Prise en charge des perforations coliques au cours de la coloscopie en 2009

Objectives

Colonic perforations during a colonoscopy can occur when there is excessive pressure on the colonic wall, during a therapeutic procedure (coagulation, polypectomy, mucosectomy) or by a reaction secondary to the use of a high frequency current in the colon with persistency of fermentation gas. It is very rare, about 2 %, and sometimes even between 0.5 and 1 % during screening colonoscopies in subjects at average risk of colorectal cancer. The purpose of this review is to discuss existing arguments and objectives in order to position endoscopic treatment with clips compared with a standard surgical approach.

Methodology

Standard treatment is surgery and is associated with mortality ranging between 3 and 10 %: The procedure is a single suture in 1/3 of cases with the risk of temporary or permanent stomy ranging from 11 to 39 %.

Results

The first endoscopic closure with clips was conducted in 1997 and since then 84 cases have been reported in the literature. A successful closure with clips was described in 69 to 100 % of cases for the largest series but this success only represents a sub-group of patients only representing 19, 56 and 90 % of 23 to 30 perforations recorded in the three largest series. Endoscopic closure can only be considered if diagnosis is made during a colonoscopy with excellent colonic preparation, total exsufflation towards the end of the closure and accurate marking of the anatomical site of the perforation closed with clips. However, treatment relies on medical-surgical monitoring and approach; the discovery of a pneumoperitoneum in an asymptomatic patient is not a formal indication for surgery. All perforations whose diagnosis is delayed are generally associated with abdominal or peritoneal symptoms, which is an indication for surgery.

Conclusions

The perfection of endoscopic closure equipment or suturing paves the way for considering a change to this algorithm. However, treatment will always be based on the need to recognise the perforation during the initial colonoscopy and to have cost-effective equipment to treat these perforations; the circumstances of which mean that they cannot be secondarily treated by a referring centre.     

Prise en charge des fractures récentes de la clavicule

Fractures of the clavicle are extremely frequent (2,6 to 5% of all the fractures). They typically occur in male children or young adults before 25 years. Because of anatomical particularity of the bone, these fractures are involving the middle third of the bone in 69% to 82% of cases. Satisfactory results are often achieved with an orthopedic treatment. However, in some cases, increasing risks of poor functional outcomes, higher risk of pseudarthrosis, ungraceful results or delayed work resumption lead to choose a surgical treatment. Many surgical procedures are described by authors to treat these fractures, but actually, there is no common consensus for surgical indication. The admitted shortening value for a surgical treatment is 20 mm. However, Altamini has shown the superiority of a surgical treatment in terms of functional results and decreasing cases of nonunion and pseudarthrosis in cases of fractures involving the middle third part of the bone.     

Prise en charge chez l’enfant en France

The prevalence of childhood obesity, changes in its development, and recent data on risk factors justify the development of prevention and early screening programmes based on health checkups carried out by PMIs (maternal and child protection programmes) and PSE services (organisations promoting the health of schoolchildren). An initial review of strategies developed at the national, regional and local levels highlight three strengths: 1) the training of health professionals; 2) their commitment with the support of various institutions (French ministry of education, local authorities, PMIs, and the national health insurance plan) within the framework of calls for tenders; 3) the decompartmentalization of health professionals within RéPOP networks (dealing with the prevention, screening and management of obesity in children). There are five such networks (Ile-de-France, Toulouse, Lyon, Franche-Comté and Aquitaine) offering innovative alternatives through multidisciplinary management programmes involving agencies that work within the same network culture. It is important that their progress be reviewed at the end of an initial trial period. There have been only a small number of initiatives in this area, with demand exceeding resources. New solutions must be found throughout France. Moreover, there must be better communication with families, especially those most at risk who have limited access to care and are reluctant to seek help because of discrimination suffered by obese patients, including children. Guilt is reflected onto the parents and even children, making an extensive informational campaign necessary.     

Prise en charge chez l’adolescent en France

Risk factors and circumstances that trigger obesity show characteristics specific to adolescence, a high risk period due to the significant impact of social and psychological factors linked to age and development. Changes in behaviour are closely associated with asserting independence, being influenced by peers, developing critical faculties, hormonal changes, and other factors. Reductions in the time spent exercising and increasing sedentary behaviour are linked to changing leisure patterns (television, video games and the Internet) and the importance given to IT tools by schools. There are many references supporting the link between sedentary behaviour and body fat and that between a sedentary lifestyle and time spent watching television, whereas spontaneous but sufficiently vigorous exercise seems to provide a high degree of protection against obesity. Two major public health initiatives bringing together screening, healthcare, nutritional policy and exercise promotion programmes have been implemented in a number of French schools (in Val de Marne and Bas-Rhin). The preliminary results are encouraging. Schools are ideal places to intervene, yet the home and community remain the best places to foster sustainable and significant behaviour change. Changing a young person’s environment-taking into account recent changes in local behaviours and eating habits, and the management of television and computer habits-is more important than simply providing advice in a classroom. Healthcare in this age group remains difficult, and a multidisciplinary approach tailored to its particular psychological and biological characteristics should be adopted. Few teenagers consult doctors when they experience health problems, and few doctors receive the specific training required to manage them when they do.     

Prise en charge chez l’adulte en France

The widespread, overly pessimistic view of adult obesity treatment in the medical community is no longer justified. Treatment failure often results from inappropriate recommendations or inadequacies within the healthcare system. What is primary is clarity about the WHO objectives, which are, in order of increasing importance: weight loss, treatment of comorbidities, weight stabilisation and prevention of weight gain. Weight regain is natural because of the numerous mechanisms that prevent weight loss-some physiological, some psychological and some behavioural. Therapeutic strategies must be multifaceted and personalized, taking into account that obesity is a chronic and progressive condition with little clinical or pathophysiological uniformity. Therapeutic changes in lifestyle (we should no longer speak of balanced diets) include eating behaviour, daily exercise and, on a more global scale, personal and social behaviour. Supporting and monitoring these patients is as important as choosing which measures to take. Obesity medications are primarily useful in maintaining reasonable weight loss (5% to 8% after one to four years) following the initial phase of weight loss. They also impact favourably on quality of life and comorbidities. Bariatric surgery is an effective way to treat morbid and complex obesity, although it is invasive and only palliative. In addition, it involves two constraints: the medical and surgical team must be highly experienced and nutritional monitoring must be possible for life. The French health care system lacks the infrastructure and physicians trained in obesity therapy and treatment education, and it remains poorly equipped to tackle the problem. Initiatives aimed at prevention and education must be promoted. The role played by dieticians is clearly inadequate, as is that of nurses, psychologists, physiotherapists and sports instructors. Healthcare networks make it possible to expand the availability of services. There is also a need for referral centres. In addition to socioeconomic factors, access to care is often problematic because of inadequate human and material resources tailored to treat obesity. Obesity has become a social illness, and those with the least resources are affected most severely.     

Prise en charge des syncopes aux urgences

Patients admitted for syncope in emergency room represent 1% or 2% of all the patients admitted in these departments. The management of these patients is in European countries far from optimal with a bad cost-effectiveness ratio. A perfect knowledge of the definition of syncope associated to precise management, based initially on history taking and exclusion of old ideas should improve markedly the effectiveness of emergency departments. Their role is in fact crucial due to the usually short latency between event and examination. Exclusion of useless exams, particularly neurological and their replacement by useful ones would improve the chances of patients to have an appropriate treatment at a lower cost.     

Prise en charge thérapeutique des pubalgies de l’adulte sportif

Groin pain is a very complex pathology in sports. We described our experience in therapeutic management of male athletes in each specific clinical form of groin pain and for each step of treatment and rehabilitation.