Techniques de la décortication

Decortication is a surgical procedure that consists in restoring the ventilatory function of the lung by removing the constricting membrane that compresses it over the mediastinum. The constricting membrane is the last stage of loculated and complicated pleural effusions: haemothorax, empyemas, pleural tuberculosis, various other pleural diseases and sequellae of earlier collapsotherapeutic procedures. Decortication typically involves removal of the entire complicated pleural disease, freeing the visceral pleura (decortication strico sensu) and the parietal pleura (pleurectomy). After decortication the lung can expand again and improved functioning can be expected. Multiple technical procedures are available. When the pleural thickening is induced by underlying lung disease, it may be necessary to resect the underlying diseased parenchyma during the same intervention. In chronic parapneumonic empyemas, the current availability of video-assisted procedures allows to avoid thoracotomy for decortication.     

Prévention de la douleur postopératoire

The pre-emptive analgesia concept suggests that pre-administration of analgesics may enhance the efficacy of these drugs. This review has selected the data from the literature according to two types of methodological criteria: Sackett's criteria, and those specific of pre-emptive analgesia studies. Infiltration, spinal and peripheral nerve blocks using local anaesthetic drugs do not seem to produce pre-emptive analgesia. The few positive results have limited clinical significance. The results concerning opioids are contradictory and the clinical significance is limited. Preoperative oral administration of non steroidal anti-inflammatory drugs (NSAIDs) offers no benefit. Intravenous pre-administration has a limited advantage, but enhances perioperative bleeding. Kétamine, an NMDA receptor antagonist, may have some pre-emptive analgesic properties according to the few studies available. In conclusion, pre-administration of analgesic drugs represents the usual strategy for the anaesthesiologist (spinal or peripheral block, infiltration, opioids). In other cases (NSAIDs, kétamine), pre-administration represents a change in usual practice. This is not justified for NSAIDs; NMDA receptor antagonists may offer an interesting research area. Data concerning pre-emptive analgesia for chronic pain syndrome such as phantom limb pain are quite limited.     

Capacité de la biopsie de la prostate à prédire le score réel du cancer de la prostate?

ObjectiveTo evaluate the correlation between Gleason score at needle biopsy and prostatectomy specimen.Subjects and MethodsWe reviewed the records of 47 patients treated for prostate cancer by radical prostatectomy and the evaluation of the agreement was made according to the differentiation groups (well, moderately and poorly differentiated).ResultsThe concordance of the Gleason score was 70%, a sub-staging of 25.5%, and 4.2% for on-staging. For the positive predictive value (PPV), well differentiated group was 81.25% and 100% for moderately differentiated group. The Kappa concordance coefficient was 0.36 with a better concordance observed in the moderately differentiated group.ConclusionThe biopsy Gleason score imperfectly reflects the one of radical prostatectomy specimens. However, these limits of staging must be understood in the determination of therapeutic strategies.     

Validation francophone de la grille d’évaluation de la douleur-déficience intellectuelle – version postopératoire

Purpose

The aim of the study was to test the validity of a French language version of the Non-Communicating Children’s Pain Checklist - Postoperative Version (NCCPC-PV): grille d’évaluation de la douleur-déficience intellectuelle (GED-DI).

Methods

We assessed the intensity of pain in 87 intellectually disabled surgical patients recruited in four Canadian and French hospitals in the pre- and post-operative settings using the GED-DI, a 100-mm visual analogue pain scale (VAS) and the Rosen sedation scale. The validity of the GED-DI was measured by the difference in scores between pre- and postoperative conditions. The checklist was made up of 30 items divided into seven subgroups. Items were rated from 0 to 3 for a total score ranging from 0 to 90 points.

Results

The mean (standard deviation) age of the patients was 17 (11) yr and the mean mental age 24.5 (24) months. The total GED-DI score was 6.1 (4.9) pre- and 13.4 (11.2) post-surgery (P < 0.001). All subgroups had a higher score after surgery (P < 0.001). The receiver operating characteristic (ROC) curves, comparing the absence of pain to mild pain scores and moderate to severe pain scores, showed a cutoff at 6 (mild pain) and 11 (moderate to severe pain).

Conclusion

The French version of the NCCPC-PV can be used to assess pain in non-communicating patients with intellectual disabilities in a postoperative setting. It has good content validity, as the total pre-surgery score for the GED-DI was significantly lower than the postoperative score, and showed a good concurrent validity when compared to the VAS.     

Chirurgie pariétale de la douleur

Sans résuméRapport du Congrès Européen de Neuro-chirurgie de Zurich, Juillet 1959.