Edith Koning

Operative Stress Response Is Reduced After Laparoscopic Compared toOpen Cholecystectomy

Our objective was to determine the least invasive surgical procedure; to do this we compared postoperative pain, duration of ileus, and level of neurohormonal stress response after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). Postoperative recovery of patients was faster after LC than OC but comparison of the neurohormonal stress response after laparoscopic and open surgical procedures revealed conflicting results. Forty-one consecutive patients with noncomplicated gallstones were randomized for LC (N = 25) and OC (N = 16). The stress level was evaluated in patients before surgery by the Hamilton anxiety scale. Postoperative pain was assessed by a visual analogic scale (VAS) pain score and by the amount of analgesic drugs (propacetamol) administered, while the duration of ileus was determined by the delay between surgery and the time to first passage of flatus as well by the colonic transit time (CTT) measured by radiopaque markers. Plasma concentrations of anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), β-endorphin (BE), neurotensin (NT), and aldosterone (Ald) were measured before and during surgery as well as 2 and 5 hr after the surgery (D0) and on the day following surgery (D1). Urinary cortisol (uCOR) and urinary catecholamine metabolites were assessed before surgery, during D0, and on D1. Patient characteristics, the duration of surgery, and the doses of anesthetic drugs were not different in LC and OC. In LC patients the VAS pain score and the doses of postoperative antalgics were lower (P < 0.05), the time to first passage of flatus was shorter (P < 0.001), and the CTT tended to be shorter (54 ± 12 hr vs 81 ± 17) compared to OC patients. Patients who required the highest doses of postoperative antalgics had the longest delay to first passage of flatus (P < 0.01). During surgery, all neurohormonal parameters increased compared to the preoperative period (P < 0.05), and only plasma NT concentrations were lower during LC than OC (P < 0.05). During the postoperative period, ACTH, BE, Ald, catecholamines, and uCOR concentrations were lower in LC than in OC (P < 0.05). Concentrations of hormonal parameters were higher when the duration of surgery increased (P < 0.05). A greater need for propacetamol to relieve pain was associated with a greater increase in BE, ACTH, and urinary catecholamine levels (P < 0.05–P < 0.005). When the time to first passage of flatus was delayed, levels of BE, ACTH, and catecholamines and NT concentrations were increased (P < 0.05–P < 0.005). In conclusion, LC is less invasive because this surgical procedure induces a shorter neurohormonal stress response than OC, even if the peroperative response is not different. Postoperative pain levels and the duration of ileus are associated with BE, ACTH, and catecholamine levels and NT concentrations, suggesting the importance of hormones in postoperative functional recovery.

Radiologic evaluation of pelvic floor disorders.

Several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI for the evaluation of patients with pelvic floors disorders. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes. This article focuses on standard imaging procedures including defecography, ultrasonography, and MRI and discusses its use in clinical practice by illustrating both normal and abnormal patterns.

Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear.

Background: Disruption of the anal sphincter occurs in 0.6%–6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third‐degree obstetric tear in order to compare the findings with the clinical outcome. Methods: Twenty‐one women aged 27–41 (mean 31.5 years) who had undergone primary suture of a third‐degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery. Results: Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 ± 23 cm H 2 O) than in incontinent women (48 ± 36 cm H 2 O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome. Conclusion: After primary repair of a third‐degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.

Focal nodular hyperplasia occurring after blunt abdominal trauma

Focal nodular hyperplasia of the liver is a benign neoplasm. The pathogenesis is unknown, but it was hypothesized that focal nodular hyperplasia may be a response to a vascular abnormality. We report on a case of focal nodular hyperplasia that developed in a young patient 1 year after a blunt hepatic injury.

Autologous Myoblasts for the Treatment of Fecal Incontinence: Results of a Phase 2 Randomized Placebo-controlled Study (MIAS)

Objective: The aim of this study was to evaluate the efficacy of intrasphincteric injections of autologous myoblasts (AMs) in fecal incontinence (FI) in a controlled study. Summary of Background Data: Adult stem cell therapy is expected to definitively cure FI by regenerating damaged sphincter. Preclinical data and results of open-label trials suggest that myoblast therapy may represent a noninvasive treatment option. Methods: We conducted a phase 2 randomized, double-blind, placebo-controlled study of intrasphincteric injections of AM in 24 patients. The study compared outcome after AM (n = 12) or placebo (n = 12) injection using Cleveland Clinic Incontinence (CCI), score at 6 and 12 months. Patients in the placebo group were eligible to receive frozen AM after 1 year. Results: At 6 months, the median CCI score significantly decreased from baseline in both the AM (9 vs 15, P = 0.02) and placebo (10 vs 15, P = 0.01) groups. Hence, no significant difference was found between the 2 groups (primary endpoint) at 6 months. At 12 months, the median CCI score continued to ameliorate in the AM group (6.5 vs 15, P = 0.006), while effect was lost in the placebo group (14 vs 15, P = 0.35). Consequently, there was a higher response rate at 12 months in the treated than the placebo arm (58% vs 8%, P = 0.03). After delayed frozen AM injection in the placebo group, the response rate was 60% (6/10) at 12 months. Conclusions: Intrasphincteric AM injections in FI patients have shown tolerance, safety, and clinical benefit at 12 months despite a transient placebo effect at 6 months.

Defecographic disorders in anal incontinent women: Relation to symptoms and anal endosonographic patterns

Objective The need for a defecography in incontinent women is still debatable. We prospectively evaluated the prevalence of defecographic abnormalities in incontinent women in order to determine whether any symptom or endosonographic findings could be associated with a particular defecographic pattern. Material and methods Fifty incontinent women (aged 30–87 years) underwent defecography and anal endosonography to look for pelvic floor descent, rectocele, intussusception, enterocele and the presence of anal sphincter defects. Other symptoms, i.e. straining at stools and pelvic pressure, were recorded. Results Twenty-five cases of external sphincter defect (12 associated with an internal defect) and 4 cases of isolated internal defect were identified. Defecography identified 25 patients with perineal descent at rest, 28 with perineal descent at straining, 30 with rectocele, 30 with intussusception and 14 with enterocele. Three defecographies were normal. In the 29 women with sphincter defects, the prevalence of defecographic abnormalities did not differ from that observed in the 21 women without sphincter defects. In women complaining of straining at stools (n=26) or idiopathic pelvic pressure (n=32), the prevalence of defecographic abnormalities did not differ from that observed in women who did not have these symptoms. Conclusions The prevalence of pelvic floor disorders in incontinent women was similar whether associated symptoms or anal sphincter defects were present or not. When defecography has to be performed to investigate female anal incontinence, neither clinical nor endosonographic features can predict a higher diagnostic efficiency.

Magnetic resonance imaging may predict deep remission in patients with perianal fistulizing Crohn's disease

AIM To evaluate the imaging course of Crohn’s disease (CD) patients with perianal fistulas on long-term maintenance anti-tumor necrosis factor (TNF)-α therapy and identify predictors of deep remission. METHODS All patients with perianal CD treated with anti-TNF-α therapy at our tertiary care center were evaluated by magnetic resonance imaging (MRI) and clinical assessment. Two MR examinations were performed: at initiation of anti-TNF-α treatment and then at least 2 years after. Clinical assessment (remission, response and non-response) was based on Present’s criteria. Rectoscopic patterns, MRI Van Assche score, and MRI fistula activity signs (T2 signal and contrast enhancement) were collected for the two MR examinations. Fistula healing was defined as the absence of T2 hyperintensity and contrast enhancement on MRI. Deep remission was defined as the association of both clinical remission, absence of anal canal ulcers and healing on MRI. Characteristics and imaging patterns of patients with and without deep remission were compared by univariate and multivariate analyses. RESULTS Forty-nine consecutive patients (31 females and 18 males) were included. They ranged in age from 14-70 years (mean, 33 years). MRI and clinical assessment were performed after a mean period of exposure to anti-TNF-α therapy of 40 ± 3.7 mo. Clinical remission, response and non-response were observed in 53.1%, 20.4%, and 26.5% of patients, respectively. Deep remission was observed in 32.7% of patients. Among the 26 patients in clinical remission, 10 had persisting inflammation of fistulas on MRI (T2 hyperintensity, n = 7; contrast enhancement, n = 10). Univariate analysis showed that deep remission was associated with the absence of rectal involvement and the absence of switch of anti-TNF-α treatment or surgery requirement. Multivariate analysis demonstrated that only the absence of rectal involvement (OR = 4.6; 95%CI: 1.03-20.5) was associated with deep remission. CONCLUSION Deep remission is achieved in approximately one third of patients on maintenance anti-TNF-α therapy. Absence of rectal involvement is predictive of deep remission.

Cas anatomocliniqueCholangiopathie ischémique secondaire à des brûlures étenduesIschemic cholangiopathy induced by extended burns

Ischemic cholangiopathy is a recently described entity occurring mainly after hepatic grafts. Very few cases after intensive care unit (ICU) for extended burn injury were reported. We report the case of a 73-year-old woman consulting in an hepatology unit, for a jaundice appearing during a hospitalisation in an intensive care unit and increasing from her leaving from ICU, where she was treated for an extended burn injury. She had no pre-existing biological features of biliary disease. Biological tests were normal. Magnetic resonance imaging acquisitions of biliary tracts pointed out severe stenosing lesions of diffuse cholangiopathy concerning intrahepatic biliary tract, mainly peri-hilar. Biopsie from the liver confirmed the diagnosis, showing a biliary cirrhosis with bile infarcts. This case is the fourth case of ischemic cholangiopathy after extended burn injury, concerning a patient without a prior history of hepatic or biliary illness and appearing after hospitalisation in intensive care unit.

Cholangiopathie ischémique secondaire à des brûlures étendues

Ischemic cholangiopathy is a recently described entity occurring mainly after hepatic grafts. Very few cases after intensive care unit (ICU) for extended burn injury were reported. We report the case of a 73-year-old woman consulting in an hepatology unit, for a jaundice appearing during a hospitalisation in an intensive care unit and increasing from her leaving from ICU, where she was treated for an extended burn injury. She had no pre-existing biological features of biliary disease. Biological tests were normal. Magnetic resonance imaging acquisitions of biliary tracts pointed out severe stenosing lesions of diffuse cholangiopathy concerning intrahepatic biliary tract, mainly peri-hilar. Biopsie from the liver confirmed the diagnosis, showing a biliary cirrhosis with bile infarcts. This case is the fourth case of ischemic cholangiopathy after extended burn injury, concerning a patient without a prior history of hepatic or biliary illness and appearing after hospitalisation in intensive care unit.

Fiche de lecture des suppurations anoperineales en IRM

Objectifs Connaitre les grands cadres cliniques des suppurations ano-perineales et la place de l’IRM. Connaitre la technique de realisation d’une IRM ano-perineale. Savoir interpreter une IRM ano-perineale. Connaitre la classification anatomique des fistules en IRM. Connaitre les elements du score d’activite des suppurations ano-perineales en IRM. Messages a retenir L’IRM est l’examen cle pour le bilan des suppurations ano-perineales notamment dans le cadre de la maladie de Crohn. Une cartographie precise des lesions peut etre faite. Elle permet le diagnostic d’abces profond et evalue l’activite des trajets fistuleux identifies. Resume Le bilan morphologique des suppurations ano-perineales representees principalement par les atteintes ano-perineales de la maladie de Crohn repose aujourd’hui sur l’IRM. Elle a une place importante lorsqu’un traitement par anti-TNF est discute chez les patients ayant une atteinte severe de maladie de Crohn. Elle est realisee avec une antenne de surface, des sequences en T2 dans les 3 plans et en Tl avec injection. Elle permet le diagnostic precis des fistules et des abces. Une classification des fistules par rapport aux sphincters (inter/trans/extra-sphincteriennes) doit etre donnee. Le caractere actif d’une fistule (hypersignal T2 et prise de contraste) est important pour preciser le degre d’inflammation.