Liquid Chromatography-Mass Spectrometry-Based Parallel Metabolic Profiling of Human and Mouse Model Serum Reveals Putative Biomarkers Associated with the Progression of Nonalcoholic Fatty Liver Disease

Keywords: NAFLD, steatosis, NASH, metabolomics, biomarkers. FOOTNOTE

Relations entre différents scores tomodensitométriques et l'obésité morbide

REIMS-BU Santé (514542104) / SudocSudocFranceF

Complicated diverticular disease: the changing paradigm for treatment

The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies

Problems associated with education and teaching laparoscopic surgery: the role of the European Association for Endoscopic Surgery

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Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery

BACKGROUND: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60 degrees, an elevation angle (alpha(e)) of 30 degrees to 60 degrees, and an intracorporeal/extracorporeal length ratio (TIE) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm. RESULTS: Trocar placement can be calculated easily according to simple formulas dependent on the alpha(e), the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH’): when the alpha(e) is 30 degrees: d is XH’ root 2 and when alpha(e) is 45 degrees, d is XH’/root 2. Likewise, when alpha(e) is 30 degrees the intertrocar span (LR) is 2XH’, half on either side of the optical axis (d), and when alpha(e) is 45 degrees, LR is XH’ root 2, XH’/root 2 on either side of the optical axis. The most ergonomic solution is to work with an alpha(e) of 40 degrees to 45 degrees by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an alpha(e) closer to 30 degrees, then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the alpha(e) would be 40 degrees and 32 degrees, for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the alpha(e) by 2 degrees and 3 degrees, respectively. Hyperlordosis, as obtained by placing a cushion under the patient’s back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction. CONCLUSIONS: Based on ergonomic principles (manipulation angle, 60 degrees; alpha(e), 40 degrees-45 degrees; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ. (C) 2010 Elsevier Inc. All rights reserved