[Carotid surgery under locoregional anesthesia]. / Chirurgie carotidienne sous anesthésie loco-régionale.

Eight-five carotid endarterectomies were performed in 77 patients, under regional anaesthesia using 2 different techniques: cervical epidural anaesthesia (35 cases) and cervical plexus block (50 cases). The patients' mean age was 71 years; 80 per cent had arterial hypertension and 41 per cent coronary disease. Transoperative cerebral ischaemia was detected by a 5-minute carotid clamping test, the occurrence of a neurological event indicating that shunting was required. In 62 patients this test was combined with measurement of carotid back pressure. None of the patients needed general anaesthesia. Intraoperative neurological events occurred more frequently (P less than 0.01) when the carotid back pressure was 25 mmHg or less, and 12 temporary shunts were installed for that reason (14.1 per cent). Three neurological events occurred at the end of endarterectomy: no shunt was installed and complete recovery was observed immediately after declamping. No complications ascribable to the anesthetic techniques were recorded. Mortality was nil, and the only neurological morbidity was a brachio-facial deficit which left few sequelae. The frequency of intra- or postoperative arterial hypertension was similar in both groups. Intraoperative hypotension, frequent under epidural anaesthesia, was observed in only one patient who had brachial plexus block (P less than 0.01). The analgesia obtained was equally good with both anaesthetic techniques, but cervical plexus block anaesthesia is easier to perform, had less haemodynamic repercussions and therefore tends to be preferred to cervical epidural anaesthesia. The lack of mortality, low morbidity and absence of systemic complications in this series despite the high number of patients at risk are in favour of this type of anaesthesia, notably for such patients. Moreover, because vigilance is preserved attention can be paid to the quality rather than the rapidity of endarterectomy, which is the best way of preventing embolism.

Surgical treatment of a tuberculous thoracoabdominal aneurysm.

We report a case of tuberculous thoracoabdominal aneurysm successfully treated by surgery. Computerized tomography was diagnostic for location and etiology. The therapeutic plan included antituberculosis drug therapy started before surgery, direct PTFE prosthetic replacement and omentoplasty. A survey of other reports dealing with tuberculous abdominal or thoracic aorta involvement shows that their frequency, as that of tuberculosis in general, is diminishing.

[Treatment of pheochromocytoma]. / Traitement du phéochromocytome.

Apart from the problems of preparation for surgery, the difficulties lie mainly in general anaesthesia. Blood pressure variations and cardiac arrhythmias must be prevented. Anaesthesia must be given with a lot of care and must be deep, and some stages are particularly dangerous: induction, intubation (it is best to give a local anaesthetic with lignocaine), manipulation during dissection which should be very gentle, ablation of the tumour or clamping the draining veins. Treatment of the arrhythmias detected on ECG monitoring is based mainly on the use of lignocaine. Continuous monitoring of intra-arterial pressure is used to detect any variation. Only the severe bouts of hypertension need correction with phentolamine or nitroprussiate. In cases of shock, the essential point of management is to reestablish an adequate circulating volume: intravenous fluids are best given with control of pulmonary pressures which allows dangerous overload to be avoided. The specific problem of malignant pheochromocytoma is two-fold: treatment of the hypertension, at best with alpha-methyl-tyrosine or otherwise, with labetolol or prazosine, and treatment of the tumour, which has still not been resolved, and for which trials of chemotherapy are in progress.

[Control of gastric acidity with cimetidine given as premedication before general anesthesia: efficacy and tolerance]. / Contrôle de l'acidité gastrique par la cimétidine donnée en prémédication avant l'anesthésie générale: efficacité et tolérance.

Cimetidine 400 mg was administered intramuscularly 60 minutes before the beginning of general anaesthesia. The double blind experiment was conducted on 84 patients divided in two groups: cimetidine and control. There was no difference in gastric fluid volume between the two groups during general anaesthesia, but acid secretion decreased significantly in the cimetidine group. Values of pH lower than 2.5 were observed in 33.3 per cent at induction and 34 per cent at recovery in the control group against 14.6 per cent and 0 per cent in the cimetidine group. Clinical tolerance to cimetidine was studied in 100 patients during operation. Cimetidine did not alter pharmacological action of usual anaesthetics. There were no significant changes in cardiovascular and electrocardiographic data.

[Venous fistulization of an iliac aneurysm (author's transl)]. / Fistulisation veineuse d'un anévrysme iliaque.

The first reported case of a left iliac arteriovenous fistula from rupture of an aseptic atheromatous aneurysm is described. The fistula occurred proximally to a primary iliac vein thrombosis which explains the clinical picture observed of very severe "blue" phlebitis and the absence of any cardiac complications. The fistula was treated by the endo-aneurysmal approach and arterial continuity re-established with a prosthesis. The postoperative result was excellent.

[Cimetidine in pre-anaesthetic premedication. Intra-operative clinical tolerance (author's transl)]. / La cimétidine donnée en prémédication. Etude de sa tolérance per-opératoire en vue du contrôle de l'acidité gastrique.

Intra-operative clinical tolerance of cimetidine was studied in 100 patients undergoing abdominal surgery. Cimetidine (400 mg) was administered one hour before operation intramuscularly. Cimetidine did not alter pharmacological action of usual anesthetics. Recovery was quieter. There was no significant changes in cardiovascular and electrocardiographic datas. These results are in accordance with previous prospectives works. However, heart rate seems to decrease three hours after cimetidine injection. Such bradycardias as well as blood pressure drop have been recently published by various authors in retrospective studies, and may be explained by an action of cimitidine on cardiac H2 receptors.