of the surviving patients in the intensive care unit averaged 50 days. 29 patients (27%) were reoperated on for complications or insufficient drainage.     

Doppler blood flow analysis of erectile function: who, when, and how

The underlying processes in vasculogenic erectile dysfunction (ED) are arterial insufficiency, venoocclusive disease, or combinations of both. Doppler blood flow analysis is a diagnostic modality useful in elucidating the cause of ED and the magnitude of its severity. This article describes the procedural techniques, typical findings, and relevant pathophysiology for in-office Doppler studies. Specific conditions include arterial insufficiency, venous occlusive disease, Peyronie's disease, and priapism.     

Intravenous nutrition. Why,when, and with what?

The catabolic reaction to operation or severe trauma will give rise to a real risk of starvation unless sufficient attention is paid to the patient's energy and nitrogen requirements as well as to his fluid and electrolyte balance. The indications for intravenous nutrition in such cases are outlined and the various preparations available for the supply of energy and nitrogen are detailed. In the planning of an intravenous feeding regimen the patient's daily nitrogen losses must be estimated and a formula is provided for this purpose. The technique of parenteral nutrition is discussed and attention drawn to the various metabolic and complications that may be encountered. Neither hepatic impairment nor renal failure need be regarded as a contra-indication to intravenous feeding.     

Why and when to delay TFL flaps

Summary Sensory TFL flaps have to be extended to the ischial and perianal region of patients suffering from a low spinal cord lesion if they are to provide optimal sensitivity as well as adequate length. A sensory TFL flap which extends to the perianal area may also help such patient to control his bowel function. In order to mobilize a large sensory TFL flap, 3 to 4 musculocutaneous vessels originating from the vastus lateralis femoris muscle have to be cut within 14 cm above the knee joint. The resulting random pattern skin flap segment of such extended sensory TFL flap is prone to develop inadequate blood supply when transposed to its new bed, especially if the subcutaneous fat layer is thicker than 1,5 to 2 cm. Under such conditions the delay procedure is advisable to preserve the entire length of an enlarged sensory myodermal TFL flap.     

Hyperprolactinemia and impotence: why, when and how to investigate

The contribution of hyperprolactinemia to erectile disorders has not been clarified. Modest elevations of serum prolactin occur after administration of drugs that by themselves affect erectile function. Prolactinomas produce marked elevations of the hormone and invariably are accompanied by hypogonadotropic hypogonadism. Among 1,236 consecutive impotent patients investigated at our center 5.3% had serum levels of prolactin greater than normal. Only 34 of the 66 hyperprolactinemic patients were available for analysis. The etiology of the hyperprolactinemia in this group was pituitary adenoma in 14.7%, drug-induced in 29%, chronic renal failure in 6%, laboratory error in 2.9% and idiopathic in 47.1%. Medical management has a high degree of success but simply lowering the levels of prolactin is not invariably accompanied by restoration of function.     

Stress incontinence. Why and how operations work

We still remain uncertain of the precise mode of cure produced by many continence procedures. In achieving a cure, some operations produce unacceptable side effects of urge incontinence and voiding difficulty. True comparison of results of different procedures cannot be made until both subjective and objective results are presented, the criteria for patient entry are documented, and randomized studies using matched patients as far as possible (taking into account factors such as the patient's age, parity, and past history of bladder neck operations) are carried out. A follow-up for at least 2 years and preferably 5 years is necessary. As more than one factor may act to cause urethral sphincter incompetence, operations must be selective, and bearing that in mind, a schematic approach is needed to match the operation with the pathophysiology or anatomic lesion responsible for incontinence.     

What,why and how to monitor blood glucose in critically ill patients

Critically ill patients are prone to high glycemic variations irrespective of their diabetes status. This mandates frequent blood glucose (BG) monitoring and regulation of insulin therapy. Even though the most commonly employed capillary BG monitoring is convenient and rapid, it is inaccurate and prone to high bias, overestimating BG levels in critically ill patients. The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach. Each of these has its own fallacies, while tight control increases risk of hypoglycemia, liberal BG targets make the patients prone to hyperglycemia. Moreover, the recent evidence suggests that BG indices, such as glycemic variability and time in target range, may also affect patient outcomes. In this review, we highlight the nuances associated with BG monitoring, including the various indices required to be monitored, BG targets and recent advances in BG monitoring in critically ill patients.     

Thoracic trauma: when and how to intervene

Trauma is the leading cause of death in patients younger than 40 years of age. Thoracic injuries are common and often can be managed by tube thoracostomy. In many patients, however, the thoracic injuries must be repaired surgically in one of three time periods: immediate, urgent, or delayed thoracotomy. In this article, we describe the general approach to effectively managing thoracic trauma patients. We review common injuries and scenarios that may be encountered by the surgeon and discuss the considerations and variables that enter into the decision-making process for operative intervention.     

Glomerular stereology: Why, what and how to measure glomerular structure

Summary: Quantitative methods are frequently used to analyse the structure of renal glomeruli. However, on most occasions, measurements are made on glomerular profiles (the two-dimensional samples of glomeruli seen in histological sections), and provide little or no information about the structure of whole, three-dimensional glomeruli. Stereology is the discipline concerned with the quantitative analysis of three-dimensional structures. With stereology one can estimate the total number of glomeruli in kidneys, as well as mean glomerular volume, the number of cells in glomeruli, and the length and surface area of glomerular capillaries. In addition to providing a means for detecting structural differences between glomeruli from different specimens, stereology provides quantitative structural information that can be correlated with quantitative physiological, biochemical and molecular data. Over the past decade we have witnessed the development of a new generation of unbiased, cost-efficient stereological methods that are ideally suited to analysing glomeruli. Some of these methods are introduced in this review, and then three recent studies from our laboratories that successfully utilized these methods are described. These studies concerned hypertension, kidney development, and the pathogenesis of focal and segmental glomerulosclerosis.