Chirurgie; memoires de l'Academie de chirurgie最新文献

Diffuse cavernous hoemangioma of the rectum is rare. Correct identification is often delayed. The patients usually present with rectal bleeding. We describe two men who had diffuse cavernous hoemangiomas. They complained of rectal pain. One appeared to have a rectal tumor and the other a levator syndrome.

From 1985 to 1995, 172 patients (149 on self intracavernous injection of vasoactive drugs, 16 with Sickle cell disease, 6 surgical patients under heparin therapy, and 1 after oral administration of trazodone), having experienced one or several episodes of priapism, lasting from 3 h to 8 days have been treated or submitted to self medication with alpha-agonist agents (eprephrine, phenylephrine or etilefrine) with an eventual drainage of the corporae. All episodes have disappeared and sexual function was preserved. A conservative treatment of priapism has been designed using corporal drainage and intracavernous etilefrine for acute priapism; as well as preventive treatment for those of the patients exposed to Sickle cell disease to avoid surgery and its frequent fribrotic sequelae, leading to impotence in 50% of the cases.

Hospital expenditures in France (300 billion francs in 1995) comprise half of the expenditures of the Health Care Assurance system. The government directive dated 24 April 1996 created a national accreditation and evaluation agency. The effectiveness of the agency will largely depend on the ability of the experts to create a pragmatic system. The 5-year maximum delay for an accreditation request can be explained by the fact that the system is new, but will nevertheless delay hospital closure decisions and thus prolong the function of hospitals with reduced activity and thus less medical experience, leading to extra cost for the society. The directive also created regional hospitalization agencies which are to develop a regional health care policy, analyze and coordinate hospital activity and determine hospital resources. It is hoped that these agencies will be more effective than the former health care and social organization committees. The necessary decisions for hospital closures will be difficult due to the opposition of both the populations and elected officials. Finances for public facilities will continue on the basis of a global budget, an attempted macro-economic cost-containment policy which has had only limited effect. For private facilities, use of medicalization data systems could have unfavorable effects if the data is too approximative and could cause undue increase in cost over benefit if the data is too exhaustive. The directive does not appear to modify the authorization system for major equipment expenditures. There is no mention of the increasing size of hospital administration staffs. Finally, the directive does not address the fundamental question of medical behavior: a modification of medical training which would place more emphasis on clinical training and reasoning.

A survey of 7 surgeons in Paris collected 173 cases of adrenal gland resection using laparoscopes or lomboscopes in 164 patients. Video-assisted surgery techniques were used in the past 4 years for: Conn's syndrome (n = 69), fortuitously observed tumors (n = 39), Cushing's syndrome (n = 24), phyeochromocytoma (n = 18) and Cushing's disease (n = 4). There were 155 unilateral tumors and 9 bilateral tumors in patients with Cushing's disease. This survey showed that conversion rate was 14% and local complications rate 2.4%, mean operative time for unilateral operations was 144 minutes (range 50-240) and 266 minutes (range 125-480) for bilateral tumors. Although this was a retrospective uncontrolled survey, pain relief and hospitalization time were greatly improved over traditional open surgery. The difference between the transperitoneal and the retroperitoneal route could not be evaluated due to differences in the number of patients for which each technique was used. Surgeon experience varied greatly, but it appears that video-assisted adrenal gland surgery is the preferred route due to reduced risk and improved post-operative period. Tumors with a diameter greater than 6 cm and malignant or suspected malignant tumors still require open surgery.

Out of 15 patients operated on for a carotid stenosis 3 to 19 years after a cervical irradiation, 2 were treated by a subclavian-carotid by-pass, 3 by a common carotid-internal carotid by-pass, 10 by an endarterectomy (6 closed with a patch), 3 of these endarterectomy extended largely down on the common carotid. Although the surgical approach was often difficult through the sclerotic tissues and 8 times the scar of a lymphadenectomy, the removal of the atherosclerotic core was as easy as usual. We observed neither mishap in arterial and cutaneous healings nor post operative stenotic myointimal hyperplasia.

Perineo-genital wounds involving the anterior perineum or the urogenital perineum are uncommon; 1-4% of all war wounds. We report 18 cases observed in war situations. Isolated uretrogenital wounds are rarely life-threatening, but the functional prognosis is always compromised in these men whose mean age is under 30 years. Debridements should be limited and all isolated lesions should be repaired early with tight suture of the cavernous body albuginea, preservation of viable testicular and adnexal tissue (but the rate of orchidectomy is greater than 50%), and immediate suture of any wound to the urethra rather than simple alignment. In war situations, these wounds are usually caused by perforating or blast trauma. The wounds are complex, with damage to the soft tissues, sometimes involving lesions to the anal sphincter, the gluteal masses or the abdomino-pelvic structures. Laparostomy for hemostasis is justified. The risk of sepsis is high, requiring triple antibiotics, cystostomy, careful debridement, discharge drainage or possibly colostomy. Treatment of urogenital lesions is a secondary operation in these cases but must not be neglected if the mictional and sexual functions are to be preserved.