[Atrial fibrillation: from cardiology to perioperative management]. / Fibrillation atriale en anesthésie-réanimation : de la cardiologie médicale à la période périopératoire.

Atrial fibrillation (AF) is the most frequent arythmia. During the perioperative period and in intensive care units, management of patients with AF is frequent and difficult. As in cardiology, two main issues are present: the risk of acute hemodynamically instability and the risk of thromboembolic complication. Cardiological guidelines recently published must guide the management of patients in this context. Two main factors must be kept in mind: acute AF in these situations are often of short duration; the risk of anticoagulation can be superior to the risk of thrombotic complication in this situation. An individualized benefit-risk analysis must be done in each patient. New treatments, antiarrhythmic or mainly antithrombotic drugs, are under evaluation and will be soon available.

Nobody likes premies: the relative value of patients' lives.

OBJECTIVE: The objective of this study was to examine whether patient selection or triage requires placing a relative value on human lives and whether the values placed on these lives are consistent with current ethical theories. STUDY DESIGN: An anonymous questionnaire was administered to groups of physicians and students in Montreal. It presented eight currently incompetent patients with potential neurological sequelae requiring emergency care. Predicted outcomes were explicitly described. Four patients had a predicted 50% survival and a 50% chance of impairment; they were a preterm and a term neonate, a 2-month-old and a 50-year-old. Two already disabled patients, a 7-year-old and an 80-year-old, had 50% predicted survival. A 14-year-old and a 35-year-old had 5% survival, but differing impairment. Respondents were asked if they would resuscitate and in what order they would resuscitate if all needed intervention simultaneously. RESULT: Eighty-five percent response rate, n=524. The proportion stating they would always resuscitate was smallest for the 80-year-old (18% P<0.001 compared to other patients), then the preterm (35%, P<0.001), then the term and the 50-year-old (53 and 58%, P<0.01). The 2-month-old and the 7-year-old would be resuscitated most frequently (74 and 77%, P<0.01), followed by the patients with 5% survival (64 and 68%, P<0.001). The median order of triage was first the 2-month-old, followed by the 7-year-old, the 14-year-old, the term newborn, the 50-year-old, the 35-year-old, the premature newborn and the 80-year-old. CONCLUSION: Order of resuscitation was not closely related to the predicted survival, impairment or potential life years gained. Age appeared to have a strong influence, with children's lives being valued more than the adults'. This tendency was reversed for the newborn infants who were undervalued compared with older children, and most particularly for the premature. The value placed on the life of newborns, in particular the premature, is less than that expected by any objective medical data and was not consistent with any ethical theory that we tested.

Gastric electrical stimulation modulates hypothalamic corticotropin-releasing factor-producing neurons during post-operative ileus in rat.

High-frequency/low-energy gastric electrical stimulation (GES) is an efficient therapy to treat gastric emptying-related disorders but its mechanism of action remains poorly understood. We aimed to assess the effects of high-frequency/low-energy GES on corticotropin-releasing factor (CRF)-producing neurons in the paraventricular nucleus of the hypothalamus (PVN), which are involved in gastric ileus induced by laparotomy. Two electrodes were implanted in the rat gastric antrum during laparotomy, then stimulation (amplitude: 2 mA; pulse duration 330 micros; frequency: 2 Hz; 1 min ON/2 min OFF) or sham stimulation (control group) were applied. Using immunohistochemistry, the number of c-Fos protein-expressing neurons (c-Fos protein-immunoreactive cells, Fos-IR) was quantified in the PVN after 1 h of stimulation. The number of neurons expressing simultaneously c-Fos protein and CRF mRNA was measured by means of immunocytochemistry combined with in situ hybridization. Finally, c-Fos and CRF mRNA levels in the hypothalamus were determined by in situ hybridization or quantitative reverse transcriptase-polymerase chain reaction. Fos-IR in the PVN was significantly decreased 1 h after GES (P<0.05) but was not affected by sub-diaphragmatic vagotomy. The number of neurons containing c-Fos protein and CRF mRNA was lower in the GES group compared with the control group (P<0.05). In addition, c-Fos and CRF mRNA levels in the PVN were significantly decreased by GES (P

Administration of desmopressin in brain-dead donors and renal function in kidney recipients.

BACKGROUND: Diabetes insipidus is common among brain-dead donors and may lead to decreased graft function. The use of desmopressin to limit the consequences of diabetes insipidus is controversial. We assessed the effects of desmopressin administered to brain-dead donors on early and long-term graft function in kidney recipients. METHODS: In a randomised controlled study, 97 brain-dead donors received desmopressin as 1 microg bolus every 2 h when diuresis was more than 300 mL/h (desmopressin group n=49) or no desmopressin (control group n=48). In 175 kidney recipients (controls n=89, desmopressin group n=86) we measured serum concentrations of creatinine and haemodialysis requirements to assess early renal function in the first 15 days after transplantation. We assessed long-term results of transplantation (median time 45 months) for a homogeneous subgroup of 95 recipients (48 in the desmopressin group). FINDINGS: We found no significant differences between the two groups of brain-dead donors, except for final diuresis, which was lower in the desmopressin group than among controls. Haemodialysis requirement in controls and the desmopressin group (20 vs 23%, p=0.63) and serum creatinine concentrations (decrease from 903 micromol/L to 206 micromol/L vs 814 micromol/L to 193 micromol/L, p=0.14) did not differ significantly in the first 15 days after transplantation. Long-term graft survival was similar in the two groups (88 vs 87%). INTERPRETATION: Desmopressin can be given to brain-dead donors to limit the harmful effects of diabetes insipidus without any substantial effects to graft function in recipients.

Ileoanal anastomosis for ulcerative colitis: results of an evolutionary surgical procedure.

BACKGROUND/AIMS: Proctocolectomy with ileoanal anastomosis (IAA) has proved to be the most suitable surgical treatment for ulcerative colitis. The aim of this study was to compare the results of IAA according to the evolution of surgical procedures and particularly to compare the results of stapled versus hand-sewn anastomosis. METHODOLOGY: From 1984 to 1996, 37 men and 31 women were operated on in our centre for ulcerative colitis. The anastomosis between the J pouch and the dentate line was handsewn in 35 patients (group 1) and stapled in 33 patients (group 2). RESULTS: The mean operative time was significantly shorter in group 2 as compared with group 1 (265+/-59 vs. 323+/-53, p<0.01, respectively), whereas morbidity and functional results were comparable in both groups. In 10 patients with stapled IAA, a diverting ileostomy was not performed and the morbidity in this group did not increase. CONCLUSIONS: These results suggest that stapled IAA anastomosis is a safe procedure. The stapling technique of IAA simplifies total excision of the rectum and could mean that a diverting ileostomy is not necessary.

Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidney-transplant recipients.

BACKGROUND: Hydroxyethylstarch used as a plasma-volume expander in brain-dead kidney donors has been suggested to induce osmotic-nephrosis-like lesions. We have studied its effect on kidney-transplant function. METHODS: 52 patients who had received hydroxyethylstarch of iodinated contrast-media before brain death were excluded. 69 other brain-dead patients were prospectively included over 18 months and randomised into two groups. In the hydroxyethylstarch-gelatin group, patients received hydroxyethylstarch up to 33 mL/kg for colloid plasma-volume expansion, and afterwards received modified fluid gelatin. In the gelatin-only group, patients received only modified fluid gelatin as colloid plasma-volume expander. Multiple organs were procured in 29 cases, which included the kidneys in 27 cases (hydroxyethylstarch-gelatin 15, gelatin-only 12). FINDINGS: There were no significant differences in the characteristics of patients between the two groups of kidney donors or of recipients (except for a small imbalance in sex in the recipients). During the first 8 days after transplantation, nine of 27 (33%) patients required extrarenal haemodialysis or haemodiafiltration in the hydroxyethylstarch-gelatin group compared with one of 20 (5%) in the gelatin-only group (p = 0.029). Serum creatinine concentrations were significantly lower in the gelatin-only group than in the other group (p = 0.009). 10 days after transplantation, mean (SD) serum creatinine was, respectively, 145 (70) and 312 (259) mumol/L. INTERPRETATION: These data suggest that hydroxyethylstarch used as a plasma-volume expander in brain-dead donors impairs immediate renal function in kidney-transplant recipients.

Experimental measure of the tensile strength of biological sealant-collagen association after hepatectomy in dogs.

Fibrin sealants are commonly used in liver surgery. The aim of this study was to test the adhesive properties of a biological sealant-collagen bonding, using an experimental model. After hepatectomy in dogs, we measured the rupture stress point of a fibrin clot on the liver cross-section. The tensile strength was 0.28 N, 5 times higher than the force of arterial pressure in a 2-mm-diameter vessel. These results indicate that the adhesion of fibrin sealants is effective to prevent hemorrhage from the liver cross-section after hepatectomy.

Eversion of the rectum. A simplified technical approach to ileoanal anastomosis.

Eversion of the rectum allows complete excision of the rectum. Here, we describe a modification of the stapling technique of ileoanal anastomosis, which leads to a safer anastomosis.

[Practical approach to tumoral perforations of cancers of the colon. Apropos of 7 cases]. / Attitude pratique devant les perforations tumorales des cancers du colon. A propos de 7 cas.

In 4 to 5% of cases, the cancer of large bowel is presented with a perforation in situ. The mortality rate in these conditions is high, and it is evaluated in the literature between 40 to 50% of cases. The authors present their experience with 7 consecutive patients, operated for this complication. In all cases, the tumour is excised: in 6 patients, terminal colostomy is realised while one patient only had a direct resection anastomosis. No per-operative mortality, was noted, and in four patients retauration of intestinal tract is realised, within 3 to 6 months latter. In our experience, the perforated tumour does not appear as a factor of immediate gravity.

[Appendiceal mucoceles. Pathophysiology and therapeutic indications]. / Les mucocèles appendiculaires. Physiopathologie et implications thérapeutiques.

Appendiceal mucoceles (AM) are rare lesions of the appendix, characterized by an accumulation of mucus. Two main pathogenic mechanisms may be invoked to explain their development. Firstly, AM are secondary to an obstruction of the appendiceal lumen for a wide variety of reasons. Secondly, they may be due to tumours of the appendix, whether malignant (cystadenocarcinomas) or benign (cystadenomas), responsible for a hypersecretion of mucus. Intraperitoneal mucinous effusion (IME) develops when appendiceal perforation occurs, especially with malignant AM. We found 13 retention AM and in most a definite obstructive lesion was present. There were 3 malignant AM, all associated with a neoplastic IME. While they are frequently described in the literature, no cystadenoma was observed in these series. Clinical symptoms are often confusing, but paraclinical investigations may lead to preoperative diagnosis. Appendectomy is the treatment of retention AM and cystadenoma. Their prognosis is related to other associated diseases, namely ovarian and colorectal tumours, but is otherwise good. Cystadenocarcinomas require a right hemicolectomy with evacuation of IME but their prognosis is poor.

[Pericranial sinus]. / Sinus pericranii.

This study concerns four cases of sinus pericranii observed at the Neurological Department of Nancy. Sinus pericranii is a direct communication between the outer surface of the skull and the intracranial venous sinuses. It may be congenital, acquired or traumatic. This abnormality, usually located in the midline and often in the frontal region, is usually symptomless, but some patients complain of headache, nausea and vertigo. Sinus pericranii shows as a fluctuating non pulsatile mass of reddish or bluish colour, expanding when the patient bends his head down. Radiography usually shows one or several bone defects opposite the lesion found at CT bone window. On soft tissue window the mass is not calcified and usually enhanced by contrast injection. It is sometimes possible to visualize the vascular communication between the extracranial region and the underlying dural sinus. When visualization is blurred, or CT shows intracerebral abnormalities, MRI examination is required. Angiography with subtraction in venous phase (40 to 60 seconds after the injection), sometimes aided by films taken in head down position. It is of interest only in cases where CT and MRI have shown associated vascular abnormalities. Otherwise, direct injection of contrast medium into the malformation makes it possible to assert the diagnosis of sinus pericranii and to determine the flow rate within the malformation, which to some extent commands the the therapeutic technique. In patients with small and asymptomatic sinus pericranii absention is the rule. When the sinus is of moderate size, and the flow rate not rapid and when there is no significant communication with the cerebral veins, endovascular sclerosis may be advocated. In all other cases, surgical removal is recommended and is usually easy.

[Superficial gastric cancer. A review of 30 cases]. / Le cancer gastrique superficiel. Revue de 30 cas.

Thirty cases of superficial cancer of the stomach were treated over a ten-year period from 1984 to 1993. Actuarial survival rate at 5 years was 73%. The depth of cancer invasion has a predominant effect on two prognosis factors: mucosal and submucosal involvement. Invasion of the lymph nodes is more frequent in cases with submucosal invasion. Treatment is based on gastric surgery. Nevertheless, if the diagnosis of superficial cancer is certain before operation and deep extension is clearly identified by histology and especially by echoendoscopy, more selective surgery could be justified: R1 type exeresis for cancers involving the mucosa only and R2 type exeresis for submucosal involvement.

[Study with flow cytometry of the peritumoral mucosa adjacent to colorectal cancers]. / Etude en cytométrie en flux de la muqueuse péritumorale adjacente aux cancers colorectaux.

Tumour and peritumoral mucosa were analyzed using flow cytometry in 21 consecutive patients operated on for colorectal carcinoma. Thirteen tumours were DNA aneuploid. No foci of aneuploidy bordering the tumours were detected, regardless of the tumour type. On the other hand, a significant decrease in the proliferative index was observed adjacent to the DNA aneuploid tumours. This study provides an additional argument for segmentary excision in colorectal cancers. Complementary studies are still required to specify the mechanisms of proliferation inhibition in the area of the DNA aneuploid tumours.

Ileal involvement in toxic epidermal necrolysis (Lyell syndrome).

Intestinal involvement in toxic epidermal necrolysis (TEN) has been identified only rarely. This report describes a case of TEN with ileal manifestations characterized by a profuse diarrhea with malabsorption, protein-losing enteropathy, and radiologically by multiple stenosis. After healing of the cutaneous lesions, total parenteral nutrition was initiated, resulting in a decreased diarrhea. However, after one month of total parenteral nutrition, malabsorption and protein-losing enteropathy continued and the radiological lesions were still present with an aspect consistent with a sclerotic process. A surgical resection of the pathological ileal segment was performed with end-to-end anastomosis. Pathological examination of the resected segment showed a necrosis of the ileal mucosa with a pattern similar to that of the epidermal necrosis. No sclerosis was observed. It seems that a prolonged total parenteral nutrition could have induced a complete healing of intestinal lesions. This case report is the first clinical, radiological, and histological study of an ileal involvement in TEN.

[Aneurysm of the splenic artery: an uncommon etiology of segmental portal hypertension]. / L'anévrysme de l'artère splénique: une étiologie exceptionnelle d'hypertension portale segmentaire.

A patient presented with gastrooesophageal varices secondary to splenic vein compression by a splenic artery aneurysm. Splenectomy and aneurysm resection ensured a good clinical result and disappearance of the segmental portal hypertension.