Valentin Rousson

A Prospective Randomized Study in 100 Consecutive Patients Undergoing Major Liver Resection With Versus Without Ischemic Preconditioning

Objective: To evaluate the protective effects of ischemic preconditioning in a prospective randomized study involving a large population of unselected patients and to identify factors affecting the protective effects. Summary Background Data: Ischemic preconditioning is an effective protective strategy in several animal models. Protection has also been suggested in a small series of patients undergoing a hemihepatectomy with 30 minutes of inflow occlusion. Whether preconditioning confers protection in other types of liver resection and longer periods of ischemia is unknown. Therefore, we conducted a prospective randomized study to evaluate the impact of ischemic preconditioning in liver surgery. Methods: A total of 100 unselected patients undergoing major liver resection (> bisegmentectomy) under inflow occlusion for at least 30 minutes were randomized during surgery to either receive or not receive an ischemic preconditioning protocol (10 minutes of ischemia followed by 10 minutes of reperfusion). Univariate and multivariate analyses were performed to identify independent factors affecting the protective effects of ischemic preconditioning. ATP contents in liver were measured as a possible mechanism of protection. Results: Both groups (n = 50 in each) were comparable regarding age, gender, duration of inflow occlusion, and resected liver volumes. Postoperative serum transaminase levels were significantly lower in preconditioned than in control patients (median peak AST 364 U/L vs. 520 U/L, P = 0.028; ALT 406 vs. 519 U/L, P = 0.049). Regression multivariate analysis revealed an increased benefit of ischemic preconditioning in younger patients, in patients with longer duration of inflow occlusion (up to 60 minutes), and in cases of lower resected liver volume (<50%). Patients with steatosis were also particularly protected by ischemic preconditioning. ATP content in liver tissue was preserved by ischemic preconditioning in young but not older patients. Conclusions: This study establishes ischemic preconditioning as a protective strategy against hepatic ischemia in humans. The strategy is particularly effective in young patients requiring a prolonged period of inflow occlusion, and in the presence of steatosis, and is possibly related to preservation of ATP content in liver tissue. Other strategies are needed in older patients.

Evidence-based Value of Prophylactic Drainage in Gastrointestinal Surgery: A Systematic Review and Meta-analyses

Objective:To determine the evidence-based value of prophylactic drainage in gastrointestinal (GI) surgery. Methods:An electronic search of the Medline database from 1966 to 2004 was performed to identify articles comparing prophylactic drainage with no drainage in GI surgery. The studies were reviewed and classified according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. Seventeen randomized controlled trials (RCTs) were found for hepato-pancreatico-biliary surgery, none for upper GI tract, and 13 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random-effects model. Results:There is evidence of level 1a that drains do not reduce complications after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis. Drains were even harmful after hepatic resection in chronic liver disease and appendectomy. In the absence of RCTs, there is a consensus (evidence level 5) about the necessity of prophylactic drainage after esophageal resection and total gastrectomy due to the potential fatal outcome in case of anastomotic and gastric leakage. Conclusion:Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A), whereas prophylactic drainage remains indicated after esophageal resection and total gastrectomy (recommendation grade D). For many other GI procedures, especially involving the upper GI tract, there is a further demand for well-designed RCTs to clarify the value of prophylactic drainage.

Evidence-based treatment of acute pancreatitis : A look at established paradigms

Background:The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment. Methods:A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A = large randomized; B = small randomized; C = prospective trial). Results:None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over “open-packing” because of fewer complications with comparable mortality rates (level C). Conclusions:While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.

Morbidity and recurrence after completion lymph node dissection following sentinel lymph node biopsy in cutaneous malignant melanoma.

Objective:To assess the nature and rates of complications and recurrences after completion lymph node dissection (CLND) following positive sentinel lymph node biopsy (SLNB) in melanoma patients. Summary Background Data:In contrast to SLNB, CLND is associated with considerable morbidity. CLND delays nodal recurrence, thereby prolonging disease-free survival (DFS), but not overall melanoma-specific survival. Elaborate studies on morbidity and recurrence rates after CLND are scarce. Therefore, many controversies concerning extent and nature of CLND exist. Methods:We conducted a retrospective study on 100 melanoma patients, on whom we performed CLND between October 1999 and December 2005. The median observation period was 38.8 months. Results:We performed a total of 102 CLNDs, [46.1% axillary (47/102), 42.2% groin (43/102), 11.8% neck (12/102)]. Groin dissection (GD) and axillary dissection (AD) led to comparable morbidity (47.6% and 46.8%), but complications were more severe in GD, mandating additional surgery in 25.6% (11/43), versus 8.5% (4/47) in AD. Of the GD patients, 18.5% (8/43) were readmitted for complications compared with 10.4% (5/47) of AD patients. Only 8.3% (1/12) of ND patients suffered complications, mandating neither readmittance nor further surgery. During the median observation period, 65 (65%) of these patients showed DFS, and 35 (35%) exhibited recurrences after a median DFS of 12.5 months. Of the recurrences, 31.4% were nodal, 42.9% distant, and 25.7% local/in-transit. Of our AD patients, 28.3% suffered recurrences (13/46), as did 33.3% of the GD (14/42) and 66.7% of the ND patients (8/12). Conclusions:CLND is fraught with considerable morbidity. Local control of the dissected nodal basins was achieved with a modified radical approach in ADs (levels I + II only) and, to a lesser extent, GDs, but not in NDs. Clinical trials are necessary to establish guidelines on the extent of lymphatic dissection.

Impaired motor performance and movement quality in very-low-birthweight children at 6 years of age

Motor performance and movement quality were quantitatively examined (Zurich Neuromotor Assessment: timed motor performances and associated movements) in 87 prospectively enrolled very-low-birthweight (VLBW; <1250g) children (38 males, 49 females; mean birthweight 1016.2g [SD 141.5]:, range 720-1240g; mean gestational age 28.7wks [SD 2], range 25.7-33.4wks) at 6 years of age. All motor tasks were below the reference population: pure motor (median z-score) -0.46; adaptive fine motor (pegboard) -0.99; adaptive gross motor -0.88; static balance -0.48; and associated movements -1.90. All tasks correlated with the degree of neurological abnormalities (p<or=0.004). VLBW children with no neurological abnormality also performed below the 10th centile and associated movements occurred more frequently than in the reference population (odds ratio 18, 95% confidence interval 6.7-47.9). Severity of periventricular leukomalacia and intraventricular haemorrhage assessed by ultrasound was associated with adaptive fine and gross motor tasks. We conclude that speed of motor performance and movement quality in particular were substantially impaired in VLBW children and are related to the degree of neurological abnormalities and neonatal cerebral injury.

Limited Diagnostic Value of Laryngopharyngeal Lesions in Patients With Gastroesophageal Reflux During Routine Upper Gastrointestinal Endoscopy

BACKGROUND AND AIMS:u2003There is growing evidence that gastroesophageal reflux disease (GERD) may cause typical laryngeal/pharyngeal lesions secondary to tissue irritation. The prevalence of those lesions in GERD patients is not well established. The aim of this study was to evaluate the prevalence of GERD signs in the laryngopharyngeal area during routine upper gastrointestinal endoscopy.METHODS:Between July 2000 and July 2001, 1,209 patients underwent 1,311 upper gastrointestinal endoscopies and were enrolled in this study. The structured examination of the laryngopharyngeal area during upper gastrointestinal endoscopy was videotaped for review by three gastroenterologists and one otorhinolaryngologist, blinded to the endoscopic esophageal findings. From the 1,209 patients enrolled in this prospective study, all patients (group I, N = 132) with typical endoscopical esophageal findings of GERD (Savary–Miller I–IV) were selected. The sex- and age-matched control group II (N = 132) underwent upper gastrointestinal endoscopy for different reasons, had no reflux symptoms, and had normal esophagoscopyRESULTS:In the two groups of patients, we found no difference in the prevalence of abnormal interarytenoid bar findings (32% vs 32%), arytenoid medial wall erythema (47% vs 43%), posterior commissure changes (36% vs 34%), or posterior cricoid wall edema (1% vs 3%). The only difference was noted in the posterior pharyngeal wall cobblestoning (66% vs 50%, P = 0.004).CONCLUSION:The results of this large systematic investigation challenge the diagnostic specificity of laryngopharyngeal findings attributed to gastroesophageal reflux.

Gender, Age, and Body Surface Area are the Major Determinants of Ascending Aorta Dimensions in Subjects With Apparently Normal Echocardiograms

BACKGROUNDnLimited data have been published on the normal size of the ascending aorta (AA) measured using transthoracic echocardiography (TTE).nnnMETHODSnAA diameters were measured in 1799 patients with normal cardiac findings on TTE and compared with the diameters of the sinus of Valsalva (SoV).nnnRESULTSnMean diameters in men and women, respectively, were 3.4 and 3.1 cm for the SoV and 3.2 and 3.0 cm for the AA. The sizes of the SoV and the AA showed strong correlations with age, age squared, and body surface area. The 5th and 95th percentile curves for the SoV and AA showed faster growth of diameters in early adulthood compared with old age. The dimensions of the SoV were larger than those of the AA (mean differences, 0.19 cm in men and 0.08 cm in women), and the difference between the SoV and AA was negatively correlated with age.nnnCONCLUSIONnThe findings of this study stress the importance of indexing dimensions of the SoV and the AA to age and body surface area separately for men and women.

Analysis of risk factors for low bone mineral density in inflammatory bowel disease

Background/Aim: Several risk factors have been suggested for osteoporosis which frequently occurs in inflammatory bowel disease (IBD) patients. We studied prevalence and risk factors for reduced bone mineral density (BMD) in IBD patients at the University Hospital of Zürich, Switzerland. Methods: The BMD was determined by dual-energy X-ray absorptiometry at the lumbar spine and femoral neck in 88 IBD patients (55 with Crohn’s disease, 30 with ulcerative colitis, and 3 with indeterminate colitis). Z scores were obtained by comparison with age- and sex-matched normal values, and T scores by comparison with sex-matched healthy young adults. Osteopenia and osteoporosis were defined according to the WHO guidelines. Predictive factors for BMD were analyzed by group comparison and stepwise regression analysis. Results: Osteopenia was present in 43% of the patients at the lumbar spine and in 42% of them at the femoral neck. Osteoporosis was present in 14% of the patients at the lumbar spine and in 5% of them at the femoral neck. At the lumbar spine, stepwise regression analysis showed that body mass index, age, number of bowel resections, topic steroids, and azathioprine correlated with the Z scores. Cumulative steroid dose, topic steroids, age and bowel resection were found to be predictors for a pathological T score. At the femoral neck, regression analysis showed that body mass index, age, topic steroids, and azathioprine correlated with the Z scores. Only a low body mass index was a significant predictor for pathological femoral T scores. Conclusions: Osteopenia and osteoporosis are commonly found in IBD patients. Steroid treatment and bowel resection were significant risk factors for osteoporosis of the lumbar spine. However, disease-inherent factors also appear to confer a major risk, indicating that the BMD should be determined in all IBD patients, irrespective of steroid treatment.

The influence of sentinel lymph node tumour burden on additional lymph node involvement and disease-free survival in cutaneous melanoma--a retrospective analysis of 392 cases.

Twenty per cent of sentinel lymph node (SLN)-positive melanoma patients have positive non-SLN lymph nodes in completion lymph node dissection (CLND). We investigated SLN tumour load, non-sentinel positivity and disease-free survival (DFS) to assess whether certain patients could be spared CLND. Sentinel lymph node biopsy was performed on 392 patients between 1999 and 2005. Median observation period was 38.8 months. Sentinel lymph node tumour load did not predict non-SLN positivity: 30.8% of patients with SLN macrometastases (⩾2u2009mm) and 16.4% with micrometastases (⩽2u2009mm) had non-SLN positivity (P=0.09). Tumour recurrences after positive SLNs were more than twice as frequent for SLN macrometastases (51.3%) than for micrometastases (24.6%) (P=0.005). For patients with SLN micrometastases, the DFS analysis was worse (P=0.003) when comparing those with positive non-SLNs (60% recurrences) to those without (17.6% recurrences). This difference did not translate into significant differences in DFS: patients with SLN micrometastasis, either with (P=0.022) or without additional positive non-SLNs (P<0.0001), fared worse than patients with tumour-free SLNs. The 2-mm cutoff for SLN tumour load accurately predicts differences in DFS. Non-SLN positivity in CLND, however, cannot be predicted. Therefore, contrary to other studies, no recommendations concerning discontinuation of CLND based on SLN tumour load can be deduced.

Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study.

OBJECTIVEnProlonged air leak is reported in up to 50% of patients after lung volume reduction surgery. The effect of an autologous fibrin sealant on the intensity and duration of air leak and on the time to chest drain removal after lung volume reduction surgery was investigated in a randomized prospective clinical trial.nnnMETHODSnTwenty-five patients underwent bilateral thoracoscopic lung volume reduction surgery. In each patient, an autologous fibrin sealant was applied along the staple lines on one side, whereas no additional measure was taken on the other side. Randomization of treatment was performed at the end of the resection on the first side. Air leak was assessed semiquantitatively by use of a severity score (0 = no leak; 4 = continuous severe leak) by two investigators blinded to the treatment.nnnRESULTnMean value of the total severity scores for the first 48 hours postoperative was significantly lower in the treated group (4.7 +/- 7.7) than in the control group (16.0 +/- 10.1) (P < .001), independently of the length of the resection. Prolonged air leak and mean duration of drainage were also significantly reduced after application of the sealant (4.5% and 2.8 +/- 1.9 days versus 31.8% and 5.9 +/- 2.9 days) (P = .03 and P < .001).nnnCONCLUSIONSnAutologous fibrin sealant for reinforcement of the staple lines after lung volume reduction surgery significantly reduces prolonged air leak and duration of chest tube drainage.