A simple tool to evoke physicians' real training needs.

Commonly used methods for identifying the training needs of general practitioners do not enable the real needs felt during interviews with patients during office visits to be detected. In this study, the authors evaluate how physicians' use of a personal-office-visit diary affects the level of specificity of their expressed training needs. In 1999, the authors carried out a controlled intervention trial using a random sample of 1,038 general practitioners from a region of France, randomized to intervention and control groups. The practitioners in the intervention group were asked to identify their training needs using a personal-office-visit diary. The level of specificity for their expressed needs was compared with that of the expressed needs of the practitioners in the control group. The use of the diary was associated with a significantly higher level of specificity in the training needs identified by the general practitioners who participated. Independent of the intervention, practitioners under 40 years of age, those in urban practice, and those who were members of a continuing medical education (CME) association expressed their training needs with higher specificity. The personal-office-visit diary would seem to be a simple, inexpensive, and useful tool for more specifically identifying training needs, which could help establish more appropriate and better-targeted training programs. However, it should be assessed further by those involved in CME for general practitioners.     

Obturator hernias — Report of seven cases

Summary Obturator hernias comprise a rare group of abdominal hernias. They are often diagnosed when the small bowel has become obstructed and the patients are operated on without the causes of the obstruction being known. Although many techniques for closure of the defect are available, there is no agreement at the present time as to which is the procedure of choice.     

Preoperative imaging versus intraoperative localization of tumors in adult surgical patients with hyperinsulinemia: A multicenter study of 338 patients

Three hundred thirty-eight patients with organic hypoglycemia were referred to French-speaking surgeons during an 18-year period (1965–1983). Two hundred sixty-eight (79%) of these patients proved to have benign tumors (12 multiple), 37 (11%) had carcinoma, and 11 (3%) had hyperplasia. Of the remaining 22 patients, 9 (2%) were not operated, 12 (4%) underwent negative pancreatic explorations, and 1 (0.3%) was misdiagnosed. The use of preoperative localization studies (computed tomographic scan, arteriography, ultrasound, and transhepatic portal sampling) were successful in 195 (62%) of 315 patients. Intraoperative diagnostic studies (blood sugar and insulin assays) in peripheral and portal blood, and intraoperative ultrasound were positive in 86% (265/305) of patients.

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Resumen Fuimos comisionados por la Asociación Francesa de Cirugía para resumir la experiencia de los cirujanos de habla francesa que manejaron insulinomas a partir del advenimiento de la arteriografía en 1965. El período cubierto por el estudio fue el de 1965–1983; su enfoque principal fue el análisis de las imágenes diagnósticas pre- e intraoperatorias y la localización de los insulinomas.Trescientos treinta y ocho pacientes con hipoglicemia orgánica fueron referidos a cirujanos de habla francesa durante el período de 18 años del estudio. Doscientos sesenta y ocho (79%) de estos pacientes presentaron tumores benignos (12 fueron múltiples), 37 (11%) presentaron carcinoma, y 11 (3%) presentaron hiperplasia. De los restantes 22 pacientes, 9 (2%) no fueron operados, 12 (4%) tuvieron una exploración pancreática negativa, y 1 (0.3%) tuvo un diagnóstico erróneo. La realización de estudios preoperatorios de localización (tomografía computadorizada, arteriografía, ultrasonografía, y muestreo portal transhepático) fue exitosa en 195 (62%) de 315 pacientes.Los estudios intraoperatorios de diagnóstico (determinación de glicemia y de niveles de insulina) en la sangre periférica y la sangre portal, y la ultrasonografía intraoperatoria fueron positivos en 86% (265/305) de los pacientes.

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Résumé Nous avons étudié les résultats de 338 patients adressés pour hypoglycémie organique entre 1965 et 1983. Deux cent soixante-huit patients (79%) avaient une tumeur bénigne (12 tumeurs multiples), 37 (11%) avaient une lésion maligne, et 11 (3%) avaient une hyperplasie. Des 22 patients restants, 9 (2%) n'avaient pas eu d'opération, 12 (4%) ont eu des explorations pancréatiques négatives, et chez 1 (0.3%) patient, le diagnostic était faux.La localisation préopératoire par tomodensitométrie, artériographie, échographie, et dosages de la veine porte par voie transhépatique était positive chez 195 (62%) des 315 patients.Les études diagnostiques préopératoires (glycémie et dosage d'insuline) dans les prélèvements sanguins périphérique et porte, et l'échographie étaient positives chez 265/305 (86%) des patients.

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Commissioned by the French Association of Surgery.     

Stenosing and perforated ulcers of the small intestine related to potassium chloride in enteric-coated tablets. Apropos of 11 cases

The enteric coated KCl tablet formulation generates complications that affect selectively the small intestine. A novel 1 g KCl tablet preparation proved to be accountable for the development of a specific type of intestinal disease. 11 cases of stenotic ulcers of the proximal ileum have been treated at the Clinique chirurgicale "C" (CHRU, Nancy) since January 1986, 9 of them presenting with perforations. These 11 patients required potassium replacement, which was being supplied by the same tablet formula. A study of these 11 cases focusing on the patients history and clinical characteristics was carried out, that included both macroscopic and microscopic examinations of the lesions. Arterial and venous networks were visualized by X-ray in two surgical tissue specimens, respectively, following injection of contrast material. The authors were thus able to bring forth evidence of the clinical uniqueness (prodromal pain reminiscent of K?nig's syndrome and peritonitis characterized by asthenia); to identify the main risk factor (i.e., reduced bowel movement); as well as describe the basic lesion (pylorus-like stenosis), and propound a novel theory concerning the etiology and the pathology of this condition. The observation of the aforementioned cases initiated a nation-wide, post-marketing pharmacological survey, which resulted, as did a similar investigation which had been carried out in the States, in the discontinuation of any treatment by this type of galenic form of the product.     

Ventricular fibrillation following administration of thrombolytic treatment: The EMIP experience

Reperfusion-induced ventricular fibrillation has been dem onstratedin animal models of myocardial ischaemia, but no evidence existsfor this in humans. The European Myocar dial Infarction Projectcompared the efficacy and safety of pre-hospital thrombolytictherapy with that of hospital therapy. The objective of thisstudy was to investigate the occurrence of reperfusion-inducedventricular fibrilla tion in acute myocardial infarction patientsfollowing thrombolytic therapy. In a double-blind multicentre trial, eligible patients wererandomized to receive anistreplase at home followed by placeboin the hospital (A/P group), or placebo followed by anistreplase(P/A group). The occurrence of ventricular fibrillation, andother adverse events were recorded on specific study forms andcould be attributed to defined time intervals. The incidence of ventricular fibrillation in the A/P group wassignificantly higher following the pre-hospital injection thanin the P/A group (2.5% vs 1.6%; P=0.021); the situation wasreversed following the hospital injection (3.6% vs 5.3%; P=0.002).No relationship was found be tween this excess of ventricularfibrillation and the patients condition, with the exceptionof the site of the infarct. These results suggest the existence of reperfusion-induced ventricularfibrillation in patients developing myocardial infarction whoreceive thrombolytic treatment.     

Pediatric-Like Therapy for Adults with ALL

Ten years ago, the first studies comparing the results of adult versus pediatric protocols in adolescents with acute lymphoblastic leukemia (ALL) clearly showed that differences in ALL genetics and treatment tolerance could not be the only reasons for the worse outcome observed in adults with this disease as compared to children. It became evident that intensified pediatric chemotherapy regimens could be associated with better response rates and longer survival in adults as well. During the last decade, the use of pediatric-like or pediatric-inspired protocols in adults allowed markedly improving the outcome of young adult patients aged up from 40 years to 60 years, confirming this initial observation. Administration of pediatric-like therapy in adults is now associated with estimated 5-year overall survival comprised between 60 % and 70 %. In this new context, the risk factors and the place of stem cell transplantation need to be reassessed.     

Solitary rectal ulcer syndrome: a series of 13 patients operated with a mean follow-up of 4.5 years

Solitary rectal ulcer syndrome (SRUS) is an infrequent pathology often associated with pelvic floor disorders. The aim of this retrospective study was to review the long-term results of a surgical series of SRUS. Between 1988 and 1998, 13 patients were operated on for SRUS. Seven patients had associated internal rectal prolapse (58%), two had associated total rectal prolapse (15%), and two had associated mucosal prolapse (15%). We performed simple resection of the SRUS in one case (8%), a stoma as primary operation in one (8%), three rectopexies according to Orr-Loygue (23%), and eight Delorme's operations as modified by Berman (62%). Mean follow-up was 57 months (range 15-112). Simple resection of the solitary rectal ulcer syndrome did not improve symptoms. Colostomy permitted relief of symptoms and healing of the SRUS. Two of the three rectopexies achieved good results, and the third patient relapsed at the 6th postoperative month. A secondary modified Delorme's operation permitted relief of symptoms and healing of the SRUS. Five of the eight patients (62.5%) who received modified Delorme's operations had improved at a follow-up of 46 months. We conclude that, considering the high failure rate after surgery, operations should be performed only in patients with total rectal prolapse or intractable symptoms not amenable to behavioral therapy. Delorme's operation and abdominal rectopexy help in about 60% of cases.     

Long-Term Results of Transanal Repair of Rectocele Using Linear Stapler

PURPOSE: This study was designed to determine the long-term outcomes of transanal rectocele repair using a linear stapler.METHODS: Between 1989 and 1999, 21 patients with symptomatic rectocele were enrolled for this study. Median age at time of presentation was 52 (range, 21–75) years. All patients underwent a transanal repair using a linear stapler. End evaluation to assess long-term results was performed after a median duration of follow-up of 58 (range, 12–118) months. Patients were asked about current problems with constipation, use of laxatives, incontinence, vaginal digitalization, presence of vaginal bulge, pain, bleeding, and sexual dysfunction.RESULTS: The postoperative course was uneventful in all cases. Sixteen (76 percent) patients had symptomatic relief. The operation reduced symptoms of obstructed defecation (21 vs. 5, preoperative vs. postoperative; P < 0.001) and the need of vaginal digitalization (21 vs. 6; P < 0.001). Only three patients (14 percent) showed no sign of improvement. Two patients (9 percent) had temporary improvement for three years before recurrence.CONCLUSIONS: Transanal repair of rectocele using a linear stapler is an easy, safe, and useful procedure for the correction of symptomatic rectocele. Successful long-term outcome can be achieved with this procedure.Reprints are not available.