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P Cougard

Publications and source records attributed to P Cougard.

At least 37 records · Page 2Linked to original sources
PubMed2001

Hyperparathyroidism in multiple endocrine neoplasia type I: surgical trends and results of a 256-patient series from Groupe D'etude des Néoplasies Endocriniennes Multiples Study Group.

The French and Belgian GENEM study group's multiple endocrine neoplasia type I (MEN-I) database was used to evaluate trends in clinical presentation, surgical treatment of primary hyperparathyroidism (pHPT) (n = 245), and prognostic factors for hypercalcemia correction among 256 MEN-I cases. The patients were retrieved through the GENEM network from various Belgian and French institutions with the help of genetics laboratories. Among the 245 pHPT patients (96%), 42% were men. The mean age at the time of diagnosis was 39.5 +/- 13.3 years. Trends were studied for three periods: before 1986, from 1986 to 1990, and thereafter. After 1990 MEN-I patients were more often diagnosed with isolated pHPT (8%, 11%, 28%, for the three periods, respectively; p = 0.002); it was seen more often in screened patients (31%, 28%, 53%; p = 0.001), more often among those in already known MEN-I families (64%, 45%, 72%; p = 0.005), and among those with lower preoperative calcemia (2.93, 2.87, 2.79 mmol/L; p = 0.001). The age at pHPT diagnosis remained constant throughout the study. The percentage of cervical explorations dropped during the entire study (87%, 87%, 53%; p < 0.0001). After 1985 the percentage of subtotal parathyroidectomies increased (25%, 59%, 51%; p = 0.0004). Pathology disclosed more hyperplasias (59%, 85%, 74%; p = 0.008). Postoperative hypercalcemia decreased (47%, 15%, 19%; p < 0.0001); and postoperative hypocalcemia increased nonsignificantly (5%, 15%, 15%; p = 0.1). Subtotal parathyroidectomy [odds ratio (OR) 13], no MEN-I family background (OR 3), and the most recent study period (> 1985) (OR 3) were significant predictive factors of hypercalcemia correction according to the multivariate analysis. This is the first multicentric study on the management of MEN-I-related pHPT. Immediate postoperative hHPT cure increased, but only 80% of the operated patients were cured after 1990. Fifteen percent were hypocalcemic. Because MEN-I-related hHPT cure remains difficult to achieve, we advocate that subtotal parathyroidectomies be performed in specialized centers.

Adult↗
PubMed2001

Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group.

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% (n = 182) of patients underwent resection for cure, and 41.5% (n = 105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% (n = 89) of the cases. The operative mortality was 5.5% (n = 14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases (n = 135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 (p = 0.04), in those with precursor-secreting tumors (p = 0.005), and in those at local stages of the disease (p = 0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.

Adolescent↗
PubMed2001

[Videoendoscopic approach for parathyroid adenomas: results of a prospective study of 100 patients].

STUDY AIM: The aim of this prospective study was to report the results of 100 consecutive video-endoscopic parathyroidectomies in patients suspected of having a single adenoma. PATIENTS AND METHOD: From March 1997 to September 2000, 80 females and 20 males (mean age: 49.5 years) were operated on. They were selected on the basis of the following criteria: preoperative imaging in favour of a single adenoma, absence of goiter and no prior neck dissection. The technique required three trocars; one 5 mm trocar inserted through the middle line of the neck for the 0-degree 5 mm endoscope, and two 3 mm trocars inserted laterally in order to perform a bilateral exploration. The neck was inflated to 10 mm Hg pressure with a low flow (3 L/min). RESULTS: Exploration was unilateral, bilateral and interrupted respectively in 52, 45 and 3% of the cases. The reasons for stopping were: an incidentally discovered thyroid carcinoma; moderate bleeding occurring from an anterior jugular vein after introduction of a lateral trocar; and a too-short neck. Parathyroid abnormalities were found in 86% of the patients (84 single adenomas, one double adenoma, one hyperplasia of the four glands). In 14% of the cases, the exploration was unsuccessful. A horizontal cervicotomy was required in 15% of the cases (14 negative explorations and one hyperplasia of the four glands). No intraoperative or postoperative complications occurred. The mean hospital stay was 24 hours. After 3-month follow-up, the serum calcium level was normal in 96% of the cases and cosmetic results were excellent. CONCLUSION: A video-endoscopic approach for parathyroidectomy is feasible and safe. With sufficient experience, a bilateral and complete exploration of the neck is possible. Therefore this technique represents a good alternative to the traditional cervicotomy in patients with uniglandular disease.

Adenoma↗
PubMed2000

[Treatment of perforated duodenal ulcer by laparoscopy. 35 cases].

OBJECTIVE: Laparoscopic treatment of perforated duodenal ulcer is an alternative to laparotomy. We reviewed our experience to determine feasibility and reliability of the surgical procedure and the subsequent morbidity and mortality. PATIENTS AND METHODS: This was a retrospective series of 35 patients who underwent laparoscopic repair of perforated duodenal ulcers between January 1994 and November 1999. The perforation was closed by interrupted sutures in 86% of cases associated with irrigation-suction of the abdominal cavity. RESULTS: Two complications were observed: pyloric stenosis in one patient with a large perforation and Douglas pouch abscess in another. Conversion to laparotomy was necessary in 8 cases: in 2 of them the edges of the perforation were fragile, in 3 the perforation could not be identified (posterior position), and in 3 intraabdominal adhesions were important. There were no deaths. The 2-year results are quite satisfactory. CONCLUSION: This study shows that the laparoscopic procedure is reliable and adapted to treat ulcer perforation if the size is less than 1 cm.

Adolescent↗
PubMed2000

[Insulinomas in multiple endocrine neoplasia type 1. Report of a series of 44 cases by the multiple endocrine neoplasia study group].

STUDY AIM: The aim of this retrospective study conducted by the "Groupe d'étude des néoplasies endocriniennes multiples type 1" (GENEM) was to report a series of insulinomas associated with multiple endocrine neoplasias type 1 (NEM 1) and to determine the most appropriate strategy for the topographical exploration and surgical management. PATIENTS AND METHODS: From 1960 to 1996, 44 patients were included, 16 men and 28 women (mean age: 36.4 +/- 13.9 years). This study concerned morphological investigations, tumoral features, modalities and results of the treatment. RESULTS: Insulinomas were associated with other functional islet tumors in 15 patients: ZE syndrome (n = 8), glucagonoma (n = 6), vipoma (n = 1). Malignant lesions were present in 6 patients: isolated insulinomas (n = 2), insulinomas associated with ZE syndrome (n = 2) and vipoma (n = 1). The sensitivity of the preoperative imaging procedures was less than 70%. Fourty-one patients were operated on: subtotal pancreatectomy (n = 26 including cephalic enucleations in 8), enucleations (n = 8), total pancreatectomy (n = 3), pancreaticoduodenectomy with caudal enucleations (n = 1), and for 3 patients, no details were available. There was no postoperative mortality. Hyperinsulinism disappeared in 27 patients (including 2 after reoperation) with a mean follow-up of 9 years. Among 6 patients with malignant lesions, 3 were alive with a 3, 4 and 10 year-follow-up. CONCLUSION: Subtotal pancreatectomy with splenic conservation and enucleation of cephalic lesions is suggested as the procedure of choice in this group of patients. This procedure allows simplification of preoperative imaging investigations because lesions of the pancreatic head have only to be detected. Preoperative endoscopic ultrasonography and intraoperative ultrasonography are the best investigations.

Adult↗
PubMed2000

[Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position].

STUDY AIM: The aim of this retrospective study was to assess the feasibility of the treatment of recent diaphragmatic ruptures through laparoscopic approach in lateral position in patients with stable hemodynamic condition. PATIENTS AND METHOD: From 1994 to 1999, seven patients, 16 to 68 years old, were operated on for diaphragmatic rupture after a 6 hours to 15 days delay. Diaphragmatic rupture was located on the left side in 6 patients, on the right side in 1. Diagnosis was confirmed by CT-scan with reconstructions; there was no associated visceral injury. Patients were operated on by laparoscopic approach in lateral position, herniated viscera reintegrated by moderate pulling and diaphragmatic rupture repaired with non resorbable continuous suture. RESULTS: Stomach was the usual herniated viscera (n = 6); hemothorax was less than 300 cL; diaphragmatic rupture was 8 to 12 cm long. Duration of surgery was no more than 120 minutes. The seven patients after a two months to two years delay had normal chest X-rays. CONCLUSION: The laparoscopic approach in lateral position provides good visibility of the diaphragmatic lesions, easy reduction of herniated organs, complete thorax exploration and cleaning, and easy diaphragmatic repair. This technique is only feasible in patients with stable hemodynamic conditions and does not provide a complete abdominal exploration.

Adolescent↗
PubMed2000

[Repair of midline incisional hernias using the Lazaro da Silva aponeuroplasty technique].

STUDY AIM: The aim of this retrospective study was to assess Lazaro da Silva's rectus sheath aponeuroplasty technique for repair of midline incisional hernias situated above the arcuate line. PATIENTS AND METHOD: Twenty-six patients underwent surgical repair of a supraumbilical (n = 19) or periumbilical (n = 7) incisional hernia. Six patients had had repeated laparotomies and two of them had recurrent incisional hernia. There were 11 obese patients (42%). Muscle diastasis ranged from 4 to 20 centimeters (mean: 9.7 cm). Three overlapping aponeurotic and peritoneal layers were used. The peritoneal sac was partially or totally incorporated in the repair. RESULTS: There was one postoperative death at day 5 from acute pancreatitis in a patient with associated cholecystectomy. Postoperative complications occurred in six patients. There were 3 abdominal wall infections. Obesity was the main factor associated with operative complications (p = 0.03). Mean follow-up was 19.1 months. There were 2 recurrences, one of them related to an abdominal wall infection. CONCLUSION: The Lazaro da Silva aponeuroplasty technique compares favourably with alternative techniques using mesh implants. It is indicated for incisional hernias less than 20 centimeters wide, situated above the arcuate line.

Female↗
PubMed2000

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery].

STUDY AIM: The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach. PATIENTS AND METHODS: Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%). RESULTS: Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy. CONCLUSION: Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.

Adult↗
PubMed2000

Primary hyperparathyroidism with normal serum intact parathyroid hormone levels.

To evaluate the features of primary hyperparathyroidism (HPT) with normal serum intact parathyroid hormone (iPTH) levels, we studied 271 consecutive patients undergoing surgery for primary HPT. In 20 patients, serum iPTH levels were within the normal range (10-65 ng/l). In their records, the most common clinical features were fatigue (n=13), polyuria (n=6), renal stone (n=5), and hypertension (n=5). Mean serum calcium and phosphorus were 2.78 and 0.85 mmol/l, respectively: 14 had serum phosphorus within the normal range. Mean serum iPTH was 48.5 ng/l, and was <45 ng/l in nine patients. Cervical ultrasound demonstrated a parathyroid adenoma in nine, and was normal in four. Tc sestamibi parathyroid scintigraphy always demonstrated an adenoma (9/9). In eight patients, normal iPTH values delayed diagnosis. Physicians should be aware of the possibility of HPT in patients with hypercalcaemia, even when serum phosphorus and iPTH levels are within the normal limits. Particularly, HPT cannot be excluded when serum iPTH levels are below the upper part of the normal range. In such cases, cervical imaging, which has the same sensitivity as in other HPT, should be undertaken. These explorations are useful, because many patients are symptomatic and can take advantage of surgery.

Adenoma↗
PubMed1999

[Experiences with adrenalectomy in 1997. Apropos of 247 cases. A multicenter prospective study of the French-speaking Association of Endocrine Surgery].

STUDY AIM: The aim of this prospective study conducted by the AFCE was to analyze the indications, approach and results of all adrenalectomies performed during the year 1997 in 17 centers, active or specialized in endocrine surgery. PATIENTS AND METHODS: During 1997, adrenalectomy was performed in 247 patients, 149 men and 98 women (mean age: 51 years). The lesion was located in the right side in 166 patients, in the left side in 99, in both sides in 28 patients and ectopic in four patients. Pheochromocytomas (n = 61), Conn adenomas (n = 50) and Cushing syndrome lesions (n = 48) were the most frequent in this series. Laparoscopic adrenalectomy was performed in 172 patients (70%) through a transperitoneal approach in all cases except one, and by 'open' surgery in 75 patients (30%). RESULTS: In patients operated on by the laparoscopic approach, the mean duration of surgery was 132 min, and there were peroperative complications in 15 patients (8.7%), mainly hemorrhages. Conversion rate into laparotomy was 7%. In the postoperative course, there were three reoperations and two deaths, an early one in a patient reoperated for bleeding and a very late one in relation with necrotising acute pancreatitis. Mean duration of hospitalization was 5.8 d. Mean tumoral size was 49 mm. In patients operated on by 'open' surgery, the mean duration of surgery was 148 min. There was a postoperative complication in eight patients (10.6%), mostly hemorrhages, and two intraoperative deaths in relation with uncontrollable bleeding. Mean duration of hospitalization was 11 d. Mean tumoral size was 72 mm. CONCLUSION: Laparoscopic adrenalectomy is now indicated for the majority of adrenal tumors. Several complications observed in this series were related to the learning curve in several centers. Laparoscopic adrenalectomy is the 'gold standard' in uni- or bilateral benign tumors no larger than 6 or 7 cm. 'Open' surgery is indicated in malignant tumors, especially in adreno-cortical carcinomas, and in all large tumors.

Adenoma↗
PubMed1999

[Value of a single low-pressure drain in the postoperative care of bilateral thyroidectomies. Retrospective comparison with bilateral Redon drains].

Double "high vacuum drains" are usually recommended following bilateral thyroidectomy. A single "low vacuum drain" is an attractive alternative when the surgeon considers drainage is necessary. This retrospective study was designed to compare the postoperative outcome following the use of two types of drains. The clinical features, biochemical profile and histopathology were comparable between the two groups: group 1 (high vacuum, n = 77), and group 2 (low vacuum, n = 71). The percentage of total thyroidectomies was significantly higher in group 2 (51% versus 34%, p = 0.04) and this discrepancy was adjusted in the statistical analysis. There was no statistical difference in the outcome of group 1 versus group 2 in terms of wound infections (0% vs 0%), haematoma (0% versus 0.04%), duration and volume of drainage (2.1 versus 2.0 days, 118 versus 117 ml), and hospital stay (3.2 versus 3.2 days). A single "low vacuum drain" is therefore a safe and simple alternative to provide adequate post operative drainage following bilateral thyroidectomy.

Adolescent↗
PubMed1998

[Laënnec, re-inventor of the stethoscope?].

According to our common medical culture, some facts are simply unquestionable, for instance Laënnec invented the stethoscope. But was he the first one? On a recent trip to Egypt we visited the temple of Kom Ombo, built prior to the roman period and renowned as a medical care center. Today, the tourist is fascinated by the magnificent hieroglyphics on the well-preserved walls testifying to significant advances in various fields of medicine including ophthalmology and gynecology. We were particularly interested by the basreliefs presenting vivid drawings of some of the first medical instruments. We easily identified curettes, scissors, a balance, forceps for dental extraction, and a surgical saw, but were captivated by two other instruments. The first one looked a lot like what Laënnec invented around 1820. The second one was amazingly similar to the instrument we use everyday, with a distal opening and flexible tubes (woven papyrus?) leading to proximal ear pieces. Our Egyptian guide was formal: the stethoscope was invented in Egypt. The scientific impact of our observations leaves something to be desired, but did make us think about the huge gap between the advancement of medical knowledge in ancient Egypt and Laënnec's (re)-invention. Exposed to a similar gap in history, what would our documents stored on CD and video tapes have to say to future touring doctors?

Egypt↗
PubMed1998

Intestinal infarctions: a reappraisal of the factors predictive of operative mortality.

OBJECTIVE: To assess the factors that predict operative mortality after intestinal infarction, and show what effect referral patterns have on mortality. DESIGN: Retrospective study. SETTING: Two university departments of surgery, France. SUBJECTS: 144 patients with intestinal infarctions operated on between January 1980 and August 1995. INTERVENTIONS: Univariate and multivariate analyses. MAIN OUTCOME MEASURES: Operative mortality and the factors associated with it. RESULTS: Operative mortality was 67% (96/144) during the first 45 days postoperatively. The univariate analysis showed that age over 75 years (p=0.0002), female sex (p=0.007), the presence of shock (p < 0.0001), and referral from cardiovascular medical or surgical unit (p=0.01) were significantly associated with mortality. However, the multivariate analysis reduced these to extent of infarction (p=0.0001), the presence of shock (p=0.0002), age over 75 years (p=0.0001), and recent cardiac or vascular operation (p=0.03). CONCLUSIONS: The influence of referral pattern was related to previous cardiac or vascular operation, and the risk among women to the fact that their age was 10 years older than that of men. This study shows how the type of referral may explain the wide variations in reported mortality. To compare published series, care should be taken to avoid any selection bias.

Adult↗
PubMed1998

Germ-line mutation analysis in patients with multiple endocrine neoplasia type 1 and related disorders.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant syndrome predisposing to tumors of the parathyroid, endocrine pancreas, anterior pituitary, adrenal glands, and diffuse neuroendocrine tissues. The MEN1 gene has been assigned, by linkage analysis and loss of heterozygosity, to chromosome 11q13 and recently has been identified by positional cloning. In this study, a total of 84 families and/or isolated patients with either MEN1 or MEN1-related inherited endocrine tumors were screened for MEN1 germ-line mutations, by heteroduplex and sequence analysis of the MEN1 gene-coding region and untranslated exon 1. Germ-line MEN1 alterations were identified in 47/54 (87%) MEN1 families, in 9/11 (82%) isolated MEN1 patients, and in only 6/19 (31.5%) atypical MEN1-related inherited cases. We characterized 52 distinct mutations in a total of 62 MEN1 germ-line alterations. Thirty-five of the 52 mutations were frameshifts and nonsense mutations predicted to encode for a truncated MEN1 protein. We identified eight missense mutations and five in-frame deletions over the entire coding sequence. Six mutations were observed more than once in familial MEN1. Haplotype analysis in families with identical mutations indicate that these occurrences reflected mainly independent mutational events. No MEN1 germ-line mutations were found in 7/54 (13%) MEN1 families, in 2/11 (18%) isolated MEN1 cases, in 13/19 (68. 5%) MEN1-related cases, and in a kindred with familial isolated hyperparathyroidism. Two hundred twenty gene carriers (167 affected and 53 unaffected) were identified. No evidence of genotype-phenotype correlation was found. Age-related penetrance was estimated to be >95% at age >30 years. Our results add to the diversity of MEN1 germ-line mutations and provide new tools in genetic screening of MEN1 and clinically related cases.

Amino Acid Substitution↗