Intraoperative Right Colic Graft Ischemia, Followed by Delayed Oesophagoplasty Including an Ileo-Transverse Anastomosis and the Cervical Revascularisation of the Ileum: Case Report.

The ischemic complications during the isolation of the substituting oesophageal graft placement and after its placement may lead to graft necrosis and to the need to find a different reconstructive procedure. The most frequent reports of graft necroses occur in the days following the reconstruction. We are presenting the case of a 27-y.o. with full dysphagia as a result of caustic stenosis, in whose case the oesophageal reconstruction was abandoned following the irreversible ischemia of the right colic graft during the vascular isolation, followed by right-side hemicolectomy and ileo-transverse anastomosis. 4 years post the ingestion of a caustic substance and 2 years post the right colic graft ischemic necrosis, we performed an oesophageal reconstruction using a pediculated, cervically revascularized, ileo-colic graft on the left colic vessels. The graft's particularity is that is formed from left and transverse colon and ileum portions, including the ileo-transverse anastomosis performed 2 years prior to the oesophageal reconstruction.

Non-invasive laparoscopic detection of small tumors of the digestive tract using inductive sensors of proximity.

The precise location of gastric and colorectal tumors is of paramount importance for the oncological surgeon as it dictates the limits of resection and the extent of lymphadenectomy. However, this task proves sometimes to be very challenging, especially in the laparoscopic setting when the tumors are small, have a soft texture, and do not invade the serosa. In this view, our research team has developed a new instrument adapted to minimally-invasive surgery, and manipulated solely by the operating surgeon which has the potential to locate precisely tumors of the digestive tract. It consists of an inductive proximity sensor and an electronic block encapsulated into an autoclavable stainless-steel cage that works in tandem with an endoscopic hemostatic clip whose structure was modified to increase detectability. By scanning the serosal side of the colon or stomach, the instrument is capable to accurately pinpoint the location of the clip placed previously during diagnostic endoscopy on the normal bowel mucosa, adjacent to the tumor. In the current in-vivo experiments performed on large animals, the modified clips were transported without difficulties to the point of interest and attached to the mucosa of the bowel. Using a laparoscopic approach, the detection rate of this system reached 65% when the sensor scanned the bowel at a speed of 0.3 cm/s, and applying slight pressure on the serosa. This value increased to 95% when the sensor was guided directly on the point of clip attachment. The detection rate dropped sharply when the scanning speed exceeded 1 cm/s and when the sensor-clip distance exceeded the cut-off value of 3 mm. In conclusion, the proposed detection system demonstrated its potential to offer a swift and convenient solution for the digestive laparoscopic surgeons, however its detection range still needs to be improved to render it useful for the clinical setting.

Biological and Histological Assessment of the Hepatoportoenterostomy Role in Biliary Atresia as a Stand-Alone Procedure or as a Bridge toward Liver Transplantation.

Background and objectives: In patients with biliary atresia (BA), hepatoportoenterostomy (HPE) is still a valuable therapeutic tool for prolonged survival or a safer transition to liver transplantation. The main focus today is towards efficient screening programs, a faster diagnostic, and prompt treatment. However, the limited information on BA pathophysiology makes valuable any experience in disease management. This study aimed to analyze the evolution and survival of patients with BA referred for HPE (Kasai operation) in our department. Materials and Methods: A retrospective analysis was performed on fourteen patients with BA, diagnosed in the pediatric department and further referred for HPE in our surgical department between 2010 and 2016. After HPE, the need for transplantation was assessed according to patients cytomegalovirus (CMV) status, and histological and biochemical analysis. Follow-up results at 1-4 years and long term survival were assessed. Results: Mean age at surgery was 70 days. Surgery in patients younger than 60 days was correlated with survival. Jaundice's clearance rate at three months was 36%. Total and direct bilirubin values had a significant variation between patients with liver transplants and native liver (p = 0.02). CMV was positive in eight patients, half with transplant need and half with native liver survival. Smooth muscle actin (SMA) positivity was proof of advanced fibrosis. The overall survival rate was 79%, with 75% for native liver patients and an 83% survival rate for those with liver transplantation. Transplantation was performed in six patients (43%), with a mean of 10 months between HPE and transplantation. Transplanted patients had better survival. Complications were diagnosed in 63% of patients. The mean follow-up period was six years. Conclusions: HPE, even performed in advanced cirrhosis, allows a significant survival, and ensures an essential time gain for patients requiring liver transplantation. A younger age at surgery is correlated with a better outcome, despite early CMV infection.

Laparoscopic compatible device incorporating inductive proximity sensors for precise detection of gastric and colorectal small tumors.

The accurate localization of small tumors of the digestive tract is of paramount importance in surgical oncology because it dictates the limits of resection and the extent of lymph node dissection. In this view, we have designed and fabricated a highly efficient sensing laparoscopic instrument focused on precise non-invasive extralumenal intraoperative detection of small colorectal or gastric tumors. The equipment is fully adapted for laparoscopic surgery and consists of an inductive proximity sensor encapsulated into a watertight stainless-steel case that is connected to an electronic functional block dimensionally scaled-down by the desired form and size for optimal surgical manipulation. The sensor-case unit and the electronic block are coupled together using a modular system which allows disconnection of the latter and sterilization by autoclavation of the former, followed by swift plugging of the electronic block just before surgery in a sterile-controlled environment. The instrument works in tandem with a modified endoscopic hemostatic clip which is attached endoscopically, before surgery, in the mucosa proximal and distal to the tumor. By scanning the serosal side of the digestive organ during the laparoscopic surgical procedure, the detector senses the modified clip and thus pinpoints to the location of the tumor. Additional engineering of the standard endoscopic hemostatic clips by coating them with various combinations of metallic alloys of Cu and Zn was necessary to improve the detection range and sensitivity without compromising on their functionality. The clips were also covered with nanometric layers of Au to ensure their biocompatibility. The ex-vivo dry-lab experiments showed a satisfactory detection distance which was later confirmed in ex-vivo wet-lab experiments on animal organs and human surgical specimens.

Hepatoportoenterostomy in Selective Obstructive Cholestasis - An New Experimental Model in the Rat.

Biliary atresia is the most frequent cause for neonatal obstructive cholestasis. Hepatoportoenterostomy (HPE) is the only method allowing survival until liver transplantation. For a maximum rate of success, the HPE procedure has to be performed within the 60 days of life. We aimed to create an experimental model for relieving obstructive cholestasis. In 20 Wistar rats selective bile duct obstruction was induced by the microsurgical ligature of the bile ducts corresponding to the median and left lateral liver lobes. After four weeks surgical re-intervention was carried out and HPE was performed microsurgically on the hilum of the median and left lateral liver lobes. One week after HPE, the integrity of the anastomosis and the hepatic changes were assessed. The survival rate throughout the study was 90%. The surgical re-intervention revealed hepatic-hilum adhesions, with fibrosis. Microscopically, an initial fibrogenic repair was identified, equivalent of moderate cholestasis. After the HPE, there was no bile leak from the anastomosis and no biliary peritonitis. The evolution was marked by a reduction in food intake. The experimental model we propose for the HPE is reliable by using microsurgical techniques. Based on it, one can study the changes induced by the bile duct obstruction.

New inductive proximity sensor platform for precise localization of small colorectal tumors.

Location of small gastric or colorectal tumors during a laparoscopic procedure is often imprecise and can be misleading. There is a real need for a compatible and straightforward tool that can be used intraoperatively to help the surgeon in this regard. We emphasize in the present work on the fabrication of a new and innovative inductive proximity switch architecture, fully compatible with laparoscopic surgery and with direct application in precise localisation of bowel tumors. An electromagnetic detection probe optimized for laparoscopic surgery and preconditioned for sterilisation was designed and constructed. Various metallic markers designed to be attached to the gastrointestinal mucosa were used for detection by the probe, from standard endoscopic and laparoscopic haemostatic clips to other custom made tags. Experiments were performed in dry and wet-lab experimental laboratory environment using ex-vivo segments of calf's small bowel and colonic surgical specimens from human patients. The dry-lab detection range varied considerably depending on the metallic component of the tags, from 0.5 mm for the endoscopic hemostatic clip to 3.5 mm for the 0.9 mm thickness stainless-steel custom tags. The latter was actually detectable from the serosal side of the fresh colonic surgical specimens in 85% of the attempts if the scanned area was less than 150 cm2 and less than 2 mm of fat was interposed between the probe and the bowel. The newly designed system has the potential to discover metallic tags attached to the bowel mucosa for precise intraoperative laparoscopic location of digestive tumors. Further work is in progress to increase the sensitivity and detection range of the system in order to make it fully compatible with the clinical use.

Cervical Exenteration - Guidelines and Surgical Technique Principles.

Introduction: Neoplastic invasion of the structures of the cervical region originating from a malignant tumour developed in one of the viscera of the throat may benefit from cervical exenteration. Defined as resection of the hypopharynx, cervical oesophagus, larynx and cervical trachea, exenteration has limited indications and is mandatorily accompanied by digestive tube reconstruction. The aim of this article is to highlight the indication, surgical strategy and important surgical stages illustrated by images from personal professional experience. MATERIALS AND METHOD: Pharyngo-laryngo-oesophageal en bloc resection and radical cervical lymphadenectomy were followed by reconstruction via free jejunal transfer or colic pedicle grafting. Between 2000 and 2018 we have performed cervical exenteration in 25 patients with tumours originating in the pharynx, larynx or cervical oesophagus. In the cases of 5 patients in whom we did not obtain the oncological safety margin for oesophageal cancer we performed transhiatal pharyngo-laryngo-oesophagectomy. In these patients, we performed reconstruction of the oesophagus with colonic graft. In 20 cases we performed jejunal autotransplant. Results: We recorded 4 perioperative deaths, due to major arterial vessel haemorrhage (1 case), after jejunal necrosis (2 cases), and mediastinitis after oesophageal striping and colonic graft necrosis (1 case). One patient presented tumour recurrence at the level of the tracheal stump. Survival rate varied between 6 months and 4 years for the group of patients who presented for postoperative follow-ups. Conclusions: Cervical exenteration remains an option for tumour recurrence after radiochemotherapy or for obstructive airway or digestive tract tumours. It can be burdened by complications difficult to treat. The surgical team has to adapt its initial surgical strategy to the reality of the surgical field, both in terms of exeresis and in terms of types of pharyngo-oesophageal reconstruction.

Expression of TLR4 protein is reduced in chronic renal failure: evidence from an experimental model of nephron reduction.

Toll-like receptor 4 (TLR4) signaling is involved in various acute and chronic renal lesions and contributes to inflammation and fibrosis in several organs; the latter are important determinants to the progression of chronic kidney disease (CKD). We aimed to assess TLR4 expression in progressive CKD and relate it to severity of kidney damage, using an experimental nephron reduction model. Male Wistar rats were subjected to subtotal nephrectomy using the ligation technique, after 12 weeks of observation, serum creatinine and proteinuria were determined, animals were sacrificed, glomerulosclerosis and interstitial scarring were quantified histologically, and TLR4 expression was assessed by immunohistochemistry. Sham-operated rats served as controls. Case animals had significantly higher creatinine, proteinuria, glomerulosclerosis and tubulointerstitial involvement. TLR4 expression was prominent in proximal tubes, less staining was observed on infiltrating inflammatory cells. Percentage of TLR4-positive tubes was reduced in the subtotal nephrectomy animals, when compared to controls (0.67±0.09 versus 0.79±0.07, p=0.003). Percentage of TLR4-positive tubes correlated inversely to markers of kidney damage: to proteinuria (r=-0.55, p=0.02), serum creatinine (r=-0.53, p=0.01); percentage of glomeruli with glomerulosclerosis (r=-0.54, p=0.01) and tubulointerstitial score (r=-0.36, p=0.01). As TLR4 staining appears in tubular casts only in nephrectomy animals, shedding from damaged tubular cells is a very likely explanation for the reduced TLR4 expression in the kidneys of subjects with experimental nephron reduction.

Luminal solutions protect mucosal barrier during extended preservation.

BACKGROUND: Mucosal barrier injury during intestinal preservation (IP) and transplantation favors life-threatening infections. Luminal delivery of solutions containing amino acids or polyethylene glycols (PEGs) may improve preservation results and reduce this injury. We tested if solutions containing glutamine and PEG influence the mucosal injury. MATERIALS AND METHODS: Rat intestines were perfused and stored in Viaspan-University of Wisconsin solution. Before IP, a PEG 3350 solution was introduced intraluminally alone (group 1) or supplemented with 40 mmol/L L-glutamine (group 2). Controls underwent vascular flush alone (group 3). Preservation injury was evaluated after 8, 14, and 24 h by histology and goblet cell count. Tight-junction proteins zonula occludens-1, claudin-3, claudin-4, and caveolin-1 were studied by immunofluorescence. Maltase and caspase-3 activity were also analyzed. RESULTS: Group 1 showed mild edema at 8 h and mucosal disruption by 24 h; these features were greatly improved in group 2 where continuous mucosa was found after 24 h of IP. Intestines in group 3 did worse at all time points with subepithelial edema (Park/Chiu grade 3) and marked goblet cell depletion; caspase-3 activity was lowest in group 2. Tight-junction proteins varied continuously during IP; zonula occludens-1 expression and colocalization with claudins decreased significantly in group 3 but not in other groups. Claudin-3 was distinctly localized in the membrane, but stained diffuse, cytoplasmic at later time-points. Claudin-4 changed to a cytoplasmic granular pattern. No caveolin-1 colocalization was observed. CONCLUSIONS: Luminal PEG and glutamine delay epithelial breakdown and preserve several important mucosal features during extended IP.