[Natural history of postoperative intraperitoneal adhesions. Surely, a question of the day]. / Histoire naturelle des adhérences intra-péritonéales post-opératoires. Une question vraiment à l'ordre du jour.

Postoperative intraperitoneal adhesions are known to occur after conventional surgery. The prospective study that we have performed in 1992 shows that the frequency of postoperative intraperitoneal adhesions is very high (93% of patients). It is higher than was stated 20 years ago, while so-called "spontaneous" adhesions seem to be decreasing. The histological study of postoperative intraperitoneal adhesions shows a specific evolution in time and a very high frequency of foreign bodies (starch, variably decayed textile fibers) (92%). The very great frequency of such foreign bodies in postoperative intraperitoneal adhesions, logically involving them in the genesis of this condition, may be an argument in favor of the new surgical techniques, especially of celioscopy.

Airway complications in thyroid surgery.

Perioperative and postoperative morbidity and mortality were studied in a series of 3,008 thyroidectomies. Compressive symptoms, frequent in substernal and cancerous goiters, were present in 11.0% of the patients, although a low rate of dyspnea (2.7%) was observed. In large goiters, some orotracheal intubations were difficult. In such cases, the transtracheal approach can also be difficult, so failure should be anticipated. Postoperative causes of respiratory obstruction included local hemorrhages, bilateral recurrent nerve palsies, and laryngeal edema. A tracheal collapse was not observed. These respiratory obstructions led to repeat surgery in 11 patients, tracheostomy in 3, and temporary reintubation with steroid therapy in 1. The recurrent laryngeal nerve, which may have been affected preoperatively, was found to be damaged postoperatively in 0.5% of the patients with benign goiters, compared to 10.6% of the patients with thyroid cancer. In this last group a bilateral palsy was observed in 3 cases with prolonged or extensive surgery. After these short-term orotracheal intubations (114 minutes on average), injuries of the airway caused by the endotracheal tube were found in 4.6% of the patients.

Analysis and prevention of recurrent goiter.

The current study was done to analyze our experience with recurrent goiter. Prevention must be stressed because reoperations of the thyroid gland present technical difficulties and are associated with an increased risk of hypoparathyroidism and permanent hoarseness. Nodular recurrences occurred in 36 of 1,456 patients (2.5 percent) who underwent thyroidectomy between 1968 and 1983. All patients had the initial operation at Jean Bernard Hospital, Poitiers, France, and had follow-up evaluation from five to 20 years. Multinodular goiter accounted for 70 percent of the recurrences. Sixty percent of the recurrences were in patients with multinodular goiters. Recurrent goiter was usually first detected about eight years after thyroidectomy. Thirty patients with recurrence had reoperations. Two patients had paralysis of the vocal cord and one patient had permanent hypoparathyroidism. Recurrent goiter may occur because of the development of new nodules (true recurrence) or because of the growth of "residual" or persistent macroscopic or microscopic nodules left at the previous thyroid operation. Intraoperative digital palpation of the entire thyroid gland is essential for detecting residual macroscopic thyroid nodules, and all enlarged nodules should be removed. Thyroid-stimulating hormone (TSH) suppressive therapy is recommended by some authorities to prevent "true" recurrences, although its efficacy is debated. Since recurrence is uncommon in the current series, perhaps TSH suppressive therapy should only be used in high-risk patients. In the current experience, only the multinodular character of the nodules in euthyroid patients has a significant correlation with subsequent development of recurrent goiter (p < 0.01), and one must consider patients with multinodular goiter at risk for recurrence. Once TSH treatment is begun, it will logically be continued for life. Total thyroidectomy has been recommended by some endocrine surgeons for treating patients with multinodular goiter. We prefer subtotal thyroidectomy and reserve total thyroidectomy for patients when no normal thyroid tissue can be preserved because only 2.5 percent of the patients in the current study had recurrent goiter. Prevention of residual nodules is probably best assured by systematic palpation during operation of the two thyroid lobes. This considerably lessens the risk of recurrence. Since nodular recurrences occurred in only 2.5 percent of the patients in the current study, although multinodular goiter must be considered at risk for recurrence, we do not recommend systematic total thyroidectomy in multinodular goiter.

[Hepatobiliary complications of total parenteral nutrition]. / Complications hépato-biliaires de la nutrition parentérale totale.

Total parenteral nutrition has showed his efficacy in severe digestive diseases. However, infections, metabolic and hepato biliary complications can appear. Aim of this study is to report hepato biliary complications in 200 adult patients, mean age 53 years, treated between 1979 and 1988. Three types of hepato biliary complications occurred in 138 patients initially free of hepato biliary disorders: 1) biochemical hepatic disorders (cholestasis and/or cytolysis) occurred in 58 patients (42%) with mean time of 27 days. In 40% these disorders disappeared after modifications or stop of parenteral nutrition. 2) Jaundice occurred in 9 patients (7%) with mean time of 73 days. Regression of Jaundice is possible only if enteral nutrition is reestablished. Sludge or cholelithiasis occurred in 34 patients (25%) with mean time of 43 days. In five of these patients cholecystectomy must be performed. Literature confirms high frequency of hepato biliary complications in total parenteral nutrition. Occurrence of these complications seems to be related to duration of total parenteral nutrition and to type of nutrition. Most complications decrease when we can stop total parenteral nutrition. Use of lipids in separated perfusion decreases significantly (p < 0.05) biochemical hepatic disorders occurrence. In conclusion, 1) biochemical hepatic disorders are very common, requiring biochemical hepatic tests weekly. 2) Jaundice is rare but serious, requiring stop of parenteral nutrition, and sometimes surgery to reestablish an enteral nutrition. 3) high frequency of cholelithiasis justifies ultrasonographic follow-up, and perhaps preventive cholecystectomy in operation leading total parenteral nutrition.

[Legg-Perthes-Calve disease. Clinical and radiological study of 37 children (43 hips) reviewed following cicatrization of the lesions]. / Maladie de Legg-Perthes-Calve. Etude clinique et radiologique de 37 enfants soit 43 hanches revus à cicatrisation des lésions.

Results of treatment of 43 hips with primary osteochondritis lesions (Legg-Calvé-Perthes disease) are reviewed at the healing stage (mean follow up 3 1/2 years). Orthopedic treatment was applied to 27 hips and 19 good or very good results were obtained, 5 results being rated as fair and 3 as poor. Operation on 16 hips produced 8 good and very good results, 2 fair and 6 poor. The influence of various factors are studied in relation to results obtained, and the importance emphasized of the onset of epiphyseal exentration and the early performance of surgery.