Peri-operative management of an adult with POLG-related mitochondrial disease.

POLG-related mitochondrial disease is a rare mitochondrial disorder that is potentially associated with anaesthetic complications such as propofol-related infusion syndrome. A 19-year-old man with mitochondrial DNA deletions and POLG-related disorders presented for an elective robotic Heller-Dor myotomy for the treatment of oesophageal pseudo-achalasia associated with severe gastro-oesophageal reflux. The fasting period was minimised to reduce the risk of metabolic stress. The anaesthetic technique included a rapid sequence induction with propofol and rocuronium, a remifentanil and sevoflurane-based general anaesthesia with multimodal monitoring and peri-operative lactate-free intravenous fluids with added dextrose. The patient did not experience propofol-related infusion syndrome but did have delayed tracheal extubation due to residual neuromuscular blockade requiring a second dose of sugammadex. This report demonstrates the safety of single-use, low-dose propofol in this patient group. Patients with POLG-related mitochondrial disease may be at risk of prolonged neuromuscular blockade, and appropriate dosing of neuromuscular blocking agents with monitoring of neuromuscular blockade is strongly encouraged.

Modification of the Daily Activity Pattern of the Diurnal Triatomine Mepraia spinolai (Hemiptera: Reduviidae) Induced by Trypanosoma cruzi (Trypanosomatida: Trypanosomatidae) Infection.

Mepraia spinolai, (Porter) 1934, is a diurnal triatomine endemic to Chile and a wild vector of the protozoan Trypanosoma cruzi, (Chagas) 1909, which causes Chagas disease. Behavioral changes in M. spinolai induced by this parasite have been reported previously, which include detection of a potential host, defecation latency, and some life history traits. In this study we assessed changes in locomotor and daily activity due to infection with T. cruzi. No difference was detected in distance traveled between infected and uninfected individuals. However, the groups differed in their daily activity patterns; infected individuals showed significant reduction of movements during the light phase and concentrated their activity in the dark phase. Uninfected individuals showed no differences in locomotor activity between the phases. The results suggest that T. cruzi induces a displacement in the activity of M. spinolai toward the dark phase of the circadian cycle, which may improve its vector competence.

Migration of an intragastric balloon may necessitate enterotomy for extraction.

Intragastric balloon (IGB) placement for the treatment of obesity is presented as a non-invasive and safe technique leading to significant weight loss. We report a case of an IGB migration that led to small bowel occlusion. Radiological analysis confirmed impaction at 250cm from the angle of Treitz. Enterotomy was necessary to treat the occlusion.

Early metabolic response to chemoradiotherapy by interim FDG PET/CT is associated with better overall survival and histological response in esophageal cancers.

BACKGROUND: Early assessment of response to neoadjuvant chemoradiotherapy (CRT) is crucial in determining the most suitable treatment strategy in locally advanced oesophageal cancer (LAEC). AIMS: We evaluated the impact of early metabolic response during CRT on overall survival (OS) and histological response. METHODS: Patients with biopsy-proven oesophageal carcinoma underwent FDG PET/CT with evaluation of the standardized uptake value (SUV) before any treatment and during CRT after 20 Gy. RESULTS: 116 patients (Male: 66.4%, Median age: 63; squamous cell carcinomas (SCC): 70%) met inclusion criteria. Median OS was 21.7 months. There was a significant positive correlation between interim metabolic response and OS. In multivariate analysis, only metabolic response using the 50% cut-off value remained significantly associated with OS (IC95% = 0.28-0.73; p = 0.001). In this statistical analysis, surgery (p = 0.007) and T stage (p = 0.023) were also correlated with OS. There was a significant correlation between early metabolic response and local recurrence (Chi-squared test p = 0.0001). CONCLUSIONS: Early metabolic response using FDG PET/CT is associated with better OS, disease-free survival, local control and pathological response in patients treated by CRT for LAEC.

An esophageal tumor unlike others: The fibrovascular polyp.

A fibrovascular polyp is a rare benign pseudotumor of the esophagus or the hypopharynx. It comes to light through dysphagia and can lead to death by asphyxiation. CT scan and MRI suggest this diagnosis by highlighting a lobed endoluminal tumor primarily composed of adipose tissue and pedicled on a vessel. Anatomo-pathological analysis of biopsies can exclude liposarcoma, the main differential diagnosis. Treatment consists in complete reconstruction by cervicotomy.

Feeding profile of Mepraia spinolai, a sylvatic vector of Chagas disease in Chile.

American trypanosomiasis is a chronic disease transmitted mainly by vectors. The hematophagous triatomine vectors transmit Trypanosoma cruzi to a wide variety of mammals, which usually are their food source. This study determined the feeding profile of Mepraia spinolai, a sylvatic triatomine vector, present in endemic areas of Chile. Vectors were captured in the north-central area of Chile. Samples of intestinal contents were analyzed by an Enzyme-linked immunosorbent assay (ELISA) that identifies and discriminates the presence of serum antigens from Homo sapiens and nine animal species (Canis familiaris, Felis catus, Capra hircus, Mus musculus, Gallus gallus, Octodon degus, Thylamys elegans, Phyllotis darwini and Oryctolagus cuniculus). Our data indicate the most frequent feeding source in this area was P. darwini, followed by O. degus, O. cuniculus, M. musculus, G. gallus, T. elegans, C. familiaris, F. catus and C. hircus. Mixed food sources were also identified.

Soil and river contamination patterns of chlordecone in a tropical volcanic catchment in the French West Indies (Guadeloupe).

The aim of this study was to identify primary flow paths involved in the chlordecone (CLD) river contamination and quantify the CLD fluxes to assess CLD pollution levels and duration according to a typical catchment of the banana cropping area in the French Indies (Guadeloupe): the Pérou Catchment (12 km(2)) characterized by heavy rainfall (5686 mm year(-1)). Three sub-catchments (SC1, SC2 and SC3) were studied during the hydrological year 2009-2010: a pedological survey combined with a spatialized hydrochemical approach was conducted. The average soil concentration is higher in the Pérou Catchment (3400 µg kg(-1)) than in the entire banana cropping area in Guadeloupe (2100 µg kg(-1)). The results showed that CLD stocks in soils vary largely among soil types and farming systems: the weakest stocks are located upstream in SC1 (5 kg ha(-1)), where a majority of the area is non-cultivated; medium stocks are located in Nitisols downstream in SC3 (9 kg ha(-1)); and the greatest stocks are observed in SC2 on Andosols (12 kg ha(-1)) characterized by large farms. The annual water balance and the hydro-chemical analysis revealed that the three sub-catchments exhibited different behaviors. Pérou River contamination was high during low flows, which highlighted that contamination primarily originated from groundwater contributions. The results showed that only a small part of the catchment (SC2), contributing little to the water flow, comprises a major CLD contribution, which is in agreement with the highly contaminated andosol soils observed there. Another significant result considers that at least 50 years would be required to export the totality of the actual CLD soil stocks retained in the topsoil layer. The actual time for soil remediation will however be much longer considering (i) the necessary time for the chlordecone to percolate and be stored in the shallow aquifers and (ii) its travel time to reach the river.

Esophageal tissue engineering: Current status and perspectives.

Tissue engineering, which consists of the combination and in vivo implantation of elements required for tissue remodeling toward a specific organ phenotype, could be an alternative for classical techniques of esophageal replacement. The current hybrid approach entails creation of an esophageal substitute composed of an acellular matrix and autologous epithelial and muscle cells provides the most successful results. Current research is based on the use of mesenchymal stem cells, whose potential for differentiation and proangioogenic, immune-modulator and anti-inflammatory properties are important assets. In the near future, esophageal substitutes could be constructed from acellular "intelligent matrices" that contain the molecules necessary for tissue regeneration; this should allow circumvention of the implantation step and still obtain standardized in vivo biological responses. At present, tissue engineering applications to esophageal replacement are limited to enlargement plasties with absorbable, non-cellular matrices. Nevertheless, the application of existing clinical techniques for replacement of other organs by tissue engineering in combination with a multiplication of translational research protocols for esophageal replacement in large animals should soon pave the way for health agencies to authorize clinical trials.

Esophagojejunostomy after total gastrectomy for caustic injuries.

The objective of the study was to compare outcomes of emergency esophagogastrectomy (EGT) and total gastrectomy with immediate esophagojejunostomy (EJ) in patients with full-thickness caustic necrosis of the stomach and mild esophageal injuries. After caustic ingestion, optimal management of the esophageal remnant following removal of the necrotic stomach remains a matter of debate. Between 1987 and 2012, 26 patients (men 38%, median age 44 years) with isolated transmural gastric necrosis underwent EGT (n = 14) or EJ (n = 12). Early and long-term outcomes of both groups were compared. The groups were similar regarding age (P = 0.66), gender (0.24), and severity of esophageal involvement. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Emergency morbidity (67% vs. 64%, P = 0.80), mortality (17% vs. 7%, P = 0.58), and reoperation rates (25% vs.14%, P = 0.63) were similar after EJ and EGT. One patient (8%) experienced EJ leakage. One patient in the EJ group and 13 patients in the EGT group underwent esophageal reconstruction (P < 0.0001). Aggregate in hospital length of stay was significantly longer in patients who underwent EGT (median 83 [33-201] vs. 36 [10-82] days, P = 0.001). Functional success after EJ and EGT was similar (90% vs.69%, P = 0.34). Immediate EJ can be safely performed after total gastrectomy for caustic injuries and reduces the need of further esophageal reconstruction.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer.

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.

Oesophagogastrectomy and pancreatoduodenectomy for caustic injury.

BACKGROUND: The justification for pancreatoduodenectomy (PD) for extended duodenal and pancreatic caustic necrosis is still a matter of debate. METHODS: This was a retrospective evaluation of patients who underwent PD in association with oesophagogastrectomy from a large single-centre cohort of patients with caustic injuries. Morbidity, mortality and long-term outcome were assessed. RESULTS: PD was performed in 18 (6·6 per cent) of 273 patients who underwent emergency surgery for caustic injuries. Biliary and pancreatic duct reconstruction during PD was performed in ten and six patients respectively. Seven patients died and 17 experienced operative complications after PD for caustic injuries. Twelve patients required at least one reoperation. Specific PD-related complications occurred in 13 patients. Initial (P = 0·038) or secondary (P < 0·001) extension of necrosis to adjacent organs were independent predictors of operative death. After a median follow-up of 24 months following reconstruction, three patients had recovered nutritional autonomy. In an intention-to-treat analysis, functional success was recorded in three patients and the 5-year survival rate was 39 per cent after PD for caustic injury. CONCLUSION: PD can save the lives of patients with caustic injuries extending beyond the pylorus, but has poor functional outcome. Immediate pancreatic duct reconstruction should be preferred to duct occlusion to decrease the rate of pancreatic complications.

Esophageal perforations.

The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.

[Colonic interposition for esophageal replacement after caustic ingestion]. / Reconstruction oesophagienne pour séquelles de brûlure caustique: coloplasties, mode d'emploi.

Retrosternal coloplasty is the gold standard for esophageal reconstruction after caustic injury of the digestive tract. Complete preoperative otolaryngology evaluation and the control of the psychiatric disease are key factors for success. In the absence of controlled studies, the choice between the right and the left colon graft relies on the anatomy of the blood supply to the colon and on the individual surgeon's preference. Treatment of associated pharyngeal and laryngeal injuries is mandatory at the time of esophageal reconstruction. In experienced hands mortality rates are less than 5% but specific postoperative complications (graft necrosis, leakage, anastomotic stricture) are high. The low risk of cancer development in the by-passed esophagus does not justify routine esophagectomy at the time of reconstruction. Sixty to eighty percent of patients would finally retrieve nutritional autonomy after coloplasty for caustic injury. Late acquired dysfunctions of the coloplasty (anastomotic strictures, graft redundancy) requiring revision surgery occur frequently and might jeopardize an already fragile functional result. Timely diagnosis and treatment of such complications and the necessity of continuous psychological surveillance justify the need for long term follow up in these patients.

Comparative population dynamics of the bug Mepraia spinolai, a sylvatic vector of Chagas' disease, in different hosts.

The aim of this work was to determine the impact of specific hosts on a population of Mepraia spinolai (Porter) (Hemiptera, Reduviidae), a sylvatic vector of Chagas' disease in Chile. We assessed whether a recently introduced host could be an important epidemiological factor in maintaining Chagas' disease in Chile. The study stressed the variations in survival, individual weight and fecundity in the insect population when the vector was raised with a species-specific food supply. The study compared the European rabbit Oryctolagus cuniculus, introduced in Chile

Predominance of Trypanosoma cruzi genotypes in two reservoirs infected by sylvatic Triatoma infestans of an endemic area of Chile.

We report results of Trypanosoma cruzi infection and parasite genotypes in the wild Octodon degus and synantropic reservoir Rattus rattus from an endemic area with sylvatic Triatoma infestans as the only detected vector. The infection status was determined by hemi-nested PCR directed to minicircles DNA and genotyping by hybridization tests with a panel of five specific probes, including two probes for TcI subgroups (clones 19 and 20). O. degus was found infected with 13.3% and mainly with sublineage TcIId, and less with TcIIb and TcI. Meantime the synantropic R. rattus was found infected with 27.7% and mainly with TcI and much less with TcIId, TcIIb and TcIIe. The results are discussed to explain the distribution of T. cruzi genotypes between these two reservoirs and the importance of sylvatic foci of T. infestans allowing the permanence of the wild and peridomestic cycle of Chagas disease.

Long-term pollution by chlordecone of tropical volcanic soils in the French West Indies: a simple leaching model accounts for current residue.

Chlordecone was applied between 1972 and 1993 in banana fields of the French West Indies. This resulted in long-term pollution of soils and contamination of waters, aquatic biota, and crops. To assess pollution level and duration according to soil type, WISORCH, a leaching model based on first-order desorption kinetics, was developed and run. Its input parameters are soil organic carbon content (SOC) and SOC/water partitioning coefficient (K(oc)). It accounts for current chlordecone soil contents and drainage water concentrations. The model was valid for andosol, which indicates that neither physico-chemical nor microbial degradation occurred. Dilution by previous deep tillages makes soil scrapping unrealistic. Lixiviation appeared the main way to reduce pollution. Besides the SOC and rainfall increases, K(oc) increased from nitisol to ferralsol and then andosol while lixiviation efficiency decreased. Consequently, pollution is bound to last for several decades for nitisol, centuries for ferralsol, and half a millennium for andosol.