Yohann Renard

Management of large incisional hernias with loss of domain: A prospective series of patients prepared by progressive preoperative pneumoperitoneum

BACKGROUNDnThe surgical treatment of giant incisional hernias with loss of domain is challenging due to the possibility of intra-abdominal hypertension after the herniated content is returned to the peritoneal cavity. Progressive preoperative pneumoperitoneum has been described before repair of the hernia, although its efficacy has not been demonstrated clearly. Our aim was to evaluate the efficacy of preoperative progressive pneumoperitoneum in expanding the volume of the peritoneal cavity and the outcomes after surgical treatment of incisional hernias with loss of domain.nnnMETHODSnAll consecutive patients with incisional hernias with loss of domain undergoing preoperative progressive pneumoperitoneum and operative repair were included in a prospective observational study. All patients had pre- and postoperative progressive pneumoperitoneum computed tomography of the abdomen. Open incisional hernias with loss of domain repair consisted of anatomic reconstruction of the abdominal wall by complete closure of the defect and reinforcement with a sublay synthetic mesh, whenever possible.nnnRESULTSnThe cohort was composed of 45 patients (mean age, 60.5xa0years). Before the preoperative progressive pneumoperitoneum, the mean volume of the herniated content was 38% of the total peritoneal volume. The mean abdominal volume increased by 53% after the preoperative progressive pneumoperitoneum. One patient died during preoperative progressive pneumoperitoneum, but the postoperative mortality was zero, giving a mortality rate of 2% to the treatment using preoperative progressive pneumoperitoneum. Complete reduction of the herniated content intraperitoneally with primary closure of the fascia was achieved in 42 out of 45 patients (94%). Reinforcement by a synthetic mesh was possible in 37 patients (84%). Overall, surgical complications related directly to the operative procedure occured in 48% of cases. The rates of overall and severe morbidity were 75 and 34%, respectively. At a mean follow-up of 18.6xa0months, the recurrence rate was 8% (3 out of 37 patients) with non-absorbable meshes and 57% (4 out of 7 patients) with absorbable mesh.nnnCONCLUSIONnPreoperative progressive pneumoperitoneum increased the volume of the abdominal cavity in patients with incisional hernias with loss of domain, allowing complete reduction of the herniated content and primary fascial closure in 94% of patients, with acceptable overall morbidity.

Definition of giant ventral hernias: Development of standardization through a practice survey

BACKGROUNDnGiant ventral hernias represent a real handicap for patients and constitute a challenge for surgeons. European Hernia Society classification defines all ventral hernia over 10xa0cm in the same group. However, this group represents different clinical entities with numerous therapeutic possibilities, and no standardized recommendation has been made. The objective of our work was to define consensual criteria that define giant ventral hernias requiring specific management and determine management modalities.nnnMETHODSnA national survey consisting of 21 questions was proposed through a secure, anonymous internet interface and on a voluntary basis to all surgeons practising in France involved in care of patients affected by giant ventral hernias.nnnRESULTSnFor more than 68% of respondents, loss of domain and a hernia volume greater than 30% of abdominal volume were mandatory to define giant ventral hernias. Pre-operative screening should include abdominal CT scan, functional respiratory exploration, and a cardiology consultation for 98%, 71% and 50% of the respondents respectively. Respiratory and cutaneous preparations were systematically proposed before surgery by 91% and 56% of respondents. Regarding surgical techniques, none has gained the support of the majority of respondents. However, 71% of respondents use a non-resorbable mesh in retro muscular position for more than 70% of their patients treated for giant ventral hernias.nnnCONCLUSIONnGiant ventral hernias could be defined as ventral hernia larger than 10xa0cm with loss of domain. A specific management is advocated.

Open retromuscular large mesh reconstruction of lumbar incisional hernias including the atrophic muscular area

PurposeLumbar incisional hernias (LIH) are a rare wall defect, whose surgical management is challenging because no recommendation exists. Moreover, LIH are frequently associated with flank bulging which should be taken into account during LIH surgical repair. We aimed to describe a cohort of patients operated on for LIH using a homogeneous surgical technique and to report surgical outcomes.MethodsThe records of all consecutive patients operated on in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh into the retroperitoneal space posteriorly, placed with the largest overlap inferiorly and posteriorly, and fixed through the controlateral abdominal wall muscles under strong tension to correct the flank bulging.ResultsThe cohort included 31 patients, of median age 62, who presented two or more comorbidities in 68% of cases. LIH was recurrent in 45% of patients, and was related to nephrectomy in 61% of patients. The mesh was totally extraperitoneal in 65% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 32.3%, and the rate of overall postoperative morbidity (Clavien-Dindo classification) was 38.7%. After a median follow-up of 27.5xa0months, the recurrence rate was 6.5% and 9.7% reported chronic pain.ConclusionThe open approach for LIH repair was safe and enabled treating flank bulging simultaneously in all patients. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of LIH surgical management.

Anatomical and CT approach of the adipose tissue: application in morbid obesity.

AbstractPurposeThe importance and proportion of visceral adipose tissue (VAT) represent the best criterion to define obesity. Because VAT value is difficult to obtain in clinical practice, the nindication for bariatric surgery is still based at present on Body Mass index (BMI), even though BMI is a poor predictor of obesity-related morbid complications. This correlation study aimed at determining a simple and accurate computed tomography (CT) anatomic marker, which can be easily used clinically, well correlated with the volume of VAT and consequently with morbid complications.MethodsWe studied 108 CT scans of patients presenting with morbid obesity. Several simplified measures (external and internal abdominal diameters and circumferences) were conducted on CT scan view, going through the fourth lumbar vertebra (L4), in addition to various vertebral measurements (area of the vertebra, sagittal and transversal diameters), VAT and subcutaneous adipose tissue (SAT). Then, we reported the simplified measures values on the vertebral areas, and we calculated the Bertin index. Finally, we conducted a correlation study between all variables to obtain accurate VAT measurements.ResultsThe internal abdominal circumference and the Bertin index showed the best correlations with VAT in morbidly obese patients (rxa0=xa00.84 and 0.85, respectively). BMI and anthropometric measures were not correlated with VAT.ConclusionCT scan study allows to simply approximate VAT value in morbidly obese patients. An abdominal CT scan could be part of the tests used in the evaluation of obese patients to base therapeutic strategies on VAT values and not on BMI as it is the case today.

Developmental anatomy of the liver from computerized three-dimensional reconstructions of four human embryos (from Carnegie stage 14 to 23).

BACKGROUND & AIMnSome aspects of human embryogenesis and organogenesis remain unclear, especially concerning the development of the liver and its vasculature. The purpose of this study was to investigate, from a descriptive standpoint, the evolutionary morphogenesis of the human liver and its vasculature by computerized three-dimensional reconstructions of human embryos.nnnMATERIAL & METHODSnSerial histological sections of four human embryos at successive stages of development belonging to three prestigious French historical collections were digitized and reconstructed in 3D using software commonly used in medical radiology. Manual segmentation of the hepatic anatomical regions of interest was performed section by section.nnnRESULTSnIn this study, human liver organogenesis was examined at Carnegie stages 14, 18, 21 and 23. Using a descriptive and an analytical method, we showed that these stages correspond to the implementation of the large hepatic vascular patterns (the portal system, the hepatic artery and the hepatic venous system) and the biliary system.nnnCONCLUSIONnTo our knowledge, our work is the first descriptive morphological study using 3D computerized reconstructions from serial histological sections of the embryonic development of the human liver between Carnegie stages 14 and 23.

Human developmental anatomy: Microscopic magnetic resonance imaging (μMRI) of four human embryos (from Carnegie Stage 10 to 20)

BACKGROUND AND AIMnTechnological advances in the field of biological imaging now allow multi-modal studies of human embryo anatomy. The aim of this study was to assess the high magnetic field μMRI feasibility in the study of small human embryos (less than 21mm crown-rump) as a new tool for the study of human descriptive embryology and to determine better sequence characteristics to obtain higher spatial resolution and higher signal/noise ratio.nnnMETHODSnMorphological study of four human embryos belonging to the historical collection of the Department of Anatomy in the Faculty of Medicine of Reims was undertaken by μMRI. These embryos had, successively, crown-rump lengths of 3mm (Carnegie Stage, CS 10), 12mm (CS 16), 17mm (CS 18) and 21mm (CS 20). Acquisition of images was performed using a vertical nuclear magnetic resonance spectrometer, a Bruker Avance III, 500MHz, 11.7T equipped for imaging.nnnRESULTSnAll images were acquired using 2D (transverse, sagittal and coronal) and 3D sequences, either T1-weighted or T2-weighted. Spatial resolution between 24 and 70μm/pixel allowed clear visualization of all anatomical structures of the embryos.nnnCONCLUSIONnThe study of human embryos μMRI has already been reported in the literature and a few atlases exist for educational purposes. However, to our knowledge, descriptive or morphological studies of human developmental anatomy based on data collected these few μMRI studies of human embryos are rare. This morphological noninvasive imaging method coupled with other techniques already reported seems to offer new perspectives to descriptive studies of human embryology.

Standard of Open Surgical Repair of Suprapubic Incisional Hernias

BackgroundSuprapubic incisional hernias (SIH) are a rare wall defect, whose surgical management is challenging because of limited literature. The proximity of the hernia to bone, vascular, nerve, and urinary structures, and the absence of posterior rectus sheath in this location imply adequate technique of surgical repair. We aimed to describe a cohort of female patients operated on for SIH after gynecological surgery using a homogeneous surgical technique and to report surgical outcomes.MethodsThe records of all consecutive patients operated on for SIH in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh placed inferiorly in the preperitoneal space of Retzius, with large overlap, and fixed on the Cooper’s ligaments, through the muscles superiorly and laterally with strong tension, in a sublay or underlay position.ResultsThe cohort included 71 female patients. SIH were recurrent in 31% of patients and was related to cesarean in 32 patients (45.1%) and to gynecologic surgery in 39 patients (54.9%). The mesh was totally extraperitoneal in 76.1% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 29.6%. After a median follow-up of 30.3xa0months, the recurrence rate was 7%.ConclusionThe open approach for SIH repair was safe and efficient. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of SIH surgical management.

Dynapenia could predict chemotherapy-induced dose-limiting neurotoxicity in digestive cancer patients

BackgroundFIGHTDIGO study showed the feasibility and acceptability of handgrip strength (HGS) measure in routine in 201 consecutive patients with digestive cancer treated with ambulatory chemotherapy. The present study focuses on the second aim of FIGHTDIGO study: the relationships between pre-therapeutic dynapenia and chemotherapy-induced Dose-Limiting Toxicities (DLT).MethodsIn this ancillary prospective study, DLT were analyzed in a sub-group of 45 chemotherapy-naive patients. Two bilateral consecutive measures of HGS were performed with a Jamar dynamometer before the first cycle of chemotherapy. Dynapenia was defined as HGSu2009<u200930xa0kg (men) andu2009<u200920xa0kg (women). DLT and/or Dose-Limiting Neurotoxicity (DLN) were defined as any toxicity leading to dose reduction, treatment delays or permanent treatment discontinuation.ResultsTwo-thirds of chemotherapies were potentially neurotoxic (nu2009=u200931 [68.7%]) and 22 patients (48.9%) received FOLFOX (5FU, leucovorin plus oxaliplatin) regimen chemotherapy. Eleven patients (24.4%) had pre-therapeutic dynapenia. The median number of chemotherapy cycles was 10 with a median follow-up of 167xa0days. Twenty-two patients experienced DLT (48.9%). There was no significant association between pre-therapeutic dynapenia and DLT (pu2009=u20090.62). Nineteen patients (42.2%) experienced DLN. In multivariate analysis, dynapenia and tumoral location (stomach, biliary tract or small intestine) were independent risk factors for DLN (HRu2009=u20093.5 [1.3; 9.8]; pu2009=u20090.02 and HRu2009=u20093.6 [1.3; 10.0]; pu2009=u20090.01, respectively).ConclusionsDigestive cancer patients with pre-therapeutic dynapenia seemed to experience more DLN. HGS routine measurement may be a way to screen patients with frailty marker (dynapenia) who would require chemotherapy dose adjustment and adapted physical activity programs.Trial registrationNCT02797197 June 13, 2016 retrospectively registered.

Chimioembolisation intra-artérielle puis embolisation portale avant hépatectomie pour CHC chez le patient cirrhotique améliore les résultats et augmente la nécrose tumorale: une étude cas-témoin

Introduction Une embolisation portale (EP) seule ou associee de maniere sequentielle avec une chimioembolisation intra-arterielle (CEIA) a ete proposee avant une resection hepatique pour carcinome hepato-cellulaire (CHC). Le but de cette etude etait de comparer les suites operatoires precoces de ces deux strategies. Methodes De janvier 2012 a juin 2013, 12 patients atteints de CHC recevaient un traitement sequentiel CEIA + EP (groupe 1, G1). Le groupe-controle (12 patients) etait traite par EP seule avant chirurgie (groupe 2, G2). Resultats Les caracteristiques des patients et des tumeurs etaient identiques dans les deux groupes. L’augmentation moyenne de VFR etait de 7,36 % dans le G1 et 4,6 % dans le G2 (p = ns). Dans le G1, 10 hepatectomies majeures ont ete realisees vs 12 dans le G2 (p = ns). L’incidence d’insuffisance hepato-cellulaire (IHC) post-ope-ratoire etait plus elevee dans le G2 (41,6 %, 5/12) que dans le G1 (8,3 %, 1/12). Parmi les 5 patients du G2, seul un est decede d’IHC post-operatoire. Les taux de complications et de mortalite post operatoire n’etaient pas differents dans les 2 groupes. La duree de sejour en reanimation etait plus elevee dans le G1 que dans le G2 (pxa0=xa00,03). L’incidence de necrose tumorale etait significativement plus elevee dans le G1 (11/12 vs 3/12 pxa0=xa00,002). Conclusion Le traitement sequentiel CEIA + EP avant hepa-tectomie pour CHC augmente le volume de foie restant, avec des suites operatoire plus simples, et augmente le taux de necrose tumorale.