P-133 PROSPECTIVE INTERVENTIONAL STUDY OF THE ANALGESIC EFFICACY OF A CYCLOMESH™ PARIETAL REINFORCEMENT IMPLANT SOAKED IN ROPIVACAINE HYDROCHLORIDE 10MG/ML IN THE TREATMENT FOR UNCOMPLICATED INGUINAL HERNIA

Background

20–30% of patients operated for inguinal hernia will present early postoperative pain (EPP) which is, after the organizational causes, the first cause of conversion from ambulatory to traditional hospitalization. The objective of this study was to evaluate the interest of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine in the management of EPP.

Materials and Methods

This is a randomized, phase III, comparative superiority, double-blind, international multicentre study. From October 2019 to February 2022, 290 patients underwent surgery for inguinal hernia with placement of a ropivacaine or saline soaked parietal prosthesis. The primary endpoint was the H6 coughing pain assessment (EVA).

Results

The intention to treat population (ITTp) was composed of 150 patients in the ropivacaine group and 140 in the placebo group, for the per-protocol population (PPp) it was 125 and 115. The prosthesis type had no significant effect on H6 coughing pain, either for the ITTp (3.3 vs 3.2, p=0.12) or the PPp (3.3 vs 3.7, p=0.15). The ropivaciane soaked prosthesis resulted in a decrease in the overall pain at H2 (2.3 vs 3.2, p<0.0001), H4 (2.3 vs 3.1, p<0.0001) and H6 (2.3 vs 2.7, p=0.0039). Regarding painkillers consumption, postoperative complications and number of ambulatory conversions, there was no difference between the two groups.

Conclusion

The placement of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine did not reduce the H6 coughing pain but allowed a decrease in the overall pain over the first 6 hours after surgery and could simplify the management of patients.

[Risks acceptability related to obstetrical epidural analgesia]

OBJECTIVES

Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists.

STUDY DESIGN

Prospective, transversal, single center study.

MATERIALS AND METHODS

Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability.

RESULTS

One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations.

CONCLUSION

In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

[Medium and long-term results of anatomical correction of transposition of the great arteries in Marseille]

The object of this study was to evaluate the results of anatomical correction of transposition of the great arteries (TGA) in an inter-regional centre. The characteristics of 220 patients operated between 1985 and 2002 were analysed. Prenatal diagnosis of TGA was made in 38 patients (17%) including 36 of the 109 patients operated since 1995 (33%) and leading to earlier atrial septostomy in this situation (p= 0.046). Since 1995, the global early mortality of 12.3% has been significantly reduced to 5.5% (N= 6) including 4.4% (3/68 cases) of simple TGA (p= 0.002). In multivariate analysis, the only independent risk factor for early mortality was the occurrence of a major per-operative complication (p< 0.0001). The average follow-up was 4.8 +/- 4.5 years with an 86% survival at 5, 10 and 15 years and 97% survival at 5 years for patients operated after 1995. There were 22 reoperations including 14 on the right ventricular outflow tract. The non-reoperation rate at 10 years was 80% for simple TGA versus 70% in complex TGA (p= 0.0001). Survivors are asymptomatic with a normal ECG and normal LV function on echocardiography. Five patients have significant pulmonary stenosis and 4 have mild aortic regurgitation. The exercise stress tests performed between the ages of 7 and 10 were all normal. The authors conclude that that modern and reproducible management of TGA is possible in an inter-regional centre with results comparable to those of surgical centres of reference.

Pressure-induced lock-in in an aperiodic nanoporous crystal

This Letter reports on the first observation of a commensurate lock-in inside an aperiodic composite. This result is obtained by neutron diffraction, under hydrostatic pressure, in the prototype self-assembled crystal of hexadecane urea. A selective compressibility of the sublattices is a required condition together with the existence of a lock-in energy term in these supramolecular materials. This measurement, under one-dimensional confinement, opens the way for the use of continuously controlled forces to manipulate molecular properties or functions.

[Extracorporeal assistance in paediatric intensive care]

OBJECTIVE

For 3 years we have used extracorporeal assistance in intensive care frequently. This study evaluates our results.

METHOD

We studied the patient records for those treated between January 2002 and January 2005. The method used, indications and morbidity/mortality were analysed.

RESULTS

We performed 24 circulatory assistance procedures in 20 patients (median age: 5 months), arterio-venous with oxygenation (n=18), veino-venous with oxygenation (n=3) or biventricular (n=3). The indications were post cardiotomy cardio-respiratory failure (Group I; n=20, 16 patients), pure respiratory failure (Group II: n=1), or pre-transplant/recovery (Group III: n=3). Five procedures (4 from group I and 1 from group III) required cardiac massage (no fatalities). The average duration of assistance was 7 +/- 6 days (2 to 20 days). Treatment was successfully discontinued in sixteen patients 80%), one of them thanks to heart transplant. Four (20%) died during assistance. The morbidity essentially consisted of further surgery for haemostasis, multiple transfusions, and infections. Three patients (15%) died later (1 at 17 months after discontinuation) from complications unrelated to the assistance. No neurological sequelae were noted in the survivors.

CONCLUSION

These results confirm the usefulness of circulatory assistance when medical treatment has failed, particularly in the post-operative period of paediatric cardiac surgery or while awaiting transplantation.

[Medico-surgical treatment of occlusion of the left pulmonary artery by extension of ductal tissue (pulmonary coarctation)]

The authors report the results of surgical treatment completed by interventional catheterisation of occlusion of the left pulmonary artery by extension of ductal tissue. Since 2001, 7 patients operated for occlusive coarctation of the left pulmonary artery at an average age of 11 months (3 to 37 months) had a restenosis. The cardiac malformation was pulmonary atresia with ventricular septal defect (N=4), tetralofy of Fallot (N=2) and critical pulmonary valvular stenosis (N=1). Pulmonary artery surgery consisted of resection anastomosis in 4 cases and a plasty in 3 cases. A primary angioplasty was performed 5 to 170 months (median 12 months) later, at an average age and weight of 3.4 years (0.7 to 16.9 years) and 14 Kg (8 to 52 Kg) with implantation of 3 stents. The median diameter increased from 5 mm (1 to 9 mm) to 10 mm (6 to 16 mm). Tc-99m scintigraphy showed an increase in mean left pulmonary perfusion from 9% (6 to 28%) to 28% (18 to 42%). Secondarily, 3 repeat angioplasties were necessary with a total of 6 stents implanted in 7 patients. After an average of 2.9 years (0.8 to 6.3 years) follow-up, the patients were asymptomatic with normal right ventricular pressures and a mean left pulmonary perfusion of 33% (24 to 45%). The authors conclude that the treatment of left pulmonary occlusion by coarctation requires a medico-surgical approach in which angioplasty and stenting complete successfully the surgical revascularisation.

[Results of surgery for coarctation of the aorta in children under one year of age]

The aim of this study was to determine the surgical results of repair of coarcta tion of the aorta in children under 1 year of age and to assess the risk of recoarctation. Between 1984 and 2004, 206 children under 1 were operated for coarctation of the aorta. Three groups of patients were identified: Group I (isolated coarctation, N=99), Group II (associated ventricular septal defect, N=63), and Group III (complex congenital heart disease, N=44). The transverse aorta was hypoplastic in 51% of cases. Uni- and multivariate analysis of the risk factors for mortality and recoarctation was performed. An extended resection anastomosis was performed in 206 patients. Reconstruction of the transverse aorta was performed in 32 cases. The hospital mortality was 3.9% (N=8). The presence of a complex intracardiac anomaly was a risk factor for mortality on multivariate analysis (p=0.023). In univariate analysis, a two-step management of patients in Group III was a significant risk factor for mortality (p=0.036). Thirty patients (14.6%) had recoarctation (gradient > 20 mmHg, follow-up 40 +/- 44 months). On multivariate analysis the severity of the immediate postoperative gradient was the only risk factor for recoarctation. The authors conclude that surgery for coarctation of the aorta is associated with excellent results in children under 1 year of age. The prognosis is related to the presence of associated severe cardiac malformations. Survival seems to be better if treatment is carried out in a single stage in this group. The risk of recoarctation is related to the immediate postoperative transisthmic gradient which justifies extensive repair of hypoplastic aortic arches.

[Efficacy of angioplasty of native coarctations of the aorta of the big infant and of the adult with systematic endoprosthesis implantation]

The angioplasty of native coarcatations of the aorta remains a controversial treatment due to recurrences and the potential risk of aneurysm or of descending aorta dissection during catheterization. The interest of a systematic implantation of an endoprothesis is poorly documented. We report our experience in a small series of 3 patients aged from 7, 28 to 52 years at the moment of the angioplasty of their native aortic coarctation. In all the three cases it corresponded to a "membranous" type, localized a the level of the isthmus without hypoplasia of the aortic arch. All presented a refractory hypertension. One patient presented an intermittent claudication related to a low perfusion of lower limbs. The angioplasty was performed with BIB balloon, associated at the same time with the implantation of a Palmaz P308 stent in two cases and Genesis PG2910P in the last patient. The efficacy was immediate in all the 3 cases with stopping antihypertensive drugs at the very day of the procedure. The immediate results were complicated by a bilateral hematoma of the scarpa in a context of excessive anticoagulation in one patient requiring blood tranfusion. After a follow-up of one, 12 and 21 months, all the 3 patients are asymptomatic without any significant residual hypertension. The control scan of the infant confirmed the absence of re-coarctation. In conclusion, the angioplasty followed by systematic implantation of an endoprosthesis is a safe and effective technique for treating simple forms of native coarctations of the aortic isthmus. It can be proposed as a first line treatment for big infants and adults affected by localized types.

[Dextrocardia with situ solitus, ventricular loop, double outlet hypoplastic right ventricle and L-malposition of the great arteries. Description and surgical treatment of a rare and complex cardiopathy]

Despite the cardiac surgery improvements allowing the correction of the majority of congenital heart diseases with ventricle-great vessels discontinuity, some abnormalities increase the risk of bi-ventricular reparation. We herein report the case of a patient presenting a rare form of double outlet right ventricle with a ventricular loop, with moderate right ventricle hypoplasia. L-malposition of great vessels and pulmonary artery stenosis, and for whom we opted for a palliative surgical treatment including a systemic-pulmonary anastomosis followed by a upper right bi-directional cavo-pulmonary derivation. The last surgery was followed by recurrent right pleural effusions disappearing after the embolization of the systemic-pulmonary anastomosis by catheterism as it probably obstructed the draining of the cavo-pulmonary anastomosis. The relevance of this clinical case reported is, firstly the description of this ventricle loop resulted from a marked ventricular malposition which is a rare heart disease, and secondly the discussion about the surgical treatment, especially about the choice between palliative and curative surgery. Only comparative studies on long term morbidity and mortality between the bi-ventricular reparation and mono-ventricular palliation will allow the selection of the most appropriate surgical treatment.

[Rehabilitation of hypoplastic pulmonary arteries and anatomic correction of pulmonary atresia with interventricular communication]

Conventional treatment of pulmonary atresia with ventricular septal defect (VSD), hypoplastic pulmonary arteries (PA) and major aorto-pulmonary collaterals (MAPCAs) is controversial: from symptomatic and palliative treatment for some authors to surgery with unifocalisation of collaterals for others. These treatments never use native pulmonary arteries as only source of pulmonary flow, but create "neo-pulmonary arteries". Nine cases of pulmonary atresia with VSD, hypoplastic PA and MAPCAs were treated by rehabilitation of native PA through a staged approach: 1) surgical neonatal connection between right ventricule (RV) and hypoplastic PA, 2) evaluation and interventionnal catheterism with angioplasty of PA stenosis and closure of collaterals, 3) complete surgical correction with reconstruction of right outflow track and PA and closure of VSD. After first surgical stage of RV-PA connection at the mean age of 4.8 months (+/- 5.6 months), 8 patients were alive and underwent 22 cardiac catheterisms (mean of 2.7 per patient), with angioplasty of PA, and occlusion of MAPCAs in 6 and 2 patients respectively. Seven patients underwent complete anatomical correction at the mean age of 28.8 months (+/- 17.7 months) with one late death. The 6 remaining patients had encouraging hemodynamic status (RV pressure/LV pressure ratio at 0.6 +/- 0.26; mean left and right distal pulmonary pressure at 15.2 mmHg (+/- 9.1 mmHg)), and good functionnal status (3 in NYHA functionnal class 1, and 3 in class 2), for a mean follow-up of 79.5 months (+/- 41.4 months). One patient had reoperation on right outflow track stenosis, 6 years after correction. This small series enhances the feasibility of a staged approach with rehabilitation of small PA, allowing complete surgical correction with the native PA with good hemodynamic and functional results in pulmonary atresia, with VSD, hypoplastic PA and MAPCAs.

[Management of Hirschsprung's disease during the neonatal period]

Hirschsprung's disease is one of the common est causes of neonatal intestinal obstruction. Despite progress in the identification of genetic mutations, the pathogenesis of Hirschsprug's disease is not completely resolved. The management consists of septic complications of treatment, and a variable "pull-through" procedure, immediately or at a later date. Long-term follow-up is an important component of patient care.

Primary Epstein-Barr virus-related non-Hodgkin's lymphoma of the pleural cavity following long-standing tuberculous empyema

Primary non-Hodgkin's lymphomas of the pleural cavity have been described mostly in Japan. We report a case of high-grade non-Hodgkin's lymphoma (immunoblastic type) of the pleural cavity occurring in a nonimmunocompromised patient 55 years after an artificial pneumothorax was performed for the treatment of pulmonary tuberculosis. Immunohistochemical study revealed a B phenotype (CD20), and an in situ hybridization detected small nuclear RNAs encoded by Epstein-Barr virus in most lymphomatous cells. A link between primary pleural lymphoma and the local long-standing chronic inflammation, inducing a clonal transformation of Epstein-Barr virus-infected immortalized B lymphocytes, is suspected.

Increased axonal regrowth of lesioned rat sciatic nerve by veratrylguanidine methane sulfonate

Neurotrophic factors appear as essential factors for normal development and repair of the nervous tissue. Veratrylguanidine methane sulfonate, has been shown to induce important neurite outgrowth of cultured dorsal root ganglia isolated from newborn rats. Its action was similar to that of NGF and was found to be additive to that of NGF. In order to see if this compound was able to stimulate axonal growth in adult animals, we examined the effect of this substance on the regeneration of the lesioned sciatic nerve. Using histochemical, immunohistochemical and ultrastructural studies, it is shown that a single intraperitoneal injection of veratrylguanidine methane sulfonate significantly increases the axonal growth during repair of the adult rat sciatic nerve. The efficiency of this substance is explained by its good targeting and long life time in the sciatic nerve.

Predominant labeling of beta- over alpha-tubulin from porcine brain by a photoactivatable taxoid derivative

An [(azidophenyl)ureido]taxoid (TaxAPU) was synthesized in a radiolabeled form by coupling an aminotaxoid to tritiated N-methyl-N-(chloroformyl)-p-azidoaniline. TaxAPU was used to photolabel polymerized porcine brain tubulin. This newly synthesized probe possesses taxoid properties as demonstrated by its effect, in the absence of light, on the kinetics of tubulin assembly and microtubule disassembly and on the critical concentration of tubulin. TaxAPU apparently competes with Taxol for the same binding site with an equilibrium dissociation constant of 6 microM. The photoactivation of 266 nm of the radiolabeled probe in the presence of microtubules led to a covalent incorporation of radioactivity. Analysis of the radiolabeled polypeptides by electrophoresis under denaturing conditions revealed a specific incorporation of tritium in both the alpha-and beta-subunits of tubulin. A dependence on probe concentration was observed for the irreversible radioactivity incorporated into both subunits and maintained essentially a ratio of 2.5:1 between beta/alpha. Therefore, TaxAPU constitutes a true photoaffinity probe for the taxoid binding site on microtubules. Our results complement those reported by Rao et al. (1992) of photo-cross-linking experiments with unmodified Taxol.

Synthesis and contractile activity of new acetylenic and allenic analogues of leukotrienes C4 and D4: importance of the Z-11,12 double bond

The (5S,6R) isomers of new acetylenic and allenic analogues of leukotrienes C4 and D4 were synthesized for comparative pharmacological studies on intestinal smooth muscle preparations. These new analogues are poor spasmogenic agonists, the replacement of the 11,12-ene with a relatively more stable triple bond causing an important reduction in intrinsic activity. They did not show any significant antagonist activity. Unexpectedly, these results prove that the 11,12 portion in the triene structure of the lipophilic chain is critical for an agonist activity.