Myélolipome présacré

Presacral myelolipoma is a rare benign tumour of unknown aetiology, composed of mature adipose tissue with intermixed normal haematopoietic cells. Computed tomography is of help in the diagnosis but biopsy is mandatory in order to avoid unnecessary surgery. A case is reported.     

Les cystadénocarcinomes pancréatiques sont-ils des cystadénomes mucineux dégénérés?

Objectives of the studyTo define arguments in agreement or disagreement with the generally accepted theory of transformation from benign mucinous cystadenoma (MC) to malignant cystadenocarcinoma (CC) of the pancreas.MethodsA review of the literature since 1978 was conducted together with a comparative analysis of a multicentre retrospective study of the different mucinous cystic tumours of the pancreas: 150 MC, 79 CC and 55 intraductal papillary mucinous tumours of the pancreas (TIPMP). Multiple epidemiological and clinicopathological data were compared between MC and CC: mean age at diagnosis, sex distribution, association with diabetes or concurrent cancer, tumour location and size, type of pancreatic main duct communication, pancreatic fibrosis and serum CA 19-9 levels. The analysis concerned also histopathological features of resected cystadenocarcinomas (n = 58).ResultsTwo features suggested malignant transformation of mucinous cystadenomas: older mean age at diagnosis of CC and histological characteristics revealing areas of benign-appearing epithelium associated with areas of invasive carcinoma in 55% of cases. Conversely, two statistically significant discordant features were observed: a higher proportion of men (40% for CC vs 13% for MC) and a more frequent location in the head of the pancreas (49% vs 27%). The other differences were not in contradiction with the malignant transformation of MC: associated diabetes mellitus, increasing serum CA 19-9 levels and chromosomal aberrations were more frequent in CC. TIPMP were predominant in men (67%), and more common in the head of the pancreas (67%).ConclusionThe risk of malignant transformation of MC should not be questioned, despite sex distribution and location differences between MC and CC. These differences may be due to inaccurate designation of intraductal mucinous carcinomas as communicating CC or of CC as pancreatic mucinous adenocarcinomas.     

Médicalisation préhospitalière héliportée et agressions cérébrales secondaires d'origine systémique chez les traumatisés craniocérébraux graves

Advanced supportive therapy at the site of the accident, associated with direct transfer to a trauma centre increases survival and reduces morbidity rates. Patients with severe head injury, especially those with multiple injuries, often arrive in the emergency department with potentially causes of serious secondary systemic insults to the already injured brain, such as acute anemia (Hematocrit ≤ 30 %), hypotension (systolic arterial pressure (Pa_sys) ≤ 95 mmHg, 12,7 kPa), hypercapnia (PaCO₂ ≥ 45 mmHg, 6 kPa) and/or hypoxemia (Pao₂ ≤ 65 mmHg, 8,7 kPa). The incidence of such insults and their impact on mortality were studied in a group of 51 consecutive adults suffering from non penetrating severe head injury (Glasgow score ≤ 8, mean age 31 ± 17 yrs) rescued by a medicalised helicopter. Each patient received medical care on the site of the accident by an anaesthesiologist of a university hospital (UH) complying with an advanced trauma life support protocol including intubation, hyperventilation with FIO₂ = 1, restoration of an adequate Pa_sys and direct transportation to the UH. Mean delay from call to arrival of the rescue team on the site was 15 ± 5 min. Mean scene time was 32 ± 10 min in cases not requiring extrication. Nineteen patients (Group I) were admitted without secondary systemic insults to the brain, 13 with isolated head injury, and 6 with multiple injuries, with a low Glasgow Outcome Score (GOS 1–3) of 42 % at 3 months. In 32 patients (Group II), despite advanced supportive measures at the scene of the accident and during transportation, one or more secondary systemic insults to the brain were detected upon arrival at the emergency room, one with isolated head injury, 31 with multiple injuries, with a bad GOS of 72 % at 3 months. We conclude that : 1) advanced trauma life support prevents from secondary systemic insults in the great majority of isolated severe head injured patients, 2) secondary systemic insults to the already injured brain are frequent in patients with multiple injuries and are difficult to avoid despite rapid aeromedical trauma care, 3) secondary systemic insults to the brain have a catastrophic impact on the outcome of severely head injured patients.     

Analgésie postopératoire. Spécificités du sujet âgé

The necessity of an adapted, optimal postoperative analgesia in the elderly is widely recognised. Reduced physiological capacities must be taken into consideration during the perioperative period. Class I analgesics, such as paracetamol, are both safe and efficient, and can be used for basic analgesia. Non steroid anti-inflammatory drugs carry an increased iatrogenic risk in the elderly. Their benefits should always be considered with regard to their risk. Their dosage should be decreased by 40–60% in comparison to the standard adult doses. Opioids, though highly efficient, carry a higher risk of respiratory depression due to the increased sensitivity to this class of molecules in the elderly. Doses must be reduced by 50% of the standard adult dose in order to limit adverse events while maintaining an equivalent level of analgesia. Patient-controlled and spinal opioid analgesia can be used in elderly patients. However surveillance of both the state of consciousness and respiratory rate must be carried out hourly over a period ranging from 12 to 24 hours. Pulse oximetry can be of value. After orthopaedic surgery, perineural or peripheral analgesia should be favoured considering the excellent benefit-risk ratio. Close clinical monitoring is essential for providing safe and efficient analgesia in the elderly using the techniques currently at our disposal.     

Hypothermie modérée et protection cérébrale

To define the part played by mild-to-moderate hypothermia in neuroprotection, it is necessary to take into account the thermoregulatory responses that occur in the normal human as the change in central temperature exceeds 0.2 °C. The mechanisms induced by cold are cutaneous vasoconstriction and shivering. They must be suppressed before starting controlled hypothermia. In these conditions, controlled moderate hypothermia between 32 and 35 °C dœs not seem to have deleterious side-effects, especially on coagulation. Caution is needed with the analysis of the numerous papers reporting experiments concerning the effects of moderate hypothermia in animals with induced cerebral ischaemia because of significant differences in the study designs. These differences concern mainly the time of onset of hypothermia, viz before or after ischaemia, the fact that the ischaemia is either global or focal, that it is caused by vascular occlusion posttraumatic or initiated by hypo or hyperglycemia. Some differences are also existing in the criteria used to appreciate the neuronal damage, as well as in the level of temperature and the site where it is measured. The mechanism of neuroprotectionfrom moderate hypothermia seems to be not only a decrease in cerebral metabolism, but also involves a specific action on some intra-cellular events such as the blocking of the release of glutamate and of lipid peroxydation in brain tissue. An indirect proof of the neuroprotective effect of moderate hypothermia is the increase in the neuronal damage induced by moderate hyperthermia. It is conceivable that moderate hypothermia could exert a better neuroprotective effect than the drugs having this reputation, such as barbiturates, isoflurane and propofol. The possible induction of hypothermia into experiments concerning barbiturate or isoflurane protection could even explain the protection observed, as this has been proven for anti NMDA, MK-801. The few clinical studies already published do not show obvious differences allowing to recommend moderate hypothermia as a standard technique among the therapeutic modalities used for cerebral protection for intracerebral vascular surgery or cerebral resuscitation after severe head trauma. However, the experimental results are strong enough to justify futur controlled clinical studies. The prevention of brain hyperthermia may also emerge as a major objective of resuscitative intervention.     

Hypercalcémie sévère et lupus érythémateux disséminé

A rare case of severe hypercalcemia strongly associated with systemic lupus erythematosus (SLE) is reported. On admission, a young woman showed severe hypercalcemia and photosensitivity. Criteria for diagnosis of SLE were not sufficient. All causes of hypercalcemia were excluded. Radiographs of the skeleton were normal. One year later diagnosis of SLE was evident. In addition, diffuse and severe osteopenia and chest deformities had occurred. The treatment of SLE normalized persistently calcemia. Mild elevation of calcium levels occurred during flares of SLE. It has been hypothesized that hypercalcemia in patients with SLE could be caused by the presence of stimulatory anti-PTH receptor antibodies. This case report suggests that in patients with severe hypercalcemia associated with SLE early diagnosis and treatment of SLE may prevent bone loss. In these patients the prevention of severe bone damage is very important. Indeed severe osteopenia may favour skeletal deformities and fractures; in addition it may represent a serious obstacle in using adequate doses of glucocorticoids for treatment of SLE.     

Kyste du cholédoque ≪dégénéré≫. Une observation

Choledochal cysts have an increased risk of biliary tract malignancy, induced by reflux of pancreatic juice and anomalous pancreatobiliary ductal junction. We report one case of congenital choledochal cyst in a 68-year-old female whose malignancy was revealed by history of pain and jaundice. Pancreatico-duodenectomy was performed and the patient was alive 6 months later.     

Protection cérébrale médicamenteuse : agents spécifiques

Dysfunctional sodium influx is the first step in the ischaemic cascade. It has been recently demonstrated that reducing ionic flux through voltage-gated Na channels shortens the NMDA receptor activity of cultured hippocampal slices in which oxidative phosphorylation and glycolysis have been blocked. The implication of this finding is that blocking initial events in the ischaemic cascade, events which do not directly cause neuronal damage, will reduce the damage done by downstream events. It also seems intuitively reasonable to suppose that truncating initial steps of the ischaemic cascade, as distinct from blocking glutamate receptors and scavening free radicals, will reduce the probability of interferring with endogenous mechanisms of repair. Clinically useful, substantive, prophylactic, pharmacological cerebral protection will come from drugs that work upstream. And for pharmacological protection that can only be initiated subsequent to an ischaemic event, the more we learn about endogenous repair, or genetic pharmacology, the closer we will come to maximizing the benefits and minimizing the costs of downstream intervention.     

Série du GECO de 77 métastases vertébrales opérées

Résumé Le traitement chirurgical des métastases vertébrales a considérablement évolué ces dernières années, tant en ce qui concerne ses indications que ses possibilités techniques. En fait ce traitement chirurgical a suivi les progrès de l'oncologie et des malades, jusque là condamnés à brève échéance ont ainsi été dirigés vers les équipes chirurgicales par les oncologues et les radiothérapeutes afin de stabiliser leur rachis. A l'inverse, nous orthopédistes, bénéficiant des progrès de l'imagerie médicale, avons tous des dossiers de malades dont les métastases ont été découvertes par nous devant des rachialgies, confirmées par une biopsie et stabiliséees, puis adressées secondairement aux équipes de cancérologie. Ce sont donc à la fois les cas avancés, récupérés grâce à la chimiothérapie et les cas débutants diagnostiqués plus tôt que jadis, qui expliquent le regain du traitement chirurgical. Enfin, last but not least, les progrès de la chirurgie elle même rendent possibles des stabilisations qui auparavant étaient impossibles à obtenir et ce, non pas comme on l'a cru au départ, en utilisant des substances de remplissage comme le "ciment", mais en accordant au traitement des métastases les moyens les plus modernes, les plus "sophistiqués". Les métastases rachidiennes sont à considérer comme des fractures métastatiques et méritent le même traitement que les fractures traumatiques.     

Pancréatectomie médiane avec anastomose pancréatogastrique pour néoformation pancréatique

Aim of the studyTo report a personal series of ten patients who underwent a medial pancreatectomy with pancreaticogastrostomy for tumor of the pancreas.Material and methodsAn equal number of five patients had solid and cystic tumors. The solid tumors were all endocrine and included two cases of insulinoma and solitary cases of VIPoma, glucagonoma, and non-secreting tumor. Five patients had a cystic tumor which was in two cases a serous cystadenoma, and in the other cases, a mucinous cystadenoma, a solid pseudopapillary tumor, and a solitary hydatid cyst of the pancreas. The operative procedure included a middle segment pancreatectomy, a suture of the proximal pancreatic stump, an anastomosis of the distal pancreatic stump with the stomach and an external transgastric drainage of the distal main pancreatic duct.ResultsIn the postoperative course, a sero-hematic collection close to the anastomosis occurred in four patients and required external drainage in three cases. All patients recovered without sequela of pancreatic dysfunction.ConclusionThis series confirms the place of medial pancreatectomy in resection of non-enucleable tumors of the middle part of the pancreas. It also shows that pancreaticogastrostomy is a technical simplification compared to Roux-en Y pancreaticojejunostomy in this particular modality of pancreatectomy.     

Hémodialyse en unité de dialyse médicalisée télésurveillée : une expérience de cinq années

The ageing population, the need for patient care delivery closer to home and reducing travel cost and isolation and, not at least, optimising medical team activity lead to adapt treatment by hemodialysis. Telehealth is an alternative now enabled by recent regulatory changes. We summarize here the regulatory and organisational conditions in a monitored Medicalized Dialysis Unit (MDU) and report the local experience of Saint-Brieuc Hospital; the feasibility and functionality over time (5 years) of this approach was demonstrated in clinical practice with selected patients; over short-term and for a still-limited number of patients, its clinical results are comparable to those observed in a MDU running on a traditional regimen (weekly visits and on-call 24 hours on-site 24 of the nephrologist); the degree of patient satisfaction, some of them very old people, is high. Stability of communications mainly depending of the operators and audio-video quality needed for a friendly and efficient exchange, could be improved. Relevant analysis of cost is necessary to adjust compensation and to encourage the deployment of teledialysis. The development of this technique is suitable in order to maintain oldering populations close to home, to assure the fairest access to medical care and to serve its purpose, which is the care in all its dimensions.