Digestive perforations related to endoscopy procedures: a local management charter based on local evidence and experts' opinion.

Background and study aims Perforations are a known adverse event of endoscopy procedures; a proposal for appropriate management should be available in each center as recommended by the European Society of Gastrointestinal Endoscopy. The objective of this study was to establish a charter for the management of endoscopic perforations, based on local evidence. Patients and methods Patients were included if they experienced partial or complete perforation during an endoscopic procedure between 2008 and 2018 (retrospectively until 2016, then prospectively). Perforations (size, location, closure) and management (imagery, antibiotics, surgery) were analyzed. Using these results, a panel of experts was asked to propose a consensual management charter. Results A total of 105 patients were included. Perforations occurred mainly during therapeutic procedures (91, 86.7%). Of the perforations, 78 (74.3 %) were diagnosed immediately and managed during the procedure; 69 of 78 (88.5 %) were successfully closed. Closures were more effective during therapeutic procedures (60 of 66, 90.9 %) than during diagnostic procedures (9 of 12, 75.0 %, P  = 0.06). Endoscopic closure was effective for 37 of 38 perforations (97.4 %) < 0.5 cm, and for 26 of 34 perforations (76.5 %) ≥ 0.5 cm ( P  < 0.05). For perforations < 0.5 cm, systematic computed tomography (CT) scan, antibiotics, or surgical evaluation did not improve the outcome. Four of 105 deaths (3.8 %) occurred after perforation, one of which was attributable to the perforation itself. Conclusions Detection and closure of perforations during endoscopic procedure had a better outcome compared to delayed perforations; perforations < 0.5 cm had a very good prognosis and CT scan, surgeon evaluation, or antibiotics are probably not necessary when the endoscopic closure is confidently performed. This work led to proposal of a local management charter.

ESD with double clips and rubber band traction of neoplastic lesions developed in the appendiceal orifice is effective and safe.

Background and study aims Endoscopic submucosal dissection (ESD) of superficial colorectal lesions in close proximity to the appendiceal orifice (L-PAO) was shown to be feasible except in case of deep invasion into the appendix (type 3 of Toyonaga's classification). This study aimed to determine the outcomes of ESD with double clip and rubber band traction (DCT-ESD) of L-PAO including a majority of type 3. Patients and methods We reviewed retrospectively all consecutive DCT-ESD of L-PAO performed in 3 French centers. Each lesion was described according to Toyonaga's classification and type 0 lesions were excluded. The primary outcome was en bloc and R0 resection rates for L-PAO. Morbidity and salvage surgery were recorded. Results A total of 32 patients underwent DCT-ESD; 22 lesions (68.8 %) were type 3, including 11 with previous appendectomy (34.4 %). Median lesion size was 35 mm range (10-110 mm) and median duration of resection was 47 min range (10-230 min). We achieved 100 % of En bloc resection exclusively with DCT-ESD and 90.6 % of histological R0 resection rate. Per-procedure, 11 perforations occurred and were all immediately closed with clips. Overall, 3 patients (10.7 %) underwent surgery without stoma (2 complications related and 1 incomplete resection). No death occurred. Conclusion ESD of lesions deeply invading appendiceal orifice is feasible with the help of a traction system. Technical success by endoscopy avoiding surgery was achieved in 90.6 % of cases.

DRESS Syndrome in the ICU: When a Patient Is Treated with Multiple Drugs.

The Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is life-threatening. It associates a skin condition with hematological and visceral disorders. The DRESS syndrome diagnosis in the intensive care unit (ICU) is difficult as clinical features are nonspecific. Furthermore, the need to treat patients with multiple drugs usually prevents the identification of the causative drug. We report the case of a patient who developed two bouts of DRESS caused by piperacillin-tazobactam, the first being complicated with a distributive shock. Cases of DRESS occurring inside ICU are seldom reported. However, any intensivist may encounter this situation during his career and should be aware of its diagnostic and management specific aspects.

In vivo antibiotic removal during coupled plasma filtration adsorption: a retrospective study.

Coupled plasma filtration adsorption (CPFA) is a blood purification therapy aimed at modulating the host inflammatory response involved in sepsis pathogenesis. One potential drawback of this technique is the unexpected elimination of antibiotics. The aim of this study was to assess the elimination of several antibiotics with CPFA. We performed a retrospective analysis of the serum and ultrafiltrate concentrations of different antibiotics routinely measured during CPFA sessions in five patients experiencing septic shock. The adsorbent extraction ratio (AER) for piperacillin and vancomycin 2 h into the CPFA session were high: 95.4 ± 6.9% and 99.6 ± 0.9%, respectively. These AER decreased significantly by 8 h (at 8 h: 6.3 ± 51.8% and -30.2 ± 25.6%, respectively), suggesting saturation of the resin cartridge. Conversely, the tazobactam AER was low (7.2 ± 15% after 2 h of CPFA). No significant changes in the mean serum concentrations of piperacillin, tazobactam, and vancomycin were observed. Thus, as opposed to tazobactam, we report high adsorption of piperacillin and vancomycin on the CPFA resin but with no reduction in serum concentrations.

[Super high-flux continuous hemodialysis in septic shock: a case report]. / Hémodialyse continue avec membrane super high-flux au cours d'un choc septique : application clinique.

Continuous renal replacement therapy (CRRT) with a high cutoff (HCO) membrane is proposed for septic shock as a blood purification technique. The aim of this therapy is to modulate the immune response through the increase of the clearances of the inflammatory mediators as compared to standard CRRT. The use of HCO membranes in daily clinical practice is limited due to the related theoretical albumin loss. Super high-flux (SHF) membranes have an optimized cutoff and, when used in a diffusive mode, may allow for high clearances of middle molecules with limited albumin loss. We report the case of a patient with pneumonia and septic shock treated with continuous hemodialysis with a SHF membrane in order to present the clinical application of this new extracorporeal blood purification technique.

Adult left liver transplantation from split livers and living donors: a 14-year single-center experience.

BACKGROUND: In an era of organ scarcity, the use of left liver grafts for adult recipients could increase the access to liver transplantation (LT). The aim of this study was to evaluate the results in a single-center series of adult left LT over a 14-yr period. PATIENTS AND METHODS: Between March 1996 and March 2010, 30 adult patients underwent LT with a left liver obtained from 16 split cadaveric livers and 14 living donors (LD). Portal vein inflow modulation was performed in selected cases. RESULTS: A total of 19 (63.3%) grafts had early dysfunction leading to graft failure in six cases (20%). One third of the grafts developed small-for-size syndrome (SFSS). One-yr patient and graft survival was 80% and 76.7%, respectively. Regarding two successive periods, one-yr patient and graft survival dramatically increased from 62.5% to 100% (p = 0.01) and 56.2% to 100% (p = 0.002), respectively. Multivariate analysis disclosed that completion of a portosystemic shunt and the occurrence of post-operative ascites were significantly associated with graft failure. CONCLUSIONS: Our results support that improved surgical techniques and careful patient selection can lead to a safe use of left livers for transplantation in adult recipients. Inflow modulation could be performed in very selected cases.

Pancreas retransplantation: a second chance for diabetic patients?

BACKGROUND: If pancreas transplantation is a validated alternative for type 1 diabetic patients with end-stage renal disease, the management of patients who have lost their primary graft is poorly defined. This study aims at evaluating pancreas retransplantation outcome. METHODS: Between 1976 and 2008, 569 pancreas transplantations were performed in Lyon and Geneva, including 37 second transplantations. Second graft survival was compared with primary graft survival of the same patients and the whole population. Predictive factors of second graft survival were sought. Patient survival and impact on kidney graft function and survival were evaluated. RESULTS: Second pancreas survival of the 17 patients transplanted from 1995 was close to primary graft survival of the whole population (71% vs. 79% at 1 year and 59% vs. 69% at 5 years; P=0.5075) and significantly better than their first pancreas survival (71% vs. 29% at 1 year and 59% vs. 7% at 5 years; P=0.0008) regardless of the cause of first pancreas loss. The same results were observed with all 37 retransplantations. Survival of second simultaneous pancreas and kidney transplantations was better than survival of second pancreas after kidney. Patient survival was excellent (89% at 5 years). Pancreas retransplantation had no impact on kidney graft function and survival (100% at 5 years). CONCLUSION: Pancreas retransplantation is a safe procedure with acceptable graft survival that should be proposed to diabetic patients who have lost their primary graft.

Early relaparotomy after simultaneous pancreas-kidney transplantation.

BACKGROUND: Simultaneous pancreas-kidney transplantation (SPKT) is a promising therapy for type 1 diabetes mellitus with chronic kidney disease. Although the long-term outcome of SPKT is extensively documented, the incidence of early complications within the first weeks after the surgery is less described. The aim of this study was to assess the incidence, causes, and risk factors of early relaparotomy after SPKT. METHODS: All SPKT performed in the university hospital between 2005 and 2008 were enrolled. The primary endpoint was defined as the need for at least one relaparotomy after SPKT within the initial hospital stay. The secondary endpoints were the incidence of vascular graft thrombosis, postoperative sepsis, patient, and graft survival. RESULTS: Sixty-one patients were included. During their initial hospital stay, 27 (44.3%) SPKT recipients required at least one relaparotomy. The main causes of relaparotomy were hemorrhage (59.3%) and vascular graft thrombosis (22.2%). First relaparotomy occurred at a median postoperative time of 1 day (interquartile range, 1-6). Pretransplant dialysis and nontraumatic cause of donor brain death were identified as independent risk factors for early relaparotomy. Thirty-two patients (52.4%) experienced a symptomatic or asymptomatic vascular graft thrombosis. CONCLUSIONS: The early postoperative period remains a high-risk phase for relaparotomy. The selection of recipients before initiation of long-term dialysis and of donors deceased from traumatic causes may reduce the rate of these early complications after SPKT. Vascular graft thrombosis and bleeding are two major issues that arise during this critical period, suggesting the importance an adequate management of postoperative anticoagulation and hemostasis.

[Acute renal failure after acetaminophen poisoning: report of three cases]. / Insuffisance rénale aiguë lors d'intoxication à l'acétaminophène: à propos de trois cas.

PURPOSE: Management of acetaminophen overdose focuses on the risk hepatic failure. However, acute renal failure, although less frequent, can lead to serious metabolic complications and require hemodialysis. We report three cases of acute renal failure related to acetaminophen overdose. CLINICAL FEATURES: Three patients, aged 17-46 yr ingested acetaminophen 19 to 32 g, and were admitted to the intensive care unit because of acute liver failure without hepatic coma. While liver function improved, each patient developed acute renal failure starting on the fourth day. Four sessions of hemodialysis were required in one patient because of anuria. Hepatic function improved from the fourth to the ninth day in each case, whereas renal function recovered later, 10-20 days after ingestion. Investigations were negative for other causes of renal failure, and acute tubular necrosis due to acetaminophen was suspected. CONCLUSION: The pathophysiology of this type of acute tubular necrosis remains unclear and thus, there is no specific treatment. Nevertheless, in all cases of acetaminophen overdose, we suggest following serum creatinine levels during the first week, regardless of the degree hepatic failure or quantity of acetaminophen ingested.

[The electroencephalogram is not an adequate test to confirm the diagnosis of brain death]. / L'électroencéphalogramme n'est pas un examen légitime pour la confirmation du diagnostic de mort cérébrale.

PURPOSE: In France, legislation mandates that the clinical diagnosis of brain death be confirmed by one paraclinical test before organ donation is allowed. That test may be either the electroencephalogram (EEG) or cerebral angiography. We report a case in which the clinical diagnosis of brain death was first confirmed by two EEGs performed according to the French guidelines, but ruled out by cerebral angiography. Considering that the EEG is no longer recommended to establish the diagnosis of brain death, we discuss the relevance of maintaining the EEG for brain death diagnosis in France. CLINICAL FINDINGS: A 58 yr-old man was admitted to the intensive care unit because of coma secondary to a massive subarachnoid hemorrhage with herniation below the falx shown by computed tomography. Clinical criteria of brain death were rapidly present. Two EEGs first confirmed the diagnosis but a four-vessel cerebral angiography was finally performed because the patient moved spontaneously. This cerebral angiography showed flow in the right internal carotid artery. A computed tomography performed the next day definitely confirmed the absence of brain death and organ donation did not occur. CONCLUSIONS: This case demonstrates the limitations of the EEG for this indication and suggests that angiography should be preferred. French legislation is probably maladjusted and would benefit by incorporating guidelines of other countries like Canada. International harmonization of criteria for brain death diagnosis would also be welcome.