PREOPERATIVE SEDATION BEFORE REGIONAL ANAESTHESIA: COMPARISON BETWEEN ZOLPIDEM, MIDAZOLAM AND PLACEBO

The quality of premedication induced by oral midazolam and zolpidem, a new imidazopyridine hypnotic, was assessed in a controlled, double-blind study in 93 patients undergoing elective surgery under spinal or extradural anaesthesia. The patients were allocated randomly to three groups. Each group received the same treatment twice at two different doses. The night before operation, patients received zolpidem 10 mg, midazolam 7.5 mg or placebo and, 1 h before operation, zolpidem 20 mg, midazolam 15 mg or placebo. The sleep inducing effects of the drugs were comparable. Zolpidem and midazolam were significantly more effective sedatives than placebo 45 min after administration, but no difference was noted between the drugs. There was a comparable incidence of anterograde amnesia with zolpidem and midazolam, but the onset was shorter after zolpidem. Side effects were comparable in the three groups. Zolpidem is an effective hypnotic with a rapid onset and short duration of action which may be an alternative to midazolam for premedicatio

Utility of CT in the diagnosis of pancreatic fistula after pancreaticoduodenectomy in patients with soft pancreas.

OBJECTIVE: The purpose of this study was to evaluate the sensitivity and specificity of routine performance of CT on postoperative day 7 in patients at high risk of pancreatic fistula after pancreaticoduodenectomy. MATERIALS AND METHODS: Two radiologists analyzed images from CT examinations of 50 patients with soft pancreas 7 days after pancreaticoduodenectomy. Pancreatic fistula was defined at CT as a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis. Clinicobiologic criteria for the diagnosis of pancreatic fistula were drain output of any measurable volume of fluid on or after postoperative day 3 that had an amylase content more than three times the serum amylase activity. The final diagnosis of pancreatic fistula was rendered on the basis of clinicobiologic data at hospital discharge or at first readmission. RESULTS: At hospital discharge or at first readmission, 27 of 50 patients (54%) had a pancreatic fistula. On postoperative day 7, 30 patients (60%) had a total of 51 fluid collections, and CT showed a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis in 21 of 51 cases. CT had a sensitivity of 63% (17/27 patients) and a specificity of 83% (19/23 patients) for the diagnosis of pancreatic fistula with four false-positive and 10 false-negative findings. The diagnosis of pancreatic fistula on the basis of clinicobiologic criteria on postoperative day 7 was made in 22 of 27 patients (81%), whereas five cases were false-negative. Four of these patients had CT evidence of pancreatic fistula. CONCLUSION: In patients at high risk who have undergone pancreaticoduodenectomy, systematic postoperative CT may be proposed as a complementary tool in the diagnosis of pancreatic fistula, particularly for detection of clinically occult pancreatic fistula

Complications after pancreatic resection: diagnosis, prevention and management

BACKGROUND: Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR). METHODS: A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases. RESULTS: The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD. CONCLUSION: There is a need for improved strategies to prevent and treat complications after PR

Pancreaticogastrostomy After Pancreatoduodenectomy

The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June 1991, 32 consecutive patients (mean age, 57 years) were operated on, 25 for malignant disease (78%). The pancreatic remnant was normal in 17 patients (53%) and sclerotic in the others. There was one operative death (3.1%) unrelated to PG. Post-operative complications occurred in five patients (16%). Only two complications were related to PG: 1 patient had anastomotic intra-gastric bleeding and was reoperated on, 1 patient with a normal pancreatic remnant developed a pancreatic fistula (3.1%) treated conservatively

Interactions with M cells and macrophages as key steps in the pathogenesis of enterohemorrhagic Escherichia coli infections

Enterohemorrhagic Escherichia coli (EHEC) are food-borne pathogens that can cause serious infections ranging from diarrhea to hemorrhagic colitis (HC) and hemolytic-uremic syndrome (HUS). Translocation of Shiga-toxins (Stx) from the gut lumen to underlying tissues is a decisive step in the development of the infection, but the mechanisms involved remain unclear. Many bacterial pathogens target the follicle-associated epithelium, which overlies Peyer's patches (PPs), cross the intestinal barrier through M cells and are captured by mucosal macrophages. Here, translocation across M cells, as well as survival and proliferation of EHEC strains within THP-1 macrophages were investigated using EHEC O157:H7 reference strains, isogenic mutants, and 15 EHEC strains isolated from HC/HUS patients. We showed for the first time that E. coli O157:H7 strains are able to interact in vivo with murine PPs, to translocate ex vivo through murine ileal mucosa with PPs and across an in vitro human M cell model. EHEC strains are also able to survive and to produce Stx in macrophages, which induce cell apoptosis and Stx release. In conclusion, our results suggest that the uptake of EHEC by M cells and underlying macrophages in the PP may be a critical step in Stx translocation and release in vivo. A new model for EHEC infection in humans is proposed that could help in a fuller understanding of EHEC-associated diseases

Auxiliary liver transplantation for acute liver failure

In patients with acute liver failure (ALF) who fulfil criteria, liver transplantation is the only effective treatment which can substitute metabolic and excretory function of the liver

Outcomes and risk score for distal pancreatectomy with celiac axis resection (DP-CAR) : an international multicenter analysis

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes. Methods: This multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000-2016) and three very-high-volume international centers in the United States and Japan (model validation 2004-2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival. Results: For 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2-11%) at 5 high-volume (1 DP-CAR/year) and 18% (95 CI, 9-30%) at 18 low-volume DP-CAR centers (P=0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P=0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19months (95 CI, 15-25months). Conclusions: When performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor

A micro-bead device to explore Plasmodium falciparum-infected, spherocytic or aged red blood cells prone to mechanical retention by spleen endothelial slits

Présentation oraleInternational audiencen.

Central pancreatectomy without anastomosis

<p>Abstract</p> <p>Background</p> <p>Central pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen.</p> <p>Methods</p> <p>This is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed.</p> <p>Results</p> <p>All 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma.</p> <p>Conclusion</p> <p>Central pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.</p

Management of Asymptomatic Sporadic Non-Functioning Pancreatic Neuroendocrine Neoplasms No Larger Than 2 Cm: Interim Analysis of Prospective ASPEN Trial

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