Laparoscopic splenectomy: comparison between anterior and lateral approaches.

AIM: Splenectomy, except for a traumatic purpose, is now performed through a laparoscopic approach. There are mainly two ways for laparoscopic total or partial splenectomies. For the classic anterior dissection of the splenic vessels, patient is placed in supine position and five ports are required to elevate the spleen and proceed to vessel divisions. With a lateral approach of the pedicle, patient is placed in lateral decubitus position and three ports are sufficient, because gravity help to provide traction on the splenic ligaments and to present hilar vessels and pancreas tail. The aim of our study was to compare surgical complications of those two approaches of laparoscopic splenectomy in children. METHODS: We reviewed 84 medical records of patient operated on for hematological disease between January 1993 and December 2009. RESULTS: There were 47 anterior and 37 lateral approaches. Sex, disease, median age, operative time, blood lost or hospital stay, and associated laparotomy were not different between the two groups. Operative complications included hemorrhage (5), bowel injury (1), diaphragmatic wound (1), pancreas tail section (1), and parietal hematoma (1) in the anterior group (9 cases) versus 1 hemorrhage in the lateral group (P<.02). There were five laparotomies owing to surgical complications in the anterior group, and none in the lateral group. CONCLUSION: Splenectomy through laparoscopic approach is an effective technique. Lateral dissection of the vessels provides less operative complications in children

Soluble markers of B cell activation suggest a role of B cells in the pathogenesis of systemic sclerosis-associated pulmonary arterial hypertension

IntroductionSoluble markers of B cell activation are interesting diagnostic and prognostic tools in autoimmune diseases. Data in systemic sclerosis (SSc) are scarce and few studies focused on their association with disease characteristics.Methods1. Serum levels of 14 B cell biomarkers (β2-microglobulin, rheumatoid factor (RF), immunoglobulins (Ig) G, IgA, IgM, BAFF, APRIL, soluble (s)TACI, sBCMA sCD21, sCD23, sCD25, sCD27, CXCL13) were measured in SSc patients and healthy controls (HC). 2. Associations between these biomarkers and SSc characteristics were assessed. 3. The pathophysiological relevance of identified associations was explored by studying protein production in B cell culture supernatant.ResultsIn a discovery panel of 80 SSc patients encompassing the broad spectrum of disease manifestations, we observed a higher frequency of RF positivity, and increased levels of β2-microglobulin, IgG and CXCL13 compared with HC. We found significant associations between several biomarkers and SSc characteristics related to disease phenotype, activity and severity. Especially, serum IgG levels were associated with pulmonary hypertension (PH); β2-microglobulin with Nt-pro-BNP and DLCO; and BAFF with peak tricuspid regurgitation velocity (TRV). In a validation cohort of limited cutaneous SSc patients without extensive ILD, we observed lower serum IgG levels, and higher β2-microglobulin, sBCMA, sCD23 and sCD27 levels in patients with pulmonary arterial hypertension (PAH). BAFF levels strongly correlated with Nt-pro-BNP levels, FVC/DLCO ratio and peak TRV in SSc-PAH patients. Cultured SSc B cells showed increased production of various angiogenic factors (angiogenin, angiopoietin-1, VEGFR-1, PDGF-AA, MMP-8, TIMP-1, L-selectin) and decreased production of angiopoietin-2 compared to HC.ConclusionSoluble markers of B cell activation could be relevant tools to assess organ involvements, activity and severity in SSc. Their associations with PAH could plead for a role of B cell activation in the pathogenesis of pulmonary microangiopathy. B cells may contribute to SSc vasculopathy through production of angiogenic mediators

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Prise en charge des traumatismes hépatiques fermés de l'enfant

ANGERS-BU Médecine-Pharmacie (490072105) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Tolérance et efficacité de la gastrostomie d'alimentation par voie endoscopique en oncologie pédiatrique

Introduction : La dénutrition en oncologie pédiatrique est fréquente et souvent mésestimée. Elle induit une altération de l'état général du patient, une baisse des défenses immunitaires et serait un facteur de risque indépendant de récidive carcinologique. La gastrostomie par voie endoscopique (GPE) permet, par une nutrition entérale (NE) adaptée, de corriger ou prévenir la survenue d une dénutrition. Le but de cette étude était d'évaluer la tolérance de la GPE et de valider l'intérêt de la NE précoce en oncologie pédiatrique. Patients et méthodes : Les complications des gastrostomies ont été comparées rétrospectivement entre les services d'oncologie et de neurologie pédiatriques du CHU de Nantes depuis 1995. L'efficacité de la NE précoce a été évaluée dans les tumeurs osseuses, en termes de paramètres nutritionnels, de survenue de complications post-opératoires et de récidive carcinologique. Le seuil de signification statistique était de 0,05. Résultats : Il n'a pas été retrouvé plus de complications de la GPE chez les 74 patients d'oncologie comparés aux 57 patients de neurologie. La NE a permis de stabiliser ou d'améliorer le Z-score P/T dans 78% des cas. L'instauration d'une NE précoce a permis d'amoindrir la baisse de Z-score T/A observée de plus de 0,5 DS. Dans les tumeurs osseuses, l'instauration d'une NE dès le diagnostic chez 29 patients a permis de maintenir un poids stable durant toute la durée de la chimiothérapie, et il a été retrouvé une tendance à un moindre taux de complications post-opératoires (24 vs 37%), de récidives carcinologiques (3 vs 47%) et de décès (3 vs 26%) par rapport aux 19 patients non supplémentés. Conclusions : cette étude confirme l'intérêt nutritionnel de l'utilisation de la NE dans la prise en charge des patients d'oncologie pédiatrique, et ce dès un stade précoce de la maladie. La GPE reste une technique simple d utilisation et n'induit pas un taux plus élevé de complications chez les enfants traités pour cancer. Néanmoins des études prospectives complémentaires devront confirmer le lien entre un bon statut nutritionnel et un taux moindre de complications dans la prise en charge des cancers.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Approche chirurgicale de la thérapie génique in vivo des maladies héréditaires du foie

Idéalement, la thérapie génique des hépatopathies héréditaires doit permettre une synthèse continue d une protéine thérapeutique active. Néanmoins, les transferts de gène hautement efficaces obtenus dans les hépatocytes in vivo se traduisent par une expression transitoire du transgène, du fait de l induction d une réponse immunitaire dirigée contre le produit de celui-ci. Afin d éviter cet inconvénient, nous avons développé chez le rat une approche chirurgicale dans laquelle l administration des vecteurs a été effectuée grâce à une perfusion du foie après exclusion vasculaire complète. En vue d un essai clinique, nous avons aussi appliqué des techniques chirurgicales de perfusion hépatique sur deux modèles de grands animaux, l agneau et le macaque. Nos travaux ont montré que : (1) le foie isolé-perfusé et la purification du surnageant viral afin d enlever la protéine soluble transgénique sont tous deux nécessaires pour diminuer de manière significative la réponse immunitaire, (2) les interventions chirurgicales ont été bien tolérées dans les deux espèces de grands animaux, (3) les hépatocytes du foie des agneaux n ont pas étés facilement accessibles aux vecteurs viraux, probablement à cause d une membrane basale épaisse. En conclusion, la technique de perfusion avec exclusion vasculaire pour le transfert de gène in vivo dans le foie est un bon moyen d obtenir une expression durable de la protéine thérapeutique. Le primate non-humain est le seul modèle qui peut permettre de clairement définir le potentiel de la thérapie génique du foie en pratique clinique.Ideally, gene therapy for inherited diseases should result in indefinite synthesis of fully active therapeutic protein. Nevertheless, highly efficient gene transfer into hepatocytes in vivo resulted in transient expression of the transgene, due to induction of an immune response against the transgene product. To circumvent this drawback, we developed in rats a surgical approach in which vectors administration was performed through asanguineous perfusion of the liver after complete vascular exclusion. In sight of clinical trial, we also applied surgical techniques of liver perfusion on two large animal models, the lamb and the macaque. Our works demonstrated that: (1) both asanguineous perfusion of the liver together with purification of the viral surpernatant in order to remove soluble transgenic protein were required to decrease significantly immune response, (2) surgical procedures were well tolerated in the two large animal species, and (3) hepatocytes in lamb liver were not easily accessible to viral vectors probably because of thick basal lamina. In conclusion, asanguineous perfusion for in vivo liver gene transfer is a good way to obtain sustained expression of the transgenic protein. Non-human primate is the only relevant model to clearly define the potential of liver gene therapy in clinics.NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Résultats à long terme de la cure de reflux gastro-oesophagien par la technique de Nissen-Rossetti laparoscopique chez l'enfant

Matériel et méthode : de juillet 1992 à mai 2003, 155 enfants ont été opérés d'une intervention anti-reflux laparoscopique (15 Nissen, 140 Nissen-Rossetti). Une surveillance comportant un examen clinique, un TOGD et une pHmétrie à 3 mois, 15 mois, et 5 ans post-opératoires ont été proposés à tous les patients. Le suivi minimum pour l'inclusion était de 15 mois, et 3 groupes ont été distingués : les sujets avec un reflux gastro-œsophagien primaire (61), les enfants neurologiques (82), et les patients avec des anomalies anatomiques oeso-gastriques (12 dont 8 atrésies de l œsophage). Résultats : L'âge médian à l'intervention était de 4 ans [1 mois-20 ans]. Vingt-huit enfants sont décédés, dont 26 pour le groupe des neurologiques avec un seul décès imputable à l'intervention (0,6 %). Seize enfants ont été perdus de vue. Le temps médian de pH inférieur à 4 passait de 9,7% en pré-opératoire à 0%, 2,2%, 1,3% respectivement à 3 mois, 1 an et 5 ans. Sept enfants ont été réopérés pour réfection du montage (4,5 %) dans un délais médian de 10 mois [7j -16 mois], 3 provenant du groupe des anomalies anatomiques (25%), 3 du groupe des neurologiques (3,6%) et 1 du groupe des RGO primaire (1,6%). Conclusion : L'intervention de Nissen par laparoscopie est efficace excepté pour les patients de petit poids ayant une anomalie anatomique oeso-gastrique, nous faisant préférer actuellement la laparotomie à la laparoscopie dans cette indication. 75% des enfants neurologiques revus à 5 ans ont des résultats satisfaisants avec une amélioration de leur qualité de vie. Pour le groupe de RGO primaire, plus de 95% sont considérés comme guéris au bilan à 5 ans.NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Unilateral pulmonary agenesis: a report of four cases, two diagnosed antenatally and literature review

International audiencePulmonary agenesis is a rare congenital malformation of lung development defined as complete absence of lung tissues, bronchi, and pulmonary vessels; it may be uni- or bilateral. The right-sided form carries the poorest prognosis due to severity of co-existent anomalies. Its diagnostic circumstances are variables: first reported cases were diagnosed at autopsy, but early postnatal as well as fortuitous discovery have been reported. In recent years, progress in obstetrical imaging has made antenatal diagnosis possible so that fetal ultrasound and MRI allow early diagnosis and refinement by permitting the elimination of differential diagnoses (diaphragmatic hernia, cystic adenomatoid malformation of the lung, giant lobar emphysema, and situs inversus). This anomaly is compatible with normal life provided co-existent malformations are thoroughly investigated and managed in a multidisciplinary setting. We report four cases of lung agenesis two of which were diagnosed antenatally at 23rd and 30th weeks of gestation respectively. Our aim is to describe the circumstances having led to diagnosis and report both follow-up and outcome of our patients.</p

Moving from Laparoscopic Synthetic Mesh to Robotic Biological Mesh for Ventral Rectopexy : Results from a Case Series

Introduction:Laparoscopic ventral mesh rectopexy (VMR) is the standard procedure for the treatment of posterior pelvic organ prolapse. Despite significant functional improvement and anatomical corrections, severe complications related to mesh augmentation can occur in a few proportions of patients. In order to decrease the number of rare but severe complications, we developed a variant of the conventional VMR without any rectal fixation and using a robotic approach with biological mesh. The aim of this study was to compare the results of laparoscopic ventral rectopexy with synthetic mesh (LVMRS) to those of robotic ventral rectopexy with biological mesh (RVMRB). Methods: Between 2004 and 2021, patients operated on for VMR in our unit were identified and separated into two groups: LVMRS and RVMRB. The surgical technique for both groups consisted of VMR without any rectal fixation, with mesh distally secured on the levator ani muscles.Results:269 patients with a mean age of 62 years were operated for posterior pelvic floor disorder: rectocele (61.7%) and external rectal prolapse (34.6%). 222 (82.5%) patients received LVMRS (2004-2015), whereas 47 were operated with RVMRB (2015-2021). Both groups slightly differed for combined anterior fixation proportion (LVMRS 39% vs. RVMRB 6.4%,p&lt; 0.001). Despite these differences, the length of stay was shorter in the RVMRB group (2 vs. 3 days,p&lt; 0.001). Postoperative complications were comparable in the two groups (1.8 vs. 4.3%,p= 0.089) and mainly consisted of minor complications. Functional outcomes were favorable and similar in both groups, with an improvement in bulging, obstructed defecation symptoms, and fecal incontinence (NS in subgroup analysis). In the long term, there were no mesh erosions reported. The overall recurrence rate was 11.9%, and was comparable in the two groups (13% LVMRS vs. 8.5,p= 0.43).Conclusions:VMR without rectal fixation is a safe and effective approach in posterior organ prolapse management. RVMRB provides comparable results in terms of recurrence and functional results, with avoidance of unabsorbable material implantation