Total laparoscopic right colectomy: The duodenal window first approach

Background Total laparoscopic right colectomy (TLRC) is a demanding procedure requiring laparoscopic skills and expertise in surgical oncology. Identifying the correct plane of dissection may be difficult. A correct management of ileocecal and right colic vascular pedicles is pivotal to achieve an oncological resection and the adequate blood supply of ileal and colic stumps. Methods We describe a technique for TLRC with a duodenum-first approach. Using three ports, dividing the "duodenal window", ileocecal and right colic vascular pedicles, and the right ureter are easily identified. The procedure is completed with an intracorporal stapled side-by-side anastomosis. Results In 2014, 19 patients underwent TLRC using this technique. The median operative time was 178 min (132-237 min) and median intraoperative blood loss reached 60 mL (10-400). Conversion rate was 15.8%. No urinary tract, vascular, duodenal injury or anastomotic fistula were reported. Fifteen patients (79%) underwent a colectomy for cancer with a median of 16 (7-27) harvested lymph-nodes and 100% of R0-resection. Minor morbidity (Clavien-Dindo I-II) was 52.6% mainly related to cardiopulmonary complications (26.3%). Severe morbidity (Clavien-Dindo ≥ III) was 10.5% (two patients), including one reoperation (due to a sepsis related to an intra-abdominal abscess) and one death (due to complications of an aortic aneurism). Median hospital stay was 7 days (2-23 days). Long-term outcomes are unremarkable. Conclusions Using three trocars, the "duodenal window" approach to TLRC is technically feasible and safe, with good outcomes. The early access to the duodenum and the exposure of ilea-cecal and right colic pedicles rationalizes the procedure

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

Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study

BACKGROUND: Western multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE). METHODS: Retrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C). RESULTS: We included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10-37). We observed no impact of PHAE on ischemic complications. CONCLUSIONS: DP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes

A Woman’s Loss of Imagination: Paola Masino’s Magical Realism in Nascita e morte della Massaia

Criticism on Paola Masino has flourished since the early 2000s. This increased attention has contributed towards reclaiming an author often overshadowed by the attention received by her partner, Massimo Bontempelli, the father of realismo magico. Masino experimented with a variety of styles—realismo magico was one of them—as she rejected strictly naturalistic forms of representation, preferring to co-opt myths and the supernatural. Nascita e morte della Massaia (1945) is Masino’s most renowned literary effort, both for its critique of Fascist Italy and for its sophisticated stylistic effects. Nascita, while indebted to Bontempelli’s theorizations, features all the chief characteristics listed in Faris’s analysis of magical realism as an international phenomenon, and illustrates how magical realism offers strategies for evading censorship to those writing against totalitarianism regimes. At the same time, it is an example of how magical realism can be used to denounce socially imposed gender roles. My analysis shows how this narrative mode emerges on multiple levels within Masino’s text

TISSUE CLASSIFICATION AS NON- INVASIVE ASSESSMENT METHODS FOR LIVER STEATOSIS

Hepatic steatosis (HS) is one of the most important organ donor characteristics that can influence negatively graft function and so liver transplantation (LT) outcome. Despite histopathological analysis of liver tissue is currently the gold reference standard for diagnosis and grading of HS in liver grafts, it is invasive, time-consuming and expensive. Due to the short time availability between liver procurement and transplantation, the surgeon usually performs HS assessment through clinical evaluation (medical history, blood tests) and qualitative visual liver graft assessment. In this context, visual liver texture analysis is recognized as crucial in grading HS: livers that cannot be transplanted due to high HS are usually characterized by inhomogeneous texture and are more yellowish than the transplantable ones. It is nonetheless recognized that the precise estimation of HS remains challenging even in experienced surgeon\u2019s hands. The automatic image-based intraoperative tissue classification is a valuable solution to provide decision support to the liver surgeon and context awareness intra-operatively. The surgical data science (SDS) community is focusing more and more on machine learning (ML) to perform tissue classification in the operating room (OR). However, several technical challenges as noise in the image, varying illumination level, different camera pose with respect to the tissues, and intra- and inter-patient tissue variability, are still present, hampering the clinical translation of the developed methodology in the clinical practice. On this background, the overall goal of this PhD thesis was to tacke most of theese issues by developping an hardware device able to allow high-quality standard intraoperative image acquisition and a framework for ML-based SDS algorithms for robust and reliable tissue classification for intraoperative images. In particular, the contributions of this PhD work are: 1. A new tool for intraoperative RGB images acquisition 2. A new method for reliable hepatic tissue classification that utilised images acquired with the new device and non-invasive biomarkers donor\u2019s data 3. A machine-learning based evaluation of non-invasive biomarkers donor\u2019s data with the goal of estimate the real value of clinical and biochemical donor\u2019s features in HS classification 4. A new method for hepatic tissue classification arising from human visual cortex method, that utilised only images acquired with the new device designed This PhD thesis work lies in the wider research field of SDS, which aims at providing the surgeons with decision support and context awareness during interventional medicine procedures. The methodologies presented in this PhD thesis demonstrated the feasibility of using SDS ML-based algorithms for intra-operative hepatic tissue classification in liver transplantation setting. The methodological progress made in this work highlights the potential of SDS ML-based algorithms in extracting useful information implicitly contained in intra-operative optical images, overcoming challenges typical of intra-operative tissue classification to support surgeons during liver transplanatation procedures

Liver transplantation for bariatric surgery-related liver failure: a systematic review of a rare condition

International audienceBackground: Protein malnutrition and bacterial overgrowth occurring after bariatric surgery (BS) might cause severe liver failure (LF) needing liver transplantation (LT).Objectives: To evaluate indications and outcomes of LT for BS-related LF.Setting: University hospital in France.Methods: The EMBASE, MEDLINE, and COCHRANE central databases were systematically searched according to the PRISMA criteria from inception up through December 2017 for articles describing LT for LF after BS.Results: Fourteen studies reporting 36 patients listed for LT, of which 32 underwent the procedure, were retained. The types of previously performed BS included jejunoileal bypass (n = 16), bilio-pancreatic diversion according to Scopinaro (n = 14) or with duodenal switch (n = 3), bilio-intestinal bypass (n = 1), long-limb Roux-en-Y gastric bypass (n = 1), and single anastomosis omega gastric bypass (n = 1). Liver failure developed a median of 20 months after BS (mean ± SD: 105 ± 121 mo; range, 5-300 mo). This interval of time was significantly shorter after biliopancreatic diversion than jejunoileal bypass (mean ± SD: 22 ± 21 mo versus 269 ± 27 mo; P = .0001). Four patients (11.1%) died while on the waiting list for LT, and 4 more (12.5%) died after LT. Morbidity and liver retransplantation were reported in 8 (25%) and 2 (6.2%) patients, respectively. Twenty-one patients (65.6%) had their BS procedure reversed (1 patient before, 15 patients during, and 5 patients after LT, respectively). Biopsy-proven steatosis recurrence after LT was reported in 6 patients (18.7%), 4 of whom did not have BS reversal.Conclusions: Severe LF occurring after BS, although rare, might require LT. When indicated, LT is effective at restoring liver function, even when BS reversal is performed synchronously

Significant Smartphone Images Features For Liver Steatosis Assessment

International audienc

Reappraisal of primary hepatic lymphoma: Is surgical resection underestimated?

Primary hepatic lymphoma (PHL) is defined as a lympho-proliferative disorder limited to the liver without any involvement of the spleen, lymph nodes, bone marrow or blood. Diffuse large B-cell lymphoma (DLBCL) is the most common histological type counting more than 60-80% of all PHL. Usually, it occurs in middle-aged men with aspecific symptoms and diagnosis is confirmed by histopathology. In order to expand current knowledge and to investigate an optimal therapeutic strategy, a systematic review of literature was conducted in February 2016. A total of 274 articles were retrieved, and after exclusion, 55 were retained, reporting 147 cases of PHL. Patients were mainly men (64.9%) with a median age at diagnosis of 57 years (range: 17-92) and right hepatic lobe involvement (69.6%). Among the 147 patients, 9% received no therapy while 77% underwent treatment including chemotherapy, surgery and radiotherapy in 64%, 26% and 1% of cases, respectively. Mean follow-up was 22.6 months (range: 0.2-360). Overall mortality was 29.2% with a 90-day mortality of 26%. Risk factors for increased mortality include; bilobar lesions (p = 0.001), right lobe localisation (p = 0.003) and non-surgical approach or the absence of any treatment (p = 0.001). A trend towards favourable outcomes for young patients (mean = 50.4 years) with a large liver lesion was achieved by surgical management of PHL but this did not achieve statistical significance. Statistical analysis indicates that in cases of resectable disease, an aggressive surgical approach in selected patients leads to increase long-term survival. Thus, two hypotheses should be assessed in further randomized studies: 1°) resectable PHL is a less severe form or 2°) hepatectomy is an effective treatment for PHL