[Study of gastric elimination of ornidazole after intravenous administration in patients undergoing digestive surgery]. / Etude de l'élimination gastrique de l'ornidazole après administration intraveineuse chez des patients en chirurgie digestive.

In a previous study, performed in patients undergoing gastrointestinal surgery receiving antibiotics intravenously we pointed out that the gastric aspiration was an additional route of elimination for some drugs. In order to estimate the extra-dose required to replace losses in patients receiving ornidazole, a study was set up. 8 patients entered the trial; the patients were infused 500 mg of ornidazole for 3 days every 12 hours. Blood was sampled at 0-2-4-8-24 h after the last infusion. Urines and gastric aspirate were collected. The results indicate that the amount aspirated through the tubings is 69.1 +/- 37.5 mg per 24 hours (24.8 - 116.8) with a very high variability; the half-life was not different of what is known for ornidazole: 10.5 +/- 1.7 h. The results confirm that for the molecules weakly bound to protein which "concentrate" in the gastric secretion, the aspiration is an important route of elimination.

[Corticotherapy and surgery. Apropos of 73 cases]. / Corticothérapie et chirurgie. A propos de 73 observations.

The authors reviewed the outcome of 73 operations performed on 60 patients on long-term steroid therapy: Eighteen operations were carried out for gastro-intestinal perforation but the causal role of steroid therapy was only established in 6 cases (4 gastric and 2 colonic perforations). In the other 12 cases there was intercurrent pathology or a recrudescence of the underlying disease process. More selective indications for steroid therapy and the protective action of new drugs on the gastro-intestinal mucosa are probably responsible for the low incidence of iatrogenic complications compared with previously published series. However, steroid therapy did affect the postoperative course: the risk of infection was 20 to 30 p. 100 higher than normal, very common after emergency surgery (75 p. 100) and a major cause of mortality (60 p. 100); the risk seems to be high when the steroid dose exceeds 0.5 mg/kg/day, the disunion of an anastomosis was observed in 6 cases, including 5 "dirty" operations with a mortality of 60 p. 100, healing was slow: 2 cases of evisceration and 2 of abdominal hernia were observed. It was not possible to assess the threshold dose of steroids with regards to this complication, metabolic complications, especially adrenal failure were much less common. Of the diseases requiring steroid therapy the problem of angiitis seemed particularly prominent. Although the prognosis of the intercurrent surgical condition was not aggravated; mortality from a relapse of the angiitis was nearly 100 p. 100. Therefore, medical control of the relapse would seem to be the first priority and should be taken into account when assessing the surgical indications.

Respiratory effects of intrathecal morphine after upper abdominal surgery.

The effects of intrathecal (IT) administration of two doses of morphine (Group 1: 2 mg, n = 9; Group 2: 5 mg, n = 10) were studied in 19 patients after upper abdominal surgery. The ventilatory variables and occlusion pressure (P0.1) were recorded during room air breathing and during CO2 rebreathing tests prior to surgery, 24 h after surgery before IT morphine (n = 12), and 3, 5, 7, 11, and 24 h after injection. During room air breathing, minute ventilation (VE) did not change significantly in Group 1 and decreased significantly 3, 5, 7, and 11 h after injection in Group 2. During the rebreathing tests, there was a significant shift to the right of the ventilatory response to CO2 in both groups. The peak of the ventilatory depression was delayed, occurring 7 h and 11 h postinjection in Groups 1 and 2, respectively. Two patients in Group 2 developed clinically significant ventilatory depression. The shallow breathing observed after surgery was not changed after analgesia. In group 2, 5, mg IT morphine was responsible for a significant decrease in f60 (respiratory frequency for a PETCO2 of 60 mmHg). P0.1 increased markedly after surgery during both room air breathing and the rebreathing tests. After IT morphine, compared with the postoperative preanalgesic values, P0.1(60) (P0.1 at a PETCO2 of 60 mmHg) did not change in Group 1 and decreased significantly in Group 2. It is concluded that IT morphine is responsible for a ventilatory depression that is delayed and seems to be dose related and that analgesia does not abolish the shallow breathing observed after upper abdominal surgery.

[Large excision for caustic gastroduodenal burn]. / Exérèse large pour brûlure caustique gastro-duodénale.

A patient presenting with gastric and duodenal necrosis following ingestion of sulphuric acid was successfully treated by excision of the stomach and duodeno-pancreas with delayed re-establishment of digestive tract continuity. This technique would not be possible without continuous enteral nutrition.

Metronidazole kinetics and bioavailability in patients undergoing gastrointestinal surgery.

Kinetics and bioavailability of metronidazole were studied in 17 patients admitted in our emergency care unit for gastrointestinal surgery. All were treated with intravenous metronidazole (500 mg three times a day) before, during, and for 4 days after surgery. Seven of the patients continued the intravenous regimen and seven were switched to oral therapy with the same dose and dosing interval for 4 additional days. Kinetic evaluations were performed at steady state on days 4 and 8. The main unexpected result was a consistent 51% increase in AUC with no increase in elimination t 1/2 when intravenous was changed to oral therapy. This change was accompanied by an upward 75% shift in the trough metronidazole plasma concentrations. There was no change when patients remained on intravenous metronidazole. Reduction of clearance on oral treatment appears to be the most likely explanation.

[Parietal complications of cholecystectomy : results of prophylactic antibiotic therapy with cefazoline (author's transl)]. / Complications pariétales après cholécystectomie. Intérêt d'une antibiothérapie prophylactique par le céfazoline.

Patients undergoing cholecystectomy were randomly divided into two groups. The effects of a single injection of one gram of cefazoline given thirty minutes before operation to 30 patients were compared with those obtained in a second group of 29 untreated cases. The efficiency of the second generation cephalosporins in preventing postoperative complications of this type was confirmed. Prophylactic administration of this antibiotic therapy before uncomplicated biliary tract surgery can significantly reduce the incidence of postoperative parietal infections and therefore the duration of hospitalization.

[Diagnosis and treatment of a hydatid cyst of the liver. Report of 52 cases (author's transl)]. / Diagnostic et traitement du kyste hydratique du foie. A propose de cinquante-deux cas.

A series of 52 hydatid cysts of the liver is reported. It is emphasized that diagnosis should be easily done with simple explorations as liver scan, echography, immunologic tests. As far as treatment is concerned the possibility of anaphylactic accidents during operation must be kept in mind. To avoid as much as possible postoperative complications special attention must be taken in the choice of the operative technic. In young, unilocular cysts hydatidectomy should be performed. In old cysts complete resection of both cyst and adjacent hepatic parenchyma (pericystectomy) gives the best results.

[Value of duodenostomy in cases where duodenal stump closure is difficult following gastrectomy for ulcer (author's transl)]. / L'intérêt de la duodénostomie en cas de fermeture difficile du moignon duodénal dans les gastrectomies pour ulcère.

The authors report 3 cases of gastrectomy with terminal duodenostomy in patients which were operated on in emergency for large duodenal ulcers. They outline the history of this method, which seems to be seldom used in France. Technic and results are presented. This procedure is advised when closure of the duodenal stump is difficult and may lead to postoperative leakage : it is therefore advocated in large perforated ulcers involving the anterior wall of the duodenum.

[External pancreatic fistulas. Medical treatment (author's transl)]. / Les fistules pancréatiques externes. Traitement médical.

Ten patients treated for pancreatic fistulas have been reviewed. They all received a nutritional support via a jejunal tube in association with an external drainage of the fistulous tract. Enteral hyperalimentation do not stimulate external pancreatic secretion and all fistulas closed up spontaneously within three months (mean 55 days) without major complications. In one case fistula reappeared two months later and needed surgical procedure.

[Phenoperidine and operative common bile duct pressure (author's transl)]. / La pression intra-cholédocienne. Influence de la phénopéridine au cours de la chirurgie des voies biliaires.

The pressure variations registered in the common bile duct, after injection of phenoperidine (0,033 mg/kg) during sixteen anaesthesias performed for cholecystectomy, showed no significant modifications. In one case a spasm of the common bile duct was observed before analgesic administration which induced no change in the biliary pressure, an inhalation of amyl nitrite made it possible to affirm the functional character of the anomaly. The analgesic anaesthesia using phenoperidine, method chosen for high-risk patients, is compatible with bile duct surgery without risk of bringing about unnecessary surgical procedures.

[Early enteral nutrition in gastrointestinal surgery]. / Alimentation entérale précoce en chirurgie digestive.

In a series of twenty similar patients, having a healthy small intestine and having undergone elective surgery, two protocols of alimentation were studied. Beginning from the 8th post-operative hour, enteral alimentation is carried out by means of access to the jejunum and continued for ten days. The volume of liquid in the alimentary canal is progressively increased allowing the intravenous route to be stopped on average after 3,9 days. The high amount of the nitrogen and calory supply limits the post-operative nitrogen catabolism and rapidly restores a positive nitrogen balance. In other respects the weight loss is less than 2%, the biological constants are stable and no serious complications are linked with this technique. The early use of GI tract deals with the alimentational and electrolyte needs of the post-operative patient and diminishes the risks of iatrogenic complications of long term intravenous infusions. Relying on experimental data proving the absence of cessation of peristalsis of the small intestine in the immediate post-operative period and also the continuation of its capacity for absorption, this work demonstrates the possibility of early enteral alimentation. A better knowledge of the indications and contra-indications of this technique of feeding, of its methods of administration, and of the capabilities of absorption of the alimentary canal, must extend its indications to the high risk operative patients.

[Enteral feeding with reinjection in the terminal gut (author's transl)]. / Alimentation entérale et réinstillation iléale.

About one case, we describe our technology. The main avantage of the method is to reduce strongly septic complications resulting from intravenous feeding. It can be used as soon as the gastrointestinal tract is functional without any risk and it is the most effective means of providing nutrition for an extended period.

[Surgery of hepatic hydatic cyst. Per-operative complications. Possibility of anaphylactic etiology (author's transl)]. / Les complications per-opératoires au cours de la chirurgie des kystes hydatiques du foie Le rôle possible des phénomènes d'histaminolibération.

Among fifty cases hepatic hydatid cysts, we have observed four serious complications during operation. These complications appeared at the time of the puncture of the cysts with a severe shock in three cases. Anaphylactic etiology can be suspected but not proved without specific tests. Because the severity of these accidents (one death), anesthesiologist must be aware of the possibility of such complications: it is important to recognize anaphylactic reactions during surgical procedure to institute immediately a treatment to restore both circulatory competency and cardiac out put. Vasopressors with both alpha and beta properties are most useful under the conditions of massive peripheral vasodilatation and bronchospasm which occur in anaphylaxis.