Acute esophageal necrosis: Case report of an unknown entity

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Acute esophageal necrosis is an unknown entity because it is a rare disease.

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Management including different specialties.

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Time is necessary and surgery is not the only therapy.

Introduction

Acute Esophageal Necrosis Syndrome (AENS) is a rare and unknown clinical entity, defined as a diffuse circumferential black-appearing friable esophageal mucosa going from the distal esophageal mucosa to the gastroesophageal (GE) junction. Esophagogastroduodenoscopy (EGD) remains the gold standard in making diagnosis.

Presentation of case

We report here the case of a 45-year-old man with necrosis of the esophagus treated conservatively. Regression of the lesion but persistence of ulcerations were seen on the endoscopic follow-up. Distal esophageal stenosis was then diagnosed and treated by endoscopic dilation.

Discussion

Diagnosis of AENS must be considered when an old patient, with multiple comorbidities, presents an upper digestive hemorrhage. Upper endoscopy is mandatory. Treatment is in most of the cases conservative. Esophageal stenosis is a frequent complication.

Conclusion

Although AENS is a rare clinical entity, it should not be dismissed by doctors, avoiding useless surgical management. This pathology remains nevertheless associated with a considerable mortality rate.

Can machine learning predict resecability of a peritoneal carcinomatosis?

BACKGROUND

Approximately 20% of initially eligible patients in a HIPEC procedure eventually underwent a simple surgical exploration. These procedures are called 'open & close' (O & C) representing up to 48% of surgery. The objective of this study was to predict the resecability of peritoneal carcinomatosis using a machine-learning model for decision-making support, for eligible patients of HIPEC.

METHODS

The study was conducted as an intention to treat based on three databases including a prospective, between January 2000 and December 2015. A propensity score allowed us to obtain two groups of comparable and matched patients. Subsequently, several algorithm models of classification were studied (simple classification, conditional tree, support vector machine, random forest) to determine the model having the best performance and accuracy.

RESULTS

Two groups of 155 patients were obtained: one group without resection and one group with resection. Nine criteria of non-resecability reflecting the organ involvement have been retained. They were coded according to their importance. Five classification algorithms were tested. The training data included 218 patients and 92 test data. The random forest model exhibited the best performance with an accuracy of close to 98%. Only two errors of predictions were observed.

DISCUSSION

The largest number of patients will allow us to improve the precision prediction. Gathering more data such as biologic, radiologic, and even laparoscopic features, should improve the knowledge of the disease and decrease the number of 'O & C' procedures.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center

INTRODUCTION

Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations.

METHOD

We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum.

RESULTS

Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France.

CONCLUSION

As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

Bone metastasis from endometrioid ovarian carcinoma: a case study and literature review

INTRODUCTION

Bone metastases from epithelial ovarian carcinoma are rare, usually discovered postmortem. The survival of these patients is poor. Furthermore, only two cases of endometrioid ovarian carcinoma with metastasis to the skeletal structures have been described in the literature.

CASE REPORT

We present the case of a 58-year-old woman with a lytic metastasis in the left iliac ramus from endometrioid ovarian carcinoma that occurred seven years after the initial diagnosis.

DISCUSSION

A review of the literature since 1966 on bone metastasis of ovarian cancer is also presented. In patients suffering from a neoplasm that rarely metastasises to bone, histological proof should be obtained to diagnose uncommon sites of disease relapse.

Characterization of Bacillus and Pseudomonas strains with suppressive traits isolated from tomato hydroponic-slow filtration unit

Bacillus and Pseudomonas spp. are known to be involved in plant pathogenic fungi elimination during the slow filtration process used in tomato soilless cultures. We isolated 6-8 strains of both Bacillus and Pseudomonas from the top, middle, and bottom sections of filters and identified them after 16S rDNA sequencing. Four Pseudomonas strains were identified as Pseudomonas fulva, 5 as Pseudomonas plecoglossicida, and 12 as Pseudomonas putida. The use of specific oligonucleotide polymerase chain reaction primer sets designed from gyrB gene sequences additionally permitted the identification of 17 Bacillus cereus and 3 Bacillus thuringiensis strains. Ribotyping with EcoRI pointed out an important polymorphism within Bacillus and Pseudomonas strains. Molecular characterization did not reveal a correlation between the location of isolates within the filter (top, middle, or bottom) and bacterial identification or riboclusters. Functional aspects assessed by community-level physiological profiling showed marked phenotypic differences between Pseudomonas communities isolated from the top and bottom filter layers; differences were lower between Bacillus communities of different layers and far less noticeable between mixed communities of Bacillus and Pseudomonas. These strains were tested for several suppressive activities. Conversely to most Bacillus, the majority of Pseudomonas strains were auxin producers and promoted the growth of tomato plantlet roots. On the other hand, only Bacillus strains displayed antagonistic activities by inhibiting the growth of pathogenic fungi frequently detected in soilless cultures. Siderophores were produced by nearly all bacteria, but at higher amounts by Pseudomonas than Bacillus strains. The biocontrol agent potentiality of certain strains to optimize the slow filtration process and to promote the suppressive potential of nutrient solution is discussed.

Soil microbial diversity as affected by the rhizosphere of the hyperaccumulator Thlaspi caerulescens under natural conditions

It is hypothesized that metal hyperaccumulator plants have specific rhizosphere conditions, potentially modifying the bioavailability of soil metals. This article aims to further the knowledge about the rhizosphere of the hyperaccumulator Thlaspi caerulescens, focusing on its microflora isolated from metalliferous soils collected in situ where the plants grow naturally. We characterized the cultivable microbial communities isolated from the rhizosphere of one population of this Ni hyperaccumulator species grown on a serpentine soil. The rhizosphere soil harbored a wide variety of microorganisms, predominantly bacteria, confirming the stimulatory effect of the T. caerulescens rhizosphere on microbial growth and proliferation. We tested the hypothesis that the rhizosphere of T. caerulescens influences (1) the metabolic diversity of the bacterial community and (2) the bacterial resistance to metals. The principal component analysis of the Biolog plate's data confirmed a structural effect of the rhizosphere of T. caerulescens on bacterial communities. The percentage of Ni-resistant bacteria was higher in the rhizosphere than in the bulk soil, suggesting a direct effect of the rhizosphere on Ni tolerance, reflecting a greater bacterial tolerance to Ni in the rhizosphere.

[Bening enterogenital fistulas arising from the digestive tract: three cases]

Fistulas between the female genital tract and the digestive tract occur after obstetrical, oncological, or post-operative complications. We report herein 3 rare cases of enterogenital fistulas: one colouterine fistula and one colotubal fistula in a patient with diverticulitis, and one ileovaginal fistula in a patient with Crohn's disease. Vaginal discharge was frequent and incited patients to consult a gynecologist. Better knowledge of enterogenital fistulas is necessary to enable earlier diagnosis and apply specific treatment. The incidence of colovaginal fistulas is increasing in diverticular disease because of increased prevalences of hysterectomies and diverticular disease.

Treatment of synchronous peritoneal carcinomatosis and liver metastases from colorectal cancer

AIM

To report our experience of peritoneal carcinomatosis (PC) discovered during abdominal exploration in patients with liver metastases (LM).

METHODS

Liver resection plus cytoreductive surgery were combined in 24 patients with LM and moderate PC from colorectal origin treated with a curative intent between January 1993 and November 2003.

RESULTS

The mean operative time was 357+/-112 min and median blood loss was 719 ml. One postoperative death occurred and postoperative morbidity was 58%. The mean hospital stay was 21.4+/-4.2 days. Three-year overall and disease-free survival rates were respectively 41.5% (confidence interval [CI]: 23-63) and 23.6% (CI: 11-45). Seven patients are disease-free with a mean follow-up of 27.8 months after their last surgery, 3 having a repeated hepatectomy. Three patients developed a peritoneal recurrence and 13 had recurrence in the liver. The only significant prognostic factor was a number of LMs of less than 3 (p < 0.01).

CONCLUSION

A combined treatment of LM plus PC is feasible and is beneficial in selected patients presenting three or fewer metastases.

Trans-metastasis hepatectomy: Results of a 21-case study

AIM

The aim of this study was to report the feasibility and efficiency of a new approach, called post-RF trans-metastasis hepatectomy (PRFTMH). This technique consists in using RF to first ablate an ill-located liver metastasis (LM) along the planned hepatectomy resection line, the only one possible for volumetric reasons, and then to perform the hepatectomy passing via this initially ablated LM.

MATERIAL AND METHODS

Twenty-one patients were treated with PRFTMH between January 2000 and May 2004. Thirteen of them had a primary colorectal tumour, four had a primary endocrine tumour and four had miscellaneous primaries. The mean number of LMs per patient was 13.8 (10.7 for primary colorectal tumours and 22.2 for primary endocrine tumours). Pre-operative hypertrophy of the future remaining liver was obtained by selective portal vein embolisation in 11 patients.

RESULTS

One patient died post-operatively (4.7%) and five developed complications (24%). No local recurrence has occurred at the site of PRFTMH after a median follow-up of 19.4 months (range: 47-7), demonstrating the efficacy of this technique. All patients, except the patient who died post-operatively, are currently alive, and the median survival rate has not yet been attained, after a median follow-up of 19.4 months.

CONCLUSION

PRFTMH combining RF ablation and trans-metastasis hepatectomy is a new and safe technique, allowing a curative approach to be proposed to some patients with unresectable bilateral LMs.

[Evaluation of the TVT technique according to age]

OBJECTIVE

To compare efficacy and long-term morbidity of the TVT between patients younger than 70 years and patients older than 70 years.

METHOD

Retrospective monocentric study from January 2000 to May 2001. A postal questionnaire was sent to patients to evaluate their satisfaction and their functional status after surgery.

RESULTS

The study included 154 patients, and 137 (89%) answered the questionnaire. Seventy-two were less than 70 years old (52.5%) and 65 were more than 70 years old (47.5%). The satisfaction rate in the total population was 88.3%. Amongst the patients younger than 70 years, 97.5% were cured or improved, versus 78.5% of the oldest patients (p=0.001). The study within age groups showed that the satisfaction rate between 70-74 years was higher (92.6%) than in the total population and lower after 75 years (66.7%). This difference is linked to the rates of de novo and persistent urge incontinence, which increase after 75 years.

CONCLUSION

The TVT seems to be a good treatment for urinary incontinence in women younger than 75 years. Patients should be warned that preoperative urge incontinence may persist after surgery.

Découverte fortuite d’une tumeur vésicale au cours d’une opération de TVT

With the common use of the tension-free vaginal tape (TVT) procedure, we will probably be facing more and more pathologies that will require a transurethral treatment. We report an intra-operative discovery of a bladder tumor during a cystoscopic TVT procedure. The tumor was easily treated by several transurethral resections without any consequences on the result of the TVT procedure.

Anatomy of the presacral venous plexus: implications for rectal surgery

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.

Influence of maize mucilage on the diversity and activity of the denitrifying community

In order to understand the effect of the maize rhizosphere on denitrification, the diversity and the activity of the denitrifying community were studied in soil amended with maize mucilage. Diversity of the denitrifying community was investigated by polymerase chain reaction (PCR) amplification of total community DNA extracted from soils using gene fragments, encoding the nitrate reductase (narG) and the nitrous oxide reductase (nosZ), as molecular markers. To assess the underlying diversity, PCR products were cloned and 10 gene libraries were obtained for each targeted gene. Libraries containing 738 and 713 narG and nosZ clones, respectively, were screened by restriction fragment analysis, and grouped based on their RFLP (restriction fragment length polymorphism) patterns. In all, 117 and 171 different clone families have been identified for narG and nosZ and representatives of RFLP families containing at least two clones were sequenced. Rarefaction curves of both genes did not reach a clear saturation, indicating that analysis of an increasing number of clones would have revealed further diversity. Recovered NarG sequences were related to NarG from Actinomycetales and from Proteobacteria but most of them are not related to NarG from known bacteria. In contrast, most of the NosZ sequences were related to NosZ from alpha, beta, and gammaProteobacteria. Denitrifying activity was monitored by incubating the control and amended soils anaerobically in presence of acetylene. The N2O production rates revealed denitrifying activity to be greater in amended soil than in control soil. Altogether, our results revealed that mucilage addition to the soil results in a strong impact on the activity of the denitrifying community and minor changes on its diversity.

Small bowel volvulus resulting from a congenital band treated laparoscopically

In recent years, laparoscopy has dramatically changed the approach to the patient with acute abdominal pain. We report the case of a patient with small bowel volvulus caused by a congenital band binding the greater omentum to the mesentery, which was promptly diagnosed and treated using laparoscopy. Early intervention averted irreversible ischemic lesions of the intestine and the need for bowel resection. With the routine use of laparoscopy in the setting of acute abdominal pain, rare affections can be easily diagnosed and effectively treated.

[Surgical treatment of anterior rectoceles in women. The transanal approach]

Anterior rectocele is a herniation of the anterior rectal wall into the vagina, which may be either isolated or associated with other pelvic floor disorders. Rectocele could result in outlet obstruction with dyschezia, manual extraction of faeces and/or false incontinence. Rectocele is diagnosed clinically, and can be confirmed by defecography. Other tests may demonstrate associated causes of constipation. Symptomatic rectoceles can be treated via a transrectal route, with two or three layers of plication of the rectal wall and excision of the redundant mucosal flap. The results of transrectal repair are good: short hospital stay, no mortality, morbidity less than 5%, good short- and mid-term results in approximately 80% of cases. Selection criteria in favour of the transrectal approach have not been clearly identified.

Prolonged allograft survival in cynomolgus monkeys treated with a monoclonal antibody to the human type I interferon receptor and low doses of cyclosporine

A monoclonal antibody (mAb) directed against the extracellular domain of the IFNAR1 chain of the human interferon-alpha (IFN-alpha) receptor (IFN-alphaR), which inhibits activation of the Jak-Stat signal transduction pathway, administered together with a subeffective dose of cyclosporine induced prolonged survival of skin allografts in major histocompatibility complex (MHC) divergent cynomolgus monkeys. Skin biopsies from animals treated with anti-IFN-alphaR mAb and cyclosporine revealed very low levels of MHC class I and class II antigen expression and the absence of histologic signs of rejection. Monkey antibodies (IgG) to the mouse antihuman IFN-alphaR mAb were not detected in the serum of any of the animals treated with the anti-IFN-alphaR mAb either alone or together with cyclosporine. The anti-IFN-alphaR mAb abrogated activation of the Jak-Stat signal transduction pathway in IFN-treated cells. These results, which show that selective and long-lasting immunosuppression can be obtained by short-term administration of an IFN-alpha antagonist together with a subeffective dose of cyclosporine, may have important implications for the therapy of human allograft rejection.

[La Peyronie disease. Historical, epidemiological, physiopathological data. Diagnostic and therapeutic approaches]

The origin of Peyronie's disease remains obscure although the first description dates back to 1743. The prevalence of the disease is 388.6 per 100,000 population. Little physiopathologic data is available. Repeated microtrauma to the tunica albuginea appears to favor the onset of inflammatory phenomena, in turn the source of fibrosis. Clinical examination remains the ideal method for diagnosis and follow-up: it can be completed by ultrasonography of the corpora cavernosa. Magnetic resonance imaging does not appear to provide any significant benefits. The inflammation and pain encountered in early stages of the disease can be managed medically. Numerous treatments have been tested (oral route or local injections); results are in the course of evaluation. In the absence of well-controlled clinical trials, there is no standard medical therapy. Radiotherapy today appears inadvisable. The sequels of Peyronie's disease can be treated surgically, especially in patients who can maintain and adequate erection but suffer from a deformation incompatible with sexual activity. Numerous technical artifices have been proposed; correction of deformations is generally satisfactory but perfections need to be made concerning the quality of erection. Patients with advanced disease and severe erectile insufficiency can be offered reconstructive surgery using penile implants: results of the various procedures are analyzed.

Gangrene of the perineum

Fournier's gangrene, an anaerobic necrotizing cellulitis of the infradiaphragmatic soft tissues, is a serious pathologic entity with an unpredictable course. From 1978 to 1991, a total of 24 men (mean age, 57 years; range 27 to 90) were treated for this entity at our institution. Diagnosis prompted immediate institution of multimodal treatment combining triple antibiotics, surgical dissection, debridement, and repeated surgical drainage. Fecal diversion (16 patients), hyperbaric oxygenation, and standard intensive care procedures were widely indicated and performed quasi-systematically. The mean interval between initial symptoms and diagnosis was 7.4 days. Lesions were limited to the perineum in 11 patients but extended to the abdomen, thighs, or loins in the remaining 13. The pathogens were identified in 19 patients, and hemoculture results were positive in 5. A coloproctologic origin was identified in 12 patients and a urogenital origin in 4. In 2 patients, perineal gangrene occurred postoperatively, and no etiology was determined for 6. Six patients died, and 18 patients recovered, without any sequelae. The prognosis is better when the patient is young (less than 60 years old), has clinically localized disease, without systemic involvement, and sterile hemocultures and is managed with colostomy. A thorough workup is mandatory to determine the etiology (locoregional lesion, malignancy, hemopathy, arteritis).

Role of the type I interferons in allograft rejection

Type I interferons are potent immuno-modulatory cytokines that enhance expression of the major histocompatibility complex (MHC) class I antigens, T-cell cytotoxicity, and natural killer (NK) cell activity, all of which are implicated in graft rejection. A monoclonal antibody (mAb) directed against the extracellular domain of the human interferon gamma (IFN-gamma) receptor (IFN-alpha R), which inhibits both the binding and biological activity of all the type I IFNs tested, exerted a dose-dependent inhibition of the mixed lymphocyte reaction and induced permanent survival of skin allografts in MHC-divergent Cynomologus monkeys treated with a subeffective dose of cyclosporin A. Marked differences were observed in the composition of T lymphocyte subpopulations in anti-IFN-alpha R mAb-treated animals relative to the various control groups. Skin biopsies from animals treated with anti-IFN-R Mab + cyclosporin A revealed very low levels of MHC class I and class II antigen expression and the absence of histological signs of rejection, whereas skin biopsies from control animals exhibited high levels of MHC antigen expression and the histological signs of acute rejection, including a pronounced lymphocytic infiltrate, edema, and necrosis. No monkey antibodies (IgG) to the mouse anti-human IFN-alpha R mAb were detected in the serum of any of the animals treated with the anti-IFN-alpha R mAb either alone or together with cyclosporin A. Treatment of lethally irradiated Cynomologus monkeys with the anti-IFN-alpha R mAb together with a subeffective dose of cyclosporin A was also found to markedly enhance the survival of animals grafted with allogeneic bone marrow cells from donors differing in both MHC class I and class II antigens. These results show that selective and lasting immunosuppression can be obtained by the short-term administration of an IFN-alpha antagonist together with a subeffective dose of cyclosporin A, and may have important implications for the therapy of human allograft rejection.

[Surgical treatment of gangrene of the perineum]

Acute perineal gangrene due to anaerobic Gram negative bacilli or streptococci rapidly leads to tissue necrosis and death in 50% of the cases despite progress in intensive care. Emergency treatment requires adapted antibiotics, hyperbaric oxygen therapy and repeated surgery. Factors of poor prognosis include age over 60 years, lomboabdominal or crural extension, septic shock, positive blood cultures and lack of fecal derivation. Surgery is performed under general anaesthesia since loco-regional anaesthesia is contraindicated during the septic phase. Repeated operations are needed to make large incisions, evacuate pus, search for foreign bodies and resect damaged tissue in order to expose all the infected areas to air and hyperbaric oxygen. A colostomy must be performed in order to avoid fistulization and contamination of the infected areas. An indwelling urine catheter is usually sufficient although a suprapubic catheter may be needed at the risk of further extension of the gangrene. Surgical treatment is associated with intensive care and hyperbaric oxygen therapy. Three effective antibiotics are recommended. Using this aggressive surgical protocol, we have been able to reduce mortality to 20% in patients under 60 years of age.

Comparison of 2 pulsed lasers for lithotripsy of ureteral calculi: report on 154 patients

Extracorporeal lithotripsy does not always provide satisfactory results for the treatment of ureteral stones. Such cases appear to be excellent indications for endocorporeal lithotripsy based on an association of ureteroscopy and laser. To compare the performances of 2 pulsed lasers, the pulsed dye laser (Candela) and solid Q switched laser (HMT), for the treatment of these calculi 161 ureteral stones were treated successively from November 1990 to March 1992 by a combination of ureteroscopy and laser. Endocorporeal lithotripsy was performed in 102 cases with the Candela laser, in 47 with the HMT laser and in 7 with both lasers. With a stable success rate greater than 90%, both lasers demonstrated equivalent performances regardless of the location of the stone along the ureter. However, while stone fragmentation was more rapid with the Candela laser, the HMT laser appeared to be more effective for dark stones (monohydrate calcium oxidate).

[Endoscopic surgery during pregnancy. A case report of cholecystectomy]

Pregnancy used to be considered a contraindication for endoscopic surgery of the digestive tract. We report a case of cholecystectomy carried out laparoscopically for complicated gall stones in a woman who was 14 weeks pregnant. There was no post-operative maternal or fetal morbidity. The mother carried on the pregnancy to term normally and gave birth to a normal infant. The same results have been reported in the literature for three other cases of cholecystectomy and six of appendicectomy. The sole technical precautions that had to be undertaken were in introducing and placing the trocars, taking into account the size of the uterus. There has been no scientific proof that CO2 is toxic for the fetus. Clinical practice shows that endoscopic surgery is possible without any obstetrical risk including thrombo-emboli, nor specific sepsis occurring in any of the three trimesters of pregnancy. The advantages of the endoscopic approach are that there is less post-operative pain and therefore less need to take analgesics. There are no complications because of an abdominal wound and the patient can both feed and walk about immediately after the operation with a reduction of the time spent in hospital. There is probably less risk of aborting when compared with classical laparotomy. The endoscopic route can be chosen when surgery is needed in the digestive tract during pregnancy.

Extracorporeal lithotripsy of ureteric calculi using the Dornier HM-3 lithotriptor

Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporeal shock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n = 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required pre-ESWL drainage of the urine. X-ray localisation required intravenous urography during lithotripsy in 52 cases (30%). On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.

[Perineal gangrene. Analysis of 24 cases]

Fournier's syndrome, characterised by anaerobic necrotising cellulitis of the soft tissues situated below the diaphragm, is a serous disease with an unpredictable course. From 1978 to 1991, we treated 24 men with a mean age of 57 years (27 to 90 years). Following the diagnosis of this disease, rigorous treatment was instituted immediately, consisting of a triple antibiotic combination, repeated surgical exposure, debridement and drainage with a frequent, almost systematic indication for faecal diversion (n = 16), hyperbaric oxygen therapy and classical intensive care measures. The mean interval between the first clinical signs and the diagnosis was 7.4 days. The lesions were limited to the perineum in 11 cases and extended to the abdomen, thighs and/or loins in 13 cases. The microorganisms responsible for the infection were identified in 19 cases and blood cultures were positive in 5 cases. This infection was of coloproctological origin in 12 cases, urogenital origin in 4 cases and postoperative in 2 cases, while no aetiology could be identified in 6 patients. There were 6 deaths and 18 cures without sequelae. 1. The prognosis of this disease is better in younger subjects (under the age of 60 years) with a localised clinical form, with no deterioration in the general status, sterile blood cultures and treated by a diversion colostomy. 2. A detailed aetiological work-up must be performed, looking for local or regional infection, cancer, haematological malignancy or arterial disease.

[Endoscopic internal urethrotomy. Retrospective studies of 132 cases]

The authors report a series of 132 patients with urethral stricture all treated by the same surgical technique between 1979 and 1984: direct vision internal urethrotomy. 62% of good results were obtained after a single operation with a follow-up ranging between 18 months and 5 years. There was no mortality and the morbidity was considered to be 5%. The authors indicate that the results were more favourable when the operation was performed in a solitary, short (less than 2 cm) non-infected stricture of the proximal urethra. The duration of postoperative catheterization was 10 days; catheterization for a longer period did not provide any significant advantage. The poor results (38%) were reported in cases of extensive strictures situated in the distal urethra or in patients with a history of urethral surgery. These cases were treated by repeated internal urethrotomy; 32% were cured after a second urethrotomy, while the others required maintenance sessions of urethral dilatation or even a urethroplasty procedure.

[Prostatic specific antigen (PSA). Interpretation of results as a function of the assay method]

The authors compare the two PSA assay methods most widely used in France. The first method (RIA Baxter) uses an isotope marker (Iodine 125), the other (EIA Biotrol) uses an enzymatic marker (alkaline phosphatase). PSA was assayed by means of these two techniques in 2 groups of patients: one group of 49 men considered to be free of any prostatic disease, recruited from blood donors; another group of 87 male patients in whom a PSA assay was performed prospectively at the first urology outpatients visit. The two PSA assay techniques gave different results, but the values obtained by these two methods were not discordant. It is therefore possible to define a coefficient of proportionality of 1.47 regardless of the PSA concentration or the urological disease considered (EIA Biotrol x 1.47 = RIA Baxter).