Biomedical subjects
Publications and source records attributed to P Mouret.
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BACKGROUND: Ximelagatran and its subcutaneous (s.c.) form melagatran are novel direct thrombin inhibitors for the prevention and treatment of thromboembolic disease. METHODS: In a double-blind study, 2835 consecutive patients undergoing total hip or knee replacement were randomized to either melagatran/ximelagatran or enoxaparin. Melagatran 2 mg was started immediately before surgery; 3 mg was then administered postoperatively, followed by 24 mg of oral ximelagatran b.i.d. beginning the next day. Enoxaparin 40 mg, administered subcutaneously o.d., was started 12 h before surgery. Both treatments were continued for 8-11 days. The main efficacy outcome measures were major venous thromboembolism (VTE); [proximal deep vein thrombosis (DVT), non-fatal and/or fatal pulmonary embolism (PE), death where PE could not be ruled out], and total VTE (proximal and distal DVT; PE; death from all causes). DVT was detected by mandatory bilateral ascending venography at the end of the treatment period or earlier if clinically suspected. The main safety outcome was bleeding. RESULTS: The rates of major and total VTE were significantly lower in the melagatran/ximelagatran group compared with the enoxaparin group (2.3% vs. 6.3%, P = 0.0000018; and 20.3% vs. 26.6%, P < 0.0004, respectively). Fatal bleeding, critical site bleeding and bleeding requiring reoperation did not differ between the two groups. 'Excessive bleeding as judged by the investigator' was more frequent with melagatran/ximelagatran than with enoxaparin. CONCLUSIONS: In patients undergoing total hip or knee replacement, preoperatively initiated s.c. melagatran followed by oral ximelagatran was significantly more effective in preventing VTE than preoperatively initiated s.c. enoxaparin.
AIM: The efficacy and safety of the new oral, direct and selective thrombin inhibitor Ximelagatran and its active form Melagatran was analysed in patients undergoing total hip or knee replacement. METHODS AND PATIENTS: Methro II, a randomised, double-blind controlled dose-finding study, involved 1876 patients. Melagatran (1, 1.5, 2.25 or 3 mg; twice daily; start: immediately before surgery) was given subcutaneously, followed by orally administered Ximelagatran (8, 12, 18 or 24 mg, twice daily, day after surgery) and compared to subcutaneously administered dalteparin (5000 IE, once daily). Methro III was a randomised, double blind controlled study involving 2788 patients. The fixed dose of 3 mg Melagatran was given (start: 4-12 hours postoperatively) followed by oral Ximelagatran (24 mg, twice daily, day after surgery) compared to subcutaneous enoxaparin (40 mg, once daily). In both studies, dalteparin or enoxaparin was applied at the evening before operation; the treatment lasted 8 to 11 days. A bilateral venography was performed at the last day of treatment. RESULTS: In the Methro II study, 1270 patients underwent total hip, 606 total knee replacement. In both groups the thromboembolism rate was reduced depending on the dose of Ximelagatran/Melagatran. Compared to dalteparin, it was significantly lower for the Ximelagatran/Melagatran group with the highest dose. In the Methro III study 1923 patients underwent a total hip, 865 a total knee replacement. The thromboembolism rate was 31% for the Ximelagatran/Melagatran group compared to 27% for the enoxaparin group. In both studies blood loss and transfusion requirement were in the same range as with low weight molecular heparins. CONCLUSIONS: A fixed subcutaneously given dose of Melagatran, followed by orally administered Ximelagatran is effective and well tolerated as prophylaxis against venous thromboembolism.
Laryngocele is an unusual laryngeal disease caused by an abnormal dilatation of the saccule of the laryngeal ventricule. Infection results in laryngopyocele. We report a case of laryngopyocele discovered in a patient presenting with fever, an inflammatory mass, dysphagia and minimal respiratory distress. Diagnosis was established from direct laryngoscopy and CT-scan. Early treatment consisted in antibiotics and needle aspiration followed by external excision. Laryngopyocele can sometimes be revealed by an episode of acute respiratory distress requiring tracheotomy. If there is no respiratory distress and if the infection is cured, endoscopic treatment with or without laser can be performed for internal laryngocele. The cervical approach can only be recommended for external or combined laryngocele.
INTRODUCTION: Thyroglossal duct cyst (TGDcs) is the most common malformation of the neck. The risk of infection and malignant transformation impose its treatment. OBJECTIVES: The purpose of our study were: 1) to specify some points about the symptomatology and preoperative evaluation necessary for TGDcs diagnosis; 2) to analyse the factors who can explain an unsuccessful surgical treatment. PATIENTS AND METHODS: Our study is based on a retrospective review of cases and a review of the literature. From 1981 to 2000, 99 children with a mean age of five years were treated for a TGDcs with a surgical procedure in the Grenoble University Hospital. 3 excision and 96 Sistrunck's procedure were performed. In all cases a histological study was made. RESULTS: Ultrasonography was the most frequent preoperative evaluation. We have had 7 complications: 3 haematoma, 2 abscess and 2 desunited scar. 6 children have had recurrent disease. Among these 6 children, 3 have had an excision and 3 a Sistrunck's procedure. No case of malignant transformation was reported. CONCLUSION: Ultrasonography is the first preoperative evaluation to obtain before surgical treatment of a TGDcs. Sistrunck's procedure is the best surgical treatment with a value of recurrence from 1% to 10%. Areas of surgical failure included breaking of cyst during the dissection, inadequate hyoïd bone resection, an anatomical variation with many ductuli in the base of tongue, inadequate muscles of tongue resection.
PURPOSE OF THE STUDY: The purpose of our study was to determine the position and value of ultrasound scan of the liver in the initial check-up of patients treated for a squamous cell carcinoma of the upper respiratory and digestive tract. MATERIAL AND METHODS: Our study is based on a retrospective review of 267 patients (249 males and 18 females) managed in the E.N.T. Department of Grenoble universitary hospital from 1993 to 1995 for a upper respiratory and digestive tract malignant tumor. No patient has been previously treated. The site of the primary tumor was: the oropharynx (108 cases), the hypopharynx (88 cases), the oral cavity (44 cases), the larynx (20 cases), the rhinopharynx (6 cases) and the cervical oesophagus (1 case). Endoscopic procedure with biopsy was performed for all the patients. Histologic examination revealed an invasive squamous cell carcinoma in all the cases. The complete check up included a ultrasound scan of the liver and a chest X-ray for all the patients. RESULTS: Ultrasound scan of the liver revealed one or several metastases in 4 cases (1.5%). The primary tumor was hypopharyngeal in 3 cases (2 stages III, 1 stage IV) and oropharyngeal in 1 case (stage III). In three cases, carcinoma was poorly differentiated. Ultrasound scan of the liver was doubtful for 8 patients (3%). The primary tumor was oropharyngeal in 6 cases (1 stage I, 3 stages III, 2 stages IV), laryngeal in 1 case (stage III) and hypopharyngeal in case (stage IV). In six cases carcinoma was well differentiated. All the complementary examinations concluded to a benign liver disease, with a mean diagnosis delay of 4 weeks for the 8 patients. The mean follow-up duration of the 8 patients was 22 months (range 9 to 42 months). None presented any metastases during the follow up. CONCLUSION: Our results compared with those of the literature revealed that ultrasound scan of the liver is a few specific examination which may be recommended for hypopharyngeal tumors, or for a large cervical adenopathy (N2 or N3), a poor differentiated tumor wherever the site of the primary tumor is.
A new case of well differentiated hypopharyngeal liposarcoma is reported. The author reviews the literature about the clinical and histologic features of these tumors. From the 93 head and neck liposarcomas reported 13 are located in the hypopharynx. The mean age of presentation is 61 years and males are largely predominant. Etiology is still unknown. Tumor size does not seem to affect the prognosis. Usually patients do not present with cervical lymph node metastasis nor distant metastasis. Histologic diagnosis according to Enzinger and Weis's classification could be difficult especially to distinguish between lipoma and well differentiated liposarcoma. The main prognostic factor is histologic grade but early recognition combined with a complete surgical excision can result in a decreased local recurrence rate and high survival rate. Low grade tumors often recur locally but distant metastases are rare. From the 8 well differentiated tumors reviewed 6 presented a local recurrence 2 months to 20 years after surgery but only 1 patient died without disease. High grade tumors are much more aggressive locally and metastasize frequently. Radiotherapy and chemotherapy are proposed in selected cases without evidence to be of value.
BACKGROUND: Patients who undergo total hip replacement have a high risk of thromboembolic complications. Recombinant hirudin (desirudin), a specific inhibitor of thrombin, represents a new development in antithrombotic therapy. We compared the efficacy and safety of desirudin with those of a low-molecular-weight heparin (enoxaparin) for the prevention of thromboembolic complications in patients undergoing primary total hip replacement. METHODS: Both treatments, which were assigned in a randomized, double-blind manner, were started preoperatively: enoxaparin on the evening before surgery, and desirudin within 30 minutes before the start of surgery. The dose of desirudin was 15 mg subcutaneously twice daily, and the dose of enoxaparin was 40 mg subcutaneously once daily. The duration of treatment was 8 to 12 days. Deep-vein thrombosis was verified by bilateral venography performed at the end of the treatment period or earlier, if there were clinical signs of deep-vein thrombosis. RESULTS: At 31 centers in 10 European countries, 2079 eligible patients were randomly assigned to receive desirudin or enoxaparin. A total of 1587 patients were included in the primary analysis of efficacy. In the desirudin group, as compared with the enoxaparin group, there was a significantly lower rate of proximal deep-vein thrombosis (4.5 vs. 7.5 percent, P=0.01; relative reduction in risk, 40.3 percent) and a lower overall rate of deep-vein thrombosis (18.4 vs. 25.5 percent, P=0.001; relative reduction in risk, 28.0 percent). The safety profiles were similar in the two treatment groups. CONCLUSIONS: When administered 30 minutes before total hip replacement surgery, desirudin is more effective than enoxaparin in preventing deep-vein thrombosis.
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The aim of this prospective study was to judge the efficiency of laparoscopic adhesiolysis: 52 patients have been treated laparoscopically either for obstruction (group 1: 17 patients) or for chronical abdominal pain (group 2: 35 patients). Two out of five peroperative complications required a laparoconversion whereas two postoperative complications required a laparotomy for intestinal obstruction. Six patients of group 1 developed a recurrence of obstruction treated by laparoscopy in four and by laparotomy in two cases. At the time of the study (among 50 patients with a mean follow-up of 24 months), 32 patients were asymptomatic, 13 found that their symptoms had lessened, and finally, five patients were not improved. We concluded that laparoscopic adhesiolysis is an attractive surgical procedure, allowing a clinical improvement in 45 out of 50 patients in our study.
The authors treated 16 patients with small bowel obstruction by 19 laparoscopy (3 patients underwent 2 laparoscopies). The operation was performed 4 times as an emergency and in 15 cases after resolution of the obstruction in patients who had already experienced such attacks. Adhesiolysis was complete in 14 cases and incomplete in 5 cases. Conversion in laparotomy was necessary in one patient to cure a total obstruction. 2 operative complications were reported (bowel perforation during enterolysis); one of which required conversion into laparotomy). This patient also developed post-operative complications whereas the post-operative course was uneventful for the other patients. Five patients developed an obstructive recurrence which required laparotomy in 2 cases and laparoscopy in the other 3 cases; but for two patients, initial enterolysis had been incomplete and a laparotomy was performed on another patient. Laparoscopic viscerolysis seems to be attractive but, the long-term outcome, and the frequency of adhesion recurrence need to be defined.
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The main demands on a total hip replacement are to reduce pain or achieve painlessness and to recover or improve mobility and walking ability. Today more younger patients were operated replacing a destroyed hip joint: the reintegration in professional and sportive activities is a major part of the rehabilitation process. The postoperative management especially in physical therapy can be standardized inspite of the use of various models. Usually full weight bearing is accepted after 3 months. A review of consecutive treatment methods and professional and sportive rehabilitation measures are presented. Hip replacement leads to restrictions in activity in general. The evaluation, in relation to the different indemnifying, is differentiated.
Over the last 24 years the authors operated 21 branchiomeric paragangliomas in 18 patients. They emphasize the difficulty of making the diagnosis and the importance of completing a thorough work-up before deciding surgery. Adequate imaging is particularly important (neck sonography, computed tomography, arteriography) to avoid making the diagnosis by exploratory neck dissection and to assess the vascular risk. Biological studies have regained importance, especially in the context of complex neuro-cristopathy. Treatment is essentially surgical and must be considered with prudence in patients with bilateral lesions. The surgical removal of branchiomeric paragangliomas necessitates preparation of a small saphenous vein bypass in case it is not possible to avoid sacrificing the internal carotid artery.
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6,512 laparoscopic cholecystectomies have been performed by 141 surgeons. The lithiasis was uncomplicated in 80% of cases. Conversion from laparoscopy to laparotomy was necessary in 350 cases (5.37%), for technical problems (22 cases), complications (87 cases) or surgical difficulties (241 cases): 107 cholecystitis, 68 adhesions, 14 difficulties in finding the cystic duct and 25 common bile duct stones were the principle surgical difficulties. Among the 304 complications, we have observed 35 general and 251 local complications: 58 haemorrhages, 12 common bile duct lesions (10 cases of iatrogenic trauma and 2 accidental ligations), 4 cystic duct problems and 3 cases of intestinal trauma were the principle per-laparoscopic complications. Among the 164 post-laparoscopies cholecystectomy's complications, we have observed 50 biliary fistulae with 32 requiring further surgery (damage to the common bile duct in 14 cases), 3 common bile duct strictures, 20 haemorrhages (7 requiring further surgery), 31 deep or sub-phrenic abscesses (16 requiring further surgery) and 2 peritonitis after intestinal trauma. We have had 7 deaths (0.10%). Prognostic factors are: 1) The degree of surgeon's experience; the first 50 laparoscopies cholecystectomies performed are more likely to require further surgery (P < 0.05). 2) Cholecystitis with an significantly higher rate of conversion to laparotomy (P < 0.001) and morbidity (P < 0.01). For an experienced surgeon the biliary morbidity is near to that observed in classical cholecystectomy.
Fifty four patients with cervical lymph node metastasis from an unknown primary tumor underwent treatment from 1969 to 1988. Fourty five underwent radical neck dissection. 69% had node capsular effraction and 36% perinodal vascular embolism. Thirty four patients underwent postoperative radiotherapy including rhinopharynx, cervical oesophagus and all the bilateral cervical nodes. The primary tumor appeared after treatment in 7 cases. Total survival rate is 36% 5 years after treatment. Vascular embolism aggravates the prognosis. Radiosurgical association allow effective control of loco-regional cancer but does not improve survival rate. Prognosis is aggravated by metastases arising (18%).