Donor age as a risk factor in donation after circulatory death liver transplantation in a controlled withdrawal protocol programme.

BACKGROUND: Results of donation after circulatory death (DCD) liver transplantation are impaired by graft loss, resulting mainly from non-anastomotic biliary stricture. Donor age is a risk factor in deceased donor liver transplantation, and particularly in DCD liver transplantation. At the authors' institute, age is not an absolute exclusion criterion for discarding DCD liver grafts, DCD donors receive comfort therapy before withdrawal, and cold ischaemia is minimized. METHODS: All consecutive DCD liver transplantations performed from 2003 to 2012 were studied retrospectively. Three age groups were compared in terms of donor and recipient demographics, procurement and transplantation conditions, peak laboratory values during the first post-transplant 72 h, and results at 1 and 3 years. RESULTS: A total of 70 DCD liver transplants were performed, including 32 liver grafts from donors aged 55 years or less, 20 aged 56-69 years, and 18 aged 70 years or more. The overall graft survival rate at 1 month, 1 and 3 years was 99, 91 and 72 per cent respectively, with no graft lost secondary to non-anastomotic stricture. No difference other than age was noted between the three groups for donor or recipient characteristics, or procurement conditions. No primary non-function occurred, but one patient needed retransplantation for artery thrombosis. Biliary complications were similar in the three groups. Graft and patient survival rates were no different at 1 and 3 years between the three groups (P = 0.605). CONCLUSION: Results for DCD liver transplantation from younger and older donors were similar. Donor age above 50 years should not be a contraindication to DCD liver transplantation if other donor risk factors (such as warm and cold ischaemia time) are minimized.

Postoperative morbidity and mortality in patients with diabetes after colorectal surgery with an enhanced recovery program: A monocentric retrospective study.

BACKGROUND: Diabetes mellitus may increase the risk of adverse perioperative outcomes and prolong hospital stay. An enhanced recovery program (ERP) reduces surgical stress and its metabolic consequences, so attenuating the impact of preoperative risk factors. We tested the hypothesis that diabetes would have only a minor impact on outcome after colorectal surgery with an ERP. METHODS: The data for patients scheduled for colorectal surgery between 2015 and 2021, were analyzed (n=769). All the patients were managed with the same protocol. Demographic data, preoperative risk factors, postoperative complications, and length of stay were compared between patients with and without diabetes. RESULTS: In all, 124 patients (16.1%) had diabetes, of whom 30 (24.1%) required insulin. The following preoperative risk factors for postoperative complications were significantly more frequent in the patients with diabetes: age>70 years, ASA score ≥ III, renal failure, cardiac disease, BMI>30 kg/m2, anemia, and cancer as indication for surgery. Despite more risk factors, patients with diabetes did not experience more overall postoperative complications than controls (OR (95%IC): 0.9 [0.6-1.5], p=0.85). Length of hospital stay was not significantly longer in patients with diabetes than in those without (4 [2-7] vs. 3 [2-7] days; p=0.45). CONCLUSIONS: Despite more risk factors, patients with diabetes did not experience more complications or longer length of stay after colorectal surgery with an ERP. The multimodal, multidisciplinary approach of ERP to reducing surgical stress may thus help mitigate the reported deleterious effects of diabetes.

[Proven and expected benefits of intravenous lidocaine administered during the perioperative period]. / Bénéfices démontrés et potentiels de l'administration intraveineuse périopératoire de lidocaïne.

Local anesthetics which inhibit sodium channels are used for neural blockade during infiltration and locoregional anesthesia. Furthermore lidocaine given intravenously acts on other cellular systems and produces multiple properties, some of which are beneficial during the perioperative period. Indeed, intravenous lidocaine is analgesic, antihyperalgesic, antiinflammatory, and improves the recovery of bowel function after abdominal surgery. As a consequence, lidocaine has been added to postoperative analgesic strategies. This article reviews clinically relevant properties of intravenous lidocaine. Its future perspectives for the prevention of chronicisation of postoperative pain, facilitation of postoperative fast track programs, and prevention of tumoral recurrence are also discussed.

Intravenous lidocaine infusion reduces bispectral index-guided requirements of propofol only during surgical stimulation.

BACKGROUND: I.V. lidocaine reduces volatile anaesthetics requirements during surgery. We hypothesized that lidocaine would also reduce propofol requirements during i.v. anaesthesia. METHODS: A randomized controlled study of 40 patients tested the effect of i.v. lidocaine (1.5 mg kg(-1) then 2 mg kg(-1) h(-1)) on propofol requirements. Anaesthesia was maintained with remifentanil and propofol target-controlled infusions (TCI) to keep the bispectral index (BIS) around 50. Effect-site concentrations of propofol and remifentanil and BIS values were recorded before and after skin incision. Data were analysed using anova and mixed effects analysis with NONMEM. Two dose-response studies were then performed with and without surgical stimulation. Propofol TCI titrated to obtain a BIS around 50 was kept constant. Then patients were randomized into four groups: A, saline; B, 0.75 mg kg(-1) bolus then infusion 1 mg kg(-1) h(-1); C, 1.5 mg kg(-1) bolus and infusion 2 mg kg(-1) h(-1); and D, 3 mg kg(-1) bolus and infusion 4 mg kg(-1) h(-1). Lidocaine administration coincided with skin incision. BIS values and haemodynamic variables were recorded. Data were analysed using linear regression and two-way anova. RESULTS: Lidocaine decreased propofol requirements (P<0.05) only during surgery. In the absence of surgical stimulation, lidocaine did not affect BIS nor haemodynamic variables, whereas it reduced BIS increase (P=0.036) and haemodynamic response (P=0.006) secondary to surgery. CONCLUSIONS: The sparing effect of lidocaine on anaesthetic requirements seems to be mediated by an anti-nociceptive action.

Effect of an intravenous infusion of lidocaine on cisatracurium-induced neuromuscular block duration: a randomized-controlled trial.

BACKGROUND: Intravenous lidocaine can be used intraoperatively for its analgesic and antihyperalgesic properties but local anaesthetics may also prolong the duration of action of neuromuscular blocking agents. We hypothesized that intravenous lidocaine would prolong the time to recovery of neuromuscular function after cisatracurium. METHODS: Forty-two patients were enrolled in this randomized, double-blind, placebo-controlled study. Before induction, patients were administered either a 1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/h infusion or an equal volume of saline. Anaesthesia was induced and maintained using propofol and remifentanil infusions. After loss of consciousness, a 0.15 mg/kg bolus of cisatracurium was administered. No additional cisatracurium injection was allowed. Neuromuscular function was assessed every 20 s using kinemyography. The primary endpoint was the time to spontaneous recovery of a train-of-four (TOF) ratio ≥ 0.9. RESULTS: The time to spontaneous recovery of a TOF ratio ≥ 0.9 was 94 ± 15 min in the control group and 98 ± 16 min in the lidocaine group (P=0.27). CONCLUSIONS: No significant prolongation of spontaneous recovery of a TOF ratio ≥ 0.9 after cisatracurium was found in patients receiving intravenous lidocaine.

Elderly patients over 70 years benefit from enhanced recovery programme after colorectal surgery as much as younger patients.

AIM OF THE STUDY: Enhanced recovery programme (ERP) reduces length of hospital stay (LOS) and postoperative complications after colorectal surgery. ERP is feasible and effective in elderly patients. We tested the hypothesis of non-inferiority for elderly patients as compared to younger patients with regard to LOS. PATIENTS AND METHODS: The first 302 consecutive patients scheduled for colorectal surgery and prospectively introduced in our audit database were retrospectively analysed. LOS (primary endpoint), postoperative complications, and adherence to the ERP of elderly (≥70 years, n=100) were compared with those of younger patients (n=202). The same ERP was used in all patients. Non-inferiority hypothesis for LOS was tested using the confidence interval method. Secondary endpoints were compared using the Mann-Whitney U and the Chi2 tests. RESULTS: Except for age patients' demographic data were not different in both groups: 53.8 (17-69) vs. 76.8 (70-90) years. The actual LOS were 3.5 [2-7] and 4.0 [3-7] days in the young and elderly group, respectively. The difference in median LOS between the two groups was 0 (95% CI, -0.97-0.97), demonstrating non-inferiority. Although with more risk factors (anaemia, COPD, cardiac disease, and cancer, P<0.05), elderly patients experienced neither more postoperative medical (17.0 vs. 16.3 %) nor surgical (19.0 vs. 22.3 %) complications than young patients. The adherence to protocol was slightly less in elderly (16 [15-18] vs. 17 [16-18], P=0.05). CONCLUSION: Not only ERP is feasible in seniors, but elderly patients benefit from this perioperative care as much as younger patients. CLINICAL TRIALS REGISTRATION: NCT03620851.

Liver transplant donation after cardiac death: experience at the University of Liege.

OBJECTIVE: Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD. PATIENTS AND METHODS: From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months. RESULTS: Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation. CONCLUSIONS: Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.

Postoperative respiratory problems in morbidly obese patients.

Morbid obesity results in a restrictive pulmonary syndrome including decreased functional residual capacity. General anaesthesia further decreases functional residual capacity, and consequently alters gas exchanges more profoundly in morbidly obese patients than in nonobese patients. Moreover, these changes persist longer during the postoperative period, rendering obese subjects vulnerable to postoperative respiratory complications. In this review, we present postoperative measures improving respiratory function of these patients. Whether these measures affect outcome remains however unknown. Patients suffering from obstructive sleep apnoea syndrome deserve special considerations that are briefly described. Finally, the algorithm of the postoperative respiratory management of morbid obese patients used in our institution is provided.

Effects of oral preoperative carbohydrate on early postoperative outcome after thyroidectomy.

BACKGROUND: Preoperative carbohydrate (CHO) reduces perioperative insulin resistance and improves preoperative patient comfort. We tested the hypotheses that preoperative CHO reduces the risk of postoperative nausea and vomiting (PONV) and improves early postoperative patient comfort. METHODS: Two hundred women scheduled for thyroidectomy were randomly allocated to drink 50 g CHO in 400 ml of water or 0.5 g aspartam in 100 ml of water 2 h before surgery. The incidence and the severity of PONV, pain scores, and analgesic consumption were recorded postoperatively. Intensity of thirst, hunger, anxiety, fatigue were recorded on 100-mm visual analog scales just before the induction of anesthesia, 2, 6, and 24 h postoperatively. RESULTS: The incidence and severity of PONV were similar in both groups. Patients from the CHO group reported significantly less thirst (P = 0.007), hunger (P = 0.04), and fatigue (P = 0.01) than patients from the control group. Postoperative pain scores did not differ significantly between both groups (P = 0.34). However patients from the CHO group requested less acetaminophen during the first 24 postoperative h: 3 g vs. 2 g (median, P = 0.002). CONCLUSIONS: Oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia, but has no effect on the PONV.

Involvement of signalling molecules NO, H2O2 and H2S in modification of plasma membrane proton pump in cucumber roots subjected to salt or low temperature stress.

In the present study we demonstrate that the signalling molecules NO, H2O2 and H2S are important for understanding the mechanisms of modification of plasma membrane H+-ATPase (EC 3.6.3.14) activity in conditions of both salt (50mM NaCl) and low temperature (10°C, LT) stress. Plants were subjected to stress conditions for 1 or 6 days. After 3 days of exposure to stress some of the plants were transferred to control conditions for another 3 days: post-stressed plants (3+3). We measured the endogenous levels of signalling molecules in stressed plants. To determine the physiological significance of NO, H2O2 and H2S induced activity of plasma membrane H+-ATPase (PM H+-ATPase) in salt and LT stresses, we investigated the activity of the plasma membrane proton pump in stress conditions, and plants were additionally supplemented with PTIO (a scavenger of NO), ascorbic acid (a scavenger of H2O2) or hypotaurine (a scavenger of H2S). H2S contributed to increased activity of PM H+-ATPase in short-term salt stress (1 day) and in low temperature treated plants (both 6 days and post-stressed plants), by stimulation of expression of several genes encoding isoforms of the plasma membrane proton pump (CsHA2, CsH4, CsH8, CsH9 and CsHA10). In contrast, NO and H2O2 play a minor role in the regulation of ATPase activity at the genetic level, because they significantly increased the expression of only one isoform, CsHA1, the expression level of which was very low in the tissues of the control plants, and additionally they slightly increased the expression of the gene encoding the isoform CsHA2. However, NO plays an important role in stimulation of the plasma membrane proton pumps under salt stress and low temperature. NO participates in post-translational modifications because it leads to increased enzyme phosphorylation and an increased H+/ATP coupling ratio.

Can I improve postoperative outcome after abdominal surgery?

Most of the textbooks of anesthesia do not devote any chapter to anesthesia for abdominal surgery. Whereas the choice of anesthetics has minimal impact on postoperative outcome of the patient scheduled for these procedures global perioperative anesthetic management however affects postoperative recovery, convalescence, or even morbidity. This presentation highlights practical measures susceptible of reducing postoperative complications and of shortening patient convalescence.

[Recent advances in liver surgery and transplantation]. / Actualités en chirurgie et transplantation hépatique.

Over the last 20 years, significant improvements in hepatic surgery and transplantation have allowed better results. Better patients selection, new preoperative modalities aiming at modifying the volume of the liver or the tumour, new surgical techniques, and better postoperative management are the keys to improved outcome. These progresses are reviewed in this article. In hepatic surgery, the latest surgical improvements are the possibility of laparoscopic hepatic resection and of radiofrequency ablation. Modern neoadjuvant chemotherapy may in some cases allow a reduction of large liver colorectal metastases and render them resectable. Improved radiological techniques allow better planning of the surgical resections, reduction of the risks by calculation of the residual liver mass, and induction of liver hypertrophy by preoperative portal embolisation. In liver transplantation, the most significant changes were the use of living related liver donors and of non-heart beating donors to overcome the cadaveric organ donor shortage.

[Tinea capitis in department of dermatology and venerology in the University hospital of Donka at Conakry, Guinea]. / Les teignes du cuir chevelu dans le service de dermatologie-vénéréologie du C.H.U. de Donka- Conakry, Guinée.

The authors report the results of a study carried out on tinea capitis, in the Department of Dermatology and Venerology at the University Hospital of Donka in Conakry, during one year In this department, the tinea capitis represents 3.2% of the consultations and remains the second mycosis. Out of 414 consulted children, a male predominance of 75% was noted especially regarding the Trichophytic tinea. School children aged of 6-14 years old are the most affected by the disease. The trichophytic tinea is widely spread with 65.5% more than the microsporic 17% and inflammatory tinea 16.5%. The mixed tinea is exceptional and no case of favus has been found. The Trichophyton violaceum is the most dermatophyte to be found 56.70% whereas a survey carried out in 1959 showed the predominance of T. soudanense and M. audouini. The Microsporum canis and an association of M. canis and T. violaceum are also to be found.

Right lobe living related liver transplantation in adults without venous drainage of the paramedian sector.

INTRODUCTION: There is some controversy on the necessity of venous reconstruction of the right paramedian sector (segments V and VIII) during right lobe living related liver transplantation. In this report we describe the evolution of posttransplant graft function in five consecutive right lobe recipients without specific drainage of the right paramedian sector. MATERIAL AND METHODS: The technique of common right hepatectomy for right lobe graft harvesting and transplantation did not include the middle hepatic vein in the graft. The mean total ischemic time was 51 minutes (ranges: 35 to 64 minutes). The mean graft to recipient weight ratio was 1.35% +/- 0.15%. No patient developed small-for-size syndrome. RESULTS: All patients showed a rise in transaminases with a maximum at postoperative day 2 (mean aspartate aminotransferase: 1067 +/- 432 IU/mL). Liver function improved rapidly, with coagulation normalized at postoperative day 5. Bilirubin decreased progressively to normalize in three patients at postoperative day 14. Ultrasonography and computed tomography demonstrated that the paramedian sector of the right liver was congested, a state that was temporary with normalization of the liver tests and congestion disappeared at follow-up. No complication was linked to congestion. DISCUSSION: This series showed that in right lobe liver transplantation with a relatively large-size graft, reconstruction of the hepatic veins of the paramedian sector may not be necessary despite the induction of some degree of venous congestion. In smaller grafts, this congestion might be avoided by reconstruction of the large veins draining segments V and VIII.

Avoiding blood products during liver transplantation.

Liver transplantation is a major surgical procedure usually requiring large amount of blood products (red cells, platelets, fresh-frozen plasma). We developed a multidisciplinary transfusion-free protocol for liver transplantation in Jehovah's witnesses who refuse the use of blood products but accept organ transplantation. Between September 1998 and November 2004, 9 of 29 Jehovah's witnesses evaluated for liver transplantation were transplanted after medical preparation. None of these patients received any blood product during the surgical procedure. This experience may be beneficial for the entire liver transplantation population, as excessive transfusion has been linked to increased morbidity and mortality in liver transplantation.

Acute rehabilitation program after laparoscopic colectomy using intravenous lidocaine.

BACKGROUND: The concept of postoperative acute rehabilitation was introduced to accelerate postoperative recovery and improve outcome. We investigated whether intravenous lidocaine infusion, which decreases postoperative pain and speeds the return of bowel function, can be used instead of epidural analgesia in an acute rehabilitation protocol for patients undergoing laparoscopic colectomy. METHODS: Twenty eight consecutive patients scheduled for laparoscopic colectomy were prospectively included in this case series study. Segmental colectomy was performed only for benign pathology. Intraoperative opioid use was restricted. After a bolus injection of lidocaine 1.5 mg x kg(-1), an infusion (2 mg x kg(-1) x h(-1), i.v.) was started before pneumoperitoneum. Balanced analgesia was used to reduce postoperative opioid consumption. Patients were allowed to drink 6 h postoperatively. The day after surgery, patients were allowed to eat a normal breakfast. Enforced mobilisation and ambulation were required from the patients. Our goal was to discharge patients within 3 days after surgery. Postoperative pain was measured. Time to first flatus, defecation, and hospital discharge were recorded. RESULTS: Mean postoperative pain at rest and mobilisation remained below 30 mm on a 100 mm visual analogue scale. Time to first flatus, defecation, and hospital discharge were 29 +/- 13 h, 38 +/- 13 h, and 3.0 +/- 1.0 days, respectively. CONCLUSION: Acute rehabilitation after laparoscopic colectomy using i.v. lidocaine gives similar outcomes to those reported using epidural analgesia.

Role of sarcolectin (SCL) and interferons in coordinated T cell clonal expansion.

T cell multiplication is attributed to the growth factor interleukin-2 (IL-2), which is, however, only activated when a specific cell membrane-bound receptor can be expressed. We found in all human sera tested a lectin that we described and called sarcolectin (SCL). SCL is a molecularly cloned 55-kDa protein that stimulates DNA synthesis in all immunocompetent cells and inhibits the interferon (IFN)-dependent antiviral state. SCL is excreted in conditioned medium of T cell cultures grown under serum-free conditions, where it can be demonstrated regularly by Western blots. In such cultures, in addition to SCL and IL-2, IFN-gamma and IFN-alpha also can be found, likely as a feedback response to DNA stimulation. Considered together, the data suggest that coordinated clonal expansion of T cells is governed by SCL-IL-2, both which induce T cell proliferation and simultaneously activate IL-2 receptors. T cell replication is downregulated by the effect of feedback IFN-gamma and IFN-alpha. To initiate a new growth cycle, SCL is thought to block the residual IFN-dependent antiproliferative state.

Localization and structure of v-mos in transformed mouse fibroblasts reverted by long-term interferon treatment to nonmalignancy.

We have reported previously that Moloney virus-transformed cells, when treated for over 200 passages in the presence of low concentrations of mouse interferon-alpha/beta, can be reverted to a stable nonmalignant status. The cells recover full contact inhibition and are unable to raise tumors when grafted in nude mice. In the present report, we show that whether reverted or malignant, these cells contain deleted v-mos oncogenes, which have lost 392 nucleotides. The truncated oncogenes contain a reduced and modified open reading frame but are able, however, to induce tumors when transfected in mouse 3T3 cells. As there is no difference either in the location or in the structure of this modified v-mos, whether yielded by reverted or malignant cells, we postulate that both cell lines derive from the same population and this modification does not play any role in the reversion process obtained through prolonged IFN-dependent selection. We suggest that reversion could be an epigenetic phenomenon, involving the constitutive synthesis of IFN-beta only in the reverted and not in the malignant cells. The continued persistence of such noncancerous cells could result at least partly from a balance involving the expression of v-mos, IFN-beta, and an IFN antagonist, sarcolectin. These reverted cells can undergo an unlimited number of passages, but they must be trypsinized before day 5 in confluent cultures. Thereafter, the cells stop dividing, cannot proliferate anymore, progressively show signs of apoptosis, and die.