Acute mesenteric venous thrombosis: Case for nonoperative management

AbstractObjective: Initial treatment in the management of acute mesenteric vein thrombosis (MVT) is controversial. Some authors have proposed a surgical approach, whereas others have advocated medical therapy (anticoagulation). In this study, we analyzed and compared the results obtained with surgical and medical treatment to determine the best initial management for this disease. Methods: We retrospectively reviewed the records of patients treated for MVT in a secondary care surgical department from January 1987 to December 1999. Before January 1995, our departmental policy was to perform surgery in patients with suspected MVT. Since January 1995, we have preferred a medical approach when achievable. Each patient in this study was assessed for diagnosis, initial management (laparotomy or anticoagulation), morbidity, mortality, duration of hospitalization, the need for secondary operation, portal hypertension, and survival rates. Results: Twenty-six patients were treated, 14 before January 1995 (group 1) and 12 since January 1995 (group 2). Morbidity, mortality, secondary operation, portal hypertension, and 2-year survival rates were 34.6%, 19.2%, 15.3%, 19.2%, and 76.9%, respectively. No statistical difference was observed between the two groups. The mean duration of hospitalization was 51.6 days in group 1 and 23.2 days in group 2 (P <.05). Among the 12 patients treated by means of laparotomy with bowel resection, 10 patients (83%) had mucosal necrosis without transmural necrosis at pathologic study. Conclusion: Nonoperative management for acute MVT is feasible when the initial diagnosis with a computed tomography scan is certain and when the bowel infarction has not led to transmural necrosis and bowel perforation. The morbidity, mortality, and survival rates are similar in cases of surgical and nonoperative management. The length of hospital stay is shorter when patients are treated with a nonoperative approach. A nonoperative approach, when indicated, avoids the resection of macroscopically infarcted small bowel (without transmural necrosis) in cases that are potentially reversible with anticoagulation alone. (J Vasc Surg 2001;34:673-9.

Déterminants nutritionnels et métaboliques de l'homocystéine au niveau hépatique (évaluation de 3 modèles expérimentaux)

La physiopathologie et les conséquences cellulaires de l'hyperhomocystéinemie observée après gastrectomie ou thyroïdectomie restent mal élucidées. Nous avons étudié 3 modèles expérimentaux. Le rat gastrectomisé présente une carence en vitamine B12, permettant d'obtenir une hyperhomocystéinémie en rapport avec une diminution de l'activité MTR. Cependant, la méthylation de l'ADN était corrélée à l'activité MTR et à la B12, mais pas directement à l'homocystéinémie. La thyroïdectomie chez le rat entraîne un défaut de synthèse des coenzymes flaviniques par la riboflavine kinase qui se traduit par une baisse des activités MTHFR et MTR. Cependant, les rats thyroïdectomisés présentent une hypohomocystéinémie en rapport avec une stimulation de la voie de la transulfuration via l'augmentation de l'activité CBS. Les ratons nés de rates soumise à une carence présentent une hyperhomocystéinémie liée à un effondrement de l'activité MTR, due à une véritable carence hépatique en B12.NANCY1-SCD Medecine (545472101) / SudocSudocFranceF

Resection of Locally Advanced Pancreatic Neoplasms after Neoadjuvant Chemotherapy with Nab-Paclitaxel and Gemcitabine following FOLFIRINOX Failure

The incidence of pancreatic cancer has dramatically increased over the past years, but the prognosis has not improved. Between 30 and 40% of tumors are considered locally advanced, essentially due to vascular involvement. In recent years, new chemotherapy protocols with high response rates have been developed. FOLFIRINOX seems to be an interesting option in this situation, but hematologic toxicity could be an obstacle to its prescription. Nab-paclitaxel and gemcitabine offer significant response rates with a reasonable safety profile. We report here a single-center experience of 2 cases with a locally advanced pancreatic cancer initially considered unresectable, progressive after first-line neoadjuvant FOLFIRINOX chemotherapy, and then treated with second-line nab-paclitaxel/gemcitabine chemotherapy

Is Hartmann’s Pouch an Option in the Management of Acute Severe Ulcerative Colitis?

Background: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann’s pouch. The aim of this retrospective study was to investigate whether Hartmann’s pouch may be a safe option. Methods: Thirty-eight Hartmann’s pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. Results: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. Conclusions: Hartmann’s pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty

Simulator Practice Is Not Enough to Become a Robotic Surgeon: The Driving Lessons Model

International audienc

Long-term Outcomes of Robot-assisted Laparoscopic Rectopexy for Rectal Prolapse

International audienceBACKGROUND: Robot-assisted laparoscopic rectopexy for total rectal prolapse is safe and feasible. Small series proved clinical and functional short-term results comparable with conventional laparoscopy. No long-term results have been reported yet.OBJECTIVE: The primary objective of the study was to evaluate long-term functional and anatomic results of robot-assisted laparoscopic rectopexy. The secondary objective was to evaluate the learning curve of this procedure.DESIGN: Monocentric study data, both preoperative and perioperative, were collected prospectively, and follow-up data were assessed by a telephone questionnaire.SETTINGS: The study was performed in an academic center by 3 different surgeons.PATIENTS: We evaluated all of the consecutive patients who underwent a robot-assisted laparoscopic rectopexy between June 2002 and August 2010.INTERVENTION: Rectopexy was performed with 2 anterolateral meshes or with 1 ventral mesh, and in 9 patients a sigmoidectomy was associated with rectopexy.MAIN OUTCOME MEASURES: The actuarial recurrence rate was evaluated using the Kaplan-Meier method.RESULTS: During the study period, 77 patients underwent a robot-assisted laparoscopic rectopexy, and the mean age was 59.9 years (range, 23–90 y). Average operating time was 223 minutes (range, 100–390 min); the learning curve was completed after 18 patients were seen. Two patients died of causes unrelated to surgery at 5 and 24 months. There were 5 conversions (6%) to open procedure. Overall morbidity was low and concerned only 8 patients (10.4%). Mean follow-up time was 52.5 months (range, 12–115 mo). Recurrences have been observed in 9 patients (12.8%). Preoperatively, 24 (34%) of the patients had constipation. Postoperatively, constipation disappeared for 12 (50%) of 24 and constipation appeared for 11 (24%) of 46 patients. Fecal incontinence decreased after surgery from Wexner score 10.5 to 5.1 of 20.LIMITATIONS: There was a lack of standardization of the surgical procedure. The study was monocentric. Seven patients (9%) were lost to follow-up.CONCLUSIONS: Long-term results of robot-assisted laparoscopic rectopexy are satisfying. Further studies comparing robot-assisted and conventional laparoscopy, including cost-effectiveness, are needed