Expérience des premiers cas de sialendoscopie à l'Hôpital Bicêtre

Objectif : Rapporter les premiers résultats de sialendoscopie pour la prise en charge des pathologies salivaires non-néoplasiques au CHU du Kremlin Bicêtre.Méthodes : Etude prospective de tous les cas de sialendoscopie réalisés par un même opérateur de mars 2010 à octobre 2011 pour une symptomatologie obstructive des glandes submandibulaire ou parotide. Recueil de données grâce à un formulaire patient et chirurgien. Matériel utilisé : sialendoscope all in one (1,3 mm) ou sialendoscope pédiatrique (0,75 mm), sonde de Dormia, sonde à ballonnet et laser Holmium. Résultats : 89 glandes de 76 patients (40F/36H), âge moyen = 39,4 ans, suivi moyen = 6mois, temps opératoire moyen = 51,9 mn, taux de succès de sialendoscopie diagnostique = 95,5%, pathologie lithiasique (n= 37) : extraction à la sonde de Dormia = 63,2%, taille endobuccale = 20,4%, échec d extraction = 16,3%, sténose canalaire (n= 28), échec de dilatation = 10,7%, taux de succès de sialendoscopie interventionnelle = 84%. Conclusion : La sialendoscopie bien qu apparue il y a plus de dix ans est encore peu connue du monde médical et des ORL. Cette étude, en accord avec les données de la littérature, montre que l endoscopie des glandes salivaires est non seulement d un intérêt certain pour le diagnostic des pathologies salivaires obstructives, mais aussi une option thérapeutique efficace et dénuée de risques majeurs dans la prise en charge de ces pathologies. Elle peut être réalisée sous anesthésie locale. Cependant, la sialendoscopie doit être pratiquée par des chirurgiens capables de convertir la sialendoscopie en une technique classique d exérèse de la glande concernée et d en gérer les possibles séquelles et complications.PARIS13-BU Serge Lebovici (930082101) / SudocSudocFranceF

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons