On the dimorphism of prednisolone: The topological pressure-temperature phase diagram involving forms I and II

The dimorphism of the corticosteroid anti-inflammatory drug prednisolone has been investigated by the construction of a topological pressure-temperature phase diagram, using crystallographic and calorimetric data. The system is enantiotropic, because the temperature of the I-II equilibrium under atmospheric conditions (400 - 463 K) is lower than that of the two melting equilibria (518.7 K for form II and 526.3 K for form I). The slope of the I-II equilibrium in the pressure-temperature phase diagram is negative and relatively steep; therefore, form II, which is the stable form at room temperature, will not easily encounter conditions where form I will become stable even under industrial processing conditions. On the other hand, extreme small amounts of form I have been observed to spontaneously transform into form II in a time interval of about six years at room temperature and it can be concluded that although form I is very persistent under ambient conditions, it does slowly convert into form II. Moreover, the system does not obey the density rule.

Atypic large hepatic cyst with persistent elevated CA19.9 serum value: utility of intracystic CA72.4 dosage for a mini-invasive management

Simple hepatic cysts are very common, but may be difficult to differentiate from a biliary cystadenoma or cystadenocarcinoma. Because the surgical treatment if needed, such as a hepatic fenestration or resection, depends on the diagnosis, the assay of intracystic tumor markers is useful.We report the case of a 67-year-old woman with a large hepatic cyst responsible of pain and inflammation. The combination of imaging findings, serum, and intracystic fluid tumor markers [CA72.4 (carbohydrate hydrogen)] permitted to diagnose a simple hepatic cyst despite an unusual persistent elevated serum CA19.9 level. A laparoscopic cyst fenestration was proposed with an uneventful postoperative course. The pathological findings showed a simple hepatic cyst.In case of hepatic cysts, radiological findings can discriminate between benign and (pre)malignant lesions, but in case of doubtful diagnosis, the serum and intracystic tumor markers can be helpful.The use of serum or intracystic tumor marker allows to choose the correct therapeutic strategy and to use mini-invasive approach when feasible.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

A87 A NEW ERA: CIRCUMFERENTIAL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY ESOPHAGEAL NEOPLASM AND BARRET’S ERADICATION

Background

Endoscopic submucosal dissection (ESD) has become increasingly important over the last few years as the treatment of choice for early gastrointestinal malignancies. Esophageal adenocarcinoma is among the most rapidly rising malignancies associated with a poor 5-year survival rate. ESD is emerging as a novel minimally invasive treatment for superficial esophageal neoplasms. However, with increasing circumference of dissection, the rate of stricture increases with over 90% stricture rate reported with complete circumferential ESD (cESD). Currently, for superficial Barrett’s neoplasms the dysplastic lesion is resected and subsequent eradication of remaining Barrett’s is with radiofrequency ablation over multiple sessions.

Aims

To report on a case of cESD for intramucosal carcinoma and Barrett’s eradication with one procedure with the application of prophylactic dual steroid treatment (DST) for prevention of stricture.

Methods

We present the case of a 62-year-old female with C1M5 Barrett’s esophagus with pathology confirming high grade dysplasia with a focus suspicious for intramucosal adenocarcinoma. Staging CT excluded metastatic disease. Repeat endoscopy with magnification revealed multiple areas with highly irregular vascular and surface patterns with premature loss of acetowhitening reaction consistent with multifocal at least high-grade dysplasia. Subsequently, the entire segment of Barrett’s was removed via cESD. Histopathologic analysis of the resected tissue confirmed multifocal high grade disease with margins negative for dysplasia or intestinal metaplasia. The patient was started on DST with oral prednisone and topical (swallowed) budesonide along with sucralfate as prophylactic measures to prevent luminal stricturing.

Results

During the re-epithelization period the patient required 2 prophylactic dilations. Five months post-ESD, full clinical, endoscopic and histopathologic healing had been observed. There was complete squamous re-epithelization with normal squamous mucosa without stricture. The patient remains on a yearly endoscopic surveillance protocol.

Conclusions

cESD represents a novel therapeutic strategy for the definitive histologic and endoscopic eradication of superficial esophageal neoplasms along with remaining Barrett’s. In this patient, there were no complications and significant stricturing was prevented with DST. Multiple prior studies have assessed single steroid therapy as a therapeutic option for strictures. In this report, DST represents a novel regime in preventing severe strictures post cESD. Longer term follow-up and further reports are needed to confirm these findings.

Funding Agencies

None

What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?

AIM

In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry.

METHOD

From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation.

RESULTS

A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm³ (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm³ (P = 0.001) was correlated with the risk of impending caecal perforation.

CONCLUSION

Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Lycopene crystalloids exhibit singlet exciton fission in tomatoes

Transient absorption studies conducted on in vitro lycopene aggregates, as well as on lycopene crystalloids inside tomato chromoplasts, reveal the appearance of a long-lived excited state, which we unambiguously identified as lycopene triplet. These triplet states must be generated by singlet exciton fission, which occurs from the lycopene 2Ag state. This is the first time the singlet fission process has ever been shown to occur in a biological material. We propose that the formation of carotenoid assemblies in chromoplasts may constitute a photoprotective process during chromoplast maturation, in addition to their function in signaling processes.

Repeat sleeve gastrectomy: optimization of outcomes by modifying the indications and technique

BACKGROUND

Few series are available concerning repeat sleeve gastrectomy (re-SG), and series have reported contradictory results concerning morbidity rates, with limited data concerning weight loss.

OBJECTIVE

Evaluate the short- and medium-term outcomes of re-SG.

SETTING

University hospital, France, public practice.

METHODS

Between June 2007 and March 2016, all patients undergoing re-SG (n = 46 patients) were included. Re-SG was proposed for patients with insufficient excess weight loss (EWL) (≤50%) or renewed weight gain with excessively high residual gastric volume (>250 mL and/or large gastric pouch). The primary efficacy endpoint was the overall complication rate of re-SG. The secondary efficacy endpoints were operative data, evaluation of weight loss, and correction of co-morbidities, risk factors for gastric leak (GL), by comparing 2 periods (period 1, January 2004-December 2013: blue/green or purple staplers without reinforcement; period 2, after December 2013: black staplers with reinforcement) and comparison of weight loss according to the indication for re-SG.

RESULTS

The re-SG group consisted of 46 patients (35 women, mean age: 47.5 yr). The mean body mass index (BMI) before SG was 47.2 kg/m² (35-63.6). The mean time interval between SG and re-SG was 73 months (11-106). The BMI before re-SG was 41.2 kg/m² (29-54.7). Indications for surgery were insufficient weight loss in 25 patients (54.3%) and weight regain in 21 patients (45.7%). A large gastric pouch was visible in 4 patients (8.6%). The mean operating time was 97.6 minutes (45-220). One death (2.1%) and 7 complications (15.2%) were observed. The mean length of hospital stay was 3.6 days (1-30). At last follow-up, mean BMI was 32.1 kg/m² (20.3-41.3) and mean EWL was 62.3% (18-127.2). When analyzing risk factors for GL, residual gastric volume between 250 and 350 mL was associated with a higher GL rate compared with a volume ≥350 mL, and re-SG performed during period 1 was associated with a higher GL rate than re-SG performed during period 2 (17.4% versus 0%; P = .13). Re-SG performed for weight regain was associated with a significantly higher additional weight loss compared with re-SG performed for insufficient weight loss (mean additional EWL of 45.9%; P = .06).

CONCLUSION

Re-SG is feasible, but it requires adaptation of the surgical procedure to decrease complications. Results on weight loss are acceptable, but the best indications for re-SG were a gastric volume>350 mL and in the case of weight regain with the exception of technical failure of the primary SG.

Pressure-temperature phase diagram of the dimorphism of the anti-inflammatory drug nimesulide

Understanding the phase behavior of active pharmaceutical ingredients is important for formulations of dosage forms and regulatory reasons. Nimesulide is an anti-inflammatory drug that is known to exhibit dimorphism; however up to now its stability behavior was not clear, as few thermodynamic data were available. Therefore, calorimetric melting data have been obtained, which were found to be T_I-L=422.4±1.0K, Δ_I→LH=117.5±5.2Jg^-1,T_II-L=419.8±1.0K and Δ_II→LH=108.6±3.3Jg^-1. In addition, vapor-pressure data, high-pressure melting data, and specific volumes have been obtained. It is demonstrated that form II is intrinsically monotropic in relation to form I and the latter would thus be the best polymorph to use for drug formulations. This result has been obtained by experimental means, involving high-pressure measurements. Furthermore, it has been shown that with very limited experimental and statistical data, the same conclusion can be obtained, demonstrating that in first instance topological pressure-temperature phase diagrams can be obtained without necessarily measuring any high-pressure data. It provides a quick method to verify the phase behavior of the known phases of an active pharmaceutical ingredient under different pressure and temperature conditions.

Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy

BACKGROUND

Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient.

OBJECTIVE

Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population.

SETTING

University hospital, France, public practice.

MATERIAL AND METHODS

This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies.

RESULTS

A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures.

CONCLUSION

Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.

Design of a Physical Activity Program to Prevent Functional Decline in Onco-Geriatric Patients (CAPADOGE): A Randomized Multicenter Trial

BACKGROUND

Cancer in older patient favours the development of frailty: feeling of exhaustion, loss of weight, decreased muscle strength, slow gait speed, and low physical activity.

OBJECTIVES

To evaluate the efficacy of adapted physical activity phone advices in limiting the cancer-induced loss of autonomy and frailty phenotype development.

DESIGN

Multicenter randomized controlled trial.

SETTING

Patients (>70y) undergoing curative treatment for cancer (n=400) will be recruited from 12 centres.

INTERVENTION

The intervention consists in phoned personalized physical activity advices related to strength, aerobic, balance, proprioception, and flexibility. The contacts are performed twice a month during six months and then monthly until 1 year. The intervention complements the PNNS booklet advices (National Nutritional Health Program). The trial compares «individualized phone advices + PNNS» to «usual care + PNNS».

MEASUREMENTS

Functional, cognitive, clinical and self-reported data are assessed before treatment and at 3, 6, 12, 18, and 24 month follow-up. The primary outcome is the proportion of subjects with a one-year decreased SPPB (Short Physical Performance Battery) score of one point or more, as compared to baseline. The secondary outcomes include quality of life items, rate of hospitalizations, institutionalizations, mortality, Fried phenotype at 1 and 2 years, and the SPPB score at 2 years.

DISCUSSION

This large trial will provide clinical data of the effects of an exercise advices intervention in older patients during cancer therapy on function and cognition evolution, and quality of life. The possibilities of minimizing the development of frailty phenotype due to these advices will be explored.

ID: 128: FTY720 S-PHOSPHONATE DOES NOT ACTIVATE GRK2-MEDIATED S1PR1 PHOSPHORYLATION AND DEGRADATION

Rationale

A significant and sustained increase in vascular permeability is a hallmark of acute inflammatory diseases such as acute lung injury (ALI), but effective therapies for preserving or reconstituting the vascular barrier are lacking. Prior work has demonstrated that FTY720 S-phosphonate (Tysiponate/Tys), an analog of sphingosine 1-phosphate (S1P) and FTY720, has more potent pulmonary barrier protective effects than these agents in vitro and in the LPS- and bleomycin-induced models of mouse ALI. Moreover, Tys preserves expression of the barrier promoting S1P1 receptor (S1PR1), whereas S1P and FTY720 induce its ubiquitination and degradation. In this report, we further characterize the mechanism of preservation of S1PR1 expression by Tys in cultured human pulmonary endothelial cells (EC).

Results

P-FTY720 significantly induced the association of S1PR1 and GRK2 and increased the p-serine content of S1PR1, which are critical for S1PR1 internalization and degradation, but Tys failed to do so. In contrast, both p-FTY720 and Tys induced significant tyrosine phosphorylation of S1PR1. Tys also preserves expression of S1PR2 and S1PR3. Although prior work reported that E3 ubiquitin-protein ligase WWP2 is critical for ubiquitination and degradation of S1PR1, neither p-FTY720 nor Tys changed its association with S1PR1 in human lung EC. Moreover, ubiquitin activating enzyme E1 inhibitor significantly inhibited S1PR1 degradation induced by p-FTY or S1P. Pharmacological inhibition of PKA, PKG, PKC, GSK3, PI3K, ERK, Src, or c-Abl activity, as well as inhibition of calcium flux, all fail to inhibit p-FTY720-induced S1PR1 degradation.

Conclusion

Unlike p-FTY720, Tys fails to activate the GRK2-mediated ubiquitination pathway and thus preserves S1PR1 expression. These results provide additional mechanistic insights into the barrier-regulatory effects of this potential ALI therapy.

Multidisciplinary management of Mirizzi syndrome with cholecystobiliary fistula: the value of minimally invasive endoscopic surgery

Mirizzi syndrome, a rare complication of gallstones, is defined by obstruction of the main bile duct. This obstruction may worsen and thus result in cholecystobiliary fistula. Surgical management of Mirizzi syndrome is complicated by the presence of inflamed tissue around the hepatic pedicle, making it impossible to distinguish between the main bile duct and the gallbladder. The surgeon's first task is to perform subtotal cholecystotomy (from the fundus of the gallbladder to the neck) without trying to locate the cystic duct. In a second step, the gallstones are extracted and the main bile duct is then repaired. In most cases, a T-tube is used to drain the main bile duct, and abdominal drainage is left in place (in case a bile fistula forms). This study concluded that preoperative drainage of the main bile duct in the treatment of Mirizzi syndrome types II and III is feasible and might help to decrease the postoperative complication rate.

Unusual course of the aberrant right hepatic artery running through the pancreatic parenchyma during modified Frey's procedure

We report a variation of an aberrant right hepatic artery arising from the superior mesenteric artery and crossing into pancreatic head without other hepatic artery substitution. The variant was discovered during radiological examinations in a patient with symptomatic chronic pancreatitis requiring Frey's procedure with reinsertion of the common bile duct into the pancreatic head. An aberrant right hepatic artery arising from the superior mesenteric artery is present in 10 to 20% of case and its course is usually retro-pancreatic. The course of this artery into the pancreatic head is uncommon and can be present up to 10% in case of ARHA. Knowledge of an aberrant right hepatic artery crossing into the pancreatic head is important before pancreatic surgery in order to avoid surgical complications, especially for liver necrosis.

Impact of oral meloxicam administered alone or in combination with gabapentin on experimentally induced lameness in beef calves

This study examined the pharmacokinetics and analgesic effect of oral meloxicam (MEL) administered alone or in combination with gabapentin (GABA) in an experimental bovine lameness model. Eighteen male British × Continental beef calves aged 4 to 6 mo and weighing 297 to 392 kg were randomly assigned to receive either 1) 0.5 mg/kg lactose monohydrate placebo (PLBO; n = 6), 2) 0.5 mg/kg MEL (n = 6), or 3) 0.5 mg/kg MEL combined with 15 mg/kg GABA (MEL-GABA; n = 6) once daily for 4 d. The first treatment was administered 4 h after a chemical synovitis/arthritis was induced with injection of 15 mg amphotericin B into the left hind lateral distal interphalangeal joint. Changes in activity were evaluated continuously with pedometers. Contact force, contact area, contact pressure, impulse, and stride length were recorded once daily with a pressure mat and visual lameness scores were determined by a masked observer using a 5-point scale. Cortisol and drug concentrations were determined daily by immunoassay and HPLC-mass spectrometry, respectively. Outcomes were compared statistically using a random effects mixed model and analysis of covariance. There was a positive association between lameness scores and serum cortisol concentrations (P = 0.02) and a negative association between lameness score and step count (P < 0.0001), total force (P = 0.001), force applied to the lateral claw (P = 0.02), contact pressure (P = 0.005), and impulse of the lateral claw (P = 0.01). Step count was greater in MEL calves compared with PLBO (P = 0.008) and MEL-GABA (P = 0.04) calves. Impulse was greater in the MEL-GABA calves compared with the PLBO calves (P = 0.03). There was an inverse relationship between plasma MEL concentrations and lameness score (P = 0.02) and a positive association between MEL concentrations and force applied to the lateral claw (P = 0.03), total contact pressure (P = 0.03), and impulse on the lateral claw (P = 0.02). There was a tendency towards a positive association between GABA concentrations, total impulse, and impulse on the lateral claw (P = 0.08) and a negative associate between GABA concentrations and step count (P = 0.08). The results of this study suggest that MEL administered alone or in combination with GABA reduced the severity of lameness in calves following induction of lameness with amphotericin B. These findings have implications for developing analgesic protocols in lame calves that address both production and welfare concerns.

Efficacy of the double-pigtail stent as a conservative treatment for grade B pancreatic fistula after pancreatoduodenectomy with pancreatogastric anastomosis

BACKGROUND

Despite improvements in surgical techniques and postoperative care, morbidity associated with pancreatoduodenectomy (PD) is still high. Grade B pancreatic fistula (PF) requires a specific combination of radiologically guided external drainage and medical support. This treatment is effective but requires prolonged hospitalization and maintenance of external drainage. The objective of this study was to evaluate the feasibility and efficacy of a double-pigtail stent (DPS) to treat grade B PF after PD with pancreatogastric anastomosis.

METHODS

Between January 2008 and October 2011, all patients who presented grade B PF after PD (n = 6) were included in the study. The PF was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula. Endoscopic treatment was standardized with a DPS. The primary efficacy end point was the feasibility and efficacy of DPS placement. Secondary end points included data on the PF, the DPS placement procedure, and long-term outcome.

RESULTS

Endoscopic DPS placement was achieved in all patients with no complications. The median time to onset of PF after PD was 14 days. Closure of the external PF was obtained 7 days after the introduction of the DPS. The median time to external drain removal was 7 days after DPS placement, and the median time to oral refeeding was 7 days after DPS placement for all patients. The median time to DPS removal was 60 days. The median length of hospital stay after DPS placement was 10 days. During a median follow-up period of 21 months, there was no recurrence of PF after removal of the DPS.

CONCLUSION

Endoscopic treatment of grade B PF after PD appears to be effective and safe and is associated with shorter hospitalization.

Preclinical validation of AXL receptor as a target for antibody-based pancreatic cancer immunotherapy

AXL receptor tyrosine kinase (RTK) is implicated in proliferation and invasion of many cancers, particularly in pancreatic ductal adenocarcinoma (PDAC), for which new therapeutic options are urgently required. We investigated whether inhibition of AXL activity by specific monoclonal antibodies (mAbs) is efficient in limiting proliferation and migration of pancreatic cancer cells. Expression of AXL was evaluated by immunohistochemistry in 42 PDAC. The AXL role in oncogenesis was studied using the short hairpin RNA approach in a pancreatic carcinoma cell line. We further generated antihuman AXL mAbs and evaluated their inhibitory effects and the AXL downstream signaling pathways first in vitro, in a panel of pancreatic cancer cell lines and then in vivo, using subcutaneous or orthotopic pancreatic tumor xenografts. AXL receptor was found expressed in 76% (32/42) of PDAC and was predominantly present in invasive cells. The AXL-knockdown Panc-1 cells decreased in vitro cell migration, survival and proliferation, and reduced in vivo tumor growth. Two selected anti-AXL mAbs (D9 and E8), which inhibited phosphorylation of AXL and of its downstream target AKT without affecting growth arrest-specific factor 6 (GAS6) binding, induced downexpression of AXL by internalization, leading to an inhibition of proliferation and migration in the four pancreatic cancer cell lines studied. In vivo, treatment by anti-AXL mAbs significantly reduced growth of both subcutaneous and orthotopic pancreatic tumor xenografts independently of their KRAS mutation status. Our in vitro and preclinical in vivo data demonstrate that anti-human AXL mAbs could represent a new approach to the pancreatic cancer immunotherapy.

Addition of Molecular Adsorbent Recirculating System (MARS(®)) Albumin Dialysis for the Preoperative Management of Jaundiced Patients with Hilar Cholangiocarcinoma

The preoperative management of hilar cholangiocarcinoma (HC) with jaundice focuses on decreasing the total serum bilirubin level (SBL) by performing preoperative biliary drainage (PBD). However, it takes about 6–8 weeks for the SBL to fall at a sufficient extent. The objective of this preliminary study was to evaluate the impact of Molecular Adsorbent Recirculating System (MARS^®) dialysis (in association with PBD) on SBL decrease. From January 2010 to January 2011, we prospectively selected all jaundiced patients admitted to our university hospital for resectable HC and requiring PBD prior to major hepatectomy. The PBD was followed by 3 sessions of MARS dialysis over a period of 72 h. A total of 10 patients with HC were screened and two of them were included (Bismuth-Corlette stage IIIa, gender ratio 1, median age 68 years). The initial SBL in the two patients was 328 and 242 μmol/l, respectively. After three MARS dialysis sessions, the SBL had fallen by 30 and 52%, respectively. After the end of each session, there was a SBL rebound of about 10 μmol/l. The MARS decreased the serum creatinine level, the platelet count and the prothrombin index, but did not modify the serum albumin level. Pruritus disappeared after one and two sessions, respectively. MARS-related morbidity included hypotension (n = 1), tachycardia (n = 1), thrombocytopenia (n = 2) and anaemia (n = 1). When combined with PBD, MARS dialysis appears to accelerate the decrease in SBL and thus may enable earlier surgery. This hypothesis must be validated in a larger study.

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature

AIM

Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature.

MATERIALS AND METHODS

We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient's short-term treatment outcome.

RESULTS

From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14-88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn's disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3-33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage.

CONCLUSION

When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).

Radiologic drainage of post-operative collections and abscesses

Since the initial studies published in the eighties, percutaneous radiologic drainage, is considered the first-line treatment of infected post-operative collections and is successful in over 80% of patients. Mortality due to undrained abscesses is estimated between 45 and 100%. Radiology-guided percutaneous drainage can be performed either with curative intent or to improve patient status prior to re-operation under better conditions. Cross-sectional imaging, using either ultrasound or computed tomography (CT), has changed the management of post-operative complications. Percutaneous drainage is most often performed by interventional radiologists and imaging is essential for road-mapping and guiding the puncture and drainage of intra-abdominal collections. Indeed, such imaging allows both identification of adjacent anatomical structures and determination of the best tract and the safest route. Cooperation between the surgeon and the interventional radiologist is essential to optimize the management and to avoid, if possible, surgery, which is so often difficult in this setting.

Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure?

BACKGROUND

Causes of failure after laparoscopic sleeve gastrectomy (LSG) are not known but may include a high residual gastric volume (RGV). The aim of this study was to use gastric computed tomography volumetry (GCTV) to investigate the RGV and relate the latter parameter to the outcome of LSG.

METHODS

A single-center, prospective study included patients with>24 months of follow-up after LSG. The RGV was measured with a unique GCTV technique. We determined the LSG outcomes according to a variety of criteria and examined potential relationships with the RGV. When the RGV was>250 cc, we offered a repeat LSG (RLSG).

RESULTS

Seventy-six patients were included. The mean RGV was 255 cc but differed significantly when comparing "failure" and "success" subgroups, regardless of whether the latter were defined by a percentage of excess weight loss>50 (309 cc versus 225 cc, respectively; P = .0003), a BAROS score>3 (312 cc versus 234 cc; P = .005), the Reinhold criteria (290 cc versus 235 cc; P = .019), or the Biron criteria (308 cc versus 237 cc; P = .008). The RGV threshold (corresponding to the volume above which the probability of failure after LSG is high) was 225 cc. Fifteen RLSGs were performed during the inclusion period.

CONCLUSION

A high RGV 34 months after LSG is a risk factor for failure. Knowledge of the RGV can be of value in the management of failure after LSG.

MR-guided adaptive focusing of therapeutic ultrasound beams in the human head

PURPOSE

This study aims to demonstrate, using human cadavers the feasibility of energy-based adaptive focusing of ultrasonic waves using magnetic resonance acoustic radiation force imaging (MR-ARFI) in the framework of non-invasive transcranial high intensity focused ultrasound (HIFU) therapy.

METHODS

Energy-based adaptive focusing techniques were recently proposed in order to achieve aberration correction. The authors evaluate this method on a clinical brain HIFU system composed of 512 ultrasonic elements positioned inside a full body 1.5 T clinical magnetic resonance (MR) imaging system. Cadaver heads were mounted onto a clinical Leksell stereotactic frame. The ultrasonic wave intensity at the chosen location was indirectly estimated by the MR system measuring the local tissue displacement induced by the acoustic radiation force of the ultrasound (US) beams. For aberration correction, a set of spatially encoded ultrasonic waves was transmitted from the ultrasonic array and the resulting local displacements were estimated with the MR-ARFI sequence for each emitted beam. A noniterative inversion process was then performed in order to estimate the spatial phase aberrations induced by the cadaver skull. The procedure was first evaluated and optimized in a calf brain using a numerical aberrator mimicking human skull aberrations. The full method was then demonstrated using a fresh human cadaver head.

RESULTS

The corrected beam resulting from the direct inversion process was found to focus at the targeted location with an acoustic intensity 2.2 times higher than the conventional non corrected beam. In addition, this corrected beam was found to give an acoustic intensity 1.5 times higher than the focusing pattern obtained with an aberration correction using transcranial acoustic simulation-based on X-ray computed tomography (CT) scans.

CONCLUSIONS

The proposed technique achieved near optimal focusing in an intact human head for the first time. These findings confirm the strong potential of energy-based adaptive focusing of transcranial ultrasonic beams for clinical applications.