[Iatrogenic events: a significant cause of admission in intensive care units]. / L'événement indésirable grave: un motif d'admission fréquent en réanimation.

OBJECTIVE: Identification and analysis of iatrogenic events leading to admission in intensive care units. STUDY DESIGN: Prospective observational monocentric study. PATIENTS: Critically ill patients hospitalized in adult medical intensive care unit of a general hospital over a twelve-month period. METHODS: We recorded for each patient the following characteristics: origin, demographic datas, cause of admission, medical background, severity, diagnosis, ICU length of stay and provided treatments. Two medical investigators identified the iatrogenic character of events and determined their potential preventability. Univariate statistical analysis was performed. RESULTS: During the study period, 603 patients were admitted and 71 (12%) due to iatrogenic events. In comparison to patients hospitalized for other causes, these patients were older (66 years vs. 60, P 0.009) and often previously treated in a hospital (82% vs. 54%, P<0.0001). They had increased need for transfusions (39% vs. 26%, P 0.02) but less frequent indications for mechanical ventilation (67% vs. 77%, P 0.07). They had similar ICU mortality (20% vs. 19%). Among them, 27 iatrogenic events were considered as preventable. CONCLUSIONS: Iatrogenic event is a significant cause of ICU admission, involved in 12% of all the hospitalizations in our unit. It has an impact on the patient's profile (significantly older) and their ICU stay (increased need for transfusion). More than a third of events could be preventable and potentially accessible to corrective actions.

[Arsenic poisoning: a special gastroenteritis...]. / Intoxication à l'arsenic: une gastro-entérite un peu particulière...

Arsenic (As) intoxication is nowadays extremely rare. Two cases of acute and chronic As criminal poisoning leading to death of a couple of retired people, are reported. Clinical presentation was simulating a gastro-enteritidis with fast evolution to refractory shock. Toxicological analysis confirmed this diagnostic, with respectively blood As concentrations at 579 and 21 765 microg/l for our two patients.

Multiorgan failure caused by intravascular lymphoma: a highly rare and malignant hemopathy mimicking multisystemic disease.

This manuscript describing a case of intravascular lymphoma, displays the difficulties underlying its diagnosis. We emphasize that intravascular lymphoma should be considered in patients with multisystemic manifestations without obvious etiology. Despite the heterogeneous presentation of this lymphoma, some clinical and biological investigations should prevail clinicians to do tissue biopsy which is required to make the diagnosis.

[Implication of dexamethasone adjunctive therapy after the onset of cerebral vasculitis in Streptococcus pneumoniae meningitis]. / Implication du traitement adjuvant par dexaméthasone dans la survenue d'une artérite septique cérébrale au cours d'une méningite à Streptococcus pneumoniae.

Few adverse effects have been reported with adjunctive dexamethasone treatment in pneumococcal meningitis. Nevertheless, we report a case of cerebral vasculitis. A 49-year-old man was admitted for fever and altered mental status. Lumbar puncture revealed a high inflammatory response and Streptococcus pneumoniae was identified by culture. Antibacterial therapy and adjunctive dexamethasone treatment were initiated as recommended. The immediate outcome was favorable but due to the onset of focal cerebral abnormalities, a CT scan was performed on the ninth day showing cerebral vasculitis. The patient died on the thirteenth day despite antibacterial therapy and resuscitation. In our case, a secondary neurological worsening appeared when adjunctive dexamethasone treatment was stopped suggesting a rebound effect. Observation of similar cases may lead to modifying adjunctive dexamethasone treatment protocol in bacterial meningitis.

Patient's opinion about written information before laparoscopy: a consecutive series of 100 cases.

PURPOSE: The aim of this study was to assess the opinion of the surgical patient concerning written information before laparoscopic operations. MATERIAL AND METHODS: A prospective and consecutive series of 100 patients was studied. Information sheets concerning the planned laparoscopic operation were distributed at preoperative consultation. A short and clear questionnaire regarding this information was answered upon hospitalization. RESULTS: The majority of the 87 patients, who had read the information, were very pleased to be informed about the techniques (91%) and the risks (97%), although a significant group was worried by the explanations of the risks (41%). None of the patients cancelled the planned operation. None of the patients had become less confident in the surgeon. Most of the patients (95%) found this system of informed consent necessary. CONCLUSIONS: Surgeons should no longer be reluctant to distribute standardized information sheets, as a majority of patients find this system of information necessary.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

SUMMARY: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Safety of laparoscopic approach for acute cholecystitis: retrospective study of 609 cases.

Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.

[Hepatopulmonary syndrome: physiopathology of impaired gas exchange]. / Syndrome hépatopulmonaire. Physiopathologie des anomalies des échanges gazeux.

The hepatopulmonary syndrome (HPS) consists of a triad of liver dysfunction, increased alveolar-arterial oxygen gradient and intrapulmonary vascular dilations. The mechanisms of impaired arterial oxygenation are still debated but the multiple inert gases elimination technique and more recently contrast echocardiography, greatly facilitated the investigation of such mechanisms. Subsequently the cause of hypoxemia can be attributed to several mechanisms such as ventilation-perfusion mismatch, right-to-left intrapulmonary shunts and alveolar-to-capillary diffusion defect, variously implicated in the severity of the disease. SHP may result from intrapulmonary vascular dilations and angiogenesis but the pathogenesis of such abnormalities is not completely explained. The hypothesis of an imbalance in vasoactive mediators and angiogenic factors has been put forward. Increasing data support the theory that the increase in synthesis and release of nitric oxide (NO) is the key factor modulating vascular tone. If this hypothesis is true, the use of compettive inhibitors of NO synthesis should restore pulmonary vascular tone, reversing the hemodynamic changes and gas exchange impairment of HPS.

Value of microlaparoscopy in the diagnosis of right iliac fossa pain.

BACKGROUND: The possibility of performing minimally invasive exploration of the abdomen could avoid unnecessary appendectomies. Micro-optics and instruments of 2 mm in diameter allow this type of exploration, but the feasibility and the accuracy of the diagnosis resulting from this method have not been evaluated. METHODS: A prospective study of 36 patients (11 men and 25 women) operated on for acute right iliac fossa pain was carried out. The abdomen was explored with a 2 mm optic and with a 10 mm optic in order to characterize the aspect of the appendix. The results were compared with the postoperative pathologic findings of the appendix. RESULTS: The micro-optic procedure failed in 3 patients. The appendix was visualized in 26 patients: in 18 patients through the needle-optic alone, 8 patients requiring additional instruments. The appendix was visualized in all cases with the 10 mm optic. Appendectomy was performed in 34 patients: with microinstruments in 6, with 5 mm instruments in 26, and through a MacBurney incision in 2. The appendix was not removed in 2 patients. A correct diagnosis was made by microlaparoscopy and confirmed by the pathology in 21 patients (58%), made and confirmed in 32 patients with a 10 mm optic (89%). Minor complications included a cecal wall insufflation in 1 patient and a peroperative hemorrhage on a 2 mm port site in another with an uneventful postoperative course. One postoperative parietal hematoma required reoperating removal. No mortality was observed. CONCLUSIONS: The low quality of the image obtained with microlaparoscopy does not permit safely evaluating the aspect of the appendix in case of acute right iliac pain. This method is not recommended for routine abdominal exploration.

Hernia of the diaphragm with gastric volvulus: laparoscopic repair.

The authors present a case of a diaphragmatic hernia with gastric volvulus, 29 months after a left thoracophrenolaparotomy. The surgical repair was performed by laparoscopy. The authors discuss the laparoscopic approach in the treatment of diaphragmatic disorders.

[Cardiac arrest in an adolescent with arrhythmogenic right ventricular dysplasia]. / Arrêt cardiocirculatoire chez une adolescente et dysplasie arythmogène du ventricule droit.

We report the case of a 16-year-old girl who experienced sudden cardiac arrest from ventricular fibrillation, complicating an arrhythmogenic right ventricular dysplasia, a rare heart muscle disorder, occurring typically in young adults, characterized by a fibrofatty replacement of the right ventricular myocardium. Symptomatic ventricular arrhythmias are frequent, and sudden death has been reported. In our case, diagnosis of arrhythmogenic dysplasia was based on the association of one major criterion and two minor criteria as suggested by the relevant task force. In contrast with most other reports, the chest ECG did not display the typical features. An automatic transvenous pectoral cardioverter-defibrillator was implanted. The authors emphasise that juvenile forms are more exposed to ventricular fibrillation and sudden cardiac death, and consequently require the early detection of the disease. Family cases have been described and the occurrence in one individual must lead to investigations in the relatives.

Laparoscopic management of acute peritonitis.

BACKGROUND: The presence of peritonitis has previously been considered to be a contraindication for the laparoscopic approach because of the theoretical risk of malignant hypercapnia and toxic shock syndrome. The aim of this retrospective study was to demonstrate that laparoscopy is feasible, safe and efficient in cases of peritonitis. METHODS: From January 1990 to July 1995, 231 patients had a laparoscopy for acute peritonitis in two centres (91 appendicular peritonitis, 69 gastroduodenal perforated ulcers, 35 perforations of the colon, 36 miscellaneous). RESULTS: The diagnostic accuracy of laparoscopic exploration was 84.8 per cent. The clinical preoperative diagnosis was changed by laparoscopic exploration in 25.1 per cent of patients. An unnecessary laparotomy was avoided in 6.5 per cent of patients and the site of traditional incision was modified in 8.7 per cent. Conversion rates were 25 per cent for appendicular peritonitis, 16 per cent for gastroduodenal perforation and 83 per cent (29 of 35 patients) for colonic perforation. The overall mortality rate was 3.9 per cent. No malignant hypercapnia occurred. Two patients (0.9 per cent) had postoperative septic shock but survived. CONCLUSION: Laparoscopy is feasible and safe in cases of peritonitis. Laparoscopic treatment is particularly effective in the case of appendicular and gastroduodenal perforation. In the case of colonic perforation, the conversion rate remains high but with growing experience and surgical skill, more of these cases will be treated laparoscopically in the future.

Laparoscopic approach in acute small bowel obstruction. A review of 68 patients.

BACKGROUND/AIMS: Laparoscopic management of acute small bowel obstruction has potential advantages over classical laparotomy. The aims of this study were to assess the feasibility and the safety of this technique, as well as to find any predictive success factors. METHODOLOGY: A laparoscopic approach was undertaken in 68 out of 150 patients admitted between 1991 and 1997 for acute small bowel obstruction. RESULTS: The cause of obstruction was bands or adhesions in 80% of the patients. A correct laparoscopic diagnosis was established in 66% of the cases. A laparoscopic treatment was performed successfully in 31 patients (46%), and was assisted by minilaparotomy in 4 patients (6%), and by open herniorraphy in 2 patients (3%). Thirty-one patients (46%) needed a conversion to laparotomy. There were 6 bowel injuries (9%), all recognized during laparoscopy. There were 2 deaths in converted patients and 2 early reoperations for persisting ileus in patients treated by laparoscopy alone or by assisted laparoscopy. CONCLUSION: Acute small bowel obstruction can be treated by laparoscopy alone, or assisted by minilaparotomy or open herniorraphy with advantages for the patient and few complications despite a high rate of conversion. There were no pre-operative predictive factors for successful laparoscopy, except for an isolated previous scar from an appendectomy. Pre-operative predictive success factors were parietal intestinal adhesions, as the only cause of obstruction. Multiple adhesions will mostly require conversion to laparotomy.

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients.

BACKGROUND: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. METHODS: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. RESULTS: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. CONCLUSIONS: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage.