Ivor Lewis procedure for epidermoid carcinoma of the esophagus. A series of 264 patients.

Since 1982, Ivor Lewis esophagectomy has been performed on 264 patients with epidermoid esophageal carcinoma in our series. The mean age was 59. There were 243 men and 21 women; 91 patients had respiratory or cardiovascular problems. Two-hundred forty-eight tumors were located in the lower two thirds of the esophagus. Sixty-eight patients had preoperative radiochemotherapy with cisplatinum and 5-flourouracil. One half of the resected specimens showed no residual tumor after radiochemotherapy. Tumor infiltration was T3 or deeper in 162 specimens, and 142 were N0. The main complications were respiratory (16%) and leaks (7%). Respiratory insufficiency was always fatal, but only 16% of the leaks led to death. The overall postoperative mortality was 4.5%, and the overall 5-year survival is 33.3%. Only T1 tumors have a significantly better prognosis (53.2% 5-year survival) as compared to T2 (30.6%) and T3 (27.2%), both at 5-year survival. Negative lymph node patients have a significantly improved 5-year survival rate of 44.8% vs. 15.2% for node-positive patients. For T3 tumors, preoperative radiochemotherapy seems to improve survival. Comparison of Ivor Lewis esophagectomy with other procedures shows no radical differences in complications. The 5-year survival rate seems unaffected by the procedure chosen; radiochemotherapy and extended lymphadenectomy still need further assessment.

Interactions between H-2 and background genes modulate collagen induced arthritis in high (HI) and low (LI) antibody producer Biozzi mice.

The experimental arthritis (collagen induced arthritis, CIA) induced in mice by heterologous collagen of type II is mainly restricted to the H-2q or H-2r haplotypes. However, data including ours, strongly suggest that CIA is also under non MHC polygenic control. This point has been studied in new sub-strains of high (HI) and low (LI) Biozzi mice made congenic for H-2q and H-2s: the original Biozzi lines HI/H-2q and LI/H-2s and the new HI/H-2s, LI/H-2q congenic mice. 80% of the HI/H-2q mice develop severe chronic inflammatory symptoms with joint deformation and swelling soon after induction of the disease, while 60% of LI/H-2q counterpart develop at a later stage, deformation of joints with no or mild swelling. In the H-2s haplotype, considered to be non or weakly permissive to CIA, 40% of HI/H-2s have strong CIA symptoms; the LI/H-2s being totally refractory. Thus, if MHC products play a crucial role in selecting the arthritogenic epitope of CII; non H-2 genes strongly modulate the severity of experimental arthritis.

Functional differences in the specific B-cell compartment in high or low antibody responder mice.

The role of antigen-presenting cells (APC) in quantitative antibody synthesis regulation was studied in mice genetically selected for high (HI) or low (LI) antibody response. Irradiated spleen cells and enriched specific B cells from HI and LI mice co-isogenic at H-2s locus, were compared for their capacity to present chicken ovalbumin (OVA) to specific T-cell hybridomas. Minor differences were observed between HI and LI mice when three distinct hybridomas were stimulated in the presence of OVA and splenic macrophages APC. These differences were totally abolished when APC were pulsed with OVAxAb complexes. Looking at the B-cell compartment, hybridoma IL-2 responses were similar when TNP primed B cells were pulsed with OVA. However, when OVA was targeted on TNP-specific enriched B cells by pulsing with TNP-OVA, the IL-2 production by the T-cell hybridomas was stronger in the presence of HI B cells than in the presence of LI B cells. These results strongly suggest that an efficient Ag handling/processing by specific B cells is a major component of the high Ab responder status in Biozzi mice.

T helper subset involvement in two high antibody responder lines of mice (Biozzi mice): HI (susceptible) and HII (resistant) to collagen-induced arthritis.

CD4+ T helper cells play a critical role in the chronicity of collagen-induced arthritis (CIA) in mice. The present results focus on the involvement of Th1 and Th2 subsets at the initial stage of the experimental disease in two lines of mice selected for high antibody production: HI that is susceptible, and HII that is resistant to CIA. Both lines are known to be H-2q, display an identical full set of V-beta genes, and mount similar antibody responses to both heterologous and autologous CII. The kinetic analysis of local T cell and anti-bovine CII antibody responses was followed by Elispot assays, the production of interferon-gamma (IFN-gamma) and IgG2a being considered indicative of a Th1 profile, and interleukin-5 (IL-5) as well as IgG1-IgE, of a Th2 profile. The number of IL-5 Elispots is constantly higher in susceptible than in resistant mice. The IFN-gamma production is rather low in HI compared to HII, and besides, preferential help is observed for the Th2-dependent IgG1-IgE isotype-producing B cells in HI, while a switch-over toward IgG2a anti-CII isotype is found in HII. These results suggest that a Th1 preeminence at the onset of the anti-CII response is decisive in the resistance to CIA.

[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.

[Significance of skin tests in pre-operative assessment]. / Intérêt des tests cutanés dans le bilan pré-opératoire.

The authors report their experience of skin tests used to investigate cellular immunity in the detection of a high risk population pre-operatively. Over an 18 month period, 114 patients about to undergo major surgery were tested. The following three antigens were used: candinin, varidase and tuberculin. Results confirmed the prognostic value of these tests in terms of the overall prediction of complications (75 per cent in anergic individuals as against 24,4 per cent in reactors--p less than and deaths (45 per cent in anergics as against 8,5 per cent in reactors--p less than). Similarly, complications and deaths due to infection were more numerous in the anergic group (respectively 45 per cent and 25 per cent) than in the reactors (respectively 14,8 per cent and 4,2 per cent). Amongst factors which might influence the immune response, the authors studied successively the sex and age of the patients, pre-operative infection, neoplasia and undernutrition.

[Value of cimetidine in the prevention of Mendelson's syndrome in abdominal surgery]. / Intérêt de la cimétidine dans la prévention du syndrome de mendelson en chirurgie abdominale.

The action of cimetidine on gastric acid secretion being perfectly known, the authors sought to confirm the possible efficacy of a single injection of cimetidine, by the intramuscular route, combined with the premedication, on the reduction in gastric secretion during the operative period. Fifty patients undergoing routine surgery were divided into two groups at random. One group was used as a control. The patients of the other group received 200 mg of cimetidine by intramuscular injection one hour before surgery. In all patients, gastric pH was measured by a colorimetric technique at the time of induction, one hour after induction and two hours after induction. The number of samples with a pH of less than 2.5 was very significantly decreased (p less than 0.01) at the time of the induction of anaesthesia. The authors suggest the administration of cimetidine as pre-anaesthetic premedication in all cases where a Mendelson's syndrome is particularly feared.

[Postoperative gas gangrene. Apropos of 22 cases]. / Gangrènes gazeuses post-opératoires. A propos de 22 cas.

The authors report twenty two cases of post-operative gas gangrene. In the series studied mortality was 40.9 p. 100, independent of age and sex. Rapidly progressive forms were the most severe. The delay before effective treatment was prescribed influenced prognosis. In clinical terms, shock and associated renal insufficiency were grave, as well as a picture of respiratory distress which led, in certain cases, to contra-indication of one of the therapeutic possibilities, i.e. that of hyperbaric oxygen. Responsible organisms could be isolated in nineteen cases from local samples. There was a marked predominance (15 cases) of clostridium perfringens. Contamination with aerobic flora was common. Examination to assess favourizing circumstances led essentially to a conclusion of the role of microbial contamination, ischemia, broad spectrum antibiotics, absence of appropriate antibiotics and underlying immuno-depression. Treatment was based in the majority of cases on the triple combination of antibiotics, surgery and hyperbaric oxygen, as well as the correction of any general systemic disorders. Mortality was markedly reduced (31 p. 100) in patients receiving complete and early treatment. The gravity and recrudescence of disorders due to anaerobic organisms lead the authors to review current therapeutic possibilities. Appropriate treatment should be prescribed in all situations where an infection due to anaerobic organisms is feared, and should cover the risk of clostridial infection (penicillin 200,000 mu/kg/24 h) as well as the risk of bacteroides (metronidazole 25 mg/kg/24 h). Curative treatment should be prescribed, even in the absence of bacteriological proof, on the basis of presumptive clinical evidence, this being a true emergency which should not be delayed under any circumstances.