Surgical patient advocacy: role and value in surgery.

Patient advocacy may be necessary during medical care in the home or office as well as during hospitalization in either private or public sector care. Patients may choose a relative, a close friend or a physician as their patient advocate. The patient advocate may provide physical assistance and usually accompanies the patient throughout the course of disease. By agreeing to the presence of a patient advocate during visits, the patient implicitly acknowledges that confidentiality may be breached. Patient advocates may be particularly useful for the patient in case of severe disease or poor prognosis. The advocate becomes an intermediary contact and, at the same time, provides educational, relational and psychological support for the patient. The patient advocate should be consulted when the patient is incapable of making his own decisions. The patient advocate is supposed to be able to express the wishes of the patient, when the latter is incapable of doing so. The patient should therefore choose someone who, in his judgment, is competent to voice the patient's opinion for him. When the patient advocate remains at the patient's side at the end of life, whether in the hospital or at the patient's home, the advocate can benefit from "family solidarity leave" and obtain a daily stipend if this interrupts his or her professional activity.

[Suing the surgeon: what are procedures? How to conduct an assessment?]. / Mise en cause du chirurgien: quelles sont les procédures? Comment gérer une expertise?

Surgeons are particularly exposed to lawsuits. Most will be threatened or confronted with litigation several times during their career. The surgeon can be held directly and personally liable during a penal procedure. Civil jurisdictions oversee expert evaluation in cases involving self-employed and salaried surgeons in private practice. An administrative structure for expert evaluation is set up for surgeons working in the public sector. The law of March 4, 2002 has set up a new structure with commissions for reconciliation and compensation of medical accidents (CRCI); these apply to all surgeons. It is essential that the practitioner prepare himself fully, studying both the patient dossier and the pertinent medical literature in order to participate in an expert evaluation under the best circumstances and to justify the diagnostic and therapeutic measures taken. The surgeon may be accompanied by legal counsel and an expert medical witness, but he should not abdicate all responsibility for testimony to them; he, as the treating physician, has the fullest knowledge of the medical case and can best respond to the expert's interrogation. This behavior also demonstrates both responsibility and respect to the patient and his family.

[Tissue adhesive treatment of persistent recto-cutaneous fistula following Hartmann procedure]. / Encollage du trajet fistuleux dans les fistules recto-cutanées persistantes après intervention de Hartmann.

BACKGROUND: Cutaneous fistulas from the rectal stump after Hartmann procedure are not rare. Rarely do they require operative intervention, but they may result in prolonged skin care during hospitalization. PURPOSE: of study: To describe the use of fibrin glue in the treatment of rectocutaneous fistulas occurring after Hartmann procedure. STUDY DESIGN: Ten patients underwent irrigation of the fistulous tract followed by fibrin glue injection. The glue was reconstituted using the usual two syringe admixture technique; the tract was catheterized as far as the rectal stump, and the glue was injected as the catheter was withdrawn to skin level. RESULTS: No complications were noted and the discharge from seven out of ten fistulas dried up completely. CONCLUSION: Biologic glue occlusion of rectocutaneous fistulas simplified local care and decreased hospital stay.

[The Association Française de Chirurgie (AFC) colorectal index: a reliable preoperative prognostic index in colorectal surgery]. / L'index (AFC) colorectal : un index préopératoire reproductible en chirurgie colorectale.

INTRODUCTION: Evaluation of outcome after colorectal surgery is always necessary. A new index which permits to appreciate preoperatively postoperative mortality after colorectal resection in colorectal cancer (CRC) and in diverticular disease has been published (i.e., Association Française de Chirurgie, AFC colorectal index). PATIENTS AND METHODS: From November 2002 to July 2004, in-hospital mortality was analysed on 253 patients who underwent colic resection (N = 220, 87%) or rectal resection, with anastomosis (N = 175, 70%). Mortality was analysed according to emergency resection, neurological co morbidity, lost of weight more than 10% of weight, age older than 70 years. RESULTS: Mean age of patients was 63 +/- 18 years (17-92) (45% older than 70 years), 26% of patients were ASA >or= III, 35% underwent surgery in emergency, and 12% underwent laparoscopic surgery. One hundred and fifteen (45%) patients underwent surgery for CRC and 50 (20%), for diverticular disease and 11 patients underwent surgery for ischemic colitis. Overall mortality rate was 10% (N = 26), it was 19% in emergency surgery versus 5% after elective surgery. Global morbidity was 38%, percentage of anastomotic leak was 8% (N = 14/175), reoperation was necessary in 14%. The mean length of stay was 13 +/- 8 days. Ten percent of patients necessitated unplanned readmission. After surgery for CCR or diverticular disease. -i) overall mortality was 9% - ii) among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0% , 5% 15% and 33%. After surgery for other aetiology than CCR or diverticular disease, among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0%, 12% 36% and 25%. CONCLUSIONS: These results showed the reproducibility of the AFC colorectal index and its potential application in all aetiologies after colorectal surgery.

[Morbi-mortality after Hartmann procedure for peritonitis complicating sigmoid diverticulitis. A retrospective analysis of 85 cases]. / Morbimortalité de l'intervention de Hartmann pour péritonite diverticulaire. Etude rétrospective multicentrique à propos de 85 patients.

INTRODUCTION: Hartmann's procedure (HP) is a simple operation, which can be performed by all the surgeons. However, it remains criticized (high morbimortality, low rate of intestinal continuity restoration). The aim of this study was to analyse natural history of HP and intestinal continuity restoration for sigmoid diverticulitis, and to assess risk factors for mortality, morbidity and absence of intestinal continuity restoration. PATIENTS AND METHODS: In three centers, from 1992 to 2002, 85 patients underwent HP. A retrospective analysis was performed on mortality, early and late morbidity of HP and intestinal continuity restoration. RESULTS: 22% of patients (mean age, 68 years) presented comorbidity, 17% of them, an altered immunity, and 3 or 4 Hinchey score for 64%. ASA score was > or =3 in 49% of the cases. Mean AFC and Mannheim scores were 2 and 21 respectively. Mortality rate was 14% and in-hospital morbidity, 50%. Main complications were: cardiorespiratory (18%), wound abcess (14%) and stomal (6%). No rectal stump fistula was noted. Mean hospital stay was 19+/-13 days. Late morbidity rate was 29%, mainly due to stomal complications (12%) and small bowel obstruction (7%). Intestinal continuity restoration was done in 77% of the cases, followed by only 1 fistula. Mortality rate for intestinal continuity restoration was 0% and morbidity was 13%. Mean hospital stay was 10+/-3 days. Age >75 years, ASA score > or =3 and comorbidity were risk factors for morbidity and mortality and for absence of intestinal continuity restoration. CONCLUSIONS: HP is associated with a high morbidity and mortality rates. Intestinal continuity restoration rate was high in this series. HP is a simple operation in high-risk patients with advanced peritonitis. This study allows to precise natural history of HP. Knowledge of this history is crucial for choosing the best operation (between HP and anastomosis) for patient with peritonitis complications sigmoid diverticuitis.

[Autopsies and surgical service]. / Autopsies et services de chirurgie.

The aim of autopsy is to define the causes of a patient's death by studying the gross and microscopic visceral lesions. It is in actual decline but nevertheless the post-mortem examination remains one of the basic tools for the assessment of medical care in hospital. The aim of this paper is to finalize the present French legislation of autopsy and to show its importance in surgical practice.

[Pancreas divisum and the dominant dorsal duct syndrome]. / Pancréas divisum et syndrome du canal pancréatique dorsal dominant.

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

[Self expanding metallic stent in the management of malignant colonic obstruction]. / L'endoprothèse colique métallique expansive (ECM) dans les occlusions coliques d'origine tumorale.

INTRODUCTION: Fifteen to thirty percent of colonic cancers are diagnosed at acute colic obstruction stage. In this situation surgery is associated with a high morbi-mortality. The self-expandable metallic stents (SEM) have two objectives: (a) resolution of the obstructive to allow secondary planified radical surgical procedure; (b) palliative in the event of advanced disease. PATIENTS AND METHODS: From May 2001 to December 2002, 11 patients, mean age 75 +/- 8 years, presenting with acute colic obstruction were initially treated by SEM placed by endoscopy. Four patients were classified score ASA 4. Ten patients had a colonic cancer, and a patient presented a peritoneal carcinomatosis from an ovarian carcinoma. Overall five patients had a carcinomatosis. Stenosis, mean length 4 +/- 3 cm, were located on the left colon. In five patients the SEM was proposed as a palliative treatment. RESULTS: Successfully placement of SEM was obtained in 10 (91%) patient without perforation. Three complications (bleeding, reobstruction, migration) were observed. Clinical success (colonic decompression within 96 h without endoscopic or surgical reintervention) was observed in nine out of ten (90%) patients. Six patients had a SEM with curative attempt allowing (i) colonic resection (9 +/- 2 days) without stomy (one postoperative death) in five patients; (ii) a colo-colic derivation for diffuse carcinomatosis discovered peroperatively. A diverting colostomy was carried out in two of the four patients (j6, j30) (reobstruction, migration) for whom the SEM had been proposed as palliative treatment. CONCLUSIONS: This study confirms that SEM and surgery are not competitive but complementary techniques. When the SEM is placed with curative attempt, it allows resolution of the obstructive syndrome and secondary planified radical surgical procedure under better conditions. The results observed in the palliative SEM group suggested to reconsider this indication.

[Umbilical hernias treatment by the "stamp mesh technique"]. / Les hernies ombilicales : traitement par la technique de la prothèse << timbre-poste >>.

We describe an original technique for umbilical hernia repair ("stamps mesh technique") during which no umbilical ring widening is carried out. A non-absorbable mesh is positioned in the preperitoneal space.

[Management of umbilical hernia in cirrhotic patients]. / Prise en charge de la hernie ombilicale du cirrhotique.

The treatment of umbilical hernia in the setting of cirrhosis poses unique and specific management problems due to the pathophysiology of cirrhotic ascites. The high intra-abdominal pressures generated by ascites when applied to areas of parietal weakness are the cause of hernia formation and enlargement. Successful surgical treatment depends on minimization or elimination of ascites. Umbilical rupture and hernia strangulation are the most life-threatening complications of umbilical hernia with ascites and they demand urgent surgical intervention. In non-emergency situations, medical therapy to control ascites should precede hernia repair. When ascites is refractory to medical therapy, treatment will vary depending on whether transplantation is an option. In liver transplantation candidates, hernia repair can be performed at the end of the transplantation procedure. If transplanation is not envisaged, concomitant treatment of both ascites and hernia is best achieved by placement of a peritoneo-venous shunt at the time of the parietal repair.

[Laparoscopy: incisional hernias]. / Coelioscopie: les éventrations sur orifices de trocarts.

Post-laparoscopics incisionals hernias are among the serious complications of laparoscopy, however they are probably under-reported. We undertook a literature review to discuss their main characteristics. We emphasized on the need of controlled studies regarding their prevention measures.

[Hematoma of the abdominal large right muscles: diagnosis and treatment]. / Hématome des muscles grands droits de l'abdomen: diagnostic et traitement.

Rectus sheath hematoma is an uncommon event, and exception post-trauma hematoma, affects predisposed patients. The typical clinical case combine abdominal pain, a palpable mass, and parietal eccymosis appearing when a patient under anticoagulant therapy coughs. Diagnosis is confirmed by abdominal ultrasonography or CT scan. Surgical treatment is indicated only in complicated forms.