Randomized study of 5 fluorouracil and cis platin as neoadjuvant therapy in head and neck cancer: a preliminary report.

A randomized prospective study of 5 fluorouracil (5-FU) and Cis platin preceding definitive local treatment for squamous cell carcinoma of the head and neck region was initiated in September 1986. Seventy-five patients were stratified by site (oral cavity-12, oropharynx-28, larynx-16, hypopharynx-19), and by Stage (Stage II-20, Stage III-43, Stage IV-12) and randomized to receive definitive local treatment (surgery and post-operative radiation or radiation alone) or chemotherapy followed by definitive local treatment. Chemotherapy consisted of three cycles of 120 hr 5-FU infusion 1 g/m2/day plus Cis platin 100 mg/m2 on day 1 on each cycle. Response to chemotherapy was complete in 17 patients (46%) for an overall response rate of 68%. All the patients have completed therapy with a median follow-up of more than 12 months. After local treatment, the complete response rate is 84% for the control group and 86% in the chemotherapy group. Actuarial disease-free survival at 1 year is 61% in the control group and 73% in the chemotherapy group (p = 0.25). These preliminary results show that in spite of initial tumor response, neoadjuvant chemotherapy does not improve long-term control and survival.

[Postoperative iatrogenic lesions of the external branch of the accessory spinal nerve]. / Lésions iatroènes post-opératoires de la branche externe du spinal.

Iatrogenic lesions of the spinal nerve are rare and generally occur during cervicotomy for aetiological assessment of adenopathy. The spinal nerve is essentially damaged at two sites: the supraclavicular fossa (where the nerve is very superficial) and in the antero-lateral triangle of the neck (where the nerve approaches the sterno-cleido-mastoid muscle). The lesion of the spinal nerve essentially presents in the form of paralysis of the trapezius; which should be examined systematically postoperatively and at subsequent consultations, as the clinical signs may only develop after a certain latency period. The spinal nerve lesion requires early surgical repair (graft, suture) which gives the best results when it is associated with long-term, patient physiotherapy. Legally, the practitioner is generally condemned due to failure to obtain informed consent, which emphasises the importance of preoperative consultations during which the patients should be warned of the possibility of a lesion to this nerve.

[Drug ototoxicity. Medicolegal aspects]. / L'ototoxicité médicamenteuse. Aspects médico-légaux.

Drug ototoxicity is a preoccupying iatrogenic complication. Experimental studies over recent years, in particular a pharmacokinetic study of the elimination of aminoglycosides, have enabled the authors to define rules of prescription for parenteral aminoglycosides designed to reduce to a minimum the risk associated with their use. New aminoglycosides such as Netromycin appear to be associated with reduced toxicity. The medico-legal consequences of this complication are still rare, although more precise rules of prescription tend to make the experts more rigorous. The experimental evidence of cochleovestibular toxicity of aminoglycosides applied locally in the presence of a perforated tympanum leaves no room for doubt. The principal factor seems to be the duration of treatment. The prescription of a local aminoglycoside in the presence of a perforated tympanum would only appear to be justified from a legal point of view when absolutely indicated by antibiotic sensitivity tests.

[Iatrogenic complications of nasal sinuses surgery]. / Complications iatrogènes de la chirurgie nasosinusienne.

In order to illustrate the necessity of obtaining informed consent before any form of nasal sinus surgery, the authors present 23 cases of insurance claims filed between 1976 and 1986 in private practice. Ten serious complications (6 cases of blindness, 4 fractures of the anterior cranial (fossa) and eight cases of oculomotor nerve paralysis are reported. The legal proceedings demonstrate the real risks of radical surgery to the sinuses, as well as intranasal ethmoidectomy and rhinoplasties.

[Severe iatrogenic complications of surgery of the middle ear and their medicolegal aspects]. / Complications iatrogènes graves de la chirurgie de l'oreille moyenne et aspects médico-légaux.

The authors analysed 62 cases of severe iatrogenic complications occurring after middle ear surgery (death, cophosis, PFP) between 1976 and 1986. They compared their results to those of a similar study conducted between 1950 and 1975. They observed an increase in the number of legal proceedings, probably due more to the increased demand by patients than to a higher incidence of these complications. Civil proceedings are much more frequent than penal proceedings. The authors stress the importance attributed by judges to the expert report and to the obtaining of informed consent.

[Severe complications of tonsillectomy]. / Accidents graves de l'amygdalectomie.

The authors report 15 fatal complications after tonsillectomy based on the claims made between 1976 and 1986 to three insurance companies specialised in medical defence. The advantages and disadvantages of tonsillectomy with intubation and with the Sluder apparatus are recalled. Analysis of the legal proceedings of these cases reveals the principal points of jurisprudence: the importance of the preoperative assessment, pre-anaesthetic examination and informed consent. The concept of shared responsibility means that the surgeon must ensure the quality of the technical equipment of the establishment in which the operation is performed and the quality of the postoperative care.

[Medicolegal aspects of esthetic surgery]. / Aspects médico-légaux de la chirurgie esthétique.

The particular features of the contractual agreement binding patient and plastic surgeon are recalled. The obligation of the result appears to be distorted in the course of jurisprudence. The severity of the judgements means that great care must be taken in the management before, during and after the operation (study of the patient's motivations, informed consent, iconographic survey, technical equipment, postoperative care,...). The problem of competence and the technical training of the surgeon are also discussed.