[Cardiac arrest and secondary pulmonary oedema following accidental intramucosal injection of naphazoline in an adult]. / Arrêt cardiaque peropératoire et oedème pulmonaire retardé consécutif à l'injection intramuqueuse accidentelle de naphazoline chez un adulte.

During neurosurgery for hypophysary adenoma under general anaesthesia in a prone position, a 34 year-old-women received accidental 6 ml intramucosal injection of lidocaine with naphazoline. The patient presented a severe bradycardia associated with a major increase in arterial blood pression followed by a brief cardiac arrest. She also presented a prolonged awakening and a pulmonary oedema, which lead to mechanical ventilation. The patient rapidly recovered a normal clinical state.

Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research.

PURPOSE: Because evacuation of effusion or collection could depend on the type of drainage, we compared the effects of closed suction drainage with passive drainage through tubes or undulated drains after abdominoperineal rectal excision for carcinoma on early and late perineal wound healing. METHODS: Of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma between January 1983 and August 1990, unsatisfactory hemostasis or gross intraoperative septic contamination were recorded in 48 patients who were not included in the trial. After rectal excision and closure of the perineum, the remaining 186 patients were randomized to receive passive drainage (PD; n = 96) or closed suction drainage (SD; n = 90). Eighteen patients were withdrawn because of protocol violation, and three were lost to follow-up, leaving 165 (89 PD and 76 SD) patients for analysis. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative and pathologic findings (Dukes stage), and postoperative courses (recurrence, late mortality) were similar in both groups. All patients were followed up for 12 months or until death. RESULTS: The rate of perineums healed at one month was significantly lower (P < 0.05) in PD (55/89 = 61 percent) compared with SD (54/72 = 75 percent) patients. At three months, the rate of healed perineums no longer differed between the two groups (70/87 = 81 percent vs. 60/72 = 84 percent). The number of vaginal fistulas, secondary reopenings, and perineums not healed at 12 months was similar in both groups. Median duration to complete healing was similar in both groups (23 vs. 21 days, respectively). On the other hand, three retained drains were seen in PD patients only. The median duration of hospital stay was identical in both groups (22 days). Seven patients died in the early postoperative period, including one in the PD group and six in the SD group. There was no significant difference in the number of late deaths (3 vs. 7) in PD and SD patients, respectively. CONCLUSION: These results suggest that closed suction drainage should be used after abdominoperineal rectal excision with satisfactory hemostasis or absence of gross introperative septic contamination.

Perineal wound management after abdominoperineal rectal excision for carcinoma with unsatisfactory hemostasis or gross septic contamination: primary closure vs. packing. A multicenter, controlled trial. French Association for Surgical Research.

PURPOSE: This study was designed to compare the results of two methods on the rate of postoperative perineum healing. PATIENTS AND METHODS: In this prospective, randomized, multicenter trial of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma, 48 had unsatisfactory hemostasis or intraoperative gross septic contamination. Three patients were withdrawn because of protocol violation. Of the 45 remaining patients, 21 were randomized to undergo primary closure of the perineum with drainage while 24 underwent packing. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative findings (Dukes stage, degree of hemostasis, gross septic contamination), and postoperative oncologic courses (recurrence, mortality rate) were similar in both groups. All patients were followed for at least 12 months or until their demise. RESULTS: There was no significant difference in the number of early (one vs. zero) or late (five vs. four) deaths between primary closure and packing groups, respectively. Median duration of hospital stay was 25 and 27 days, respectively. Primary closure was associated with a significantly higher rate of healed perineums at one month (30 percent vs. 0 percent) (P = 0.01) and a shorter delay to complete cicatrization (median, 47 vs. 69 days) (P < 0.01). From three months onward, there was no difference in healing between the two groups, but two patients in the packing group had not healed at one year. Conversely, hematoma, perineal abscess, and reoperations were significantly more frequent (P < 0.01) in the primary closure group. CONCLUSION: Primary closure associated with drainage after abdominoperineal resection for carcinoma expedites perineal healing but morbidity is higher.

Indications for right hemicolectomy in carcinoid tumors of the appendix. The French Associations for Surgical Research.

The records of 181 patients with carcinoid tumor of the appendix, seen during a ten year period (1977 to 1987), were analyzed retrospectively to determine the indications for right colectomy and the signification of intermediate histopathologic forms. Appendectomy was the only treatment in 146 patients; while right hemicolectomy was performed upon 35 patients--in seven patients with one postoperative death initially and in 28 patients without any death or morbidity, secondarily. Colectomy was indicated initially in seven patients for bulky tumors of the base of the appendix invading the cecum or for associated carcinoma of the right colon. The 28 secondary colectomies were indicated for tumors that were statistically larger and more invasive than those treated by simple appendectomy or for intermediate forms, or both, in five instances. There were five instances of residual tumor on secondary hemicolectomy specimens. In 11 of the 181 carcinoid tumors (6 percent), the intermediate type tumor was associated with mucinous production--seven adenocarcinoids and four carcinoids with mucocele. Of the seven instances of adenocarcinoid, there was one death at two years and one patient is alive with metastases. Other than size greater than 2 centimeters and base localization, the results of the current study suggest that the presence of mucinous production cells is a further indication for secondary right hemicolectomy.

[Disclosure of protein C deficiency with pulmonary embolism followed by cardiac arrest during the recovery period]. / Révélation d'un déficit en protéine C par une embolie pulmonaire suivie d'un arrêt cardiaque en phase de réveil.

A case of unexpected cardiac arrest occurring in a 17-year-old male patient is reported. The patient had been admitted after sustaining hand trauma. A first emergency surgical procedure was carried out, followed about three weeks later by another one. No incidents occurred during or after either of these two operations. A third procedure was required about two months after the accident (free toe graft to the thumb of the left hand). The twelve-hour operation was carried out under general anaesthesia and axillary block. The patient was given intravenous heparin (800 IU.h-1) during the procedure on the arm. The patient recovered quickly, and was extubated before his transfer to the recovery room. Fifteen minutes later, the patient's heart rate decreased to 40 b.min-1, followed by a transient cardiorespiratory arrest. The suspicion of pulmonary embolism was confirmed by pulmonary scintigraphy. Thrombolysis was carried out with 2,000 IU.kg-1.h-1 of urokinase for a 72 h period, combined with continuous heparin administration (16 to 36 x 10(3) IU.day-1). The patient recovered after one week. No thrombophlebitis was found for origin of the emboli. Biological investigations carried out both before and after 10 minutes of anoxia revealed a normal fibrinolytic system, but a deficit in protein C (62% antigen, 64% activity). Two years after the episode of pulmonary embolism, the patient, still taking acenocoumarol, remained free from any sequela. Current perioperative management of patients with a known protein C deficit is discussed.

[Effect of the parenteral feeding regimen on postoperative nitrogen sparing. Comparison of 3 regimens containing 0%, 30% and 50% lipid calories]. / Influence du régime d'alimentation parentérale sur l'épargne azotée postopératoire. Comparaison de trois régimes apportant 0%, 30% et 50% de calories lipidiques.

Forty one non emaciated patients undergoing major visceral surgery were randomly divided into three groups according to the postoperative parenteral diet (0% fat versus 30% or 50% fat). During five days daily nitrogen balance was studied. There was no evidence of any significant difference between the group 0% and the group 50%. On the other hand significant differences occurred in group 30% on the second, third and fifth postoperative days. The responsibility of inappropriate glucose intakes in envisaged.

[Influence of epidural anesthesia on postoperative nitrogen sparing in major digestive surgery]. / Influence de l'anesthésie péridurale sur l'épargne azotée postopératoire en chirurgie viscérale majeure.

In order to determine the role of epidural anaesthesia on protein sparing, eighteen patients undergoing major visceral surgery were randomly divided into three different groups according to the mode of anaesthesia used (general anaesthesia, epidural anaesthesia, continuous epidural anaesthesia for 24 h). These patients were intravenously fed for five days postoperatively; their nitrogen balance was studied. Compared with the "general anaesthesia" group, only the daily averages of nitrogen balance of the "continuous epidural" group were significantly better. IN order to correlate stress with nitrogen saving, the early evolution of several parameters (cortisol, glucose, prolactin) used as "stress markers" was studied : there was no evidence of any significant difference between the three groups.

[Severe hypophosphoremia in a patient on parenteral nutrition with phosphorus enrichment]. / Hypophosphorémie sévère chez un patient sous alimentation parentérale enrichie en phosphore.

A twenty-four year old patient showed severe hypophosphataemia after emergency surgery for colectasia. A critical study of the case isolated the factors which had favoured the development of this metabolic complication. The necessity for great care in the nutrition of emaciated patients as well as that of a phosphorus supply adapted to the metabolic status of the patient were emphasized. Frequent measurement of serum phosphate was recommended for patients undergoing intravenous hyperalimentation.

[Postoperative hypophosphoremia in digestive surgery. Influence of the parenteral diet]. / Hypophosphorémie postopératoire en chirurgie digestive. Influence du régime d'alimentation parentérale.

Twenty-seven non emaciated patients undergoing major visceral surgery were randomly divided into two different groups according to the postoperative parenteral diet (100% glucose versus 50% fat 50% glucose). All patients received the same anaesthetic protocol and, peroperatively, none received any glucose. In the postoperative phase, parenteral feeding was started on the day of operation (18.5-21.8 kcal X kg-1) and was continued for a minimum of four days (37-44 kcal X kg-1 X 24 h-1). All patients received intravenous insulin and phosphorus (0.15 mmol X kg-1 X 24 h-1). During five days, daily measurements of serum phosphate and glucose levels were made and nitrogen balance was studied. For all these parameters, there was no evidence of any significant difference between the two groups. A significant fall in plasma phosphate occurred in each group on the first postoperative day, was maximum on the second and lasted until the fourth. This fall was not influenced by parenteral diet. No patients in this study developed symptoms of phosphate depletion. The glucose levels increased significantly and the nitrogen sparing effect was similar in both groups. The mechanism of hypophosphataemia seemed to be an intracellular transfer under the influence of hyperglycaemia and high plasma insulin levels rather than an increase in urinary phosphate excretion. The advantage of using lipid solutions did not appear under the dietary conditions studied. Indeed a glucose supply greater than or equal to 3 mg X kg-1 X min-1 seemed to induce a maximum intracellular transfer of phosphorus. Because of this, phosphate supplementation and frequent measurement of serum phosphate are recommended for patients undergoing major visceral surgery and postoperative intravenous feeding.

[Treatment of an urethrorectal fistula by anterior transanorectal perineal approach. Apropos of a case]. / Traitement d'une fistule uréthrorectale par voie périnéale antérieure transanorectale. A propos d'une observation.

The authors report a case of acquired urethro-rectal fistula which was treated by an anterior perineal, transano-rectal approach. They review all of the techniques of approaching these urethro-rectal fistulae which have the reputation for being difficult to treat. This case, like others, demonstrates the harmlessness of section of the anal sphincter, provided it is repaired correctly. The authors propose extending the indications for this approach to include prostato-rectal fistulae.