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.     

Insuffisance rénale aiguë révélatrice d’un lymphome rénal. À propos d’un cas

Acute renal failure, as the initial manifestation of lymphoma, has been reported only in a few cases. In this work, we report the case of a 28-year-old women admitted for acute renal failure. Her physical examination detected bilateral kidney enlargement. Laboratory evaluation revealed a serum creatinine value 218 μmol/l. A 24-hour urine collection analysis allowed the detection of 1 g of protein. No red cells were found after urinanalysis. Renal ultrasound showed massively enlarged kidneys. Renal biopsy of the kidney and pathologic examination showed diffuse infiltration of the interstitium with lymphocytes and atypical cells positive for CD20 markers. A diagnosis of diffuse large B-cell type non-Hodgkin lymphoma was made. However, investigations revealed the presence of two others sites of lymphoma: gastric and ophthalmic. The patient's renal function and kidney size as well as the other lymphoma locations were normalized after the initiation of chemotherapy.     

Les causes d’échecs des prothèses unicompartimentales

Our study of failures of unicompartmental prostheses deals with 38 revisions. A failure is most often the result of several factors; they will be grouped into four chapters.

1. Selection of operated on patients: The diffusion of lesions beyond the prosthetized compartment is frequently responsible for he failure: rhumatoid polyarthritis (0 case), injury of the opposite compartment side (3 cases) and deterioration of the patella (0 case). The non-correction of an important deviation overburdens the prosthesis which deteriorates (3 cases) all the more so that there is a laxity of the concavity (3 cases).
2. Errors in the operative technique: They are divided up into ill positioning of the femoral component (6 conflicts between the frontal patin and the mass of the épines), source of oblique space and of 3 frontal subluxations. The errors in the femoro-tibial alignment are responsible for 5 hypercorrectings with degradating of the opposed compartment and of 3 hypocorrectings overloading the prosthesis.
3. Bad conception of the prosthesis: Either at the femoral component level (defect in the condylar curvature and incorrect osseous support) or at the tibial plate level (weakness of the polyethylene, 4 cases and bad osseous support, 1 fracture). The degree of conformity of the prosthesis is also responsible for failures: 2 by constraint prosthesis.
4. Longevity of the prosthesis: Time realizes with wear and unsealing a real trilogy very often responsible for failures: 8 femoral unsealing and 21 tibial unsealings. Let us not forget the responsibility in these wears and unsealings of the ligamentous unbalance and of the knee morphotype (constitutional varum).

The analysis of the causes of failures of unicompartmental prostheses should enable to better encircle the indications of this type of prostheses and to place only prostheses respecting the concept of resurfacing. The unicompartmental prosthesis must be a wedge of substitution of an osteo-cartilagenous substance loss. Thus, it should be ale to give results that can be compared in a distance to those of tricompartmental prostheses.     

Données nouvelles en orthèses

Summary The authors propose a technique for determining the limits and value of the 46 zones, either convex qibbus or concave lordoses, in which previously Chêneau had divided the scoliotic body and the corresponding brace. This technique is based upon the comparison of 8 specially prepared photographs of the patient. Owing to the extreme intricacy and the great number of scoliotic deformations present in a single scoliotic body, the authors propose two ways of avoiding bungles. 1. Computerized fabrication of the positive form. 2. Use of a product, the shape of which can easily be changed even during the time the patient is wearing it.Résumé Nous tentons de préciser la topographie des déformations scoliotiques par l'étude photographique des contours du corps. Un artifice de retournement d'images rend comparables entre elles les vues obliques. Nous avons défini quarante six zones situées chacune soit en relief gibbeux soit en méplat concave. Chacune a reçu une définition précise, comme gibbosité, méplat, constituant du dos creux ou du vrillage des ceintures. Il n'y a plus d'incertitude. Le corset obtenu ne comporte plus aucun effet restrictif ou écrasant. Il reste à préciser des détails concernant notamment le vrillage des ceintures. Depuis toujours, nous attendons une matière plastique qui serait remodelable au fur et à mesure de l'évolution du corps scoliotique dans le corset. Des espoirs se dessinent, non encore confirmés. La fabrication informatique du moule positif est au point. Cela donnera une ligne directrice précieuse aux équipes. Mais cela ne les dispense pas de tout connaître sur la scoliose.

Travail présenté à la 37ème Réunion de la S.O.T.EST à Strasbourg, du 11 au 13 juin 1993     

Prise en charge de la sténose athéromateuse d’artère rénale en 2016

Endovascular revascularization as treatment of atherosclerotic renal-artery stenosis (aRAS) is controversial since 3 large and multicentric randomised trials (CORAL, ASTRAL, STAR) failed to prove the superiority of percutaneous transluminal renal-artery stenting (PTRAS) over medical treatment only (MT). However, considering the multiple bias of these trials, among which questionable inclusion criterias, these results must be extrapolated in clinical practice with caution. New pathophysiological data have been helping to understand why restoring blood flow does not necessarily lead to kidney function improvement. Today, the diagnostic approach must in one hand confirm the artery stenosis and on the other hand assess its severity and impact on the kidney. Therapeutic options still lie on the American guidelines published in 2006, since no study data can be reasonably used in everyday practice. However, particular sub-groups of patients who could benefit from revascularisation have been identified through recent cohort studies. Further prospective studies are needed in order to confirm the superiority of PTRAS in these populations. Meanwhile, multidisciplinary approach should be promoted, in order to provide the best treatment for each patient.     

Comment traiter un goutteux résistant ou allergique à l’allopurinol en 2004 ?

The manifestations of gout can be abolished permanently by lifelong urate-lowering therapy maintaining serum urate levels under 360 μmol/l, as this ensures dissolution of pathogenic crystals of monosodium urate monohydrate. Benzbromarone has been withdrawn from the market, leaving allopurinol as the only urate-lowering drug readily available in France. Allopurinol may induce unacceptable side effects, and in patients with dose-limiting renal failure it may not be sufficiently effective. Because allopurinol can induce serious side effects when given concomitantly with purine antimetabolites, it is contraindicated in organ transplant recipients. In patients who cannot tolerate allopurinol, dietary treatment, discontinuation of diuretic agents, and use of losartan or fenofibrate to treat concomitant hypertension or dyslipidemia, respectively, may ensure adequate control of serum urate levels. Desensitization to allopurinol can be attempted in patients with mild cutaneous hypersensitivity reactions but is difficult to perform and rarely used. Uricosuric agents may be helpful in patients with normal or diminished urate excretion. Probenecid is available in France from hospital pharmacies, and benzbromarone can be prescribed via a time-limited authorization procedure. Rasburicase, a bacterial urate oxidase produced by genetic engineering, is indicated to prevent acute hyperuricemia induced by chemotherapy for hematological malignancies. Factors that limit the use of rasburicase include the absence of a marketing authorization, the need for parenteral administration, and the absence of validated treatment schedules. Patients with renal failure precluding the use of effective allopurinol dosages are good candidates for benzbromarone therapy. Organ transplant recipients can be given benzbromarone, within the current restrictions to its use; alternatively, mycophenolate mofetil can be substituted for calcineurin inhibitors, which elevate serum urate levels, or for azathioprine, which contraindicates the use of allopurinol.     

Comment surveiller les patients opérés à visée curative d’un cancer colorectal ?

Despite their frequency, the terms of colorectal cancer surveillance after surgery remains badly codified. The use of scanner, echography and thoracic radiography remains to be determined. The dosage of CEA is still matter of debate.