Clinical and polygraphic evolution of sleep-related breathing disorders in adolescents.

It has been suggested that sleep-related breathing disorders (SRBD) involve a continuum that develops over the course of life. If modifiable factors could be identified, the progression of SRBD could perhaps be addressed early in life. Although some studies have looked at the evolution of SRBD in pre-pubertal children, very few studies obtained data in adolescents. Anthropometric, clinical and polygraphic variables were collected during a 4-yr follow-up study among 148 normal adolescents after initial cross-sectional analysis. From a total of 267 adolescents studied at baseline (mean+/-sd age 14.3+/-2.1 yrs), 148 (55.4%) were followed up for 4 yrs. During follow-up, there were no significant changes in snoring and polygraphic parameters. However, a tendency toward weight gain with centrally distributed fat was observed. Habitual snorers had a significantly higher body mass index and more centrally distributed fat than nonsnorers. Males had a higher snoring prevalence and a higher number of respiratory events than females. Snoring at baseline, male sex and poor academic performance were significant predictors of snoring at follow-up. Snoring tends to persist during adolescence and male sex acts as a risk factor. A relationship between snoring and academic performance was observed. These findings may have implications for long-term management of sleep-related breathing disorders.

Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure.

The present study assessed the usefulness of home cardiorespiratory polygraphy as an alternative to overnight polysomnography for the diagnosis of sleep-disordered breathing in heart failure. A total of 75 patients with chronic stable heart failure due to systolic dysfunction (left ventricular ejection fraction < or =45%) underwent polysomnography at the Virgen del Rocio Hospital and cardiorespiratory polygraphy at home. The two studies were performed in random order and within 30 days. The accuracy of polygraphical findings was determined by sensitivity and specificity obtained by area under the receiver operating characteristics (ROC) curves for apnoea-hypopnoea index (AHI) thresholds of > or =5, > or =10 and > or =15 in the polysomnography. The area under the ROC curve for AHI > or =5, > or =10 and > or =15 was 0.896, 0.907 and 0.862, respectively. The diagnostic accuracy of polygraphy compared with polysomnography ranged 78.6-84%, with sensitivities of 68.4-82.5%, and specificities of 88.6-97.8% for the different AHI thresholds. Altogether, 29 patients had an AHI > or =10 (central pattern 24, obstructive pattern 5). Sensitivity and specificity of home polygraphy for identifying the sleep-disordered breathing pattern was 100%. These data show that home cardiorespiratory polygraphy has a high sensitivity and specificity for the diagnosis of sleep-disordered breathing associated with heart failure.

[Assessment of excessive day-time sleepiness in professional drivers with suspected obstructive sleep apnea syndrome]. / Evaluación de la somnolencia diurna excesiva en conductores profesionales con sospecha de síndrome de apnea obstructiva durante el sueño.

Excessive daytime sleepiness is a common symptom of obstructive sleep apnea syndrome (OSAS) and can be a cause of traffic accidents, creating a problem of particular importance for professional drivers given the associated death, disability and professional repercussions. We assessed whether the Epworth sleepiness scale (ESS), which is a subjective measure of daytime sleepiness, correlates well with multiple sleep latency (MSL) testing, which gives an objective measure of daytime sleepiness. We also compared each method with the results of polysomnography (apnea-hypopnea index, arousal index and minimum oxygen saturation). We studied 55 professional drivers suspected of OSAS. All answered the ESS questionnaire and underwent polysomnographic and MSL testing. We found a significant, though not relevant, correlation between the degree of excessive daytime sleepiness estimated by the ESS and by MSL testing (r = -0.41; p = 0.002). A significant, though weak, correlation was found between the ESS score and the arousal index (r = 0.26; p < 0.05). Our results do not clarify which method is best for measuring excessive daytime sleepiness in professional drivers suspected of OSAS.

Evaluación de la somnolencia diurna excesiva en conductores profesionales con sospecha de síndrome de apnea obstructiva durante el sueño / Assessment of excessive daytime sleepiness in professional drivers suspected of obstructive sleep apnea syndrome

La somnolencia diurna excesiva es un síntoma frecuente en el síndrome de apnea obstructiva durante el sueño, y puede ser causante de accidentes de tráfico. Este aspecto tiene especial importancia en los conductores profesionales, por la morbimortalidad y repercusión laboral que puede suponer. Hemos evaluado si la escala de somnolencia de Epworth (ESE) (medida subjetiva de la somnolencia diurna) se correlaciona bien con el test de latencia múltiple del sueño (TLMS) (medida objetiva de la somnolencia diurna). Además, hemos comparado ambos métodos con algunos parámetros de la polisomnografía (PLSG) (índice de apnea-hipopnea, índice de arousals y saturación de oxígeno mínima). Hemos estudiado a 55 conductores profesionales con sospecha de síndrome de apnea obstructiva durante el sueño. A todos se les aplicó la ESE y se les realizó una PLSG y un TLMS. Encontramos una correlación significativa, aunque no relevante, entre el grado de somnolencia diurna excesiva estimada mediante la ESE y la medida por el TLMS (r = -0,41; p = 0,002). Al comparar ambos métodos con la PLSG, tan sólo encontramos una correlación significativa, aunque muy débil, entre la ESE y el índice de arousals (r = 0,26; p < 0,05). Según nuestros resultados, no está claro cuál es el mejor método para medir la somnolencia diurna excesiva en conductores profesionales con sospecha de síndrome de apnea obstructiva durante el sueño (AU)

[Interest in several surgeries for serious abdominal trauma]. / Intérêt de la chirurgie en plusieurs temps dans un cas de traumatisme abdominal grave.

Abbreviated laparotomy and planned reoperation(s) is a new concept in severely injured patients with multivisceral failure by hemorrhagic shock, coagulopathy and hypothermia. The aim of an abbreviated laparotomy is to control hemorrhage, prevent digestive contamination and close the abdominal wall without tension. After a delay for reanimation during 24 to 96 hours, discovery of unknown lesions and anatomic reconstruction will be possible through planned reoperation in better conditions. Emergency reoperation for hemorrhage and abdominal hyperpression severely worsens prognosis.

Laparoscopy for acute small-bowel obstruction secondary to adhesions.

BACKGROUND AND PURPOSE: Postoperative adhesions are the leading cause of small-bowel obstruction in developed countries. Several arguments suggest that laparoscopy may lead to fewer adhesions than does laparotomy. We report here the short-term results of laparoscopy in patients admitted on an emergency basis for acute small-bowel obstruction secondary to adhesions. PATIENTS AND METHODS: This prospective trial included 134 consecutive patients: 39 underwent emergency surgery, and 95 had laparoscopic adhesiolysis shortly after resolution of the obstruction with nasogastric suction. Of the previous operations for which the dates were known, 16% had taken place within 1 year of the obstruction and 33.5% within 5 years. In all, 27% of the patients had open laparoscopy, and 16% had conversions: 7% after elective laparoscopy and 36% after emergency laparoscopy. RESULTS: There were no operative deaths. One patient underwent a reoperation the following day for fistula after incomplete adhesiolysis attributable to multiple adhesions found during elective laparoscopy. If laparoscopy is considered to have failed when adhesiolysis was incomplete or conversion or reoperation was necessary, our success rate was 80% after elective laparoscopy and 59% after emergency laparoscopy. CONCLUSION: Emergency situations in acute small-bowel obstruction combine several circumstances unfavorable for laparoscopy: a limited work area and a distended and fragile small bowel. Laparoscopic adhesiolysis after the crisis has passed may produce better results, but only long-term follow-up can confirm the role of elective laparoscopy for this indication.

Endermologie: humoral repercussions and estrogen interaction.

Endermologie is a motorized rhythmic folding-unfolding and suction technique of the panniculus adiposus. Our study shows that one 40-min Endermologie session produces no noticeable changes in biological parameters, except for plasma estradiol levels, which vary significantly, first by decreasing during the session, then by increasing afterward. Such an Endermologie/estrogen interaction can be compared to the clinical effects observed in some patients undergoing regular Endermologie treatment: return of menses in amenorrheal patients and a trophic effect on skin and subcutaneous connective tissue comparable to that observed during postmenopausal hormone replacement therapy. Understanding such an interaction with the estrogen metabolism requires additional studies and opens many paths for research on therapeutic applications before and after menopause beyond refinement of the body contour and improvement of the appearance of the panniculus adiposus.

[Laparoscopic treatment of recurrent inguinal hernia after only mesh]. / Traitement par voie coelioscopique des récidives après mise en place de plaques pour cures de hernies de l'aine.

The recurrences of inguinal hernia after onlay mesh may cause technical difficulties for a new repair. The aim of our study was to assess intraoperative findings, feasibility and results of laparoscopic transpreperitoneal mesh onlay in this indication. Twenty-one repairs were performed. In all cases, direct, internal, inguinal recurrences were observed, associated in two cases with an external or femoral recurrence. In 16 cases, there were no adhesions in the peritoneal cavity. The were no conversions and peritonealisation was always completed. The mean length of hospitalization was 2.7 days. Our study suggests that technical errors during the first procedure, insufficient mesh or wrongly positioned are responsible for recurrence and allow reinsertion of a mesh laparoscopy via transpreperitoneal in this indication.

[Acute occlusions of the small intestine caused by adhesions. Indications and results]. / Occlusions aiguës du grêle sur bride. Indications et résultats.

Postoperative adhesions are the first cause of small bowel occlusion in developed countries. Nevertheless no progress was done in prevention and treatment of this disease. The aim of this trial is to report results of 276 small bowel occlusions caused by adhesion recently operated and consecutive between first january 1993 and 31 december 1996. These patients had 400 previous surgical procedures, within 67.4% infra mesocolic or pelvic. 15.1% of previous surgical procedures took place less than one year before and 36% less than 5 years. Thirty five per cent of patients were operated during 24 hours following admission 23.2% of patients had a digestive resection, caused by necrosis or iatrogenic dissection. Operative mortality was 4.3% without resection and 16.6% with resection. Progress are warranted to reduce the rate of redux of occlusion and mortality and morbidity in this benign disease: more peri operative attention and place of laparoscopy should be considered.

[Association of obstructive apnea syndrome during sleep and narcolepsy]. / Asociación del síndrome de apnea obstructiva durante el sueño y la narcolepsia.

Obstructive sleep apnea syndrome (OSAS) is highly prevalent. Daytime hypersomnolence (DHS) is among its symptoms, although other diseases, such as narcolepsy, can also give rise to DHS. We describe three men diagnosed of OSAS whose DHS persisted even after snoring disappeared following treatment with continuous positive airway pressure. We suspected associated narcolepsy, which was confirmed by multiple sleep latency testing. Narcolepsy, therefore, should be considered when DHS persists even after appropriate treatment of OSAS.

Results of liver transplantation in the treatment of metastatic neuroendocrine tumors. A 31-case French multicentric report.

OBJECTIVE: The purpose of this study was to assess the value and timing of orthotopic liver transplantation (OLT) in the treatment of metastatic neuroendocrine tumors (NET). SUMMARY BACKGROUND DATA: Liver metastasis from NET seems less invasive than other secondary tumors. This observation suggests that OLT may be indicated when other therapies become ineffective. However, the potential benefit of this highly aggressive procedure is difficult to assess due to the scarcity and heterogeneity of NET. METHODS: A retrospective multicentric study was carried out, including all cases of OLT for NET performed in France between 1989 and 1994. There were 15 cases of metastatic carcinoid tumor and 16 cases of islet cell carcinomas. Hormone-related symptoms were present in 16 cases (55%). Only 5 patients (16%) had no previous surgical or medical therapy before OLT. Median delay from diagnosis of liver metastasis and OLT was 19 months (range, 2 to 120). RESULTS: The primary tumor was removed at the time of OLT in 11 cases, by upper abdominal exenteration in 7 cases and the Whipple resection in 3. Actuarial survival rate after OLT was 59% at 1 year, 47% at 3 years, and 36% at 5 years. Survival rates were significantly higher for metastatic carcinoid tumors (69% at 5 years) than for noncarcinoid apudomas (8% at 4 years), because of higher tumor- and non-tumor-related mortality rates for the latter. CONCLUSION: OLT can achieve control of hormonal symptoms and prolong survival in selected patients with liver metastasis of carcinoid tumors. It does not seem indicated for other NET.

[Cystic pneumatosis of the colon. Report of 3 cases and review of the literature]. / Pneumatose kystique du côlon. Rapport de trois cas et revue de la littérature.

Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas is found in cysts located in the intestinal wall. PCI is a sign, not a disease; therefore, its relevance should be interpreted within the whole clinical context. PCI has been found in several distinctive clinical settings, which the authors review in the light of their 3 new cases. Morphologic and endoscopic examinations showed "polypoid" intraluminal formations corresponding to pneumocysts which should not be misdiagnosed with a diffuse polyposis. The most important tasks of the physician include: 1) recognition of the entity of PCI so that patients are not misdiagnosed and mismanaged as having malignancy or polyposis; and 2) differentiation of the benign noncomplicated cases from life-threatening forms (bowel necrosis, perforation, and infections), in which immediate surgery is necessary, and which are associated with high mortality.

[Reevaluation of surgical treatment of cancers of the anus. Therapeutic proposals based on an experience with 33 patients]. / Réévaluation du traitement chirurgical des cancers de l'anus. Propositions thérapeutiques fondées sur une expérience de 33 malades.

Radiotherapy remains the basic treatment of anal cancer especially for epidermoid carcinomas. Tumorectomy and rectal amputation still have indications in the many others histological types and also in aguamous cell carcinomas (> T2) which cannot be totally healed by radiotherapy or after recurrences.

[Surgical hemostasis for hemorrhage after liver biopsy]. / Chirurgie d'hémostase pour hémorragie après biopsie hépatique.

Bleeding after needle liver biopsy (NLB) is well known but surgical hemostasis in these circumstances is rarely assessed. We report 7 cases of laparotomy for hemostasis after NLB. The 7 NLB were done for 6 diffuse hepatopathies and one focal lesion. Three patients had hemostasis disorders at the time of the biopsy. None had cirrhosis. Five patients were operated few hours after the biopsy. Direct hemostasis was performed in 6 cases and in hepatectomy in one. Two patients were reoperated for three repeated hemostasis. Two died. The occurrence of hemoperitoneum after NLB is very rare but serious, occasionally occurring a few days after the biopsy. The respect of contre-indications and technical precautions are the best prevention of this kind of accident.

Does Bilio-intestinal Bypass Still have a Role in the Treatment of Super-obesity?

BACKGROUND: Super-obesity (BMI > 50) is life-threatening. The jejunoileal bypass had Potential long-term problems, and weight loss with gastroplasty May be inadequate. METHODS: From 1988 to 1995, 19 Patients with morbid obesity had jejunolleal bypass with anastomosis of the fundus of the gallbladder to the proximal end of the bypassed jejunum. Of these patients, 11 were superobese, with ages 19-49 years, weight 125-172 kg, mean excess weight 97 kg (73-119) and BMI 56 (50-67). RESULTS: Mean weight loss at 3 years was 60 kg. There was no mortality and no major complications. Patients had 5-6 stools per day and some flatulence. There have been no hepatic, renal, calcium or electrolyte problems. Diseases secondary to obesity resolved. CONCLUSION: Billo-intestinal bypass has been effective and safe thus far.

[Perforations and porosity of surgical gloves. Frequency, mechanism, risk]. / Les perforations et la porosité des gants chirurgicaux. Fréquence, mécanisme, risque.

Surgical gloves constitute part of the most exposed barrier material, as one half of accidental exposures to blood in the exposures to blood in the operating room involve the hands. Approximately 15% of gloves tested at the end of the operation were found to be perforated. Double gloving lowers this rate to 5% with apparently acceptable tolerance for surgeons. Although surgical glove are initially impermeable to various viruses, the porosity increases with the duration of use. This porosity is related to hydratation and deformation of latex fibres. The maintenance of a good barrier function of surgical gloves requires regular changing, at least hourly, in the current state of knowledge.

[Proctitis of diversion on an excluded rectum in patients with hemorrhagic rectocolitis]. / Proctite de diversion sur rectum exclu chez des patients atteints de rectocolite hémorragique.

OBJECTIVES: Diversion colitis is characterized by inflammatory lesions affecting colon or rectum excluded from the fecal stream for varied etiologies. These lesions may mimic both ulcerative colitis and Crohn's disease. The aim of our study was to examine the excluded rectum in patients with ulcerative colitis, and to study the evolution of the pathological lesions after ileo-rectal anastomosis. METHODS: Eighteen patients with ulcerative colitis treated by total colectomy before ileo-rectal anastomosis were studied. The pathological features i.e. glandular alteration, inflammatory infiltrate and mucosal ulceration or fissure, were studied during 3 periods: initial colectomy, excluded rectum at surgery for anastomosis and rectal biopsies after anastomosis. RESULTS: We observed on the excluded rectum a follicular lymphoid hyperplasia (18 cases), granulomas with giant cells (9 cases), mucosal fissures (9 cases). The inflammation extended to the submucosa in all cases and was occasionaly transmural. These lesions disappeared after the anastomosis and then seemed to be connected with the rectal diversion. CONCLUSIONS: The pathological changes of diversion proctitis that includes mucosal fissures, granulomas with giants cells or transmural inflammation, may lead to an erroneous diagnosis of Crohn's disease. The review of the previous colectomy is then mandatory to confirm the initial diagnosis of ulcerative colitis. These lesions disappear after anastomosis.