Antibiotic prophylaxis in pulmonary surgery. A prospective randomized double-blind trial of flash cefuroxime versus forty-eight-hour cefuroxime.

The aim of this study was to determine whether a 48-hour antibiotic prophylaxis regimen with a second-generation cephalosporin was more efficient than a flash antibiotic prophylaxis regimen in pulmonary operations. All the included patients underwent lung resection. Patients with preoperative infection were excluded. All the patients were given cefuroxime (1.5 gm intravenously) at the time of the anesthetic induction and again 2 hours later. The randomization was done postoperatively: group 1 was given placebo intravenously (n = 102) and group 2 was given cefuroxime intravenously (n = 101), each every 6 hours for 48 hours. The overall rate of infections was 46% in the 48-hour cefuroxime group versus 65% in the flash group (p = 0.005). The difference remained significant even after an adjustment with prognosis variables (p = 0.01). Six empyemas (6%) in the flash group were noted versus one (1%) in the 48-hour group (p = 0.03). From day 3 to day 8 after the operation, chest x-rays films were more often assessed as being normal in the flash group than in the 48-hour group (p = 0.005). On day 3 after operation, white blood cell counts were 13,020 +/- 1,220 elements/mm3 in the flash group versus 11,620 +/- 1,220 elements/mm3 in the 48-hour group (p = 0.03). A 48-hour antibiotic prophylaxis regimen decreases the rate of deep infections and particularly the rate of empyemas.

[Calcific constrictive pericarditis of anginal form complicated by hemopericardium and tamponade during anticoagulant treatment]. / Péricardite constrictive calcifiante à forme angineuse compliquée d'hémopéricarde et de tamponnade au décours d'un traitement anticoagulant

The case-history of a patient with calcified constrictive epicardopericarditis with rapidely progressive aggravation after digestive hemorrage due to excessive dose or oral anticoagulant therapy is reported. The occurrence of a cardiac tamponade has necessitated pericardectomy which has permitted to detect a partitionned hemopericardium. The surgical act was followed by gross improvement of both constrictive phenomenon and angina pectoris which have grounded the prescription of anticoagulant therapy. Anticoagulant therapy is likely responsible of the hemopericardium. Such facts are exceptionals in the course of constrictive pericarditis; diagnostic and therapeutic problems related to this complication are studied. The question of angina pectoris in the course of acute and chronic pericarditis is briefly studied by the way of this observation. Attention is drawed on the danger of the prescription of anticoagulant therapy in the course of some constrictive pericarditides.

[Cavernous hemangioma of the liver associated with angiosarcoma: malignant transformation?]. / Hémangiome caverneux du foie associé à un angiosarcome: transformation maligne?

Angiosarcoma of the liver is a rare tumor. Its treatment is usually regarded as unsuccessful and its prognosis extremely poor. The authors report the case of a solitary and encapsulated hepatic tumor characterized by the association of a cavernous hemangioma surrounded by an angiosarcoma. The hypothesis of an eventual malignant transformation of cavernous hemangiomas of the liver is raised.

[Practical role of ultrasonography and clinical examination for the diagnosis of acute appendicitis. Prospective study]. / Rôle pratique de l'échotomographie et de l'examen clinique dans le diagnostic de l'appendicite aiguë. Etude prospective.

The aim of this 100-patient prospective study was to compare three types of investigations in the diagnosis of acute appendicitis: initial clinical examination, initial appendicular ultrasound examination, and final results of repeated clinical examinations carried out within the first 48 hours. Final results included initial evaluation, obvious clinical results and definitive results from patients under 48 hour observation for uncertain diagnosis. Clinical initial or appendicular ultrasound examinations were poorly contributive to diagnosis (overall accuracy: 76 percent). On the contrary, repeated clinical examinations yielded a 100 percent sensitivity, a 94 percent specificity, a 94 percent positive predictive value, a 97 percent negative predictive value and a 97 p. 100 overall accuracy. No morbidity was noted in observing patients for 48 hours. Unwarranted appendectomies were carried out in 3 percent of cases. Ultrasonography of the appendix seems useful for the differential diagnosis of acute appendicitis.

[Lympho-epithelial lesions induced by plasma cells in a pulmonary MALT lymphoma]. / Lésions lympho-épithéliales induites par des plasmocytes dans un lymphome MALT du poumon.

One case of pulmonary lymphoma of MALT origin is reported. The diagnosis was made by histological and immunohistological study of surgical specimen. Cytologically, the tumoral proliferation was made by an admixture of centrocyte-like cells, small lymphocytes and vacuolized plasma cells. Lympho-epithelial lesions were particular because induced by tumoral plasma cells. From this case, problems of diagnosis and physiopathology of pulmonary MALT lymphomas are discussed.

[Postoperative morbidity and mortality of infectious complications of colonic diverticulosis: multifactorial study]. / Morbidité et mortalité post-opératoires des complications infectieuses diverticularies coliques: étude multifactorielle.

The objective of this study was to determine parameters influencing the mortality due to postoperative adverse events, by taking into account surgical techniques and many other perioperative parameters. From 1967 to 1989, 83 patients were operated for pericolic abscess (level 1, n = 22), pelvic abscess (level 2, n = 38) purulent peritonitis (level 3, n = 16) and fecal peritonitis (level 4, n = 7). Surgical techniques were: first colostomy with drainage (n = 21), first resection without immediate anastomosis (n = 34), and first resection with immediate anastomosis (n = 28). The overall complications were 51% (n = 42) with a mortality of 28% (n = 23). During univariate analysis, variables linked to postoperative complications were neurologic events (p < 0.0001), cirrhosis (p = 0.01), current treatment by steroids (p = 0.007), infectious level (p = 0.002), first colostomy (p = 0.005) and first resection with anastomosis (p = 0.007). Postoperative mortality was linked with neurologic events (p < 0.0001), age (p = 0.005), infectious level (p = 0.04), first colostomy (p = 0.005), and first resection with anastomosis (p = 0.0012). Logistic regression determined 3 independent variables influencing complications: neurologic events (p < 0.0001), first colostomy (p = 0.01), and infectious level (p = 0.002). The mortality determined by multivariate analysis was dependent on 3 variables: neurologic events (p < 0.0001) first colostomy (p = 0.007) and age (p = 0.01). The adjusted relative risk was 17 for neurologic events and 6 for first colostomy.

[Factors influencing survival after resection of cancer of the cardia. Comparison of total esophagogastrectomy and upper pole esophagogastrectomy]. / Facteurs influençant la survie après résection d'un cancer du cardia. Comparaison de l'oesogastrectomie totale et de l'oesogastrectomie polaire supérieure.

Total oesophagogastrectomy (TOG) is the best surgical technique for carcinoma of the cardia. However, oesophagogastric anastomosis is easier in upper pole oesophagogastrectomy (UPOG). This is a retrospective study excluding post-operative deaths and palliative surgery. We studied the factors affecting the survival and then compared TOG (n = 15) and UPOG (n = 26) in carcinomas of the cardia. Bad prognosis was related to several factors: poorly differentiated adenocarcinomas, tumor size, lymph node involvement and residual tumor at the resection margins. The survival rate of resected carcinomas of the cardia was 22 +/- 13%. No difference was noted between extended and limited resections. 5-year survival after UPOG was 20 + 18% and after TOG 11% (0-30) (p = 0.21). In stage 1B, 5-year survival after UPOG 11% and TOG was 50% (19-81) and 33% (0-82) (p = 0.54). In stages II and III A, 3-year survival after UPOG and TOG was 7% (0-20) and 0% (p = 0.16). For a given tumor size, 5-year survival is the same whatever the technique.

[Cystic tumor of the mediastinum of digestive origin. Apropos of a new case. Diagnostic and pathogenic hypotheses]. / Tumeur kystique du médiastin d'origine digestive. A propos d'un nouveau cas. Hypothèses diagnostiques et pathogéniques.

An incidental discovery of a posterior and inferior mediastinal cyst-like opacity allowed us to diagnose a pulmonary sequestration in a 45-year old woman. The operative findings showed an hour-glass tumor of the inferior mediastinum with an abdominal prolongation attached by a stalk onto the top of the stomach. These findings made us change our diagnosis in favour of an abdomino-thoracic gastric duplication. This new hypothesis was not confirmed by the results of the pathological report which revealed two kinds of tissue; intestinal in the abdomen and broncho-pulmonary in the chest. Two diagnoses where then proposed: complex hamartoma or mediastinal bronchogenic cyst. The pathogenic interpretation in such cases is still very controversial. English authors are prone to classify them as broncho-pulmonary foregut malformations. Macroscopic and microscopic data of the specimen led us to consider our case-report to be a foregut malformation.

[Colorectal cancers associated with ulcero-hemorrhagic rectocolitis. Detection of and prognosis for postoperative patients]. / Cancers colorectaux sur rectocolite ulcéro-hémorragique. Détection et pronostic des patients opérés.

Between January 1976 and December 1986, 86 patients underwent surgery for colorectal adenocarcinoma (AC) complicating ulcerative colitis (UC) at Mayo Medical Center in Rochester, Minnesota. Seventy-two percent were men, contrasting with only 55% in the population operated for UC without AC during the same time period at the same institution (p = 0.001). The mean duration of UC symptoms was 19.2 years. The diagnosis of cancer was established preoperatively in 65% of patients, while the remainder of patients, except for three (n = 30, 35%) were at high risk for cancer. A colonoscopy performed in 16 of those 30 patients less than six months prior to the operation did not detect cancer. Overall, cancer was either proven or highly suspected preoperatively in 96.5% of patients, while the sensitivity of colonoscopy was 78%. During the study period, histological tumor features, such as number of tumors, Dukes' stage, Broder's stage, and curative/palliative ratio, remained unchanged, and the five-actuarial survival of 50% did not improve with time (p = 0.37). Multivariant analysis indicated that Dukes' stage and male gender were two poor prognosis factors. For patients with long-standing UC, we offer either proctocolectomy, possibly with ileal pouch-anal anastomosis, or surveillance colonoscopy, emphasizing their respective hazards and limitations.

[Prevention of postoperative wound dehiscence. Comparative study of polyglactin 910 mesh and total reinforced extraperitoneal sutures]. / Prévention de l'éviscération post-opératoire. Etude comparative du treillis de polyglactine 910 et de points totaux extrapéritonéaux appuyés.

Postoperative wound dehiscence is a serious complication. Various surgical procedures have been proposed to prevent it but only few studies have compared their effectiveness. The authors report a retrospective study on 292 high risk patients operated between 1980 and 1988. These patients were divided in two groups according to the methods of abdominal wall support: 226 patients (group I) with total reinforced extraperitoneal sutures and 66 (group II) with a polyglactin 910 mesh. Preoperative risk factors, surgical pathology and the incisions performed were similar in the two groups. Only two parameters were different: the number of previous operations and emergency surgery which were more frequent in group II (p less than 0.05). Fourteen patients in group I developed postoperative wound dehiscence and none in group II (p = 0.02). Nine of these patients were reoperated with a mortality of 28.5%. The frequency of the other complications was similar in the two groups. Polyglactin 910 mesh was more effective than total reinforced extraperitoneal sutures in the prevention of post operative wound dehiscence justifying its use in high risk patients.

[Dumbbell neurogenic tumors of the posterior mediastinum. Apropos of five cases]. / Tumeurs nerveuses en sablier du médiastin postérieur. A propos de cinq observations.

The authors present 5 cases of dumbbell neurogenic tumors with intraspinal extension. There were 4 neurilemmomas in four adults and 1 ganglioneuroma in one child. These tumors were benign. Neurological signs were observed in two cases. Widening of the intervertebral foramen at the level of the tumor is a very suggestive sign of dumbbell tumor confirmed by CT-Scan or MRI. Precise morphologic features must be assessed before embarking on the operation. The procedures used were: thoracotomy only in two cases, laminectomy then thoracotomy because of neurological signs in two cases, thoracotomy then laminectomy to fully remove tumor remnants in one case. No major morbidity was noted. The neurological symptoms resolved in two cases. A combined two-team approach with thoracic and neurosurgeons working together has not been used so far, but this possibility is probably the best choice for the future.

[Post-traumatic retroligamentary pneumatocele. Apropos of a case]. / La pneumatocèle rétroligamentaire post-traumatique. A propos d'une observation.

A case-report of a 17 year-old man admitted for thoracic trauma associated with a vertical air and fluid collection located behind the pulmonary ligament raises the question of the exact nature of retroligamentary pulmonary pneumatoceles. They may be intraparenchymatous pneumatoceles or simple loculated pneumothorax but whatever the actual lesion, exact recognition of this radiological image avoids drainage and operation. This lesion resolves spontaneously within several weeks.

[Pulmonary metastasis with left intra-atrial extension of liposarcoma. Apropos of a case]. / Métastase pulmonaire avec extension intra-auriculaire gauche d'un liposarcome. A propos d'un cas.

The direct extension of a neoplastic thrombus of the pulmonary veins into the left atrium is extremely rare. The authors report the case of a pulmonary metastasis from a liposarcoma of the thigh extending into the pulmonary veins and prolapsing into the left atrium. The patient was successfully treated by tumorectomy under cardiopulmonary bypass then by left upper lobectomy.

[Peristomal pyoderma gangrenosum after colectomy for Crohn disease. Successful medical treatment]. / Pyoderma gangrenosum péri-stomial après colectomie pour maladie de Crohn. Succès du traitement médical.

A case of Pyoderma gangrenosum with two different abdominal sites in a female patient suffering from colonic Crohn's disease is presented. Local trauma on the midline scar of an incisional hernia and around the stoma were the possible triggering factors. Despite the major abdominal wall defect and an infected parietal collection, steroid therapy was very effective without the need for surgery.

[Intestinal infarctions. A re-evaluation of prognostic factors of postoperative mortality]. / Les infarctus intestinaux. Une ré-évaluation des facteurs pronostiques de mortalité post-opératoire.

The aim of this study, based on a series of 67 patients, was to assess the prognostic factors of postoperative mortality of intestinal infarctions (small and large bowel). Known risk factors were studied (age, sex, shock, Concomitant disease, use of arteriography and vasodilators), together with less studied factors, such as recent vascular or cardiac surgery less than 4 months before the infarction and length of bowel infarction. Postoperative mortality was defined as any death occurring within 45 days after surgery. The risk factors were assessed by univariate and multivariate analysis with logistic regression. The postoperative mortality was 63%. Age, shock, other medical diseases, recent cardiovascular surgery, and length of bowel infarction were significant predictive factors of postoperative mortality on univariate analysis. Shock, age greater than 70 years and recent cardiovascular surgery were three independent risk factors selected on multivariate analysis with equivalent weights.

[Coloplasty after esophagectomy in cancer. A retrospective study of morbidity and mortality]. / Les coloplasties après oesophagectomie pour cancer. Etude rétrospective de la morbidité et de la mortalité.

Aim of this study has been to evaluate retrospectively morbidity and mortality of 42 colon substitutions after resection for esophageal cancer. Colon substitution was the intervention of first choice in six patients. In the other patients the stomach was useless, because of previous gastric surgery (n = 14), of gastric involvement by the tumor (n = 21) or technical problem (n = 1). Patients have been separated in 2 groups: from 1969 to 1983 (group A, n = 22), and from 1983 to 1997 (group B, n = 20). Mortality and morbidity (all eventful postoperative course) have been collected for the 30 postoperative days. Total morbidity has been 57% as 77% in group A and 35% in group B (p < 0.05). Cervical and colo-colic leak have been the most common complications. Total mortality has been 14% as 22% in group A and 5% in group B (p < 0.1). In group A 3 patients died from anastomosis leak (intrathoracic or intraabdominal) and 2 from medical complications. In group B 1 patient died from unexplained sepsis. Our results show significative decrease of morbidity and mortality in group B. These results can be compared to those of gastroplasty for cancer or coloplasty for benign disease. In cancer of the esophagus, if stomach can not be used as substitutes, colon substitution is the best alternative, which can be used without increase of mortality and morbidity.

[Twisted pedunculated pleuro-pericardial cyst (author's transl)]. / Kyste pleuro-péricardique pédiculé et tordu.

An unusual case of a pleuro-pericardial cyst is reported. The mobile character of its shadow in thoracic chest x-rays and the sudden onset of the unilateral chest pain suggested that the cyst was pedunculated and twisted. This was confirmed by operation.

[Uncommon cardiac manifestations disclosing pheochromocytoma. Apropos of 3 cases]. / Manifestations cardiaques inhabituelles révélatrices du phéochromocytome. A propos de trois observations.

The diagnosis of pheochromocytoma is usually considered in the presence of permanent hypertension with exacerbations. However, pheochromocytoma may be responsible for a varied range of adrenergic symptomatology and hemodynamic equilibrium may be threatened by the spontaneous or induced massive release of pressor amines. Three cases form the basis of a description of unusual situations: acute pulmonary edema, acute circulatory failure and myocardial infarction with normal coronary vessels. The divercity and severity of these clinical situations are such that the possibility should always be suspected when confronted by any cardiomyopathy without obvious etiology, in particular in a hypertensive patient. The only treatment remains ablation of the tumour and diagnosis as an emergency is based, apart from history, on ultrasonography and/or abdominal CT scan and assay of urinary catecholamine derivative levels, which can be obtained within a few hours.

[Substernal goiters. 218 operated cases]. / Les goitres plongeants. 218 cas opérés.

The authors are presenting a retrospective study on 218 retrosternal goiters operated between 1968 and 1991. 33% of the goiters were incidentally discovered on a plain X-ray of the chest. Symptoms of compression were present in 50.5% of patients and hyperthyroidism in 16.5%. Respiratory manifestations were more frequent and more severe in patients aged 70 and more. Moreover 90% of those old patients were symptomatic. Goiters migrated anteriorly in 57.7% of cases, posteriorly in 33.9%, both anteriorly and posteriorly in 5.5%. Type of migration was unknown in 2.5%. 3.7% were malignant. 27 patients with respiratory symptoms received corticosteroids to reduce the airway compression. Among 52 patients with hyperthyroidism, 36 were given antithyroid drugs. Among them, some received corticosteroid drugs in order to reduce risks of mediastinal compression. A simple cervicotomy was adequate in 92.7% of case and was completed by sternotomy in 7.3%. The operation was iterative for relapsing or forgotten thoracic goiters in 24 cases. Morbidity was slight even for sternotomized patients. Mortality was noted in 2 cases (0.9%) one of them operated on for poorly-differentiated and suffocating carcinoma of the thyroid. We advise a straightforward surgical attitude as a result of the slight morbidity and mortality, even in sternotomized patients in order to avoid severe compressive complications of the airways.

[Spontaneous pneumothorax. A comparison of thoracoscopy and thoracotomy]. / Pneumothorax spontané. Comparaison de la thoracoscopie et de la thoracotomie.

The aims of this study were to assess the advantages of surgical thoracoscopy versus thoracotomy. Two 16-patient groups (thoracotomy, thoracoscopy) were compared. They were equivalent with regards to technique, age, etiology and lung dystrophy. Patients were called by phone to evaluate the surgical and functional results. The questionnaire was filled out by an independent physician who ignored the surgical technique used. Hospital stay was 7 +/- 2 days for thoracoscopy versus 11.5 +/- 5 days for thoracotomy (p < 0.003). During the J30 to J60 period of time, pain was mild in 94% of thoracoscopy cases and severe or unbearable in 69% of thoracotomy cases (p < 0.002). Mobility of the shoulder was fully recovered in all thoracoscopy patients within the first month versus only 62% of recovery at 3 months in the thoracotomy group (p < 0.0001). Working was possible at 1 +/- 0.8 month in the thoracoscopy group versus 2.6 +/- 0.8 months in the thoracotomy group (p < 0.002). Leisure activities were resumed at 2 +/- 1 month in the thoracoscopy group versus 4 +/- 1 months in the thoracotomy group (p < 0.0005). Only one relapse occurred in the thoracoscopy group. Thoracoscopy prevents the drawbacks of thoracotomy but keeps the same efficiency in the treatment of pneumothorax.