A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

BACKGROUND: Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS: All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS: Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION: The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Bringing nature into private urban housing: Environmental, social and food connections for urban resilience.

Ongoing confinement for millions of urban citizens due to the Covid-19 pandemic has raised ecological consciousness, changed food habits and questioned the relationship urban dwellers have with nature. There is more interest in bringing plants into urban homes and in sustainable food sources, but no research have studied the relationships between food behaviours and plant-care activities. To address this gap and explore urban citizens' nature relatedness through the greening of private areas, we conducted a national survey of French, young urban citizens (n = 1000), who are more committed to 'edible' cities than older generations but have the lowest rate of plant purchasers. A quantitative approach reveals the prevalence of aesthetic/hedonistic expectations for plants in private housing but also demonstrates contrasting perceptions of tasks for plant maintaining and unequal valuation of social issues around plants. We discuss continuities between environmental awareness, commitment to sustainable food and natural/social uses of plants and argue that urban planning processes should address potential synergies for more integrative resilience. Community building around green areas, urban agriculture or collective gardens, in cities, can have ripple effects towards the greening of private housing. Lastly, the multi-disciplinary approach bridging psychosociology and urban studies can inspire multi-scalar urban planning.

Mapping of etiologies of computed tomography-proven acute colitis: a prospective cohort study.

Our objective was to describe the etiologies of acute colitis and to identify patients who require diagnostic endoscopy. Patients with symptoms of gastrointestinal infection and colonic inflammation on CT were prospectively included. Those immunosuppressed, with history of colorectal cancer or inflammatory bowel disease (IBD), were excluded. Microbiological analysis of the feces was performed using PCR assays BD-Max and FilmArray (GI panel,) and fecal cultures. Fecal calprotectin was determined. Patients with negative BD-Max underwent colonoscopy. One hundred and seventy-nine patients were included. BD-Max was positive in 93 patients (52%) and FilmArray in 108 patients (60.3%). Patients with infectious colitis (n = 103, 57.5%) were positive for Campylobacter spp. (n = 57, 55.3%), Escherichia coli spp. (n = 8, 7.8%), Clostridioides difficile (n = 23, 22.3%), Salmonella spp. (n = 9, 8.7%), viruses (n = 7, 6.8%), Shigella spp. (n = 6, 5.8%), Entamoeba histolytica (n = 2, 1.9%) and others (n = 4, 3.9%). Eighty-six patients underwent colonoscopy, which was compatible with ischemic colitis in 18 patients (10.1%) and IBD in 4 patients (2.2%). Fecal calprotectin was elevated in all patients, with a mean concentration of 1922.1 ± 2895.6 µg/g, and was the highest in patients with IBD (8511 ± 9438 µg/g, p < 0.001). After exclusion of patients with infectious etiology, a fecal calprotectin > 625 µg/g allowed identifying patients with IBD with an area under ROC curve of 85.1%. To conclude, computed tomography-proven colitis was of infectious etiology in 57.5% of patients. The main pathogens identified were Campylobacter spp. (55.3%), Clostridioides difficile (22.3%) and Salmonella spp. (8.7%). Ischemic colitis (10.1%) and IBD (2.2%) were seldom represented. No colorectal cancer was found.

Implementation and validation of a competency assessment tool for laparoscopic cholecystectomy.

BACKGROUND: Achieving proficiency in a surgical procedure is a milestone in the career of a trainee. We introduced a competency assessment tool for laparoscopic cholecystectomy in our residency program. Our aim was to assess the inter-rater reliability of this tool. METHODS: We included all laparoscopic cholecystectomies performed by residents under the supervision of board certified surgeons. All residents were assessed at the end of the procedure by the supervising surgeon (live reviewer) using our competency assessment tool. Video records of the same procedure were analyzed by two independent reviewers (reviewer A and B), who were blinded to the performing trainee's. The assessment had three parts: a laparoscopic cholecystectomy-specific assessment tool (LCAT), the objective structured assessment of technical skills (OSATS) and a 5-item visual analogue scale (VAS) to address the surgeon's autonomy in each part of the cholecystectomy. We compared the assessment scores of the live supervising surgeon and the video reviewers. RESULTS: We included 15 junior residents who performed 42 laparoscopic cholecystectomies. Scoring results from live and video reviewer were comparable except for the OSATS and VAS part. The score for OSATS by the live reviewer and reviewer B were 3.68 vs. 4.26 respectively (p = 0.04) and for VAS (5.17 vs. 4.63 respectively (p = 0.03). The same difference was found between reviewers A and B with OSATS score (3.75 vs. 4.26 respectively (p = 0.001)) and VAS (5.56 vs. 4.63 respectively; p = 0.004)). CONCLUSION: Our competency assessment tool for the evaluation of surgical skills specific to laparoscopic cholecystectomy has been shown to be objective and comparable in-between raters during live procedure or on video material.

Development and Validation of a Predictive Model for Internal Hernia After Roux-en-Y Gastric Bypass in a Multicentric Retrospective Cohort: The Swirl, Weight Excess Loss, Liquid Score.

OBJECTIVE: The aim of this study was to develop and validate a prediction score for internal hernia (IH) after Roux-en-Y gastric bypass (RYGB). SUMMARY BACKGROUND DATA: The clinical diagnosis of IH is challenging. A sensitivity of 63% to 92% was reported for computed tomography (CT). METHODS: Consecutive patients admitted for abdominal pain after RYGB and undergoing CT and surgical exploration were included retrospectively. Potential clinical predictors and radiological signs of IH were entered in binary logistic regression analysis to determine a predictive score of surgically confirmed IH in the Geneva training set (January 2006-December 2014), and validated in 3 centers, Geneva (January 2015-December 2017) and Neuchâtel and Strasbourg (January 2012-December 2017). RESULTS: Two hundred twenty-eight patients were included, 80 of whom (35.5%) had surgically confirmed IH, 38 (16.6%) had a negative laparoscopy, and 110 (48.2%) had an alternate diagnosis. In the training set of 61 patients, excess body weight loss >95% (odds ratio [OR] 6.73, 95% confidence interval [CI]: 1.13-39.96), swirl sign (OR 8.93, 95% CI: 2.30-34.70), and free liquid (OR 4.53, 95% CI: 1.08-19.0) were independent predictors of IH. Area under the curve (AUC) of the score was 0.799. In the validation set of 167 patients, AUC was 0.846. A score ≥2 was associated with an IH incidence of 60.7% (34/56), and 5.3% (3/56) had a negative laparoscopy. CONCLUSIONS: The score could be incorporated in the clinical setting. To reduce the risk of delayed IH diagnosis, emergency explorative laparoscopy in patients with a score ≥ 2 should be considered.

Platelet Interactions with Liver Sinusoidal Endothelial Cells and Hepatic Stellate Cells Lead to Hepatocyte Proliferation.

(1) Background: Platelets were postulated to constitute the trigger of liver regeneration. The aim of this study was to dissect the cellular interactions between the various liver cells involved in liver regeneration and to clarify the role of platelets. (2) Methods: Primary mouse liver sinusoidal endothelial cells (LSECs) were co-incubated with increasing numbers of resting platelets, activated platelets, or platelet releasates. Alterations in the secretion of growth factors were measured. The active fractions of platelet releasates were characterized and their effects on hepatocyte proliferation assessed. Finally, conditioned media of LSECs exposed to platelets were added to primary hepatic stellate cells (HSCs). Secretion of hepatocyte growth factor (HGF) and hepatocyte proliferation were measured. After partial hepatectomy in mice, platelet and liver sinusoidal endothelial cell (LSEC) interactions were analyzed in vivo by confocal microscopy, and interleukin-6 (IL-6) and HGF levels were determined. (3) Results: Co-incubation of increasing numbers of platelets with LSECs resulted in enhanced IL-6 secretion by LSECs. The effect was mediated by the platelet releasate, notably a thermolabile soluble factor with a molecular weight over 100 kDa. The conditioned medium of LSECs exposed to platelets did not increase proliferation of primary hepatocytes when compared to LSECs alone but stimulated hepatocyte growth factor (HGF) secretion by HSCs, which led to hepatocyte proliferation. Following partial hepatectomy, in vivo adhesion of platelets to LSECs was significantly increased when compared to sham-operated mice. Clopidogrel inhibited HGF secretion after partial hepatectomy. (4) Conclusion: Our findings indicate that platelets interact with LSECs after partial hepatectomy and activate them to release a large molecule of protein nature, which constitutes the initial trigger for liver regeneration.

Ultrasound-based prediction of cephalic vein cutdown success prior to totally implantable venous access device placement.

BACKGROUND: Surgical venous cutdown is a method for totally implantable venous access device (TIVAD) insertion. The main drawback of this technique is its higher failure rate when compared with the percutaneous approach, which is mostly related to anatomic variations of the cephalic vein. The aim of this study was to assess preoperative ultrasound imaging as a tool to predict cephalic vein cutdown failure for TIVAD insertion. METHODS: Ultrasound and operative reports of a cohort of patients undergoing TIVAD insertion by cephalic vein cutdown were reviewed. Ultrasound venous (vein visibility, diameter, length, subcutaneous depth, vein path, and subclavian junction visibility) and patient variables were tested by logistic regression as predictors of TIVAD insertion failure. RESULTS: One hundred sixty consecutive patients underwent cephalic vein cutdown for attempted TIVAD insertion. An inability to visualize the vein on the preoperative ultrasound examination (odds ratio, 4.39; 95% confidence interval, 1.57-12.30; P < .05) and depth of the vein (odds ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .042) were predictors of failure of TIVAD insertion by cephalic vein cutdown. CONCLUSIONS: Preoperative ultrasound examination allows identifying patients at risk of failure of TIVAD insertion by cephalic vein cutdown. Preoperative ultrasound examination constitutes an efficient tool for choosing the most appropriate surgical approach and improving patient comfort.

Platelets and Platelet-Derived Extracellular Vesicles in Liver Physiology and Disease.

Beyond their role in hemostasis, platelets are proposed as key mediators of several physiological and pathophysiological processes of the liver, such as liver regeneration, toxic or viral acute liver injury, liver fibrosis, and carcinogenesis. The effects of platelets on the liver involve interactions with sinusoidal endothelial cells and the release of platelet-contained molecules following platelet activation. Platelets are the major source of circulating extracellular vesicles, which are suggested to play key roles in platelet interactions with endothelial cells in several clinical disorders. In the present review, we discuss the implications of platelet-derived extracellular vesicles in physiological and pathophysiological processes of the liver.

Randomized Controlled Trial of Enhanced Recovery Program Dedicated to Elderly Patients After Colorectal Surgery.

BACKGROUND: Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question. OBJECTIVE: Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied. DESIGN: This was a nonblinded, randomized controlled study. SETTINGS: This study was conducted in a single high-volume university hospital. PATIENTS: A total of 150 eligible elderly patients undergoing elective colorectal surgery were included. INTERVENTIONS: Enhanced recovery after colorectal elective surgery in elderly patients was studied. MAIN OUTCOME MEASURES: The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance. RESULTS: An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001). LIMITATIONS: Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program. CONCLUSIONS: Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta. OBJETIVO: Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego. ESCENARIO: Este estudio se realizó en un único hospital universitario de alto volumen. PACIENTES: Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos. INTERVENCIONES: Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo. RESULTADOS: El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001). LIMITACIONES: Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal. CONCLUSIONES: El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.

A comparison of the da Vinci Xi vs. the da Vinci Si Surgical System for Roux-En-Y gastric bypass.

PURPOSE: The da Vinci Surgical System family remains the most widely used surgical robotic system for laparoscopy. Data about gastric bypass surgery with the Xi Surgical System are not available yet. We compared Roux-en-Y gastric bypass surgery performed at our institution with the da Vinci Xi and the da Vinci Si Surgical System. METHODS: All robotic gastric bypass procedures performed between January 2013 and September 2016 were analyzed retrospectively. Patient demographics and operative and postoperative outcomes up to 30 days were compared for the da Vinci Xi and Si Surgical System. Robotic costs per procedure were modeled including posts for a standard set of robotic instruments, capital investment, and yearly maintenance. RESULTS: One-hundred forty-four Xi Surgical System and 195 Si Surgical System procedures were identified. Mean age (p = 0.9), gender distribution (p = 0.8), BMI (p = 0.6), and ASA scores (p > 0.5) were similar in both cohorts. Operating room times were similar in both groups (219.4 ± 58.8 vs. 227.4 ± 60.5 min for Xi vs. Si, p = 0.22). Docking times were significantly longer with the Xi compared with the Si Surgical System (9 ± 4.8 vs. 5.8 ± 4 min, p < 0.0001). There was no difference in incidence of minor (13.9 vs. 10.3%, p = 0.3) and major complications (5.6 vs. 5.1%, p = 1 for Xi vs. Si). Costs were higher for the Xi Surgical System caused by higher capital investment and yearly maintenance. CONCLUSIONS: Roux-en-Y gastric bypass surgery can be safely performed with the Xi Surgical System, while drawbacks include longer docking times and higher costs.

Microbiologic Changes Induced by Biliary Drainage Require Adapted Antibiotic Prophylaxis during Duodenopancreatectomy.

Background: Patients with periampullary tumors frequently undergo endoscopic biliary investigations and biliary drainage (BD) prior to surgery. Recent literature shows a shift of the biliary microbiome toward more resistant bacteria in patients having BD. This study aimed to evaluate the local microbiome and changes induced by BD and related antibiotic exposure and to consider the choice of antibiotic for peri-operative prophylaxis. Methods: A single-center retrospective cohort study included patients operated on for periampullary tumors between January 2013 and November 2017. All patients had intra-operative bile samples taken for culture and peri-operative antibiotic use as well as documentation of complications according to the Dindo-Clavien classification. Results: A total of 37 patients were included. All received pre-operative endoscopy, and 29 (78%) had BD preceded by administration of ceftriaxone or metronidazole. Intra-operative antibiotic prophylaxis consisted of cefuroxime (92%) or ceftriaxone (13%) combined with metronidazole (100%). Bacterial contamination of bile samples was more common in the BD group than in the no biliary drainage (NBD) group (93% vs 38%; p < 0.01). A shift was observed from bile containing mainly Escherichia coli and Streptococcus spp. toward Enterococcus faecalis (0 in the NBD group versus 44.8% in the BD group; p < 0.01), Enterococcus faecium (0 versus 23%; p = 0.3), and Candida albicans (0 versus 34.5%; p = 0.08). Post-operative antibiotic modifications were common. No difference was found regarding Dindo-Clavien complications, post-operative stay, or antibiotic use in the two groups, although one patient in the NBD group who had pre-operative biliary endoscopy with antibiotic prophylaxis developed a fatal septic clot caused by Escherichia coli resistant to cefuroxime. Conclusions: We observed a significant change toward colonization by enterococci and fungi in the microbiome of patients who had pre-operative biliary investigations or drainage with antibiotic prophylaxis. These findings indicate that bile samples should be obtained systematically during surgery for periampullary tumors to guide any post-operative antibiotic therapy and peri-operative antibiotic prophylaxis and might need adaptation to target the modified microbiome.

Extracellular vesicles: Future diagnostic and therapeutic tools for liver disease and regeneration.

Extracellular vesicles are membrane fragments that can be produced by all cell types. Interactions between extracellular vesicles and various liver cells constitute an emerging field in hepatology and recent evidences have established a role for extracellular vesicles in various liver diseases and physiological processes. Extracellular vesicles originating from liver cells are implicated in intercellular communication and fluctuations of specific circulating extracellular vesicles could constitute new diagnostic tools. In contrast, extracellular vesicles derived from progenitor cells interact with hepatocytes or non-parenchymal cells, thereby protecting the liver from various injuries and promoting liver regeneration. Our review focuses on recent developments investigating the role of various types of extracellular vesicles in acute and chronic liver diseases as well as their potential use as biomarkers and therapeutic tools.

Laparoscopic Surgery for Gastric Cancer: The European Point of View.

OBJECTIVE: Multiple Asian studies have proved the feasibility of laparoscopic approach for surgical treatment of gastric cancer. The difference between Asian and European patients could limit their application in Europe. We reviewed the literature for European studies comparing open gastrectomy with laparoscopic approach in the treatment of gastric cancer. METHOD: We searched the keywords gastric cancer and laparoscopy in MEDLINE and EMBASE. We included all studies published between 1990 and 2016 and conducted in Europe. RESULT: We found 1 randomized and 13 cohort studies which compared laparoscopic with open gastrectomy. We found no mean difference in the number of lymph nodes harvested between laparoscopic and open group (mean difference: -0.49; 95% CI: -2.42; 1.44, p=0.62) and no difference of short-term or long-term mortality (short-term odds ratio: 0.74, p=0.47; long-term odds ratio: 0.65, p=0.11). We found a longer operative time in the laparoscopic group (mean difference: 35.75 minutes, p<0.01) but lesser reoperation rate than the open group (odds ratio: 1.55 p=0.01). CONCLUSION: European based population studies found results comparable with their Asian counterpart. In the current state of evidence, minimally invasive surgery for gastric cancer is safe and can achieve the same oncological results.

Bazedoxifene as a novel strategy for treatment of pancreatic and gastric adenocarcinoma.

Experimental studies have shown that the IL6/GP130/STAT3 pathway is involved in pancreatic cancer tumorigenesis and progression as well as in the development of other tumors. Bazedoxifene, a selective estrogene receptor modulator clinically available for the treatment of osteoporosis, has been shown to be an effective GP130/STAT3 signaling inhibitor through in vitro and small animal studies. Our aim was to investigate the effect of bazedoxifene on tumor progression in patients with advanced pancreatic and gastric tumors. We analyzed the data of 7 patients (5 suffering from pancreatic and 2 from gastric adenocarcinoma), with locally advanced and/or metastatic disease, median age 73 years old (range 48 - 86 years). Bazedoxifene was given orally at a dose of 20 mg per day for a median duration of 9 months (range 5 - 14 months). Two patients received bazedoxifene as monotherapy, 5 patients were under concomitant chemotherapy. Results showed tumor marker reduction in 5 patients, stable disease on CT in 5 patients and metabolic regression on PET-CT in 3 patients. Weight was gained in 4 patients. Two patients developed deep vein thrombosis and one pulmonary embolism, the treatment was otherwise well tolerated. An immunhistochemical study of pSTAT3 was performed in 6 patients, out of which 3 were positive. Our preliminary data indicate that bazedoxifene is a potential new therapeutic option for pancreatic and gastric cancer therapy, safe to use and at low cost. It might be administrated at an early stage with current strategies. Based on these preliminary results, we will initiate a prospective clinical study.

Systematic review and meta-analysis of thrombocytopenia as a predictor of post-hepatectomy liver failure.

BACKGROUND: We performed a systematic review and meta-analysis to assess whether thrombocytopenia constituted a risk factor for post-hepatectomy liver failure (PHLF). METHODS: We searched MEDLINE and EMBASE from inception until February the 17th, 2018 for studies reporting cases of PHLF in patients with and without thrombocytopenia (defined as a platelet count below 100 or 150 (G/l)) and/or platelet counts in patients with and without PHLF. Pooled odd ratios for PHLF, as well as mean difference in platelet counts between patients with and without PHLF, were obtained by random effects models. Robustness was tested by subgroups and leave-one out sensitivity analyses. Heterogeneity was assessed using the Q-test and quantified based on I2 value. RESULTS: We included 15 studies representing 3966 patients. Pooled odds ratio for PHLF in thrombocytopenic patients was 3.71 (95% CI: 2.51 to 5.48; I2 = 0%). Pooled odds ratio was 5.53 (95% CI: 2.85 to 10.48) when pooling only studies based on preoperative platelet count, and 3.13 (95% CI: 1.75 to 5.58) when pooling studies including only patients without liver cirrhosis. The pooled mean difference in platelet counts between patients with and without PHLF was -21.2 (G/l) (95% CI: -36.1 to 6.4) in disfavor of patients with PHLF. When pooling only patients with various qualities of liver tissue, the pooled mean difference was 0.6 (G/l) (95% CI: -21.1 to 22.2). CONCLUSION: Preoperative and/or postoperative thrombocytopenia constitute significant risk factors for PHLF in cirrhotic and non-cirrhotic patients.

Evaluation of donor kidneys prior to transplantation: an update of current and emerging methods.

The lack of suitable kidney donor organs has led to rising numbers of patients with end stage renal disease waiting for kidney transplantation. Despite decades of clinical experience and research, no evaluation process that can reliably predict the outcome of an organ has yet been established. This review is an overview of current methods and emerging techniques in the field of donor kidney evaluation prior to transplantation. Established techniques like histological evaluation, clinical scores, and machine perfusion systems offer relatively reliable predictions of delayed graft function but are unable to consistently predict graft survival. Emerging techniques including molecular biomarkers, new imaging technologies, and normothermic machine perfusion offer innovative approaches toward a more global evaluation of an organ with better outcome prediction and possibly even identification of targets for therapeutic interventions prior to transplantation. These techniques should be studied in randomized controlled trials to determine whether they can be safely used in routine clinical practice to ultimately reduce the discard rate and improve graft outcomes.

Interleukin-1 Receptor Antagonist Modulates Liver Inflammation and Fibrosis in Mice in a Model-Dependent Manner.

BACKGROUND: Interleukin-1 (IL-1)ß and IL-1 receptor antagonist (IL-1Ra) have been proposed as important mediators during chronic liver diseases. We aimed to determine whether the modulation of IL-1ß signaling with IL-1Ra impacts on liver fibrosis. METHODS: We assessed the effects of IL-1ß on human hepatic stellate cells (HSC) and in mouse models of liver fibrosis induced by bile duct ligation (BDL) or carbon tetrachloride treatment (CCl-4). RESULTS: Human HSCs treated with IL-1ß had increased IL-1ß, IL-1Ra, and MMP-9 expressions in vitro. HSCs treated with IL-1ß had reduced α-smooth muscle actin expression. These effects were all prevented by IL-1Ra treatment. In the BDL model, liver fibrosis and Kuppfer cell numbers were increased in IL-1Ra KO mice compared to wild type mice and wild type mice treated with IL-1Ra. In contrast, after CCl-4 treatment, fibrosis, HSC and Kupffer cell numbers were decreased in IL-1Ra KO mice compared to the other groups. IL-1Ra treatment provided a modest protective effect in the BDL model and was pro-fibrotic in the CCl-4 model. CONCLUSIONS: We demonstrated bivalent effects of IL-1Ra during liver fibrosis in mice. IL-1Ra was detrimental in the CCl-4 model, whereas it was protective in the BDL model. Altogether these data suggest that blocking IL-1-mediated inflammation may be beneficial only in selective liver fibrotic disease.

Early Experience with Intraoperative Leak Test Using a Blend of Methylene Blue and Indocyanine Green During Robotic Gastric Bypass Surgery.

INTRODUCTION: Leak tests using air or methylene blue (MB) for gastrojejunal anastomoses are often performed during gastric bypass surgeries to avoid leaks due to technical errors. Still, early leaks have been reported in the literature. Indocyanine green (ICG) fluorescence with laser excitement makes this dye easily visible even in small amounts, and, thus, may be an excellent agent for leak testing. METHODS: During robotic gastric bypass surgery, a leak test of a gastrojejunal anastomosis was performed with air through a nasogastric tube under manual occlusion of the jejunum. Afterward, 50 ml of a mix of 100 ml sterile water, 2 mg of MB, and 5 mg ICG was injected through the same tube. The entire anastomosis was inspected for integrity under both fluorescent and normal light modes. RESULTS: Leak tests with air and the blend of MB and ICG have been performed in 95 patients from January 2017 to April 2018. No intraoperative leak test-related adverse events occurred. Zero (0%) patients had a positive leak test with air, 0 patients showed MB excretion, and an ICG leak was observed in four (4.2%) patients. No anastomotic complications, including leaks and/or strictures, were found 30 days postoperatively. CONCLUSIONS: Leak tests using a blend of MB and ICG appear to be more sensitive for small defect detection of gastrojejunal anastomoses during robotic gastric bypass surgery. Larger datasets and research that is more stringent are needed to determine the exact clinical value of this new method.

Risk of Colorectal Cancer in Patients With Acute Diverticulitis: A Systematic Review and Meta-analysis of Observational Studies.

BACKGROUND & AIMS: We performed a systematic review and meta-analysis to assess the prevalence of colorectal cancer in patients with acute diverticulitis. METHODS: We searched MEDLINE from inception through November 2nd, 2017 for studies reporting the prevalence of colorectal cancer in patients with diverticulitis, identified based on the protocol CRD42017083272. This systematic review was conducted in accordance to the MOOSE guidelines. Pooled prevalence values were obtained by random effects models and robustness was tested by leave-one out sensitivity analyses. Heterogeneity was assessed using the Q-test and quantified based on I2 value. The critical appraisal of included studies was performed using the Newcastle-Ottawa scale. RESULTS: Our final analysis included 31 studies, comprising 50,445 patients. The pooled prevalence of colorectal cancer was 1.9% (95% CI, 1.5%-2.3%). Patients with complicated diverticulitis had a significantly higher risk for colorectal cancer (prevalence, 7.9%; 95% CI, 3.9%-15.3%) than patients with uncomplicated diverticulitis (prevalence, 1.3%; 95% CI, 0.1%-2%), corresponding to a pooled prevalence ratio of 6.7 (95% CI, 2.5-18.3). Subgroup analyses did not find significant difference in prevalence when separately pooling studies according to ranking on the Newcastle-Ottawa scale, geographical location or length of follow-up. Meta-regression did not find any association between age and colorectal cancer. Among patients who underwent endoscopy, the pooled prevalence of polyps was 22.7% (95% CI, 19.6%-26.0%), of advanced adenomas was 4.4% (95% CI, 3.4%-5.8%), of adenomas was 14.2% (95% CI, 11.7%-17.1%), and of hyperplastic polyps was 9.2% (95% CI, 7.6%-11.2%). CONCLUSION: In a meta-analysis of observational studies of patients with acute diverticulitis, we found the pooled prevalence of colorectal cancer to be 1.9%. The risk of colorectal cancer was significantly higher in patients with complicated diverticulitis than in patients with uncomplicated diverticulitis.

[Gastric cancer : management and multidisciplinary treatment]. / Cancer de l'estomac : prise en charge et traitement multidisciplinaire.

Despite a decreasing incidence, gastric cancer remains a burden. Generally discovered at an advanced stage, survival improved with progress in perioperative treatment and surgical management. Preoperative staging is essential to accurately classify the tumor and introduce the appropriate treatment. Tumor location is particularly important because the treatment of tumors of the esophageal junction and the stomach is different. Minimally invasive techniques can probably reduce postoperative morbidity and help to put patients in the best possible conditions for adjuvant treatment.

Malgré une incidence en diminution, le cancer gastrique reste un fardeau. Généralement découvert à un stade avancé, la survie a pu être améliorée grâce aux progrès effectués dans le traitement périopératoire et la prise en charge chirurgicale. Le bilan complémentaire préopératoire est capital afin de classifier de manière précise la tumeur et d'introduire le traitement adéquat. La localisation de la tumeur est en particulier importante car le traitement des tumeurs de la jonction œsogastrique et de l'estomac est différent. Les techniques minimalement invasives permettent de diminuer la morbidité postopératoire et de mettre les patients dans les meilleures conditions possibles pour un éventuel traitement adjuvant.