Differential transferrin receptor density in human colorectal cancer: A potential probe for diagnosis and therapy.

Transferrin receptor density was investigated in human colorectal surgical specimens. Crude membranes were prepared from 23 cancer tumors (adenocarcinoma or malignant villous tumor) and 3 non-cancer tumors (polyadenoma or villous tumor) and 26 adjacent control mucosa. Contrary to non-cancer tumors, Scatchard analysis of 125I-transferrin binding data evidenced higher maximal transferrin binding capacity and lower dissociation constant in cancer tissues (Bmax cancer 1.828+/-0.320 nmol/g, Kd 24.1+/-4.7 nM), as compared to paired control colonic mucosa (Bmax contol 0.851+/-0.182 nmol/g, Kd 30.7+/-7.3 nM), paired t-tests: Bmax p<0.001, Kd p<0.05). As the cancer/control Bmax ratio was 2.6+/-0.4,transferrin carrier constructs should be proposed for cancer imaging or therapy.

[Pharmacokinetic study of pyrazinamide and pyrazinoic acid in subjects with normal renal function and patients with renal failure]. / Etude pharmacocinétique du pyrazinamide et de l'acide pyrazinoïque chez le sujet à fonction rénale normale et l'insuffisant rénal.

The main pharmacokinetic parameters of pyrazinamide and pyrazinoïc acid (its major metabolite) were determined after oral administration of 1,500 mg/d in 10 patients with normal renal function and of 1,000 mg/d in 10 patients with impaired renal function (renal insufficiency). This study shows that, with these dosage regimens, almost all the pharmacokinetic parameters are identical for pyrazinamide and pyrazinoic acid in patients with normal renal function and patients with impaired renal function. Comparison of results between patients allows us to propose a dosage regimen of 1,000 mg/d as maintenance in patients with renal insufficiency.

[Carcinosarcoma of the gallbladder. Echographic and anatomopathological diagnosis. Apropos of a case with review of the literature]. / Carcinosarcome de la vésicule biliaire. Diagnostic échographique et anatomo-pathologique. A propos d'un cas avec revue de la littérature.

Precise diagnosis of carcinosarcoma of gallbladder, a rare tumor, is based on histopathology since clinical and epidemiologic elements fail to differentiate it from other gallbladder cancers. Ultrasound imaging is the most effective radiodiagnostic technique since it allows visualization of the tumor and suggests the presence of a carcinosarcoma when a polypoid or vegetating mass is detected within the gallbladder.

[Retroperitoneal gas images following subperitoneal hollow viscus rupture (author's transl)]. / Images de rétropneumopéritoine dans les ruptures d'organes creux sous-péritonéaux.

Three cases of traumatic rupture of a subperitoneal hollow viscus are reported : two duodenal lesions and one rectal wound. Early diagnosis was possible in all three cases by the recognition of retroperitoneal gas on simple radiographs of the abdomen, which was evidenced by images containing air bubbles, which were also fasciculated and fairly fixed. They were unilateral, on the right side, and usually associated with disappearance of the psoas shadow in duodenal injuries. Rectal perforation produces a bilateral distribution of the retroperitoneal gas, which extends to the subperitoneal fat and the posterior extraperitoneal space, according to the amount of effusion.

[Small intestine transit anomalies in a patient with chronic abdominal pain and treated for Hansen's disease]. / Anomalies du transit du grêle chez une patiente présentant des douleurs abdominales chroniques et traitée pour une maladie de Hansen.

This new case of enteropathy due to Clofazimine provided demonstration of the diagnostic value of small bowel follow-through examination in this complication. Various small intestine anomalies have been reported: ileal or partial jejunal lesions; variations in caliber; loss of physiologic folds; irregularly outlined surface and border lacunae and persistence of suppleness of pathologic loops. Knowledge of these anomalies should avoid exploratory laparotomy, Clofazimine-induced enteropathy regressing after discontinuation of treatment. Repeat small bowel follow up examinations can be performed to review course of this regression.

[New data on the adrenal-post-pituitary system of cancer patients]. / Nouvelles données sur le système surréno-posthypophysaire du cancéreux.

A water loading test was performed in 10 patients with a cancer of the digestive tract without hyponatremia and in 10 controls. A lowering of the CfH2O was observed in the patients during the test, as well as an increase in the cortisol plasmatic rates, while aldosterone rates remained normal. To valid the hypothesis of a hypervasopressinic state in these patients, 15 cancerous patients and 12 controls had a plasmatic ADH dosage, which pointed indicated higher hormonal level in the first group.

[Hemorrhoidectomy by surgical excision with anoplasty by mucocutaneous suture]. / Hémorroïdectomie par excision chirurgicale avec anoplastie par suture muco-cutanée.

The technique suggested here consists of radical excision of the haemorrhoids with preservation of skin flaps which are sutured to the healthy rectal mucosa inside the anus. There is no traction nor sphincteral damage. This simple procedure, derived from the Whitehead's technique, is suitable for large haemorrhoids, notably when they are prolapsed and associated with lesions of the mucosa Resections "as required", with preservation of healthy mucocutaneous bridges, avoids the development of stenosis. Rectal palpation by the patients themselves twice a day from the 8th to the 30th post-operative days is essential. In a series of 150 cases evaluated 5 to 15 years after surgery, 9 out of 10 patients showed evidence of persistent success without functional sequelae.

[Hepatic metastases. Value of chemotherapy by the intra-arterial route]. / Métastases hépatiques. Intérêt de la chimiothérapie par voie intra-artérielle.

Forty-three patients with metastatic liver cancer were treated with multiple chemotherapy by the intra-arterial route. Metastases originated from primary cancer of the breast (16) or colon (10), melanoma (7) and miscellaneous tumours (10). In 35 patients chemotherapy was administered by selective catheterization of the hepatic artery via the axillary artery; it usually (31 cases) consisted of doxorubicin (60 mg/m2) and mitomycin (10 mg/m2) injections, and continuous infusion of 5-fluorouracil (1 g/24 or 72 hours). In 14 patients (10 responders to the above method and 4 new cases), a catheter with subcutaneous chamber was implanted surgically so that chemotherapy could be continued through the chamber. Blood toxicity was usually moderate. The main complication of injections through the catheter (114) or through the chamber (60) was thrombosis. However, except for 1 lethal cerebral thrombosis, the others (axillary artery 3, hepatic artery 5) were unattended by functional symptoms. Transient biochemical signs of hepatic cytolysis were frequent after each course. Hepatic insufficiency was severely aggravated in 2 cases. Painful digestive disorders were relieved by symptomatic treatments. Four complete responses, 16 partial responses, 8 stabilizations and 10 failures were observed; 5 patients died soon after one single course of intra-arterial therapy. The high response rates (greater than 50%) in metastases from cancer of the breast and colon, and chiefly the 3 complete responses obtained in patients with mammary carcinoma were most encouraging, bearing in mind that one of these 3 patients had not responded to intravenous chemotherapy.

[The surgeon, the expert, the judge]. / Le chirurgien, l'expert, le juge.

A study of 125 medico-legal opinions and evaluation of the literature allows for: an appreciation of the evolution in the concept in the jurisprudence pertaining to the responsibility of the surgeon in France in present practice conditions, a definition of the role of the legal expert, an explanation of the development of paths outside the procedural setting. In the present state of our knowledge the responsibility related to a prejudicial error has a frequency of 25-30% all jurisdictions and disciplines considered together. In 66% of cases the error is the absence of a timely treatment decision or a defective postoperative follow up. A mishap without proven error is present 50% of the cases which justifies a decision of coverage outside the civil responsibility of the surgeon. The modern conditions of surgical practice, the implications of the new technologies, the evolution of economic and socio-cultural ideas must lead the political decision makers and health-professionals to rapidly define a clear line of conduct. In the absence of comprehensive statistics from the courts, the qualitative and quantitative information contained in the national database "Remedhos France", now available, will be useful to inform the surgical community on the risk and its prevention, as well as to orient a homogenous doctrine and its applications in view of a common European approach.

[From risk to damage: the limit between chance and fault in medical responsibility]. / Du risque au dommage: les frontières aléa/faute en responsabilité médicale.

Rare, but serious, the possible accidents of medical or surgical procedures without fault compromise the doctor patient relationship. A pro-compensation philosophy leads to a drift in the classical concept of prejudicial act. This type of confusion adds a random/aleatory legal risk to the random/aleatory medical risk. Determining the limit between random/aleatory risk and malpractice is one of the difficulties in medical evaluation of responsibility. In order to evaluate the random/aleatory risk without malpractice, in relationship to the medical team, we propose a notation grid for the facts of the case, based on simple, precise, identifiable criteria present in all medical records and accepted by both the practising physicians and medico legal experts. This medico-legal research was done in a double blind study of 45 cases which intially brought up a random/aleatory risk related problem for three medical procedures: coronary arteriography, colonoscopy and laparascopy. In 66.6% of the cases the random/aleatory risk was ruled unrelated to any malpractice, but in 33.4% of the cases observed, the initial random/aleatory risk was transformed into actionable malpractice, essentially due to faulty surveillance or tardy treatment of the complication. This notation system, carried out in identical and well defined terms, should allow a reasonable comparison of cases for medico-legal research or computerised databases. It is reserved exclusively for use by medical experts or consultants so they can give a reasoned technical opinion in order to assist the judge in his legal decision. The objective of the proposed grid is to homogenise the concepts used by experts in all national courts. After a multicenter validation, this grid could have an European future as to the boundary between random/aleatory risks and medical malpractice and responsibility.

[Home enteral nutrition: functional partnership experience in the network of care of the Centre Médical de Forcilles, 1990-1999]. / Nutrition entérale à domicile: expérience de partenariat fonctionnel en réseau de soins du Centre Médical de Forcilles de 1990 à 1999.

Since 1990, the home enteral nutrition (HEN) has been experienced by the Centre Médical de Forcilles (CMDF), according to the 1988 and 1993 instructions. This service has a regional vocation and forms an integral part of a partnership system in care including: the prescribing hospital, the usual physician and various specialists. We have a triple objective: 1) To define the structure and the action of this medical service, the only one in France. 2) To appreciate the 9 years experience with 4297 patients: Medical interest, with the nutritional care of patients suffering of heavy diseases, more particularly ORL cancers and neurological troubles disturbing deglutition. The use of regulating flow pumps, care avoid "Mendelson syndrome". Repercussion on patients quality of life, who stays in a family environment. This seems to be beneficial for 58.9% cases. More over, 95.8% patients prefer this solution instead an hospitalization. The permanent communication between the members of this plural disciplinary team guarantees safety, comfort and relief. Economical benefit with a computerized management, recovering of the products and reduction in purchase (large quantities). This allows a very reasonable "price per day" (120.38 F in 1999), to wit a thrift of 95% in comparison with a classical hospitalization. 3) To propose, according to the CMDF example, a quality charter for a HEN centers regional organisation, and the valuation of their activity. According to the fact that the HEN has to be legally realized all over the national territory, the CMDF exemplary fitted to local needs, should allow an appropriate solution, with a control of the costs, thanks to a real partnership in network of care, for this public health problem.

[Treatment of lithiasis of the common bile duct]. / Traitement de la lithiase de la voie biliaire principale (V.B.P.).

The aim of this review is to explain the multidisciplinary conception of the treatment of stones of the common bile duct in terms of the various techniques available. Treatment is designed to decrease mortality and morbidity, particularly acute complications in elderly or high risk subjects. A rational tactic determined dispassionately by common sense constitutes the best chance of preventing complications.

[Damage through surgical risk. A persistent challenge]. / Le dommage par risque chirurgical. Un défi persistant.

No surgical act is innocuous and a complication is not inevitably the result of a mistake. Improved definition of the risk involved should allow a new approach to compensation for damages to be envisaged. Publicly or privately sponsored mutual insurance is worth considering for application of the single European act. Without questioning the concept of professional responsibility, a response should be prepared adapted for damages due to medicosurgical accidents for which a fault cannot be demonstrated. By stimulating enlightened reflection, the present study should allow acceptance of this persistent challenge.

[Surgical treatment of sigmoid diverticulitis]. / Traitement chirurgical des sigmoidites diverticulaires.

Diverticular disease is generally benign but may be life threatening should progressive complications occur. Under these circumstances cure may only be obtained if properly performed surgery is undertaken at the right moment. The end result of a low fibre diet, diverticular disease may affect the entire colon, but always tends to particularly affect the sigmoid region. This is the usual site of complications where the etiology is related to diverticular infection associated with fecal impaction proximal to the high pressure zone at the recto-sigmoid junction. The radical treatment of sigmoid diverticulitis is rectosigmoid resection, however, this concept may be altered according to the circumstances as follows: 1 - sigmoid diverticulitis without pericolic complications 2 - peri-sigmoid complications: peri-sigmoid abscess, intestinal and vesical fistulae. 3 - generalised peritonitis due to perforation into the peritoneal cavity. The advanced age of the patient should be stressed (mean age 65 years and 25% over 75 years) associated with a high incidence of multiple organ failure and hence the high mortality in more than 50% of cases in the event of peritonitis.

[Liver traumas]. / Traumatismes hépatiques.

The high mortality rate in hepatic trauma is a concern for the surgeons on duty, who must know the physiopathological problems and the therapeutic solutions in order to make the decisions needed in view of both hepatic and extra-hepatic injuries according to the available means. The early vital risk is produced by 2 facts: injuries to the liver, in which bleeding account for the death in every second case, especially in case of vascular disinsertion in the caval-suprahepatic junction, which fortunately occurs rarely; associated intra- or extra-abdominal injuries, which are unfortunately frequent, cause death in every second case of multiple trauma. On the basis of a series of 135 cases in our department and of a bibliographic study, this article is aimed at defining a strategy for treatment that will be adapted to the lesions, in order to try and improve the prognosis. With hemodynamically stable patients, a surgical watch and wait policy is possible under strict observation. Conservative surgery still has to play a dominant part. Hepatic resection is only rarely indicated, if absolutely necessary. Temporary tight packing for a few days, with early reoperation in a specialist department if required, is a logical approach in initially unfavorable circumstances.

[Risk and responsibility in celiosurgery]. / Risque et responsabilité en coeliochirurgie.

Not performing laparoscopic surgery is not a dishonour. Likewise, it is not shameful to convert a laparoscopic operation to conventional laparotomy. The mission of the surgical community is to avoid inhibiting progress while assuring patient safety. Based on accepted standards, experts designated by the courts establish a report on the pre, per and postoperative procedures to enlighten the judge who decides on the notion of responsibility in the specific context of laparoscopic surgery. The aim of this work was to inform the practicing surgeon on the known complications, prevention of accidents, the forensic classification and the current estimation of risk. Statistically, laparoscopic surgery is not an accrued risk for insurance companies. Practicians should know that there are specific potential risks involved in this technique which are expressed as a function of the surgeons behaviour before, during and after the operation. Effective training in laparoscopic surgery which reproduces the same action as conventional surgery, but with different procedures, requires, as for conventional surgery regular "fellow" training. The trained, competent, conscientious surgeon can propose the advantages of laparoscopic surgery to his patients while avoiding the disadvantages.

[Percutaneous drainage of intra-abdominal collections. Conditions for success]. / Ponctions percutanées des collections intra-abdominales. Conditions du succès.

Technological advances currently allow safe percutaneous puncture of certain intra-abdominal collections, provided the indications and technical precision are imperatively respected. Our aim is to draw attention to success factors and the limits of this procedure.

[Duodenal ulcer perforating into the free peritoneal cavity]. / L'ulcère duodénal perforé en péritoine libre.

Duodenal ulcer perforation into the free peritoneal cavity remains a topic of interest and should be managed surgically. Most often emergency surgery is required to treat both the ulcer disease and the perforation.

[Densitometry of the pancreas (author's transl)]. / Tomodensitométrie du pancréas.

The authors present their experience of 15 months use of a C.T. Scanner of the third generation. Of 1,000 patients in which the tomography sections involved the pancreas, in one third the examination was requested for a suspected pancreatic lesion. The image of the pancreas was obvious in 9 cases out of ten. The diagnosis was correct in 8 cases out of ten. These results are extremely encouraging, and reliable compared with those of echotomography in the present state of the technic. The illustrations show the interest of C.T. Scanning in surgery, for the surgeon then has available anatomical sections of the whole supramesocolic region. The authors emphasize the necessity of pluridisciplinary comparison for better use of this technic.

[Radiomanometric studies of bile flow during surgery on extrahepatic biliary ducts: effects on postoperative course in 1600 patients after follow-up for more than 5 years (author's transl)]. / La radiomanodébitmétrie per-opératoire: incidences sur la chirurgie des voies biliaires extra-hépatiques pour 1600 opérés depuis plus de t ans.

The use of a simple, rapid, and reliable method for studying the anatomy and physiopathology of the main biliary pathway during operation by means of radiomanometry is described. This procedure enables a rational and precise therapeutic decision to be taken, as shown by comparing the results obtained in 1600 cases after a period of 5 years, with the interpretation of the initial radiomanometric findings and the type of operation performed. The overall rate of error based on the radiomanometric results, and leading to erroneous therapy, was 2 p. cent (0.43 p. cent excessive and 1.57 p. cent insufficient). No complications due to the method were observed. The main points noted were the absence of wounds to the main biliary pathway and of external bile tract fistulae, and a considerable reduction in the number of repeat operations and postcholecystectomy syndromes (1.5 p. cent).