[Premature rupture of membranes: pathophysiology of neurological impact]. / Rupture très prématurée des membranes: physiopathologie des conséquences neurologiques.

The premature rupture of membranes (PROM) is responsible for 30 % of the premature births because of a high risk of associated chorioamnionitis. PROM and the perinatal infection are recognized as 2 of the main risk factors of periventricular leukomalacia and white matter disease in very preterm neonates. Inflammation associated with PROM is likely to induce neuronal or glial cell death at a developmental stage of great vulnerability for the developing brain. Several mechanisms (release of cytokines, accumulation of free radicals, excitotoxicity, apoptosis...) account for this deleterious effect. The decision to actively extract a fetus subjected to a fetal inflammatory response syndrome should take account of the risks of a proved intrauterine infection for both the mother and the fetus and the risks for the neonate related to a very preterm birth per se. A reasonable attitude seems not to maintain a fetus in an undoubtful septic context in utero if a preterm birth in the very short term appears unevitable. Practically, no consensus gives a recommendation between aggressive or conservative management in case of PROM within 30 and 34 weeks'gestation. Expectant management seems to be indicated before 28 weeks'gestation and intentional delivery could be recommended beyond 34 weeks'gestation due to increased maternal risks compared to relatively low incidence of the complications of prematurity at this term.

Different segmental transit times in patients with irritable bowel syndrome and "normal" colonic transit time: is there a correlation with symptoms?

BACKGROUND: The Rome criteria serve as gold standard for establishing a diagnosis of irritable bowel syndrome (IBS), but only represent a cluster of symptoms. On the other hand, measurement of colonic transit time (CTT) with radiopaque markers is a solid and more objective method to quantify functional abnormalities. The goal of this study was to investigate whether the IBS symptoms, as defined in the Rome II criteria, correspond to objective physiological parameters, i.e. CCTs. METHODS: The study enrolled 148 healthy control subjects and 1385 consecutive IBS patients. Transit times were measured for the whole rectocolon (overall CTT) and for 3 segments (right colon, left colon, rectosigmoid area); segmental distribution of markers and diffusion coefficients were also assessed. In order to analyze homogeneous groups, we restricted analysis to subjects with "normal" CTT (< or =70 hours). RESULTS: Six hundred forty four IBS patients (46%) and 14 control subjects (9%) had CTT >70 h and were eliminated. In subjects with CTT < or =70 h, CTT did not follow a normal (Gaussian) distribution. We identified 3 different CTT clusters in healthy controls and 4 clusters in IBS patients. Even if CTT was not significantly different between clusters, each cluster was characterized by a specific pattern of segmental colonic transit. There was a marked gender difference: women had longer overall CTT values than men, both in control and IBS patient groups (p<0.001). However, female IBS patients had significantly shorter colorectal transit times than female controls (p<0.001), as well as faster transit than in men through the left colon and rectosigmoid area. There were no significant differences in transit time between male IBS patients and male controls with the exception of a faster rectal transit in IBS patients (p<0.01). There was no association between segmental colonic transit values and sign or symptoms comprising the Rome II criteria. CONCLUSIONS: In subjects with CTT < or =70 h, CTT does not follow a normal distribution but is clustered in subgroups that can be distinguished only by measuring segmental colonic transit. Within these subgroups, there is a marked difference in transit times between IBS patients and normal subjects, suggesting that IBS patients with "normal" CTT are not "normal". The Rome II criteria do not reflect differences in segmental transit times in IBS patients with "normal" CTT. We therefore propose to evaluate segmental transit times in IBS patients with "normal" CTT, before and after treatment, in order to correctly interpretate variations in signs and symptoms. These findings have important implications in evaluating the effect of drugs on bowel function and should help define better inclusion criteria for studies evaluating new drugs for the treatment of IBS.

[Early spontaneous ileal perforations in preterm infants: report of 4 cases]. / Perforations iléales précoces sans signes d'entérocolite ulcéronécrosante: à propos de quatre cas survenus chez des prématurés.

An ileal perforation occurred shortly after birth in 4 very premature newborns. Diagnosis was made on an abdominal distension with a pneumoperitoneum on X-ray. There were no biological, radiological nor histological signs of necrotizing enterocolitis. There were no digestive short- or long-term complications. According to the few authors who described this syndrome, there are some risk factors, but they were not clearly involved in our cases. Ileal perforation in the absence of signs of necrotizing enterocolitis is rarely reported but should be well known because of its good prognosis.

Anal sphincter response to distension.

Resting anal pressure as determined by manometry is unsuited for assessing the competence of a sphincter. To validate a compliance method of sphincter evaluation we investigated the response of the anal canal to distension. In 20 healthy subjects the anal sphincter was distended using a cylindrical balloon probe subjected to continuous inflation. Two speeds of distension were used: 12 and 80 ml/min. Deflation, at the rate of inflation, immediately followed the inflation at 12 ml/min, and at 80 ml/min was performed after a deformation volume of 12 ml was maintained for 2 min. The response of the anal sphincter to 12 ml/min distension was characterized by an initial phase of resistance followed by relaxation of the anal sphincter in all subjects. In contrast, at 80 ml/min no opening was obtained. During the deformation a biomechanical relaxation curve was recorded. We conclude that the anal sphincter acts as a low-pass filter and not only as a pressure barrier. The response of the anal sphincter to distension is a simple test, which provides functional information on the behavior of the anal sphincteric zone.

Effects of oral pinaverium bromide on colonic response to food in irritable bowel syndrome patients.

We have recently developed a simple method to investigate the colonic response to food (CRF). This study describes the modifications of CRF induced by treatment with oral pinaverium bromide in irritable bowel syndrome (IBS) patients. Thirty healthy subjects and 43 patients suffering from IBS were studied. Colonic transit time (CTT) was measured in fasting conditions and after eating a standard test meal. Colonic response to food was quantified by calculating the variation in number of markers in each zone of interest of the large bowel between the X-ray films of the abdomen taken before and after eating. CRF is characterized by caudal propulsion of colonic contents in the two groups. In controls, there is emptying of the caecum-ascending colon region and filling of the rectosigmoid. In IBS patients, only the left transverse colon and the splenic flexure empty. Pinaverium bromide exerts no effect in controls but reverses the CRF of the right colon in IBS patients by inhibiting right colon emptying. These results suggest that the inhibitory action of pinaverium bromide on CRF may support the clinical efficacy of this calcium channel blocker in the treatment of IBS.

Anal pressure waves in patients with irritable bowel syndrome.

PURPOSE: Many data suggest in irritable bowel syndrome a generalized smooth-muscle disorder, but data are scant concerning anal waves in patients with irritable bowel syndrome. The aim of the present study was first to propose a new method of anal pressure-wave analysis and second to apply this method to patients with irritable bowel syndrome. METHODS: Spectral analysis was used in 20 healthy controls and 60 patients with irritable bowel syndrome to investigate anal pressure waves at rest during a standard anorectal test and during a maintained 12-ml anal distention. RESULTS: Adaptation of the anal canal to maintained distention was similar in the two groups of subjects. Using a cluster analysis, three groups of anal waves were defined (in cycles per minute): ultra slow waves (0.9-3.3), slow waves (3.8-16.4), and simple waves (16.9-23). In the resting state only simple waves were found less prevalent in patients with irritable bowel syndrome. During maintained distention, ultra slow waves increase in both groups, but slow waves increase in patients with irritable bowel syndrome and simple waves decrease in controls. CONCLUSIONS: Characterization of anal pressure waves is a simple procedure that is easy to perform in outpatients. Anal pressure waves of patients with irritable bowel syndrome have altered organization and respond differently to distention as compared with controls.

[A new approach of functional recto-anal exploration: the compliance of the rectum and the anal canal]. / Une nouvelle approche de l'exploration fonctionnelle recto-anale: la compliance du rectum et du canal anal.

We have developed an original method of determining the rectal and the anal compliance. The rectum must serve as a fecal reservoir. This storage function requires that the rectum must be distensible. The anal canal must become easily looser for defecation. These features are not explored by the usual rectoanal manometric recordings. Very few investigations about the compliance are carried out. In our procedure, exploration balloons are connected via polyethylene tubes to pressure transducers, direct-writing electrical recorder and pump under the command of the computer. The pressure generated is as high as the distensibility is poor, as the compliance is decreased. The pressure/volume curve shows the compliance. The procedure is different for the rectum on the one hand, and for the anal canal on the other. The rectal device consists of a balloon at the end of the tube. It shall be inflated until only 60 ml., and then deflated at the same rythm, which is constant during each test. The first test takes place at the speed of 30 ml. per minute; so the inflation lasts 2 mn and the deflation the same time, afterwards the second test lasts one mn for each one, and finally the third one 40 seconds in the same way. For the anal canal, the balloon, ring shaped around the tube, measuring an inch in length, is inflated at only 12 ml. For the first test the inflation and deflation rate of speed is 3 ml per mn, afterwards 6 ml./mn then 9 ml./mn. and thereafter 12 ml./mn/; these series are done in randomized order. In both procedures, an additional relaxation test at the maximum of inflation takes place for 2 minutes. We have explored ten healthy volunteers and 120 patients suffering from various digestive diseases. The curves show the rectal compliance, and in the case of the anus a relaxation, which seems to be an active opening, occurs for a distension of 5-8 ml, i.e. 19-21 mn in diameter. In pathology, the excess of compliance is observed in patients with incontinence, whereas an inadequate compliance is seen in the dyschesia, descending perineum and prolapse, traumatic or surgical injuries, etc. This exploration will be a useful guide for the choice of the convenient treatment and the follow-up.

[Role of surgical visceral manifestations in the natural history of the acquired immunodeficiency syndrome in adults]. / La place des manifestations chirurgicales viscérales dans l'histoire naturelle du syndrome d'immunodéficience acquise de l'adulte.

The surgical effects of AIDS in adults are rather frequent. On the basis of 74 cases, from 1985 to 1992, that we have studied clinically, by imaging procedures, biology, previous and long term follow-up, we have tried to set up the place of these effects in the natural history of the disease. The infectious complications must distinguished from tumorous ones. As to the first, we must underline the alithiasic cholecystitis, more often by cytomegalovirus, the sclerosing cholangitis and anorectal sepsis. So far as concerns tumors, note should be taken of the visceral Kaposi's tumors, and the non-hodgkins lymphomas which may given mass effect, haemorrhage or perforation. The common carcinomas shows an abnormal swiftness of growth. The complications chiefly happen at the C stage, so they are mixed up with other effects and their numerous treatments. Thereafter, the diagnosis and the treatment are difficult as well. In spite of some success in the short term on the complications themselves, the surgical procedures did not alter the general course of the disease. The advanced stage of this one leads to a high rate of mortality. Fifty-three of our patients died in a short time. We lost sight of 10 but in a critical state. The other 11 are still now in remission.

[Anastomoses of the small intestine in a septic environment protected by polyglactin 910-collagen mesh. Experimental study in rats]. / Anastomoses de l'intestin grêle en milieu septique protégées par un treillis de polyglactine 910-collagène. Etude expérimentale chez le rat.

An experimental study was carried out in rats to evaluate the outcome of small bowel anastomoses in the presence of peritonitis with and without protection by a polyglactin 910 mesh. One hundred and thirty rats were operated. 1) Thirty small bowel anastomoses were performed in a sterile environment to evaluate the morbidity and mortality due to the surgical procedure itself. All these animals had an uneventful course. 2) Forty anastomoses were performed in a septic environment without protection. Twelve rats died immediately after the procedure. Six rats developed an anastomotic fistula and 22 had an uneventful course. 3) Sixty anastomoses were performed in a septic environment and protected by a polyglactin 910 mesh. Seventeen rats died immediately after the procedure. There were no anastomotic disruptions. Seventeen rats had an uneventful course, and 28 (65%) developed stenosis of the anastomosis. Protection of small bowel anastomoses by a polyglactin 910 mesh appears to effectively prevent disruptions (no anastomotic fistulae or locoregional infections were recorded). However, the mesh is responsible for an intense inflammatory reaction, that often results in intestinal obstruction.

[Surgical emergencies and pseudo-surgical syndromes in the course of acquired immunodeficiency syndromes in adults]. / Urgences chirurgicales et syndromes pseudo-chirurgicaux au cours des syndromes d'immunodéficience acquise de l'adulte.

Numerous abdominal manifestations were noted among 600 patients undergoing treatment at Hospital Laennec for various stages of infection by the acquired immunodeficiency virus. These included violent abdominal pain in 30% of cases, the development of abdominal lymphoma, and occasionally alarming pseudo-surgical syndromes. Diagnosis is difficult, all the more so since authentic emergencies may be aggravated by the immunodeficiency state. 18 cases were collected in 3 years and included 6 cases of acute cholecystitis and 2 of appendicitis. The gangrenous and extensive nature of infection was generally noted and required appropriate antibiotic therapy.

Comparative analgesic efficacy and tolerability of ketorolac tromethamine and glafenine in patients with post-operative pain.

In a randomized, single-dose, double-blind, parallel comparative trial of analgesic efficacy, 96 adult patients received either 10 mg ketorolac tromethamine or 400 mg glafenine orally the morning after surgery if they requested pain relief medication. Each patient provided a baseline pain assessment and then received the assigned medication. Patients assessed pain intensity and pain relief and reported any adverse events in interviews held 30 minutes after drug administration and then hourly for 6 hours. The demographic characteristics, baseline pain intensity, and surgical categories of the 47 patients who received ketorolac tromethamine and the 49 who received glafenine were similar. Both drugs provided prompt, sustained pain relief throughout the 6-hour observation period, and there were no statistically significant differences between the two groups in any of the efficacy measures analyzed. The global assessment recorded by patients suggested a slight clinical advantage for ketorolac tromethamine (32.6% of 'excellent' responses) as compared to glafenine (12.5% 'excellent'). The differences in overall response were statistically significant (p = 0.017). Fourteen (30%) patients who received ketorolac tromethamine and 17 (35%) who received glafenine reported adverse experiences that began or seemed to worsen after administration of the study drugs. The most prominent were drowsiness and sleeping, both of which are common in post-surgical patients.

[Surgical management of inguinal hernia. A reliable hernioplasty technic with long-term results]. / Cure chirurgicale des hernies de l'aine. Un procédé de hernioplastie fiable à long terme.

The technique described and used by the authors for the past 30 years has the advantage of a low recurrence rate, as proven by the follow-up of most patients. The fascia transversalis is repaired in a way similar to Marcy's technique but in addition the hernial sac is ligated and attached at a high level and parts of the internal and external oblique muscles are folded behind the spermatic cord. This reinforcement of the musculo-tendineous layers makes prosthetic surgery unnecessary in the vast majority of cases.