[Surgery of acute necrotizing pancreatitis. Active prolonged drainage in 157 consecutive patients]. / Chirurgie des pancréatites aiguës nécrosantes. Drainage actif prolongé chez 157 patients consécutifs.

OBJECTIVES: Conventional surgery and non-surgical methods have given unsatisfactory results for the treatment of acute necrotic pancreatitis. We therefore adoptive active prolonged drainage with the aim of controlling both acute enzyme toxicity and secondary necrosis. METHODS: One hundred fifty-seven patients with necrotic pancreatitis defined as the presence of extensive pancreatic or peripancreatic necrosis at laparotomy were divided into three groups according to previous care: group 1 no prior medical or surgical treatment (n = 46, 29%), group 2 prior medical but no surgical treatment (n = 48, 31%) and group 3 prior medical and surgical treatment (n = 63, 40%). Spiral drains were placed in the drainage grooves after necrosectomy and post-operative drainage with Mikulicz bags. Continuous lavage-drainage was then maintained for 45 days. Enteral nutrition was initiated on day 7 (mean) and increased progressively to 75 kcal/kg/day so parenteral nutrition could be interrupted 8 days later. RESULTS: There were 28 deaths (18%) including 6 in group 1, 10 in group 2 and 12 in group 3 (13, 21 and 19% respectively). Deaths were due to early multiple organ failure (n = 16), progressive degradation of the clinical situation (n = 8) and sudden death despite improvement (n = 4). Complications requiring re-operation occurred in 44 patients (28%). Among the 129 survivors, mean duration of hospitalization was 70 days including 60 days in the intensive care unit. CONCLUSIONS: Compared with results from former series, active prolonged drainage appears to be more adapted to the natural history and anatomic presentation of acute necrotic pancreatitis.

[Implantation of pancreatic islets in arteriolar epiploic flap. Preliminary note on 3 cases]. / Implantation d'ilôts pancréatiques en site artériolaire épiploïque. Note préliminaire à propos de 3 cas.

Presently, no long-term insulin withdrawal after islet graft in a diabetic patient has been reported. From October 1988 to December 1989 we have performed 3 pancreatic islet grafts in 3 type I diabetic patients. Islets were isolated from pancreatic glands collected during multiple organs harvesting. Implantation was conducted in an original site, by an arteriolar embolization of an epiploic flap pedicled from the right gastroepiploic vessels. Those grafts were combined twice with a kidney and in one occasion with a liver transplant. After 15 months, this last case is an unique metabolic success with complete insulino-independence. Endogenous insulin-secretion determined by C-peptide measurement was not detectable before surgery but was normalized and stimulable 6 months after the graft. Insulin injections were stopped one month later. Blood glucose is fully normal since 8 months without insulin. For the two other cases with kidney transplants after two months, endogenous insulin is already detectable. Compared with 3 segmental pancreatic grafts performed during the same period, islet graft in diabetic patients appears as a promising approach.

[Comparison of the antithrombotic effects of heparin, enoxaparin and prostacycline in continuous hemofiltration]. / Comparaison des effets antithrombotiques de l'héparine, l'énoxaparine et la prostacycline au cours de l'hémofiltration continue.

Continuous anticoagulation is required during haemofiltration to prevent the deposition of fibrin and the formation of thrombus which would lead to early clotting of the haemofilter. This study aimed to compare the efficiencies of 3 different anticoagulation protocol: 150 IU.kg-1.day-1 heparin (group HEP), 1.2 mg.kg-1.day-1 enoxaparin (group ENX), and a combination of 0.8 mg.kg-1.day-1 enoxaparin with 5 ng.kg-1.min-1 prostaglandin I2 (group ENX and PGI2). A flat ANS69S (Hospal) haemofilter was used for continuous venovenous haemofiltration. Antithrombotic efficiency was assessed with a haemofilter permeability index (HPI) including the transmembraneous pressure gradient and the rate of production of ultrafiltrate. The time required for HPI to decrease to 1/3 of its initial value (HPI1/3) was used to compare the 3 protocols. Treatment tolerance was judged by monitoring the usual haemodynamic and haemostatic parameters. No adverse effects (bleeding, thrombosis, hypotension) were observed. HPI1/3 was 15.1 +/- 2.4 h, 18.3 +/- 3.1 h and 28.2 +/- 4.2 h in groups HEP, ENX and ENX and PGI2 respectively. High dose enoxaparin reached antithrombotic efficiency without increasing the risk of haemorrhage. The use of low doses of prostaglandin I2 greatly increased HPI1/3, without any deleterious haemodynamic effects. However, the high cost of prostaglandin I2 needs to be put in the balance with the increase in duration of haemofilter life. Therefore, further investigations are required to evaluate the possible synergy between heparin and prostaglandin I2, as well as the biological parameters which need to be monitored.

[Effects of anesthesia induction with propofol on plasma renin activity and atrial natriuretic factor secretion. A preliminary study]. / Effets de l'induction anesthésique au propofol sur l'activité rénine plasmatique (ARP) et la sécrétion de facteur natriurétique auriculaire (ANF). Etude préliminaire.

The authors have noted a substantial increase in plasma renin activity, when the patients were induced with propofol (2.5 mg.kg-1). Although a direct or an indirect effect of propofol may be suggested, the design of this study is not helpful in pointing out the responsibility of the drug in the observed effects. Further studies including peripheral vascular resistance measurements should be undertaken.

Functional evaluation of gastric transplants used in esophageal reconstruction.

Gastric transplants using the Akiyama method were used to treat esophageal carcinoma in 12 patients. Endoscopic examination, prolonged manometry (greater than 30 min), and 24 h pH monitoring were performed postoperatively to evaluate functional results. All patients could swallow without difficulty at the time of examination and had no dysphagia, regurgitation, heartburn, or sensation of abdominal fullness. Histologic examinations of residual esophagus showed microscopic esophagitis in 5 patients. Percentage of time that pH less than 4 was 42.6 +/- 10.9% (mean +/- SEM) and median pH was 4.3 +/- 1.0. The manometric examination showed no 'esophageal-like' peristaltic waves, but synchronous contractions were demonstrated in 9 patients, gastric type activity in two patients, and no activity was detected in one patient. We conclude that retained gastric peristaltic function is not a prerequisite for a good clinical outcome for swallowing and that despite vagotomy, the stomach continues to produce enough acid to maintain an acidic pH.

[Biological criteria of denutrition. Search of significant parameters for diagnosis and management in surgical departments]. / Critères biologiques de la dénutrition. Recherche de paramètres significatifs pour le diagnostic et la thérapeutique en milieu chirurgical.

Assessment of the nutritional status of surgical patients with a mean weight loss of 11.5 kg included determination of the following biochemical parameters: prealbumin, retinol-binding protein (RBP), serum vitamin A and serum zinc. Patients' immunological status was investigated by delayed hypersensitivity skin tests. Prealbumin and RBP are decreased in patients. RBP levels are significantly lower than in controls: RBP therefore seems to be a better criterion of denutrition than prealbumin. Serum RBP and vitamin A concentrations are not always correlated in patients; for instance, in malabsorptions, the sharp fall in serum vitamin A is isolated. The decrease in mean serum zinc concentrations is minor. Three patients have positive skin tests with severe biochemical disturbances; only serum zinc concentrations are normal and correlated with the results of skin tests. Interpretation of investigations in surgical patients is dependent on the cause of weight loss. However, biochemical and immunological assessment of the nutritional status can demonstrate specific deficits and improve preoperative nutrition.