[Transabdominal removal of femoral and acetabular components of a severely protruded and infected hip arthroplasty with urinary tract complications]. / Depose par laparotomie des composants d'une prothèse totale de hanche compliquée de migration intra-pelvienne avec complication urinaire.

We present the first report of transabdominal removal of femoral and acetabular components of a severely loosened hip prosthesis protruding into the pelvis. In a 73-year-old woman post-operative development of urinary tract complications emphasize importance of careful assessment of the prosthetic relations with the vascular and nervous structures as well as pelvic organs before removal of the hip prosthesis. Angio-computed tomography is the most contributive exploration to assess vascular relations. In patients with particular clinical presentations or with threatened structures in the vicinity of the prosthesis, this examination must be completed by complementary opacifications (urinary and gastrointestinal tracts, joints). Ureteral catheterization may be needed if the structures are close or if there is a suspected modification of the urinary tract (retraction, mass effect). In present case, we did not opacify the urinary tract before laparatomy despite the presence of urinary signs preoperatively. A suspected ureterovaginal fistula was discovered. But they where also a ureteral lesions which can result from difficult dissection in contact with infected tissues. In this patient, urinary complications led to nephrectomy after temporary pyelostomy for urine bypass. At last follow-up, the urinary tract infection was controlled but reimplantation was not attempted because of insulin dependent diabetes mellitus and poor general condition. The spontaneous course of this infection with prosthesis loosening recalls the importance of regular surveillance of total hip replacements.

Emergency major abdominal surgery in patients over 85 years of age.

The aim of this retrospective study was to evaluate the outcome and prognostic parameters of patients over 85 years of age undergoing major abdominal emergency surgery. The medical records of 45 consecutive patients aged over 85 years who underwent major abdominal emergency surgery between May 1999 and November 2001 were reviewed. The mean patient age was 88 years. Eight patients were American Society of Anesthesiologists (ASA) IV or V, 21 were ASA III, and 16 were ASA I or II. We performed 38 median and 7 right subcostal laparotomies. Perioperative mortality was 26.6% (3 times higher than that of the overall population at the same age). Perioperative complications occured in 29.5% of patients. Ten patients returned home after surgery, of whom 70% remained alive at the end of the study. Twenty-three left the hospital for a long-term care institution or post-acute care unit: of these 20% remained alive at the end of the study. Among ASA I or II patients, 43.7% remained alive at the end of the study, although 18.7% died within 1 month of the surgery. Among ASA III, IV, or V patients, only 17.2% remained alive at the end of the study, and 34.5% died within 1 month of the surgery. None of patients classified as ASA IV or V survived for more than 6 month after surgery. With an overall mortality rate of about 30%, and with the clear correlation between increased mortality and higher ASA scores, the place of palliative treatment must remain a major consideration for patients in this age group classified ASA III or higher. When surgery is performed, early return home, should be encouraged.

[Severe blunt liver injury: reappraisal of criteria for nonoperative management decision. Experience with 88 cases]. / Traumatismes graves fermés du foie: à la recherche de critères décisionnels pour le choix du traitement non-opératoire. A propos d'une série de 88 cas.

AIM OF THE STUDY: To analyze the predictive value of computed tomography (CT) and initial physiologic and laboratory data findings in the immediate operative (OP) or non-operative (NOP) management of blunt liver injury (BL). METHODS: Eighty-eight BL, grade III (51), grade IV (28) and nine grade V (9), aged 26.2 years (16-75) were identified. Hemoperitoneum on CT, hemodynamic status, physiologic and laboratory data <24 hours or preoperative (transfusion, vascular filling) and follow-up >48 hours were analyzed. RESULTS: Data of 71/88 (80%) NOP and 17/88 (20%) OP patients were reviewed. A secondary laparotomy or laparoscopy was necessary in 11/71 TNO. Six OP (35%) and 1 NOP patients died. Blood units transfused were 1.33 (0-10) vs 5.9 (0-22) and vascular filling 1.45 (0.5-5.5) vs 3.6L (2-12) (P<10(-6), P<4.10(-3) respectively). NOP patients had less severe hemoperitoneum (31 vs 94%, P<10(-5)) and hemodynamic instability (8.5 vs 94%, P<10(-4)). But, there was an overlap of values of blood units transfused, amount of vascular filling and initial haemoglobin levels between NOP and OP patients and among CT grades of liver injury. No cut-off values could be determined: 33% NOP received >4 blood units and >3 L vascular filling; 30% had severe hemoperitoneum. In OP group 23.5% patients had lower values and no severe hemoperitoneum. CONCLUSION: In the management of BL, vascular filling and blood transfusion increased with the grade of CT liver injury and were globally more elevated in the operative group but did not individually correlate with hemodynamic stability and did not authorize, by themselves, to decide between operative versus non-operative management.