Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery.

BACKGROUND AND AIMS: Bariatric surgery provides a useful opportunity to perform intraoperative liver biopsy to screen for non-alcoholic steatohepatitis (NASH). There is currently no consensus on whether intraoperative liver biopsy should be systematically performed. The aim of this study was to develop and validate a decision tree to guide that choice. APPROACH AND RESULTS: This prospective study included 102 consecutive patients from the severe obesity outcome network (SOON) cohort in whom liver biopsy was systematically performed during bariatric surgery. A classification and regression tree (CART) was created to identify the nodes that best classified patients with and without NASH. External validation was performed. Seventy-one biopsies were of sufficient quality for analysis (median body mass index 43.3 [40.7; 48.0] kg/m2). NASH was diagnosed in 32.4% of cases. None of the patients with no steatosis on ultrasound had NASH. The only CART node that differentiated between a "high-risk" and a "low-risk" of NASH was alanine aminotransferase (ALT). ALT>53IU/L predicted NASH with a positive predictive value (PPV) of 68% and a negative predictive value (NPP) of 89%, a sensitivity of 77%, and a specificity of 84%. In the external cohort (n=258), PPV was 68%, NPV was 62%, sensitivity was 27%, and specificity was 90%. CONCLUSIONS: The present work supports intraoperative liver biopsy to screen for NASH in patients with ALT>53IU/L; however, patients with no steatosis on ultrasound should not undergo biopsy. The CART failed to identify an algorithm with a good sensitivity to screen for NASH in patients with ultrasonography-proven steatosis and ALT≤53IU/L.

Early experience with ambulatory robotic ventral rectopexy.

OBJECTIVE OF THE STUDY: Ventral rectopexy can be performed robotically with only limited trauma for the patient, making its performance in an ambulatory setting potentially interesting. The aim of this study is to report our preliminary experience with ambulatory robotic ventral rectopexy in consecutive patients. PATIENTS AND METHODS: Ten consecutive patients underwent robotic ventral rectopexy for total rectal prolapse (n=8) or symptomatic enterocele (n=2) between February 2014 and April 2015. Patients were selected for outpatient treatment based on criteria of patient motivation, favorable social conditions, and satisfactory general condition. Patient characteristics, technical results and cost were reported. RESULTS: The mean operating time was 94minutes (range: 78-150). The average operating room occupancy time was 254minutes (222-339). There were no operative complications, conversion to laparotomy, or postoperative complication. The average duration of hospital stay was 11 (8-32) hours. Two patients required hospitalization: one for persistent pain and the other for urinary retention. The average maximum pain score recorded on postoperative day 1 was 2/10 on a visual analog scale (range: 0-5/10). Estimated average cost (excluding amortization of the purchase of the robot) was €9088 per procedure. CONCLUSIONS: Ambulatory management of robotic ventral rectopexy is feasible and safe.

Day case robotic ventral rectopexy compared with day case laparoscopic ventral rectopexy: a prospective study.

BACKGROUND: Ventral rectopexy to the promontory has become one of the most strongly advocated surgical treatments for patients with full-thickness rectal prolapse and deep enterocele. Despite its challenges, laparoscopic ventral rectopexy with or without robotic assistance for selected patients can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. The aim of this prospective case-controlled study was to assess the feasibility, safety, and cost of day case robotic ventral rectopexy compared with routine day case laparoscopic ventral rectopexy. METHODS: Between February 28, 2014 and March 3, 2015, 20 consecutive patients underwent day case laparoscopic ventral rectopexy for total rectal prolapse or deep enterocele at Michallon University Hospital, Grenoble. Patients were selected for day case surgery on the basis of motivation, favorable social circumstances, and general fitness. One out of every two patients underwent the robotic procedure (n = 10). Demographics, technical results, and costs were compared between both groups. RESULTS: Patients from both groups were comparable in terms of demographics and technical results. Patients operated on with the robot had significantly less pain (p = 0.045). Robotic rectopexy was associated with longer median operative time (94 vs 52.5 min, p < 0.001) and higher costs (9088 vs 3729 euros per procedure, p < 0.001) than laparoscopic rectopexy. CONCLUSIONS: Day case robotic ventral rectopexy is feasible and safe, but results in longer operative time and higher costs than classical laparoscopic ventral rectopexy for full-thickness rectal prolapse and enterocele.

Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients.

This is a single center retrospective review of abdominal or abdomino-thoracic penetrating wounds treated between 2004 and 2013 in the gastrointestinal and emergency unit of the university hospital of Grenoble, France. This study did not include patients who sustained blunt trauma or non-traumatic wounds, as well as patients with penetrating head and neck injury, limb injury, ano-perineal injury, or isolated thoracic injury above the fifth costal interspace. In addition, we also included cases that were reviewed in emergency department morbidity and mortality conferences during the same period. Mortality was 5.9% (11/186 patients). Mean age was 36 years (range: 13-87). Seventy-eight percent (145 patients) suffered stab wounds. Most patients were hemodynamically stable or stabilized upon arrival at the hospital (163 patients: 87.6%). Six resuscitative thoracotomies were performed, five for gunshot wounds, one for a stab wound. When abdominal exploration was necessary, laparotomy was chosen most often (78/186: 41.9%), while laparoscopy was performed in 46 cases (24.7%), with conversion to laparotomy in nine cases. Abdominal penetration was found in 103 cases (55.4%) and thoracic penetration in 44 patients (23.7%). Twenty-nine patients (15.6%) had both thoracic and abdominal penetration (with 16 diaphragmatic wounds). Suicide attempts were recorded in 43 patients (23.1%), 31 (72.1%) with peritoneal penetration. Two patients (1.1%) required operation for delayed peritonitis, one who had had a laparotomy qualified as "negative", and another who had undergone surgical exploration of his wound under general anesthesia. In conclusion, management of clear-cut or suspected penetrating injury represents a medico-surgical challenge and requires effective management protocols.

Explosive Contagion in Networks.

The spread of social phenomena such as behaviors, ideas or products is an ubiquitous but remarkably complex phenomenon. A successful avenue to study the spread of social phenomena relies on epidemic models by establishing analogies between the transmission of social phenomena and infectious diseases. Such models typically assume simple social interactions restricted to pairs of individuals; effects of the context are often neglected. Here we show that local synergistic effects associated with acquaintances of pairs of individuals can have striking consequences on the spread of social phenomena at large scales. The most interesting predictions are found for a scenario in which the contagion ability of a spreader decreases with the number of ignorant individuals surrounding the target ignorant. This mechanism mimics ubiquitous situations in which the willingness of individuals to adopt a new product depends not only on the intrinsic value of the product but also on whether his acquaintances will adopt this product or not. In these situations, we show that the typically smooth (second order) transitions towards large social contagion become explosive (first order). The proposed synergistic mechanisms therefore explain why ideas, rumours or products can suddenly and sometimes unexpectedly catch on.

Prominent effect of soil network heterogeneity on microbial invasion.

Using a network representation for real soil samples and mathematical models for microbial spread, we show that the structural heterogeneity of the soil habitat may have a very significant influence on the size of microbial invasions of the soil pore space. In particular, neglecting the soil structural heterogeneity may lead to a substantial underestimation of microbial invasion. Such effects are explained in terms of a crucial interplay between heterogeneity in microbial spread and heterogeneity in the topology of soil networks. The main influence of network topology on invasion is linked to the existence of long channels in soil networks that may act as bridges for transmission of microorganisms between distant parts of soil.

Epidemics in networks of spatially correlated three-dimensional root-branching structures.

Using digitized images of the three-dimensional, branching structures for root systems of bean seedlings, together with analytical and numerical methods that map a common susceptible-infected-recovered ('SIR') epidemiological model onto the bond percolation problem, we show how the spatially correlated branching structures of plant roots affect transmission efficiencies, and hence the invasion criterion, for a soil-borne pathogen as it spreads through ensembles of morphologically complex hosts. We conclude that the inherent heterogeneities in transmissibilities arising from correlations in the degrees of overlap between neighbouring plants render a population of root systems less susceptible to epidemic invasion than a corresponding homogeneous system. Several components of morphological complexity are analysed that contribute to disorder and heterogeneities in the transmissibility of infection. Anisotropy in root shape is shown to increase resilience to epidemic invasion, while increasing the degree of branching enhances the spread of epidemics in the population of roots. Some extension of the methods for other epidemiological systems are discussed.

[Acyclovir-induced acute renal failure: An under-estimated secondary effect?]. / Insuficiencia renal aguda por aciclovir, un efecto secundario infraestimado?

The increasing use of oral or IV acyclovir to treat infections caused by herpesviridae family involves a rise in the number of observed adverse effects. Neuro- and nephrotoxicity are most serious observed and reported secondary effects. The monitoring of renal function is essential to detect these cases since it develops as a non-oliguric renal failure. Because of this, the outpatient and oral use of the drug can result in an underestimation of the number of cases reported. We report two patients with genital herpes and viral encephalitis that required IV acyclovir. Both inpatients developed an acute renal failure that resolved after the drug was withdrawn.

Organochlorine pesticides in serum and adipose tissue of pregnant women in Southern Spain giving birth by cesarean section.

Since the appearance of DDT, increasingly potent insecticides have been developed to overcome the resistance developed by insects to successive products. Pesticides are also used in public health programs to control disease vectors. Despite legislation to control the use of certain products, they repeatedly appear in the adipose tissue, milk and serum of human populations. The present study determined the presence of organochlorine molecules in the adipose tissue, serum, and umblical cord of women giving birth by cesarean section in order to establish a possible correlation in organochlorine molecule content between these biological compartments and to examine fetal exposure to molecules with hormonal effects. Presence of nine organochlorines was detected by GC/ECD and confirmed by GC/MS. Highly significant differences (p<0.000) were observed between adipose tissue and maternal serum in concentrations of lindane, HCB, DDE, DDD, and endosulfan but not (p>0.5) in concentrations of endosulfan II or endosulfan sulfate. Only DDE concentrations differed (p<0.001) between maternal serum and umbilical cord serum. An association between pp'DDE and op'DDT was observed in maternal serum (p<0.094). An association in pp'DDE and pp'DDD content was found between adipose tissue and umbilical cord serum, and in pp'DDT content between adipose tissue and maternal serum. Results obtained indicate that exposure can be measured solely in serum when relatively high concentrations of pesticides are present.

[The treatment of intradural arteriovenous fistulas in the spine: two case reports]. / Tratamiento de fístulas arteriovenosas intradurales dorsales medulares: presentación de dos casos.

INTRODUCTION: Spinal dural arteriovenous fistulas (AVFs) frequently cause progressive myelopathy. Although endovascular approaches to spinal cord vascular malformations become an important adjunct or primary treatment of theses disorders, surgery can be safely performing in some categories. CASE REPORTS: Two males patients presented with progressively myelopathy two months and three years before, were diagnosed by typical MRI findings and spinal selective arteriograms of dorsal AVFs with single feeder of Spetzler's modified classification of spinal cord vascular lesions. After an attempt of embolization following diagnostic angiography in first case, surgical approach for clipping the afferent single feeder was done for both. CONCLUSIONS: Early recognition by selective diagnostic spinal angiography in patients with slowly progressive and fluctuating myelopathy, allow us surgery as recommended treatment in AVFs, so can effect a better outcome and often reverse presenting neurologic deficits.

[Colo-rectal surgery, through laparoscopic approach. Considerations concerning a personal experience of 613 cases]. / Chirurgia colo-rectala pe cale laparoscopica. Reflectii apropo de o experienta personala de 613 cazuri.

The start of colo-rectal laparoscopic surgery, after an initial period of enthusiasm tempered by predictable technical difficulties, was finally slowed down by the risk of port site metastases. However, this kind of surgery continued to be used for benign colonic pathology, allowing the achievement of surgical skill. Some well-trained teams reported comparable loco-regional relapse rate and 5-years survival in both laparoscopic and conventional trials. The some good results concern also mortality and morbidity in both kind of trials. Based on 613 personal cases, the authors reveal this surgery's peculiarities, justifying a predictable development.

Determination of N-nitrosamines in latex by sequential supercritical fluid extraction and derivatization.

A new method to determine N-nitrosamines in latex products has been developed by combination of supercritical fluids and chemical derivatization. A new design for a liquid trap has been introduced. A factorial fractional design was used in order to evaluate the influence of the different factors affecting the process. Factors such as pressure, temperature, static and dynamic time, restrictor temperature and volume of an hydrobromic acid-acetic anhydride mixture (1:10, v/v) were included in the design. CO2 was used as the extraction fluid. Gas chromatography with nitrogen and phosphorus sensitive detection was employed to achieve good sensitivity attending to the molecular structure of these compounds (N-nitrosamines and their corresponding secondary amines). The obtained results have shown to be useful to increase selectivity and reduce sample handling.

Determination of aromatic amines formed from azo colorants in toy products.

A study for the determination of the aromatic amines formed after reduction of the azo colorants mostly used in toys was conducted. Sodium dithionite was used in the reductive cleavage of the azo group for the dyes, and the released amines were subsequently analysed by high-performance liquid chromatography with UV detection. The influence of different variables related to the reduction process was investigated by the use of a full-level factorial design, where most significant parameters as well as order interactions were studied. Reduction profiles for each colorant were obtained by studying the changes in the amount of amine obtained with different dithionite/colorant ratios. The expected aromatic amines forming azo colorants were detected, and in the presence of a nitro group a further reduction was observed. The yield of the total reduction process was determined by using standard addition of different quantities of amines to the colorants.