La dilatation pneumatique est un traitement efficace de l'achalasie. Le risque majeur de cette technique est représenté par la survenue de perforation. Notre étude a porté sur 483 patients recrutés sur une période de 15 ans (1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005). La dilatation a été réalisée avec un dilatateur de Witzel (40 mm). Selon la pression d'insufflation du ballonnet utilisé lors de la séance initiale, deux groupes de patients ont été individualisés : groupe 1 (n = 118) : ces patients ont bénéficié d'une seule séance de dilatation à l'aide d'une pression supérieure à 250 mmHg ; groupe 2 (n = 365) : ces patients ont subi plusieurs séances de dilatation graduelle avec une pression initiale de 100-150 mmHg. La pression de 300 mmHg n'a été atteinte qu'à la troisième séance. Au total, 1 159 dilatations pneumatiques ont été réa-lisées. Cinq perforations ont été enregistrées dans le groupe 1 et aucune dans le groupe 2. Le traitement conservateur a été efficace chez quatre patients. Un seul patient a été opéré avec succès, après échec du traitement médical. Il n'y a eu aucun décès. La pression d'insufflation du ballonnet, lors de la séance initiale, et l'âge étaient les seuls facteurs de risque significativement associés à la perforation (p < 0,01). Mots clés Achalasie · Dilatation pneumatique · Perforation · Dilatateur de WitzelAbstract Pneumatic dilatation is an efficient treatment for achalasia. The most serious complication of this procedure is esophageal perforation. Over a period of 15 years (1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005), we treated 483 patients. The dilatations were performed ambulatory using a Witzel dilator (diameter: 4 cm). The first 118 patients (group 1) underwent dilatation with an initial inflation balloon pressure of 300 mmHg. In-group 2 (N = 365), we used a gradual dilatation with an initial pressure of 150 mmHg during the first session. In case of relapse, dilatation was repeated with an incremental pressure (200 and 300 mmHg) during the second and the third session. During the 1159 sessions of dilatations, five perforations occurred. All these perforations occurred in group 1, whereas no perforation took place in group 2. The medical conservative treatment was efficient for four patients. One patient was operated successfully after the failure of the medical treatment. There was no death. Inflation pressure, during the first session, and patient age were the only factors of risks, significantly associated to the perforation (P < 0.01).

Tunnelled catheter endocarditis is a frequent and sever situation among hemodialysis patients. The management should be fast and multidisciplinary.Case report: We report the case of a 36 year old woman with a history of systemic erythematous lupus, discovered at the age of twenty. She profited from a tunneled catheter because of exhaustion of her venous capital. One year later, the patient had an endocarditis of the tricuspid valve. An echocardiogram demonstrated mobile and friable 8 mm vegetation in the tricuspid valve. Blood cultures were positive for pseudomonas and klebsiella. The catheter was removed at the fifth day of the infection. The patient received antibiotic treatment which was changed on several occasions in front of multiresistant strains. Ten days later, the blood culture showed Candida albicans. The echocardiogram demonstrated an increase of the size of the vegetation to 15 mm. A chest CT carried out in front of a respiratory distress showed pulmonary septic emboli. Tricuspid valve replacement was performed. Culture of native valve was positive for multiresistant candida famata. The patient developed a pulmonary embolism causing her death.Discussion: Endocarditis with permanent catheter is a severe situation with high mortality and poor prognosis among hemodialysis patients. Immune suppression due to a renal failure and auto immune disease can support the development of multiresistant strains difficult to treat. Conclusion:Endocarditis on tunneled catheter is a serious infection. Nephrologists, cardiologists and infectiologists must collaborate in order to provide adequate therapy.

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