Adenocarcinoma de células en anillo de sello en colocistoplastia

We report a case of signet ring-cell adenocarcinoma in augmentation colocystoplasty. We review the current litterature about tumours developping in augmentation bladder     

État des lieux de l’activité de publications en neurochirurgie en France

Bibliometrics are methods used to quantitatively analyze the scientific literature. The application of bibliometrics in neurosurgery is emerging and has not yet been studied in the French neurosurgical community. In France, the most used statistical method is named SIGAPS; the scores are based on the position of the author and the impact factor of the journal. The SIGAPS score, which can be calculated for a research team or an individual, impacts the public financial support of university hospitals in France. We analyzed retrospectively the publication productivity and the SIGAPS score of university neurosurgery departments in France for the period 2009–2016. This was supplemented by a list of current academic research protocols granted by the Minister of Health. The SIGAPS score is higher in large university hospitals even though all teams are dedicated to publishing more in the traditional neurosurgery journals (Neurosurgery, Journal of Neurosurgery, World Neurosurgery, J Neuro-oncology, Neuro oncology, Eur Spine J). Of note, the national Neurochirurgie journal (publishing in French and English) is progressively improving its impact factor (0.8). The most common themes are functional neurosurgery, neuro-oncology and spine. There are 14 on-going national multicenter research programs, 4 of them focused on the health economics of treatment innovations. These data provide the most accurate available snapshot of the scholarly efforts of all the French university neurosurgery departments. It is based on a national statistics method (SIGAPS). For future evaluation, it should be combined with internationally available parameters such as the h-index and m-quotient. Publication productivity has broad implications for the success of both academic departments and individual faculty members and their financial support.     

Quoi de neuf en hyperthermie maligne en 2012 ?

Malignant hyperthermia (MH) is a pharmacogenetic disorder of anesthesia. Recent advances dealing with epidemiology of MH and the safe anesthetic course of MH susceptible patients are shortly presented here with a special insight into the preparation of modern anesthesia workstations, which they will share in operating room.     

Análisis de los factores implicados en el fracaso de la uretroplastia en el varón

IntroductionOutcome of urethroplasty techniques in our environment and risk factors for recurrence of stenosis in these patients are studied in this paper.Material and methodsRetrospective study on men with urethral strictures treated with urethroplasty in the period 2000-2012. Maximum flow (Qmax), post-void residual (PVR) urine and patient perception of voiding were obtained pre- and postoperatively. Complications were recorded according to the Clavien-Dindo scale. Recurrent stricture was defined according to clinical criteria and endoscopic or imaging confirmation (failure of urethroplasty). Univariate analysis (log-rank) and multivariate (Cox regression) were performed to define the variables implied in the recurrence.Results82 patients with mean age 55.6 ± 17.4 (19-84 years) underwent surgery for urethroplasty. 28% of patients showed multiple stricture, 73.2% bulbar stricture, 41.54% penile stricture and 14.6% membranous stricture. End-to-end anastomosis was performed in 26 cases (31.7%), flap urethroplasty in 21 (25.6%), urethroplasty with free graft in 31 (37.8%) and two-time urethroplasty in 4 (4.9%). Graft urethroplasty showed a longer operative time (p = 0.02) and shorter hospital stay (P = 0.0035). The results were: mean ΔQmax (mean on baseline) 9.1 ± 7.5 and mean ΔPVR −65.8 ± 136 (both P < 0.0001). Minor early complications occurred in 8 (9.8%) and major in 3 (3.6%). Recurrence occurred at a mean time of 39.8 ± 39.2 months in 18 patients (21.9%). The percentage of recurrence-free patients was: 91.4% (1-year), 82.1% (5-year) and 78.1% (10-year). Univariate analysis assessed technique used (log-rank, P = 0.13), age (P = 0.2), length stricture (P = 0.003), previous Sachse (P = 0.18), associated lichen (P = 0.18), multiplicity (P = 0.36), year of surgery (P = 0.2), Qmax (P = 0.3) and RPM (P = 0.07) preoperative. End to end anastomosis (HR 4.98, P = 0.04) and length > 3 cm (HR 4.6, P = 0.01) were identified by regression analysis as independent variables associated with poor prognosis.ConclusionLength stricture is both prognostic factor and criterion on choosing the type of urethroplasty, and it makes more complicated to compare the success rates of each surgical procedure. Whatever the stricture size is, the results of anastomotic urethroplasty are worse than those of urethroplasty with buccal mucosal-free grafts.     

Influencia de la fragilidad en el pronóstico de pacientes quirúrgicos mayores de 70 años con criterios de ingreso en UCI

IntroductionFrailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU.MethodsA prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months.ResultsA total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related.ConclusionsThe estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.     

Réalité de la prise en charge de la maladie rénale chronique en néphrologie en France : étude de cohorte CKD-REIN

BackgroundTo be able to assess the impact of the bundled payment system on real-life management of patients with chronic kidney disease, an overview of patient-care management before its implementation is needed.Patients and methodsWe describe patterns of nephrology care over 3 years in 2835 patients with moderate to severe chronic kidney disease, who were followed-up from 2013 to 2019 in the CKD-REIN cohort study. Compliance with health authority guidelines during this period is also studied.ResultsAt baseline, patients’ mean age was 67 years, 65% were men, and 43% had chronic kidney disease stage 4 or 5. The mean number of nephrology visits increased from 1.1 to 2.7 per year, from chronic kidney disease stage 3A to stage 5. The minimum number of nephrology visits as recommended by health authorities was achieved in 84%, 63%, and 33% of patients with chronic kidney disease stages 3B, 4, and 5, respectively. In chronic kidney disease stages 4 and 5, only 34% and 40% of patients had seen a dietitian, and 33% and 54% had received information about treatment options, respectively. The average waiting time for a first appointment with a nephrologist was longer, 60 days and its duration shorter, 30 vs 38 to 40 minutes, in university hospitals compared with non-university hospitals and private clinics.ConclusionThe significant gap between received and recommended care reflects human resources and organizational limits in chronic kidney disease management in the nephrology setting. Improvements with bundled payment are expected.     

Vigilancia activa de masas renales pequeñas diagnosticadas en pacientes de edad avanzada o con comorbilidad: en busca de la mejor estrategia de tratamiento

IntroductionAim of this study is to provide our results after long-term active surveillance (AS) protocol for small renal masses (SRMs), and to report the outcomes of patients who remained in AS compared to those who underwent delayed surgical intervention.Patients and methodsWe retrospectively reviewed our database of 58 patients diagnosed with 60 contrast enhancing SRMs suspicious for renal cell carcinoma (RCC). All patients had clinical and radiological follow-up every 6 months. We evaluated the differences between patients who remained on AS and those who underwent surgical delayed intervention.ResultsThe mean age was 75 years, the mean follow-up was 88.5 months. The median initial tumor size at presentation was 2.6 cm, and the median estimated tumor volume was 8.7 cm³. The median linear growth rate of the cohort was 0.7 cm/year, and the median volumetric growth rate was 8.8 cm³/year. Death for metastatic disease occurred in 2 patients (3.4%). No correlation was found between initial tumor size and size growth rate. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4 cm/year and 16.1 vs. 4.6 cm³/year, respectively; P < .001).ConclusionsMost of SRMs demonstrate to have an indolent course and low metastatic potential. Malignant disease could have faster linear and volumetric growth rates, thus suggesting the need for a delayed surgical intervention. In properly selected patients with low life-expectancy, AS could be a reasonable option in the management of SRMs.     

Experiencia de traumatismo renal abierto en un Servicio de Urología

IntroductionOpened renal trauma in urban areas reaches 15 to 20% of all renal traumas. It is mainly caused by gunshot wounds or knifes. Gunshot wounds are classified as high energy trauma and are usually associated to other organ injuries. We present our experience in opened renal trauma in the last 24 months.Material and methodsRetrospective study: patients with thoracic, abdominal and thoraco-abdominal trauma admitted to the emergency room between July 2009 and June 2011 were studied. Fourteen patients were identified with opened renal trauma, with diagnostic confirmation by imaging study or during surgery.ResultsAges ranged from 16 to 37 years, with a mean age of 24.5 years. Thirteen patients were males. The mechanism of injury was produced by gunshot in 71% (10/14) and by knife in 29% (4/14). The opened renal traumas were classified according to the American Association for the Surgery of Trauma. Of these, 3/14 (21%) belonged to grade II, 4/14 (29%) to grade III, 4/14 (29%) to grade IV and 3/14 to grade V (21%). Fall in hematocrit ranged from 1% to 27%, with an average of 13.9%. Expectant management was done in six patients, however, this management did not take into account those surgeries performed due to non-urologic organ injuries. Six patients (42%) required nephrectomy. Thoraco-abdominal injuries were associated in 11 patients (79%).ConclusionsDespite the low incidence of opened renal trauma, many patients are observed when other national reports are considered, probably due to the socio-cultural characteristics of this hospital.     

Evaluación de la calidad de vida en el periodo postoperatorio inmediato en cirugía general

IntroductionHealth related quality of life measurement (HRQL) is widely accepted as an appropriate outcome of surgical care for assessing effectiveness and for risk adjusted outcomes. Nevertheless its use in the immediate postoperative period has show limitations. The aim of this study is to prove that is possible, with a specific new tool, to assess the HRQL during this period.Patients and MethodsThe study is designed to create a specific close questionnaire related to the patient's condition after surgery, structured in domains, with the subsequent use of: literature searches, patient interviews (n=30), and a Delphi survey with health care providers. Finally the tool was validated using a pre-test (n=36) and a prospective observational cohort trial (n=250), to assess the discriminant validity for different cohorts of patients, reliability, responsiveness, and convergent validity, and to compare with the widely used generic tool, Short Form 36 (SF-36).ResultsThe questionnaire was shown to have good sensitivity to change (single index and domains score), as well as good sensitivity to distinguish cohorts of patients, a high internal consistency (Cronbach's alpha 0.88), absence of redundancy between domains (Spearman's rho range, 0.29–0.84), and good convergent validity with patient opinion. The SF-36 questionnaire showed poor discriminant validity, and lack of convergent validity with patient opinion.ConclusionsThese results support that the created questionnaire is appropriate to assess HRQL in the immediate postoperative period; and was more specific than SF-36.     

Place de l'imagerie isotopique en réanimation

The real place of isotopic imaging in intensive care patients remains still unclear. This review aimed to consider the indications of isotopic imaging for improved diagnosis and therapy and to specify its place among the other techniques of exploration. Pulmonary perfusion and ventilation scintigraphies are valuable for the diagnosis of pulmonary embolism (PE). A « high probabilityscintigraphy of the lungs ascertains the diagnosis of PE and allows to start a specific treatment without requiring a pulmonary angiography. This is not the case in the presence of a history of previous PE or if the arguments for a PE are only weak. A normal lung scintigraphy eliminates the diagnosis of a clinically significant PE all the more as an exploration of good quality of the lower limb veins remains negative. In the opposite a « non diagnosticscintigraphy justifies a pulmonary angiography in intensive care patients. The diagnosis of myocardial contusion is made uneasy as the clinical symptoms, the ECG, the cardiac enzymes and the chest X-ray are only of limited value. Isotopic explorations of the heart could provide additional valuable data or be an alternative for 2 D echocardiography. The comparison of CPK-MB concentrations with a myocardial scintigraphy using thallium 201 is given as being very reliable, with positive and negative predictive values higher than 80 %. An exploration restricted to the cardiac ejection fractions is only of limited value. In the future, an improvement will perhaps be obtained with tracers such as MIBI labelled with technetium 99m, which allow the simultaneous assessment of myocardial perfusion and the ventricular ejection fractions as well. The localisation of centres of infection, especially when intra-abdominal, remains difficult in intensive care patients. Isotopic imaging, especially the scintigraphies with labelled polynuclears, could allow in combination with conventional imaging techniques (computed tomography and 2 D echocardiography) to prevent from errors in diagnosis. An array of arguments is essential for ascertaining the presence of an abscess. Scintigraphies with leucocytes labelled with indium 111 or technetium 99m are qualified as having a sensitivity and a specificity greater than 90 %. The conventional techniques of measurement of the cerebral blood flow (CBF) using xenon 133 require a special equipment or are invasive. Other cerebral tracers, such as cyclic amines (HMPAO) labelled with technetium 99m and administrable by i.v. route, allow the use of a standard tomo-gamma camera, and could be of help in various pathological conditions. In association with cerebral computed tomography, the assessment of CBF with an isotopic technique would allow to differentiate an irreversible ischaemia from a functional hypoperfusion complicating a vasospasm. A cerebral scintigraphy using HMPAO labelled with technetium allows the diagnosis of cerebral death. In case of acute renal failure, the isotopic renal explorations (scintigraphies using DTPA and MAG labelled with technetium 99m) take part in the assessment strategy. These techniques are neither invasive nor toxic. They allow a simultaneous evaluation of the renal perfusion, the glomerular filtration, the tubular secretion and the urinary tract as well. The perfusion phase assesses the renal blood flow. The analysis of the captation phase allows the distinction between unilateral or bilateral and segmentary or global renal failure. The elimination phase can show an obstacle in the upper or lower urinary tract. Isotopic imaging allows sometimes to restrict in intensive care patients the indications for conventional radiology. It also allows a better monitoring and an improved treatment of these patients.