Richard Douard

Comparison of FDG-PET/CT and MR with diffusion-weighted imaging for assessing peritoneal carcinomatosis from gastrointestinal malignancy

ObjectivesTo assess the accuracy of FDG-PET/CT and MR with diffusion-weighted imaging (MR-DWI) for diagnosing peritoneal carcinomatosis (PC) from gastrointestinal malignancies.MethodsThirty consecutive patients referred for staging of gastrointestinal malignancy underwent FDG-PET/CT and MR-DWI in this retrospective study. Extent of PC was characterised by dividing the peritoneal cavity into three sites in each patient: right and left supramesocolic areas and inframesocolic level (total 90 sites). Presence of PC was confirmed either by surgery (18/30) or by follow-up (12/30).ResultsPC was confirmed in 19 patients (19/30). At a total of 90 sites, 27 showed proven PC. On a patient-based analysis, sensitivity, specificity, PPV, NPV and accuracy were respectively 84%, 73%, 84%, 73% and 80% for PET/CT and 84%, 82%, 89%, 75% and 83% for MR-DWI. On a site-based analysis, overall sensitivity and specificity of PET/CT (63%, 90%) and MR-DWI (74%, 97%) were not statistically different (Pu2009=u20090.27). In the supramesocolic area, MR-DWI detected more sites involved than PET/CT (7/9 vs. 4/9). The sensitivities of PET and MR were lower for subcentimetre tumour implants (42%, 50%). Interobserver agreement was very good for PET/CT and good for MR-DWI.ConclusionsFDG-PET/CT and MR-DWI showed similar high accuracy in diagnosing PC. Both techniques underestimated the real extent of PC because of decreased sensitivity for subcentimetre lesions.Key Points• FDG-PET/CT and MR-DWI showed similar high accuracy for diagnosing peritoneal carcinomatosis.• In the supramesocolic area, MR-DWI could be more sensitive than PET/CT.• Both techniques showed lower sensitivity for subcentimetre lesions.• Interobserver agreement was very good for PET/CT and good for MR-DWI.

Clinical interest of digestive arterial trunk anastomoses.

Arterial vascularization of the gastrointestinal tract is a three-level system composed of the coeliac trunk, and both superior and inferior mesenteric arteries. The three levels are joined together via arterial trunk anastomoses such as the so-called and well-known Riolan arcade or supramarginal arcade. The aim of this study was to review the embryology of the digestive arteries in order to understand the anatomic variations, the development of the arterial trunk anastomoses and the potential collateral circulation in the case of obstruction of one or several arterial trunks. The arch theory by Mac Kay and Tandler longitudinal arterial anastomosis account for the genesis of the arterial trunk anastomoses and the main anatomic variations. The coeliac trunk and the superior mesenteric artery are joined together via the pancreaticoduodenal arcades and the Bühler arcade. These anastomoses are divided during pancreatic resections but developed in the case of coeliac trunk stenosis. The mesenteric arteries are joined together by the Riolan, Villemin arcades and by the marginal artery of Drummond. This collateral circulation and the Riolan arcade in particular, is utilized during left colonic resection. In the case of this collateral circulation insufficiency, inferior mesenteric artery reimplantation is necessary during abdominal aortic aneurysmectomy. Arteriopathy, more and more frequent due to population ageing is responsible for frequent obliteration of one or several digestive arterial trunks with subsequent development of collateral circulation. For such reasons, a sound knowledge of digestive arterial anatomy is an absolute prerequisite for surgical practice.

Anomalies of lateralization in man : a case of total situs inversus

Total or complete visceral situs inversus is the complete inversion of position of the thoracic and abdominal viscera. The aim of this study is to report a case of complete situs inversus and to review our knowledge of the anomalies of lateralization. A case of complete sinus inversus was discovered incidentally during anatomic dissection in a female subject aged 87 years. The thoracic and abdominal organs had a position symmetric with the normal. This was associated with a common mesentery and incomplete rotation of the colon, placing the cecum under the left lobe of the liver. These alimentary anomalies were discovered in adult life during a surgical operation for small intestinal occlusion, as evidenced by the abdominal scar and peritoneal adhesions. No cardiac, pulmonary, splenic or facial sinus anomalies were encountered. The incidence of complete situs inversus is estimated as 1/8000 in the general population. It may be isolated or associated with malformations, especially cardiac or alimentary. It may be discovered in infancy because of associated anomalies but often remains asymptomatic and discovered by chance in adult life. Complete situs inversus may form part of the multiple malformational syndromes such as that of Kartagener, with recessive autosomal transmission (complete situs inversus, bronchiectasis, chronic sinusitis, male infertility), which represents 20–25% of cases of complete situs inversus. In view of the frequency of this type of anomaly, a knowledge of anomalies of lateralization is essential in clinical practice.

A two-step strategy for enlargement of left arterial branch in a living related liver graft with dual arterial supply

The use of small caliber arteries is probably responsible for the higher hepatic artery thrombosis rate initially reported after living related liver transplantation. We described a two-step strategy generating flow-induced enlargement of a small diameter artery in case of left graft dual arterial supply. The smaller arterial branch was ligated during a laparoscopic first-step procedure inducing a 30% enlargement of the remaining branch. The second-step donor hepatectomy was performed 1 week later using a larger artery for successful vascular anastomosis. The flow-induced enlargement of donor hepatic artery may help to reduce hepatic artery thrombosis risk after pediatric living related liver transplantation.

Terrorist attacks in Paris: Surgical trauma experience in a referral center

BACKGROUNDnOn November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou.nnnMETHODSnThis study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records.nnnRESULTSnForty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up.nnnCONCLUSIONnRapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

Traditional versus three-dimensional teaching of peritoneal embryogenesis: a comparative prospective study

IntroductionAnatomy teaching is newly boosted by the development of interactive three-dimensional (3D) teaching techniques. Nevertheless, their superiority as teaching aids has never been demonstrated. The aim of this study was to compare 3D and traditional chalk teaching efficiency in terms of student memorization concerning peritoneal embryogenesis.Materials and methods165 students from the Faculties of Medicine of Sfax (Tunisia) (nxa0=xa081) and of Paris-Descartes (France) (nxa0=xa084) were taught peritoneal embryogenesis either via a 3D technique (interactive DVD ROM) (3D group, nxa0=xa085) or via the traditional chalk technique (CL group, nxa0=xa080). Both groups were subjected to an evaluation test including 34 questions distributed in six chapters at the end of the course.ResultsThe overall rate of correct answers was higher in the 3D group (65.12xa0±xa014.88 vs. 49.33xa0±xa016.17%, pxa0<xa00.001). It was the same for five of the six chapters of questions excluding the chapter concerning the clinical implications (pxa0=xa00.06). There was no significant difference between 3D and CL groups regarding the 20 questions focusing on static phenomena (64.52xa0±xa027.10 vs. 58.87xa0±xa023.67%, pxa0=xa00.24), but the rate of correct answers was higher in the 3D group for the 14 questions focusing on dynamic phenomena (65.96xa0±xa020.97 vs. 28.17xa0±xa024.40%, pxa0<xa00.001).ConclusionThe 3D technique is significantly more efficient than the traditional chalk technique for the teaching of peritoneal embryogenesis in terms of short-term memorization and particularly for the assimilation of dynamic phenomena. Medium-term and long-term studies are needed to demonstrate that this benefit has a long-lasting impact.

Celiac trunk compression by arcuate ligament and living-related liver transplantation: a two-step strategy for flow-induced enlargement of donor hepatic artery.

Abstract. The median arcuate ligament is a tendinous arch joining the two medial borders of the diaphragm crura together. In 10–50% of subjects it is responsible for significant angiographic celiac trunk compression. In severe cases, a decrease in hepatic arterial blood flow with subsequent artery caliber reduction and reverse vascularization via the gastroduodenal artery is present. In liver transplantation, small-caliber hepatic arteries are higher risk factors for hepatic arterial thrombosis and frequent graft loss. We report a case of celiac trunk compression in a living-related donor and the two-step strategy we developed to perform a safer liver transplantation via flow-induced enlargement of the donor hepatic artery. A 29-year-old father was selected as a living-related liver donor for his 4-year-old daughter. Angiography revealed celiac trunk compression by the median arcuate ligament with reverse vascularization of the middle hepatic artery via the gastroduodenal artery, a proper hepatic artery 2xa0mm in diameter irrigating the left lateral segment exclusively, and a right hepatic artery irrigating the right lobe and segment 4. First-step division of the median arcuate ligament and gastroduodenal artery ligation were performed. Repeat angiography at the third week showed a 50% enlargement of the middle hepatic artery (3xa0mm). Second-step left lobectomy was performed at the fifth week. The transplantation was achieved with an arterial anastomosis between the middle hepatic arteries of donor and recipient. This two-step strategy including median arcuate ligament division provided flow-induced enlargement of the donor middle hepatic artery for a safer transplantation with arteries of more suitable calibers. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0073-y.Résumé. Le ligament arqué est un arc tendineux qui relie les deux parties médiales des piliers du diaphragme. Le ligament arqué est responsable dune compression significative du tronc cœliaque visible sur lartériographie chez 10 à 50% des sujets. Dans les cas les plus graves, on observe une diminution du débit artériel hépatique avec réduction significative du diamètre de lartère hépatique et vascularisation a retro par lartère gastro-duodénale. En transplantation hépatique, une artère hépatique de petit calibre est un important facteur de risque de thrombose de lartère hépatique, fréquemment associée à la perte du greffon. Nous rapportons un cas de compression cœliaque chez un donneur vivant et la stratégie de prélèvement en deux temps qui nous a permis deffectuer une transplantation hépatique plus sûre après élargissement de lartère hépatique du donneur grâce à laugmentation du débit artériel. Un homme de 29 ans a été sélectionné comme donneur vivant pour effectuer une transplantation hépatique pour sa fille de 4 ans. Lartériographie a montré une compression cœliaque par le ligament arqué avec vascularisation a retro de lartère hépatique moyenne par lartère gastro-duodénale, une artère hépatique propre de 2xa0mm de diamètre vascularisant exclusivement le lobe gauche et une artère hépatique droite issue de lartère mésentérique supérieure vascularisant le foie droit et le segment 4. Une première intervention a permis de sectionner le ligament arqué et de lier lartère gastro-duodénale. Une nouvelle artériographie réalisée trois semaines plus tard a mis en évidence une augmentation de 50% du diamètre de lartère hépatique moyenne (3xa0mm). Une deuxième intervention effectuée cinq semaines après la première a permis de procéder au prélèvement du greffon hépatique gauche. La transplantation a nécessité une anastomose artérielle entre les artères hépatiques moyennes du donneur et du receveur. Cette stratégie de prélèvement en deux temps a eu pour effet délargir lartère hépatique du donneur par augmentation du flux sanguin pour permettre une transplantation hépatique plus sûre.

Total situs inversus: a genetic material bank as a new tool for anatomical research

For morphologists, a chest radiograph with a mirrorimage inversion may represent a rare case of situs inversus instead of a routine radiological misprint. Such lateralization anomalies are rather well documented in animals (i.e., mouse, Xenopus toad, or Drosophila) but remain ill defined in humans and have a complicated and confused terminology. These anomalies are separated into two main subgroups: partial situs inversus and total situs inversus. Partial situs inversus is frequently associated with cardiac malformations and is therefore mostly discovered during childhood, whereas total situs inversus is often asymptomatic with absence of associated malformations. The overall situs inversus frequency ranges from 1/8,000 to 1/25,000 [2]. Several syndromes have been described in humans, such as Kartagener’s syndrome including ciliary motility disorders, responsible for complete situs inversus, chronic sinusitis, bronchiectasis and male infertility [1, 2]. In other situs inversus cases, only slight anomalies are present. We had the opportunity to observe a case of complete situs inversus associated with incomplete mesentery rotation during the dissection of a female cadaver aged 87 years [3]. When no malformations are present, complete situs inversus remains asymptomatic and is therefore discovered during intercurrent disorders, routine clinical examination or radiography. By chance, we were able to study two such cases of asymptomatic total situs inversus incidentally discovered in a woman during pregnancy and in a man during colorectal cancer therapy. As the inversion was complete and presented no associated malformations, we postulated that the genetic alteration was at the beginning of the polygenic cascade of the lateralization process. As our anatomists cooperate with biochemists, we decided to undertake genetic research on the alterations involved in such amazing variations. After informed consent, blood samples were drawn from both volunteers for DNA studies on different genes possibly involved. The closest cooperation between anatomists and biochemists is mandatory to allow more subjects to be studied. As morphologists are interested in anatomical problems and are in contact with numerous patients, they may help to detect living or cadaveric subjects with total situs inversus and collect material for genetic research. Moreover, our colleagues’ unique experience would be helpful in the publication of such works and could possibly enable them to contribute as co-authors. The delayed deterioration of blood or tissue samples used for DNA studies allows them to be mailed to the laboratory [4]. Informed consent can be e-mailed to the anatomist before inclusion of a new living patient. After processing of the sample, the patient’s white blood cells are immortalized using in vitro Epstein-Barr virus infection into a non-limited source of genetic material [5]. The material collected from the study patients will constitute the basis of a genetic material bank available for research on total situs inversus but accessible to anatomists for their own studies. Thus, the anatomists’ long experience in embryology combined with the Surg Radiol Anat (2003) 25: 173–174 DOI 10.1007/s00276-003-0143-9

Le nerf dorsal du clitoris : de l’anatomie à la chirurgie reconstructrice du clitoris

OBJECTIVESnTo describe the course of the dorsal nerve of the clitoris (DNC) to better define its anatomy in the human adult and to help surgeons to avoid iatrogenic injury during surgical procedures.nnnMETHODnAn extensive review of the current literature was done on Medline via PubMed by using the following keywords: anatomie du clitoris, anatomy of clitoris, nerf dorsal du clitoris, dorsal nerve of clitoris, réparation clitoridienne, transposition clitoridienne, surgery of the clitoris, clitoridoplasty. This review analyzed dissection, magnetic resonance imaging, 3-dimensional sectional anatomy reconstruction and immuno-histochemical studies.nnnRESULTSnThe DNC comes from the pudendal nerve. He travels from under the inferior pubis ramus to the posterosuperior edge of the clitoral crus. The DNC reappears under the pubic symphysis and enters the deep component of the suspensory ligament. He runs on the dorsal face of the clitoral body at 11 and 1 oclock. Distally, he gives many nervous ramifications, runs along the tunica and enters the glans.nnnCONCLUSIONnThe NDC might be surgically injured (i) under the pubic symphysis, at the union of the two crus of clitoris and (ii) on the dorsal surface of the clitoral body. The pathway of the DNC on the dorsal face of the clitoris permits to approach the ventral face of the clitoris without risk of iatrogenic injuries. The distance between the pubic symphysis and the DNC implies that the incision should be done just under the pubic symphysis. Distally, the dissection of the DNC next the glands appears as dangerous and impossible, considering that the DNC is too close to the glandular tissues.

Intérêt du contrôle des connaissances après dissection

But de l’etude dans certaines facultes de medecine, les dissections sont programmees dans le cursus au debut des etudes medicales. Pour donner toute leur valeur a ces seances, il nous est apparu necessaire qu’elles soient sanctionnees par un examen. C’est cette experience que nous voulons rapporter. Materiel et methodes pendant trois ans (deux ans, Necker, 120 etudiants et un an, Rene Descartes, 350 etudiants), les etudiants ont eu 12 seances de deux heures de dissection. Tout le corps humain a ete disseque. Les seances debutaient par un expose ou un film sur la region a dissequer. Dans la salle, des coupes anatomiques et des radiographies etaient a la disposition des etudiants. L’examen etait theorique (120 questions en amphi) et pratique (48 questions sur sujet) : la moitie des questions portaient sur une structure a reconnaitre et l’autre moitie complementaire de la premiere question. Les resultats ont porte sur l’annee 2005-2006. Resultats l’enseignement a ete accepte et suivi avec assiduite avec un encadrement (un enseignant pour 20 etudiants). Au moment de l’examen, 14 sur 350 etudiants etaient absents. Pour les epreuves pratiques (48 questions) les notes s’echelonnaient entre 20 et 35 (extremes 10-47). Pour les epreuves (120 questions) les notes s’echelonnaient entre 81 et 105. Conclusion la verification des connaissances a stimule l’interet des etudiants pour la dissection. Concluant l’enseignement de l’anatomie, elles ont ete une revision de toute l’anatomie vue au cours des deux dernieres annees et une valorisation de celle-ci.