Il transito intestinale è assicurato dalla contrazione ciclica della muscolatura liscia distribuita lungo il tratto digerente. Diversi fattori elettrici, ormonali e vascolari nonché il contenuto del tratto digerente possono modulare la progressione del cibo, spiegando il gran numero di condizioni patologiche responsabili di una sindrome occlusiva. Tuttavia, la causa più comune è un’occlusione intestinale per ostacolo meccanico, o per briglia o tumorale. L’occlusione è responsabile di una stasi di liquido digestivo a monte dell’ostacolo e di un’ischemia parietale che porta a un aumento della permeabilità capillare e può essere complicata da una perforazione intestinale. Il sequestro di liquidi può essere responsabile di profondi disturbi volemici e idroelettrolitici, che possono compromettere lo stato emodinamico e alterare la funzione respiratoria. Così, secondo la causa, la sede, la durata di evoluzione e il terreno su cui si verifica la sindrome occlusiva, sono possibili tutte le situazioni clinicolaboratoristiche intermedie, tra il semplice dolore addominale e uno shock settico da perforazione intestinale con insufficienza multiorgano. La diagnosi clinica può essere completata dalla diagnostica per immagini, in particolare dalla TC, che permette di apportare degli elementi di orientamento eziologico e di gravità. Il trattamento eziologico dipende dalla causa. Il più delle volte, le occlusioni di origine meccanica richiedono un trattamento chirurgico o endoscopico, mentre le altre richiedono un trattamento medico. Le ripercussioni generali, in particolare i disturbi elettrolitici, devono essere gestite precocemente.

Parmi les erreurs médicales commises au bloc opératoire, les erreurs de coté, d'organe ou de patient sont les plus redoutées car totalement évitables depuis la mise en place de la check-list HAS [1] et avec des conséquences dramatiques pour les patients. Peu de données sont disponibles et sûrement sous estimées : les rares études nord-américaines rapportant une incidence de 1 erreur pour 50 à 100 000 interventions [2]. Aucune étude épidémiologique française ne s'est intéressée à ce sujet. SHAM est le premier assureur en responsabilité civile médicale en France (50 % du marché), garantissant 80 % des établissements publics, 27 % des établissements privés : c'est une source pertinente d'informations par le biais des dommages ayant conduit à une déclaration de sinistres auprès de SHAM puis parfois à une indemnisation par voie judiciaire. Le but de l'étude a été de décrire la sinistralité en chirurgie liée à une erreur de coté, d'organe ou de patient à opérer. Nous avons réalisé pour cela à partir de la base de données SHAM une étude rétrospective des dossiers de sinistres déclarés sur une période de 5 ans (2009 à 2013). Sur la période, parmi les 29 565 déclarations de sinistres enregistrées, 125 l'ont été pour ce type d'erreur (soit 0,42 % du total des sinistres déclarés à SHAM). 111 dossiers ont été indenisés à l'amiable ou devant CCI (Commission de Conciliation et d'Indemnisation) avec un montant moyen de 10 223 € et 14 dossiers ont été réglés par voie judiciaire, avec une indemnisation moyenne de 19 837 €. Les spécialités concernées sont principalement l'orthopédie (n = 46), la neurochirurgie (n = 18), la stomatologie (n = 13), la chirurgie ORL (n = 8) et le viscéral (n = 7). Dans 112 cas le sinistre est survenu au bloc opératoire, et dans 85 cas après le 1er janvier 2010. Ce type d'événement est survenu dans 85 établissements publics, 8 privés non lucratif, 18 privés lucratifs et 14 personnes physiques. Bien que peu fréquente ce type de sinistralité reste non négligeable sur la période avec des montants d'indemnisation relativement importants. L'analyse des dossiers rapporte que les causes sont essentiellement liées des erreurs humaines dans un contexte multifactoriel : chirurgie urgente, nombre important d'intervenants, non-communication au sein des équipes, surcharge de travail, absence de procédures formalisées de vérification (check-list)… L'épidémiologie de cette sinistralité correspond principalement aux chirurgies concernées par la latéralité : orthopédie et stomatologie. Néanmoins, la connaissance de la sinistralité rapportée de ce travail doit aider à renforcer la démarche qualité au bloc opératoire et montre l'importance du respect des recommandations de l'HAS d'utilisation de la check-list au bloc opératoire, d'autant plus que la majorité des sinistres est survenue après le 1er janvier 2010, date à partir de laquelle l'utilisation de la check-list HAS est devenue obligatoire.

PurposePostoperative infectious complications are key issues following lung transplantation (LT). Early bacterial pneumonia (EBP) worsen prognosis of LT. Assessment of bacterial epidemiology of EBP is necessary to optimize treatment of EBP, thus improving LT outcome.Methods and MaterialsFrom 2006 to 2010, all consecutive LT performed in our institution were included. Demographic and microbiologic data during the first 30 postoperative days after LT were collected.Results102 LT (emphysema 46%, idiopathic fibrosis 38%) were performed during the study period. Among 831 bacteriological cultures of bronchial aspirate, 307 were positive. Evolution of bacterial epidemiology during the first 2 weeks is presented in figure 1. Donor colonization was associated with recipient infection with Methicilin-sensitive Staphylococcus aureus (MSSA) (OR=5,84; [1,87-18,27], p=0,0033) and Enterobacteria (0R=2,8; [1,15-6,83], p=0,037). Presence of purulent expectoration, contrary to fever, leukocyte count, chest X ray, impairment in lung function and CPIS scor, was associated with positive bacterial cultures (OR=1,99; IC [1,45-2,72] p=0,01). Interestingly, type of bacteria did not have any impact on mortality at day 30.ConclusionsThere is an evolution of bronchial bacterial epidemiology during the 2 weeks following LT with an increase in Pseudomonas aeruginosa proportion. Only purulent expectoration, but not other parameters currently used to diagnose post operative pneumonia, is associated with positive bacterial culture of bronchial aspiration. These findings highlight the challenging problems raised by the diagnosis of respiratory infection after LT. Postoperative infectious complications are key issues following lung transplantation (LT). Early bacterial pneumonia (EBP) worsen prognosis of LT. Assessment of bacterial epidemiology of EBP is necessary to optimize treatment of EBP, thus improving LT outcome. From 2006 to 2010, all consecutive LT performed in our institution were included. Demographic and microbiologic data during the first 30 postoperative days after LT were collected. 102 LT (emphysema 46%, idiopathic fibrosis 38%) were performed during the study period. Among 831 bacteriological cultures of bronchial aspirate, 307 were positive. Evolution of bacterial epidemiology during the first 2 weeks is presented in figure 1. Donor colonization was associated with recipient infection with Methicilin-sensitive Staphylococcus aureus (MSSA) (OR=5,84; [1,87-18,27], p=0,0033) and Enterobacteria (0R=2,8; [1,15-6,83], p=0,037). Presence of purulent expectoration, contrary to fever, leukocyte count, chest X ray, impairment in lung function and CPIS scor, was associated with positive bacterial cultures (OR=1,99; IC [1,45-2,72] p=0,01). Interestingly, type of bacteria did not have any impact on mortality at day 30. There is an evolution of bronchial bacterial epidemiology during the 2 weeks following LT with an increase in Pseudomonas aeruginosa proportion. Only purulent expectoration, but not other parameters currently used to diagnose post operative pneumonia, is associated with positive bacterial culture of bronchial aspiration. These findings highlight the challenging problems raised by the diagnosis of respiratory infection after LT.

II transito intestinale è assicurato dalla contrazione ciclica della muscolatura liscia distribuita lungo il tratto digestivo. Diversi fattori, elettrici, ormonali, vascolari, come anche il contenuto del tratto digerente, possono modulare la progressione dei cibi, fatto che spiega la presenza di un gran numero di situazioni patologiche responsabili di una sindrome occlusiva. Tuttavia, la causa più frequente è l’occlusione intestinale da ostruzione meccanica da briglia aderenziale o da neoplasia. L’occlusione è responsabile di una stasi di liquido digestivo a monte dell’ostacolo e di ischemia parietale, che determina un aumento della permeabilità capillare e che può complicarsi con una perforazione digestiva. Il sequestro di liquidi potrà essere responsabile di profondi disturbi volemici e idroelettrolitici, che possono compromettere lo stato emodinamico e alterare la funzione respiratoria. Così, a seconda della causa la sede, la durata di evoluzione e il terreno su cui si verifica la sindrome occlusiva sono possibili tutti gli stadi intermedi clinici e biologici compresi tra un dolore addominale e uno shock settico da perforazione digestiva con insufficienza multiviscerale. La diagnosi clinica può essere completata dalla diagnostica per immagini, in particolare dalla tomodensitometria addominale, che permette di produrre elementi di orientamento eziologico ed eventualmente segni di tolleranza digestiva. La terapia eziologica è dipendente dalla causa. Per le occlusioni di origine meccanica bisogna ricorrere il più delle volte a un trattamento chirurgico, negli altri casi a una terapia medica. Le ripercussioni generali, in particolare i disturbi idroelettrolitici, devono essere presi in carico precocemente.

El tránsito intestinal tiene lugar gracias a la contracción cíclica de la musculatura lisa que se encuentra a lo largo del tubo digestivo. Varios factores (eléctricos, hormonales, vasculares, así como el contenido del tubo digestivo) pueden influir en el avance de los alimentos, lo que explica el gran número de situaciones patológicas que causan un síndrome oclusivo. No obstante, la causa más frecuente es la oclusión intestinal por un obstáculo mecánico, ya sea por una brida o por un tumor. La oclusión causa una estasis del líquido digestivo proximal al obstáculo, así como una isquemia parietal que provoca un aumento de la permeabilidad capilar y que puede complicarse por una perforación digestiva. El secuestro de líquido puede causar profundos trastornos volémicos e hidroelectrolíticos que pueden comprometer el estado hemodinámico y alterar la función respiratoria. Dependiendo de la causa, la localización, la duración de la evolución y las características del paciente afectado por el síndrome oclusivo, pueden observarse todos los estados intermedios clinicobiológicos, desde un simple dolor abdominal hasta un shock séptico por perforación digestiva con falla multiorgánica. El diagnóstico clínico puede complementarse mediante técnicas de diagnóstico por imagen, en particular la tomografía computarizada abdominal, que aporta elementos de orientación etiológica y, en algunos casos, signos de tolerancia digestiva. El tratamiento etiológico depende de la causa. La mayoría de las veces, las oclusiones de origen mecánico deben someterse a tratamiento quirúrgico, y el resto a tratamiento médico. Las repercusiones generales, en particular los trastornos hidroelectrolíticos, deben tratarse precozmente.

Beside conventional therapy, the management of necrotizing cellulitis and fasciitis is based on non-pharmacological treatments. Hyperbaric oxygen therapy and dressings are the most frequently used techniques. The usefulness of hyperbaric oxygen therapy is clearly demonstrated in experimental studies while the efficacy of this technique is poorly assessed in clinical practice. The French consensus conference has concluded to an adjuvant role of hyperbaric oxygen therapy combined to intensive care management, surgery and antibiotic therapy. Occlusive conventional dressings using humid or vaseline gauze dressings are largely used. Calcium alginate or silver coated dressings might be useful. In addition, vacuum-assisted closure therapy could be proposed in replacement of conventional dressings.

Beside conventional therapy, the management of necrotizing cellulitis and fasciitis is based on non-pharmacological treatments. Hyperbaric oxygen therapy and dressings are the most frequently used techniques. The usefulness of hyperbaric oxygen therapy is clearly demonstrated in experimental studies while the efficacy of this technique is poorly assessed in clinical practice. The French consensus conference has concluded to an adjuvant role of hyperbaric oxygen therapy combined to intensive care management, surgery and antibiotic therapy. Occlusive conventional dressings using humidor vaseline gauze dressings are largely used. Calcium alginate or silver coated dressings might be useful. In addition, vacuum-assisted closure therapy could be proposed in replacement of conventional dressings. (c) 2006 Elsevier SAS. Tous droits reserves.

Objective: To compare patients undergoing valve surgery through a minithoracotomy approach with a matched group undergoing conventional valve surgery.Design: Control study.Setting: University hospital, single center.Participants: Forty-one consecutive patients scheduled for valve surgery by minithoracotomy approach were matched with a similar group of patients operated on by the sternotomy approach.Interventions: Criteria for matching included type of valve procedure (aortic valve replacement or mitral valve repair), age, surgeons, and left ventricular function. Two surgeons performed the surgical procedures. Perioperative care was standardized for all patients. Operative and postoperative data were recorded.Measurements and Main Results: The 41 pairs of patients were correctly matched, except for left ventricular function (n = 1). Twenty patients underwent mitral valve repair and 62 aortic valve replacement. Preoperative demographic data and clinical characteristics were similar in both groups. Cardiopulmonary bypass, aortic clamping, and surgery times were longer in the minithoracotomy group (p < 0.05). In 3 patients, the minithoracotomy approach had to be converted into a sternotomy during the surgical procedure for better visualization. Minithoracotomy patients had significantly increased postoperative total blood loss (p < 0.05). No difference was found between the groups for extubation time and intensive care or in-hospital lengths of stay.Conclusion: These results suggest that valve surgery is feasible in many cases through minithoracotomy. Nevertheless, this approach increases surgical complexity and in this comparative study no significant benefit was shown. (C) 2003 Elsevier Inc. All rights reserved.

In order to identify possible causes for the shortage in organ procurement today in France, a regional survey including 74 hospitals in the Paris area which are likely to receive brain dead patients (BDP) and in which there were neither harvesting nor transplantation activities was conducted. Of the 66 hospitals (89%) answering this survey, half of them were district general hospitals. In the 2 years before the survey, they received on average three BDP. Such a figure represents at least 10% of BDP seen in this area. For one half of the centres, care of these patients was difficult or impossible due to the available facilities. Organisational concerns were among the major problems raised by the transfer of these patients to harvesting centres. A preestablished geographical network would be of help for simplifying the transfer of these patients. Interestingly, about 50% of centres ai ready had such links with a transplantation centre. This study provides information concerning logistics and possible points which could be improved in order to increase the number of BDP liable to be transferred to transplantation centres. (C) 1998 Elsevier, Paris.