Biomedical subjects
Publications and source records attributed to C Arvieux.
On critically injured patient the decision to perform a damage control laparotomy is based on the volume of transfusion and shock. The aim of the surgery which is to obtain as fast as possible the best hemostasis to limit the peritoneal thermal loss and to perform as soon as possible physiologic restoration in the Intensive Care Unit.
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INTRODUCTION: Spontaneous skin necrosis revealed acquired protein S deficiency due to isotype G autoantibodies. CASE: This 31-year-old male renal transplant recipient, receiving immunosuppressive treatment, was hospitalized for necrotic purpural lesions. We were not able to detect any triggering factor. Sustained anticoagulant therapy remained essential to prevent new skin lesions and perhaps more thrombotic events. COMMENTS: This condition is rare in adulthood, but is well described in children's purpura fulminans, especially the post-varicella form. Its mechanism remains unclear.
PURPOSE: Peritoneal carcinomatosis and particularly those from digestive origin has long been considered as an automatically terminal disease in abdominal cancer patients. CURRENT KNOWLEDGE AND KEY POINTS: Over the past decade, new locoregional treatments combining cytoreductive surgery, peritonectomy procedures with perioperative intraperitoneal chemotherapy (with or without hyperthermia) have been developed by specialized teams. Because of its high but acceptable mortality and morbidity, this aggressive but comprehensive therapeutic strategy requires accurate and strict patient's selection into multidisciplinary and specialized teams. It may allow prolonged survival and cure for patients with pseudomyxoma peritonei, peritoneal mesothelioma, carcinomatosis from colorectal or gastric cancer. Qualitative and quantitative prognostic indicators are needed to assess a patient's eligibility, including tumor histopathology, assessment of carcinomatosis extent or completeness of cytoreduction which appears to be the most important. PERSPECTIVES: Combination of cytoreductive surgery with perioperative intraperitoneal chemotherapy appears to be an adapted therapeutic approach for patients strictly selected, with peritoneal carcinomatosis. Phase III studies are now needed for the validation and the evaluation of the type of intraperitoneal chemotherapy.
The technique of abdominal wall closure by vacuum pack is described. Indications are essentially the abbreviated laparotomy or damage control (especially with abdominal packing), and the post traumatic abdominal compartment syndrome (in the treatment and prevention).
OBJECTIVES: To study the frequency of a factor of immunodepression in patients with tuberculosis, the differences in presentation, and the diagnosis and therapeutic management according to the immune status. METHODS: Retrospective study of the files of patients hospitalised in the University Hospital Centre of Rennes in 1998 for a Mycobacterium tuberculosis infection. Comparison of two populations, immunodepressed versus non immunodepressed. RESULTS: 75 patients aged 20 to 91 were included, 41 patients were considered immunodepressed and 34 non immunodepressed. The causes of immunodepression were: HIV infection (n = 2), diabetes (n = 4), chronic alcoholism (n = 12), chronic respiratory diseases treated with corticosteroids (n = 6), neoplasia (n = 9), and inflammatory diseases (n = 7). Comparison between the 2 populations revealed more a frequent history of tuberculosis in the immunodepressed (p = 0.04), shorter delay before diagnosis (p = 0.04), greater frequency of disseminated forms (p = 0.02) and enhanced mortality (p = 0.01). There was no difference in the 2 groups with regard to the clinical signs having evoked tuberculosis, the diagnostic method, the bacteriological results or the modalities of treatment. CONCLUSION: The frequent reactivation of tuberculosis in immunodepressed patients and the severity of the infection in these patients should evoke tuberculosis and the rapid initiation of an efficient treatment in such patients. In the case of alteration in immune defences, prophylactic treatment should help to reduce the number of such reactivations.
If an emergency laparotomy is necessary, a damage control laparotomy may be useful. If during the laparotomy the hemodynamic is stabilised, the severity is depending on the existence of a ductal injury and an associated duodenal lesion. Surgical indications and techniques are described in these different cases. If no laparotomy, the location and type of injury is assessed by CT scan, magnetic resonance cholangiopancreatography or ERCP. Injury of the pancreatic duct is the main part of prognosis and indications. The non operative treatment in case of ductal injury remains controversial.
AIM: Of the work: evaluation of a multidisciplinary strategy and a prospective medicosurgical protocol for the treatment of occlusion due to unresectable peritoneal carcinomatosis. PATIENTS AND METHODS: All the included patients had occlusion and intraabdominal carcinomatosis. None could benefit a curative treatment. 75 patients were included for 80 episodes of intestinal obstruction. The protocol involved three successive therapeutic phases. (i) Treatment during five days by corticosteroids associated to antiemetic agents, anticholinergic antisecretory agents, and analgesics as needed (Phase I); (ii) In the event of refractory occlusive symptoms treatment by somatostatin analog during 3 days (phase II); (iii) If this treatment was ineffective a gastrostomy was performed (phase III). RESULTS: Median survival was 31 days. Outcome showed that for the 80 episodes of obstruction, phase I medical treatment enabled relief in 50 cases (63%) and phase II medical treatment (somatostatin) enabled relief in 11 cases (14%). 10 more patients (13%) were relieved by the gastrostomie and one by a duodenal endoprothesis. Symptom control without a long-term nasogastric tube was achieved for 72 of the 80 episodes (90%). Fifty-eight episodes (72% of overall total) were controlled for 10 days or less. Median time to gastrostomy was 17 days. Eight patients experienced persistent vomiting and required a nasogastric aspiration until death. CONCLUSION: This multidisciplinary approach between Palliative Care and Specialized Medical and Surgical teams enabled relief of the occlusive symptoms for 90% of the patients of the study. The protocol was useful for the caregivers for the management of terminally ill patients. To enhance these results, it would be necessary to shorten the delay of relief, which has been longer than ten days for one third of the patients. The simplification of the protocol including two steps instead of three is on study.
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Guidelines recommend high doses of beta-lactams for the therapy of endocarditis. This report describes a retrospective study of 15 endocarditis patients (median age 64 years), treated according to guidelines, whose beta-lactam trough plasma concentrations were measured with high-performance liquid chromatography because of tolerance or efficacy concerns. For amoxycillin, the mean level was 86.8 mg/L (range: 30-212 mg/L); five (45%) patients had concentrations > 1000 x MIC. For cloxacillin, the mean level was 47.9 mg/L (range: 16.7-104 mg/L). The consequences of high and unpredicted beta-lactam trough plasma concentrations for a prolonged period have not yet been thoroughly evaluated.
Leptospirosis has a highly variable clinical presentation, which may be related to different infecting serovars, host factors, or a combination of these. This study investigated retrospectively 34 consecutive patients with serologically confirmed leptospirosis admitted during the period 1992-2002. On admission, the most frequent symptoms were fever (100%), headache (75%), myalgia (55%), arthralgia (45%) and vomiting (39%). Pertinent laboratory findings included lymphopenia (85%), thrombocytopenia (75%), elevated liver enzymes (87%) and renal abnormalities (proteinuria, 77%; haematuria, 58%; elevated serum creatinine, 53%). The study confirmed the variable clinical and biological symptoms of leptospirosis, and indicated that lymphopenia is a common feature of leptospirosis cases.
INTRODUCTION: There is little information on the frequency, physiopathology and management of extra-cerebral manifestations of N. meningitidis meningitis. Articular, pleural and pericardial involvement is occasionally reported with a symptomatology that can be delayed with regard to the initial diagnosis. OBSERVATIONS: In two patients in whom the diagnosis of meningococcal meningitis had been confirmed, the progression was towards a recurrent pericarditis up until the 4th month after the initial episode of infection in the first case and pericarditis with tamponade and surgical draining in the second. However, the final outcome was favourable for both patients following treatment with non-steroidal anti-inflammatories (NSAIs). COMMENTS: The incidence of pericardial involvement is unknown. The distinction has to be made between purulent pericarditis, more frequent in children, and the inflammatory pericarditis that is often of late onset. The indication for surgical draining must be dominated by the clinical hemodynamic impact. The indication for NSAIs and/or acetyl-salicylic acid is not codified (doses, duration), but in the two cases reported here we would privilege NSAIs.
Severe decompression sickness occurs unfrequently, with, generally an identifying cause (error in decompression protocols, promoting factors.). We report a case of severe spinal cord damage; onset after a common dive, neither deep nor long, without any promoting factor, absence of responsiveness to recompression, three hours post-dive, importance of MRI signal abnormalities, make us to point out the confounding variability of onset and evolution of such illness.
Peritoneal carcinomatosis may occur after curative surgery of any gastrointestinal carcinoma, but it is however the most frequent form of evolution after curative resection of gastric carcinoma and is present at the time of surgery in many cases. This locoregional extension of cancer has a poor prognosis, with a great mortality and a poor quality of life. It is sometimes considered of such a poor prognosis that patients do not go through any resection or palliative procedure. Techniques of radiotherapy, chemotherapy and intraperitoneal chemotherapy have been used with moderate clinical efficacy. Since the 1990s, intraoperative hyperthermic peritoneal chemotherapy combined with comprehensive cytoreductive surgery has been proposed to improve prognosis of patients with peritoneal carcinomatosis from gastric origin as well as carcinomatosis from colorectal origin or pseudomyxoma peritonei.
AIM OF THE STUDY: Damage control laparotomy is a new approach to the more severe abdominal traumas. It stems from a better understanding of the physiopathology of the haemorragic shock. PATIENTS AND METHODS: A national retrospective study from 27 centers about 109 trauma patients who underwent a damage control procedure between January 1990 and December 2001, is analysed. Surgical procedures included 97 hepatic packing, 10 abdominal packing, 4 exclusive skin closure, 1 open laparotomy technique and 3 digestive stapplings. RESULTS: The mortality rate is 42%. Eleven abdominal compartment syndromes have occurred with 7 decompressive laparomy (4 deaths). CONCLUSION: This study is based on the largest series of damage control laparotomy published in France. Results in terms of mortality and morbidity are similar to those of published studies from the USA.
INTRODUCTION: Cutaneous metastatic Crohn's disease is a granulomatous inflammation of the skin that is noncontiguous to the gastrointestinal tract. CASE REPORT: A 42-year-old man with Crohn's disease is admitted for antibiotic resistant erysipela-like dermo-hypodermitis. The presence of granulomatous lesions on skin biopsy, the absence of any infectious agent identified despite extensive investigations and the dramatic improvement observed with corticosteroid eventually lead to the diagnosis of cutaneous metastatic Crohn's disease. CONCLUSION: During Crohn's disease, biopsy should be considered for every undiagnosed skin lesion as the characteristics of cutaneous metastatic Crohn's disease are not specific. The presence of a non caseous granulomatous dermal infiltration suggests the diagnosis and should make consider the initiation of corticosteroid and the discontinuation of others inappropriate therapeutics (i.e. surgical treatment, antibiotics).
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Early diagnosis of pancreatic trauma has always been challenging because of the lack of correlation between the initial clinical symptomatology, radiologic and laboratory findings, and the severity of the injury. Thanks to the improved performance of spiral CT scanning and magnetic resonance pancreatography, it is now often possible to make an early diagnosis of pancreatic contusion, to localize the site of the injury, and (most importantly) to identify injury to the main pancreatic duct which has major implications for the management of the case. When the trauma victim is unstable, radiologic work-up may be impossible and urgent laparotomy is required. Control of hemorrhage is the primary concern here and a damage control approach with packing may be appropriate; if the pancreatic head has been destroyed, a pancreaticoduodenectomy with delayed reconstruction may be required. If the trauma victim is stable, the treatment strategy will be governed by a variety of parameters--age, clinical condition, associated local anatomic findings (pancreatitis, injury to the duodenum or biliary tract), involvement of the pancreatic duct, and localization of the injury within the gland (to right or left of the mesenteric vessels).