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Resume Objectif Determiner les outils de la decision therapeutique qui conduisent a poser l’indication chirurgicale devant un cancer de la prostate (CaP) non metastatique relevable d’un traitement local. L’evaluation optimalisee de la maladie causale et des eventuelles comorbidites permet d’ameliorer la selection du malade dont le dossier sera presente a la RCP onco-urologique pour valider le Programme personnalise de soins. Materiel et methode Recherche bibliographique a partir de la base de donnees Medline (National Library of Medicine, outil Pubmed) et Med Science selectionnee selon la pertinence scientifique. La recherche a ete centree sur les outils de diagnostic du CaP, l’evaluation des caracteristiques de la maladie et du patient et des elements orientant vers une prise en charge chirurgicale (antecedents medico-chirurgicaux, situation fonctionnelle, comorbidites, esperance de vie). Resultats L’evaluation carcinologique pretherapeutique permet d’estimer le risque lie au CaP, aspect essentiel de la prise de decision therapeutique. Plusieurs criteres cliniques, biologiques, d’imagerie et anatomopathologiques permettent d’orienter la decision selon l’agressivite tumorale et le risque de recidive tout en estimant les resultats des traitements proposes. Parallelement, l’evaluation mictionnelle, de la continence urinaire et du statut sexuel, l’integration des donnees anatomiques et les antecedents medico-chirurgicaux sont indispensables dans la decision therapeutique aidee par les scores de comorbidite (Charlson, ASA, ICD). Ces elements sont indissociables pour decider d’un traitement radical ou conservateur du CaP, ils aboutissent a la prise en charge globale du patient candidat a la chirurgie. L’âge joue un role primordial dans le choix du traitement, meme chez les hommes âges susceptibles de developper un CaP a haut risque avec un impact sur la survie globale a estimer. Conclusion L’evaluation combinee de la maladie et du patient est fondamentale pour ameliorer la prise en charge en cancerologie, notamment dans le CaP non metastatique pour lequel les possibilites curatives sont nombreuses. L’aide de l’anesthesiste dans l’analyse et l’interpretation des comorbidites autour d’outils de plus en plus performants reste fondamentale pour selectionner les bons candidats informes a orienter vers la chirurgie en accord avec les prerogatives de programmes de soins personnalises.

The surgical care pathway of neurologic patients has two aims: preventing urinary morbidity and mortality and improving their quality of life. It requires taking into account the specificities of disabilities in domains of body functions: circulatory, ventilation and digestive physiology, motor functions, sensory functions, mental functions, and skin fragility which are responsible of dependencies in this heterogeneous group of patients. This management is necessarily multidisciplinary to be optimal and through specific clinical care pathway, providing guidance to the surgical procedure: preparation of the surgery, its realization, and post-operative rehabilitation. The indication for surgery must be coordinated and validated in neuro-urology multidisciplinary staff. Preoperative stay in a physical and rehabilitation medicine center may be useful to ensure a complete assessment and anticipate problems related to surgery. The patient will be hospitalized in the urology department in a single room suited to their disabilities and handicaps. The chronic treatments should be not modified if possible. The lack of sensitivity does not dispense anesthesia to prevent autonomic hyperreflexia, the most severe complication after high complete spinal cord injury. The laparoscopy and sub-peritoneal surgery, the early removal nasogastric tube and early refeeding make it possible to early resumption of intestinal transit. In many cases, the patients should be transferred to a physical and rehabilitation medicine during post-operative period where the nursing care will be most suitable. A quickly adapted rehabilitation must be able to reduce loss of function and physical dependence.

Objective To compare the results of retroperitoneal laparoscopic adrenalectomy using the antegrade and retrograde approach. Materials and Methods We performed an analysis of a single-center series of 279 retroperitoneal laparoscopic adrenalectomies from 1996 to 2010. We compared 172 cases performed with an antegrade approach and 107 with a retrograde approach without dissection of the renal hilum and initial control of the adrenal vein in comparable populations. Results The operative time was shorter in the group treated with the retrograde technique, 101 ± 51 vs 140 ± 40 minutes, respectively (Student's t test, P

The esCCO monitor (ECG- estimated Continuous Cardiac Output, Nihon Kohden(®)) is a new non-invasive tool for estimating cardiac output (CO). It derives CO from the pulse wave transit time (PWTT) estimated by the ECG and the plethysmographic wave. An initial calibration is needed to refine the relation linking pulse pressure (measured by arterial pressure cuff) to PWTT. To assess the accuracy and reliability of the esCCO system, we performed an analysis of agreement of CO values obtained by transthoracic echocardiography (TTE).Thirty-eight intensive care unit patients were prospectively included. CO was determined simultaneously using esCCO (CO(esCCO)) and TTE (CO(TTE)) as our reference method.A total of 103 paired readings from 38 patients were collected. The correlation coefficient between CO(esCCO) and CO(TTE) was 0.61 (P0.001). The Bland and Altman analysis corrected for repeated measures showed a bias of -1.6 litre min(-1) and limits of agreement from -4.7 to +1.5 litre min(-1), with a percentage error (2 sd/mean CO) of 49%. The correlation for CO changes was significant (R=0.63, P0.001), but the concordance rate was poor (73%). Polar plot analysis showed an angular bias of -9° with radial limits of agreement from -54° to +36°. The bias appeared to correlate with systemic vascular resistance (R=-0.45, P0.001).In critically ill patients, the performance of the esCCO monitor was not clinically acceptable, and this monitor cannot be recommended in this setting. Moreover, the esCCO failed to trend CO data reliably.

Age should not be a limiting factor for optimal surgical care of cancer. Preoperative assessment and therapeutic line decision must be a multidisciplinary team work. A specific geriatric oncology consultation would help assessing the level of autonomy or dependence, the patient cognitive functions and his nutritional status. The preoperative interview and clinical examination aim to assess the overall general health of the patient and to detect cardiovascular, pulmonary and neurological disorders which are the main postoperative factors of morbidity and mortality, other than related to tumor itself. Many scores of surgical risk assessment have been proposed. The Charlson index and the CIRS-G are the most widely used. Because of pharmacokinetic and pharmacodynamic changes related to age, new anesthesia techniques, such as target intravenous anesthesia (TIVA), which allow fine adjustment of anesthesia level according to the patient individual parameters (age, weight, height, sex) will be preferred. The most frequent postoperative complications are those related to hypothermia, pain and postoperative cognitive dysfunction. The main objective of the preoperative care of the elderly person is a rapid return to autonomy in a familiar environment.

Resume Introduction Le remifentanil est un puissant agoniste morphinique largement prescrit en anesthesie. Il lui est reconnu des effets hyperalgiques en periode postoperatoire. Mais a partir de quand ces effets d’hyperalgesie et de tolerance apparaissent-ils ? Bien qu’ils soient possiblement masques en pratique clinique durant le temps peroperatoire sous anesthesie generale, il semble qu’ils puissent apparaitre tres precocement. Pour tenter d’identifier le delai d’apparition de cette tolerance aigue, ce travail propose d’appliquer une technique d’evaluation de la douleur en continu, fondee sur la variation du diametre pupillaire de patients soumis a une anesthesie generale requerant de fortes doses de remifentanil. Materiels et methodes Apres induction d’une anesthesie associant du propofol (AIVOC), un bolus de remifentanil et de cisatracurium, etait initiee une perfusion continue de remifentanil a 0,3 μg/kg par minute. Le monitorage pupillaire debutait dix minutes plus tard (T + 10 minutes) et se poursuivait pendant la preparation a l’intervention, en dehors de tout stimulus chirurgical, jusqu’a l’incision cutanee qui marquait la fin de l’etude (T + 65 minutes). Resultats Trente patients programmes pour beneficier d’une chirurgie cardiaque ou vasculaire ont ete inclus dans cette etude. Au cours de cette periode, une augmentation significative du diametre pupillaire par rapport a la valeur initiale de reference des T + 45 min etait constatee. Elle persistait jusqu’a la fin de l’etude. Aucune variation significative de la frequence cardiaque, de la pression arterielle ou des valeurs d’index bispectral (BIS) n’etait observee. Discussion Une explication possible a ces resultats serait notamment l’existence des la 45 e minute d’une tolerance au remifentanil a fortes doses, phenomene potentiellement pourvoyeur d’hyperalgesie. Malgre les possibles limites des techniques d’evaluation pupillometrique de la douleur sur une periode d’une heure, ces resultats suggerent que des lors que cet agent est prescrit, et meme sur une courte periode, il y a une possible expression de l’hyperalgesie. Il parait donc indispensable de preceder son administration d’un agent anti- N -methyl- d -aspartate (NMDA).

Resume But Etudier la morbidite et les parametres hemodynamiques sur une serie consecutive de surrenalectomies realisees pour pheochromocytome par voie de laparoscopie retroperitoneale. Materiel et Methodes Vingt troix pheochromocytomes chez 20 patients ont ete traites par laparoscopie retroperitoneale en chirurgie reglee, et constituent notre population d’etude. Les parametres etudies ont ete : en peroperatoire : duree operatoire, pertes sanguines, pression arterielle, frequence cardiaque, et en postoperatoire : les complications infectieuses, hemorragiques et thromboemboliques. Resultats La duree operatoire moyenne a ete de 156 minutes (105-224). Les pertes sanguines moyennes ont ete de 58 mL (0-300). En peroperatoire, 15% des patients ont presente un pic de PAS > 220 mm Hg et 70% un pic de PAS > 200 mm Hg. A l’oppose, 20% des patients ont presente un nadir de PAS Conclusion La chirurgie laparoscopique pour pheochromocytome expose a une instabilite hemodynamique. En consequence, il demeure preferable de realiser la chirurgie du pheochromocytome dans des centres d’expertise (chirurgicale, anesthesique et endocrinologique).

Objective The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture. Methods A total of 76 patients (14–76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5–257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up. Results In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13–90 months). No major complication was observed in group 3. Conclusions In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Resume Un critere hemodynamique statique est un parametre sense representer ou evaluer la precharge cardiaque. Il s'agit par exemple des pressions de remplissage droite et gauche (PVC, PAPO), des dimensions ventriculaires (volume et surface telediastoliques droites et gauches), d'indices derives du catheterisme transpulmonaire (volume telediastolique global, volume sanguin intrathoracique), d'indices Doppler comme le temps d'ejection mesure et monitore par le Doppler œsophagien. Certains de ces criteres (PVC, PAPO, volume telediastolique VD) sont mesurables de facon invasive par catheterisme mais aussi appreciables de facon non invasive par echocardiographie. Il s'avere globalement que ces criteres ne permettent pas de predire de facon fiable la reponse a une expansion volemique, ou que pour certains des etudes manquent encore pour en apprecier la fiabilite. Cet etat de fait releve de plusieurs limites : des limites d'ordre technique, inherentes aux pieges et a la sensibilite des methodes de mesure ; mais aussi des limites physiologiques qui se traduisent par le fait qu'une mesure statique peut mal apprecier la precharge ventriculaire mais surtout la reserve de precharge qui depend entre autres de la compliance des cavites ventriculaires. Cet article fait le point sur les principales limites de chacun de ces indices, permettant de comprendre l'importance des indices dits dynamiques qui sont presentes dans le meme numero.

Background —Stent grafting is emerging as a new treatment for several pathological conditions involving the thoracic aorta. We studied the feasibility and safety of this technique for delayed treatment of ruptures of the aortic isthmus. Methods and Results —Nine patients (14 to 76 years old; mean, 37 years; male/female ratio, 8/1) underwent stent grafting of the aortic isthmus in subacute (n=5) or chronic (n=4) aortic traumatic rupture after a motor accident. In subacute ruptures, this treatment was delayed (1 to 8 months; mean, 5.4 months) because of the severity of other associated injuries. Stent grafting was technically successful (defined as complete exclusion of the pseudoaneurysmal sac) in all patients. Short-term fever and biological inflammatory syndrome occurred in 3 patients. Two major complications occurred: in 1 patient, an early occlusion of the left subclavian artery was treated by placement of 2 Palmaz stents. In another patient, an atelectasis related to an increase of preexisting compression of the left main bronchus by the pseudoaneurysmal sac was successfully treated by temporary placement of an endobronchial silicone stent. Mean follow-up was 11.6 months (range, 3 to 21 months). Thrombosis of the pseudoaneurysmal sac was found in all patients. Conclusions —In the absence of available extended follow-up about the safety and effectiveness of endovascular grafting, this approach seems to be a viable therapeutic option for traumatic rupture of the aortic isthmus, but appropriately controlled prospective studies are needed before we can recommend its widespread use.

The aim of the study was to compare changes in blood pressure (BP) and heart rate (HR) variability, catecholamine and neuropeptide Y (NPY) plasma levels induced by passive head-up tilt in normal and sino-aortic denervated (SAD) chloralose-anaesthetized dogs. In controls, 80 degrees head-up tilt test failed to change BP and increased HR. Plasma noradrenaline and NPY levels (but not adrenaline) significantly rose. In SAD dogs, head-up tilt test induced a marked and reproducible decrease in BP without any change in HR or noradrenaline and NPY plasma levels. In SAD dogs, spectral analysis in supine position was characterized by reduced variability in the high frequency (HF) band of the HR spectrum without changes in low frequency (LF) bands of both HR and systolic blood pressure (SBP). Head-up tilt test increased the LF component of SBP variability and decreased the HF component of HR variability in controls but failed to modify HR and BP variabilities in SAD dogs. In conclusion, sino-aortic denervation in dogs elicits a reproducible postural fall in BP with impaired adaptation of sympathetic nervous system activity. This model may be of value in evaluating the pharmacological effects of drugs for the management of orthostatic hypotension.

Resume Le principe de la decontamination digestive selective est de diminuer la colonisation bacterienne oropharyngee et digestive responsable en partie des pneumopathies nosocomiales. Une etude prospective, randomisee, en simple aveugle a ete realisee dans un service de reanimation polyvalente hospitalier dans le but d'evaluer l'efficacite de cette methode. Sur une population de 138 polytraumatises en ventilation artificielle, 64 patients ont ete inclus dans l'etude. Deux groupes homogenes ont ete definis, un groupe placebo et un groupe decontamine a base de Colistine, de Netilmicine, et d'Amphotericine B. Tous les patients ont recu par ailleurs une antibiotherapie parenterale. La colonisation bacterienne et les complications infectieuses ont ete etudiees, ainsi que les durees de ventilation et d'hospitalisation, la mortalite et le cout. L'emergence de germes multiresistants a ete surveillee. Les resultats ont fait apparaitre une diminution de la colonisation par des germes a Gram negatif avec en particulier une probabilite d'absence de colonisation de 59,8 p. 100 au septieme jour dans le groupe DDS et de 32,2 p. 100 dans le groupe placebo, qui s'est accompagnee d'une reduction du nombre de pneumopathies : 4/31 contre 16/33. Par contre, aucune incidence sur les durees de ventilation et d'hospitalisation n'a ete retrouvee et le cout a ete significativement plus eleve (p La diminution de cette colonisation n'a pas entraine d'augmentation de colonisation par des germes a Gram positif ou d'apparition de germes multiresistants.

The ureter responds to inflammation with some common abnormalities: loss of contraction and hypotonia, mural thickening by edema and cell infiltration, ulceration, pseudo-diverticula, cystic degeneration, and desmoplastic reaction leading to narrowing and obstruction (Wasserman 1996).

Objectifs Etudier l’evolution sur une periode de 17 ans de la stabilite hemodynamique peroperatoire de la surrenalectomie laparoscopique pour pheochromocytome. Methodes Nous avons compare les resultats sur 2 periodes : (1) 1996–2005, et (2) 2009–2013. Au total, 23 pheochromocytomes chez 20 patients ont ete traites durant la premiere periode, et 42 durant la 2 e periode. Les parametres etudies etaient duree operatoire, pertes sanguines, pression arterielle systolique maximale, pression arterielle systolique minimale et l’instabilite hemodynamique evaluee a l’aide de la formule (PAS max–PAS min)/PAS max. Resultats La duree operatoire moyenne a diminue de 156 minutes (105–224) a 113 minutes (50–270) ( p = 0,0001). Les pertes sanguines moyennes ont diminue de 58 mL (0–300) a 39 mL (0–400) ( p = 0,008). La proportion de patients ayant eu un pic de PAS > 220 mmHg a diminue de 15 % a 7 % ( p = 0,047). Parallelement, la proportion de patients ayant eu un pic de PAS p = 0,05). La stabilite hemodynamique a ete amelioree, avec un rapport (PAS max–PAS min)/PAS max passe de 0,59 ± 0,1 a 0,52 ± 0,1 ( p = 0,02). Conclusion Les progres anesthesiques et chirurgicaux, et l’experience acquise dans les centres experts ont permis d’ameliorer la stabilite hemodynamique de la chirurgie laparoscopique pour pheochromocytome.

Nitric oxide (NO) is a free radical gas and a short-lived messenger which has many paracrine functions. Direct assessment of NO production is very difficult in vivo. However, the paranasal cavities generate a high amount of NO which diffuses in the nasal cavity where it can be easily measured. Several studies have suggested alterations of the NO production in heart failure. Thus, we assessed nasal NO concentration in normal subjects and in heart failure patients. The nasal NO concentration averaged 227 +/- 10 ppb in the control group (n = 20), and 210 +/- 10, 198 +/- 20 and 159 +/- 54 ppb in New York Heart Association (NYHA) class II (n = 30), III (n = 28) and IV (n = 7) patients, respectively (mean +/- standard error [SE], not significant using analysis of variance [ANOVA]). Nasal NO level was not influenced by age, sex or etiology of the heart failure or by treatment with frusemide, angiotensin-converting enzyme inhibitor or digoxin. However, treatment with NO-releasing drugs (nitrates or molsidomine) significantly decreased the nasal NO level in heart failure patients. A two-way ANOVA revealed that treatment with a NO-releasing drug influenced nasal NO concentration (P = 0.0005), whereas NYHA class did not (P = 0.23), with a trend towards an interaction between the two parameters (P = 0.09): the inhibitory effect of NO-releasing drug on nasal NO concentration was more pronounced in severe heart failure. In an additional group of 12 patients (NYHA class II or III), the nasal NO concentration was 174 +/- 19 ppb during NO-releasing drug treatment and increased to 231 +/- 27 ppb 3 days after withdrawal of the nitrates (P = 0.0007 using paired t-test). Conversely, the nasal NO concentration in another group of seven patients (NYHA class II or III) was 219 +/- 32 ppb without nitrate treatment and decreased to 188 +/- 28 ppb 7 days after nitrate addition (P = 0.02 using paired t-test). In contrast, the nasal NO concentration in another group of ten ischemic patients without heart failure was 203 +/- 25 ppb without nitrate treatment and was similar (207 +/- 28 ppb) 7 days after nitrate addition (not significant using paired t-test). In conclusion, nasal NO production is normal in heart failure, except in patients receiving NO-releasing drugs. Nasal NO concentration could be useful for investigating the mechanism(s) by which exogenous NO donors decrease endogenous NO production.

The present paper investigates the effects of two anaesthetic drugs (pentobarbital and etomidate) on both short-term variabilities of systolic blood pressure (SBP) and heart rate (HR) using fast Fourier transformation and catecholamine plasma levels. HR and BP were continuously recorded through an arterial catheter and blood samples were taken from the jugular vein. Spectral analysis was performed first in the conscious state and six minutes after induction of anaesthesia on a series of 256 consecutive BP and HR values (delta t: 2 Hz). The area under the curve (AUC) was determined in the low-frequency component of the SBP (LF: 40-150 mHz), in the high-frequency band of HR (HF: respiratory frequency +/- 50 mHz) and in the total frequency spectra. Results were normalized by calculation of the ratio between AUC of LF and HF and the total AUC of the corresponding spectrum (TS). Etomidate (2 mg/kg i.v.) induced a significant increase in TS and LF without changing the LF/TS ratio or the HR variability when compared with the awake period. Catecholamine plasma levels did not change. In contrast, pentobarbital (30 mg/kg i.v.) decreased the values of LF, HF, LF/TS and HF/TS and catecholamine plasma levels. These results suggest that pentobarbital decreases the activity of the two components of the autonomic nervous system whereas etomidate induces only minimal changes.