B. Aussilhou

The sensing of poorly deformable red blood cells by the human spleen can be mimicked in vitro

Retention of poorly deformable red blood cells (RBCs) by the human spleen has been recognized as a critical determinant of pathogenesis in hereditary spherocytosis, malaria, and other RBC disorders. Using an ex vivo perfusion system, we had previously shown that retention of Plasmodium falciparum-infected RBCs (Pf-RBCs) occur in the splenic red pulp, upstream from the sinus wall. To experimentally replicate the mechanical sensing of RBCs by the splenic microcirculation, we designed a sorting device where a mixture of 5- to 25-μm-diameter microbeads mimics the geometry of narrow and short interendothelial splenic slits. Heated RBCs, Pf-RBCs, and RBCs from patients with hereditary spherocytosis were retained in the microbead layer, without hemolysis. The retention rates of Pf-RBCs were similar in microbeads and in isolated perfused human spleens. These in vitro results directly confirm the importance of the mechanical sensing of RBCs by the human spleen. In addition, rigid and deformable RBC subpopulations could be separated and characterized at the molecular level, and the device was used to deplete a stored RBC population from its subpopulation of rigid RBCs. This experimental approach may contribute to a better understanding of the role of the spleen in the pathogenesis of inherited and acquired RBC disorders.

Surface Area Loss and Increased Sphericity Account for the Splenic Entrapment of Subpopulations of Plasmodium falciparum Ring-Infected Erythrocytes

Ex vivo perfusion of human spleens revealed innate retention of numerous cultured Plasmodium falciparum ring-infected red blood cells (ring-iRBCs). Ring-iRBC retention was confirmed by a microsphiltration device, a microbead-based technology that mimics the mechanical filtering function of the human spleen. However, the cellular alterations underpinning this retention remain unclear. Here, we use ImageStream technology to analyze infected RBCs’ morphology and cell dimensions before and after fractionation with microsphiltration. Compared to fresh normal RBCs, the mean cell membrane surface area loss of trophozoite-iRBCs, ring-iRBCs and uninfected co-cultured RBCs (uRBCs) was 14.2% (range: 8.3–21.9%), 9.6% (7.3–12.2%) and 3.7% (0–8.4), respectively. Microsphilters retained 100%, ∼50% and 4% of trophozoite-iRBCs, ring-iRBCs and uRBCs, respectively. Retained ring-iRBCs display reduced surface area values (estimated mean, range: 17%, 15–18%), similar to the previously shown threshold of surface-deficient RBCs retention in the human spleen (surface area loss: >18%). By contrast, ring-iRBCs that successfully traversed microsphilters had minimal surface area loss and normal sphericity, suggesting that these parameters are determinants of their retention. To confirm this hypothesis, fresh normal RBCs were exposed to lysophosphatidylcholine to induce a controlled loss of surface area. This resulted in a dose-dependent retention in microsphilters, with complete retention occurring for RBCs displaying >14% surface area loss. Taken together, these data demonstrate that surface area loss and resultant increased sphericity drive ring-iRBC retention in microsphilters, and contribute to splenic entrapment of a subpopulation of ring-iRBCs. These findings trigger more interest in malaria research fields, including modeling of infection kinetics, estimation of parasite load, and analysis of risk factors for severe clinical forms. The determination of the threshold of splenic retention of ring-iRBCs has significant implications for diagnosis (spleen functionality) and drug treatment (screening of adjuvant therapy targeting ring-iRBCs).

Laparoscopic Pancreaticoduodenectomy Should Not Be Routine for Resection of Periampullary Tumors

BACKGROUND Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare the outcomes of LPD and open pancreaticoduodenectomy (OPD). STUDY DESIGN Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database. RESULTS Lower BMI (23 vs 27 kg/m(2), p < 0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p < 0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF. CONCLUSIONS This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.

Laparoscopic left lateral resection is the gold standard for benign liver lesions: a case–control study

INTRODUCTION A left lateral section is the first choice for a laparoscopic anatomic liver resection. The objective of this case-control study was to assess the surgical outcome after a laparoscopic left lateral resection for benign liver lesions compared with the open approach. METHODS From January 2004 to April 2011, 31 laparoscopic left lateral resections were matched with 31 open left lateral resections by selection based on pathology of the lesion, size of the lesion, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), age and gender of the patient. RESULTS Duration of the operation (laparoscopic: 182 ± 71 versus open: 244 ± 105 min; P = 0.04), blood loss (223 ± 281 versus 455 ± 593 ml; P = 0.03), duration of hospital stay (4.1 ± 1.7 versus 8.1 ± 4.4 days; P < 0.001) and total cost of hospitalization (7475 ± 2679 versus 11504 ± 7776 Euros; P < 0.001) were significantly lower in the laparoscopic group. CONCLUSIONS This matched case-control study demonstrated procedural safety, excellent post-operative outcomes and economic benefits for a laparoscopic liver resection. A laparoscopic left lateral liver sectionectomy is recommended as a gold standard for benign liver lesions.

Umbilical hernias and cirrhose.

Umbilical hernia (UH) is the most frequent abdominal wall complication of ascites in cirrhotic patients. Treatment to control ascites, which mainly consists of repeated paracentesis or transjugular intrahepatic portosystemic shunt (TIPS), is mandatory; otherwise the risk of hernia recurrence is very high. Nowadays, surgical portosystemic shunts are rarely performed. Classically, hernia repair was offered only to patients with symptomatic UH, but presently, even if the hernia is minimally symptomatic, there is tendency to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (rupture and strangulation). If liver transplantation is indicated, treatment of UH can be performed simultaneously, unless the hernia is highly symptomatic or complicated or if the waiting time on the transplantation list is long. During repair, necrotic skin tissue should be excised; the use of prosthetic material (if the defect is large) is possible with a low risk of infection as long as ascites is sterile. The advantage of laparoscopic repair of large UH is to avoid any skin incision (precluding ascitic fluid leak) and avoid exposing prosthetic mesh to necrotic infected tissue. If the defect is small, UH repair can be performed under local anesthesia.

The recipient celiac trunk as an alternative to the native hepatic artery for arterial reconstruction in adult liver transplantation

During liver transplantation (LT), the recipient hepatic artery (RHA) cannot always be used, and alternatives include aortohepatic conduits and the splenic artery (SA). We report our experience with arterial reconstruction on the recipient celiac trunk (RCT), which has rarely been described. Since January 2013, we have been using the RCT when the RHA could not be used. All cases were discussed in a multidisciplinary LT meeting, and arterial patency or anomalies were systemically viewed with computed tomography (CT) scan. The RCT was used after section‐ligation of all celiac trunk collaterals. Until May 2014, the RHA could not be used in 11/139 (8%) patients who underwent LT. Postoperative arterial patency was assessed by serial Doppler ultrasound and CT scan. The advantages and disadvantages of the different arterial conduits were evaluated. The RCT was used in 7/11 (64%) patients. Mean follow‐up was 10 (6‐15) months. The patency rate was 100%, and 1 patient with associated portal shunting died at day 20 from septic complications. No related gastric or splenic complications were encountered. The RCT could not be used in 4 patients with reconstruction on the SA (n = 2), infrarenal (n = 1), and supraceliac aorta (n = 1). The patency rate was 75%. One patient with SA conduit and portal shunting developed pancreatitis/anastomotic pseudoaneurysm with secondary rupture. An emergency infrarenal conduit was created, which was later embolized because of infected pseudoaneurysms. Although the literature reports a higher risk of thrombosis with aortohepatic conduits, no long‐term results are available for the SA conduits, and only 1 report is available for the RCT. In conclusion, this study shows that the RCT is a good alternative to the RHA and can be used in two‐thirds of patients with inadequate RHA flow. Liver Transpl 21:1133‐1141, 2015.

Liver transplantation and splenic artery steal syndrome: The diagnosis should be established preoperatively

We read with interest the article entitled “ContrastEnhanced Ultrasound Diagnosis of Splenic Artery Steal Syndrome After Orthotopic Liver Transplantation” by Zhu et al., which was published in the August 2012 issue of Liver Transplantation. The authors report the value of contrast-enhanced ultrasound in the diagnosis of splenic artery steal syndrome (SASS) in patients who have undergone orthotopic liver transplantation (LT). Two hundred thirty-six of 274 patients who underwent LT were studied. Eight patients (3.4%) with reduced arterial flow on color Doppler flow imaging underwent contrast-enhanced ultrasound and were shown to have delayed arterial contrast wash-in enhancement, which supports a diagnosis of SASS. The diagnosis was confirmed by arteriography, which showed rapid splenic artery (SA) and delayed hepatic artery (HA) perfusion. SA embolization resulted in increased HA flow and decreased portal vein flow. In our opinion, arterial abnormalities such as a celiac trunk arcuate ligament and SASS are significant risk factors for postoperative arterial complications and are probably underestimated in patients who are candidates for LT. Thus, we are in complete agreement with the authors that this is an interesting topic and that the diagnosis can be made with this new imaging modality. However, we feel that the diagnosis should be made or considered preoperatively or intraoperatively rather than postoperatively. SASS is observed in patients with hypersplenism or portal hyperperfusion with a weak HA flow (buffer effect). These abnormalities are routinely sought in our practice, and the diagnosis can be suspected or made simply with a computed tomography (CT) scan when the SA is larger than the HA or on the basis of the volume of the spleen. If SASS is suspected, we intraoperatively evaluate the HA flow with and without SA occlusion. If the arterial flow improves during occlusion of the SA, the SA is ligated, or an arterial anastomosis is performed directly on the SA, especially if the recipient’s HA is small and atrophied with the risk of subsequent anastomotic stenosis. We performed LT 115 times in the past 13 months, and 9 patients (8%) had confirmed SASS. The difference between the diameters of the SA at its curve and the common HA (SA diameter 2 HA diameter) was studied in 97 patients who underwent preoperative CT scanning or magnetic resonance imaging. The mean difference in the diameters was 6 mm (4-10 mm) for patients with SASS and 1 mm (27 to 5 mm) for patients without SASS. For the 9 patients with confirmed SASS, the diagnosis was made intraoperatively in 8 cases; an arterial anastomosis was performed directly on the SA in 4 patients and on the HA in 4 patients associated with SA ligation. In 1 patient, the diagnosis was made postoperatively on the basis of a weak flow in the HA and biliary complications leading to SA embolization. In the subgroup of patients with an intraoperative diagnosis (n 5 8), for 1 patient had retransplantation for delayed HA thrombosis (2 years after LT) probably related to misdiagnosed SASS, and 1 patient developed an arterial anastomotic pseudoaneurysm treated by embolization, but none developed splenic infarction. In the other subgroup (n 5 106), 5 patients (5%) underwent an arcuate ligament section, and 5 (5%) developed postoperative arterial complications represented by anastomotic stenosis (n 5 2), HA thrombosis (n 5 2), or anastomotic pseudoaneurysm (n 5 1). These complications were probably related to a misdiagnosed arcuate ligament (n 5 1) and led to retransplantation [n 5 2 (1 with an arcuate ligament)], angioplasty (n 5 2), and pseudoaneurysm embolization (n 5 1) with secondary fatal rupture. This strategy is probably more effective than postoperative screening alone, in which certain cases may be misdiagnosed or present as arterial thrombosis or anastomotic stenosis of unknown causes. Although the authors of this series reported 3

Laparoscopic pancreaticoduodenectomy: How I do it? (with video)

Please cite this article in press as: Dokmak S, et al. Laparoscopic pancreaticoduodenectomy: How I do it? (with video). Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.09.011 Laparoscopic approach; Surgical technique approach [1,2], in our experience, LPD (n = 46) was associated with increased morbidity compared to the open approach but the outcome was favorable in patients at lower risk of pancreatic fistula [3]. This video clearly shows different steps necessary to perform safely LPD. We would like mainly to emphasize on the most important technical points. Before Kocher manoeuvre, the gastroepiploic vein of Henle was rapidly controlled and ligated to avoid tearing and bleeding during mobilization of the mesocolon. After division of the bile duct and hepatic pedicle lymphadenectomy, the distal antrum is stapled and lymphadenectomy of the hepatic artery is completed. The control of the gastroduodenal artery is facilitated by the division of the pancreatic gland. Gastroenteric anastomosis can be done by stapler or extra-corporally (hand sewn) by very small midline incision (4 cm), in which the specimen can be removed. We exposed briefly our results in 60 patients who underwent LPD between April 2011 and April 2015. The mean age was 59 (26—85) years, the mean body mass index (kg/m2) was 24 (17—33) and 60% were male. The main indications were pancreatic adenocarcinoma (n = 21, 35%), ampullary carcinoma (n = 13, 22%), neuroendocrine tumor (n = 8, 13%), nondegenerated intraductal papillary mucinous neoplasia (n = 7, 12%), bile duct cancer (n = 5, 8%), solid pseudopapillary neoplasm (2, 3%) and other (n = 4, 7%). The mean operative time was 352 (240—540) minutes, the mean blood loss was 375 (50—1200) mL, transfusion in 5 (8%) and conversion in 5 (8%). Postoperative mortality at 90 days was recorded in two patients (3%). Overall morbidity was observed in 41 (68%) and represented mainly by PF (overall = 26, 43%; grade C = 13, 22%), delayed gastric emptying (n = 9, 15%), bleeding (n = 13, 22%) and re-intervention (n = 12, 20%). The mean hospital stay was 23 (6—104) days and readmission in 5 (8%). In conclusion, this technique of LPD is associated with relatively short operative duration, low blood loss and very low rate of conversion. Giving the high morbidity related to the increased incidence and severity of PF, we believe

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

Experimental tools to identify human red blood cells (RBC) prone to mechanical retention upstream from the spleen venous sinus inter-endothelial slits are currently suboptimal. We designed a micro-bead device mimicking the geometry of the human narrow and short inter-endothelial slits. Upon filtration through a mixture of 5-25 μm diameter micro-beads, Plasmodium falciparum-hosting RBC (Pf-RBC) were retained in a parasite developmental stage-dependent way, the retention rates of a subset of ring-RBC being similar in micro-beads and in isolated-perfused human spleens. We found that this retention might be linked principally to the reduced surface-area-to-volume ratio of Pf-RBC. Interestingly, other rigid RBC, such as heat-treated RBC, and RBC from hereditary spherocytosis patients were also retained in micro-beads without any hemolysis. Micro-beads allow (i) depletion of heterogeneous RBC population from its rigid-RBC subpopulation ii) characteriziation of distinct molecular signatures of rigid versus deformable RBC subpopulations. This simple method portends wide medical applications, such as improving the quality of stored RBC concentrates prior to transfusion.

The use of a liver with a gunshot injury as a donor for auxiliary liver transplantation: Case report

INTRODUCTION liver transplantation can be the only treatment for acute liver failure. PRESENTATION OF CASE A 59 year-old female patient with acute liver failure due to mushroom poisoning underwent auxiliary liver transplantation. The liver graft was harvested from a brain-dead donor with a deep gunshot wound in the posterior sector of the graft. The postoperative course was uneventful with rapid recovery of the recipient and no complications associated with the gunshot wound. DISCUSSION Patients scheduled for urgent liver transplantation should have rapidly a liver graft otherwise the mortality rate is high. In our case, an injured liver graft by gunshot was successfully used allowing liver transplantation and increasing the pool of liver grafts. CONCLUSION A gunshot liver graft can be used if the major vascular or biliary structures are not injured.