R. Douard

Role of intraoperative enteroscopy in the management of obscure gastointestinal bleeding at the time of video-capsule endoscopy

BACKGROUND This study aimed at evaluating the role of intraoperative enteroscopy (IOE) for the management of obscure gastrointestinal (GI) bleeding in patients who had been preoperatively explored by video-capsule endoscopy (VCE). METHODS Eighteen patients who underwent IOE for obscure GI bleeding were prospectively recorded between November 2000 and January 2007. The bleeding site was preoperatively localized by VCE in the small bowel in 15 patients, but the origin of bleeding remained unknown in 3 patients. RESULTS In the 3 patients with negative VCE, IOE was normal, but intraoperative conventional endoscopy identified gastric (n = 1) and colonic (n = 2) lesions. Among the 15 patients with VCE positive for small-bowel lesions, laparotomy and IOE yielded localization and treatment (surgical n = 11 and endoscopic n = 2) guidance for 13 of 15 (87%) lesions. At median 19-month follow-up, 3 bleeding recurrences (3 of 15 [20%]) were recorded, resulting in a 73% therapeutic efficacy of IOE. CONCLUSIONS IOE remains useful for the management of obscure GI bleeding when preoperative VCE is positive for small-bowel lesions that are not reachable by nonoperative enteroscopy. When VCE is negative, new conventional endoscopy should be proposed instead of IOE.

Anatomy of the common trunk of the middle and left hepatic veins: application to liver transplantation

An anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the inferior vena cava of the donor is one of the techniques for restoration of hepato-caval continuity in orthotopic liver transplantation. This technique avoids dissection of the retrohepatic vena cava and total caval clamping. The aim of this study was to define the feasibility of this technique by a morphologic and biometric study of the common trunk of the middle and left hepatic veins on the basis of 64 injection-corrosion hepatic specimens and 21 fresh subjects. A common trunk for the middle and left hepatic veins was present in 54 of 64 cases (84%) with a length of 3 to 17 mm. The diameter of the new ostium constructed by section 0.5 cm proximal to the junction of the middle and left hepatic veins was 23.9 ± 2.3 mm, which approximated to that of the vena cava where it traversed the diaphragm (24.4 ± 2.0 mm). These findings confirmed that restoration of hepato-caval continuity by anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the vena cava of the graft is possible without incongruence. This study makes no assumptions about the hemodynamic effects associated with the smallest diameter of the true ostium of the common trunk at its opening into the inferior vena cava. In this study, the morphology of the common trunk was comparable to that observed by Nakamura. Further, we propose an anatomo-clinical classification allowing evaluation of the facility of vascular control of the common trunk in terms of the number and location of the collateral veins.

Assessment of a Standardized Pre-Operative Telephone Checklist Designed to Avoid Late Cancellation of Ambulatory Surgery: The AMBUPROG Multicenter Randomized Controlled Trial

Objectives To assess the impact of a standardized pre-operative telephone checklist on the rate of late cancellations of ambulatory surgery (AMBUPROG trial). Design Multicenter, two-arm, parallel-group, open-label randomized controlled trial. Setting 11 university hospital ambulatory surgery units in Paris, France. Participants Patients scheduled for ambulatory surgery and able to be reached by telephone. Intervention A 7-item checklist designed to prevent late cancellation, available in five languages and two versions (for children and adults), was administered between 7 and 3 days before the planned date of surgery, by an automated phone system or a research assistant. The control group received standard management alone. Main Outcome Measures Rate of cancellation on the day of surgery or the day before. Results The study population comprised 3900 patients enrolled between November 2012 and September 2013: 1950 patients were randomized to the checklist arm and 1950 patients to the control arm. The checklist was administered to 68.8% of patients in the intervention arm, 1002 by the automated phone system and 340 by a research assistant. The rate of late cancellation did not differ significantly between the checklist and control arms (109 (5.6%) vs. 113 (5.8%), adjusted odds ratio [95% confidence interval] = 0.91 [0.65–1.29], (p = 0.57)). Checklist administration revealed that 355 patients (28.0%) had not undergone tests ordered by the surgeon or anesthetist, and that 254 patients (20.0%) still had questions concerning the fasting state. Conclusions A standardized pre-operative telephone checklist did not avoid late cancellations of ambulatory surgery but enabled us to identify several frequent causes. Trial Registration ClinicalTrials.gov NCT01732159

L'artère hépatique gauche, variations anatomiques et implications cliniques

But de l’etude l’artere hepatique gauche est une composante anatomique de la vascularisation arterielle hepatique qui nait de l’artere gastrique gauche et chemine dans la pars condensa du petit omentum. La chirurgie gastrique, hiatale, bariatrique et la transplantation hepatique imposent souvent la section de cette artere. Le but de notre travail a ete de faire le point sur la frequence de l’artere hepatique gauche, son role dans la vascularisation hepatique et ses implications cliniques. Materiel et methodes une revue de la litterature a comporte l’analyse des principales series anatomiques, radiologiques et chirurgicales. Resultats l’artere hepatique gauche est la persistance a l’âge adulte de la branche arterielle vascularisant l’ebauche hepatique embryonnaire gauche. Elle vascularise un territoire variable du foie allant d’une partie du lobe gauche a la totalite du foie dans 1 % des cas. Sa frequence varie de 14 % a 27 % dans les series anatomiques, de 12 % a 20 % dans les etudes arteriographiques et de 12 % a 24 % dans les series de transplantation hepatiques. Des etudes cœlioscopiques ont rapporte une frequence plus elevee, allant de 18 % a 34 %. La difference de sensibilite des methodes de detection explique la difference des frequences observees. Conclusions la frequence de l’artere hepatique gauche est de 12 % a 24 %. Elle vascularise le plus souvent le lobe gauche, mais dans 1 % des cas la totalite du foie. Une parfaite connaissance de ces variations est donc necessaire au cours de la chirurgie gastrique, hiatale, bariatrique et hepatique.

Intraoperative Enteroscopy: Is There Still a Role?

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

Histological basis of the liver hanging maneuver

BackgroundLiver hanging maneuver (LHM) consists in passing a tape between the retrohepatic inferior vena cava (RHIVC) and the liver to perform various kinds of hepatectomies. LHM is a well-known procedure but its histological basis remains poorly documented.MethodsTen anatomical specimens comprising RHIVC, and surrounding hepatic parenchyma were studied after conventional staining and immunohistochemistry with specific antibody for alpha smooth muscle actin.ResultsRHIVC wall structure consists of a thick muscular layer of longitudinal smooth muscle fibers and a peripheral loose connective tissue without smooth muscle fibers adherent to the liver parenchyma. This loose connective tissue between the liver and the RHIVC is the avascular plane for the passage of the clamp during LHM.ConclusionThe histological structure of the RHIVC does not seem to have any special hemostatic property. The low bleeding rate during LHM can be only explained by the very low density of RHIVC afferent veins.

Is Mini-Gastric Bypass a Rational Approach for Type-2 Diabetes?

Purpose of ReviewMorbid obesity and type-2 diabetes mellitus (T2DM) are both major public health problems. Bariatric surgery is a proven and effective treatment for these conditions; laparoscopic Roux-en-Y gastric bypass (RYGB) is currently the gold-standard treatment. One-anastomosis gastric bypass (OAGB) is described as a simpler, safer, and non-inferior alternative to RYGB to treat morbid obesity. Concerning T2DM, experts of the OAGB procedure report promising metabolic results with good long-term remission of T2DM; however, heterogeneity within the literature prompted us to analyze this issue.Recent FindingsOAGB has gained popularity given its safety and long-term efficacy. Concerning the effect of OAGB for the treatment of T2DM, most reports involve non-controlled single-arm studies with heterogeneous methodologies and a few randomized controlled trials. However, this available literature supports the efficacy of OAGB for remission of T2DM in obese and non-obese patients. Two years after OAGB, the T2DM remission and improvement rate increased from 67 to 100%. The results were improved and stable in the long term. The 5-year T2DM remission rate increased from 82 to 84.4%. OAGB is non-inferior compared with RYGB and even superior to other accepted bariatric procedures, such as sleeve gastrectomy and adjustable gastric banding.SummaryOAGB is an efficient, safe, simple, and reversible procedure to treat T2DM. The literature reveals interesting results for T2DM remission in non-obese patients. High-level comparative studies are required to support these data.

Pelvic exenteration by robotically-assisted laparoscopy: A feasibility series of 6 cases

After concomitant chemo-radiation therapy, 20 to 30% of advanced cervical cancers recur in irradiated territory. Pelvic exenteration remains a therapeutic option for selected patients. However, this procedure remains complex because of tissue fragility after radiotherapy and their associated co-morbidities. Minimally invasive surgery such as robotically assisted laparoscopy may overcome these surgical challenges. The objective of this study was to evaluate the feasibility of pelvic exenteration with robotically assisted laparoscopy. Patients who underwent this procedure between 2015 and 2016 were included. Patients characteristics, treatment indication, intraoperative events, immediate and late complications, and histological outcomes were recorded. The data of 6 patients were analyzed. The primary cancer staging ranged from IB1 to IIB. All cases were loco-regional recurrence and 2 cases presented with with vesico-vaginal fistula. All patients had a history of pelvic irradiation. The mean operative time was 6.7 h. No complications occurred during surgery. The average hospital stay was 11.5 days. Immediate complications were mostly represented by urinary tract infections (4/5). Histological margins were clear in 67% (4/6), and a focal involvement was found in 33% (2/6) of cases. Late complications occurred within 82 days on average and included stenosis of ileal anastomosis, wound infection, acute renal failure, and pulmonary embolism. Revision surgery was necessary in 2 cases. There were 3 local recurrences occurring within an average of 215 days. In the light of these results, pelvic exenteration by robotically assisted laparoscopy may represent a valuable treatment modality of recurrent cervical cancer with low immediate postoperative morbidity.

Partition pré-cave au cours de l’hépatectomie foie en place : La manœuvre de Hanging : Une étude anatomique in vivo

Introduction la manœuvre de Hanging est utilisee pour la partition pre-cave au cours de l’hepatectomie foie en place. Cette etude avait pour but d’etudier la faisabilite, le taux de complications de cette manœuvre et de s’interesser a la distribution des veines hepatiques accessoires (VHA) au niveau de la portion retrohepatique de la veine cave inferieure (VCIRH). Materiel et methodes de janvier 2001 a decembre 2004, la manœuvre de Hanging a ete planifiee lors de 49 hepatectomies consecutives. La VCIRH a ete etudiee pendant la phase d’anhepatie au cours de 17 transplantations orthotopiques avec preservation de la VCIRH. Le diametre et la localisation des VHA ont ete collectes apres division de la partie anterieure de la VCIRH en 9 parties. Resultats la manœuvre de Hanging a ete accomplie chez 47/49 malades (96 %). Un saignement, survenu dans un cas (2 %), n’a pas necessite l’interruption de la manœuvre. L’etude anatomique a revele l’existence de 86 VHA dans 17 cas (5,18 ± 4 par malade) et classees selon leur diametre (≤ 3, > 3 to Conclusions la manœuvre de Hanging a une faisabilite elevee avec de faibles risques de saignements. L’etude anatomique in vivo demontre qu’une densite reduite de VHA est presente dans le passage suppose avasculaire. Lorsqu’elles sont presentes, ces veines ont un diametre insuffisant pour mettre en jeu la securite de la manœuvre.

Bases anatomiques de la partition pré-cave au cours des hépatectomies foie en place

Introduction la manœuvre de Hanging consiste a effectuer la partition pre-cave du foie en passant un clamp a l’aveugle entre la veine cave inferieure retrohepatique (VCIRH) et le foie avant d’effectuer une hepatectomie droite sans liberation hepatique premiere. Le but de ce travail a ete de faire le point sur les bases anatomiques, la faisabilite, les complications et l’interet clinique de cette technique qui utilise un tunnel, suppose avasculaire, non decrit dans la litterature. Materiel et methodes les principales etudes sur la VCIRH et la technique de Hanging ont ete revues. Resultats le tunnel mesure 60 mm de long et n’est pas avasculaire dans 7 a 35 % des cas. Une moindre densite de veines hepatiques accessoires (0,5 a 2,07 veines), de faible diametre (100 % Conclusions la densite veineuse reduite du plan utilise permet de realiser la partition pre-cave dans plus de 95 % avec un risque de saignements mineur de 5 %. Les benefices de cette technique sont bases exclusivement sur des avis d’experts.