Hélène Behal

Laparoscopic Versus Open Surgery for Gastric Gastrointestinal Stromal Tumors: What Is the Impact on Postoperative Outcome and Oncologic Results?

OBJECTIVESnThe aim of the study was to compare the postoperative and oncologic outcomes of laparoscopic versus open surgery for gastric gastrointestinal stromal tumors (gGISTs).nnnBACKGROUNDnThe feasibility of the laparoscopic approach for gGIST resection has been demonstrated; however, its impact on outcomes, particularly its oncologic safety for tumors greater than 5u200acm, remains unknown.nnnMETHODSnAmong 1413 patients treated for a GIST in 61 European centers between 2001 and 2013, patients who underwent primary resection for a gGIST smaller than 20u200acm (Nu200a=u200a666), by either laparoscopy (group L, nu200a=u200a282) or open surgery (group O, nu200a=u200a384), were compared. Multivariable analyses and propensity score matching were used to compensate for differences in baseline characteristics.nnnRESULTSnIn-hospital mortality and morbidity rates in groups L and O were 0.4% versus 2.1% (Pu200a=u200a0.086) and 11.3% vs 19.5% (Pu200a=u200a0.004), respectively. Laparoscopic resection was independently protective against in-hospital morbidity (odds ratio 0.54, Pu200a=u200a0.014). The rate of R0 resection was 95.7% in group L and 92.7% in group O (Pu200a=u200a0.103). After 1:1 propensity score matching (nu200a=u200a224), the groups were comparable according to age, sex, tumor location and size, mitotic index, American Society of Anesthesiology score, and the extent of surgical resection. After adjustment for BMI, overall morbidity (10.3% vs 19.6%; Pu200a=u200a0.005), surgical morbidity (4.9% vs 9.8%; Pu200a=u200a0.048), and medical morbidity (6.2% vs 13.4%; Pu200a=u200a0.01) were significantly lower in group L. Five-year recurrence-free survival was significantly better in group L (91.7% vs 85.2%; Pu200a=u200a0.011). In tumors greater than 5u200acm, in-hospital morbidity and 5-year recurrence-free survival were similar between the groups (Pu200a=u200a0.255 and Pu200a=u200a0.423, respectively).nnnCONCLUSIONSnLaparoscopic resection for gGISTs is associated with favorable short-term outcomes without compromising oncologic results.

Impact of laparoscopic sacrocolpopexy learning curve on operative time, perioperative complications and short term results

OBJECTIVEnLaparoscopic sacrocolpopexy (LSCP) learning is a challenge for unexperienced surgeons, since complications occurrence and anatomical results could depend from surgeons experience. The aim of this study was to describe LSCP characteristics, perioperative complications and short term anatomical results when LSCP was performed by LSCP-experienced surgeons or trainees.nnnSTUDY DESIGNnPatients who underwent LSCP in our surgical unit in the last ten years were included. Patients were excluded if laparotomy was performed without any laparoscopic time. Interventions were divided into LSCP experienced surgeons (who had performed at least 30 procedures) and trainees (residents, fellows, and surgeons with less than 30 procedures). Main outcomes were operative time, peroperative complications (included conversions to open or vaginal surgery, bladder and vaginal perforation, epigastric vessels injury and hemorrhage) early postoperative complications, mesh complications and anatomical results at three months.nnnRESULTSn492 patients were included, 108 in the trainee group and 384 in the LSCP-experienced group. Groups were comparable for demographics, preoperative clinical examination and surgery characteristics. Average operative time was significantly higher in trainees group than in LSCP-experienced group (251 versus 178 min (p<0.0001)). There was no difference in open surgery conversion rate (5.6% versus 3.9%, p=0.42) or peroperative complication occurrence (4.7% versus 4.6%, p=0.98). Bladder perforations were more frequent in trainee group but difference was not statistically significant (3.7% versus 1.3%, p=0.11). 98% patients were assessed at three months. Overall anatomical success rate was 94.9%. There was no difference in anatomical failure rate between trainee group and LSCP experienced surgeons group (respectively 4.7% versus 5.2%, p=0.82), neither in mesh complication rate (3.9% versus 2.8%, p=0.77).nnnCONCLUSIONnLSCP learning in an experimented surgical team induces high operative time, but remains safe for patient.

Cognitive disorders in Parkinson's disease: Confirmation of a spectrum of severity

INTRODUCTIONnClinical presentation and progression of cognitive disorders in Parkinsons disease (PD) is heterogeneous. Our objective was to confirm prospectively a previous exploratory cluster analysis based on retrospective data that identified five cognitive phenotypes in PD.nnnMETHODSnA model-based confirmatory cluster analysis was conducted on the results of neuropsychological tests administered in 156 PD patients from two European movement disorder centers (Lille, nxa0=xa081; Maastricht, nxa0=xa075). The number of clusters was determined on the basis of statistical criteria as well as clinical plausibility. A factorial discriminant analysis assessed the quality of the clusters separation.nnnRESULTSnA five-cluster model was statistically superior and clinically the most relevant. These clusters can be described as follows: 1) cognitively intact patients with high level of performance in all cognitive domains (25.64%), 2) cognitively intact patients slightly slower than those in cluster 1 (26.92%), 3) patients with deficits in executive functions (37.18%), 4) patients with severe deficits in all cognitive domains, particularly executive functions (3.20%), 5) patients with severe deficits in all cognitive domains, particularly working memory and recall in verbal episodic memory (7.05%). The groups differed in terms of age, apathy and frequency of hallucinations that were all higher in the clusters with cognitive deficits, and the duration of formal education was lower in those groups.nnnCONCLUSIONnWe confirm our previous exploratory analysis. Cognitive disorders in PD patients are heterogeneous and can be separated in five clusters ranging from patients with performance in the normal range to patients with severe disorders in all cognitive domains.

Growth Pattern in Paediatric Crohn Disease Is Related to Inflammatory Status.

Objectives: The respective role of disease activity and steroid therapy in growth impairment in paediatric-onset Crohn disease (CD) is still debated. Our aim was to investigate whether the growth pattern of children with CD was correlated with the inflammatory status during the disease course, regardless the cumulative duration of steroid therapy. Methods: One hundred and seven patients with a diagnosis of CD <17 years, followed during ≥2 years and for whom ≥2 height measures were available during follow-up, were identified between 1998 and 2010. Height, C-reactive protein (CRP), orosomucoid, and steroid therapy duration were collected at each visit. The relationship between the evolution of growth velocity and inflammatory status during follow-up was investigated using a linear mixed model with random coefficients. Results: Median age at diagnosis was 11.7 years (Q1–Q3: 9.8–13.5). Mean height for age (H/A) z score was 0.14u200a±u200a1.29 at diagnosis and 0.05u200a±u200a1.23 among the 75 patients who had reached their final height at maximal follow-up (median: 4.9 years; Q1–Q3: 3.8–6.4). Growth failure (H/A z score <−2) was present in 7 (8%) patients at diagnosis and 5 (5%) at maximal follow-up. Growth velocity was negatively correlated with the evolution of CRP (Pu200a<u200a0.0001) and orosomucoid (Pu200a<u200a0.0001) during follow-up. After adjustment for the cumulative duration of steroid therapy, these 2 correlations remained significant (CRP: Pu200a=u200a0.0008; orosomucoid: Pu200a<u200a0.0001). Conclusions: Children with CD with uncontrolled inflammatory status have a lower growth velocity. The inflammatory status should be kept as close to normal as possible in paediatric-onset patients with CD to optimize their growth pattern.

Management of severe fetal anemia by Doppler measurement of middle cerebral artery: are there other benefits than reducing invasive procedures?

OBJECTIVEnDoppler measurement of peak velocity of systolic blood flow in the middle cerebral artery (PVS-MCA) can safely replace invasive testing in the diagnosis of fetal anemia in Rh-alloimmunized pregnancies and PSV-MCA is now the reference technique. However, no study has evaluated its impact in antenatal care and in survival rate. Our objective was to evaluate the impact of the measurement of PVS-MCA in antenatal management and neonatal outcome in maternal red cell alloimmunization requiring in utero transfusion (IUT).nnnSTUDY DESIGNnRetrospective study between January 1999 and January 2013. We excluded all cases of hydrops without follow-up before first IUT. From 1999 to 2006, an IUT was indicated on the optical index at 450 nm (Period 1) and was then replaced by the use of PVS-MCA (Period 2).nnnRESULTSn77 patients were included, 39 in Period 1 (104 IUT) and 38 in Period 2 (89 IUT). 5 cases of hydrops fetalis (12.8%) were diagnosed during the follow up in Period 1 and none during Period 2. The average number of IUT, the delays between 2 IUT and between last IUET and birth were comparable. The total rate of complication per IUT during the first period was 9.6% vs 1.1% during the second one (p=0.01). The overall survival rate in our population was 34/39 (86.8%) during Period 1 vs 38/38 (100%) during Period 2.nnnCONCLUSIONnPSV-ACM allowed an improved monitoring with fewer occurrences of hydrops. Conversely, it did not modify antenatal management and timing of delivery.

Evidence-based neonatal unit practices and determinants of Postnatal corticosteroid-use in preterm births below 30 weeks ga in Europe. A population-based cohort study

Background Postnatal corticosteroids (PNC) were widely used to treat and prevent bronchopulmonary dysplasia in preterm infants until studies showed increased risk of cerebral palsy and neurodevelopmental impairment. We aimed to describe PNC use in Europe and evaluate the determinants of their use, including neonatal characteristics and adherence to evidence-based practices in neonatal intensive care units (NICUs). Methods 3917/4096 (95,6%) infants born between 24 and 29 weeks gestational age in 19 regions of 11 European countries of the EPICE cohort we included. We examined neonatal characteristics associated with PNC use. The cohort was divided by tertiles of probability of PNC use determined by logistic regression analysis. We also evaluated the impact of the neonatal unit’s reported adherence to European recommendations for respiratory management and a stated policy of reduced PNC use. Results PNC were prescribed for 545/3917 (13.9%) infants (regional range 3.1–49.4%) and for 29.7% of infants in the highest risk tertile (regional range 5.4–72.4%). After adjustment, independent predictors of PNC use were a low gestational age, small for gestational age, male sex, mechanical ventilation, use of non-steroidal anti-inflammatory drugs to treat persistent ductus arteriosus and region. A stated NICU policy reduced PNC use (odds ratio 0.29 [95% CI 0.17; 0.50]). Conclusion PNC are frequently used in Europe, but with wide regional variation that was unexplained by neonatal characteristics. Even for infants at highest risk for PNC use, some regions only rarely prescribed PNC. A stated policy of reduced PNC use was associated with observed practice and is recommended.

Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial

PurposeStudies on the impact of tapered-cuff tracheal tubes on rates of microaspiration and ventilator-associated pneumonia (VAP) in intubated patients have reported conflicting results. The aim of this study was to determine the influence of this shape of tracheal cuff on abundant microaspiration of gastric contents in critically ill patients.MethodsAll patients intubated in the intensive care unit (ICU) and requiring mechanical ventilation for at least 48xa0h were eligible for this multicenter cluster-randomized controlled cross-over open-label study. The primary outcome was abundant microaspiration of gastric contents, defined by the presence of pepsin at significant level inxa0>30% of tracheal aspirates. Quantitative measurement of pepsin and salivary amylase was performed in all tracheal aspirates during the 48xa0h following enrollment.ResultsA total of 326 patients were enrolled in the ten participating ICUs (162 in the PVC tapered-cuff group and 164 in the standard-cuff group). Patient characteristics were similar in the two study groups. The proportion of patients with abundant microaspiration of gastric contents was 53.5% in the tapered-cuff and 51.0% in the standard-cuff group (odds ratio 1.14, 95% CI 0.72–1.82). While abundant microaspiration of oropharyngeal secretions was not significantly different (77.4 vs 68.6%, pxa0=xa00.095), the proportion of patients with tracheobronchial colonization was significantly lower (29.6 vs 43.3%, pxa0=xa00.01) in the tapered-cuff than in the standard-cuff group. No significant difference between the two groups was found for other secondary outcomes, including ventilator-associated events and VAP.ConclusionsThis trial showed no significant impact of tapered-cuff tracheal tubes on abundant microaspiration of gastric contents.Trial registrationClinicalTrials.gov, number NCT01948635.

The MAPT gene is differentially methylated in the progressive supranuclear palsy brain.

Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease causing parkinsonian symptoms. Altered DNA methylation of the microtubule‐associated protein tau gene correlates with the expression changes in Alzheimers disease and Parkinsons disease brains. However, few studies examine the sequences beyond the constitutive promoter.

Predictors of lung function test severity and outcome in systemic sclerosis-associated interstitial lung disease

Systemic sclerosis-related interstitial lung disease (SSc-ILD) is the leading cause of death in SSc. In this study, we aimed to describe the baseline severity and evolution of forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) in patients with SSc-ILD and to assess the baseline clinical, biological and high-resolution CT scan (HRCT) predictors of this evolution. Baseline and serial FVC and DLCO were collected in 75 SSc-ILD patients followed during 6.4±4.2 years (n = 557 individual data). FVC and DLCO evolution was modelled using a linear mixed model with random effect. During follow-up, FVC was stable while DLCO significantly decreased (-1.5±0.3%/year (p<0.0001). Baseline NYHA functional class III/IV, extensive SSc-ILD on HRCT and DLCO<80% were associated with a lower baseline FVC. Absence of digital ulcers extensive SSc-ILD, and FVC<80% and were associated with a lower baseline DLCO. Presence or history of digital ulcers and presence of pulmonary hypertension at baseline or during follow-up were associated with a faster decline of DLCO overtime. Neither age, gender, subtype of SSc nor specificity of autoantibodies were associated with baseline severity or outcome of lung function tests. In this SSc-ILD population, FVC was therefore stable while DLCO significantly declined over time. ILD extension was associated with baseline FVC and DLCO but not with their evolution. Presence or history of digital ulcers and pulmonary hypertension were predictors of a faster decline of DLCO over time.

Complications and reoperations after laparoscopic sacrocolpopexy with a mean follow-up of 4 years

Introduction and hypothesisThere is a lack of knowledge concerning long-term reoperation and complications after laparoscopic sacrocolpopexy (LSCP). We analyzed the rates and indications and potential risk factors for reoperation after LSCP in a large series of consecutive patients.MethodsThis was a single-center, retrospective study including all patients who underwent LSCP between 2003 and 2013. Data regarding pelvic organ prolapse (POP), surgical modalities and perioperative complications were collected. Patients were then contacted by telephone or postal letter in 2014. The main outcome criteria were grade III Dindo classification complications: reoperation for POP recurrence, mesh complications, and urinary incontinence (UI).ResultsBetween January 2003 and December 2013, a total of 464 consecutive patients (mean age, 59xa0years) underwent LSCP. Almost all (99.1xa0%) patients presented with POP ≥ grade 3 (POP-Q classification). Long-term evaluations were completed for 391 (84.1xa0%) patients. The median follow-up was 53.5u2009±u200928.2xa0months. The global reoperation rate was 12.5xa0%. The main reoperation indications were UI-related surgery in 21 patients (5.5xa0%), POP recurrence surgery in 20 patients (5.1xa0%), and mesh-related surgery in 11 patients (2.8xa0%). Multivariate analysis showed that older age at the time of initial surgery and concomitant subtotal hysterectomy were significant protective factors against global reoperation (HRu2009=u20090.606, CI 95xa0% [0.451–0.815] and 0.367, CI 95xa0% [0.193–0.698] respectively) and reduced the risk of POP recurrence surgery.ConclusionProlapse recurrence and mesh-related surgery occurred in 5.1 and 2.8xa0% of patients respectively, 4xa0years after laparoscopic sacrocolpopexy. Age and concomitant subtotal hysterectomy could play a role in the incidence of long-term reoperation.