NOTES et trocart unique: révolution chirurgicale ou marketing [NOTES and single port access: surgical or marketing revolution?].

Promising new technologies are emerging in digestive surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single Port Access Surgery. They both aim to limit the surgical morbidity by decreasing the number of parietal accesses. The feasibility in human is obviously demonstrated, but numerous issues remain concerning the safety of these techniques. Furthermore, the expected advantages are not clearly demonstrated until now in the literature. In the future, it will be advisable to standardize techniques, in order to allow large clinical studies and to limit the potential complications of these approaches.

Mucosal Healing with Anti-TNF Antibodies.

Nowadays, mucosal healing is regarded as a major end point in clinical trials and is increasingly used in clinical practice for the management of patients with inflammatory bowel disease. The definition of mucosal healing varies across studies and validated endoscopic scoring indices are still lacking. The advent of anti-tumor necrosis factor agents has changed the way of treating inflammatory bowel disease and high rates of induction and maintenance of mucosal healing can be achieved with this drug class. Mucosal healing is desirable as it may change the natural course of the disease by decreasing surgery and hospitalization rates in both ulcerative colitis and Crohn's disease.

Local delivery of glial cell line-derived neurotrophic factor improves facial nerve regeneration after late repair.

OBJECTIVES/HYPOTHESIS: Facial nerve regeneration is limited in some clinical situations: in long grafts, by aged patients, and when the delay between nerve lesion and repair is prolonged. This deficient regeneration is due to the limited number of regenerating nerve fibers, their immaturity and the unresponsiveness of Schwann cells after a long period of denervation. This study proposes to apply glial cell line-derived neurotrophic factor (GDNF) on facial nerve grafts via nerve guidance channels to improve the regeneration. METHODS: Two situations were evaluated: immediate and delayed grafts (repair 7 months after the lesion). Each group contained three subgroups: a) graft without channel, b) graft with a channel without neurotrophic factor; and c) graft with a GDNF-releasing channel. A functional analysis was performed with clinical observation of facial nerve function, and nerve conduction study at 6 weeks. Histological analysis was performed with the count of number of myelinated fibers within the graft, and distally to the graft. Central evaluation was assessed with Fluoro-Ruby retrograde labeling and Nissl staining. RESULTS: This study showed that GDNF allowed an increase in the number and the maturation of nerve fibers, as well as the number of retrogradely labeled neurons in delayed anastomoses. On the contrary, after immediate repair, the regenerated nerves in the presence of GDNF showed inferior results compared to the other groups. CONCLUSIONS: GDNF is a potent neurotrophic factor to improve facial nerve regeneration in grafts performed several months after the nerve lesion. However, GDNF should not be used for immediate repair, as it possibly inhibits the nerve regeneration.

Duodenal duplication cyst and pancreas divisum causing acute pancreatitis in an adult male acute pancreatitis in an adult male

Duodenal duplication cysts are rare congenital abnormalities which are more commonly diagnosed in infancy and childhood. However, in rare cases, these lesions can remain asymptomatic until adulthood. The combination of duplication cyst and pancreas divisum is extremely rare and both conditions have been linked with acute recurrent pancreatitis. We present the case of a 37 years-old patient who presented with repeated episodes of acute pancreatitis. By means of magnetic resonance imaging and endoscopic ultrasonography we discovered a duplication cyst whose cavity received drainage from the dorsal pancreas. After opening the cyst cavity to the duodenal lumen with a needle knife the patient presented no further episodes in the clinical follow-up. Comparable literature findings and therapeutic options for these abnormalities are discussed with regard to the presented case.

Esophageal leaks repaired by a muscle onlay approach in the presence of mediastinal sepsis.

BACKGROUND: Nineteen patients were evaluated after closure of intrathoracic esophageal leaks by a pediculated muscle flap onlay repair in the presence of mediastinal and systemic sepsis. METHODS: Intrathoracic esophageal leaks with mediastinitis and systemic sepsis occurred after delayed spontaneous perforations (n = 7) or surgical and endoscopic interventions (n = 12). Six patients presented with fulminant anastomotic leaks. Seven patients had previous attempts to close the leak by surgery (n = 4) or stenting (2) or both (n = 1). The debrided defects measured up to 2 x 12 cm or involved three quarters of the anastomotic circumference and were closed either by a full thickness diaphragmatic flap (n = 13) or a pediculated intrathoracically transposed extrathoracic muscle flap (n = 6). All patients had postoperative contrast esophagography between days 7 and 10 and an endoscopic evaluation 4 to 6 months after surgery. RESULTS: There was no 30-day mortality. During follow-up (4 to 42 months), 16 patients (84%) revealed functional and morphological restoration of the esophagointestinal integrity without further interventions. One patient required serial dilatations for a stricture, and 1 underwent temporary stenting for a persistent fistula; both patients had normal control endoscopy during follow-up. A third patient requiring permanent stenting for stenosis died from gastrointestinal bleeding due to stent erosion during follow-up. CONCLUSIONS: Intrathoracic esophageal leaks may be closed efficiently by a muscle flap onlay approach in the presence of mediastinitis and where a primary repair seems risky. The same holds true for fulminant intrathoracic anastomotic leaks after esophagectomy or other surgical interventions at the gastroesophageal junction.

When do we dare to stop biological or immunomodulatory therapy for Crohn's disease? Results of a multidisciplinary European expert panel.

BACKGROUND: Safety and economic issues have increasingly raised concerns about the long term use of immunomodulators or biologics as maintenance therapies for Crohn's disease (CD). Despite emerging evidence suggesting that stopping therapy might be an option for low risk patients, criteria identifying target groups for this strategy are missing, and there is a lack of recommendations regarding this question. METHODS: Multidisciplinary European expert panel (EPACT-II Update) rated the appropriateness of stopping therapy in CD patients in remission. We used the RAND/UCLA Appropriateness Method, and included the following variables: presence of clinical and/or endoscopic remission, CRP level, fecal calprotectin level, prior surgery for CD, and duration of remission (1, 2 or 4 years). RESULTS: Before considering withdrawing therapy, the prerequisites of a C-reactive protein (CRP) and fecal calprotectin measurement were rated as "appropriate" by the panellists, whereas a radiological evaluation was considered as being of "uncertain" appropriateness. Ileo-colonoscopy was considered appropriate 1 year after surgery or after 4 years in the absence of prior surgery. Stopping azathioprine, 6-mercaptopurine or methotrexate mono-therapy was judged appropriate after 4 years of clinical remission. Withdrawing anti-TNF mono-therapy was judged appropriate after 2 years in case of clinical and endoscopic remission, and after 4 years of clinical remission. In case of combined therapy, anti-TNF withdrawal, while continuing the immunomodulator, was considered appropriate after two years of clinical remission. CONCLUSION: A multidisciplinary European expert panel proposed for the first time treatment stopping rules for patients in clinical and/or endoscopic remission, with normal CRP and fecal calprotectin levels.

Fístula gastrocolocutánea: una infrecuente complicación de la gastrostomía endoscópica percutánea

Endoscopic percutaneous gastrostomy is a safe technique although with potential complications before which the clinician has to be on alert in order to early detect them even after a long period of normal functioning. Most of them represent minor problems. Gastrocolocutaneous fistula is a rare but severe complication favored by some risk factors such as previous post-surgical adherences, deformities of the spine, or excessive gastric inflation at the time of performing the technique. We present the case of a patient with PEG with this complication that occurred after the first tube replacement. Our goal was in two senses: on the one hand, to analyze the preventive aspects and basic guidelines for a safe PEG placement to minimize the risks; on the other hand, to alert on the possible presence of this entity to prevent a progressive nutritional impairment. This complication ought to be included in the differential diagnosis of the diarrhea syndrome in the patient carrying a PEG. The diagnostic techniques of choice are radiologic tests such as CT scan and contrast media administration through the tube. Surgical therapy should be reserved to patients with acute peritonitis in order to perform a new gastrostomy.

Sédation par propofol administrée par un non-anesthésiste pour l'endoscopie digestive [Administration of propofol by non-anesthesiologists for digestive endoscopy].

Propofol is progressively replacing benzodiazepines for sedation during endoscopy, even when the sedation is administered by non-anesthesiologists. Propofol ensures a more rapid induction of sedation and recovery and, in certain conditions, higher patient satisfaction and improved quality of endoscopic examination. Specific training is required to use this drug. Patients at risk of complications should be identified before the endoscopy to optimize patient management with an anesthesiologist. After sedation, psychomotor recovery is faster with propofol compared to traditional sedation agents but tasks requiring particular attention (eg, driving) should be avoided. It is important to advise patients of these restrictions in advance.

Clinical evaluation of a method for detecting superficial surgical transitional cell carcinoma of the bladder by light-induced fluorescence of protoporphyrin IX following the topical application of 5-aminolevulinic acid: preliminary results.

BACKGROUND AND OBJECTIVE: In bladder cancer, conventional white light endoscopic examination of the bladder does not provide adequate information about the presence of "flat" urothelial lesions such as carcinoma in situ. In the present investigation, we examine a new technique for the photodetection of such lesions by the imaging of protoporphyrin IX (PpIX) fluorescence following topical application of 5-aminolevulinic acid (ALA). STUDY DESIGN/MATERIALS AND METHODS: Several hours after bladder instillation of an aqueous solution of ALA in 34 patients, a Krypton ion laser or a filtered Xenon arc-lamp was used to excite PpIX fluorescence. Tissue samples for histological analysis were taken while observing the bladder wall either by means of a video camera, or by direct endoscopic observation. RESULTS: A good correlation was found between the PpIX fluorescence and the histopathological diagnosis. On a total of 215 biopsies, 143 in fluorescent and 72 in nonfluorescent areas, all visible tumors on white light cytoscopy appeared in a bright red fluorescence with the photodetection technique. In addition, this method permitted to discover 47 unsuspected carcinomatous lesions on white light observation, among which 40% were carcinoma in situ. CONCLUSION: PpIX fluorescence induced by instillation into the bladder of 5-ALA is an efficient method of mapping the mucosa in bladder carcinoma.

Mitral regurgitation.

Mitral regurgitation (MR) involves systolic retrograde flow from the left ventricle into the left atrium. While trivial MR is frequent in healthy subjects, moderate to severe MR constitutes the second most prevalent valve disease after aortic valve stenosis. Major causes of severe MR in Western countries include degenerative valve disease (myxomatous disease, flail leaflet, annular calcification) and ischaemic heart disease, while rheumatic disease remains a major cause of MR in developing countries. Chronic MR typically progresses insidiously over many years. Once established, however, severe MR portends a poor prognosis. The severity of MR can be assessed by various techniques, Doppler echocardiography being the most widely used. Mitral valve surgery is the only treatment of proven efficacy. It alleviates clinical symptoms and prevents ventricular dilatation and heart failure (or, at least, it attenuates further progression of these abnormalities). Valve repair significantly improves clinical outcomes compared with valve replacement, reducing mortality by approximately 70%. Reverse LV remodelling after valve repair occurs in half of patients with functional MR. Percutaneous, catheter-based to mitral valve repair is a novel approach currently under clinical scrutiny, with encouraging preliminary results. This modality may provide a valuable alternative to mitral valve surgery, especially in critically ill patients.

Enzymatic activity, ultrastructure and function in ganglia infected with a neurotropic virus.

This chapter attempts to answer the questions, how do the viruses reach the neurons, what are the alterations that they impose on the neuronal machinery, and what are the consequences of these alterations on the function of the infected neurons? The virus used for this research was the pseudorabies. Pseudorabies virus is transported from the eye to the superior cervical ganglion by retrograde axonal flow. In the sympathetic neurons, the virus induces an increased protein synthesis and tyrosine 3-monooxygenase activity, a transsynaptic increased activity of the cholineacetyltransferase and a great rise in the acetylcholine content. The virus also causes an abnormal spontaneous electrophysiological activity, which also seems to be of presynaptic origin, despite the fact that the virus never crossed the synaptic cleft.

Neurofilament triplet proteins are restricted to a subset of neurons in the rat neocortex.

The cellular localisation of neurofilament triplet subunits was investigated in the rat neocortex. A subset of mainly pyramidal neurons showed colocalisation of subunit immunolabelling throughout the neocortex, including labelling with the antibody SMI32, which has been used extensively in other studies of the primate cortex as a selective cellular marker. Neurofilament-labelled neurons were principally localised to two or three cell layers in most cortical regions, but dramatically reduced labelling was present in areas such as the perirhinal cortex, anterior cingulate and a strip of cortex extending from caudal motor regions through the medial parietal region to secondary visual areas. However, quantitative analysis demonstrated a similar proportion (10-20%) of cells with neurofilament triplet labelling in regions of high or low labelling. Combining retrograde tracing with immunolabelling showed that cellular content of the neurofilament proteins was not correlated with the length of projection. Double labelling immunohistochemistry demonstrated that neurofilament content in axons was closely associated with myelination. Analysis of SMI32 labelling in development indicated that content of this epitope within cell bodies was associated with relatively late maturation, between postnatal days 14 and 21. This study is further evidence of a cell type-specific regulation of neurofilament proteins within neocortical neurons. Neurofilament triplet content may be more closely related to the degree of myelination, rather than the absolute length, of the projecting axon.

Fracturas femorales periprotésicas de rodilla tratadas con clavo intramedular retrógrado y osteosíntesis con placa: comparación de resultados a medio-largo plazo

INTRODUCTION: The femoral periprosthetic fracture of the knee is one of the most feared complications because of its repercussions. Incidence are more and more likely due to the increase of total implanted arthroplasty of the knee, due to the increasing lifespan among the general population. The objective of this study is to analyze some of the perioperative aspects of the treatment of these fractures, comparing the use of osteosynthesis with plates and the retrograde nailing in those patients with femoral periprosthetic knee fractures with a stable implant. MATERIAL AND METODS: The study retrospectively examines 18 cases treated consecutively in our hospital (3 men and 15 women, average age of 72.7 years) between the years of 2000 and 2009. All fractures were located in the distal femur and on a stable implant. Eight were treated through retrograde nailing (Group I) and ten with plates (Group II). The cases are analyzed through the tests of the University of Mann-Withney and the exact Fischer test, with significant values of p≤0.05, the variables of median hospital stay, necessity of transfusion indicated with values of hemoglobin less than 8 mg/ml, preoperative radiological alignment and postoperative alignment of the total knee prosthesis (TKR), measured following the anatomical tibiofemoral axis, time of consolidation and incidence of localized complications in both groups. RESULTS: We did not find any statistically significant differences between the two groups in any of the variables analyzed. Localized complications are more frequent in Group I (62.5 percent of patients) than in Group II (10 percent of patients). The need for transfusion is greater in Group II (40 percent) than in Group I (12.5 percent). CONCLUSIONS: The type of implant used in treatment of femoral periprosthetic knee fracture does not significantly influence perioperative factors. The treatment for this type of fractures should be individually chosen in relation to the type of fracture, characteristics of the patient and stability and prosthesis model of the primary knee.

The Tertiary structural and thermal evolution of the central Alps - Compressional and extensional structures in an orogenic belt

The Western Alpine Are has been created during the Cretaceous and the Tertiary orogenies. The interference patterns of the Tertiary structures suggest their formation during continental collision of the European and the Adriatic Plates, with an accompanying anticlockwise rotation of the Adriatic indenter. Extensional structures are mainly related to ductile deformation by simple shear. These structures developed at a deep tectonic level, in granitic crustal rocks, at depths in excess of 10 km. In the early Palaeogene period of the Tertiary Orogeny, the main Tertiary nappe emplacement resulted from a NW-thrusting of the Austroalpine, Penninic and Helvetic nappes. Heating of the deep zone of the Upper Cretaceous and Tertiary nappe stack by geothermal heat flow is responsible for the Tertiary regional metamorphism, reaching amphibolite-facies conditions in the Lepontine Gneiss Dome (geothermal gradient 25 degrees C/ km). The Tertiary thrusting occurred mainly during prograde metamorphic conditions with creation of a penetrative NW-SE-oriented stretching lineation, X(1) (finite extension), parallel to the direction of simple shear. Earliest cooling after the culmination of the Tertiary metamorphism, some 38 Ma ago, is recorded by the cooling curves of the Monte Rosa and Mischabel nappes to the west and the Suretta Nappe to the east of the Lepontine Gneiss Dome. The onset of dextral transpression, with a strong extension parallel to the mountain belt, and the oldest S-vergent `'backfolding'' took place some 35 to 30 Ma ago during retrograde amphibolite-facies conditions and before the intrusion of the Oligocene dikes north of the Periadriatic Line. The main updoming of the Lepontine Gneiss Dome started some 32-30 Ma ago with the intrusion of the Bergell tonalites and granodiorites, concomitant with S-vergent backfolding and backthrusting and dextral strike-slip movements along the Tonale and Canavese Lines (Argand's Insubric phase). Subsequently, the center of main updoming migrated slowly to the west, reaching the Simplon region some 20 Ma ago. This was contemporaneous with the westward migration of the Adriatic indenter. Between 20 Ma and the present, the Western Aar Massif-Toce culmination was the center of strong uplift. The youngest S-vergent backfolds, the Glishorn anticline and the Berisal syncline fold the 12 Ma Rb/Sr biotite isochron and are cut by the 11 Ma old Rhone-Simplon Line. The discrete Rhone-Simplon Line represents a late retrograde manifestation in the preexisting ductile Simplon Shear Zone. This fault zone is still active today. The Oligocene-Neogene dextral transpression and extension in the Simplon area were concurrent with thrusting to the northwest of the Helvetic nappes, the Prealpes (35-15 Ma) and with the Jura thin-skinned thrust (11-3 Ma). It was also contemporaneous with thrusting to the south of the Bergamasc (> 35-5 Ma) and Milan thrusts (16-5 Ma).