[Infectious sequellae of 913 central catheters in oncology]. / Suivi infectieux de 913 cathéters centraux en cancérologie.

Infections associated with central catheters are a significant source of morbidity in cancer patients. The first evaluation done as part of a continuous catheter surveillance program included the 913 central catheters inserted in 1995. Three of these catheters are still in place. All were tunneled subcutaneously, and most were inserted via the subclavian route. There were 839 simple silicone catheters and 74 catheters with a cuff. Two groups were defined based on whether the central catheter was inserted for administering inpatient or outpatient chemotherapy (n = 704) or for another reason (perioperative care, symptomatic or palliative therapy; n = 209). Catheter-related infection was defined as an infection at the catheter site or as septicemia retrospectively shown to be related to the catheter. The risk of catheter-related infection was expressed as the number of cases per 1000 days of catheterization. Reasons for catheter removal were distributed in table I.

[Serum marker of the functional hepatic mass after extensive hepatectomy. The branched/aromatic amino acid ratio. Experimental and clinical studies]. / Un marqueur sérique de la masse hépatique fonctionelle après hépatectomie élargie. Le rapport des acides aminés ramifiés (AAR) sur les aromatiques (AAA). Etudes expérimentales et cliniques.

During severe hepatic insufficiency, serum amino acid profile is modified with an increase of aromatic amino acids (AAA) (Tyrosine and Phenylalanine) and methionine concentrations and a decreased value of 3 branched chain amino acids (BCAA) (leucine, isoleucine and valine). These observations have been confirmed after hepatic surgery in experimental and clinical studies. In experimental models, after 10, 32, 68, 77 or 90% hepatectomy in Wistar rats, the BCAA/AAA ratio (R) is correlated with the extent of hepatectomy: r = 0.74, p < 0.001; with the post-operative interval time (8, 24, 32, 48, 168 or 240 hours): r = 0.60, p < 0.001 and with the liver weight when animals are sacrificed: r = 0.64, p < 0.001. In clinical studies, 26 patients have undergone 60 to 80% hepatectomy for primary or secondary tumors of the liver and R is determined on the immediate post-operative day and every day during the first post-operative week. Liver regeneration is followed by single photon emission computerized tomoscintigraphy on days 0, 7 and 30 with assessment of hepatic growth index (HGI) estimated by the ratio: liver mass on day 7 or 30/remnant liver mass on day 0. On post-operative day 7, R is 1.61 +/- 0.3 (normal: 3.5 +/- 0.51). Mean liver volume is 60 +/- 11% and HGI is 1.9 +/- 0.3. On this day, a correlation is found between R and HGI (r = 0.76). On post-operative day 30, HGI is 2.34 +/- 0.50, mean liver volume is 89.6 +/- 0.9% and R is 2.02 +/- 0.65.(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapeutic strategy in 46 cases of radiation injury of the intestine]. / Stratégie thérapeutique dans 46 cas d'intestin radique.

Our expérience in the treatment of 46 cases with radiation enteritis (RE) permitted to summarize 5 key points in the Surgical Strategy: laparotomy incision, enterolysis technique, small bowel and colon preservation, anastomosis technic and parenteral nutritional support. Surgery is imposed most of the time in digestive and nutritional Insufficiencies due to radiation enteritis. 46 patients aged to 33-81 years (mean age = 59) were included for possible surgery. The first clinical digestive symptoms were occlusion (n = 39) and/or digestive fistula (n = 7) and/or perforation (n = 3). These abnormalities were often associated with severe malnutrition (weight loss > or = 20% of usual weight) inducing surgery preparation with pre-operative parenteral nutrition (8 to 350 days). 3 patients were not operated because of general problems and lived 1 to 7 months after the beginning of parenteral nutrition. For operated patients (n = 43), 12 underwent 2 operations (resection and/or enteral liberation) and one patient underwent 4 surgical interventions because of digestive fistula. In 35 cases, small bowel resection was performed leaving 135.4 +/- 62.6 cm of intestine (0 to 225 cm of jejunum and/or ileum) and in 13 cases, complete enterolysis was achieved. All the patients received a post-operative parenteral nutrition during 1 to 23 months (median = 6.2 +/- 5.3 months). 31 patients received home parenteral nutrition during the pre and/or post-operative phase for a median duration of 6.3 +/- 3.2 months (range: 1-23 months). 4 patients died during the immediate post-operative phase and among them, 3 died after the second surgery. 12 deaths were observed due to the primary cancer and 6 due to the evolution of radiation lesions. Median survival of patients without cancer evolution reach 180 months with a 5-year survival rate of 94% (Kaplan-Meier method). In patients with radiation enteritis, the pre and post-operative nutritional support associated with radical surgery allows to obtain prolonged survival in non cancer patients.

[Therapeutic strategy for large cervical, mediastinal metastatic mature teratomas and large retro- and intraperitoneal lesions]. / Stratégie thérapeutique devant de volumineuses métastases tératomateuses matures cervicales, médiastinales et d'énormes lésions rétro et intra-péritonéales.

A 27 years old man was treated after surgery and classic chemotherapy for a right testicular teratoma (stage IV). Two months after the end of chemotherapy the patient developed "a Growing Teratoma Syndrome" with left subclavian and mediastinal nodes enlargement and bulky abdominal cystic masses with vena cava compression, collateral circulation and oedema of inferior members. Four debulking surgical approaches: cervical, thoracic and abdominal were performed and permitted complete functional recovery.

[Chronic pain of cancers. How to update and promote the subcutaneous administration of morphine]. / Les douleurs chroniques des cancers. Comment réactualiser et promouvoir l'administration de morphine par la voie souscutanée?

In order to treat the cancer chronic pains, the morphine is the most relevant analgesic, since it has rapid, powerful and multiples possibilities of administration. The subcutaneous Administration should be proposed in case of impossibility to act orally. It is a simple and efficient choice, which requires to be organised outside the specialised centers, i.e. at the patient's home. Today, the arrival of news materials allows a continuous and ambulatory injection linked to a better efficiency and acceptance (less side effects). The "P.C.A. methods" allows self administration, which meets the needs.

[Prevention by naloxone of adverse effects of epidural morphine analgesia for cancer pain]. / Prévention par la naloxone des effets secondaires de l'analgésie péridurale par morphine pour douleur cancéreuse.

Forty cancer patients were randomly assigned to two groups (n = 20). All had incapacitating pain unresponsive to the usual non opioid analgesic drugs. An epidural catheter was set up at the level of the most painful metamere, and made to pass subcutaneously so as to exit either in the supraclacicular fossa, or on the patient's flank. At T0, the patients were given 4 mg morphine hydrochloride diluted in 10 ml normal saline. Thirty min later, patients in the naloxone group (group N) were given a 0.4 mg bolus, followed by a constant rate infusion of 5 micrograms.kg-1.h-1, of naloxone hydrochloride during 18 h. Patients in group P (placebo) were given normal saline instead. The degree of pain was studied with a visual analogue scale and analgesia was assessed by a clinician on a five point scale. These two parameters were obtained half an hour after the injection of morphine and 2, 4, 6 and 24 hours later. At the same time, the patients were questioned about adverse side-effects: nausea, vomiting, pruritus, dysuria, urinary retention. Respiratory depression was assessed clinically and biologically (blood gas measurements at the afore mentioned times). Heart rate, systolic and diastolic blood pressure were also measured. There was no statistically significant difference between the groups in quality and duration of analgesia. Pain reached its lowest level 4 h after the injection of morphine, returning to half its original value at the 24th h. This was also true for the incidence of nausea (11 in group N, 5 in group P), vomiting (3 in both groups), and urinary retention (6 in group P, 5 in group N).(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic percutaneous gastrostomy. A non-surgical method of enteral alimentation in ORL patients unable to feed orally]. / Gastrostomie percutanée endoscopique. Une méthode non chirurgicale d'alimentation entérale chez les malades ORL ne pouvant s'alimenter par voie orale.

Since surgical gastrostomy is not a risk-free operation in debilitated patients, a method of endoscopic percutaneous gastrostomy (EPG) is proposed. A thread is passed percutaneously into the gastric cavity and brought to the exterior through the mouth during fibroscopy. This thread allows removal of a gastrostomy tube by simple traction. Used in 18 patients with ENT cancer the EPG was simple to perform, postoperative complications being minor in 3 cases and serious in one patient. In the absence of any obstacle in the pharyngeal channel preventing the passage of a fibroscope, EPG is a simple procedure and is therefore an alternative to surgical gastrostomy.

[Intrathecal injection of morphine in the ambulatory treatment of neoplastic pain (lumbar route)]. / Injection de morphine intra-thécale dans le traitement ambulatoire de la douleur néoplasique (voie lombaire).

A intrathecal injection of morphine has been given to 26 patients who present a tumor in activity with pain which withstand to heavy analgesic drugs. A intrathecal catheter with a sub-cutaneous tunnel is in connection with a subcutaneous reservoir. The hospitalisation for implantation is short. The mean efficient dosage is 3 mg of morphine chlorhydrate once or twice a day. About 50% of the patients are improved by this technic. In the future subcutaneous computerized pumps shall give better efficiency, shall decrease the dosage of drug, secondary effects and number of injections.

[Prevention of postoperative lymphocele after breast amputation]. / Prévention des lymphocèles postopératoires après amputation du sein.

Closed suction drainage is widely used after modified radical mastectomy to prevent accumulation of serum or lymph and to promote adherence of the skin flaps to the chest wall. However, between 5 and 35% of the patients develop seroma, which may prolong their stay in hospital and require more frequent post-operative outpatient visits. The prospective study reported demonstrate a significant correlation between the incidence of post-operative seromas, the duration of suction drainage and the amounts of fluid drained. The incidence of seroma also correlated significantly with the patient's age, the size of the breast removed, the presence of arterial hypertension and the post-operative use of heparin. Pre-operative radiotherapy and the TNM type of the tumour had no effect on the duration and volume of drainage nor on the occurrence of seromas. A drainage of short duration and a short stay in hospital are advocated for most mastectomy patients. Delayed mobilization of the shoulder should decrease the volume of accumulated fluid and the incidence of seromas.

[Chemotherapy via tunneled central venous catheter left in place between drug courses. Prospective study in 98 ambulatory patients]. / Chimiothérapie par cathéters centraux tunnellisés laissés in situ entre les cures. Etude prospective chez 98 malades ambulatoires.

Chemotherapy is normally given during several months and requires a good vascular access. Repeated injections of cytotoxic agents are harmful for peripheral veins. We report here a prospective study on 98 ambulatory patients provided with a tunneled central venous catheter left in situ between drug administration. The catheter is inserted either in the subclavian or the internal jugular vein. Between chemotherapy drugs injection, heparin is given once a week in the catheter. Among the several advantages reported with this technique: easiness of drug injection, comfort of patients, possibility of new insertions in an other site in case of occlusion and the low cost. This technique is a "routine" at the Institut Curie since 5 years. Advantages and side effects of this technique are compared with arterio-venous shunting or totally implantable devices used by other authors.

[Technical, immunological and clinical study of the performance of blood filtration using Erypur filters]. / Etude technique, immunologique et clinique des performances de filtration du sang à l'aide de l'appareil Erypur.

Technical, immunological and clinical parameters of blood filtration through Erypur filters were evaluated. Red cell concentrates from which the buffy coat had not been eliminated were used throughout the study. Filtration procedure is fully automated, simple and takes about 15 minutes. 98% of leukocytes and 96% of platelets were found to be retained by the filter. Residual leukocytes were less than 3.10(7) in 68% and residual platelets less than 1.10(10) in 93% of filtered units. The incidence of lymphocyte alloantibody formation was 14.9% in the group of 67 patients who received 210 filtered units and 27.9% in the control group of 93 patients who were transfused with 298 non-filtered units. 330 filtered units were transfused to 107 carefully monitored patients and caused no reaction. 40 of these patients had polyspecific HLA antibodies and/or a documented history of non-hemolytic transfusion reactions. The clinical usefulness of Erypur filtered blood in the prevention of such reactions may thus be confirmed.