Multiorgan failure caused by intravascular lymphoma: a highly rare and malignant hemopathy mimicking multisystemic disease.

This manuscript describing a case of intravascular lymphoma, displays the difficulties underlying its diagnosis. We emphasize that intravascular lymphoma should be considered in patients with multisystemic manifestations without obvious etiology. Despite the heterogeneous presentation of this lymphoma, some clinical and biological investigations should prevail clinicians to do tissue biopsy which is required to make the diagnosis.

[Implication of dexamethasone adjunctive therapy after the onset of cerebral vasculitis in Streptococcus pneumoniae meningitis]. / Implication du traitement adjuvant par dexaméthasone dans la survenue d'une artérite septique cérébrale au cours d'une méningite à Streptococcus pneumoniae.

Few adverse effects have been reported with adjunctive dexamethasone treatment in pneumococcal meningitis. Nevertheless, we report a case of cerebral vasculitis. A 49-year-old man was admitted for fever and altered mental status. Lumbar puncture revealed a high inflammatory response and Streptococcus pneumoniae was identified by culture. Antibacterial therapy and adjunctive dexamethasone treatment were initiated as recommended. The immediate outcome was favorable but due to the onset of focal cerebral abnormalities, a CT scan was performed on the ninth day showing cerebral vasculitis. The patient died on the thirteenth day despite antibacterial therapy and resuscitation. In our case, a secondary neurological worsening appeared when adjunctive dexamethasone treatment was stopped suggesting a rebound effect. Observation of similar cases may lead to modifying adjunctive dexamethasone treatment protocol in bacterial meningitis.

Structure-activity relationships of phenytoin-like anticonvulsant drugs.

A limited series of compounds structurally related to phenytoin has been tested in the maximal electroshock seizure (MES) test in order to define the impact on their antiepileptic activity of reducing the ability to form a hydrogen bond. A net stepwise decrease of the anticonvulsant activity was observed when the hydantoin ring structure was altered into succinimide and pyrrolidinone and when these rings were N-methylated. The pharmacological data analyzed in terms of structure-activity relationships (SAR) indicate the importance of the capability of forming hydrogen bonds. Further insight into the molecular mode of action of phenytoin was gained by a 13C NMR study of three phenytoin analogues deuterated in one of the phenyl groups, i.e., o-, m-, p-deuteriophenytoin. This approach allowed the unambiguous assignment of the chemical shifts of the ortho, meta, para, and ipso carbons. Measurement of the T1 relaxation times provided a value of 0.2 s for the para carbon and 0.8 s for the meta and ortho carbons of the phenytoin phenyl rings. These data are consistent with the view that the two phenyl groups possess a certain degree of rotational freedom along the para-ipso axis. More generally, the present results, as well as some literature data, support the concept that the ability to form hydrogen bonds as well as a certain degree of motional freedom of the phenyl groups are important SAR features in antiepileptic phenytoin-like drugs.

Value of microlaparoscopy in the diagnosis of right iliac fossa pain.

BACKGROUND: The possibility of performing minimally invasive exploration of the abdomen could avoid unnecessary appendectomies. Micro-optics and instruments of 2 mm in diameter allow this type of exploration, but the feasibility and the accuracy of the diagnosis resulting from this method have not been evaluated. METHODS: A prospective study of 36 patients (11 men and 25 women) operated on for acute right iliac fossa pain was carried out. The abdomen was explored with a 2 mm optic and with a 10 mm optic in order to characterize the aspect of the appendix. The results were compared with the postoperative pathologic findings of the appendix. RESULTS: The micro-optic procedure failed in 3 patients. The appendix was visualized in 26 patients: in 18 patients through the needle-optic alone, 8 patients requiring additional instruments. The appendix was visualized in all cases with the 10 mm optic. Appendectomy was performed in 34 patients: with microinstruments in 6, with 5 mm instruments in 26, and through a MacBurney incision in 2. The appendix was not removed in 2 patients. A correct diagnosis was made by microlaparoscopy and confirmed by the pathology in 21 patients (58%), made and confirmed in 32 patients with a 10 mm optic (89%). Minor complications included a cecal wall insufflation in 1 patient and a peroperative hemorrhage on a 2 mm port site in another with an uneventful postoperative course. One postoperative parietal hematoma required reoperating removal. No mortality was observed. CONCLUSIONS: The low quality of the image obtained with microlaparoscopy does not permit safely evaluating the aspect of the appendix in case of acute right iliac pain. This method is not recommended for routine abdominal exploration.

Laparoscopic approach in acute small bowel obstruction. A review of 68 patients.

BACKGROUND/AIMS: Laparoscopic management of acute small bowel obstruction has potential advantages over classical laparotomy. The aims of this study were to assess the feasibility and the safety of this technique, as well as to find any predictive success factors. METHODOLOGY: A laparoscopic approach was undertaken in 68 out of 150 patients admitted between 1991 and 1997 for acute small bowel obstruction. RESULTS: The cause of obstruction was bands or adhesions in 80% of the patients. A correct laparoscopic diagnosis was established in 66% of the cases. A laparoscopic treatment was performed successfully in 31 patients (46%), and was assisted by minilaparotomy in 4 patients (6%), and by open herniorraphy in 2 patients (3%). Thirty-one patients (46%) needed a conversion to laparotomy. There were 6 bowel injuries (9%), all recognized during laparoscopy. There were 2 deaths in converted patients and 2 early reoperations for persisting ileus in patients treated by laparoscopy alone or by assisted laparoscopy. CONCLUSION: Acute small bowel obstruction can be treated by laparoscopy alone, or assisted by minilaparotomy or open herniorraphy with advantages for the patient and few complications despite a high rate of conversion. There were no pre-operative predictive factors for successful laparoscopy, except for an isolated previous scar from an appendectomy. Pre-operative predictive success factors were parietal intestinal adhesions, as the only cause of obstruction. Multiple adhesions will mostly require conversion to laparotomy.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

SUMMARY: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

[5 cases of neonatal duodenal obstruction]. / A propos de 5 cas d'obstruction duodénale néonatale.

The authors report five cases of intrinsic duodenal obstruction in neonates, operated upon since 1976 to 1982. In 3 cases, it's a question of atresia and in two cases of annular pancreas. The associated lesions are in one case, a macrocephaly, in a second case, a microcephaly with ocular lesions and in a third case a jejunal atresia. The operating procedure consists four times in a duodeno-jejunostomy and one time in a duodeno-duodenostomy. A complementary jejunal resection with end-to-end anastomosis is necessary in the case of associated jejunal atresia. A discharge gastrostomy is performed once only. The post operative feeding is exclusively parenteral. A cholostatic jaundice appears in two cases but run its course favourably. The postoperative course is simple. There is no death. The five cases evolue normally at long term.

[Surgical experiences with adrenal tumors (author's transl)]. / Expérience chirurgicale des tumeurs surrénaliennes.

Between 1957 and 1978 the authors operated 15 patients with an adrenal tumor. This series includes six pheochromocytomas, seven cortical tumors, one adrenal cyst and one neuroblastoma. The specific diagnostic and therapeutic problems encountered in this group of different type tumors are discussed. In the group of six pheochromocytomas one was benign but recurred nine years later, one was a paraganglioma and one a malignant pheochromocytoma with functional glandular metastases. The seven cortical tumors are divided into one functional benign tumor, two non-functional benign tumors of which one was located outside the adrenal gland, two non-functional malignant tumors, one functional malignant tumor and one syndrome of Conn.

Hernia of the diaphragm with gastric volvulus: laparoscopic repair.

The authors present a case of a diaphragmatic hernia with gastric volvulus, 29 months after a left thoracophrenolaparotomy. The surgical repair was performed by laparoscopy. The authors discuss the laparoscopic approach in the treatment of diaphragmatic disorders.

[Drainage in biliary surgery]. / Le drainage en chirurgie biliaire.

Over the past six years, the authors performed 1 018 biliary tract operations. Surgery for biliary tract cancer is not included. Drainage of the wound was only used for technical reasons and in complicated cases of cholecystitis. Five hundred sixty eight (64,3%) cholecystectomies were performed without drainage. The operative mortality in this group was 0.7% (4 patients). One of those 4 died of hemoperitoneum inspite of a rather late reintervention. From their experience the authors conclude that close postoperative follow-up and, when necessary, early reoperation is far more important than routine drainage which is often ineffective when problems arise. Multiple recent randomised studies support this attitude.

Patient's opinion about written information before laparoscopy: a consecutive series of 100 cases.

PURPOSE: The aim of this study was to assess the opinion of the surgical patient concerning written information before laparoscopic operations. MATERIAL AND METHODS: A prospective and consecutive series of 100 patients was studied. Information sheets concerning the planned laparoscopic operation were distributed at preoperative consultation. A short and clear questionnaire regarding this information was answered upon hospitalization. RESULTS: The majority of the 87 patients, who had read the information, were very pleased to be informed about the techniques (91%) and the risks (97%), although a significant group was worried by the explanations of the risks (41%). None of the patients cancelled the planned operation. None of the patients had become less confident in the surgeon. Most of the patients (95%) found this system of informed consent necessary. CONCLUSIONS: Surgeons should no longer be reluctant to distribute standardized information sheets, as a majority of patients find this system of information necessary.

[Value of celioscopy in non-traumatic acute abdomen]. / Intérêt de la coelioscopie dans les abdomens aigus non traumatiques.

The diagnostic and therapeutic value of laparoscopy in emergency was studied in 314 patients presenting with non-traumatic acute abdomen. Laparoscopy gave a correct and complete diagnosis of the underlying disease in 92% (290/314) of cases. An erroneous preoperative diagnosis was corrected by laparoscopy in 18% (58/314) of cases. This implied a change of the therapeutic strategy in 9% (27/314). Seventy five per cent (234/314) of patients were exclusively treated by laparoscopy, 22% (68/314) by laparotomy and 3% (11/314) by laparoscopically assisted surgery. Mortality was 2.5% (8/314) and morbidity 9% (29/314). In conclusion, laparoscopy is a valuable diagnostic tool for the surgeon in the context of acute abdomen and is an interesting therapeutic alternative in selected cases. However, it requires extensive experience in laparoscopic techniques.

[Is laparoscopic cholecystectomy effective and reliable in acute cholecystitis? Results of a prospective study of 221 pathologically documented cases]. / La cholécystectomie coelioscopique est-elle performante et fiable en cas de cholécystite aiguë? Resultats d'une étude prospective portant sur 221 cas vérifiés histologiquement.

From December 1989 to May 1995, a prospective study of laparoscopic cholecystectomy was carried out in our department, in order to assess the reliability and safety of this method in the case of acute cholecystitis. During this period, 1453 patients underwent laparoscopic cholecystectomy. Acute cholecystitis was diagnosed in 280 patients, based on clinical history and macroscopic lesions. Only 221 cases (15%) were included in the study after positive histology was obtained (M: 86; F: 135). The mean age was 62 years (20-90). Sixty-two patients (28%) were classified as ASA III and IV. The mean interval between the first symptoms and the operation was 9.9 days (1-53). The mean operating time was 130 minutes (45-420). Conversion to an open procedure was necessary in 22 cases (10%). The operative mortality was 0.9% (2 ASA IV patients) and the overall morbidity was 13.5%. A bile duct injury occurred in 0.4% of cases (1/221). In conclusion, laparoscopic cholecystectomy for acute cholecystitis is a safe procedure, when performed by operators experienced in laparoscopic surgery.

[Cholecystectomy by celioscopy: indications and safety of the method. Apropos of a consecutive series of 300 patients]. / Cholécystectomie par coelioscopie: indications et sécurité de la méthode. A propos d'une série consécutive de 300 patients.

We performed a laparoscopic cholecystectomy in 300 patients with gallstone disease complicated or not. The rate success was 97%, however involved the pathology might be. Indeed, 15% of the patients had an acute cholecystitis (10% catarrhalis, 5% empyema). Twenty-four patients with common bile duct stones had a complete endoscopic management of the biliary disease: endoscopic sphincterotomy and laparoscopic cholecystectomy. Operative mortality was absent and overall morbidity was 3.7%, exclusively minor.

[Laparoscopic cholecystectomy in the elderly patient]. / Cholécystectomie coelioscopique chez le sujet âgé.

Biliary surgery in the elderly is associated with a high morbidity and mortality rate. The aim of this prospective study is to determine the complications or benefits of laparoscopic cholecystectomy in patients over 75. From December 1989 to July 1992, 60 women and 15 men, all aged over 75, underwent laparoscopic cholecystectomy. 32 (43%) were at high surgical risk. In one half of cases, complications were present (30 cases of acute cholecystitis and 13 cases of choledocolithiasis). 10 underwent endoscopic sphincterotomy preoperatively and 4 patients with common bile duct stones were treated by laparoscopy during the same operating time. Eight conversions were necessary because of inflammatory process. The global morbidity rate was 10.6%. Local complications were: 1 wound abscess, 1 wound dehiscence, 2 biliary leaks and 2 cases of bleeding at puncture sites. The general complications concerned the respiratory tract except for one case of urinary tract infection. The mortality rate was zero. Laparoscopic cholecystectomy seems to be better tolerated than laparotomy. It allows curative treatment of gallstones, complicated or not, with a low morbidity rate.

[Cardiac arrest in an adolescent with arrhythmogenic right ventricular dysplasia]. / Arrêt cardiocirculatoire chez une adolescente et dysplasie arythmogène du ventricule droit.

We report the case of a 16-year-old girl who experienced sudden cardiac arrest from ventricular fibrillation, complicating an arrhythmogenic right ventricular dysplasia, a rare heart muscle disorder, occurring typically in young adults, characterized by a fibrofatty replacement of the right ventricular myocardium. Symptomatic ventricular arrhythmias are frequent, and sudden death has been reported. In our case, diagnosis of arrhythmogenic dysplasia was based on the association of one major criterion and two minor criteria as suggested by the relevant task force. In contrast with most other reports, the chest ECG did not display the typical features. An automatic transvenous pectoral cardioverter-defibrillator was implanted. The authors emphasise that juvenile forms are more exposed to ventricular fibrillation and sudden cardiac death, and consequently require the early detection of the disease. Family cases have been described and the occurrence in one individual must lead to investigations in the relatives.

[Hepatopulmonary syndrome: physiopathology of impaired gas exchange]. / Syndrome hépatopulmonaire. Physiopathologie des anomalies des échanges gazeux.

The hepatopulmonary syndrome (HPS) consists of a triad of liver dysfunction, increased alveolar-arterial oxygen gradient and intrapulmonary vascular dilations. The mechanisms of impaired arterial oxygenation are still debated but the multiple inert gases elimination technique and more recently contrast echocardiography, greatly facilitated the investigation of such mechanisms. Subsequently the cause of hypoxemia can be attributed to several mechanisms such as ventilation-perfusion mismatch, right-to-left intrapulmonary shunts and alveolar-to-capillary diffusion defect, variously implicated in the severity of the disease. SHP may result from intrapulmonary vascular dilations and angiogenesis but the pathogenesis of such abnormalities is not completely explained. The hypothesis of an imbalance in vasoactive mediators and angiogenic factors has been put forward. Increasing data support the theory that the increase in synthesis and release of nitric oxide (NO) is the key factor modulating vascular tone. If this hypothesis is true, the use of compettive inhibitors of NO synthesis should restore pulmonary vascular tone, reversing the hemodynamic changes and gas exchange impairment of HPS.

[Iatrogenic events: a significant cause of admission in intensive care units]. / L'événement indésirable grave: un motif d'admission fréquent en réanimation.

OBJECTIVE: Identification and analysis of iatrogenic events leading to admission in intensive care units. STUDY DESIGN: Prospective observational monocentric study. PATIENTS: Critically ill patients hospitalized in adult medical intensive care unit of a general hospital over a twelve-month period. METHODS: We recorded for each patient the following characteristics: origin, demographic datas, cause of admission, medical background, severity, diagnosis, ICU length of stay and provided treatments. Two medical investigators identified the iatrogenic character of events and determined their potential preventability. Univariate statistical analysis was performed. RESULTS: During the study period, 603 patients were admitted and 71 (12%) due to iatrogenic events. In comparison to patients hospitalized for other causes, these patients were older (66 years vs. 60, P 0.009) and often previously treated in a hospital (82% vs. 54%, P<0.0001). They had increased need for transfusions (39% vs. 26%, P 0.02) but less frequent indications for mechanical ventilation (67% vs. 77%, P 0.07). They had similar ICU mortality (20% vs. 19%). Among them, 27 iatrogenic events were considered as preventable. CONCLUSIONS: Iatrogenic event is a significant cause of ICU admission, involved in 12% of all the hospitalizations in our unit. It has an impact on the patient's profile (significantly older) and their ICU stay (increased need for transfusion). More than a third of events could be preventable and potentially accessible to corrective actions.