Improved surgical technique for laparoscopic Roux-en-Y gastric bypass reduces complications at the gastrojejunostomy.

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed bariatric procedures for morbidly obese patients. It is associated with effective long-term weight loss, but can lead to significant complications, especially at the gastrojejunostomy (GJS). All the patients undergoing laparoscopic RYGBP at one of our two institutions were included in this study. The prospectively collected data were reviewed retrospectively for the purpose of this study, in which we compared two different techniques for the construction of the GJS and their effects on the incidence of complications. In group A, anastomosis was performed on the posterior aspect of the gastric pouch. In group B, it was performed across the staple line used to form the gastric pouch. A 21-mm circular stapler was used in all patients. A total of 1,128 patients were included between June 1999 and September 2009-639 in group A and 488 in group B. Sixty patients developed a total of 65 complications at the GJS, with 14 (1.2%) leaks, 42 (3.7%) strictures, and 9 (0.8%) marginal ulcers. Leaks (0.2% versus 2%, p = 0.005) and strictures (0.8% versus 5.9%, p < 0.0001) were significantly fewer in group B than in group A. Improved surgical technique, as we propose, with the GJS across the staple line used to form the gastric pouch, significantly reduces the rate of anastomotic complications at the GJS. A circular 21-mm stapler can be used with a low complication rate, and especially a low stricture rate. Additional methods to limit complications at the GJS are probably not routinely warranted.

Laparoscope use and surgical site infections in digestive surgery.

OBJECTIVE: To compare surgical site infection (SSI) rates in open or laparoscopic appendectomy, cholecystectomy, and colon surgery. To investigate the effect of laparoscopy on SSI in these interventions. BACKGROUND: Lower rates of SSI have been reported among various advantages associated with laparoscopy when compared with open surgery, particularly in cholecystectomy. However, biases such as the lack of postdischarge follow-up and confounding factors might have contributed to the observed differences between the 2 techniques. METHODS: This observational study was based on prospectively collected data from an SSI surveillance program in 8 Swiss hospitals between March 1998 and December 2004, including a standardized postdischarge follow-up. SSI rates were compared between laparoscopic and open interventions. Factors associated with SSI were identified by using logistic regression models to adjust for potential confounding factors. RESULTS: SSI rates in laparoscopic and open interventions were respectively 59/1051 (5.6%) versus 117/1417 (8.3%) in appendectomy (P = 0.01), 46/2606 (1.7%) versus 35/444 (7.9%) in cholecystectomy (P < 0.0001), and 35/311 (11.3%) versus 400/1781 (22.5%) in colon surgery (P < 0.0001). After adjustment, laparoscopic interventions were associated with a decreased risk for SSI: OR = 0.61 (95% CI 0.43-0.87) in appendectomy, 0.27 (0.16-0.43) in cholecystectomy, and 0.43 (0.29-0.63) in colon surgery. The observed effect of laparoscopic techniques was due to a reduction in the rates of incisional infections, rather than in those of organ/space infections. CONCLUSION: When feasible, a laparoscopic approach should be preferred over open surgery to lower the risks of SSI.

Premature epiphyseal closure in an adolescent treated by retinoids for acne: an unusual cause of anterior knee pain.

Retinoids are effective and widely prescribed in the treatment of severe acne. However their use can be associated with numerous side effects. Some rare cases of premature epiphyseal closure were reported. We present the case of a sixteen-year-old soccer player referred for progressive anterior pain in both knees, evoking a patellar problem. Careful pharmacological questioning revealed use of isotretinoin for several months. MRI findings showed an irregularity of the growth plate and an important metaphyso-epiphyseal oedema, more noticeable in the left knee. Retinoid-induced premature epiphyseal closure was diagnosed. The treatment was stopped, with a resolution of pain within two months. After recovery a persisting small sequelar thumbprint-like growth plate lesion was observed on the control MRI. Retinoids induce an invasion of the growth plate by osteoclasts and a decrease in proteoglycans synthesis. It seems that the knee is the most affected joint. This complication being rare, a radiological follow-up of the young patients treated by retinoids is not proposed.

Surgical treatment of ingrown toenail without matricectomy.

BACKGROUND: Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed. OBJECTIVE: The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix. METHODS: Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed. RESULTS: Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable. CONCLUSIONS: Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.

Traitement non chirurgical des rectites postactiniques ou radiques chroniques [Non-surgical treatment of acute and late radiation proctitis]

Pelvic external radiotherapy with or without brachytherapy plays an important role in the management of pelvic cancers. Despite recent technical innovations including conformal three-dimensional (3D) external beam radiotherapy and more recently intensity modulated radiotherapy (IMRT), local side effects can occur secondary to normal tissue damage caused by ionising radiation. Morbidity depends on the anatomic position of the rectum within the pelvis and the fast turnover rate of the mucosa, as well as the characteristics of the radiation treatment and patient co-morbidities. Medical management is sometimes complex and merits herein a short review.

Douleurs chroniques chez les personnes âgées: dimensions psychologiques [Chronic pain in elderly people: psychosocial dimension].

Chronic pain in elderly people requires to take into account somatic co-morbidities as well as its psychosocial dimensions. Chronic pain often represents a distress signal addressed to the environment and the care providers. Psychological suffering or mood disorders can be presented in the form of somatic complaints often associated with functional impairments, sometimes severe. Therapeutic care has to address functionality through an image-enhancing approach aiming to summon the patients' resources. The treatment of a concomitant depressive state necessitates a true commitment from the therapist. Its benefits are documented in elderly patients. Analgesic treatment as a whole will seek in particular to restore feelings of self-esteem and help the patient recover a good quality of life.

Surgical glues: are they really adhesive?

OBJECTIVE: The aim of this study is to create a standard test to approve the efficacy of a surgical sealant. An industrial test, the bulge-and-blister test, which is very convenient for measuring adhesion energy, is applied to the surgical field to quantify adhesion of bioadhesives. METHODS: Samples were composed of two circular layers of equine pericardium glued by the surgical sealant studied. The sample was fixed to a support with an industrial glue. The support and the bottom layer were perforated in the centre to allow injection of pressurised water. Water was progressively introduced through the hole in the support and the bottom layer to create a blister with constant radius, increasing height and internal pressure during this first step. At a critical pressure, delamination started, the radius and height of the blister increased and the pressure decreased. At this point, the adhesion energy could be determined. The experimental parameters were measured with a pressure sensor and an optical profilometry device for deflection. RESULTS: Adhesion testing was carried out in eight paired equine pericardium samples bonded with a Dermabond cyanoacrylate glue. The average value of the practical adhesion energy is 2.3 Jm(-2) with a standard deviation of 1.5 Jm(-2). CONCLUSION: Application of the bulge-and-blister test to the surgical field was achieved and allowed a quantification of adhesion of a surgical glue. Such information is essential to compare the different surgical glues presently available. The study of the impact of bonding conditions such as pressure, hygrometry or setting conditions will provide a better understanding of the characteristics of adhesion in the surgical field.

Reverse transcription quantitative real-time polymerase chain reaction reference genes in the spared nerve injury model of neuropathic pain : validation and literature search

La douleur neuropathique est définie comme une douleur causée par une lésion du système nerveux somato-sensoriel. Elle se caractérise par des douleurs exagérées, spontanées, ou déclenchées par des stimuli normalement non douloureux (allodynie) ou douloureux (hyperalgésie). Bien qu'elle concerne 7% de la population, ses mécanismes biologiques ne sont pas encore élucidés. L'étude des variations d'expressions géniques dans les tissus-clés des voies sensorielles (notamment le ganglion spinal et la corne dorsale de la moelle épinière) à différents moments après une lésion nerveuse périphérique permettrait de mettre en évidence de nouvelles cibles thérapeutiques. Elles se détectent de manière sensible par reverse transcription quantitative real-time polymerase chain reaction (RT- qPCR). Pour garantir des résultats fiables, des guidelines ont récemment recommandé la validation des gènes de référence utilisés pour la normalisation des données ("Minimum information for publication of quantitative real-time PCR experiments", Bustin et al 2009). Après recherche dans la littérature des gènes de référence fréquemment utilisés dans notre modèle de douleur neuropathique périphérique SNI (spared nerve injury) et dans le tissu nerveux en général, nous avons établi une liste de potentiels bons candidats: Actin beta (Actb), Glyceraldehyde-3-phosphate dehydrogenase (GAPDH), ribosomal proteins 18S (18S), L13a (RPL13a) et L29 (RPL29), hypoxanthine phosphoribosyltransferase 1 (HPRT1) et hydroxymethyl-bilane synthase (HMBS). Nous avons évalué la stabilité d'expression de ces gènes dans le ganglion spinal et dans la corne dorsale à différents moments après la lésion nerveuse (SNI) en calculant des coefficients de variation et utilisant l'algorithme geNorm qui compare les niveaux d'expression entre les différents candidats et détermine la paire de gènes restante la plus stable. Il a aussi été possible de classer les gènes selon leur stabilité et d'identifier le nombre de gènes nécessaires pour une normalisation la plus précise. Les gènes les plus cités comme référence dans le modèle SNI ont été GAPDH, HMBS, Actb, HPRT1 et 18S. Seuls HPRT1 and 18S ont été précédemment validés dans des arrays de RT-qPCR. Dans notre étude, tous les gènes testés dans le ganglion spinal et dans la corne dorsale satisfont au critère de stabilité exprimé par une M-value inférieure à 1. Par contre avec un coefficient de variation (CV) supérieur à 50% dans le ganglion spinal, 18S ne peut être retenu. La paire de gènes la plus stable dans le ganglion spinal est HPRT1 et Actb et dans la corne dorsale il s'agit de RPL29 et RPL13a. L'utilisation de 2 gènes de référence stables suffit pour une normalisation fiable. Nous avons donc classé et validé Actb, RPL29, RPL13a, HMBS, GAPDH, HPRT1 et 18S comme gènes de référence utilisables dans la corne dorsale pour le modèle SNI chez le rat. Dans le ganglion spinal 18S n'a pas rempli nos critères. Nous avons aussi déterminé que la combinaison de deux gènes de référence stables suffit pour une normalisation précise. Les variations d'expression génique de potentiels gènes d'intérêts dans des conditions expérimentales identiques (SNI, tissu et timepoints post SNI) vont pouvoir se mesurer sur la base d'une normalisation fiable. Non seulement il sera possible d'identifier des régulations potentiellement importantes dans la genèse de la douleur neuropathique mais aussi d'observer les différents phénotypes évoluant au cours du temps après lésion nerveuse.

Surgical outcomes following repeat non-penetrating glaucoma filtration surgery at a tertiary referral centre

Purpose:To determine the surgical outcomes of patients undergoing repeat deep sclerectomies with collagen implant (DSCI) at a tertiary referral centre. Methods:The medical notes of 208 patients undergoing multiple DSCI were reviewed. Those undergoing repeat DSCI were identified and post operative data for each DSCI were analysed. Group A: the first DSCI; group B: second DSCI; group C: third DSCI. Results:Mean age was 66.8 ±13.0 years. At 12 months, percentage of mean IOP reduction in groups were 18%, 24% and 17% respectively. Mean interval to starting glaucoma medications, re-operation, mitomycin injection and goniopuncture all decreased as the number of operations increased. There was a significant reduction in complete success rates between groups A and B and groups B and C. Few minor complications were observed in all 3 groups. Conclusions:Despite the possibility of bleb independent outflow pathways in patients undergoing non-penetrating surgery, there are significantly reduced success rates in eyes undergoing repeat DSCI. This has important implications for the choice of subsequent operations in patients who have failed non-penetrating filtration surgery.

Clinical characteristics and outcome of patients admitted to a medico- surgical ICU requiring non invasive ventilation (NIV) for hypercapnic respiratory failure

Introduction Because it decreases intubation rate and mortality, NIV has become first-line treatment in case of hypercapnic acute respiratory failure (HARF). Whether this approach is equally successful for all categories of HARF patients is however debated. We assessed if any clinical characteristics of HARF patients were associated with NIV intensity, success, and outcome, in order to identify prognostic factors. Methods Retrospective analysis of the clinical database (clinical information system and MDSi) of patients consecutively admitted to our medico-surgical ICU, presenting with HARF (defined as PaCO2 > 50 mmHg), and receiving NIV between May 2008 and December 2010. Demographic data, medical diagnoses (including documented chronic lung disease), reason for ICU hospitalization, recent surgical interventions, SAPS II and McCabe scores were extracted from the database. Total duration of NIV and the need for tracheal intubation during the 5 days following the first hypercapnia documentation, as well as ICU, hospital and one year mortality were recorded. Results are reported as median [IQR]. Comparisons were carried out with Chi2 or Kruskal-Wallis tests, p<0.05 (*). Results Two hundred and twenty patients were included. NIV successful patients received 16 [9-31] hours of NIV for up to 5 days. Fifty patients (22.7%) were intubated 11 [2-34] hours after HARF occurence, after having receiving 10 [5-21] hours of NIV. Intubation was correlated with increased ICU (18% vs. 6%, p<0.05) and hospital (42% vs. 31%, p>0.05) mortality. SAPS II score was related to increasing ICU (51 [29-74] vs. 23 [12-41]%, p<0.05), hospital (37% [20-59] vs 20% [12-37], p<0.05) and one year mortality (35% vs 20%, p<0.05). Surgical patients were less frequent among hospital fatalities (28.8% vs. 46.3%, p<0.05, RR 0.8 [0-6-0.9]). Nineteen patients (8.6%) died in the ICU, 73 (33.2%) during their hospital stay and 108 (49.1%) were dead one year after HARF. Conclusion The practice to start NIV in all suitable patients suffering from HARF is appropriate. NIV can safely and appropriately be used in patients suffering from HARF from an origin different from COPD exacerbation. Beside usual predictors of severity such as severity score (SAPS II) appear to be associated with increased mortality. Although ICU mortality was low in our patients, hospital and one year mortality were substantial. Surgical patients, although undergoing a similar ICU course, had a better hospital and one year outcome.

A morphological grading of spinal stenosis: a radiological study on LSS and LBP patients : P173

Introduction: Clinical symptoms and degree of spinal stenosis based on cross sectional dural sac area correlate only weakly in lumbar spinal stenosis (LSS) patients. We conceived a four grade classification system (A, B, C & D) based on the morphology of the dural sac and its contents as seen on T2 axial MRI images. The categories take into account the rootlet/CSF ratio. We applied this grading to three patient groups: LSS scheduled for surgery; LSS following conservative treatment and patients with low back pain (LBP) without leg pain. Materials/Methods: A total of 346 T2 axial MRI images taken from LSS and LBP patients were included in this retroperspective study. 37 patients had decompressive surgery (132 MRI images), 31 conservative treatment (116 MRI images) and 27 patients had unspecific LBP (98 MRI images). Dural sac cross-sectional surface area and morphological grading of the canal were measured digitally both at disc and pedicle level. Intra- and inter-observer reliability were assessed (weighted Cohen's kappa statistics) from 50 MRI images taken from the surgery group. Results: At the most severe disc level, grade A (mild stenosis) was found in 3% of MRI images of the surgical group as opposed to 51% in the conservatively treated group and 85% in the LBP group. Grade B occurred in 8% of the surgical, 20% of the conservative and was negligible in LBP group (below 1%). Grade C and D (severe stenosis) was found in 89% of the surgical group, as opposed to 30% in conservative group and 11% in LBP group. The grades of all groups were comparable at the pedicle levels, exhibiting in 94% a grade A with a maximum at the A1 grade. Pedicle and disc level cross-sectional area were smallest in the surgery group and smaller in the conservative group as compared to the LBP group at the levels L2, L3 and L4. According to cross-sectional area measurements patients from the surgery group seems to have smaller vertebral canal although this was not related to smaller stature. Validation of grading: Average intra-and inter observer kappas were 0.76 and 0.69 respectively, for physicians working in the study originating institution. Combining all observers the kappa values were 0.57 +/- 0.19. and 0.44 +/- 0.19 respectively. Dural sac cross-sectional area measurements showed no statistically significant differences between observers. Conclusion: Since no specific measurement tools are needed the grading suits everyday clinical practice and favours communication of degree of stenosis between practising physicians. In our institution Grade A stenosis was less likely to require surgical treatment. This grading can therefore be an aid in surgical patient selection in teaching units.

Family doctors' consultations with people suffering from chronic pain without objective findings: Which protective practices might they develop in these challenging medical encounters?

Introduction: Consultations with patients suffering from chronic pain without objective findings represent a challenge fo r family doctors (FDs). A mutual lack of understanding may arise, which threatens the doctor-patient relationship and may lead to dissatisfaction of both patient and doctor and to a breakdown of the therapeutic alliance. Objectives: This study aims to investigate FDs' potential protective practices to preserve the doctor-patient relationship during this type of consultation. Method: In the first step of this qualitative research, I carried out a range of 10 se- mi-structured interviews with FDs to explore their reported practices and repre- sentations during consultations with people suffering from chronic pain without objective findings. The interviews' transcripts were integrally analysed with computer-assisted thematic content analysis (QSR NVivo ® ) to highlight the main themes related to the topic in the participants' talk. Results: At this point of the research, two types of FDs' protective practices can be identified: first the use of complementary sources of knowledge in addition to the medical model to provide explanations to patients, second the collaboration with multidisciplinary teams or support gr oups that allow them to share profes- sional expertise and emotional experiences. Conclusion: The findings could be useful to develop ways to improve the follow- up of patients suffering from chronic pain without objective findings and conse- quently the FDs' work satisfaction.