Low-dose combined spinal-epidural anaesthesia for caesarean section in a patient with Eisenmenger's syndrome.

A 34-year-old woman (G3,P0) with Eisenmenger's syndrome and positive HIV serology presented to hospital at 16 weeks of pregnancy. She was hospitalised at 20 weeks under the care of a multidisciplinary team. At 33 weeks caesarean section was performed under low-dose combined spinal-epidural anaesthesia using a needle-through-needle technique. Over a period of 10 min, spinal anaesthesia produced a sensory block to T4 which did not alter oxygenation or blood pressure. Epidural supplementation was not required. The caesarean section proceeded uneventfully without pain or discomfort. The post-partum period was without major incident. Low-dose combined spinal-epidural techniques combine the advantages of spinal and epidural blockade; the versatility allows its use in a wide range of clinical conditions, combining effective anaesthesia with cardiovascular stability.

Loop ileostomy versus loop colostomy for defunctioning low anastomoses during rectal cancer surgery.

Several studies have compared loop ileostomy with loop colostomy to defunction colorectal anastomoses. The discordant results may be due to the heterogeneity of the indications. We therefore performed a retrospective study to compare the two procedures in a homogeneous group of patients operated on electively for rectal cancer. Among 462 consecutive patients undergoing rectal resection for cancer during 1986-1998, 60 had a loop colostomy and 107 a loop ileostomy to defunction a low anastomosis. The two groups were similar with respect to age, gender, obesity, tumor stage, and duration before closure (109 vs. 104 days; p = 0.28). All the stoma-related complications that occurred after construction and after closure of the stoma were recorded. There were no stoma-related deaths in the two groups. After stoma construction, the morbidity rate was significantly higher following loop colostomy than after loop ileostomy (35% vs. 19%; p = 0.02). After stoma closure the complication rate was significantly higher in the colostomy group than in the ileostomy group (34% vs. 12%; p = 0.004). The risk of surgical reintervention related to the morbidity of both construction and closure of the stoma was twice as high after loop colostomy than after loop ileostomy (22% vs. 9%; p = 0.03). The results of this study showed that, in our experience, the overall stoma-related morbidity and risk of reoperation were significantly lower after loop ileostomy than after loop colostomy. This suggests that loop ileostomy is the best procedure for defunctioning colorectal anastomoses electively. We therefore recommend using a loop ileostomy during rectal cancer surgery.

Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer.

PURPOSE: Standard surgical treatment for low rectal cancer situated below 5 cm from the anal verge or at less than 1 cm from the anal ring is abdominoperineal resection. This is because of the necessity both to achieve a sufficient distal margin and to preserve the whole of the anal sphincter. The aim of this study was to evaluate morbidity, oncologic, and functional results of intersphincteric resection with excision of the internal anal sphincter and low coloanal anastomosis for carcinomas of the anorectal junction. METHODS: From January 1990 to December 1996, 16 patients were studied prospectively. All patients had an infiltrating adenocarcinoma (5 T2 and 11 T3), located between 2.5 and 4.5 (mean, 3.6) cm from the anal verge. Rectal resection with a minimum distal margin of 2 (mean, 2.4) cm was performed in all cases; six patients underwent partial resection of the internal sphincter, and ten patients had a subtotal resection. A colonic J-pouch was associated with coloanal anastomoses in eight cases. Twelve patients had preoperative radiotherapy, 3 with concomitant chemotherapy; 5 patients had postoperative chemotherapy. RESULTS: There was no postoperative mortality. Morbidity occurred in four patients, of whom two underwent permanent colostomy after pelvic hemorrhage or anovaginal fistula. After a median follow-up of 44 (range, 11-92) months, no local recurrence was observed, and two patients died of distal metastases. The five-year actuarial survival rate was 75 percent. Continence was normal in one-half of patients and was altered in the other patients who suffered from occasional minor leaks. The median resting pressure was lower after subtotal than after partial resection of the internal sphincter (40 vs. 70 cm H2O; P = 0.02), but functional results were similar in the two groups. CONCLUSION: These preliminary results suggest that intersphincteric resection can be an alternative to abdominoperineal resection for selected rectal tumors situated at the anorectal junction, without compromising chance of cure. Functional results and continence were not altered by subtotal resection of the internal anal sphincter.

Risk factors for anastomotic leakage after resection of rectal cancer.

BACKGROUND: The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6-22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum. METHODS: From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical-, and treatment-related variables were studied by univariate and multivariate analysis. RESULTS: The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6.5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2.7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage. CONCLUSION: A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.

Local recurrence of low rectal cancer after abdominoperineal and anterior resection.

BACKGROUND: The aim of this retrospective study was to compare the risk of local recurrence between two groups of patients with low rectal cancer treated by either abdominoperineal resection (APR) or anterior resection. METHODS: From 1982 to 1992, 106 low rectal cancers (tumour situated 3-8 cm from the anal verge), of Dukes stage B and C were treated by curative surgery, 52 by APR and 54 by anterior resection. Mean follow-up was 60 months after APR and 50 months after anterior resection. RESULTS: The local recurrence rate of low rectal cancer was 16 of 52 (31 per cent) after APR and 15 of 54 (28 per cent) after anterior resection. The risk of local recurrence in univariate and multivariate analysis was not associated with clinical and histological variables, nor with the type of intervention. CONCLUSION: Sphincter-saving resection can be performed for low rectal cancer without an increased risk of local recurrence.

[Value of the technique of intestinal derotation in the treatment of the mesenteric clamp syndrome]. / Intérêt de la technique de dérotation intestinale dans le traitement du syndrome de la pince mésentérique.

A new case of the mesenteric clamp syndrome was the basis for recalling the circumstances and diagnosis of this syndrome and to emphasize the modalities of surgical treatment required in more than 50% of the cases. A good result was obtained in agreement with cases reported in the literature (8 cases out of 9) and underlines the effectiveness of intestinal derotation with creation of a common mesenterium.

[Locoregional recurrences of rectal cancers. Disappointments and hopes apropos of 54 cases]. / Récidives loco-régionales des cancers du rectum. Déceptions et espoirs à propos de 54 cas.

From January 1985 to December 1993, 54 locoregional recurrences (LRR) of rectal cancer (RC) led to 30 surgical procedures, including 20 resections, of which 10 were palliative. There were 10 abdominoperineal resections (APR), 4 anastomotic resections, 4 Hartmann procedures, 2 tumoral excisions (eight of these operations were extended to other organs, locally or not). Median survival was 22.5 months after excision, 10.2 months after colostomy alone and 16.6 m in inoperable cases. Six patients are alive with recurrence and 7 without (median 31.5 months) of whom one 74 months after receiving extended APR with Bricker-type total cystectomy. Our review of the literature has shown how difficult and disappointing the treatment of LRR of RC is, and the need for early detection. Immunoscintigraphy with monoclonal antibodies (IS), which is only rarely mentioned in other published surgical studies, was used for 7 patients when diagnosis could not be made after usual explorations. IS confirmed the diagnosis of LRR in 5 cases and excluded it in the other two. IS (sensitivity: 90-100%, specificity: 79-97%), which is more accurate than CT scan or dynamic MRI, should be used at the slightest doubt during follow-up and contribute with echo-endoscopy to detect LRR early. Among the new techniques which could improve the prevention and treatment of LRR, we have used intraoperative radiotherapy (IOR) for the past year in 32 patients (including 15 invasive RC and 3 LRR of RC). In a study of LRR topography to find an eventual association with IOR, we found the following: on the one hand, no significant difference in distribution of the 54 LRR according to the anatomic quadrant of the pelvic-peritoneal cavity; on the other, an LRR site which differed 8 times from that of the primary tumour in the 31 cases in whom the latter was not circumferential.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of the artificial pancreas in the diagnosis and surgical treatment of insulinomas]. / Apport du pancréas artificiel dans le diagnostic et le traitement chirurgical des insulinomes.

Insulinomas are often hard to diagnose and difficult to locate during surgery. We tested the contribution of artificial pancreas (AP) for case management of our last eight patients including two cases with multiple insulinomas. When diagnosis is uncertain, the euglycemic hyperinsulinic clamp technique under AP is a safe method to assess inappropriate insulin secretion characterized by a high plasma level of C peptide not inhibited by insulin injection. During surgery the AP provides a feed back controlled glucose infusion and thus maintains blood glucose above a predefined level. It allows a safe operation, preventing sudden hypoglycemia. By providing continuous data about intensity of glucose infusion and blood glucose, it helps to detect an occult secreting tumor (a preoperative therapeutic test with diazoxide requires stopping treatment for at least one month before surgery to avoid false negative results) and confirms the total ablation of abnormal insulin-producing cells. Peroperative monitoring curves of glucose infusion and blood glucose related to exploration and ablation procedures illustrate the contribution of this method in helping surgical treatment which can be perfectly adapted to the lesions as shown by the total recovery of our eight patients (mean follow-up: 43.2 months).

Use of ketoconazole in the treatment of Cushing's disease and ectopic ACTH syndrome.

Ketoconazole, an imidazole derivative which inhibits adrenal steroidogenesis, has been used with success for the metabolic control of Cushing's disease. Few data are available about the use of ketoconazole in the management of the ectopic ACTH syndrome. We have used ketoconazole in eight patients: four patients with Cushing's disease, two patients with overt and two with occult ectopic ACTH syndrome. Among patients with Cushing's disease, reversible hypoadrenalism occurred once. All had full clinical and biochemical regression of the disease for more than 6 months with 400-1200 mg ketoconazole per day. Patients with ectopic ACTH syndrome received 1200 mg ketoconazole per day for at least 2 months. Partial biochemical regression was observed in two and a secondary escape to adrenal blockade in two others. These findings further indicate that ketoconazole is a valuable tool for the metabolic control of Cushing's disease. On the contrary, in ectopic ACTH syndrome, this aim can be impossible to reach with ketoconazole although the reasons for its ineffectiveness remain to be determined.

[Hypoglycemia-inducing islet cell tumors. Measurement of blood glucose and insulin levels during operation. Results in seven cases (author's transl)]. / Les tumeurs langerhansiennes hypoglycémiantes. Intérêt des dosages per-opératoires de la glycémie et de l'insulinémie. A propos de sept observations.

The identification of hypoglycemic langerhans tumours by the surgeon, being sometimes difficult, per-operative quantity determinations of the glycemia and insulinemia levels help to ensure that all the insulino-secretory tissue has been removed. The technical protocol described includes an excess of glucids. In the 5 cases of adenomas, between 30 and 60 minutes after exeresis, a distinct increase in glycemia was noted (on average 1,25 g/l) in comparison to the initial level; this increase was not however significant in the 2 observations of adenomatous hyperplasia. Following the removal of the lesion, the fall in insulinemia is also more noticeable in adenomas (reaching 75,8 per cent of the initial level) than in adenomatous hyperplasia. Nonetheless, the fall in the latter is still considerable (42,4 per cent). This examination would be the best test, excvept that the results are known only after the operation. The 7 patients operated on recovered after 2 enucleo-excisions, and 5 isthmo-corporal-caudal splenopancreatectomies, the average post-operative period reaching 4 years.

Reestablishing duodenal continuity after previous gastrectomy for peptic ulcer.

Gastroduodenal anastomosis is not routine during reoperation for stomal ulcers after primary Billroth II gastrectomy. It nevertheless is a sure way to prevent an increased peptic potential which is brought about by a duodenal bypass. We have reviewed the published cases and added three more, bringing the total to 47. We analyzed the modalities, indications and results of this method. Gastroduodenal anastomosis can be accomplished more often than is thought, despite the often necessary large gastric resections. Separation of the duodenopancreatic block and liberation of the fundus allows suturing without traction. End-to-side anastomosis of the stomach on the anterior wall of the second portion of the duodenum avoids dissection of the duodenal stump. Vagotomy is required when basal acidity is greater than 20 mEq/liter. Reestablishing a physiologic alimentary tract is particularly indicated in chronic obstruction due to stenosis associated with a proximal loop syndrome in young patients. Jejunal interposition becomes necessary when total gastrectomy is the result of repeated surgery. Such a method is the best solution for agastria. The excellent results obtained by gastroduodenal anastomosis after repeat gastrectomy should encourage wider use.

[Physiopathological and anatomo-clinical study of peritoneal irrigation in generalized acute peritonitis]. / Etude physiopathologique et anatomo-clinique de l'irrigation péritonéale dans les péritonites aiguës généralisées

The objects of peritoneal wash-out and the conditions of its efficacy in acute generalised peritonitis were first defined. The authors then report the results of their physio-pathological research. The rules of intra-peritoneal wash-out then laid down. They suggest a method of wash-out perfectly adapted to the infected peritoneum. Study of the washings provides valuable information. The appearance, bacteriology and rate of wash-out, lead one to define criteria of prognosis which are useful and reliable for later treatment. These criteria may be grouped in a triad which are of value in addition to the clinical signs. The pathological consequences are then discussed. In the immediate post-operative period, there is no noxious effect on intestinal sutures, which can be attributed to the wash-out in this series of 20 cases. In the long-term, the absence of adhesions with restitutio ad integrum of the peritoneal cavity, was noted in 4 patients, and verified later by operation. The physiopathological basis and criteria of efficacy suggest that peritoneal wash-out should be used more often in modern treatment.