Biomedical subjects
Publications and source records attributed to B Giraud.
A ruptured adenoma of liver was detected during a caesarean in a multipara woman at full term with a severe pulmonary embolus. Therapy for this rare and curious case, with combined internal hemorrhage, severe pulmonary embolism and full term pregnancy in a multipara, is discussed.
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Results of a 7-year follow-up review of a patient with intratubal cancer and lumbo-aortic glands invasion are reported. The highly lympholytic character of these tumors and the existence of elective lumbo-aortic lymph node metastases suggest that surgery should include routine bilateral lumbo-aortic curettage in tubal cancer, particularly stages I and IIA. As well as providing improved assessment of degree of extension of the disease it can also avoid the frequently poorly tolerated abdominopelvic radiotherapy.
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Surgery for recurrence of malpighian epithelioma of uterine cervix was performed in 14 patients, exenteration being necessary in 10 cases (5 anterior, 4 total and 1 posterior). Possibilities of surgical excision of recurrences are limited (10 to 20% of cases) and should not be considered except after a careful general, local and regional investigation including, if necessary, and exploratory laparotomy. This recovery surgery must be preceded by high-dose irradiation. This partly explains the high incidence of exenterations, with the need for cutaneous bypass of urine and/or fecal matter, but also the high prevalence of postoperative complications and mortality. Long-term results are deceiving and a 5-year survival rate of 20% appears to be maximum obtainable. However, this surgery remains the only solution capable of providing the patients with a chance, and it very often relieves them of the painful course of a pelvic tumor.
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Although rarely published, operative injuries to thoracic duct in neck are by no means exceptional, and can occur during all types of surgery to lower cervical and supraclavicular regions. A case is reported and used as a basis for an analysis of diagnostic means and therapeutic possibilities of injuries detected during operation or those developing manifestations at a later stage. In the case reported, long-term medical treatment resulted in arrest of lymphorrhea within 37 days.
Five observations of hamartomas are reported, and compared with the data in the literature. We recall the principal radiological and histological aspects.
Self-retaining silicone ureteral stents are used for prolonged urinary drainage in situ. Thanks to the exceptional patient tolerance, they appear to be the best indwelling catheters for the treatment of ureteral obstruction due to cancer. Eighteen catheters were placed in sixteen patients. Endoscopic insertion was carried out in 8 patients (9 catheters were inserted; one patient requiring bilateral catheterisation). An operative procedure was necessary in the remaining 8 cases: in 4 cases a simple ureteral dissection was necessary, whereas ureterostomy had to be carried out in the 5 remaining cases. During the treatment, the patient tolerance was excellent. Mean survival time, after catheterisation was 5,5 months and one patient had a functional catheter for 15 months. Obstruction of the catheter was observed in 3 cases but ureterostomy was avoided in 7 cases and 8 kidneys were protected in 6 cases. The palliative use of the double J catheter when no other treatment is possible for malignant ureteral obstruction precludes the need for ureterostomy. These catheters can be used for strategic curative treatment if nephrotoxic drugs are required to treat obstructive tumors of the ureters. Bladder disease is a contra-indication to the use of these catheters although their insertion is rarely impossible. In cases of acute obstruction, it is better to prepare the pathway with a traditional catheter, which is easier to manage, it is always possible to insert a double J catheter after some time has elapsed.
This retrospective study was carried out on 80 patients who had abnormalities discovered on mammography without any associated clinical signs. In some patients bilateral abnormalities were found so that 87 biopsies were carried out and this gave the result that 45 of the lesions were shown to be benign, 18 lesions were borderline and 24 lesions (27.6%) were of carcinomata. The frequency of these lesions goes up to 32% if areas of microcalcification only are considered. These tumours diagnosed in this sort of way, whether they are canal lesions or lobular lesions, usually show favourable histological features as far as invasion, size and lymphatic involvement is concerned. Borderline lesions are a histological group with as yet no fully evaluated significance but it has seemed to us interesting to describe them.
A quantitative evaluation of the information content exhibited by a neuronal automata assembly coupled by collateral inhibitory--type rules was undertaken on the results of a computer simulation of this partial model of the cerebellar cortex. By comparison with an uncoupled array the model exhibited two main properties: A markovian type of behavior appears in the functioning of the system in as much as the appearance of a given state is strongly and exclusively correlated to the immediately preceding one. This behavior leads to a decrease in the entropy of the system. This implies that the informational content of the efferent "activity" is significantly higher than that of the afferent one.
In view of a study on the transfer function of the cerebellar cortex a modelization of each of the various subsystems was undertaken. The recurrent collateral inhibition existing between Purkinje cells was mimicked by means of an assembly of neuronal automata (NA) temporally evolving at random through three states ("silent", "tonic" and "phasic" and interacting with simple rules. In such an assembly--by comparison with a control group of independent NA--a drastic modulation of activity appears. First the total of the mean number of state shifts is increased by more than 10%. This increase is clearly hierarchical with a maximal effect for the "silent" state. Second the average duration of each state also varies, although in a contrasted manner. Third, and moreover, a clear spatial cooperativity emerges. Indeed all the individually coupled NA are in the same "silent" state at identical moments for more than 5.5% of the total running time. A cyclic repetition of this spatiotemporal cooperativity is apparent. The emergence of these collective properties--which can not be deduced linearly from the unitary elements--introduces a parameter of order leading to a coherent functioning of the system.
Complications in 7 of 350 patients receiving radio-surgical treatment of uterine cancer were severe hemorrhages from a large pelvic arterial trunk. The often complex clinical aspects and therapeutic conduct are discussed, as well as etiological factors of these accidents. These complications are more likely to occur in patients with large, secondary infected tumors treated by extensive and difficult surgery (enlarged lymphadenocolpophysterectomy) and high dose radiotherapy. They are provoked by necrotizing arteritis lesions for which the most effective hemostatic procedure is ligature of the trunk involved, the emergency situation usually excluding a more sophisticated embolization technique. The problem of revascularization of the lower limbs may then arise, for which only an extrafocal bypass appears possible. These hemorrhagic complications could be prevented perhaps by certain precautions during therapy.
40 cases of recurrent incontinence after cure of incontinence or secondary to cure of a prolapse were investigated 6 months or more after the initial operation by means of uroflowmetry, cystometry and resting and stress urethral profile. A hyperactive bladder was observed in 20 per cent of cases, 50 per cent of cases presented sphincter incompetence and 75 per cent had a defect of transmission. In 37 per cent of cases, the post-operative incontinence was due to persistent defect in transmission and required a second operation, while in 40 per cent of cases, the cause of this incontinence was complex and required medical treatment associated with re-training. 2 cases of incontinence were also associated with severe disorders of micturition. Urodynamic investigations appear to be essential for the analysis of the frequently complex problem of post-operative incontinence. When compared with the pre-operative data, they provide a better understanding of the mechanism of action of each type of operation and guide the surgical indications.
Two cases of uretero-arterial fistulas are reported occurring in two patients after pelvic exenteration for cancer with cutaneous ureterostomy. In the first case a pelvic irradiation has been performed before surgery; in the other case a high degree of atherosclerosis was noted. Iliac artery-ureteral fistulas are uncommon and they are generally associated with several underlying pathogenic factors such as: arterial pathology, surgical complications, septis, prior x-ray therapy. It is not doubtfull that the use of a long term ureteral stenting contribute to the development of the fistula. The constant pulsation of the artery transmitted through the ureteral and the arterial wall to a stiff intraluminal stent produces a necrosis then a fistula between them. Retrograde uretero-pyelography seems the better diagnostic test. Treatment of these fistulas is always complex because operation should manage both vascular and ureteral injuries. Embolisation is a less invasive method of treatment but it needs a particular technics. Prognosis of such fistulas is poor and some precautions should be taken to prevent these accidents. When ureteral catheterization is needed for a long term one should assess the arterial conditions and during an operation catheterized ureter should be put far from the artery or an attempt for an epiplooplasty should be performed.
The authors describe 21 injuries to the ureter after pelvic surgery: 13 fistulae including 2 bilateral ones, 6 stenoses of the ureter and 2 other traumata. 16 followed colpohysterectomy with removal of lymph glands radically performed. They point out that stenoses often regress after extended surgery and how valuable the psoas hitch is. They prefer to wait before attempting to repair fistulae after radical hysterectomy because some recover spontaneously and poor results follow early cure when the tissues are septic.
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