[Apropos of jurisprudential decisions concerning nosocomial infections]. / A propos des décisions jurisprudentielles liées aux infections nosocomiales.

Nosocomial infection is as old as cares given to patients. Doctors and hospitals are both committees. Since Cohen ruling on December 9, 1988, the "Conseil d'Etat" bases the responsibility for the public hospitals on the concept of uncompromising presumption of fault. Since Bonnici ruling on May 21, 1996 and especially since decisions known as "of staphylococcus aureus" on June 29, 1999, the "Cour de cassation" bases the civil liability for doctors and private hospitals on the principle of obligation of security of result. Such a rigor of the two high jurisdictions leads to a quasi automatic repair of any prejudice recognized as related to a nosocomial infection. The epidemiology of nosocomial infections makes it possible to assess the extent of risks at stake. This is a considerable potential contentious in process of explosion, the cost of which cannot be supported by health economy in its current state. That just shows you the extent of medical, juridical, public health, economical, social and political interests linked to nosocomial infections. It seems urgent to consider definitions that were given to this concept, and within them it will be necessary to individualize what is nosocomial infection entitled to compensation. In this matter medical opinion must prevail over law to better serve it.

[Nosocomial infection: medical responsibility regarding the law]. / L'infection nosocomiale: la responsabilité médicale face au droit.

The nosocomial infection, infection transmitted to a patient at the time of medical care, constitutes a complex nosological framework. The knowledge of the risk factors is essential to their good management. It underlies all the lawful texts concerning the fight against the nosocomial infections. These texts propose to us definitions established in a context of public hygiene and health. The complexity and the cost of the management of all these risks can only be compared with jurisprudential simplification, which results from this in responsibility matters. In a pro indemnity concern, the position of the "Cour de Cassation" is closely akin to the rigor of the "Conseil d'état", which imposes the uncompromising presumption of fault against supposed guilty, persons or entities. It is necessary to redefine the risks towards praetorian right. It is the role of the legal expert, auxiliary of the judge, to provide in equity an informed opinion on the facts. The factual criteria must allow a modulation of responsibility concerning the fault, the serial risk or the medical risk.

[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.

[Risk of laparoscopic surgery. 100 records of complications. A qualitative study]. / Le risque en coeliochirurgie. 100 dossiers d'accidents. Etude qualitative.

A total of 100 accidents occurring during laparoscopic surgery between 1969 and 1993 were studied. Fifty-five of the cases concerned gynaecology surgery over a 24 year period. The other 45 concerned digestive surgery over a 5 year period (1989-1993). The surgical risk was not statistically greater compared with open surgery. Overall morbidity was 1%. Overall mortality was 0.5/1000. A more precise statistical analysis was recently reported. The examination of the 100 cases was qualitative rather than quantitative. The study demonstrated an imbalance between age (mean age 38 years) in patients with major pathology initially and the gravity of the induced accidents: 26 deaths for 100 observations. These deaths were related to technology trocar, capnoperitoneum, electrocoagulation. Technical skill, cautiousness, vigilance and humility are qualities the surgeon must have to perform successful operations. The irreversible acceleration of the new surgical technique should not cloud the basic precepts of sound surgical technique.

[Diffuse gastric angiomatosis. A clinical case. Review of the literature]. / Angiomatose gastrique diffuse. Cas clinique. Revue de la littérature.

Stomach angiomatosis is a rare disease. We report an exceptional case of diffuse gastric angiomatosis complicated with severe bleeding; the patient underwent two operations for dramatic haemorrhage with shock. Selective arteriography provided the diagnosis. Total gastrectomy was performed in a third operation providing remission with a 3 year follow-up. The diagnosis of gastric angiomatosis is difficult and is essentially based on the fundamental selective angiography. Histology examination confirms the diagnosis and demonstrates vascular malformations. Cases reported in the literature are usually isolated cases: 47 angiomatoses of the stomach have been reported. Treatment is always surgical with gastrectomy providing complete remission. This case report demonstrates the need for a revision of the classifications of vascular tumours of the stomach.

[The subscapular combined free flap. Original technique]. / Le transplant libre combiné sous-scapulaire. Technique originale.

Combinations of subscapular pediculated flaps have been used in recent years. These single pedicle flaps include the latissimus dorsi, the serratus, the scapular crest and the ortho and para-scapular skin flaps. Together these flaps comprise a combined subscapular transplant. This combined flap is particularly important since the different components provide great spatial flexibility. Complex and massive pluri-tissular substance losses can thus be reconstructed. We report our work in anatomy and techniques. We found variations in the origin of the subscapular pedicle in 25% of the cases in our anatomy study (50 cases). We recommend dissection of the vascular pedicle via the axillary route first. Thus necessary adaptations can be made as a function of the variations observed. This combined flap can be removed with the patient in supine position. The fact that the position of the patient does not have to change is essential for cervicofacial surgery performed by two teams. The pedicle of the cutaneous scapular flaps is dissected starting ventrally. Since 1990, we have performed 15 combined subscapular transplantations for cervicocephalic reconstructions.

[Tumors of the mandible. Justification of a second reconstruction after recurrence on the first revascularized bone graft]. / Tumeurs de la mandibule. Justification d'une seconde reconstruction pour récidive sur le premier transplant osseux revascularisé.

The use of free vascularized bone grafts for mandibular reconstruction has led to a consideration of the new entity of recurrent tumour on bone grafts. Exeresis of the mandible was performed in 4 patients with bone tumours: osteosarcoma 1, osteochondroma 1, carcinoma 1 and ameloblastoma 1. A free vascularized bone graft was used for the reconstruction. Tumours recurred with a delay of 10 to 18 months after the initial reconstruction. The frequency of tumoural recurrence can be measured in our series of 46 patients (24 with fibular grafts, 15 with scapular grafts, 4 with radius grafts and 3 with iliac bone grafts). Recurrence rate at our institution was 4.3%. The 2 other cases involved patients from other institutions. The main factor involved in tumoural recurrence is the aggressive nature of the primary tumours, even after extensive initial resection as performed in our patients. Free bone grafts were invaded as were neighbouring tissues. Secondary reconstruction of the mandible was performed in 3 cases with a fibula graft. In the fourth patient, no operation was possible due to the diffuse nature of the invasion and the poor status of the patient's vessels and general health. Local extension, and not the tumour histology, is the main factor in deciding upon reoperation. The explosive nature of recurrences is linked more to the aggressive character of the tumour than to the status of the revascularized free bone graft. Secondary reconstruction is justified after recurrence on bone grafts depending on the complexity of the major resection involving extensive tissue exeresis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Total esophagoplasty using a double pedicled free graft from the jejunum: the last resort]. / Oesophagoplastie totale par transplant libre de jéjunum à double pédicule: ultime recours.

After repeated failures of classic oesophagoplasties (gastroplasty and coloplasty) a last chance reconstruction could rely on a free jejunal transplant. We report an exceptional and original case where digestive tract was re-established between the orostoma and the epigastric antrum. The patient has four neoplasms in the throat, thoracic oesophagus. After circular pharyngolarynectomy and total oesophagectomy, all the usable vascularized plasties had necrosed. The ultimate reconstruction was performed with a free jejunal transplant carrying two vascular bundles revascularized with the cervical vessels and the internal thoracic vessels. Several recommendations are proposed: Save as much of the digestive tube as possible; preserve the physiological gastroduodenal circuit; redissect the residual plasty in order to raise the new one as high as possible; perform a sub-cutaneous insertion of the residual plasties and the jejunal transplant; and if the loss of digestive substance is greater than 30 cm, a long free jejunal transplant with two vascular bundles should be used.

[Multiple free transplants in microsurgery for cervicofacial reconstruction]. / Les transplants libres multiples en microchirurgie pour la reconstruction cervico-faciale.

Microsurgical techniques open the way for much creativity and originality for cervicofacial reconstruction and tumoral repair. Between 1976 and 1994, we performed 481 free transplants for cervico-facial reconstruction. A recently developed strategy has been the use of multiple free transplants, either simultaneously or successively. Between 1990 and 1994, we operated and reconstructed 9 patients using multiple free cervico-cephalic transplants after multitissular and agressive exeresis for tumoral or traumatic lesions. In 3 cases, the transplants were made simultaneously and in the 6 others successively. Three patients received 3 free transplants and 6 patients had 2. In 8 cases, each of the transplants was micro-anastomosed on different vessels. In one case, the two transplants were anastomosed in series, the most distal portion being connected to the most proximal portion (in comparison with the cervical vessels). One death occurred at 6 weeks due to infectious complications. The final result for the 8 other patients was good both morphologically and functionally. Indications for multiple free transplants include: complex tissue loss, multiple and massive tissue loss of the cervicocephalic region. This situation occurs particularly in case of voluminous tumours invading several structures, in multiple tumours and in firearm wounds. These series of patients allowed a definition of recommended techniques in case of difficulties in these very elaborate surgical procedures and confirmed that if the strategy is correctly planned, it is possible to greatly improve the quality of survival in these patients in terms of aesthetics, morphology and function.

[Posterior pharyngectomy. Reconstruction using a free antebrachial transplant]. / La pharyngectomie postérieure. Reconstruction par le transplant libre antébrachial.

Cancers of the posterior wall of the oro or hypopharynx are rare and do not invade the larynx or the oesophageal orifice. Previously, these cancers were treated with radiotherapy alone, but since 1981 new techniques in reconstruction surgery have allowed a surgical approach. Cancerological non-mutilating exeresis is possible, but reconstruction is difficult since the flap must be very thin to allow normal food intake. In addition, flap reliability is extremely important due to the gravity of cervical salivary fistulation. We treated 15 patients with a lesion of the posterior wall of the pharynx using posterior pharyngectomy and reconstruction with a free antebrachial transplant which was revascularized and reinnervated. In two cases, the operation was performed in patients who had had previous radiotherapy. A branch of the external carotid and the internal jugular vein were used for vascular microanastomoses and reinnervation was obtained using the superficial cervical plexus. The transplant was placed over the prevertebral aponevrosis and sutured to the remaining pharyngeal mucosa. One postoperative death due to heart disease occurred at D + 11. All reconstructions were successful and two salivary fistulas on irradiated tissue closed spontaneously. Postoperative radiotherapy was performed in 11 cases (50-65 Gy) and was well tolerated. These results demonstrate that a highly flexible and thin free forearm transplant is perfectly adapted to reconstruction after posterior pharyngectomy. It is more reliable than local pediculated flaps.

Anatomic basis of mandibular reconstruction by free vascularised fibular graft.

The free osteofasciocutaneous fibular transplant is a direct development of the free fibular bone graft used from 1983 in reconstructive surgery of the long bones. In 1989, Hidalgo was the first to publish a method of reconstruction of the mandible by composite free fibular transplants. The aim of this study was to specify the anatomy of the osteofascio-cutaneous fibular graft and particularly of the vessels to the skin. The sensory innervation of this transplant is described.

[Complete reconstruction of the nose using a prefabricated free forearm graft]. / Reconstruction complète du nez par transplant libre antébrachial préfabriqué.

The aim of prefabricated free transplants is to create a composite graft including a vascular pedicle with artery and vein, a muscle and its nerve, cellular tissue, bony tissue, cartilage, periosteum, and skin with its sensory nerve. This composite transplant is entirely constructed and modelled around the chosen vascular pedicle beforehand. Once the various materials of the future graft are removed and put in contact with the vascular pedicle, the subsequent neovascularisation should nourish the different elements. The vasculonervous pedicle, with the graft, are transplanted five weeks after preconstruction, revascularized and reinnervated. With these free prefabricated transplants, graft tissue which does not exist in the organism can be created. Cosmetic sequellae can be avoided since the vascular pedicle is chosen beforehand. Ear-nose-throat and plastic surgeons have used local structural preconstruction for many years, especially for ear reconstruction. The work presented here has the original feature of revascularized free transplant. From 1988, we have performed two complete reconstructions of the nose using a free forearm transplant modelled into a nasal pyramid. The classical techniques could not be used. In the first case a radius strut was used to form the nasal crest. In the second a chondrocostal cartilage was used. Transplantation was performed five weeks after preconstruction. In both cases, transplant viability was excellent but the cosmetic and functional results were less than satisfactory and required reoperation.

[Non-invasive dynamic studies of the cervico-thoraco-brachial pathway. Anatomo-clinical correlative study]. / Explorations dynamiques non invasives de la traversée cervico-thoraco-brachiale. Etude corrélative anatomo-clinique.

Based on a computer assisted analysis of the anatomic and biomechanic features of 200 subjects, the authors propose a dynamic approach to the exploration of the cervico-thoraco-brachial pathway. Results are given for 70 healthy and diseased subjects. Ultrasonic evaluations of the arterial component, dynamic echography of the axillo-subclavian venous component, electrophysiology including conventional electromyography, somesthesic and motor evoked potentials, and advanced imagery provide a panel of complementary diagnostic techniques.

[Salvage esophagoplasty using free jejunal transplant after repeated failure of other esophagoplasties. 25 cases]. / Oesophagoplastie de sauvetage par transplant libre de jéjunum après échecs répétés d'autres oesophagoplasties. 25 cas.

Salvage oesophagoplasty using a free jejunal transplant is the ultimate reconstruction possible after repeated failures using the classic procedures of oesophagoplasty. The free jejunal transplant appears to be the best choice. Twenty-five free jejunal transplants were performed by the same surgeon for such reconstructions including 13 cases involving benign lesions and 12 cases of cancer. There were no post-operative death and none of the transplantations was a complete failure although three cases of stenosis and fistulization occurred. Several recommendations can be made: save the existing digestive tract, redissect the residual digestive plasty and pull it up. The residual digestive flap can be examined by opacification or endoscopically in order to evaluate its length. An arteriography of the pediculated plasty gives information on its vascularization. A free jejunal graft can safely cover 25 to 30 cm. When possible, residual plasties should be positioned subcutaneously. The reconstruction of the cervico-thoracic oesophagus usually requires a vascular bypass with a saphene graft. In difficult cases, it may be necessary to remove a part of the sternal manubrium and the head of the clavicular bone in order to avoid compressing the jejunal graft. When the length of the reconstruction is greater than 30 cm, a long jejunal transplant with two pedicules (1 pedicule revascularized from the cervical vessels and the other pedicule from the internal thoracic vessels) is needed. An alternative technique would be a free antebrachial flap (six cases operated with two post-operative deaths at 6 weeks and two fistulas).(ABSTRACT TRUNCATED AT 250 WORDS)

[Distal arterial bypass surgery for lower limb salvage]. / La chirurgie de pontage artériel distal pour sauvetage des membres inférieurs.

From 1988 to 1990, 34 operations for distal arterial revascularization aimed at lower limb salvage were carried out in 29 patients with arteritis lesions at stage IV with distal necrosis (52%), severe stage III arteritis (10%), severe acute or subacute ischemia (38%). The indications and therapeutic modalities are described and discussed. The results are compared with the data found in the literature. This is an availability and emergency surgery, the last means to avoid life-saving amputation. The rate of patent revascularization after one year can be as high as 85 to 90%. Almost 9 extremities out of 10 can be saved.

[Free myocutaneous flap of the latissimus dorsi in cervicofacial surgery]. / Le transplant libre myocutané de grand dorsal en chirurgie cervicofaciale.

Free myocutaneous latissimus dorsi transplants are exceptionally used in cervicofacial surgery. The authors have performed an anatomical study of 23 non-embalmed subjects, using injections of neoprene latex and barium sulfate into the axillary artery and dye injections. Dissections, arteriographs and corrosion show that the lower scapular pedicle is constant, with an average length of 9.5 cm and a caliber that is sufficient for vasuclar microsurgery. Eight patients with large T4 cervicocephalic neoplasms were operated, including two with tongue tumors, one with a tumor of the oropharynx, two oromandibular lesions, two lesions of the maxillary sinus and a neuroblastoma involving the middle level of the facial structures. A free myocutaneous latissimus dorsi transplant was used. The transplant was revascularised by neck vessels using microsurgical techniques. Complete success was obtained in all eight patients. Good functional, cosmetic and morphological results were obtained as a rule. In cervicofacial surgery, the authors have thus chosen and used a free myocutaneous latissimus dorsi transplant in three topographic indications: for the oropharynx, to fill large cavities, especially the maxillary sinus, and to fill the middle level of the facial structures and of the base of the skull.

[Treatment of spontaneous pneumothorax under videosurgery, 32 cases (with videofilm presentation)]. / Traitement des pneumothorax spontanés en vidéo-chirurgie 32 observations (avec présentation d'un vidéo film).

From September, 1991, to June, 1992, 32 cases of pneumothorax were operated with thoracoscopy (video surgery). The indication was established for second recurrence in 6 cases, first recurrence in 14 cases, a persistent bulla or a lung failing to return to the wall after a first pneumothorax in 5 cases, and in the presence of a large pulmonary bulla on radiographs or CT scans during an initial episode in the last 7 cases. Thoracic CT was performed in 18 cases and demonstrated a system of bullae in 14 (13 in the apical segment and 1 in the segmentum apicale). The procedure included exeresis of the bullae on endo-GIA with apical and posterolateral parietal pleurectomy. In two cases, conversion into axillary thoracotomy was required because of extensive pleural adhesion in one case and of a technical problem in the other. The average duration of surgery was 72 mn. The thoracic drains were removed on the 2nd and 3rd postoperative days. Partial pleural detachment occurred in two cases, one on the 4th day and the other on the 5th day after surgery, with spontaneous return to the wall on the 8th day in both cases. The average stay in hospital was of 6 days. All patients were examined 15 days after discharge with a control radiograph, which was normal in all cases. No patient complained of parietal pain when no conversion into thoracotomy was made.

[Colonic perforation during colonoscopy. 100 cases]. / Perforation colique au cours de la coloscopie. 100 observations.

The analysis of 100 cases of colon perforation during colposcopic examinations highly demonstrates such a statement. The perforation risk during colposcopies is generally of the order of 0.2% for a diagnosis coloscopy. According to the statistic data used, it can reach 0.5 to 3% in therapy coloscopy. This is a risk inherent to the technique used. It is thus required to analyse the causes and take the appropriate measures to reduce it to a minimum. Mortality due to such a complication remains high (14%), i.e about 0.015 to 0.1% (#2/10000) of all colposcopies. In 11% of the patients, serious sequelae are to be observed. This demonstrates the significance of the medico-legal problem set by these perforations during colposcopies. The whole personnel responsibility can be involved: colposcopist, surgeon, anesthetist and hospital unit.