Pierre Cattan

Ketosis-Prone Type 2 Diabetes Mellitus and Human Herpesvirus 8 Infection in Sub-Saharan Africans

CONTEXTnAn atypical form of type 2 diabetes mellitus (DM-2) is revealed by ketosis (ketosis-prone type 2 diabetes mellitus), frequently occurring in individuals who are black and of African origin, and characterized by an acute onset requiring transient insulin therapy. Its sudden onset suggests precipitating factors.nnnOBJECTIVEnTo investigate the putative role of human herpesvirus 8 (HHV-8) in the pathogenesis of ketosis-prone DM-2.nnnDESIGN, SETTING, AND PARTICIPANTSnA cross-sectional study in which antibodies were searched against latent and lytic HHV-8 antigens using immunofluorescence. The presence of HHV-8 in genomic DNA was investigated in 22 of the participants at clinical onset of diabetes. We also tested whether HHV-8 was able to infect human pancreatic beta cells in culture in vitro. The study was conducted at Saint-Louis University Hospital, Paris, France, from January 2004 to July 2005. All participants were black and of African origin: 187 were consecutive diabetic patients of whom 81 had ketosis-prone DM-2 and 106 had nonketotic DM-2, and 90 individuals were nondiabetic control participants who were matched for age and sex.nnnMAIN OUTCOME MEASURESnSeroprevalence of HHV-8 and percentage of patients with HHV-8 viremia at onset in ketosis-prone DM-2.nnnRESULTSnHHV-8 antibodies were found in 71 patients (87.7%) with ketosis-prone DM-2 vs 16 patients (15.1%) with nonketotic DM-2 (odds ratio, 39.9; 95% confidence interval, 17.1-93.4; P < .001) and 36 of the control participants (40.0%) (odds ratio, 10.7; 95% confidence interval, 4.9-23.4; P < .001). HHV-8 in genomic DNA was present in 6 of 13 patients with ketosis-prone DM-2 tested at acute onset and in 0 of 9 patients with nonketotic DM-2. HHV-8 proteins were present in human islet cells that were cultured for 4 days in the presence of HHV-8.nnnCONCLUSIONSnIn this preliminary cross-sectional study, the presence of HHV-8 antibodies was associated with ketosis-prone DM-2 in patients of sub-Saharan African origin. Longitudinal studies are required to understand the clinical significance of these findings.

Early assessment of apoptosis in isolated islets of langerhans

There is substantial evidence to link early graft loss after islet transplantation to isolation-induced islet cell apoptosis. Measurement of caspase 3 activity and detection of the lost cell membrane asymmetry, revealed by annexin V binding, are newly available assays that allow the analysis of early events of apoptosis.

Patterns of engraftment in different strains of immunodeficient mice reconstituted with human peripheral blood lymphocytes

Background. Models of immunodeficient mice reconstituted with a competent human immune system would represent an invaluable tool for the study of transplantation immunobiology allergy, autoimmunity, and infectious diseases. Severe combined immune deficiency (scid) mice can be successfully reconstituted with human peripheral blood lymphocytes (PBLs), but rates and levels of engraftment are poor. New strains of mice with diverse immunodeficiencies have been recently characterized or developed, which might prove to be advantageous for in vivo studies of human immune reactivity. Methods. We have compared rates and patterns of human PBL engraftment in four available immunodeficient murine strains; scid-beige, nonobese diabetic (NOD)-scid, NOD-scid-&bgr;2 m− and rag−. T- and B-lymphocyte engraftment, phenotype of engrafted cells, and occurrence of graft-versus-host disease (GVHD) were studied and compared. Results. Successful engraftment of human PBL was readily obtained in the majority of scid-beige, NOD-scid, and NOD-scid-&bgr;2 m− with a single i.p. administration of human PBLs, whereas it was seldom achieved in rag− animals. Human Ig levels were accordingly remarkably low in rag− recipients but, interestingly also in NOD-scid-&bgr;2 m− mice. Engraftment was readily observed not only in peripheral blood but also in spleen and bone marrow of successfully reconstituted animals. Phenotypic analysis of engrafted human cells showed preserved CD4/CD8 ratios and a clear skewing toward an activated phenotype. GVHD was invariably observed in successfully reconstituted animals. Conclusions. Our data indicate that a high rate of reconstitution with human lymphocytes can be achieved in scid-beige, NOD-scid, and NOD-scid-&bgr;2 m− mice. Human Ig are produced at high levels, except in NOD-scid-&bgr;2 m−, including xenoreactive natural antibodies. Scid-beige and NOD-scid appear therefore better suited than NOD-scid-&bgr;2 m− or rag− for analysis of human immunoreactivity in vivo. An important caveat is the invariable occurrence of GVHD that precludes long-term studies in this model system.

Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy

BackgroundEsophagectomy is the standard of care for high-grade corrosive esophageal necrosis as assessed endoscopically. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to unnecessary esophageal resection, with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of endoscopic high-grade corrosive esophageal necrosis.MethodsIn a before (2000–2007)/after (2007–2012) study of patients with grade 3b endoscopic esophageal necrosis, we compared outcomes after routine emergency esophagectomy versus selection for emergency esophagectomy based on CT evidence of transmural necrosis, defined as at least two of the following: esophageal-wall blurring, periesophageal-fat blurring, and the absence of esophageal-wall enhancement. Survival estimated using the Kaplan–Meier method was the primary outcome.ResultsCompared to the routine-esophagectomy group (nxa0=xa0125), the CT group (nxa0=xa072) had better overall survival in the crude analysis (hazard ratio [HR], 0.43; 95xa0% confidence interval [95xa0%CI], 0.21–0.85; Pxa0=xa00.015) and in the analysis matched on gender, age, and ingested agent (HR, 0.36; 95xa0%CI, 0.16–0.79; Pxa0=xa00.011). No deaths occurred among patients managed without emergency esophagectomy based on CT findings, and one-third of CT-group patients had their functioning native esophagus at last follow-up. Self-sufficiency for eating and breathing was more common (84xa0% vs. 65xa0%; relative risk [RR], 1.27; 95xa0%CI, 1.04–1.55; Pxa0=xa00.016) and repeat suicide less common (4xa0% vs. 15xa0%; RR, 0.27; 95xa0%CI, 0.09–0.82; Pxa0=xa00.019) in the CT group.ConclusionThe decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.

Lipome colique : cas clinique et revue de la littérature

Colonic lipoma is a rare benign tumor infrequently met in clinical practice. We report a case of symptomatic lipoma of the ascending colon in a 61-year-old woman. Diagnosis was suspected on CT scan. Colotomy with lipectomy was performed. The diagnosis was confirmed by histological examination. Reviewing the literature and combining with our experience, we discuss the clinical features, diagnosis and treatment of this uncommon disease.

Splénectomie partielle par laparoscopie et ultracision©: À propos de deux cas

For the extirpation of a benign splenic cyst, partial splenectomy is an appropriate approach, since there is significant long-term morbidity following total splenectomy. We report two cases of laparoscopic partial splenectomy for benign splenic cyst. The use of the harmonic scalpel along with segmental ligation of the splenic pedicle allowed the completion of these interventions with minimal blood loss.Resume En cas de tumeur benigne splenique, il semble licite de proposer une splenectomie partielle ; la splenectomie totale entrainant une morbidite propre a long terme. Nous rapportons ici deux cas de splenectomie partielle par laparoscopie pour lesion kystique splenique. L’utilisation de l’ultracision©, associee au clampage segmentaire du pedicule splenique, a permis de realiser cette intervention avec des pertes sanguines minimes.

Similar Outcomes After Primary and Secondary Esophagocoloplasty for Caustic Injuries

BACKGROUNDnThe main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce.nnnMETHODSnThe operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty.nnnRESULTSnOperative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001).nnnCONCLUSIONSnSecondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent.

AbstractBackgroundnThe mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown.MethodsFrom January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51xa0%) and the median age was 44xa0years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59xa0%), strong acids in 36 patients (25xa0%), and bleach in 23 patients (16xa0%). Emergency and long-term outcomes were compared according to the nature of the ingested agent.ResultsFour patients died (3xa0%) and 40 patients (28xa0%) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13xa0%, pxa0=0.042) and duodenal (9 vs. 0xa0%, pxa0=xa00.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12xa0%, pxa0=xa00.98). No significant differences were recorded between emergency mortality (9 vs. 1xa0%, pxa0=xa00.15), morbidity (33 vs. 33xa0%, pxa0=xa00.92), the need for esophageal reconstruction (25 vs. 20xa0%, pxa0=xa00.88), and functional success rates (76 vs. 84xa0%, pxa0=xa00.31) after acid and alkali ingestion, respectively.ConclusionBleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

Emergency Management of Caustic Injuries

Ingestion of corrosive agents, accidentally or with suicidal intent, is a rare but potentially devastating event [1]. Most patients present with mild injuries that resolve without sequels, but surgery is necessary in a small number of patients for the treatment of more severe injuries [1]. Emergency management of caustic injuries requires a multidisciplinary approach and involves emergency care physicians, surgeons, anesthesiologists, gastroenterologists, radiologists, otorhynolaryngologists, and psychiatrists [2].

The cervicosternolaparotomy approach for the treatment of graft dysfunction after retrosternal esophageal reconstruction for caustic injuries

OBJECTIVEnThe study purpose was to report the indications, technical aspects, and outcomes of cervicosternolaparotomy during revision surgery after esophageal reconstruction for caustic injuries.nnnMETHODSnPatients who underwent cervicosternolaparotomy during revision surgery for graft dysfunction between 1999 and 2015 were included. Cervicosternolaparotomy was performed to mobilize and pull up the primary conduit during surgery for strictures (rescue cervicosternolaparotomy) or to allow retrosternal access for management of other graft-related complications (exposure cervicosternolaparotomy). Statistical tests were performed to identify factors associated with primary conduit preservation during rescue cervicosternolaparotomy.nnnRESULTSnFifty-five patients were included (28 men; median age, 43xa0years). Median delay between primary reconstruction and cervicosternolaparotomy was 15xa0months. Exposure cervicosternolaparotomy was performed in 12 patients (22%) for redundancy (nxa0=xa08), spontaneous perforation (nxa0=xa02), and caustic reingestion (nxa0=xa02). Rescue cervicosternolaparotomy was performed in 43 patients (78%) to treat supra-anastomotic (nxa0=xa011), anastomotic (nxa0=xa023), and diffuse (nxa0=xa09) stenosis. During rescue cervicosternolaparotomy, the primary conduit was preserved in 32 patients; median length gain obtained by transplant release was 8xa0cm. Failure to preserve the primary conduit was associated with previous surgical repair attempts (Pxa0=xa0.003) and lack of initial concomitant pharyngeal reconstruction (Pxa0=xa0.039). Two patients died (4%), and 35 patients (64%) experienced operative complications. Operative outcomes were similar after rescue and exposure cervicosternolaparotomy. With a median follow-up of 4.4xa0years, the functional success rate was 85%.nnnCONCLUSIONSnCervicosternolaparotomy during revision surgery for graft dysfunction is reliable, is associated with low morbidity and mortality, and has good results.