OC-006 LAPAROSCOPIC TOTALLY EXTRA-PERITONEAL REPAIR OF BILATERAL INGUINAL HERNIAS WITH A LARGE SINGLE MESH: A SINGLE CENTER STUDY WITH MINIMUM 5 YEARS FOLLOW UP

Background

Laparoscopic totally extraperitoneal (TEP) surgery with a single large mesh is currently the technique of choice for repair of bilateral inguinal hernias in our institution. Most surgeons use two meshes for the TEP repair. We present our experience with a single mesh repair.

Material & Methods

Records of all patients who had bilateral inguinal hernia and underwent bilateral laparoscopic TEP repair at our institution, 2010–2016, were retrospectively reviewed. We excluded patients who had a conversion to transabdominal intraperitoneal or open approach.

Results

A total of 470 patients were identified. The median age of patients was 56 (IQR 1–3; 41–66) years and median BMI was 25.9 (IQR 1–3; 23.1–28.1). 18.7% of the cohort (88 patients) had previous abdominal surgery and 39 patients (8.41%) had a recurrent inguinal hernia. Median length of operation was 63 (IQR1–3; 48–89) minutes. Operative complication were bleeding (0.4%) and bladder injury (0.2%). Post operative complications occurred in 32 patients; among the complications were seroma (2.6%), hematoma (2.1%), surgical site infection (0.4%) urinary retention (1.5%) and intestinal obstruction (0.2%). Median length of hospitalization was 1 day (IQR1–3; 1–2). After a median follow up of 102 months, 36 patients had a recurrence. 20 patients (4.3%) had a re-operation for recurrent inguinal hernia. Post-operative groin pain was present in 48 patients.

Conclusion

The use of a large single mesh is an effective and safe technique for TEP repair of bilateral inguinal hernias. The recurrence rate and prevalence of post-operative pain is consistent with the results reported by others.

Impact of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) rectal carriage in cancer patients admitted to the intensive care unit

Little data is available on extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) rectal colonization in cancer patients admitted to the intensive care unit (ICU). We aimed to describe the epidemiology of ESBL-E in cancer patients hospitalized in the ICU compared with non-cancer patients. ESBL-E colonization was detected in 6.6% of 1,013 cancer patients and 6.4% of 1,625 non-cancer patients. At admission, among the 172 colonized patients: 48/67 cancer patients and 78/105 non-cancer patients developed an infection, documented with an ESBL-E for 21% and 24% of them, respectively. The in-hospital mortality rate among colonized patients was 33% in cancer patients and 12% in non-cancer patients. In cancer patients, ESBL-E infections are rare but systematic rectal screening identifies high-risk population and guides empirical antibiotic therapy. It also contributes to being aware of the ICU microbiological ecology.

Is there an association between mesenteric panniculitis and lymphoma? A case control analysis

AIM

To determine the prevalence and association of mesenteric panniculitis (MP) in a group of patients with non-Hodgkin's lymphoma (NHL) compared to control group.

MATERIALS AND METHODS

We retrospectively evaluated computed tomography (CT) and combined positron-emission tomography (PET) with CT examinations of a total of 166 patients who were diagnosed with NHL over a period of 5 years (2008-2013). The control group consisted of 332 subjects who were matched for gender and age at the time period the examinations were performed on the study group. A combination of radiological signs and absence of 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG)-uptake was used to establish the diagnosis of MP and distinguish it from the involvement of mesentery by lymphoma.

RESULTS

MP was identified in three patients (prevalence 1.8%) from the study group as compared to seven subjects out of 332 (2.1%) in the control group (p=0.556). During the course of follow-up no changes in the imaging features of MP were seen in either group. Additionally, 27 (16.2%) patients from the study group were found to have changes in the mesentery, which were attributed to the involvement of the mesentery in the primary disease.

CONCLUSION

The prevalence of MP among patients with NHL was found to be 1.8%, which corresponds to the range of its prevalence in the general population. This is contrary to the proposition that MP is associated with NHL.

Graft infection after a Bentall procedure: A case series and systematic review of the literature

INTRODUCTION

The Bentall procedure is a cardiac surgery involving graft replacement of the aortic valve, aortic root and ascending aorta. Graft infection after Bentall's procedure (BGI) is infrequent but severe, and often difficult to diagnose and treat.

PATIENTS AND METHODS

A retrospective cohort study was performed using the Bordeaux endocarditis database of adult patients admitted to the Bordeaux University Medical Hospital for BGI between 2008 and 2014. Published case reports were identified in the literature.

RESULTS

We identified 10 BGI patients in the database and 13 in the literature. The majority of infections were late-onset (20/23) and occurred as a result of gram positive cocci bacterial infection (16/22). Detailed diagnoses of the described BGI were determined using echocardiography, computed tomography (CT) and positron emission tomography/CT (PET/CT). Labeled-leukocyte scintigraphy was not reported in any case. Prolonged antibiotic therapy and surgery were found to be the treatment of choice for BGI; however it was not always possible to perform a surgical intervention. Clinical relapses occurred even with a negative PET/CT, while PET/CT consistently positive for BGI occurred in the absence of clinical relapse. This suggests that the use of PET/CT for follow-up is questionable.

CONCLUSION

Diagnosis of BGI is difficult, due to the combination of clinical, biological, and radiological observations obtained through transesophageal echocardiography and CT. PET/CT is an alternative method to diagnosis BGI, but its impact on clinical management remains unclear. Current data suggests that if surgical replacement of the prosthesis is not possible, patients should be treated with prolonged antibiotic therapy.

Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution

BACKGROUND

The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery.

METHODS

Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected.

RESULTS

141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively.

CONCLUSION

The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.

[Leptospirosis and thrombocytopenia]

INTRODUCTION

Leptospirosis is a worldwide zoonosis caused by the spirochete Leptospira interrogans. The spectrum of symptoms reported in leptospirosis is extremely broad. Thrombocytopenia is common during the acute phase of leptospirosis but its pathophysiological mechanism remains not well defined.

CASE REPORT

We report a 56-year-old man hospitalized for severe sepsis with acute kidney injury and liver failure. Because of the recent flood of his house, we suspected leptospirosis. The diagnosis was rapidly confirmed. Blood tests revealed thrombocytopenia at 9 G/L associated with hyperferritinemia and hypertriglyceridemia. Cytological examination of bone marrow showed abundance of megakaryocytes and hemophagocytosis which confirmed the diagnosis of hemophagocytic syndrome. Clinical symptoms resolved and blood tests returned to normal values in the same time.

CONCLUSION

We suggest that hemophogocytosis is a possible mechanism of thrombocytopenia in leptospirosis and that examination of bone marrow should be performed to confirm the diagnosis.

Comparison of C4d detection on erythrocytes and PTC-C4d to histological signs of antibody-mediated rejection in kidney transplantation

C4d on erythrocytes (EC4d), C4d peritubular capillary deposition (PTC-C4d) staining and histology were compared in a cross-sectional cohort of 146 renal allograft biopsies (132 patients). EC4d levels paralleled PTC-C4d staining, but were more predictive of peritubular capillaritis (PTC). Donor-specific antibodies (DSA), PTC-C4d, EC4d and PTC were analyzed in an independent longitudinal follow-up cohort (96 biopsies, 76 patients). Seventy-six samples were PTC and EC4d concordant, 11 positive and 65 negative, 7 PTC-EC4d+ and 13 PTC+EC4d-. EC4d levels were related to DSA occurrence. With ABMR defined by PTC and DSA, all apparently discordant patients, EC4d negative, were correctly reassigned comparing EC4d level curves with rejection kinetics, with positive EC4d samples predating biopsy or late biopsies compared with ABMR flare-ups. All EC4d-positive patients without PTC or DSA had permanent high EC4d levels unrelated to rejection. EC4d was more abundant in PTC-positive (mean = 108.5%± 3.4; n = 50) than PTC-negative samples (mean = 88.1%± 1.3; n= 96; p < 0.0001). Sensitivity, specificity, positive predictive value and negative predictive value of PTC-C4d and EC4d for PTC were, respectively, 75%, 79%; 64%, 76% (p < 0.05); 28%, 46% (p < 0.05) and 93%, 94%. Values were similar for DSA. A noninvasive blood test, EC4d, and particularly longitudinally monitoring EC4d levels, may increase surrogate ABMR testing options.

Posttransplant lymphoproliferative disorder following pancreas transplantation

The incidence, risk factors and impact on patient and graft survival were evaluated for posttransplant lymphoproliferative disorder (PTLD) among 212 pancreas transplant recipients. Thirteen (6.1%) developed PTLD during 71 +/- 27 months follow-up. Cumulative incidences of PTLD at 1, 3, 5 and 10 years posttransplant were 4.2%, 5.3%, 6.0% and 7.0%, respectively. Incidence of PTLD was lower for recipients of simultaneous pancreas kidney compared to pancreas after kidney transplant or pancreas transplant alone, though not significantly so. Recipient Epstein-Barr virus (EBV) seronegativity and number of doses of depleting antibody therapy administered at transplant were associated with increased risk of PTLD, while recipient age, gender, transplant type, cytomegalovirus mismatch maintenance immunosuppression type and treated acute rejection were not. All 13 cases underwent immunosuppression reduction, and 10 received anti-CD20 monoclonal antibody. During follow-up, 10/13 (77%) responded to treatment with complete remission, while 3 (23%) died as a result of PTLD. Patient and graft survivals did not differ for recipients with and without PTLD. The strong association of PTLD with EBV-seronegativity requires considering this risk factor when evaluating and monitoring pancreas transplant recipients. With reduction of immunosuppression and anti-CD20 therapy, survival for pancreas transplant recipients with PTLD was substantially better than previously reported.

Emergency surgery for complicated acute diverticulitis

AIM

Antecedent attacks of diverticulitis are thought to increase the risk of complicated diverticulitis, and unless elective surgery is performed, a high proportion of patients with recurrent symptoms will require emergency operations for complicated diverticulitis with its associated morbidity. In this multicentre study, we aim to assess impact of previous attacks of diverticulitis on patients requiring an emergency surgical intervention.

METHOD

All patients operated on as an emergency for complicated diverticulitis were retrospectively analysed. Patients were separated into two groups: group A included patients without previous history of diverticular disease, and group B those with previous attacks of diverticulitis.

RESULTS

A total of 96 patients were included in the study. Group A included 68 (70.8%) patients, and group B 28 (29.2%) patients. Generalized peritonitis was the reason for operation in 50 (73.5%) patients in-group A and only four (14%) patients in group B. Perforated diverticulitis occurred more often in group A, whereas pericolonic abscess and phlegmon formation occurred more commonly in group B. Resection was performed in all patients in group B; 50% had a Hartmann's procedure, and the other 50% patients had primary anastomosis. Hartmann's procedure was performed in 52 patients (76.5%) in group A, and 8 patients (11.7%) had resection and primary anastomosis. No difference in postoperative complications was identified between the groups.

CONCLUSION

Multiple attacks of diverticulitis are not associated with an increased risk of complicated diverticulitis. Recurrent episodes of diverticulitis are not associated with a less favourable outcome or an increased risk of fatality if complications ensue.

Assessing glomerular filtration rate by estimation equations in kidney transplant recipients

Surveillance of glomerular filtration rate (GFR) is crucial in the management of kidney transplant recipients. With special emphasis on serum creatinine (SCr) calibration assay, we assessed the performance of estimation equations as compared to iothalamate GFR (iGFR) in 209 patients using the modification of diet in renal disease (MDRD), Nankivell and Cockcroft-Gault methods. Fifty-five percent of patients were treated with a calcineurin inhibitor (CNI) and all were taken trimethroprim-sulfametoxazole at the time of SCr measurement. The mean iGFR was 44 +/- 26 mL/min/1.73 m2. The MDRD equation showed a median difference of 0.9 mL/min/1.73 m2 with 53% of estimated GFR within 20% of iGFR. Median differences were 7.5 and 7.0 mL/min/1.73 m2 for Nankivell and Cockcroft-Gault formulas, respectively. The accuracy of the Nankivell and Cockcroft-Gault formulas was such that only 38% and 37% of estimations, respectively, fell within 20% of iGFR. The performance of all equations was not uniform throughout the whole range of GFR, with some deterioration at the extremes of GFR levels. In addition, good performance of the MDRD equation was seen in subjects taking CNI. In conclusion, the overall performance of the MDRD equation was superior to the Nankivell and Cockcroft-Gault formulas in renal transplant recipients including subjects treated with CNI.

Intermodal interference in a photonic crystal fibre

Intermodal interference in photonic crystal fibres, single mode over long lengths, is measured over a short length. Akin to conventional fibres, this poses a potential problem for practical device utilisation of photonic crystal fibres. We note that given the existing widespread fabrication capability of this fibre and indications that some commercial use in devices will come to fruition, the need for standardising measurement techniques, analogous to ITU standards for conventional fibre, specific to photonic crystal fibres will be required.

[Analysis of tablets containing the antihistamine loratadine: a contribution to the identification of impurities]

Thin-layer chromatography on silica gel (Merck) was employed to examine potential impurities present in loratadine-containing tablets. A method usable for testing of impurities was elaborated, which suitably supplements the determination of loratadine content using the spectrophotometric method in the UV region. The method was validated for selected pharmaceuticals.

Microstructured optical fiber for single-polarization air guidance

An air-core microstructured fiber design that supports a single-polarization, circularly symmetric nondegenerate mode is presented. The fiber design is modeled directly, and the microstructured cladding is analyzed by use of band diagrams to elucidate the mechanism through which polarization nondegeneracy is achieved.

Optical absorption and sensitisation dose response in LiF:Mg,Ti: application to the unified interaction model predictions of thermoluminescence dose response

Using ancilliary optical absorption and sensitisation measurements, it is demonstrated quantitatively in the framework of the unified interaction model (UNIM) that the experimentally measured peak 5 supralinearity can be theoretically predicted for all possible dose response characteristics of the competitor.

Microstructured polymer optical fibre

The first microstructured polymer optical fibre is described. Both experimental and theoretical evidence is presented to establish that the fibre is effectively single moded at optical wavelengths. Polymer-based microstructured optical fibres offer key advantages over both conventional polymer optical fibres and glass microstructured fibres. The low-cost manufacturability and the chemical flexibility of the polymers provide great potential for applications in data communication networks and for the development of a range of new polymer-based fibre-optic components.

Reversal of cathepsin D routing modulation in MCF-7 breast cancer cells expressing antisense insulin-like growth factor II (IGF-II)

We previously demonstrated that expression of IGF-II modulates the routing of cathepsin D in MCF-7 cells. In our present study, we transfected antisense IGF-II into IGF-II secreting MCF-7 cells to test the hypothesis that blocking IGF-II may reduce the secretion of cathepsin D in breast cancer cells. The concentration of IGF-II in media conditioned by the antisense clone was reduced to almost undetectable levels. Likewise, Northern blotting analysis revealed that IGF-II mRNA was nearly undetectable in the antisense transfected cells. Metabolic labeling experiments performed with 10 mM mannose 6-phosphate present in the medium to block reuptake of lysosomal enzymes demonstrated that cathepsin D secretion was dramatically reduced. Similarly, a significant reduction in cathepsin D was observed when conditioned media and cell extracts were examined by Western blotting after a 48 h incubation. No changes in cathepsin D mRNA in antisense cells were detected by Northern blot analysis. We conclude that endogenous IGF-II may modulate the routing of cathepsin D by interfering with receptor trafficking in MCF-7 cells, and that this modulation is reversible. Abnormally high levels of IGF-II may alter this homeostasis, conferring on breast cancer cells an advantageous mechanism that promotes rapid growth, and may facilitate metastasis.

Conditions and problems of the labour force in agriculture

"This paper...deals with the conditions of the agricultural labour force in the [ESCWA] region.... The study propounds several proposals which collectively could form the broad outlines of a policy aimed at finding proper solutions for the problems of the agricultural labour force in the countries of the region." The author focuses on Egypt, Iraq, Jordan, Lebanon, Syria, and Yemen.

Amyloidosis and periodic peritonitis (familial mediterranean Fever)

Some reports indicate that amyloidosis is a rare occurrence in persons with periodic peritonitis (familial Mediterranean fever), while others seem to show it occurs relatively frequently. Two cases were seen among 80 patients in Iraq. Twenty-one consecutive rectal biopsies were negative for amyloidosis. The variation in reported incidence is partly real and partly apparent. Amyloidosis occurs frequently in certain ethnic groups, and it is possible that there are two traits, one for periodic peritonitis and the other for amyloidosis.