David Jérémie Birnbaum

A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study.

Objective: To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA). Background: Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed. Methods: All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy. Results: Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14–44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6–136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397). Conclusions: The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

Hydrolytic Fate of 3/15-Acetyldeoxynivalenol in Humans: Specific Deacetylation by the Small Intestine and Liver Revealed Using in Vitro and ex Vivo Approaches

In addition to deoxynivalenol (DON), acetylated derivatives, i.e., 3-acetyl and 15-acetyldexynivalenol (or 3/15ADON), are present in cereals leading to exposure to these mycotoxins. Animal and human studies suggest that 3/15ADON are converted into DON after their ingestion through hydrolysis of the acetyl moiety, the site(s) of such deacetylation being still uncharacterized. We used in vitro and ex vivo approaches to study the deacetylation of 3/15ADON by enzymes and cells/tissues present on their way from the food matrix to the blood in humans. We found that luminal deacetylation by digestive enzymes and bacteria is limited. Using human cells, tissues and S9 fractions, we were able to demonstrate that small intestine and liver possess strong deacetylation capacity compared to colon and kidneys. Interestingly, in most cases, deacetylation was more efficient for 3ADON than 15ADON. Although we initially thought that carboxylesterases (CES) could be responsible for the deacetylation of 3/15ADON, the use of pure human CES1/2 and of CES inhibitor demonstrated that CES are not involved. Taken together, our original model system allowed us to identify the small intestine and the liver as the main site of deacetylation of ingested 3/15ADON in humans.

Very Low Stapling of the Anal Canal in Laparoscopic Ileal Pouch-Anal Anastomosis

Performing a double-stapled ileal pouch-anal anastomosis requires very low stapling of the anal canal. However, this laparoscopic procedure is often difficult to perform. We describe here a transanal method of everting the rectum, which allows easier transection under visual control and a sufficiently low anastomosis. Once the entire colon and rectum have been dissected out at laparoscopy, a plastic tube is introduced per anum and advanced into the mid sigmoid. The rectum is then divided at the level of the rectosigmoid junction by an endostapler, which also attaches the plastic tube to the rectum. The colon specimen is removed by a small incision at the chosen stoma site. Gentle traction on the plastic tube at the perineum everts the rectal tube. The anal canal is then transected at the desired level relative to the dentate line.

Salvage Liver Transplantation for Hepatic Gas Gangrene

Hepatic gas gangrene is an uncommon situation mainly due to bacterial infection by Clostridium perfringens. It remains a life-threatening condition associated with a high mortality rate. Quick diagnosis and aggressive therapy including liver transplantation should be proposed to improve the outcome. This report describes a rare case of hepatic gas gangrene on native liver, secondary to iatrogenic hepatic artery thrombosis and instrumental biliary tree infection, which was successfully treated by liver transplantation.

Validation and comparison of the molecular classifications of pancreatic carcinomas

Four molecular classifications of pancreatic ductal adenocarcinoma (PDAC), biologically and clinically relevant and based on gene expression profiles, were established in the recent years, including the Collisson’s, Moffitt’s (“tumor” and “stroma” classifications), and Bailey’s classifications. The aim of this study was to validate the prognostic value of the Moffitt’s classifications and to compare the Collisson’s, Moffitt’s, and Bailey’s classifications in a large series of samples. We collected clinical and gene expression data of PDAC samples from 15 public data sets, resulting in a total of 846 primary cancer samples, including 601 with survival annotation. All samples were classified according to each of the four multigene classifiers. We confirmed the independent prognostic value of the Moffitt “tumor”, Moffitt “stroma”, and Bailey’s classifications, but not that of the Collisson’s classification. Despite a relatively low gene overlap, all classifications were associated with pathological grade, an important prognostic feature and reflect of intrinsic molecular characteristics of tumors. The concordance rate in term of “good-prognosis” vs. “poor-prognosis” prediction by classifiers was relatively high (from 73 to 86%) between the three “tumor” classifications based on tumor gene lists (Collisson, Moffitt “tumor”, Bailey), but low (from 50 to 60%) with the Moffitt’s stroma classification based on stroma genes. Multivariate analysis incorporating the four classifiers together retained as significant variables the Moffitt “stroma” and Bailey classifications, highlighting the complementarity of classifiers based on tumor epithelium (Bailey) and tumor stroma (Moffitt stroma). Our results reinforce the clinical validity of subtyping in PDAC, which should be regarded as a collection of separate diseases. Beside their clinical utility that remains to be demonstrated, the clinical interest of the subtypes, notably those from Bailey’s and Moffitt’s “stroma” classifiers that show independent prognostic value, will be reinforced by the identification of new biomarkers and/or therapeutic targets in each subtype for designing and testing novel specific targeted therapies.

Intussusception Involving the Roux-en-Y limb Following Gastric Bypass.

Rouxen-Y gastric bypass represents a therapeutic modality for the treatment of morbid obesity. This procedure has a number of well-documented risks, including anastomotic leaks, pulmonary embolism, and small-bowel obstruction. Internal hernias represent a specific surgical complication, with an incidence rate of 3.1 % after laparoscopic Rouxen-Y bypass. Here, we report an even rarer cause of late intestinal obstruction after laparoscopic Roux-en-Y bypass. A 38-year-old woman with a history of laparoscopic Rouxen-Y gastric bypass 5 years prior and a recent history of abdominoplasty was admitted to the emergency room with acute abdominal pain for 12 h, accompanied by nausea and vomiting. There was no similar abdominal pain. She had recently experienced dramatic weight loss but currently had normal vital signs. Physical investigation revealed diffuse pain, but no guarding or rebound tenderness. Bowel sounds were markedly reduced. Apyrexia was noted. Laboratory findings were normal (no increase in C-reactive protein and no leukocytosis were noted). Abdominal radiograph showed dilated intestinal loops suggesting intestinal obstruction. Considering this small-bowel obstruction, a contrast-enhanced computed tomography scan was performed, which revealed an intestinal intussusception at the stapled jejunojejunostomy proximal to a small-bowel dilatation (Fig. 1a, b). Surgery was required because of the risk of rapid small-bowel ischemia secondary to strangulation. At exploration via an upper midline laparotomy, a long segment of retrograde small-bowel intussusception with entry point slightly distal to the previous Roux-en-Y jejunojejunostomy was noted (Fig. 1c). After a manual reduction of the intussusception, an area of ischemia was observed. Approximately 10 cm of the small bowel was resected, and a latero-lateral manual jejuno-jejunal anastomosis was performed. The patient recovered from her bowel movement at day 3 after surgery. The postoperative course was uneventful, and she was discharged 7 days after surgery. Retrograde intussusception is a rare cause of intestinal obstruction following Rouxen-Y gastric bypass, and its incidence ranges between 0.07 and 0.6 % of patients. The physiopathology of retrograde intussusception remains unclear. Diagnosis may be difficult because symptoms are nonspecific. Pain is directly related to the duration of vascular compromise but is unrelated to the degree of intestinal obstruction. In most patients, there are no peritoneal signs and the patients have only an acute presentation, as Each author participated in the work and met all four criteria.

A large inguinoscrotal hernia with stomach content

An 86-year-old man was admitted in the emergency department for nausea and vomiting without acute abdominal pain. The patient’s antecedents were atrial fibrillation, chronic obstructive pulmonary disease and inguinoscrotal hernia since several years. The patient had normal vital signs. He had no history of abdominal surgery but had similar upper gastrointestinal symptoms in the past. Clinical examination revealed no abdominal distension but a large irreducible right inguinoscrotal hernia with digestive content which had progressively increased in several years. He had no pain or tenderness in this region. The scrotal skin did not appear thickened and no signs of cellulitis were found. Laboratory findings were normal, including neither increase C-reactive protein level nor leukocytosis. A contrast-enhanced computed tomography scan showed a large inguinoscrotal hernia containing the major part of the stomach. A major stomach distension was observed but did not appear to be ischemic or necrotic. There was neither perforation nor abdominal effusion (Figs 1,2). The patient was admitted in the abdominal surgery department. Considering his severe co-morbidities, medical treatment was undertaken and consisted in intravenous rehydration and continuous gastric aspiration with gastric tube. The patient fully recovered and no surgical treatment was necessary. The patient was discharged after 2 days. Inguinal hernia with stomach content is uncommon, whereas other contents such as omentum, small intestine, colon, appendix, fallopian tube and ovary are well described. Few cases are reported in the literature showing that the stomach may occasionally be included in the contents of an inguinal hernia and very rarely becomes strangulated. In our case, the stomach did not appear to be ischemic or necrotic and the contrast-enhanced computed tomography scan did not show perforation or abdominal effusion. Considering his severe co-morbidities, a medical treatment was undertaken. Indeed, the main problem for this patient was the potentially fatal cardiorespiratory failure. The latter could develop, following reduction of inguinoscrotal hernia contents that had lost their domain in the abdominal cavity, due to sudden increase in intra-abdominal pressure and elevation of the diaphragm. Even if it is uncommon, Fig. 1. Reconstructed CT image of the large inguinoscrotal hernia with stomach content.

Molecular classification as prognostic factor and guide for treatment decision of pancreatic cancer

Clinico-pathological factors fail to consistently predict the outcome after pancreatic resection for pancreatic ductal adenocarcinoma (PDAC). PDACs show a high level of inter- and intra- tumor genetic heterogeneity. A molecular classification should help sort patients into less heterogeneous and more appropriate groups regarding the metastatic risk and the therapeutic response, with the consequences of better predicting evolution and better orienting the treatment. PDAC can be classified based on mutational subtypes and 18gene alterations. Whole-genome sequencing identified mutational signatures, mutational burden and hyper-mutated tumors with specific DNA repair defects. Their overlap/similarities allow the definition of molecular subtypes. DNA and RNA classifications can be used in prognosis assessment. They are useful in therapeutic choice for they allow the design of approaches that can predict the respective drug sensitivity of each molecular subtype. This review provides a comprehensive analysis of available molecular classifications in PDAC and how this can help guide clinical decisions.

Fusion spléno-gonadique associée à une cryptorchidie intra-abdominale chez l'adulte

a fusion spléno-gonadique est une malformation congénitale rare correspondant à une fusion entre le parenchyme splénique et le testicule. Deux formes sont décrites : la forme continue lorsqu’il existe un cordon fibreux ou une continuité tissulaire entre la rate et le testicule et la forme discontinue quand la fusion des deux tissus est totalement séparée de la rate. Le diagnostic est généralement fait à l’âge pédiatrique devant une masse scrotale ou, plus rarement, dans le cadre de l’exploration d’une cryptorchidie. Nous rapportons un cas de fusion et cryptorchidie intra-abdominale chez un adulte de découverte fortuite sur un examen scanner.

Experimental Procedure of Compression Anastomosis Using Fragmented Rings: A Porcine Model

Background. Compression anastomosis has been recently abandoned because of a nonsuperiority compared to stapling anastomosis. Nonremoval of the rings has frequently been reported and this technique does not support a routine use. The aim of this experimental study was to assess the feasibility of anastomosis using compression with a device consisting of fragmented rings. Methods. A new compression device, the “Anastocom,” was compared to standard double-stapled colocolonic anastomosis in 2 groups of 8 pigs. In each group, colocolonic anastomosis was performed with a circular stapler (DST Series EEA Staplers) in 4 pigs and with the Anastocom device for the other 4 pigs. Results. The anastomotic rings were expelled between postoperative day 7 and day 13 from the 4 animals sacrificed at day 30. The anastomosis was clean and intact in all pigs. After sacrifice, there was no difference in the bursting pressure at day 7 (P = .226) or at day 30 (P = .885) between the 2 types of anastomosis. After sacrifice at day 7, the mean bursting pressure values for the Anastocom and EEA anastomoses were 128.6 mm Hg (range 119-143 mm Hg) and 218.9 mm Hg (range 84-240 mm Hg), respectively. After sacrifice at day 30, the mean bursting pressure values for the Anastocom and EEA anastomoses were 111 mm Hg (range 59-234 mm Hg) and 105 mm Hg (range 81-130 mmHg), respectively. Conclusion. No bowel obstruction was observed with Anastocom. This fragmentation mechanism should better prevent nonexpulsion compared to basic compression anastomosis.