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Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.

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Bacterial adhesion to biomaterials is a complex phenomenon involving numerous factors. The ability to reduce urinary catheters infections simply by general hygiene and asepsis is low: an ascending colonization cannot be avoided. This will lead to a clinical infection only if several factors favour the bacterial adhesion or the bacterial coaggregation and the feeding of the bacterial biofilm. Among the many factors involved in bacterial adhesion, we focused in this paper on the physical parameters of surface hydrophobicity of the urinary catheters (Van der Waals and acido-basic forces) and the surface hydrophobicity of the bacteria (BATH and zeta potential). We also compared scanning electron microscopy (SEM) of in vivo and in vitro infected urinary catheters. We provided evidence that the more hydrophobic the bacteria, the more they are able to colonize hydrophobic materials, whereas hydrophilic cells are able to colonize hydrophilic materials more easily. Some biomaterials were found to display an irregular texture of hydrophobic and hydrophilic areas: they favour both types of adhesion. Moreover the divalent cations (MgII) drastically increased the bacterial coaggregation and favour bacterial growth within the biofilm. Finally, an increase in urinary pH and ionic strength increases the colonization risk. Consequently, choice of urinary catheter biomaterials is essential as patient hygiene and diet in order to avoid clinical infections.

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The authors report three cases--one of them lethal--of intestinal occlusion among 30 patients treated with clozapine between 1991 and 1994 in Châlons-sur-Marne Psychiatric Hospital. The responsibility of clozapine seems to be linked with its potent anticholinergic property. The attention of prescriptors is necessary and the monitoring of the drug should not be limited to the hematologic aspect.

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Percutaneous drainage has become, during the last ten years, the treatment of choice of abdominal abscesses. From January 1986 to January 1990, 205 patients have been treated in our department for an abdominal collection. In this prospective work we have realised percutaneous drainage in every patients who would have been operated, according to the classical indications. In 28 patients (acute cholecystitis), the indication has been elective because of the surgical risk, depending to the age (mean 80 years). We have treated 67 intra abdominal collections (34 post operative), 39 pseudocysts of the pancreas, 40 liver collections (18 abscesses); and we have done 37 biliary drainages. 15% of the patients showed communication of the collection with the digestive tract. Mortality was less than 5%. Half of these deaths occurred during the evolution of necrotic pancreatitis. 78% of the patients have been cured by the percutaneous drain. The other patients have been operated upon but the drainage facilitated the operation. In our experience percutaneous drainage is a secure technique and every abdominal surgeon would be able to practice this technique.

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A case of a 23-year-old primigravida with a tumour of the left adrenal gland and a medullary thyroid carcinoma is reported. Her blood pressure remained at about 100/60 mmHg throughout pregnancy. She was scheduled for elective Caesarean section combined with removal of both adrenal glands. Anaesthesia was carried out using 10 micrograms.kg-1 alfentanil, 5 mg.kg-1 thiopentone, 1.5 mg.kg-1 succinylcholine and 0.5 vol % enflurane. A single hypertensive crisis (190/100 mmHg) occurred intraoperatively, during dissection of the left adrenal gland. This responded well to 1 mg.min-1 phentolamine. The postoperative course was uneventful for both the mother and the child. Total thyroidectomy with block dissection of the lymph nodes was to be carried out within three weeks after the Caesarean section. Only two similar cases of multiple endocrine neoplasia associated with pregnancy have previously been published.

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The effects of two volatile anaesthetics on hepatic function are compared in 80 patients in hepato-biliary surgery. 40 patients were anaesthetized either with enflurane or halothane. This study is based on the variations of blood levels of gamma GT, bilirubin, SGOT SGPT, alkaline phosphatase, L.D.H. Samples were taken the day prior to the operation, one, two and five days afterwards. The results show an increase in the levels of BD, SGPT, LDH no 5, less important with enflurane than with halothane, and mainly in patients with preoperative hepatic abnormalities. Enflurane appears to be preferable in such cases.

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Postoperative nitrogen intake, which limits nitrogen catabolism and improves conditions of healing, classically implies a high calorie intake. The risks and dangers of hypertonic or hypersmotic solutions are such that the provision of nitrogen postoperatively in ordinary surgery is often avoided. The authors studied postoperative nitrogen balance for a given nitrogen intake with different calorie levels in a series of 50 patients undergoing digestive surgery. A first group (28 patients--mean age 54.6 years, mean weight 63.3 kg) received 12.4 g of nitrogen and 1000 calories per day. The second group (22 patients--mean age 52.5 years, mean weight 64.7 kg) received 12.4 g of nitrogen and 2200 calories. Daily nitrogen balance was calculated using the method of approximation described by Apfelbaum on the basis of urinary urea excretion. Statistical study of nitrogen balances for the first four days showed no statistically significant difference between the mean values in the two groups. For group A, the cumulative balance for the first four days was 7.60 g +/- 4.75 g, and for group B 7.85 G +/- 6.64 g. Limitation of postoperative nitrogen catabolism does not necessarily impose the need for high calorie intake, implying the use of a central venous catheter and administration at constant flow. The patient undergoing ordinary digestive surgery may benefit from postoperative nitrogen supplies, associated with a moderate calorie intake and administered via usual venous routes.

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