[Complications of Meckel's diverticulum. Report of 42 cases]

AIM

Our aim was to report the main complications of the Meckel's diverticulum.

METHODS

Our retrospective study concerns 42 cases of complicated Meckel's diverticulum, collected during one period of 18 active years from January 1988 to December 2005. The yearly impact is 2,33 cases/year. We excluded the asymptomatic Meckel's diverticulum, of fortuitous discovery during intervention.

RESULTS

The middle age of our patients is 25 years, with extremes going from 2 to 74 years. The sex-ratio is 3,2. The diagnosis before intervention of the complicated Meckel's diverticulum was not evoked in any time. The clinical features were an acute intestinal closure in 22 cases, an appendicitis in 13 cases, an appendicular peritonitis in 6 cases, and an acute intestinal intussusceptions in one case. In any case, it is the surgical exploration that permitted to confirm the diagnosis of a complicated Meckel's diverticulum. The approach way was median in 27 cases, MacBurney in 13 cases, and laparoscopic in 2 cases. The surgical exploration showed peritonitis in 16 cases, one diverticulitis in 23 cases, an acute intestinal intussusception in one case, a tumour in one case, and haemorrhagic diverticulum's ulcer in one case. The treatment consisted in a segmental resection of ileum with end to end anastomosis (37 cases) and a cuneiform resection (5 cases). The histological exam showed heterotopy of gastric tissue in 12 cases, of pancreatic tissue in two cases, and a Burkitt's lymphoma on a diverticulum in one case. We noted a precocious death following a septic shock.

CONCLUSION

The Meckel's diverticulum constitutes a most common benign malformation of the digestive tube. The prognosis is related extensively to the gravity of its complications that can benefit, not only of the contribution of the laparoscopic diagnosis, but also therapeutic.

[Pyogenic abscess of the breast: clinical and therapeutic aspects]

OBJECTIVE

The goal of this retrospective work was to study the clinical aspects and the principles of management of the abscess of the breast in order to determine a convenient and recent therapeutic attitude.

PATIENTS AND METHODS

Our retrospective survey concerns 114 cases of breast abscess collected in a surgery department over a period of 14 years, from 1990 to 2003. All patients have been operated and the diagnosis confirmed through the operation. The puerperal abscesses have been noted in 31 cases.

RESULTS

One hundred and four women and ten men were concerned, with a sex-ratio of 0.1. The medium age was 33 years old for the women and 42 years for the men. The diagnosis was based on the clinical criteria, confirmed by the ultrasonography in 11 cases out of 16 and by the mammary puncture in 15 cases out of 22. Two non-puerperal abscesses have revealed an infiltrating canal carcinoma. The Staphylococcus aureus was the germ the most frequently met, concerning 8 cases out of 16. The surgical biopsies carried out in 52 cases revealed a fibrocystic mastopathy in six cases, a canalar ectasia in two cases and an infiltrating canalar carcinoma in two cases. The surgical treatment, performed in any case, was associated to an anti-staphylococcus antibiotherapy. The recurrence of the abscess has been observed in four cases.

DISCUSSION AND CONCLUSION

The frequency of pyogenic abscess of the breast, particularly the puerperal abscesses, has considerably decreased. The non-puerperal abscesses often pose a differential diagnosis problem with the very aggressive inflammatory cancers. The percutaneous ultrasonography guided drainage must be proposed in first intention to treat the abscesses of the breast. However, surgical treatment is still valid with an abscess either relapsing or chronic, or else the failure of the non-operative processes.

Étude qualitative et quantitative des peuplements phyto- et zooplanctoniques dans les bassins de la saline de Sfax, Tunisie

Le plancton végétal et animal a été analysé dans différents bassins de la saline de Sfax (Tunisie), entre le mois d'août 1999 et le mois de mai 2000. Des communautés diversifiées de phyto- et de zooplancton ont été observées. Quelle que soit la saison considérée, la structure des peuplements phytoplanctoniques se caractérise par la dominance de diatomées dans les bassins primaires de la saline (salinité < 200 ‰), suivie d'une dominance de dinoflagellés dans les bassins intermédiaires (salinité 200-300 ‰), et d'un développement quasi-monospécifique de la chlorophycée Dunaliella salina dans les bassins terminaux où cristallise et se dépose la production saline (salinité > 300 ‰). En ce qui concerne le zooplancton (> 20 µm), les crustacés (copépodes) et les rotifères dominent en été et en automne dans les bassins primaires, suivis des protozoaires ciliés en hiver dans les bassins intermédiaires, et du phyllopode Artemia qui représente l'essentiel du zooplancton dans les bassins terminaux et atteint une abondance maximale au printemps. Les résultats de cette étude permettent de penser que la salinité, dont les effets sont accentués dans les zones arides, représente, probablement en conjonction avec les ressources, un paramètre déterminant et sélectif pour la diversité et la dynamique des peuplements planctoniques dans la saline de Sfax et les marais salants en général.

Predictive value of microalbuminuria in medical ICU patients: results of a pilot study

STUDY OBJECTIVES

To evaluate the predictive value of microalbuminuria in the development of acute respiratory failure (ARF) and multiple organ failure (MOF) in ICU patients.

DESIGN

Prospective, observational study.

SETTING

A 31-bed, mixed medicosurgical ICU in a university hospital.

PATIENTS

All adult medical patients admitted to the ICU over a 2-month period, except those receiving nephrotoxic drugs, or those with urologic trauma resulting in frank hematuria or urinary infection, or with existing chronic renal disease (serum creatinine level > or 2.0 mg/dL).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Urinary samples for microalbumin measurement were collected at hospital admission and at 8, 24, 48, 72, 96, and 120 h after hospital admission. The severity of illness was assessed by the APACHE (acute physiology and chronic health evaluation) II score calculated on the first ICU day, and the degree of organ dysfunction was assessed using the sequential organ failure assessment (SOFA) score. Acute respiratory failure (ARF) was defined as a SOFA respiratory score > or = 3. Patients were separated into two groups according to the trend in microalbuminuria levels over the first 48 h: patients in group 1 had increasing microalbuminuria levels, and patients in group 2 had decreasing microalbuminuria levels. Group 1 included 14 patients in whom microalbuminuria levels increased from 5.2 +/- 2.0 to 19.0 +/- 3.0 mg/dL. Group 2 included 26 patients in whom microalbuminuria levels decreased from 16.4 +/- 4.0 to 7.8 +/- 3.0 mg/dL. The hospital mortality rate was 43% in group 1 and 15% in group 2 (p < 0.05). The APACHE II score and the SOFA score were higher in group 1 than in group 2. The negative predictive value of increasing microalbuminuria was 100% for the development of ARF and 96% for MOF; the positive predictive value of increasing microalbuminuria was 57% for the development of ARF and 50% for MOF.

CONCLUSIONS

Accurate identification of patients destined for ARF and MOF development may enable therapeutic strategies to be applied to limit the disease process. Trend analysis of urinary albumin excretion over the first 48 h of an ICU admission may provide a useful means of identifying such patients. Additional studies need to be performed in larger, mixed patient populations to confirm these findings.

Normovolemic hemodilution improves oxygen extraction capabilities in endotoxic shock

We studied the effects of normovolemic hemodilution on tissue oxygen extraction capabilities in a canine model of endotoxic shock. Eighteen anesthetized and mechanically ventilated dogs underwent normovolemic hemodilution with 6% hydroxyethyl starch solution to reach hematocrit (Hct) levels around 40, 30, or 20% before the administration of 2 mg/kg of Escherichia coli endotoxin. Cardiac tamponade was then induced by repeated injections of normal saline into the pericardial sac to reduce cardiac output and study whole body oxygen extraction capabilities. Whole body critical oxygen delivery was lower in the Hct 20% and 30% groups (8.4 +/- 0.4 and 10.4 +/- 0.7 ml. kg(-1). min(-1), respectively) than in the Hct 40% group (12.8 +/- 0.8 ml. kg(-1). min(-1)) (both P < 0.005). The whole body critical oxygen extraction ratio was higher in the Hct 30% and 20% groups (49.1 +/- 8.2 and 55.2 +/- 4.6%, respectively) than in the Hct 40% group (37.1 +/- 4.4 %) (both P < 0.05). Liver critical oxygen extraction ratio was also higher in the Hct 30% and 20% groups than in the Hct 40% group. The arterial lactate concentrations and the gradient between ileum mucosal PCO(2) and arterial PCO(2) were lower in the Hct 20% and 30% groups than in the Hct 40% group. We conclude that, during an acute reduction in blood flow during endotoxic shock in dogs, normovolemic hemodilution is associated with improved tissue perfusion and increased oxygen extraction capabilities.

Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure

OBJECTIVE

The aim of the study was to determine the prognosis in patients who needed norepinephrine treatment in our institution in relation to the degree of organ failure and the evolution of the disease process.

DESIGN

Retrospective case note analysis of outcome of those patients who needed norepinephrine according to our institutional regimen.

PATIENTS

A total of 100 consecutive patients admitted to our 31-bed medical-surgical intensive care unit (ICU) who were treated with norepinephrine for severe hypotension and evidence of end-organ hypoperfusion unresponsive to both fluid resuscitation and dopamine treatment at 20 microg/kg/min.

MEASUREMENTS

The degree of organ dysfunction at the time of starting norepinephrine treatment was assessed by the sequential organ failure assessment (SOFA) score. The time before starting norepinephrine treatment was defined as the time elapsed between ICU admission and that of starting norepinephrine administration. The patients were defined as survivors or nonsurvivors according to their ICU outcome.

RESULTS

There were relationships between mortality and the degree of organ dysfunction and mortality and the duration of ICU stay before starting norepinephrine treatment. The mortality rate was 100% in the 30 patients with a total SOFA score of >12 and a delay before starting norepinephrine treatment of >1 day. The mortality rate of the other patients was 63%. The lowest mortality was seen in patients with lower SOFA scores and early norepinephrine administration after admission.

CONCLUSIONS

Both the time of starting norepinephrine treatment after admission to the ICU and the degree of organ dysfunction have an important bearing on subsequent outcome. Although norepinephrine may be a lifesaving catecholamine in some cases, its administration to patients who have already developed multiple organ failure during their stay in the ICU is associated with a poor outcome.