Single-incision flexible endoscopy (SIFE) for detection and staging of peritoneal carcinomatosis.

OBJECTIVE: To show the feasibility and the safety of peritoneal carcinomatosis (PC) evaluation by single-incision flexible endoscopy (SIFE) and to compare it to single-incision rigid endoscopy (SIRE). BACKGROUND: Direct peritoneal visualization, either by laparotomy or laparoscopy, continues to be the gold standard in diagnosing PC. We reported, in animal study, that combining single-incision laparoscopic surgery and flexible endoscopy improved evaluation of the peritoneal cavity in a live porcine model and in four human cadavers. METHODS: Patients, undergoing surgical exploration for diagnosis and staging of PC, were included in a prospective study. Using a superiority design a sample size of 47 patients was determined. Through a single incision, a standardized peritoneoscopy was conducted with rigid (SIRE) and with flexible endoscope (SIFE). Primary outcome was the access success rates for the 13 regions of the Peritoneal Carcinomatosis Index (PCI). RESULTS: Overall access to the 13 regions of PCI was successful in 83 % of the cases with SIRE and in 91.1 % with SIFE (p < 10(-10)). SIFE access rates were superior to SIREs' in the regions: R1 (87.2 vs. 61.7 %, p = 0.002), R2 (87.2 vs. 66 %, p = 0.004), R3 (85.1 vs. 59.6 %, p = 0.001) and R6 (80.9 vs. 61.7 %, p = 0.008). The mean PCI was higher (p < 10(4)) with SIFE 12.77 (±11.97) than with SIRE 11.77 (±11.63). CONCLUSION: This prospective, comparative study shows that SIFE was significantly superior to SIRE in the exploration of some difficult-to-access peritoneal areas, located in regions 1, 2, 3 and 6. These two minimally invasive staging procedures are safe, feasible and have to be seen as complementary rather than competing.

Monocytic HLA-DR expression in intensive care patients: interest for prognosis and secondary infection prediction.

OBJECTIVES: To test early measurement of human leukocyte antigen-DR expression on circulating monocytes (mHLA-DR) as prognostic marker, and the trend of mHLA-DR recovery for the prediction of late secondary infection risk in a large intensive care unit population. DESIGN: Prospective, observational study over 16 mos. SETTING: Intensive care unit in a tertiary teaching hospital. INCLUSION CRITERIA: Simplified Acute Physiology Score II >15, age >18 yrs. MEASUREMENTS AND MAIN RESULTS: The mHLA-DR was measured by flow cytometry within the first 3 days and twice a week until discharge. We used a logistic regression model for outcome prediction, and a competing risk approach to test the relationship between mHLA-DR recovery (log (mHLA-DR) slope) and incidence of secondary infection. A total of 283 consecutive patients suffering from various pathologies were monitored (Simplified Acute Physiology Score II = 39, Sepsis-related Organ Failure Assessment of 5 on day 0). Early mHLA-DR was decreased in the whole population, however, more deeply in sepsis (p < .0001). Low mHLA-DR was associated with mortality in the whole population (p = .003), as in subgroups (nonseptic, neurologic, and septic), but not when adjusted on Simplified Acute Physiology Score II. In patients with a length of stay of >7 days (n = 70), the lower the slope of mHLA-DR recovery, the higher the incidence of the first secondary infection (adjusted on early mHLA-DR, p = .04). CONCLUSIONS: For a given severity, mHLA-DR proved not to a predictive marker of outcome, but a weak trend of mHLA-DR recovery was associated with an increased risk of secondary infection. Monitoring immune functions through mHLA-DR in intensive care unit patients therefore could be useful to identify a high risk of secondary infection.