Mycobacterium bovis infection of an aortobifemoral bypass graft with Streptococcus intermedius superinfection after intravesical bacillus Calmette-Guérin immunotherapy for bladder cancer.

BACKGROUND: The Bacillus Calmette-Guerin (BCG) is a life-attenuated form of Mycobacterium bovis widely used as immunotherapy for localized bladder cancer. Adverse reactions to intravesical BCG instillations are rare. CASE: We describe a 70-year-old man with a history of an aortobifemoral bypass graft, placement of a synthetic mesh for treatment of a ventral hernia and, most recently, superficial bladder cancer treated with BCG therapy. Ten months after his final intravesical BCG instillation, he complained of fever and asthenia. After 12 months of investigation, he was diagnosed with Mycobacterium bovis infection of his aortobifemoral bypass graft and abdominal mesh, with Streptococcus intermedius superinfection. The bypass graft was excised and replaced with an in situ arterial allograft, the abdominal mesh was removed, and treatment started with amoxicillin, isoniazid, rifampicin and ethambutol. Several additional vascular interventions were needed for allograft degradation, but 12 months after the final procedure, outcome was good. DISCUSSION AND CONCLUSIONS: Among 35 cases of mycotic aneurysm reported after BCG therapy in the last 10 years, only one involved a vascular prosthesis. Surgical repair of such aneurysms using prosthetic grafts is commonly performed, associated with anti-mycobacterial treatment. Prognosis is poor with mortality of 14% (4/35) and a 26% rate of aneurysm recurrence under treatment (9/35).

Arterial vascularization of the right colon with implications for surgery.

PURPOSE: During right-sided colectomies, surgeons encounter major anatomical variations at the level of the right colon, leading to morbidity. Due to the confusion surrounding the colonic arterial vessels emerging from the superior mesenteric artery (SMA) to vascularize the right part of the colon, this review aimed to describe the arterial vessels found in the mesocolic structures of the ascending colon, the hepatic flexure and the right transverse colon. METHODS: A review of the literature was performed using the MEDLINE database. Only human studies were included. All dissection, angiographic, arterial cast and corrosion studies were analyzed. RESULTS: This review demonstrates that the right colon, the hepatic flexure and the right transverse colon are vascularized by three significant arteries emerging from the SMA and forming one peripheral paracolic arc: (1) the ileocolic artery (ICA), the most constant vessel (99.8%) with low variability; (2) the right colic artery (RCA), the most inconstant vessel (2/3 of cases) with high variability in its origin; and (3) the middle colic artery (MCA), a constant vessel (95%) with variation in its origin and its number. The marginal artery is almost constant (100%) and represents the only peripheral arterial arc at the level of the right side of the colon. CONCLUSIONS: Three arteries emerging from the superior mesenteric artery exist: the ICA, the RCA and the MCA. The ICA and the MCA are the most constant. Knowledge of this vascular anatomy is essential for performing right-sided colectomies.

Can we classify ampullary tumours better? Clinical, pathological and molecular features. Results of an AGEO study.

BACKGROUND: Ampullary adenocarcinoma (AA) originates from either intestinal (INT) or pancreaticobiliary (PB) epithelium. Different prognostic factors of recurrence have been identified in previous studies. METHODS: In 91 AA patients of the AGEO retrospective multicentre cohort, we evaluated the centrally reviewed morphological classification, panel markers of Ang et al. including CK7, CK20, MUC1, MUC2 and CDX2, the 50-gene panel mutational analysis, and the clinicopathological AGEO prognostic score. RESULTS: Forty-three (47%) of the 91 tumours were Ang-INT, 29 (32%) were Ang-PB, 18 (20%) were ambiguous (Ang-AMB) and one could not be classified. Among these 90 tumours, 68.7% of INT tumours were Ang-INT and 78.2% of PB tumours were Ang-PB. MUC5AC expression was detected in 32.5% of the 86 evaluable cases. Among 71 tumours, KRAS, TP53, APC and PIK3CA were the most frequently mutated genes. The KRAS mutation was significantly more frequent in the PB subtype. In multivariate analysis, only AGEO prognostic score and tumour subtype were associated with relapse-free survival. Only AGEO prognostic score was associated with overall survival. CONCLUSIONS: Mutational analysis and MUC5AC expression provide no additional value in the prognostic evaluation of AA patients. Ang et al. classification and the AGEO prognostic score were confirmed as a strong prognosticator for disease recurrence.

Three-Dimensional Modelization of the Female Human Inferior Hypogastric Plexus: Implications for Nerve-Sparing Radical Hysterectomy.

BACKGROUND/AIMS: This study aims to describe the autonomic nervous network of the female pelvis with a 3D model and to provide a safe plane of dissection during radical hysterectomy for cervical cancer. METHODS: Pelvises of 3 human female fetuses were studied by using the computer-assisted anatomic dissection. RESULTS: The superior hypogastric plexus (SHP) was located at the level of the aortic bifurcation in front of the sacral promontory and divided inferiorly and laterally into 2 hypogastric nerves (HN). HN ran postero-medially to the ureter and in the lateral part of the uterosacral ligament until the superior angle of the inferior hypogastric plexus (IHP). IHP extended from the anterolateral face of the rectum, laterally to the cervix and attempted to the base of the bladder. Vesical efferences merged from the crossing point of the ureter and the uterine artery and ran through the posterior layer of the vesico-uterine ligament. CONCLUSIONS: The SHP could be injured during paraaortic lymphadenectomy. Following the ureter and resecting the medial fibrous part of the uterosacral ligament may spare the HN. No dissection should be performed under the crossing point of the ureter and the uterine artery.

Is Mini-Gastric Bypass a Rational Approach for Type-2 Diabetes?

PURPOSE OF REVIEW: Morbid obesity and type-2 diabetes mellitus (T2DM) are both major public health problems. Bariatric surgery is a proven and effective treatment for these conditions; laparoscopic Roux-en-Y gastric bypass (RYGB) is currently the gold-standard treatment. One-anastomosis gastric bypass (OAGB) is described as a simpler, safer, and non-inferior alternative to RYGB to treat morbid obesity. Concerning T2DM, experts of the OAGB procedure report promising metabolic results with good long-term remission of T2DM; however, heterogeneity within the literature prompted us to analyze this issue. RECENT FINDINGS: OAGB has gained popularity given its safety and long-term efficacy. Concerning the effect of OAGB for the treatment of T2DM, most reports involve non-controlled single-arm studies with heterogeneous methodologies and a few randomized controlled trials. However, this available literature supports the efficacy of OAGB for remission of T2DM in obese and non-obese patients. Two years after OAGB, the T2DM remission and improvement rate increased from 67 to 100%. The results were improved and stable in the long term. The 5-year T2DM remission rate increased from 82 to 84.4%. OAGB is non-inferior compared with RYGB and even superior to other accepted bariatric procedures, such as sleeve gastrectomy and adjustable gastric banding. OAGB is an efficient, safe, simple, and reversible procedure to treat T2DM. The literature reveals interesting results for T2DM remission in non-obese patients. High-level comparative studies are required to support these data.

Decreased expression of the glucocorticoid receptor-GILZ pathway in Kupffer cells promotes liver inflammation in obese mice.

BACKGROUND & AIMS: Kupffer cells (KC) play a key role in the onset of inflammation in non-alcoholic steatohepatitis (NASH). The glucocorticoid receptor (GR) induces glucocorticoid-induced leucine zipper (GILZ) expression in monocytes/macrophages and is involved in several inflammatory processes. We hypothesized that the GR-GILZ axis in KC may contribute to the pathophysiology of obesity-induced liver inflammation. METHODS: By using a combination of primary cell culture, pharmacological experiments, mice deficient for the Gr specifically in macrophages and transgenic mice overexpressing Gilz in macrophages, we explored the involvement of the Gr-Gilz axis in KC in the pathophysiology of obesity-induced liver inflammation. RESULTS: Obesity was associated with a downregulation of the Gr and Gilz, and an impairment of Gilz induction by lipopolysaccharide (LPS) and dexamethasone (DEX) in KC. Inhibition of Gilz expression in isolated KC transfected with Gilz siRNA demonstrated that Gilz downregulation was sufficient to sensitize KC to LPS. Conversely, liver inflammation was decreased in obese transgenic mice specifically overexpressing Gilz in macrophages. Pharmacological inhibition of the Gr showed that impairment of Gilz induction in KC by LPS and DEX in obesity was driven by a downregulation of the Gr. In mice specifically deficient for Gr in macrophages, Gilz expression was low, leading to an exacerbation of obesity-induced liver inflammation. CONCLUSIONS: Obesity is associated with a downregulation of the Gr-Gilz axis in KC, which promotes liver inflammation. The Gr-Gilz axis in KC is an important target for the regulation of liver inflammation in obesity.

Comparison of FDG-PET/CT and MR with diffusion-weighted imaging for assessing peritoneal carcinomatosis from gastrointestinal malignancy.

OBJECTIVES: To assess the accuracy of FDG-PET/CT and MR with diffusion-weighted imaging (MR-DWI) for diagnosing peritoneal carcinomatosis (PC) from gastrointestinal malignancies. METHODS: Thirty consecutive patients referred for staging of gastrointestinal malignancy underwent FDG-PET/CT and MR-DWI in this retrospective study. Extent of PC was characterised by dividing the peritoneal cavity into three sites in each patient: right and left supramesocolic areas and inframesocolic level (total 90 sites). Presence of PC was confirmed either by surgery (18/30) or by follow-up (12/30). RESULTS: PC was confirmed in 19 patients (19/30). At a total of 90 sites, 27 showed proven PC. On a patient-based analysis, sensitivity, specificity, PPV, NPV and accuracy were respectively 84%, 73%, 84%, 73% and 80% for PET/CT and 84%, 82%, 89%, 75% and 83% for MR-DWI. On a site-based analysis, overall sensitivity and specificity of PET/CT (63%, 90%) and MR-DWI (74%, 97%) were not statistically different (P = 0.27). In the supramesocolic area, MR-DWI detected more sites involved than PET/CT (7/9 vs. 4/9). The sensitivities of PET and MR were lower for subcentimetre tumour implants (42%, 50%). Interobserver agreement was very good for PET/CT and good for MR-DWI. CONCLUSIONS: FDG-PET/CT and MR-DWI showed similar high accuracy in diagnosing PC. Both techniques underestimated the real extent of PC because of decreased sensitivity for subcentimetre lesions. KEY POINTS: FDG-PET/CT and MR-DWI showed similar high accuracy for diagnosing peritoneal carcinomatosis. • In the supramesocolic area, MR-DWI could be more sensitive than PET/CT. • Both techniques showed lower sensitivity for subcentimetre lesions. • Interobserver agreement was very good for PET/CT and good for MR-DWI.

Risks and Benefits of Prophylactic Transfusion before Cholecystectomy in Sickle Cell Disease.

Preoperative transfusion (PT) reduces acute postoperative vaso-occlusive events (VOE) in sickle cell disease (SCD), but exposes patients to alloimmunization, encouraging a recent trend towards transfusion sparing. The aim of this study was to investigate the benefit-risk ratio of PT before cholecystectomy on the occurrence of postoperative VOE. Adult SCD patients who underwent cholecystectomy between 2008 and 2019 in our center were included. Patients' characteristics, collected retrospectively, were compared according to PT. A total of 79 patients were included, 66% of whom received PT. Gallbladder histopathology found chronic cholecystitis (97%) and gallstones (66%). Transfused patients underwent more urgent surgeries and had experienced more painful vaso-occlusive crises (VOC) in the month before surgery (p = 0.05). Four (8.5%) post-transfusion alloimmunizations occurred, and two of them caused a delayed hemolytic transfusion reaction (DHTR) (4.3%). The occurrence of postoperative VOE was similar between the groups (19.2% vs. 29.6%, p = 0.45). Though not statistically significant, a history of hospitalized VOC within 6 months prior to surgery seemed to be associated to postoperative VOE among non-transfused patients (75% vs. 31.6%, p = 0.10). PT before cholecystectomy exposes to risks of alloimmunization and DHTR that could be avoided in some patients. Recent VOCs appear to be associated with a higher risk of postoperative VOE and prompt the preemptive transfusion of these patients.

Extracellular vesicles: General features and usefulness in diagnosis and therapeutic management of colorectal cancer.

In the world, among all type of cancers, colorectal cancer (CRC) is the third most commonly diagnosed in males and the second in females. In most of cases, (RP1) patients' prognosis limitation with malignant tumors can be attributed to delayed diagnosis of the disease. Identification of patients with early-stage disease leads to more effective therapeutic interventions. Therefore, new screening methods and further innovative treatment approaches are mandatory as they may lead to an increase in progression-free and overall survival rates. For the last decade, the interest in extracellular vesicles (EVs) research has exponentially increased as EVs generation appears to be a universal feature of every cell that is strongly involved in many mechanisms of cell-cell communication either in physiological or pathological situations. EVs can cargo biomolecules, such as lipids, proteins, nucleic acids and generate transmission signal through the intercellular transfer of their content. By this mechanism, tumor cells can recruit and modify the adjacent and systemic microenvironment to support further invasion and dissemination. This review intends to cover the most recent literature on the role of EVs production in colorectal normal and cancer tissues. Specific attention is paid to the use of EVs for early CRC diagnosis, follow-up, and prognosis as EVs have come into the spotlight of research as a high potential source of 'liquid biopsies'. The use of EVs as new targets or nanovectors as drug delivery systems for CRC therapy is also summarized.

Impact of laparoscopy on oncological outcomes after colectomy for stage III colon cancer: A post-hoc multivariate analysis from PETACC8 European randomized clinical trial.

BACKGROUND: In colon cancer (CC), surgery remains the mainstay of treatment with curative intent. Despite several clinical trials comparing open and laparoscopic approaches, data on long-term outcomes for stage III CC are lacking. METHODS: This post-hoc analysis of the European PETACC8 randomized phase 3 trial included patients from 340 sites between December 2005 and November 2009, with long follow-up (median 7.56 years). Patients were randomly assigned to FOLFOX or FOLFOX+cetuximab after colonic resection. The surgical approach was left to the referring surgeon's discretion. RESULTS: Among 2555 patients included, 1796 (70.29%) were operated on by open surgery and 759 (29.71%) by laparoscopy. The 5-year OS rate was better after laparoscopic resection (85.4%, 95%CI 82.5-87.7) than after open surgery (80.2%, 95%CI 78.2-82.0; p = 0.002). The 5-year DFS rate was also better after laparoscopy (p = 0.016). However, in multivariate analysis using a propensity matching, the surgical approach was not found to be an independent prognostic factor for OS or DFS. OS (p = 0.0243) and DFS (p = 0.035) were increased after laparoscopic surgery in KRAS/BRAF WT sub-group CONCLUSION: We showed that laparoscopic resection has comparable long-term outcomes to open surgery in patients with stage III CC. For those with RAS and BRAF WT CC, laparoscopic colectomy may favorably impact survival.

Delayed retroperitoneal liposarcoma diagnosis and management in a patient with massive obesity.

People suffering from extreme obesity may be exposed to delayed diagnosis and treatment of cancer. A 37-year-old woman (weight = 245 kg, body mass index (BMI) = 79 kg/m2), presented a sepsis associated with nonspecific abdominal pain for 4 months. After several unsuccessful attempts due to her weight and a large waist circumference, abdominal CT scan was finally successfully performed and showed a large retroperitoneal mass. An ultrasound-guided core needle biopsy was performed and was in favor of a liposarcoma. Surgery was performed to remove the entire tumor of an estimated weight of 98 kg, a giant retroperitoneal dedifferentiated liposarcoma. This case highlights the difficulties to screen, diagnose, and manage cancers encountered in patients suffering from massive obesity.

Traditional versus three-dimensional teaching of peritoneal embryogenesis: a comparative prospective study.

INTRODUCTION: Anatomy teaching is newly boosted by the development of interactive three-dimensional (3D) teaching techniques. Nevertheless, their superiority as teaching aids has never been demonstrated. The aim of this study was to compare 3D and traditional chalk teaching efficiency in terms of student memorization concerning peritoneal embryogenesis. MATERIALS AND METHODS: 165 students from the Faculties of Medicine of Sfax (Tunisia) (n = 81) and of Paris-Descartes (France) (n = 84) were taught peritoneal embryogenesis either via a 3D technique (interactive DVD ROM) (3D group, n = 85) or via the traditional chalk technique (CL group, n = 80). Both groups were subjected to an evaluation test including 34 questions distributed in six chapters at the end of the course. RESULTS: The overall rate of correct answers was higher in the 3D group (65.12 +/- 14.88 vs. 49.33 +/- 16.17%, p < 0.001). It was the same for five of the six chapters of questions excluding the chapter concerning the clinical implications (p = 0.06). There was no significant difference between 3D and CL groups regarding the 20 questions focusing on static phenomena (64.52 +/- 27.10 vs. 58.87 +/- 23.67%, p = 0.24), but the rate of correct answers was higher in the 3D group for the 14 questions focusing on dynamic phenomena (65.96 +/- 20.97 vs. 28.17 +/- 24.40%, p < 0.001). CONCLUSION: The 3D technique is significantly more efficient than the traditional chalk technique for the teaching of peritoneal embryogenesis in terms of short-term memorization and particularly for the assimilation of dynamic phenomena. Medium-term and long-term studies are needed to demonstrate that this benefit has a long-lasting impact.

Roux-en-Y Gastric Bypass in Patient with Situs Inversus Totalis.

In some cases, in addition to the usual difficulties that the bariatric surgeon may encounter during standard bariatric procedures, anatomical anomalies such as situs inversus can pose an additional technical challenge. A 58-year-old patient with total situs inversus underwent Roux-en-Y gastric bypass (RYGB) surgery in our department. The main difficulty was the realization of a mirrored RYGB. Laparoscopic RYGB in a patient with situs inversus totalis is feasible but requires significant concentration and three-dimensional coordination to perform the mirrored procedure.

Feasibility of a fetal anatomy 3D atlas by computer-assisted anatomic dissection.

OBJECTIVE: To assess the feasibility of 3D modelisation of fetal anatomy by using the Computer-assisted anatomic dissection (CAAD) based on immunolabeled histologic slices and MRI slices with a specific 3D software. STUDY DESIGN: For pelvis and lower limbs, subjects came from legal abortion, medical pregnancy termination, or late miscarriage. Specimens were fixed in 10 % formalin, then embedded in paraffin wax and serially sectioned. The histological slices were stained using HES and Masson Trichrome. Protein S-100 and D2-40 markers were used for immuno-labelling. Serial transverse sections were digitalized and manually aligned. Fetal brain slices were obtained from in utero or post-mortem MRI. RESULTS: CAAD was performed on 10 fetuses: pelvis was modelised with 3 fetuses of 13, 15 and 24 W G, lower limbs with 2 fetuses of 14 and 15 W G and brain with 5 fetuses aged between 19 and 37 W G. Fetal pelvis innervation was analysed after immunolabelling and nerves appeared proportionally bigger than in adults with the same topography. Lower limbs analysis revealed that nerve development was guided by vascular development: the sciatic nerve along the big axial vein, the saphen nerve along the big saphen vein and the sural nerve along the small saphen vein. Fetal brain study allowed to describe the gyration process and the lateral ventricle development. CONCLUSION: CAAD technique provides an accurate 3D reconstruction of fetal anatomy for lower limbs and pelvis but has to be improved for brain model since midline structures were not amendable for analysis. These results need to be confirmed with larger series of specimens at different stages of development.

Fistulojejunostomy for Chronic Fistula After Sleeve Gastrectomy.

The most dreadful complication after sleeve gastrectomy (SG) is staple line leak. Its rate varies between 1 and 2%. With the development of interventional endoscopy, its treatment is currently fairly standardized and allows healing in the majority of cases without revisional surgery. However, if endoscopic treatment fails, surgical treatment becomes unavoidable. Fistulojejunostomy is a surgical option in the management of chronic fistula after SG. Laparoscopic fistulojejunostomy in a patient with chronic fistula after SG is difficult but feasible. This procedure allows complete healing and nutritional recovery in the case of failure of other endoscopic modalities.

Long-Term Evaluation of Biliary Reflux on Esogastric Mucosae after One-Anastomosis Gastric Bypass and Esojejunostomy in Rats.

BACKGROUND: One-anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) remains controversial because it may cause chronic biliary reflux (BR). The risk of developing esogastric cancer due to BR after OAGB/MGB is based on the results of experimental rat studies using esojejunostomy (EJ). The aim of this study was to analyze the potential long-term consequences of BR on the esogastric mucosae in OAGB/MGB-operated rats and to compare these results to those from the use of EJ. METHODS: Wistar rats received OAGB/MGB (n = 16), EJ (n = 16), and sham (n = 8) operations. Mortality and weight changes were evaluated throughout the experiment. BR was measured using magnetic resonance imaging (MRI). Rats received follow-ups for 30 weeks. A double-blinded histological analysis was performed in the esogastric segments. RESULTS: BR was diagnosed in OAGB/MGB and EJ rats using the MRI technique; no BR occurred in the sham group. After a 30-week follow-up, no incidences of dysplasia or cancer were observed in the three groups. Additionally, esophageal intestinal metaplasia and mucosal ulcerations were observed in 41.7% and 50% of EJ rats, respectively, and no incidences of these conditions were observed in OAGB/MGB and sham rats. The incidence of esophagitis was significantly higher and more severe in the EJ group compared to those in the OAGB/MGB and sham groups (EJ = 100%, OAGB/MGB = 16.7%, sham = 8.3%; p < 0.001). CONCLUSIONS: After a 30-week follow-up period, OAGB/MGB rats did not develop any precancerous or cancerous lesions when more than 40% of EJ rats had intestinal metaplasia.

Anastomotic Location Predicts Anastomotic Leakage After Elective Colonic Resection for Cancer.

BACKGROUND: Anastomotic leakage (AL) is a potential feared complication after colorectal resection, which is associated with an increased risk of postoperative mortality and frequently requires additional surgery. The aim of this study was to assess major independent risk factors for AL after elective colonic resection for cancer, including anastomotic location. METHODS: Among 1940 consecutive patients referred to our institution for colorectal adenocarcinoma, 1025 patients had elective colonic resection with intraperitoneal anastomosis without diverting stoma. Risk factors were assessed among preoperative, operative, and histological data. RESULTS: Clinical AL was observed in 36 patients (3.5%) with 24 patients requiring revisional surgery (67%). In multivariate analysis, endoscopic impassable tumor and colo-colic or ileo-colic anastomosis were independent risk factors for AL. The occurrence of AL was associated with poor overall (43.1 months vs. 146.4 months; p < 0.001) and disease-free survival (40.5 months vs. 137.3 months; p = 0.003). CONCLUSION: Anastomotic leakage occurs more frequently after colo-colic and ileo-colic anastomosis than after intraperitoneal colorectal anastomosis. The right colectomy appears to be at higher risk of AL, with a greater risk of surgical intervention than after an elective left colectomy. Ileo-colic anastomosis should be avoided in cases of suboptimal conditions.

Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass for Weight Loss Failure.

INTRODUCTION: One anastomosis gastric bypass (OAGB) was suggested as an option in the management of weight loss failure after sleeve gastrectomy (SG). In parallel, the length of the biliopancreatic limb (BPL) is currently debated. OBJECTIVES: To evaluate morbidity and efficiency of the conversion of SG to OAGB using two lengths of BPL (150 cm versus 200 cm). METHODS: Retrospective analysis of a prospectively collected database on 72 patients operated on between 2007 and 2017: (200-cm BPL before 2014 versus 150-cm BPL since 2014). RESULTS: At revision, the mean body mass index (BMI) was 43.6 ± 7 kg/m2. Sixteen patients (20%) had type 2 diabetes (T2D) and 23 (29%) had obstructive sleep apnea (OSA). Early morbidity rate was 4.2% (n = 3). Mean BMI were 33.7 ± 6 and 34.8 ± 9 at 2 and 5 years, respectively. At 5 years, the rate of lost of follow-up was 34%. T2D and OSA improved in 80% (n = 12) and 70% (n = 16) of the patients, respectively. At revision, the mean BMI were 46 ± 8 kg/m2 and 41 ± 6 kg/m2 for patients with 200-cm BPL (n = 38) and 150-cm BPL (n = 34), respectively. Two years after conversion, the mean BMI were 34 ± 1 kg/m2 for 200-cm BPL and 32 ± 7 kg/m2 for 150-cm BPL. The rate of gastroesophageal reflux disease (GERD) and diarrhea was 13% and 5% in patients with 200-cm BPL versus 3% and 0% in patients with 150-cm BPL. CONCLUSION: This study shows that the conversion of SG to OAGB is feasible and safe allowing significant weight loss and improvement in comorbidities. Weight loss seems comparable between the 150-cm and 200-cm BPL.