Enneking type III resection of pubic chondrosarcoma: A case report.

Chondrosarcomas are rare malignant cartilaginous tumor affecting adult and elderly patient. Pelvic and long bones are the most common location. We differentiate conventional chondrosarcoma which arises do novo from preexisting normal bone (primary chondrosarcoma) or within a preexisting lesion such as enchondromas or osteochondromas (secondary chondrosarcoma), Other rare subtypes of chondrosarcoma include clear cell chondrosarcoma, dedifferentiated chondrosarcoma, and mesenchymal chondrosarcoma, which will be considered separately. Although there are diverse clinical presentations depending on the anatomic extend, radiographic features of chondrosarcoma are very characteristic comprising frequently a combination of bone expansion and heterogeneous calcifications. We report a case of a 56-year-old male suffering from fixed mass adhering to the right pubic bone. MRI views showed a lytic lesion of right superior pubic rami, surgical biopsy was in favor of chondrosarcomas, then an en bloc resection was performed following a Pfannenstiel approach without any recurrence after three years of follow-up.

A critical analysis of factors leading to next-day discharge in ambulatory surgery patients.

INTRODUCTION: Ambulatory surgery (AS) is becoming the rule. However, some patients do not have AS despite correct indications. The purpose of this retrospective study of prospectively collected data was to analyze why these patients do not have AS and evaluate their immediate post-operative course, in order to broaden the indications for AS. MATERIAL AND METHODS: Between January and December 2013, the reasons why patients who had appropriate indications for ambulatory cholecystectomy or hernia repair but later had conventional hospital management were recorded. The primary endpoint was early post-operative morbidity. Secondary endpoints were demographic, surgical, anesthetic, post-operative data as well as analysis of criteria leading to conventional hospital stay. RESULTS: Among 410 patients undergoing surgery for accepted AS indications, 158 (39%) did not have AS; 113 out of these patients (72%) were discharged the day following surgery. Of the 69 patients (43.6%) who did not have AS for medical reasons (50 by the surgeon's decision alone), 60 patients could have undergone AS since their outcome was uneventful in 96% of cases; only three patients (2.5%) had post-operative complications. CONCLUSION: The AS rate could have been increased by 15% through better surgical and anesthetic collaboration.

[Observational study on outpatient sleeve gastrectomy]. / Chirurgie bariatrique en ambulatoire: étude observationnelle à propos de 68 sleeve gastrectomies.

UNLABELLED: The development of outpatient surgery is one of the major goals of the public health policy in 2010. The purpose of this observational study is to evaluate the feasibility of the laparoscopic sleeve gastrectomy (LSG) in ambulatory. METHODS: This prospective observational study was conducted from May 2011 to June 2013. The procedure was proposed for patients undergoing LSG who were predetermined inclusion criteria. Following preoxygenation, anaesthesia was induced with propofol and sufentanil. Tracheal intubation was facilitated with rocuronium. Anaesthesia was maintained with desflurane and remifentanil target-controlled infusion. Antiemetic prophylaxis was supplied with intravenous (IV) droperidol and dexamethasone; postoperative pain prophylaxis was IV paracetamol, nefopam, tramadol, and ropivacaine infiltration. The patients were extubated in the operating room and kept in the postoperative care unit. A water-soluble contrast examination was performed in the output of the postoperative care unit. Oral feeding was resumed immediately in the absence of fistula on this leak test in an ambulatory surgical unit. When the patient has satisfied the modified Post-Anaesthesia Discharge Scoring System (PADSS) criteria, he or she can then be discharged and sent home. RESULTS: Among 280 patients operated on for obesity by laparoscopic sleeve gastrectomy during the study period, 68 (24.2 %) underwent ambulatory procedure. Of the 68 obese patients, 94.1 % were female. Mean age was 34.4 years (22-55). Mean preoperative BMI was 42.6kg/m(2). Thirteen patients (19.1 %) had HTN; 7 (10.2 %) had dyslipidemia and 6 (8.8 %) had diabetes not requiring treatment. The mean operating time was 60minutes (range, 45-95) and there were no conversions to open surgery. No intra-operative anesthetic or surgical complications occurred. Mean time in the recovery room was 86.5minutes (35-240). The overall satisfaction rate was 92.6 % (n=63). No patients were admitted because of nausea or inadequate pain control. There were no re-admissions or hospitalizations were reported. We recorded five surgical complications including two case of gastric fistula, one case of gastric stenosis, one case of scar dehiscence and one case of splenic upper pole ischemia. Its complications have arisen from the fourth postoperative day. This does not undermine the ambulatory procedure. CONCLUSION: The laparoscopic sleeve gastrectomy in ambulatory is feasible with a dedicated anesthesiological concept in an expert surgical team. Appropriate patient selection is important in order to secure safety and quality of care within outpatient program. The risk versus benefit must be adequately evaluated on an individual basis.

[Bilateral pneumothorax, cervicofacial and mediastinal emphysema after surgical tracheostomy]. / Pneumothorax bilatéral, pneumomédiastin et emphysème sous-cutané cervico-facial après une trachéotomie chirurgicale.

Tracheotomy is a surgical procedure for various indications, such as ventilator dependence and airway obstruction. Reported rates in the literature of complications of tracheostomy vary widely. We report an unusual presentation of serious complication after surgical tracheostomy. The correct timing of tracheostomy is still controversial in the literature. A 74-year-old male had emergency surgical tracheostomy under general anesthesia. At the end of the procedure, in recovery room, he developed subcutaneous emphysema of the eyes. There was no pneumothorax seen on chest X-ray. Bronchoscopic examination through the tracheostomy tube showed no evidence of damage to the posterior tracheal wall. Three hours later patient had difficulty breathing requiring sedation with respiratory assistance. X-ray of the chest at this stage showed a right pneumothorax and extensive subcutaneous emphysema of the chest wall. Pneumothorax was managed using a chest tube. Two days after, a control CT scan of the chest showed a left pneumothorax and pneumomediastinum. The pneumothorax was managed using a chest tube. Bronchoscopic examination showed no obvious lesion in the tracheobronchial tree. The patient was treated successfully with supportive care and large doses of antibiotic to prevent mediastinitis. Seven days later, recovery was rapid and complete and CT scan of the chest was completely normal. The patient was discharged from the hospital on the 13th postoperative day. This case illustrates that complications occurring after surgical tracheostomy could be dramatic. Management of tracheotomy is important to prevent complications. There is still debate on optimal timing of tracheotomy. The last three trials have shown no interest to perform an early tracheotomy, neither in terms of vital prognosis nor in terms of the duration of mechanical ventilation.

[Unanticipated difficult extubation]. / Extubation difficile imprévue.

Complications at extubation remain an important risk factor in anaesthesia. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. We report a new case of respiratory complications associated with tracheal extubation in a 59-year-old woman. Her medical history included obesity, no criteria difficult intubation and no adverse events during her previous anesthetic procedures. At the end of surgery, immediately after extubation, the patient developed respiratory distress requiring reintubation. A second extubation performed in postoperative recovery room was complicated by a new respiratory distress with reintubation. The patient was then admitted to the ICU. The examination on admission was unremarkable. Chest X-ray and a chest CT scan were performed in search of an etiology. Both tests showed a large thyroid "goitre plongeant" (plunging goiter) and compressive. In the suites, a thyroidectomy was performed with excision of a large cervical plunging goiter para- and retropharyngeal bilateral chest, allowing extubation successfully. The postoperative course was uneventful.

Stapling and Section of the Nasogastric Tube during Sleeve Gastrectomy: How to Prevent and Recover?

Bariatric surgery has become an integral part of morbid obesity treatment with well-defined indications. Some complications, specific or not, due to laparoscopic sleeve gastrectomy (LSG) procedure have recently been described. We report a rare complication unpublished to date: a nasogastric section during great gastric curve stapling. A 44-year-old woman suffered of severe obesity (BMI 36.6 kg/m2) with failure of medical treatments for years. According to already published technique, a LSG was performed. Six hours postoperatively, a nurse removed the nasogastric tube according to the local protocol and the nasogastric tube was abnormally short, with staples at its extremity. Surgery was performed with peroperative endoscopy. In conclusion, this is the first publication of a nasogastric section during LSG. Therefore we report this case and propose a solution to prevent its occurrence. To avoid this kind of accident, we now systematically insert the nasogastric tube by mouth through a Guedel cannula. Then, to insert the calibrating bougie, we entirely withdraw the nasogastric tube.

Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study.

INTRODUCTION: The surgical treatment of large incisional hernias with loss of domain (LIHLD) carries the risk of fascia closure under tension and, thus, abdominal compartment syndrome. We investigated volume measurements as a predictive factor for tension-free fascia closure. PATIENTS AND METHODS: From September 2004 to July 2008, we prospectively included 17 patients with LIHLD. The operation was prepared by a progressive preoperative pneumoperitoneum (PPP) technique known as the Goni Moreno procedure. The patient's age and body mass index (BMI), the incisional hernia's width, length and surface area, and the incisional hernia volume (IHV)/peritoneal volume (PV) ratio <20% were evaluated as predictive factors for tension-free fascia closure. A tension-free closure was defined as a closure in which the use of a surgical device for avoiding postoperative compartment syndrome was not required. RESULTS: The mean PPP volume introduced was 12.7 ± 4.4 l (range 4.5-19.2) over a period of 11 ± 6 days (range 4-24). The mean width, height and surface area of the incisional hernia after PPP were 11.3 ± 4.7 cm (range 4.5-19), 13.4 ± 7.8 cm (range 4.4-30) and 165 ± 101 cm(2) (range 19-304), respectively. The mean IHV after PPP was 2,374 ± 1,356 cc (range 517-4,802) and the mean abdominal cavity volume was 9,558 ± 4,106 cc (range 4,785-21,782). The mean IHV/PV ratio was 16.3 ± 10.4% (range 4.4-34). In a univariate analysis, the BMI and the IHV/PV ratio were predictive of tension-free fascia closure. In a multivariate analysis, only an IHV/PV ratio <20% was a significant predictive factor. CONCLUSIONS: The IHV/PV ratio is predictive of tension-free fascia closure for hernias or incisional hernias with loss of domain. Simplification of the volumetry method is necessary.

[Management of a retroperitoneal paraganglioma]. / Prise en charge d'un paragangliome rétropéritonéal.

Paragangliomas are rare tumors arising from extraadrenal chromaffin cells. We report a 43-year-old man who presented with abdominal pain. An abdominal computed tomography scan revealed a large retroperitoneal mass. During an endoscopic biopsy of this tumor, the patient experienced marked hemodynamic fluctuations with tachycardia and high blood pressure, and an extraadrenal pheochromocytoma was suspected. Measurements of plasma and urinary catecholamines and urinary total metanephrines ruled in the diagnosis. Echocardiography disclosed acute myocardial dysfunction that returned to normal after surgical resection of the paraganglioma. This report also underlines the importance of the anesthetic preparation and monitoring around the surgical procedure and the need of a long-term follow-up to detect malignant paraganglioma in the absence of histological criteria of benign tumor.

[Splenic rupture and anticoagulant therapy]. / Rupture de la rate et anticoagulant.

Splenic rupture associated with anticoagulant therapy is a rare entity. We report a case of spontaneous splenic rupture in a 62-year-old man who was treated by acenocoumarol orally after an aortic-valve replacement. Unrecognised, minor trauma may lead to splenic haemorrhage in patients receiving anticoagulant therapy. The symptoms and signs may mimic those of acute myocardial infarction and cardiogenic shock. Early diagnosis is essential. Reversal of the anticoagulant and emergent splenectomy are the treatments of choice.

[Spleen trauma during pregnancy (a case report)]. / Traumatisme de la rate au cours de la grossesse (à propos d'un cas).

Splenic injury during pregnancy after blunt abdominal trauma is rare. The physiological and anatomical changes during pregnancy modify the clinical, biological and radiological signs. The authors report a case of a 30-year-old-woman in the 32nd week of pregnancy, with an isolate splenic injury after a motor vehicle accident. Splenectomy was realised 4 days after an initial decision of abstaining from surgery. In pregnancy, the frequency of recurrent bleeding, the possibility of concomitant uterine injuries and the risk of foetal loss should modify the surgeon's attitude to splenic rupture after abdominal blunt trauma.

[Aortobronchial fistula developing from an infectious aneurysm of the thoracic aorta]. / Fistule aortobronchique à partir d'un anévrisme infectieux de l'aorte thoracique.

Aortobronchial fistula presenting as massive haemoptysis is a rapidly fatal process if not promptly diagnosed and repaired. It's an unusual complication of thoracic aneurysm. We report the case of a 61-year-old woman with rupture of a thoracic aortic infectious aneurysm secondary to an Escherichia coli infection. Aortobronchial fistula diagnosis should be considered in patients who have minor or major haemoptysis and correct diagnostic procedures should be performed early. An aggressive surgical approach is often necessary.

[Postoperative analgesia by auriculotherapy during laparoscopic cholecystectomy]. / Analgésie postopératoire par auriculothérapie lors de la cholécystectomie par coelioscopie.

Auriculotherapy based on traditional Chinese cartography can be used for pain relief after laparoscopic cholecystectomy. It consists of palpating and pricking some well defined ear points corresponding to the surgical site. Relief was quickly obtained and compares favourably with minor parenteral analgesics.