Postlaryngectomy voice restoration. A prospective study in 83 patients.

From July 1985 until May 1990, 83 patients underwent a total laryngectomy. We prospectively studied voice restoration in 81 of them (two died postoperatively). Esophageal voice was used by 19 patients; a tracheoesophageal procedure (myomucosal shunt, primary or secondary puncture with Blom-Singer prosthesis) by 41; and 21 patients had no voice restoration. Results were assessed according to voice quality and usage. Tracheoesophageal speech had a success rate of 73% (good voice, daily use) after 1 month, while esophageal voice proved to have only a 5% success rate. Thirty patients (37%), however, remained without a substitute voice. The reasons for their exclusion are presented; they include a high rate of refusal.

Antimicrobial prophylaxis for major head and neck cancer surgery with piperacillin and ornidazole.

A prospective study in 53 eligible patients, undergoing major head and neck cancer surgery was carried out to assess the combination of an ureido penicillin, piperacillin with a nitro imidazole agent, ornidazole, in order to prevent post-operative general and wound infections. Both antibiotics were administered for five days. Each patient had piperacillin 4 gm every eight hours and ornidazole 1 gm every 24 hours. The overall rate of infections was 13.2 per cent (n = 7), with 3.8 per cent (n = 2) wound infections and 11.3 per cent (n = 6) general infections (one patient presented both complications). There was no wound infection in the total surgery group (n = 12). General infections who only consisted of pneumonias were respectively 12.2 per cent (n = 5) in the group with partial procedures (n = 41) and 8.3 per cent (n = 1) in the total surgery group. This antibioprophylaxis can be recommended in major oncological neck surgery, specially in the case of partial procedures.

[Antibiotic prophylaxis in biliary surgery]. / L'antibioprophylaxie en chirurgie biliaire.

Prophylactic antibiotics in gallbladder surgery is designed to reduce the incidence of postoperative wound infections. Bacteria isolated from the biliary tract are generally the same as those found in the pus of wounds. Prospective and placebo-controlled trials have shown the efficacy of prophylactic antibiotics in high-risk patients presenting one or more of the following criteria: age over 70 years, recent episode of acute chollecystitis, emergency cholecystectomy, presence of common duct stones, jaundice or diabetes mellitus in patients with no risk factors for gallbladder surgery, prophylactic antibiotics may not be essential. The efficacy of antibiotics in the prevention of wound infections has been demonstrated with first, second and third generation cephalosporins, ampicillin associated with clavulanate, ureido-penicillins, aminoglycosides, sulfonamides and quinolones. A single injection of antibiotic given one hour before incision is as effective as multiple-dose regimens. Currently, the choice of antibiotic should be mainly based on its cost. There is no evidence at the present time for systematic prophylactic antibiotics in laparoscopic surgery. Endoscopic procedures of the biliary tract do not require prophylactic antibiotics when obstruction has not been demonstrated.

[Anesthesia in high class athletes]. / Anesthésie chez le sportif de haut niveau.

A case of general anaesthesia in a 49 year old male, high level specialist in triathlon, is reported. At the preoperative assessment, the patient had a sinus bradycardia of 45 b.min-1. The electrocardiogram (ECG) exhibited 2 mm ST segment elevation in leads V3-V5, an inverted T wave in leads V1 and V4, and a prolonged QT interval. The QRS axis was 60 degrees, the Sokolow index 44 mm; there was a partial right bundle branch block. These ECG anomalies disappeared during exercise. Heart sounds and blood pressure were normal. On chest X-ray the heart was enlarged. Five mg of midazolam were given orally 30 min before induction, and 1 mg atropine intravenously to increase the heart rate (40 b.min-1). Anaesthesia was induced with 2.5 mg.kg-1 propofol and alfentanil 15 micrograms.kg-1. Vecuronium 0.05 mg.kg-1, alfentanil 0.5 mg, 0.5% isoflurane in a mixture of 40% oxygen and 60% nitrous oxide were used to maintain anaesthesia. A further bolus of 0.5 mg atropine was necessary because of persisting sinus bradycardia. Surgery lasted 70 min. Heart rate and blood pressure returned to their initial values when the patient recovered from anaesthesia. Cardiac abnormalities are common in athletes; they must be distinguished from pathological conditions. When carrying out anaesthesia in these patients, it would seem highly recommendable to give 1-2 mg atropine, and to avoid associating negative chronotropic drugs.

[Intubation in otorhinolaryngologic surgery: propofol versus propofol-suxamethonium]. / Intubation en chirurgie ORL: propofol vs propofol-suxaméthonium.

This study was carried out to assess the conditions of intubation in head and neck surgery when using propofol alone or associated with suxamethonium. Sixty patients were randomly allocated in two groups of 30. Group I was given 3 mg.kg-1 propofol and Group II 3 mg.kg-1 propofol immediately followed by 1.5 mg.kg-1 suxamethonium. All patients were premedicated orally with midazolam 0.1 mg.kg-1, 0.5 to 1 mg atropine and 7 to 10 micrograms.kg-1 alfentanil, while a colloidal solute (Plasmion) up to 250-500 ml was infused. One minute after injection of propofol, lidocaine 5% was pulverized on the glottis and intubation performed. The mean time required for intubation was similar in both groups: 128 +/- 10 sec in group I vs 132 +/- 9.7 sec in group II. Thirty-five % of patients had to be considered as difficult to intube but the mean times in these cases were not statistically different: 169 +/- 14 sec in group I vs 175 +/- 13 sec in group II. Opening of the glottis was found to be better in group II than in group I (p less than 0.01) and bucking was more frequent in group I (p less than 0.01). Successful intubation was obtained after one attempt at a similar rate in the two groups. The haemodynamic variations consisted in a significant decrease of systolic blood pressure compared to the initial value but these variations were similar in the two groups at each time (2.3 and 5 min) from induction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Distribution of a hypoxic gas mixture by retro-pollution of a medical gas distribution system]. / Distribution d'un mélange gazeux hypoxique par rétropollution d'un circuit de distribution d'oxygène par de l'air médical.

The authors report a case of retropollution through the defective gas mixer of a Logic O4T-IMV ventilator (Ohmeda) located in the recovery room. Due to a defective check valve inside the mixer, medical air entered into the oxygen pipeline when the O2 pressure decreased below the pressure inside the medical air pipeline. This incident resulted in episodes of hypoxic gas mixture delivery in the operating theatre, when nitrous oxide was associated with oxygen polluted with medical air. The occurrence of such an incident, rarely described so far, requires the association of several factors. It can be recognized without delay with the continuous use of an oxygen analyser.

[Difficult intubations. A prospective study]. / Les intubations difficiles. Une étude prospective.

A prospective tubing of tracheal tubing in view of general anesthia was performed in 441 adults undergoing scheduled surgery. Before surgery, the anesthesists and ENT specialists tried to independently predict the cases of difficult tubing, according to different criteria. Tubing actually was difficult in 38 patients (8.6ù) instead of the 21 (55.2%) expected by the ENT specialists and/or the anesthesists. These difficulties were solved by bronchoscopy, which allowed tubing to be performed with a guide-probe (3 cas), by scheduled fiberendoscopy (6), tracheotomy (1), nasotracheal tubing (1), spontaneous ventilation (2), and orotracheal tubing in 25 cases. Current knowledge of the predictive criteria is incomplete: anesthesists must be aware of the assistance techniques required in case of difficult tubing in a non-ENT context.

[Massive obesity and anesthesia]. / Obésité massive et anesthésie.

Obese subjects are at a high risk of cardiovascular, respiratory and thromboembolic diseases. Anaesthetists in charge of these patients must take this risk into account, along with technical problems such as difficult venous punctures and intubations. The supine position alone creates situations that can be catastrophic for the respiratory and cardiac functions. In addition, obesity may modify the pharmacokinetics of the often liposoluble drugs used in anaesthesia. From the preoperative to the postoperative phases the anaesthetist's intervention must be envisaged.

Intrathecal sufentanil and morphine for post-thoracotomy pain relief.

In this double-blind randomized study we compared a group of 15 patients undergoing thoracotomy who received a spinal injection of sufentanil 20 microg combined with morphine (200 microg) after induction of general anaesthesia with a control group of the same size. Post-operative pain was rated on a visual analogue scale (VAS) and a verbal rating scale at rest and with a VAS on coughing. In the recovery room, patients received titrated i.v. morphine until the VAS score was <30, and were followed by patient-controlled analgesia (PCA) for 72 h. The intrathecal sufentanil and morphine group had a lower intra-operative requirement for i.v. sufentanil and needed less i.v. morphine for titration in the recovery room. I.v. PCA morphine consumption and pain scores were lower in the active group than in the control group during the first 24 h. There were no differences after this time. Spirometric data (peak expiratory flow, forced vital capacity and forced expiratory volume in 1 s) were similar in the two groups. We conclude that the combination of intrathecal sufentanil and morphine produces analgesia of rapid onset and with a duration of 24 h.

Safety of preoperative enoxaparin in head and neck cancer surgery.

BACKGROUND: Thromboembolism is a risk in major head and neck cancer surgery patients predisposed to thrombosis. This study was designed to determine whether enoxaparin (a low molecular weight heparin) administered prior to surgery induces perioperative bleeding. METHODS: Forty patients scheduled for major cervicofacial cancer surgery were randomized in a double-blind study to receive either 20 mg enoxaparin or placebo, 12 hours before surgery. Blood losses were measured at the end of surgery and 6 hours later. RESULTS: Bleeding was equal in the placebo group and in the enoxaparin group, with losses of 648 +/- 106 mL and 602 +/- 106 mL (p = 0.76), respectively. Six hours after surgery, blood collected was 159.3 +/- 25.7 mL in the placebo group vs 151.4 +/- 21 mL in the enoxaparin group (p = 0.81). CONCLUSION: Preoperative administration of enoxaparin is safe in head and neck cancer surgery, but further studies are required to evaluate its efficacy in preventing thromboembolism.