Thyroïdectomie chez les patients en surpoids ou obèses : une chirurgie à risque ?

Objectif. Etudier et comparer les complications spécifiques postopératoires de la thyroïdectomie (hypocalcémie, atteinte récurrentielle, hématome post opératoire précoce) de la population ayant un IMC supérieur ou égal à 25 par rapport à la population ayant un IMC inférieur à 25. Matériel et méthode. Une étude prospective a été réalisée au CHU d Angers de septembre 2010 à janvier 2013. Les calcémies postopératoires, la mobilité laryngée, les complications hémorragiques ainsi que les durées d hospitalisation post opératoire et les durées d intervention ont été étudiées et comparées statistiquement par un test de Chi2 ou de Student. Résultats. Au total 240 patients étaient opérés d une thyroïdectomie totale et 126 patients d une isthmolobectomie. 168 patients présentaient un IMC inférieur à 25 et 198 patients présentaient un IMC supérieur ou égal à 25. Il n existait pas de différence statistiquement significative concernant la survenue d une hypoparathyroïdie précoce ou définitive, d une paralysie récurrentielle, d une complication hémorragique ou la durée d hospitalisation en post opératoire. Il existait en revanche une durée opératoire plus importante chez les patients ayant un IMC supérieur ou égal à 25. Conclusion. Malgré une durée opératoire plus importante, la thyroïdectomie (totale ou isthmolobectomie) peut être réalisée en toute sécurité chez les patients ayant un IMC supérieur ou égal à 25.Objective: To study and compare the specific postoperative complications of thyroidectomy in a population with a Body Mass Index (BMI) greater than or equal to 25 to a population with a BMI below 25. Design: A prospective study was performed from September 2010 to January 2013. Methods: Postoperative calcemia, laryngeal mobility, bleeding or infectious complications, postoperative hospital stay and operation time were studied and compared statistically by a Chi2 test or student. Results: 240 patients underwent total thyroidectomy and 126 a partial thyroidectomy. 168 patients had a lower BMI to 25 and 198 patients had a BMI greater than or equal to 25. There was no statistically significant difference in the occurrence of early or permanent hypoparathyroidism, recurrent laryngeal nerve palsy, bleeding complications or postoperative duration of stay. There was however a significant operative time in patients with a BMI greater than or equal to 25 Conclusion: Despite a larger operating time, thyroidectomy (total or partial) can be performed safely in patients with a BMI greater than or equal to 25.ANGERS-BU Médecine-Pharmacie (490072105) / SudocSudocFranceF

La chirurgie colo-rectale chez le patient cirrhotique (Évaluation de la morbidité et de la mortalité opératoires)

Il existe un risque élevé de mortalité et de morbidité post-opératoires après une intervention chirurgicale chez les patients cirrhotiques. La chirurgie colo-rectale est à haut risque de morbidité. Le but de cette étude était d'étudier la mortalité, la morbidité et les facteurs pronostiques de la chirurgie colo-rectale chez les patients cirrhotiques. De 1993 à 2006, les patients opérés d'une chirurgie colo-rectale et ayant une cirrhose prouvée histologiquement ou plus de quatre critères évocateurs d'une cirrhose (anamnèse, intoxication alcoolique chronique, varices œsophagiennes connues, dysmorphie hépatique à l'imagerie, taux de prothrombine < 80%, sérologies virales positives, bilans biologiques concordants, aspect hépatique per-opératoire) ont été inclus. Une analyse univariée et multivariée a été réalisée afin d'identifier les variables influençant la morbidité et la mortalité. 43 interventions ont été réalisées chez 41 patients. La mortalité post-opératoire est de 26% (11/43) dont 6 patients (54%) opérés en urgence. La morbidité post-opératoire est de 77% (33/43). Dans cette étude, quatre facteurs influencent la mortalité en analyse univariée : le caractère urgent de l'intervention (p<0,05), la survenue d'une complication post-opératoire (p<0,04) dont l'infection (p<0,01) et la réalisation d'une colectomie totale (p<0,02). En analyse multivariée, le seul facteur influençant la mortalité est l'infection post-opératoire (p<0,04). Le seul facteur influençant la morbidité est l'existence d'une ascite en pré-opératoire (p<0,04). La chirurgie colo-rectale chez le patient cirrhotique est à haut risque de mortalité et de morbidité. Le pronostique est lié au caractère septique, urgent et extensif de l'intervention et à la décompensation ascitique de la cirrhose. L'amélioration des résultats passe par une meilleure sélection et préparation des patients.Surgery for colorectal diseases has an elevated morbidity. For cirrhotic patients, there is a high risk of mortality and morbidity following surgery. The aim of this study was to evaluate morbidity, mortality and prognostic factors regarding colorectal surgery in cirrhotic patients. From 1993 to 2006, 41 cirrhotic patients who underwent 43 colorectal procedures were included. Both univariate and multivariate analyses were carried out so as to identify those variables influencing morbidity and mortality. Postoperative morbidity was 77% (33/43). Postoperative mortality was 26% (11/43) among which 6 patients (54%) underwent emergency surgery. In this study, four factors influenced mortality in the univariate analysis : emergency (p<0.05), postoperative complications (p<0.04), postoperative infections (p<0.01) and total colectomy procedures (p<0.02). In the multivariate analysis, the only factor influencing mortality was postoperative infection (p<0.04). The only factor influencing morbidity was the existence of preoperative ascites (p<0.04). Colorectal surgery for cirrhotic patients is at high risk in terms of morbidity and mortality. The prognosis is linked to the septic, urgent and extensive nature of surgery and the ascitic decompensation of cirrhosis. An improvement in the results can be achieved through better selection and preparation of patients.ANGERS-BU Médecine-Pharmacie (490072105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

LE KYSTE PARATHYROIDIEN (ETUDE ANATOMO-CLINIQUE A PROPOS DE 10 OBSERVATIONS)

NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Neoadjuvant treatment: The future of patients with breast cancer

SCOPUS: ed.jinfo:eu-repo/semantics/publishe

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

International audiencePurpose The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. Methods From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Results Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P &lt; 0.05), postoperative complications (P &lt; 0.04), postoperative infections (P &lt; 0.01), and total colectomy procedures (P &lt; 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P &lt; 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P &lt; 0.04). Conclusions Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.</p

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

AbstractBackgroundBile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred.MethodsA retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy.ResultsForty‐seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio‐digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio‐digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio‐digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001).ConclusionThe timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option

Occlusion sur bride d'une anse en Y après duodénopancréatectomie céphalique : une cause rare d'angiocholite

International audienc

Thyroidectomy in patients with a high BMI: a safe surgery?

International audienceOBJECTIVE: To study and compare the specific postoperative complications of thyroidectomy in a population with a BMI ≥25 with a population having a BMI below 25.DESIGN: A prospective study was carried out from September 2010 to January 2013.METHODS: Postoperative calcemia, laryngeal mobility, bleeding or infectious complications, postoperative hospital stay, and operation time were studied and compared statistically by a χ(2)-test or Student's t-test.RESULTS: A total of 240 patients underwent total thyroidectomy and 126 underwent a partial thyroidectomy. Of them, 168 patients had a BMI below 25 and 198 patients had a BMI ≥25. There was no statistically significant difference in the occurrence of early or permanent hypoparathyroidism, recurrent laryngeal nerve palsy, bleeding complications, or postoperative duration of hospital stay. There was, however, a significant operative time in patients with a BMI ≥25.CONCLUSION: Despite the longer operative time, thyroidectomy (total or partial) can be performed safely in patients with a BMI ≥25.</p

Comparison of Morbidity After Total Thyroidectomy Among Adult Patients With and Without Preoperative Hyperthyroidism.

International audienceHyperthyroidism is common, diagnosed in 2.0% of women and 0.2% of men worldwide. The main treatments for hyperthyroidism are antithyroid drugs, radioiodine, and surgery. Thyroidectomy has been reported to be an effective, safe, and cost-saving method and to have the lowest recurrence rate compared with radioiodine and antithyroid drugs.1 However, total thyroidectomy requires more careful and accurate hemostasis when performed in patients with hyperthyroidism vs patients with normal thyroid function (euthyroidism).2 The aim of this nonrandomized clinical trial was to compare the incidence of morbidity after total thyroidectomy among patients with preoperative hyperthyroidism vs patients with preoperative euthyroidism.MethodsWe performed an analysis of data collected in the FOThyr (Medico-Economic Evaluation Comparing the Use of Ultrasonic Scissors to the Conventional Techniques of Haemostasis in Thyroid Surgery by Cervicotomy; NCT01551914) study.3 The FOThyr study, conducted from March 2012 to June 2014, was a prospective randomized multicenter clinical trial comparing the use of a disposable hemostatic device with the use of conventional hemostasis for total thyroidectomy among adult patients. The study protocol was reviewed and approved by a regional ethics committee (Comité de Protection des Personnes Ouest IV) and by the national data protection authority in France (Commission Nationale de l’Informatique et des Libertés). The study was performed in accordance with the Guideline for Good Clinical Practice and the Declaration of Helsinki. All patients provided written informed consent before inclusion.All patients planning to undergo total thyroidectomy were eligible for inclusion if they had Graves disease, euthyroid or hyperthyroid goiter, or any thyroid nodule requiring total thyroidectomy via cervicotomy. In accordance with guidelines from the French Society of Endocrinology (http://www.sfendocrino.org), all patients with overt hyperthyroidism (ie, high triiodothyronine and/or thyroxine hormone levels) received preoperative antithyroid drugs to normalize thyroid hormone levels.An evaluation of recurrent laryngeal nerve function was systematically conducted after each surgery. A vocal cord examination with nasofibroscopy was performed before hospital discharge and 6 months after surgery to monitor potential postoperative recurrent laryngeal nerve abnormality.Postoperative hypocalcemia was defined as a serum calcium level lower than 8.0 mg/dL (corrected for albumin level; to convert to mmol/L, multiply by 0.172) at postoperative day 2, and definitive hypocalcemia was defined as a serum calcium level lower than 36.0 mg/dL at 6 months after surgery. Clinical observation was performed during hospitalization to diagnose potential hematomas. Data analysis was performed using SAS software, versions 9.2 and 9.3 (SAS Institute). Data were analyzed from September to December 2017.ResultsFrom March 2012 to June 2014, 1250 patients with usable data (mean [SD] age, 50.9 [13.3] years; 997 women [79.8%]) were enrolled at 14 sites in France. At the preoperative consultation, 255 patients (20.4%) had hyperthyroidism, and 995 patients (79.6%) had euthyroidism. All preoperative patient characteristics are shown in Table 1.Postoperative abnormal vocal cord mobility was diagnosed in 130 of 1250 patients (10.4%), representing 102 of 995 patients (10.3%) in the euthyroidism group and 28 of 255 patients (11.0%) in the hyperthyroidism group (difference, 0.70%; 95% CI, −0.05% to 0.04%) (Table 2). Definitive recurrent nerve palsy (RNP) was diagnosed in 12 patients (1.0%), representing 10 patients (1.0%) in the euthyroidism group and 2 patients (0.8%) in the hyperthyroidism group (difference, 0.22%; 95% CI, −0.01% to 0.02%). Postoperative hypocalcemia was diagnosed in 250 patients (20.0%), representing 196 patients (19.7%) in the euthyroidism group and 54 patients (21.2%) in the hyperthyroidism group (difference, 1.50%; 95% CI, −0.08% to 0.04%). Definitive hypocalcemia was diagnosed in 25 patients (2.0%), representing 19 patients (1.9%) in the euthyroidism group and 6 patients (2.4%) in the hyperthyroidism group (difference, 0.48%; 95% CI, −0.03% to 0.02%).DiscussionIn the present study, preoperative hyperthyroidism was not associated with substantial increases in the incidence of complications (neither postoperative nor definitive hypocalcemia, RNP, or hematoma) after total thyroidectomy among patients who received preoperative antithyroid drugs. These morbidity results may be surprising, given that one would expect a substantial difference between patients with preoperative hyperthyroidism and those with euthyroidism. However, our results are consistent with those of other studies.4,5This nonrandomized clinical trial was large (1250 patients), with minimal postoperative missing data. Data collection was thorough with regard to preoperative and immediate postoperative data but less thorough with regard to late postoperative data, especially for RNP incidence. Approximately 50% of postoperative patients with RNP chose not to undergo postoperative laryngoscopy at 6 months, which may have produced underestimation of definitive RNP. However, Lifante et al6 have reported an association between the incidence of definitive and immediate postoperative palsies.This study has 2 primary limitations. First, the FOThyr study, from which the sample for the present study was obtained, was not designed to assess morbidity but to evaluate the 6-month clinical efficacy and cost-effectiveness of using ultrasonic scissors (HARMONIC FOCUS; Johnson & Johnson) compared with conventional hemostasis for thyroidectomy.3 Second, data on thyroid-stimulating hormone levels were only collected at the first preoperative consultation; we did not collect data on thyroid-stimulating hormone, triiodothyronine hormone, or thyroxine hormone levels on the day of surgery. Because the study lacked data on thyroid hormone levels immediately before surgery, the effectiveness of preoperative treatments could not be assessed.Medical treatment should precede surgery. However, the results of this large nonrandomized clinical trial may encourage endocrine surgeons to reassure and motivate patients to undergo total thyroidectomy as a definitive treatment for hyperthyroidism