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.     

Comment définir une circulation extracorporelle de qualité ?

Extracorporeal circulation (ECC) has to ensure homeostasis of the patient and to minimize pathophysiological disorders inherent in the technique. However, we cannot dissociate it from the surgery and anesthesia knowing that the discipline involves a close partnership with these stakeholders. The purpose of this publication is to review the essential elements that at present can contribute to the quality of the CEC and suggest improvements and developments to be implemented in this area.     

Utilisation du masque laryngé : une enquête nationale de pratique professionnelle

Background

This survey aimed to describe the current use of laryngeal mask (LM) and to define the difference of use according to a group defined like experts.

Methods

A self-questionnaire available on Internet was sent by e-mail to French anesthesiologists. Results were compared by a Chi² test between anesthesiologists according to their expertise defined by a >750 LM use.

Results

Nine hundred and fifty-three anesthesiologists answered to the survey. Only 19 reported never using LM and 37% of responders were defined as expert. More than half of the MAR used the ideal weight to set the size of the MLA to use. Pressure leak was sought by less than one-third of the MAR. In case of leakage, a mobilization of the ML or the patient's head was performed first. In second intention, nearly a quarter of MAR changed technique for the benefit of oral intubation. Only 50% of responders used LM as a rescue technique in case of difficult intubation and ventilation. Experts had less insertion failure and laryngospasm. Complications and medico-legal suites are few.

Conclusions

Variability of practice may be explained by low-grade recommendations in the literature. LM insertion in case of difficult intubation/ventilation to provide adequate oxygenation and should be formally reminded to clinicians.     

La maladie de Dercum (adiposis dolorosa) : une nouvelle observation

Dercum’s disease, or adiposa dolorosa, is a rare condition characterized by the development of multiple painful subcutaneous lipomas. Postmenopausal women are selectively affected. The ankle area is an uncommon site of involvement. We report a case with lipomas about the ankle, and we review the relevant literature.Case-report. – This 46-year-old perimenopausal woman receiving follow-up for depression presented in December 1997 for swelling and mechanical pain in the right ankle. Lumps behind and under the malleoli were removed surgically and found to have the typical histological features of lipomas. In January 2000, a lump developed behind and under the malleoli of the left ankle, and the lumps on the right recurred. The physical examination showed obesity, with a body mass index of 32.04 kg/m². Firm, mobile, painless lumps were felt under and behind the malleoli on both sides. The ankles were painful, although range of motion was normal. Examination of the back found two similar lumps. The erythrocyte sedimentation rate was 10 mm/h and the C–reactive protein level was 6 mg/l. Serum lipid levels were normal. Findings were normal from plain radiographs of the ankles. Ultrasound scanning of the ankles confirmed that the lumps were composed of adipose tissue. Magnetic resonance imaging visualized an arc-shaped lipomatous mass on the left. Whole-body bone density measurement found an increase in fat mass of the lower limbs with normal bone mass. The ankle lipomas were removed surgically. At last follow-up 18 months later, she was free of recurrence.Discussion. – Dercum’s disease is a rare condition of unknown etiology characterized by multiple, often painful lipomas. Paresthesia in the overlying skin is common. Lipomas about the joints cause mechanical arthralgia. The diagnosis, which is often delayed, rests on ultrasonography and, above all, magnetic resonance imaging. A combination of medications, surgery, and psychiatric care is usually needed. The treatment aims at relieving the pain and restoring a normal appearance.     

Fracture de l’odontoïde chez le sujet de plus de 70 ans : morbidité, handicap et place du traitement chirurgical. À propos d’une série de 27 patients

Background and purpose

Odontoid process fractures of the axis are frequent in elderly patients. However, the impact in terms of handicap and morbidity in this particular population are unknown. The role of surgical treatment remains controversial.

Methods

We present a retrospective series of patients aged 70 years or older with odontoid fractures treated in our department between 1998 and 2006. Two cohorts were defined (surgery versus conservative) and compared. Morbidity, handicap, and radiographic fusion were analyzed.

Results

Twenty-seven patients were treated. The mean age was 80.67 years. Five patients died early during hospitalization. Fractures were type II in 66.7% of the cases and type III in 33.3%. Orthopedic treatment was chosen in 44.4% of the cases. A non-union at the fracture site was found in 33% of the cases and morbidity in 41.7% of the cases was found after a 1-year follow-up. Surgery was performed in 40.7% of the cases. There was 18% non-union and no morbidity after 1-year of follow-up. Morbidity was statistically lower in the surgery group (p = 0.037), particularly in cases of type II fracture (p = 0.0063); no statistically significant difference was found for non-union at the fracture site (p = 0.64) except for type II fractures (p = 0.028).

Conclusions

Odontoid fractures in the elderly are a very frequent problem. Immediate mortality is still high but appears correlated to associated lesions. Today's treatments must preserve autonomy for these patients. For elderly patients, the treatment must be chosen in relation to the fracture analysis. In our opinion, surgical management is the treatment of choice for unstable fractures (type II). Conservative management is indicated for stable fractures.     

Les plaies durales : à propos d’une série de 100 cas

IntroductionDural tears are a dreaded surgical incident because they are difficult to anticipate and may lead to serious complications.Materials and methodsThe French College of Neurosurgery analyzed 100 cases of dural tears declared on the physicians accreditation website from the Haute Autorité de santé (Regional Health Authority). A questionnaire on drainage, type of dural repair and bed rest duration was sent to 87 French neurosurgeons.ResultsThirty-six percent of patients with dural tears had a history of previous spinal surgery and the most common cause of tear was surgical fibrosis into the operative field for 30% of cases. Sixty-four percent had no history of spinal surgery and, in 33% of cases, the dural tear occurred during a surgery for herniated disc. Drainage was proposed case by case in 76% of cases, the patient was allowed to stand up at day 1 in 48% of cases. The treatment of dural tears combined different techniques including in situ injection of biological glue in 86% of cases. The most common complication was the need of wound repair procedure in 59.5% of cases, which was complicated by meningitis in 21.5% of cases.ConclusionThis study shows the lack of formal consensus about the procedure of repair, the method of drainage or the need to keep the patient bed ridden. This study highlights a relatively high frequency of dural tears, its potentially serious complications and stresses the need for prospective studies in order to define the appropriate action to undertake when faced with this type of incident.