Biomedical subjects
Publications and source records attributed to C Létoublon.
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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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.
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Over the past 15 years, there have been dramatic changes in the management of blunt hepatic trauma, specifically in the imaging techniques, and in the non-operative management. Actually, in more than 80% of blunt hepatic trauma, non operative management is used. In the last 20% the surgical option has to be taken without delay, sometimes in extreme emergency, using the adapted surgical techniques. In this article the author describes the nonoperative management of blunt hepatic trauma: classification, presentation, initial decision, treatment, possible complications and results.
STUDY AIM: Radiofrequency (RF) ablation of malignant hepatic tumors is an interesting and recent technique which offers new treatment possibilities. In this study, the preliminary findings have been reported on 25 patients with hepatic tumors who received RF treatment between January 1998 and February 2000. PATIENTS AND METHODS: Twenty-five patients (11 cases of hepatocellular carcinoma, HCC; and 14 cases of liver metastases, LM) underwent RF treatment. Thirty tumors (range: 10 to 54 mm in diameter) out of a total of 63 were destroyed by RF: 13 HCC (average diameter: 32 mm) and 17 LM (average diameter: 26 mm). Treatment consisted of six percutaneous and 19 surgical RF procedures. In the surgical group, there were 11 cases of hepatectomy: right hepatectomy in five patients with segment IV enlargement in one case, and sub-segmentectomy in six other patients. In all cases, hepatic tomodensitometry was performed at one month post-treatment and then every three months. RESULTS: Postoperative portal thrombosis occurred in two patients, one of whom died. Other postoperative complications were observed in five patients. During the mean follow-up period of 14 months (range: 2 to 28 months), two patients died (carcinosis, ascitic decompensation), two and four months respectively after RF treatment. In situ recurrence occurred in four HCC and two LM patients. Three HCC and four LM patients developed new hepatic or extra-hepatic lesions. CONCLUSION: RF is a particularly interesting technique for the treatment of bilobar or unresectable metastases. It appears to be equally as efficient as other local treatments for small-sized HCC. However, technical improvements remain necessary to increase the destructive field covered by RF. A more important follow-up is needed so that the long-term efficacy and specific role of this new therapy can be accurately assessed.
STUDY AIM: Acute pancreatitis (AP) is a potentially life-threatening disease in which specific severity scoring system has been developed. The aim of this prospective study was to compare efficiency of the general severity of illness scoring system and the most widely used specific scoring system of AP in order to simplify the initial monitoring of AP at the time of admission. PATIENTS AND METHODS: Eighty-seven patients with AP were hospitalized in the same center. There were 47 men and 40 women (mean age: 57 +/- 16 years). Specific scores (Ranson, Imrie, Blarney) and general severity of illness scores (SAPSI, SAPS II, Apache II) were calculated for each patient. Radiological scores (Hill, Balthazar) were also calculated when TDM was early performed (80%). Each scoring system was correlated with severity, morbidity and mortality of AP and its predictive value evaluated by the area under the ROC curve. RESULTS: Aetiology of AP was predominantly biliary (20%) and alcoholic (70%). Eight per cent of the patients died and 29% of AP were classified as severe according to the Atlanta Congress Score. Morbidity rate was 40%. All the scoring systems were significantly correlated with mortality and exhibit ROC curve area between 0.77 and 0.84, resulting in a similar prediction of death. CONCLUSION: Specific scoring system and general severity of illness scoring system have the same predictive efficiency in acute pancreatitis. The use of the specificity scoring system seems to be no more justified in acute pancreatitis.
The shortage of organ donors has led to progressive softening of selection criteria for organ donation. We report on hepatic transplantation in a 55-year-old woman with primary biliary cirrhosis, whose donor was a 50-year-old heart transplant recipient who became brain stem dead, due to cerebral bleeding 8 months after transplantation. An orthotopic liver transplantation was performed. The postoperative course was uneventful and the recipient was alive and had normal liver function after a 42-month follow-up. Analysis of the literature included ethical consideration, potential hepatotoxic effects of immunosuppressive drugs and modification of the graft immunogenicity. It confirms that transplanted patients should not be a priori excluded from organ donation.
The decision to perform damage control laparotomy in a critically injured patients depends on the risk of life-threatening coagulopathy. The main decision criteria are: presence of concomitant injuries, patient history, shock, transfusion volume, hypothermia and acidosis. The aim of surgery is to achieve satisfactory hemostasis, limit peritoneal thermal loss, and perform physiological restoration as rapidly as possible in the intensive care unit. This includes gauze packing of major liver or retroperitoneal injuries and ligation of injured blood vessels. Injuries to the intestine and the urinary tract are sutures, stapled or drained. If the skin borders cannot be reapproximated because of excessive abdominal tension, a wall prosthesis should be used to avoid abdominal compartment syndrome. Reoperation is a dangerous procedure in the immediate postoperative period but must be proposed later for reexploration or damage repair.
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Emergency conditions make laparoscopic treatment of acute cholecystitis challenging. The aim of this study is to retrospectively analyse our experience of cholecystectomy for acute cholecystitis performed between January 1995 and December 1997. In order to be included, patients had to present (i) symptoms of acute cholecystitis correlated with laboratory blood tests and ultrasonographic studies (ii) evidence of acute inflammation during the operation and (iii) histological confirmation of acute or subacute inflammation of the excised gallbladder. 192 patients were treated: 62 were totally managed laparoscopically (group CCN), 33 managed laparoscopically but required conversion to open cholecystectomy (group CCC) and 97 were managed conventionally by laparotomy (group CL). Mean age was significantly different between the three groups, (CCN: 55.6 +/- 15 years, CCC: 64.2 +/- 13 years, CL: 66.5 +/- 17 years), as was ASA score (CCN: ASA 3 and ASA 4: 16%, CCC: ASA 3 and ASA 4: 48%, CL: ASA 3 and ASA 4: 46%), and initial infectious signs (temp. > or = 38 degrees C: CCN: 35%, CCC: 39%, CL: 63%). Mean operative delay was significantly higher in the converted group [8.7 +/- 13 days (CCC) vs 4.5 +/- 8 days (CCN) and 5.4 +/- 8 days (CL)]. There were two (1%) bile duct injuries, one in the CCC group, the other in the CL group. Operative mortality was 2% (CCC: 0%, CCN: 0%, CL: 4%) and operative morbidity was 40% (CCN: 21%, CCC: 24%, CL: 57%). The mean postoperative hospital stay was shorter in the CCN group (6.5 +/- 3.5 days) and CCC group (9.6 +/- 4.4 days) vs the mean stay in the CL group (14.7 +/- 11.6 days). Appears to be beneficial for selected patients with low surgical risk to conclude laparoscopic cholecystectomy. It has yet to be shown whether this benefit can be extended to patients with a high surgical risk.
Management of Blunt hepatic injuries is dramatically modified since early 80's. Non operative management is presently used in over 80% of all cases, irrespective of haemoperitoneum and grade of injury. Close observation of the patient is requested. Laparotomy or laparoscopy must be decided in any case of suspected missed injury. Laparotomy is used for worse hemodynamic status. Peroperative mortality is mainly attributed to haemorrhage. Aggressive surgery has progressively given place to more conservative techniques. Understanding of coagulopathy related to massive transfusions, acidosis and hypothermia led to enhance efficacy of manual compression of the injured liver and of perihepatic packing and planned reoperation. In survivors this abbreviated laparotomy has pitfalls and complications which must be known, mainly rebleeding and abdominal compartment syndrome. Decision of very early reoperation is most difficult to take.
AIM: To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject. PATIENTS AND METHODS: From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required. RESULTS: There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results. CONCLUSION: Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.
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26 patients were seen with ruptured bladders at Grenoble Hospital during the last 15 years. Pelvic fractures were present in 95% of the cases. Bladder injuries were extraperitoneal (58%), intraperitoneal (27%), intraperitoneal and extraperitoneal (15%). Patients were hospitalised in Urological Department (40%) or General Surgical and Intensive Care (60%). All patients with intraperitoneal bladder injury, 61% with extraperitoneal ruptures were treated by surgical repair. 4 patients died, secondary to visceral associated injuries.
OBJECTIVES: The aim of this prospective study was to appreciate, in severe acute pancreatitis, the therapeutic choice of the surgeons for the treatment of pancreatic necrosis and the timing of operation in biliary pancreatitis. METHODS: Forty-six centers participated in the study. For every included patient, cause and severity criteria of the pancreatitis, timing of surgery, surgical management and necrosis features were recorded. Mortality and morbidity, number of surgical operations and clinical course were analyzed depending on necrosis infection. RESULTS: From August 1986 to January 1990, 143 patients were included in the present study. The main causes of pancreatitis were gallstones in 66 patients and alcohol in 45. Other causes were found in 32 patients. Overall mortality was 23.8%. Mortality was higher in 38 patients with infected necrosis than in 41 patients with sterile necrosis (39% vs 27%). In patients with severe acute biliary pancreatitis operated on within the first seven days of pancreatitis, mortality and number of reoperations were higher than in patients operated on later (30% vs 14% and 40% vs 21% respectively). CONCLUSIONS: These results suggest that clinical trials on the treatment of pancreatic necrosis and on the timing of the treatment of biliary pancreatitis are needed. The analysis of mortality shows that it will be difficult to organize these trials.