Evaluation of hepatobiliary excretion and enterobiliary reflux in rats with biliary obstruction submitted to bilioduodenal or biliojejunal anastomosis

Bilioduodenal and biliojejunal anastomoses are effective for the treatment of biliary obstruction. The objective of this study was to compare the effects of these anastomoses on hepatobiliary excretion and enterobiliary reflux. Enterobiliary reflux and biliary excretion were evaluated respectively after oral administration of technetium (Tc-99m) in combination with sodium phytate and intravenous infusion of Tc-99m with diisopropyl-iminodiacetic acid. Enterobiliary reflux occurred to an equal degree in the bilioduodenal and biliojejunal groups. Maximum hepatic activity time (T-max) and radiotracer clearance half-time (T-1/2) were similar in both groups. However, when compared with that found for the sham-operated group, T-max, and T-1/2 were higher in the biliojejunal group (P = 0.02 and P = 0.01, respectively). Histopathological analysis showed marked reduction in ductal proliferation in both groups. These data undermine the theoretical advantages attributed to biliojejunal anastomosis and further the understanding of the pathophysiology of cholangitis that occurs even with patent anastomosis.

Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension

The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmer's classification: grade 1 -- up to 3 mm, grade 2 -- from 3 to 6 mm, grade 3 -- greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size.

Histological behavior of glutaraldehyde cross-linked bovine collagen injected into the human bladder for the treatment of vesicoureteral reflux

Endoscopic subureteral collagen injection has become an accepted means for the treatment of vesicoureteral reflux in children. The aim of this study was to evaluate the histological behavior of glutaraldehyde cross-linked bovine collagen implants. The specimens were harvested from 29 patients who underwent reimplant surgery 2 to 30 months (mean 9.5) after unsuccessful subureteral injection therapy. In addition to routine hematoxylin and eosin staining, a new staining method (solophenyl red 3BL) able to demonstrate selectively neoformation of types I and III human collagen, was applied. Invasion of host fibroblasts into the bovine implant and the formation of endogenous types I and III collagen were demonstrated in all 29 cases. Adverse histological reactions were rare and, if present, they were predominantly of an inflammatory nature.

Reflux vésico-­‐urétéral et atteinte rénale: rôle de l'albuminurie

Introduction :¦Le reflux vésico-urétéral (RVU) touche environs 1% des nouveau-nés et est retrouvé chez 25 à 30 % des enfants ayant une pyélonéphrite. Le RVU peut être associé à une hypoplasie/dysplasie rénale ou/et à des cicatrices rénales causées par les pyélonéphrites. Ces changements morphologiques sont plus ou moins importants selon le grade du reflux et peuvent conduire à une insuffisance rénale chronique et potentiellement évoluer en une insuffisance rénale terminale.¦La microalbuminurie (MA) reflète une augmentation anormale de la perméabilité capillaire glomérulaire et est un indicateur prédictif de la péjoration de la fonction rénale vers l'insuffisance chronique. La MA est également un facteur de risque cardiovasculaire.¦Objectif :¦Le but de cette recherche transversale est d'évaluer la présence de MA chez des patients atteints de RVU et de voir s'il est possible de corréler la MA avec le degré de reflux, la présence d'une hyperfiltration et le degré de l'insuffisance rénale.¦Patients et méthode :¦Une base de données de 160 dossiers médicaux du service de pédiatrie du CHUV, portant sur les années 2007, 2008, 2009 et 2010, va être investiguée. Ces dossiers regroupent tous les patients atteints de RVU ayant eu une exploration fonctionnelle rénale, dont l'âge varie du nouveau-né au jeune adulte âgé de 21 ans. Les variables suivantes seront considérées et analysées en détail: âge, sexe, taille, type de RVU, taux de filtration glomérulaire (TFG), flux plasmatique rénal (FPR), fraction de filtration (FF), albuminurie, rapport albumine/créatinine.¦- Les RVU sont classés en cinq grades (I, II, III, IV, V) et peuvent être uni- ou bilatéraux¦- Le TFG est calculé avec la clairance à l'inuline, un polymère de glucose filtré, non réabsorbé, ni sécrété, qu'on perfuse au patient. TFG = Uin V/Pin (ml/min)¦- Le FPR est calculé avec la clairance au PAH (acide para-amino-hippurique), une substance entièrement filtrée et sécrétée au premier passage et qu'on injecte au patient. FPR = UPAHV / PPAH (ml/min)¦- La FF est la proportion du FPR qui est filtrée.¦FF= TGF / FPR ou FF = Cl in / Cl PAH¦- La MA a été mesurée par la méthode Immulite (Siemens) jusqu'en fin août 2010 et par la méthode ALBT2 (Roche Diagnostics) à partir d'octobre 2010. Le taux normal d'albuminurie est de moins de 20 mg/l sur un échantillon d'urine.¦- Le rapport albumine urinaire / créatinine urinaire permet d'éviter les problèmes de variation de volume urinaire lors de l'analyse d'échantillon urinaire d'une seule miction. Le rapport normal est de moins de 2,5 g/mol de créatinine.¦Un questionnaire sera envoyé aux patients pour obtenir des précisions sur la fréquence et la sévérité des infections urinaires éventuellement survenues depuis.¦Les dossiers seront revus pour connaître l'évolution du RVU.¦Résultats attendus et discussion: Les résultats nous permettront :¦1) De savoir si les patients avec un RVU ont une MA¦2) De savoir si la MA varie en fonction du grade de leur reflux¦3) De savoir si la MA varie en fonction de l'hyperfiltration mesurée par la FF.¦Interprétation :¦Si la MA varie en fonction de la FF cela indiquera que la MA est la conséquence directe de l'hyperfiltration compensatrice de la perte de la masse néphronique et qu'elle est ainsi le reflet d'une cause principalement mécanique. Si la MA ne varie pas en fonction de la FF cela indiquera qu'elle est liée à l'hypoplasie/dysplasie ou/et aux cicatrices dues aux pyélonéphrites. Elle pourra alors être par exemple la conséquence d'une néphropathie glomérulotubulointerstitielle.¦Du point de vue pratique, cette étude permettra de déterminer si la simple mesure da la MA peut aider à prédire le degré de l'atteinte rénale et/ou le degré de l'hyperfiltration dans ce groupe de patients atteints de RVU.¦Bibliographie¦1. Silbernagl S, Despopoulos A. Atlas de poche de physiologie. Paris : Flammarion médecine-sciences; 2004.¦2. Brenner BM, Rector FC. The Kidney . Philadelphia : WB Saunders Company; 1996.¦3. Brandström P, Esbjörner E, Herthelius M, Holmdahl G, Läckgren G, Nevéus T, et al. The Swedish Reflux Trial in Children: I. Study Design and Study Population Characteristics. The Journal of Urology. 2010;184:274-279.¦4. Holmdahl G, Brandström P, Läckgren G, Sillén U, Stokland E, Jodal U, et al. The Swedish Reflux Trial in Children: II. Vesicoureteral Reflux Outcome. The Journal of Urology. 2010;184:280-285.¦5. Brandström P, Esbjörner E, Herthelius M, Swerkersson S, Jodal U, Hansson S. The Swedish Reflux Trial in Children: III. Urinary Tract Infection Pattern. The Journal of Urology. 2010;184:286-291.¦6. Brandström P, Nevéus T, Sixt R, Stokland E, Jodal U, Hansson S. The Swedish Reflux Trial in Children: IV. Renal Damage. The Journal of Urology. 2010;184:292-297.¦7. Ruggenenti P, Remuzzi G. Time to abandon microalbuminuria? Kidney Int. 2006;70:1214-1222.¦8. Hostetter TH, Olson JL, Rennke HG, Venkatachalam MA, Brenner BM. Hyperfiltration in remnant nephrons: a potentially adverse response to renal ablation. J. Am. Soc. Nephrol. 2001;12:1315-1325.¦9. Basic J, Golubovic E, Miljkovic P, Bjelakovic G, Cvetkovic T, Milosevic V. Microalbuminuria in children with vesicoureteral reflux. Ren Fail. 2008:639-643.¦10. González E, Papazyan JP, Girardin E. Impact of vesicoureteral reflux on the size of renal lesions after an episode of acute pyelonephritis. The Journal of Urology. 2005;173:571-575.

Endoscopic subureteral collagen injection for the treatment of vesicoureteral reflux in infants and children.

Between June 1988 and September 1994, 100 girls and 32 boys 2 months to 15.5 years old (average 4.9 years) with 204 refluxing ureteral units were treated by endoscopic subureteral collagen injection. The collagen injected was of bovine origin and cross-linked with glutaraldehyde (Zyplast*). Followup ranged from 3 to 75 months (mean 33). Reflux was absent in 62.7% of cases 3 months after 1 endoscopic subureteral injection. Improvement to reflux grades I and II, generally not requiring further treatment, occurred in a further 15.2% of cases. A total of 66 ureters was injected twice. The overall cure rate after 1 or 2 injections was 79.4% 3 months after injection. There was no correlation between the risk of recurrent reflux and initial degree of reflux. Late recurrence of reflux following a reflux-free period occurred in 11.3% of the 204 units during the observation period, which varied from 3 months to 6 1/4 years. Reflux was absent after 1 or 2 injections, including late recurrence, in 70.6% of cases and in an additional 13.2% recurrent reflux was grade I or II, not necessitating any further treatment. Considering these results, subureteral collagen injection remains an adequate method of treatment for vesicoureteral reflux in children.

La nouvelle classification de Savary des oesophagites de reflux [Savary's new endoscopic classification of reflux oesophagitis]

Comme la classification de Savary-Miller dont elle adopte l'essentiel, la classification de l'oesophagite par refluxen 5 types de Savary-Monnier repose sur une analyse rigoureuse et précise des lésions endoscopiques. Ses principales qualités sont d'être simple, complète, logique et souple. Son impact sur la pratique est certain puisqu'elle a une excellente valeur pronostique et qu'elle permet de choisir la bonne stratégie thérapeutique. De plus, en isolant les cicatrices cylindriques (seules précancéroses à surveiller à long terme) elle permet de les utiliser pour préciser la topographie des oesophagites de reflux.

EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach.

PURPOSE: The Gastro-Intestinal Working Party of the EORTC Radiation Oncology Group (GIWP-ROG) developed guidelines for target volume definition in neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction (GEJ) and the stomach. METHODS AND MATERIALS: Guidelines about the definition of the clinical target volume (CTV) are based on a systematic literature review of the location and frequency of local recurrences and lymph node involvement in adenocarcinomas of the GEJ and the stomach. Therefore, MEDLINE was searched up to August 2008. Guidelines concerning prescription, planning and treatment delivery are based on a consensus between the members of the GIWP-ROG. RESULTS: In order to support a curative resection of GEJ and gastric cancer, an individualized preoperative treatment volume based on tumour location has to include the primary tumour and the draining regional lymph nodes area. Therefore we recommend to use the 2nd English Edition of the Japanese Classification of Gastric Carcinoma of the Japanese Gastric Cancer Association which developed the concept of assigning tumours of the GEJ and the stomach to anatomically defined sub-sites corresponding respectively to a distinct lymphatic spread pattern. CONCLUSION: The GIWP-ROG defined guidelines for preoperative irradiation of adenocarcinomas of the GEJ and the stomach to reduce variability in the framework of future clinical trials.

Tractament del reflux vesicoureteral primari pediàtric

Els nous conceptes sobre el paper del reflux en la patologia renal han posat en controvèrsia el tractament del RVU. Amb aquest treball es vol valorar la necessitat real del tractament quirúrgic i els seus avantatges. Després de realitzar una revisió retrospectiva dels pacients amb RVU que han rebut tractament quirúrgic entre el 2003 i 2007 s’ha vist que el tractament quirúrgic del RVU és efectiu amb una baixa taxa de complicacions. En casos seleccionats el tractament quirúrgic pot tindre un paper fonamental per la prevenció de lesió renal recomanant com a primera elecció el tractament endoscòpic .

Endoscopic and surgical treatment of vesico-ureteral reflux in children. Comparative long-term follow-up.

PRINCIPLES: This retrospective study analyzes the long-term results of endoscopic and surgical treatment of vesico-ureteral reflux in children. METHODS: A cohort of 130 patients, 67 girls and 63 boys with a mean age of 30 months were treated either by endoscopic subureteral collagen injection (SCIN) in 92 and by Cohen reimplantation surgery in 123 refluxing ureteral units. Mean follow-up was 4.2 years varying from 1 to 8.7 years. Reflux recurrence, urinary tract infection (UTI) and renal function were evaluated. RESULTS: After SCIN reflux was absent in 64% at 6 months. 20% of the initially 92 refluxing ureters were injected twice. After one or two injections reflux was absent in 71%. In 21% recurrent reflux was of grade I or II, not requiring further treatment. UTI was observed in 27%. After Cohen ureteral reimplantation reflux was absent in 96% at 6 months. UTI was observed in 23%. Renal function at diagnosis and follow-up was compared in children with bilateral grade III reflux only. In patients treated with SCIN it was normal in 77% preoperatively and in 90% at follow-up. In patients treated by open surgery it was normal in 47% preoperatively and in 76% at follow-up. CONCLUSION: For high-grade vesico-ureteral reflux re-implantation surgery remains the gold standard. SCIN is indicated for low and medium grade reflux. Recurrent bacteriuria was observed more often after SCIN and pyelonephritis more often after open surgery. The renal function seems to be preserved with both techniques.

Profiling safety of intravitreal injections for retinoblastoma using an anti-reflux procedure and sterilisation of the needle track.

BACKGROUND: The preservation of globe integrity has always been a major concern during the treatment of retinoblastoma for fear of extraocular or metastatic spread. Intravitreal chemotherapy has been attempted as a desperate salvage therapy only for eyes with refractory retinoblastoma. Published data on the safety and efficacy of this route are, however, limited. METHODS: A modified technique of intravitreal injection in eyes with retinoblastoma is described. All children with retinoblastoma who received one or more intravitreal injections using this technique were retrospectively reviewed concerning ocular complications of the injection procedure as well as clinical or histopathological evidence of tumour spread. RESULTS: 30 eyes of 30 children with retinoblastoma received a total of 135 intravitreal injections, with a median follw-up duration of 13.5 months. No extraocular spread was seen on clinical follow-up in any patients and there was no tumour contamination of the retrieved entry sites histopathologically analysed among the five enucleated eyes. No significant ocular side effects were observed except transient localised vitreous haemorrhage (3/135). CONCLUSION: This technique is potentially safe and effective at a low cost and may play a promising role, especially in the treatment of recurrent and/or resistant vitreous disease in retinoblastoma, as an alternative to enucleation and/or external beam radiotherapy. However, this treatment should not replace the primary standard of care of retinoblastoma and should not be considered in group E eyes. Its application should be approved by an ophthalmological-oncological team and it should be performed by an experienced eye surgeon in a tertiary referral centre after careful selection of a tumour-free injection site.