Chirurgie hépatique mineure par laparoscopie en ambulatoire : étude rétrospective observationnelle

RésuméAu cours de la dernière décennie, la chirurgie hépatique laparoscopique (CHL) a connu un essor dans le monde entier. Parallèlement, la chirurgie ambulatoire a été développée afin d’améliorer le confort des patients et de réduire les dépenses de santé. L’objectif de cette étude est de rapporter notre expérience préliminaire de la CHL en ambulatoire. Entre 1999 et 2014, 172 patients ont été opérés dans notre institution d’une CHL, incluant 151 résections hépatiques et 21 fenestrations de kystes hépatiques. Tous les patients consécutifs, hautement sélectionnés, opérés d’une CHL en ambulatoire ont été inclus. Vingt patients ont été opérés d’une CHL en ambulatoire. Les indications étaient des kystes hépatiques dans 10 cas, un angiome hépatique dans 3 cas, une hyperplasie nodulaire focale dans 3 cas, et une métastase hépatique de cancer colorectal dans 4 cas. La durée opératoire médiane était de 92minutes (dispersion : 50–240minutes). La perte sanguine médiane était de 35mL (dispersion : 20–150mL). Il n’a pas été observé de complication ni de réhospitalisation. Tous les patients étaient hospitalisés en postopératoire dans notre unité de chirurgie ambulatoire, et ont pu quitter l’établissement 5 à 7heures après la fin de la chirurgie. Le score médian de douleur postopératoire à la sortie était de 3 (échelle visuelle analogique à 10 niveaux ; dispersion : 0–4). Le score médian de qualité de vie à la première consultation postopératoire était de 8 (dispersion : 6–10), et le score médian de satisfaction esthétique était de 8 (dispersion : 7–10). Cette série montre que la CHL ambulatoire est faisable et sûre et chez des patients sélectionnés pour des interventions mineures.SummaryOver the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally-invasive LHS. Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. Twenty patients underwent ambulatory LHS. The indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92minutes (range: 50–240minutes). The median blood loss was 35mL (range: 20–150mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5–7hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale 0–10; range: 0–4). The median quality-of-life score at the first postoperative visit was 8 (range: 6–10) and the median cosmetic satisfaction score was 8 (range: 7–10). This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures

Computed tomography assessment of postoperative gastric vascular supply and staple-line leak development after sleeve gastrectomy

Background: Residual arterial supply of the gastric tube after sleeve gastrectomy (SG) can be damaged by surgery, which can reduce gastric tube perfusion and could promote postoperative leakage. Objective: To compare the postoperative vascularization of the gastric tube using early computed tomography (CT) scanning after SG in patients with or without postoperative staple-line leak. Setting: University hospital. Methods: A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Patients who presented with a staple-line leak were matched (1:3) with a control group of patients who underwent surgery without postoperative morbidity during the same period. Gastric tube vascularization was studied on a postoperative day 2 CT scan in both groups of patients. Results: During the study period, 1826 patients underwent SG, including 42 patients (2.3%) who presented with a staple-line leak. Those 42 patients were successfully matched to 126 control patients. Global identification of residual gastric arterial supply in early postoperative CT scans was similar in patients with or without staple-line leak after SG. However, residual vascular supply of the gastroesophageal junction (i.e., terminal and anterior cardiotuberosity branches of the left gastric artery or left inferior phrenic artery) was more frequently interrupted by the staple line in the group of patients who developed a gastric leak. Conclusion: This study suggests a correlation between interruption of the main arteries supplying the gastroesophageal junction by the staple line on early postoperative CT scans and the development of gastric leak after SG. These results support the vascular theory as one of the causes of leak after SG

Internal biliary stenting during orthotopic liver transplantation: anastomotic complications, post‐transplant biliary interventions, and survival

BackgroundBiliary complications are a leading source of surgical morbidity following orthotopic liver transplantation (OLT).MethodsWe examined how prophylactic internal biliary stent placement during OLT affected post‐transplant morbidity and mortality in a single‐center retrospective cohort study of 513 recipients (2006–2012). Recipient and donor covariates were collected. Biliary complications included major and minor anastomotic leaks, strictures, or stenoses. Multivariate regression models were created to estimate how operative biliary stents affected outcomes.ResultsAbout 87.3% (n = 448) of recipients had a duct‐to‐duct biliary anastomosis, and 43.1% (n = 221) had biliary stents placed. The biliary complication rate was <15% at five yr, and 44.8% (n = 230) overall. Stenting was not protective from anastomotic biliary complications (p = 0.06). Stenting was associated with a 74% higher adjusted risk of needing multiple endoscopic retrograde cholangiographies (ERCs; odds ratio [OR] 1.74, p = 0.011), and trended toward a lower adjusted risk for repetitive percutaneous transhepatic cholangiography (PTCs; OR 0.56, p = 0.063). Stenting had no effect on the cumulative freedom from biliary complications (p = 0.94). Biliary complications were associated with mortality (HR 1.86, p = 0.014) and was unaffected by stenting (aHR = 0.72, p = 0.246).ConclusionsBiliary stenting during OLT does not deter biliary complications and is associated with higher risk of multiple invasive biliary interventions, particularly ERCs. Surgeons should evaluate the utility of biliary stents at OLT within this context.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111147/1/ctr12518.pd

Submucosal Tunnel Endoscopic Resection of Gastric Lesion Before Obesity Surgery: a Case Series

Background: Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery. Methods: Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect. Results: En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection. Conclusion: STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures

Surface and Interface Effects in VLSI

ABSTRACT The effect of cation on the CdSe/polysulfide photoelectrochemical (PEC) solar cell has been investigated. The currentpotential response of the polysulfide electrolyte on a platinum electrode was measured as a function of the alkali metal cation in solution. There was a -33 mV shift in the redox potential and an increase in the current when the cation was changed from Na § to Cs § The performance of the CdSe/polysulfide PEC cell with both polycrystalline and single-crystal semiconductor electrodes increased in the open-circuit potential, the short-circuit current, the fill factor, and the energy conversion efficiency when Cs polysulfide was used as compared with K or Na polysulfide. Impedance measurements were made on the electrodes in polysulfide solutions and hydroxide solutions with the different cations. The results for both electrolytes showed a negative shift in the flatband potential, an increase in the apparent charge-carrier concentration, and an increase in the frequency dispersion of the measurements with the addition of Cs +. The impedance measurements also showed a dependence on the orientation of the CdSe crystal. The effects above are related to a combination of a change in the solution and the surface of the semiconductor. The stoichiometric distribution of the polysulfide species changes with the addition of Cs + and the surface of the semiconductor changes, facilitating charge transfer across the semiconductor/ electrolyte interface. Initial work on the cadmium chalcogenide/polysulfide PEC solar cell was published by Gerischer ~ and Ellis et aI.2 A great deal of work has been performed since those original studies on improvements to the semiconductor, the surface condition of the semiconductor electrode, and the electrolyte. CdS, CdSe, CdTe and mixed CdSe~T%x 3-~ have been investigated to increase the energy-conversion efficiency and stability of the PEC cells. Several researchers have investigated cadmium chalcogenide PEC solar cells using polycrystalline electrodes. Long-term stabilities have been demonstrated with conversion efficiencies up to 5% for polycrystalline CdSe. 7-1~ The semiconductor/liquid junction solar cell is particularly well suited to low cost polycrystalline electrodes. Changes in the make-up of the polysulfide electrolyte have a large effect on the performance of the solar cell; the effect of hydroxide ion concentration and the sulfideto-sulfur ratio have been investigated by some researchers.~l~ Both the hydroxide ion and the sulfur-to-sulfide ratio affect the equilibrium concentration of the electroactive species, the stability of the solution, and the light absorption by the solution. Changing the cation in the solution leads to changes in the performance of the cell. ~6-~9 The cation is not involved directly in the redox reactions at the semiconductor electrode but the performance of the cell increases significantly when the cation in solution is changed from Na § or K § to Cs § The improvement is in the stability of the semiconductor, the open-circuit photovoltage (Voc) and the photocurrent response. The flatband potential (V~) also shifts negative with the addition of Cs*; yet the only difference between the cations is the ionic radius and thus the charge density. The change in cation can affect the surface of the semiconductor by altering the degree of adsorption, or by incorporation into the semicon-* Electrochemical Society Active Member. a Present address: IBM Corporation, Hopewell Junction, New York 12533-6531. ductor itself; or by changing the activity of the species in solution, or the distribution of the polysulfide species. The CdSe/polysulfide system is examined here. First, the current-potential response of polysulfide on a platinum electrode was measured. Impedance measurements then were made to determine how the change in cation affects the band energies and charge-carrier concentration of the semiconductor. The measurements were made in a variety of systems to separate the different effects: CdSe singlecrystal electrodes in hydroxide electrolytes with the different cations, CdSe single-crystal electrodes in polysulfide with the different cations, and with CdSe polycrystalline electrodes in polysulfide. The impedance measurements indicate changes in the performance of both single-crystal and polycrystalline CdSe/polysulfide PEC cells with the different cations. Polysulfide Electrolyte Polysulfide solutions have been studied extensively in the pulp and paper industry. The equilibrium relationships of the solution species are presented in The electroactive species and rate-limiting step at the photoanode have been the subject of several papers. 14&apos; 24-2~ I

Functional shift with maintained regenerative potential following portal vein ligation

Selective portal vein ligation (PVL) allows the two-stage surgical resection of primarily unresectable liver tumours by generating the atrophy and hypertrophy of portally ligated (LL) and non-ligated lobes (NLL), respectively. To evaluate critically important underlying functional alterations, present study characterised in vitro and vivo liver function in male Wistar rats (n = 106; 210-250 g) before, and 24/48/72/168/336 h after PVL. Lobe weights and volumes by magnetic resonance imaging confirmed the atrophy-hypertrophy complex. Proper expression and localization of key liver transporters (Ntcp, Bsep) and tight junction protein ZO-1 in isolated hepatocytes demonstrated constantly present viable and well-polarised cells in both lobes. In vitro taurocholate and bilirubin transport, as well as in vivo immunohistochemical Ntcp and Mrp2 expressions were bilaterally temporarily diminished, whereas LL and NLL structural acinar changes were divergent. In vivo bile and bilirubin-glucuronide excretion mirrored macroscopic changes, whereas serum bilirubin levels remained unaffected. In vivo functional imaging (indocyanine-green clearance test; (99mTc)-mebrofenin hepatobiliary scintigraphy; confocal laser endomicroscopy) indicated transitionally reduced global liver uptake and -excretion. While LL functional involution was permanent, NLL uptake and excretory functions recovered excessively. Following PVL, functioning cells remain even in LL. Despite extensive bilateral morpho-functional changes, NLL functional increment restores temporary declined transport functions, emphasising liver functional assessment

Breath Analysis Using Laser Spectroscopic Techniques: Breath Biomarkers, Spectral Fingerprints, and Detection Limits

Breath analysis, a promising new field of medicine and medical instrumentation, potentially offers noninvasive, real-time, and point-of-care (POC) disease diagnostics and metabolic status monitoring. Numerous breath biomarkers have been detected and quantified so far by using the GC-MS technique. Recent advances in laser spectroscopic techniques and laser sources have driven breath analysis to new heights, moving from laboratory research to commercial reality. Laser spectroscopic detection techniques not only have high-sensitivity and high-selectivity, as equivalently offered by the MS-based techniques, but also have the advantageous features of near real-time response, low instrument costs, and POC function. Of the approximately 35 established breath biomarkers, such as acetone, ammonia, carbon dioxide, ethane, methane, and nitric oxide, 14 species in exhaled human breath have been analyzed by high-sensitivity laser spectroscopic techniques, namely, tunable diode laser absorption spectroscopy (TDLAS), cavity ringdown spectroscopy (CRDS), integrated cavity output spectroscopy (ICOS), cavity enhanced absorption spectroscopy (CEAS), cavity leak-out spectroscopy (CALOS), photoacoustic spectroscopy (PAS), quartz-enhanced photoacoustic spectroscopy (QEPAS), and optical frequency comb cavity-enhanced absorption spectroscopy (OFC-CEAS). Spectral fingerprints of the measured biomarkers span from the UV to the mid-IR spectral regions and the detection limits achieved by the laser techniques range from parts per million to parts per billion levels. Sensors using the laser spectroscopic techniques for a few breath biomarkers, e.g., carbon dioxide, nitric oxide, etc. are commercially available. This review presents an update on the latest developments in laser-based breath analysis

Liver regeneration : stimulus for hepatocyte transplantation

Le foie a des capacités de régénérations importantes qui lui permettent de reconstituer progressivement sa masse cellulaire suite à une agression. L’induction d’une régénération hépatique est une approche qui a été utilisée dans de nombreux modèles animaux afin de favoriser la prise de greffe hépatocytaire pour le traitement des maladies métaboliques héréditaires hépatiques (MMHH). Par ailleurs, les capacités de régénération du foie sont utilisées en pratique clinique courante dans le cadre de la chirurgie hépatique afin de préparer le foie à une hépatectomie majeure. Les principaux objectifs de ce travail ont été d’étudier des moyens peu invasifs pour induire une importante régénération hépatique dans deux buts précis : i) favoriser la transplantation d’hépatocytes thérapeutiques pour le traitement des MMHH ; ii) élargir les possibilités de prise en charge des patients nécessitant une hépatectomie.Dans un premier temps, nous avons évalué l’effet d’une embolisation portale partielle (EPP) au cours de la transplantation d’hépatocytes dans un des modèles animaux de l’hypercholestérolémie familiale de type IIA, le lapin Watanabe. Dans un deuxième temps, nous avons mis au point chez le rat, une technique d’EPP résorbable répétée visant à entrainer un stimulus répété de régénération hépatocytaire afin d’envisager par la suite l’utilisation de cette technique avant transplantation d’hépatocytes. En parallèle de ces travaux fondamentaux, nous avons évalué en approche clinique l’intérêt de l’EPP résorbable avant hépatectomie majeure. Nos travaux dans le modèle du lapin Watanabe ont montré la faisabilité du protocole, une correction phénotypique in vitro, une amélioration de la prise de greffe hépatocytaire et une expression prolongée du transgène. Notre équipe a développé chez le rat un stimulus additionnel de prolifération hépatocytaire qui permet une augmentation du poids et du volume du foie non embolisé en comparaison à une seule EPP résorbable. Enfin, dans une série rétrospective préliminaire, la technique d’EPP résorbable a été utilisée avant hépatectomie majeure. L’approche a été bien tolérée chez tous les patients et a permis de systématiquement envisager la chirurgie.L’EPP résorbable est une technique peu invasive capable d’induire une régénérative hépatique efficace. Cette approche pourrait permettre notamment d’augmenter les capacités de proliférations hépatiques par la répétition du stimulus d’embolisation. A terme, l’EPP résorbable répétée pourrait permettre de modeler à la demande l’organisation du volume hépatique favorisant ainsi l’hypertrophie de tel ou tel secteur en fonction des besoins.The liver has an important regenerative capacity allowing progressive reconstitution of the hepatic volume after an aggression. The induction of liver regeneration was used in different animal models in order to increase engraftment during hepatocyte transplantation for the treatment of inherited metabolic liver diseases (IMLD). Furthermore, liver regenerative capacities are used in routine clinical practice before liver surgery in order to prepare the liver for major hepatectomy.The main objective of this doctoral thesis was to evaluate minimally invasive approaches inducing substantial liver regeneration, focusing in two specific aims: i) increasing the engraftment of therapeutic cells for the treatment of IMLD; ii) expanding the therapeutic options for patients requiring an hepatectomy In a first study, we evaluated the impact of a partial portal vein embolization (PVE) during hepatocyte transplantation in the animal model of familial hypercholesterolemia type IIA, the Watanabe rabbit. In a second investigation, we developed an approach of repeated reversible PVE in a rat model to further boost liver hypertrophy, planning to apply this approach in hepatocyte transplantation. In parallel, we evaluated the clinical interest of reversible PVE before major hepatectomy.Our results of PVE during hepatocyte transplantation in the Watanabe rabbit model demonstrated the feasibility of the procedure, in vivo phenotypic correction, increase of liver cell engraftment and stable transgene expression. Our team developed in the rat an additional stimulus of hepatocyte proliferation allowing increase of non-embolized liver lobe weight and volume in comparison to a single reversible PVE. Finally, the reversible PVE approach was evaluated before major hepatectomy in a preliminary retrospective series of 20 patients. The procedure was well tolerated and allowed to plan surgery in all patients.Reversible PVE is a minimally invasive technique allowing to successfully induce liver regeneration. This approach could increase hepatocyte proliferation capacity by using an additional stimulus of repeated embolization. In the future, reversible PVE may allow on demand modeling of liver volumes organization by supporting the hypertrophy of a specific liver lobe when required