Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

Appendiceal Goblet Cell Carcinoma: Role of Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Goblet cell carcinoma (GCC) encompasses a separate entity in appendiceal neoplasms with mixed glandular and neuro-endocrine pathological features. GCC mostly presents as an acute appendicitis duo to luminal obstruction or as an incidental finding on the surgical appendectomy specimen. In case of tumour perforation or presence of other risk factors, guidelines suggest additional treatment with a completing right hemicolectomy or cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). We report the case of a 77-year-old male with symptoms of appendicitis for which an appendectomy was performed. The appendix was ruptured during the procedure. There was an incidental finding of GCC on the pathological specimen. Because of possible tumour soiling, the patient received a prophylactic CRS-HIPEC. A literature review was performed to investigate the potential role for CRS-HIPEC as a curative treatment in patients with GCC. GCC of the appendix is an aggressive type of tumour with a high risk of peritoneal and systemic dissemination. CRS and HIPEC is a treatment option: both in a prophylactic setting and in patients with established peritoneal metastases.

Peri-operative management of obese patients in digestive surgery: Clinical practice guidelines from the French Society of Digestive Surgery.

INTRODUCTION: The French Society of Digestive Surgery (Société Française de Chirurgie Digestive [SFCD]) has elaborated clinical practice guidelines for the management of the obese patient undergoing gastro-intestinal surgery. METHODS: The literature was analyzed according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology divided into five chapters: preoperative management, modalities of transportation and installation of the patient in the operating room, specific characteristics related to laparoscopic surgery, specific characteristics related to traditional surgery, and postoperative management. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). RESULTS: Synthesis of expert opinions and the application of the GRADE methodology produced 30 recommendations among which three were strong and nine were weak. The GRADE methodology could not be applied for 18 questions, for which only expert opinion was obtained. CONCLUSION: These clinical practice guidelines can help surgeons optimize the peri-operative management of the obese patient undergoing gastro-intestinal surgery.

Treating strangeness: Medicine and human dignity at the time of COVID-19.

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

Biosensing extracellular vesicles: contribution of biomolecules in affinity-based methods for detection and isolation.

Extracellular Vesicles (EVs) are lipid vesicles secreted by cells that allow intercellular communication. They are decorated with surface proteins, which are membrane proteins that can be targeted by biochemical techniques to isolate EVs from background particles. EVs have recently attracted attention for their potential applications as biomarkers for numerous diseases. This review focuses on the contribution of biomolecules used as ligands in affinity-based biosensors for the detection and isolation of EVs. Capturing biological objects like EVs with antibodies is well described in the literature through different biosensing techniques. However, since handling proteins can be challenging due to stability issues, sensors using non-denaturable biomolecules are emerging. DNA aptamers, short DNA fragments that mimic antibody action, are currently being developed and considered as the future of antibody-like ligands. These molecules offer undeniable advantages: unparalleled ease of production, very high stability in air, similar affinity constants to antibodies, and compatibility with many organic solvents. The use of peptides specific to EVs is also an exciting biochemical solution to target EV membrane proteins and complement other probes. These different ligands have been used in several types of biosensors: electrochemical, optical, microfluidic using both generic probes (targeting widely expressed membrane proteins such as the tetraspanins) and specific probes (targeting disease biomarkers such as proteins overexpressed in cancer).

Potential use of biochar, compost and iron grit associated with Trifolium repens to stabilize Pb and As on a multi-contaminated technosol.

Vegetation cover can be used in the phytomanagement of polluted areas by adding value to abandoned sites and reducing the dispersion of pollutants by erosion. Appropriate amendments, that allow both efficient plant growth and the immobilization of contaminants in the soil must be chosen in order to optimize the efficiency of this process. We used a mining technosol mainly contaminated by arsenic (1068 mg kg-1) and lead (23387 mg kg-1) to study the effect of three amendments (biochar, compost and iron grit) on (i) physico-chemical properties of the soil and soil pore water, (ii) metal(loid) mobility, bioavailability and bioaccessibility (CaCl2 and Simple Bioaccessibility Extraction Test (SBET)), and (iii) the capability of Trifolium repens to germinate and grow. All the amendments used increased the pH and electrical conductivity of the SPW, resulting in a 90% decrease in the concentration of lead in the soil pore water (SPW). We also demonstrated a decrease in Pb phytoavailability. The amendments allowed the establishment of a plant cover, although the addition of iron grit alone did not allow any clover germination. For the Pontgibaud technosol, the combination of the three amendments resulted in a significant decrease in As and Pb concentrations in clover tissues, mainly in the aerial organs. The amendments also made it possible for some of them to halve the phytoavailable fraction of arsenic. However, for compost, both the As concentrations in the SPW, and the bioavailable fraction of As increased. All the amendments used had contrasting effects on the bioaccessible fractions of metal(loid)s. The most efficient amendment combination was the addition of 5% biochar and 5% compost.

Capability of amendments (biochar, compost and garden soil) added to a mining technosol contaminated by Pb and As to allow poplar seed (Populus nigra L.) germination.

The germination capacity of poplar seeds has never been studied in the context of metal(loid)-contaminated soils, even though poplars are present over a vast geographical area. In this study, black poplar seeds from the Loire Valley (France) were grown for 28 days in mesocosm on a heavily polluted soil that was subjected to different amendments. This phytomanagement process aimed to allow the revegetation of an As and Pb-contaminated mining soil by adding appropriate amendments, resulting in metal(loid) soil stabilisation and efficient plant growth. The objectives were to evaluate the effect of three amendments (garden soil, compost and biochar) when added alone or combined to a technosol on (i) the soil physicochemical properties, (ii) the mobility of As and Pb in the soil pore water (SPW), (iii) the capacity of poplar seeds to germinate and to grow and (iv) the metal(loid) distribution within the plant organs. The addition of amendments alone or combined allowed a 90% decrease in SPW Pb concentrations, while the arsenic concentrations were between 18 and 416 times higher. However, we were only able to obtain seed germination and plant growth on amended soils. These promising results will allow us to explore the use of such amendments in rehabilitating areas that are sources of significant metal(loid) dissemination, as well as allowing a natural plant recolonisation of these sites by seeds from the surrounding environment.

Chronic hypokalemia due to gastric exclusion after bariatric surgery.

Hypokalemia is a common complication of repeated vomiting or prolonged gastric suction. In the case we observed, a patient presented with chronic hypokalemia due to gastric dilatation and the development of a superior mesenteric artery syndrome several years after gastric banding. This paper presents pre-operative and post-operative illustrations of a rare but potentially serious entity.

Europe's lost forests: a pollen-based synthesis for the last 11,000 years.

8000 years ago, prior to Neolithic agriculture, Europe was mostly a wooded continent. Since then, its forest cover has been progressively fragmented, so that today it covers less than half of Europe's land area, in many cases having been cleared to make way for fields and pasture-land. Establishing the origin of Europe's current, more open land-cover mosaic requires a long-term perspective, for which pollen analysis offers a key tool. In this study we utilise and compare three numerical approaches to transforming pollen data into past forest cover, drawing on >1000 14C-dated site records. All reconstructions highlight the different histories of the mixed temperate and the northern boreal forests, with the former declining progressively since ~6000 years ago, linked to forest clearance for agriculture in later prehistory (especially in northwest Europe) and early historic times (e.g. in north central Europe). In contrast, extensive human impact on the needle-leaf forests of northern Europe only becomes detectable in the last two millennia and has left a larger area of forest in place. Forest loss has been a dominant feature of Europe's landscape ecology in the second half of the current interglacial, with consequences for carbon cycling, ecosystem functioning and biodiversity.

Membrane Vesicles Derived from Bordetella bronchiseptica: Active Constituent of a New Vaccine against Infections Caused by This Pathogen.

Bordetella bronchiseptica, a Gram-negative bacterium, causes chronic respiratory tract infections in a wide variety of mammalian hosts, including humans (albeit rarely). We recently designed Bordetella pertussis and Bordetella parapertussis experimental vaccines based on outer membrane vesicles (OMVs) derived from each pathogen, and we obtained protection against the respective infections in mice. Here, we demonstrated that OMVs derived from virulent-phase B. bronchiseptica (OMVBbvir+) protected mice against sublethal infections with different B. bronchiseptica strains, two isolated from farm animals and one isolated from a human patient. In all infections, we observed that the B. bronchiseptica loads were significantly reduced in the lungs of vaccinated animals; the lung-recovered CFU were decreased by ≥4 log units, compared with those detected in the lungs of nonimmunized animals (P < 0.001). In the OMVBbvir+-immunized mice, we detected IgG antibody titers against B. bronchiseptica whole-cell lysates, along with an immune serum having bacterial killing activity that both recognized B. bronchiseptica lipopolysaccharides and polypeptides such as GroEL and outer membrane protein C (OMPc) and demonstrated an essential protective capacity against B. bronchiseptica infection, as detected by passive in vivo transfer experiments. Stimulation of cultured splenocytes from immunized mice with OMVBbvir+ resulted in interleukin 5 (IL-5), gamma interferon (IFN-γ), and IL-17 production, indicating that the vesicles induced mixed Th2, Th1, and Th17 T-cell immune responses. We detected, by adoptive transfer assays, that spleen cells from OMVBbvir+-immunized mice also contributed to the observed protection against B. bronchiseptica infection. OMVs from avirulent-phase B. bronchiseptica and the resulting induced immune sera were also able to protect mice against B. bronchiseptica infection.IMPORTANCEBordetella bronchiseptica, a Gram-negative bacterium, causes chronic respiratory tract infections in a wide variety of mammalian hosts, including humans (albeit rarely). Several vaccines aimed at preventing B. bronchiseptica infection have been developed and used, but a safe effective vaccine is still needed. The significance and relevance of our research lie in the characterization of the OMVs derived from B. bronchiseptica as the source of a new experimental vaccine. We demonstrated here that our formulation based on OMVs derived from virulent-phase B. bronchiseptica (OMVBbvir+) was effective against infections caused by B. bronchiseptica isolates obtained from different hosts (farm animals and a human patient). In vitro and in vivo characterization of humoral and cellular immune responses induced by the OMVBbvir+ vaccine enabled a better understanding of the mechanism of protection necessary to control B. bronchiseptica infection. Here we also demonstrated that OMVs derived from B. bronchiseptica in the avirulent phase and the corresponding induced humoral immune response were able to protect mice from B. bronchiseptica infection. This realization provides the basis for the development of novel vaccines not only against the acute stages of the disease but also against stages of the disease or the infectious cycle in which avirulence factors could play a role.

Conservative endoscopic management of a large duodenal defect after cholecystectomy.

Reports of duodenal loss of substance after laparoscopic cholecystectomy are rare. We report successful management of a large duodenal defect that occurred after cholecystectomy by endoscopic insertion of a duodenal stent and double pigtail catheters.

Biomechanical causes of trapeziometacarpal arthroplasty failure.

Trapeziometacarpal joint prosthesis revision has been widely reported, mainly due to loosening of the trapezium cup. Our hypothesis is that current prostheses do not sufficiently respect the kinematics of this joint. CT scan acquisitions enabled us to determine the position of the first metacarpal relative to the trapezium in three different characteristic postures, in subjects in different stages of arthrosis. A CAD model of a current prosthesis was inserted into the numerical 3D model of the joint under the different postures. In the numerical model, we observe penetration of the cup by the head of the prosthesis. This virtual penetration could, in vivo, amount to overstressing the prosthetic elements, which would lead to loosening of the cup or of the metacarpal stem and luxation of the prosthesis.

Routine mini-laparoscopic cholecystectomy: Outcome in 200 patients.

INTRODUCTION: In order to improve the outcome of classical laparoscopic cholecystectomy (CLC), surgeons have attempted to minimize tissue trauma. The aim of this study is to describe the technique of mini-laparoscopic cholecystectomy (MLC) and to report the outcome of this approach when used as a routine procedure. METHODS: Since January 2012, all consecutive patients undergoing MLC were included in this study. Operative and perioperative data were prospectively collected. Additionally, cost analysis was performed. RESULTS: From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16 years). Mean operative duration was 97±32min for the first 50 patients and 75±25min for the subsequent 150 patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50 procedures and in seven of the subsequent 150 procedures (P=0.003). Perioperative morbidity included gallbladder perforation (n=28) or moderate (<50mL) bleeding (n=6). Postoperative morbidity was 4%. The mean global cost for a MLC procedure was 1757±1855 euros. This cost decreased from 2946±3115 euros in the first 50 patients to 1390±1278 euros in the subsequent 150 patients (P=0.001). CONCLUSION: Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results.

Liver regeneration following repeated reversible portal vein embolization in an experimental model.

BACKGROUND: Portal vein embolization (PVE) is used routinely to prevent postoperative liver failure as a result of anticipated insufficient future liver remnant volume following resection. The authors have recently developed a technique for temporary PVE. The aim of this study was to assess the effect of repeated reversible PVE on hepatocyte proliferation and subsequent liver hypertrophy in rodents. METHODS: Four treatments were compared (n = 21 rats per group): single reversible PVE, two PVEs separated by 14 days, partial portal vein ligation or sham procedure. The feasibility and tolerance of the procedure were assessed. Volumetric imaging by CT was used to estimate the evolution of liver volumes. After death, the weight of liver lobes was measured and hepatocyte proliferation evaluated by immunostaining. RESULTS: Embolization of portal branches corresponding to 70 per cent of total portal flow was performed successfully in all animals. Repeated PVE induced additional hepatocyte proliferation. Repeated embolization resulted in superior hepatocyte proliferation in the non-occluded segments compared with portal vein ligation (31·1 versus 22·2 per cent; P = 0·003). The non-occluded to total liver volume ratio was higher in the repeated PVE group than in the single PVE and sham groups (P = 0·050 and P = 0·001 respectively). CONCLUSION: Repeated reversible PVE successfully induced additional hepatocyte proliferation and subsequent liver hypertrophy. Surgical relevance Portal vein embolization (PVE) is used routinely to prevent postoperative liver failure as a result of anticipated insufficient future liver remnant volume following resection. In the present study, a technique of repeated temporary PVE was developed in a rat model; this induced additional hepatocyte proliferation and an increase in liver volume compared with single embolization. This novel approach might help induce major hypertrophy of the future remnant liver, which could increase the rate of patients amenable to major liver resections.

Characterization of the immune response induced by pertussis OMVs-based vaccine.

For the development of a third generation of pertussis vaccine that could improve the control of the disease, it was proposed that the immune responses induced by the classic whole cell vaccine (wP) or after infection should be used as a reference point. We have recently identified a vaccine candidate based on outer membrane vesicles (OMVs) derived from the disease etiologic agent that have been shown to be safe and protective in mice model of infection. Here we characterized OMVs-mediated immunity and the safety of our new candidate. We also deepen the knowledge of the induced humoral response contribution in pertussis protection. Regarding the safety of the OMVs based vaccine (TdapOMVsBp,) the in vitro whole blood human assay here performed, showed that the low toxicity of OMVs-based vaccine previously detected in mice could be extended to human samples. Stimulation of splenocytes from immunized mice evidenced the presence of IFN-γ and IL-17-producing cells, indicated that OMVs induces both Th1 and Th17 response. Interestingly TdapOMVsBp-raised antibodies such as those induced by wP and commercial acellular vaccines (aP) which contribute to induce protection against Bordetella pertussis infection. As occurs with wP-induced antibodies, the TdapOMVsBp-induced serum antibodies efficiently opsonized B. pertussis. All the data here obtained shows that OMVs based vaccine is able to induce Th1/Th17 and Th2 mixed profile with robust humoral response involved in protection, positioning this candidate among the different possibilities to constitute the third generation of anti-pertussis vaccines.

[Evaluation of surgical skills of French ophthalmology, orthopedic and gastrointestinal surgery residents: Current status and perspectives]. / Évaluation des compétences techniques des internes de chirurgie ophtalmologique, orthopédique et digestive français : état actuel et perspectives.

The purpose of this study was to evaluate the need for nationwide assessment of surgical skills during residency, and to define ideal methods for assessment in three surgical disciplines: ophthalmology, orthopedics and gastrointestinal surgery. Three online questionnaires were sent by e-mail to 784 residents, fellows and hospital practitioners, and 119 university hospital physican-professors. Questionnaires focused on current assessment methods at the regional level, the roles of the surveyed population in these evaluations, potential obstacles to their development and the most relevant methods for practical evaluations. Nine hundred and three questionnaires were sent; 355 participants replied (response rate: 39%). The establishment of systematic assessment seemed necessary to over 90% of the survey population, and this opinion was equitably distributed among all three specialties. Over 60% of respondents felt that current assessment procedures were not satisfactory. In all three specialties, the ideal evaluation method proposed was a real patient procedure. This "in vivo" evaluation was considered applicable in 80% of cases, potential barriers to its development being the resident's anxiety, medical-legal reasons and the lack of objective criteria. The ideal timing of these assessments was bi-annual. Implementation of surgical skills assessment during residency seems necessary. The survey population appears dissatisfied with current arrangements. A step-by-step evaluation combining surgical simulations, animal training and live patient procedures may be appropriate.

Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study.

INTRODUCTION: Over the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS. METHODS: Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. RESULTS: Twenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10). CONCLUSION: This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures.

Pollen-based quantitative reconstructions of Holocene regional vegetation cover (plant-functional types and land-cover types) in Europe suitable for climate modelling.

We present quantitative reconstructions of regional vegetation cover in north-western Europe, western Europe north of the Alps, and eastern Europe for five time windows in the Holocene [around 6k, 3k, 0.5k, 0.2k, and 0.05k calendar years before present (bp)] at a 1° × 1° spatial scale with the objective of producing vegetation descriptions suitable for climate modelling. The REVEALS model was applied on 636 pollen records from lakes and bogs to reconstruct the past cover of 25 plant taxa grouped into 10 plant-functional types and three land-cover types [evergreen trees, summer-green (deciduous) trees, and open land]. The model corrects for some of the biases in pollen percentages by using pollen productivity estimates and fall speeds of pollen, and by applying simple but robust models of pollen dispersal and deposition. The emerging patterns of tree migration and deforestation between 6k bp and modern time in the REVEALS estimates agree with our general understanding of the vegetation history of Europe based on pollen percentages. However, the degree of anthropogenic deforestation (i.e. cover of cultivated and grazing land) at 3k, 0.5k, and 0.2k bp is significantly higher than deduced from pollen percentages. This is also the case at 6k in some parts of Europe, in particular Britain and Ireland. Furthermore, the relationship between summer-green and evergreen trees, and between individual tree taxa, differs significantly when expressed as pollen percentages or as REVEALS estimates of tree cover. For instance, when Pinus is dominant over Picea as pollen percentages, Picea is dominant over Pinus as REVEALS estimates. These differences play a major role in the reconstruction of European landscapes and for the study of land cover-climate interactions, biodiversity and human resources.

Follicular bronchiolitis as phenotype associated with CD25 deficiency.

Regulatory T cells [Tregs ; CD4(+) CD25(+) forkhead box protein 3 (FoxP3(+) )] are subsets of T cells involved in the maintenance of peripheral self-tolerance by actively suppressing the activation and expansion of autoreactive T cells. Signalling through the interleukin-2 receptor (IL-2R) contributes to T cell tolerance by controlling three important aspects of regulatory T cell (Treg ) biology. CD25 is the α-chain of the IL-2R that, in concert with the ß-chain and γ-chain, constitutes the complete IL-2R. CD25 contributes only to IL-2 binding affinity but not to the recruitment of signalling molecules. However, its importance in the development of a normal immune response is emphasized by the finding that a truncation mutant of CD25 results in an immunodeficiency in humans characterized by an increased susceptibility to viral, bacterial and fungal infections. In 1997, Sharfe et al. described an infant with severe bacterial, viral and fungal infections. Counts of autologous T lymphocytes were moderately low, T cells displayed a weak proliferative response to mitogens in vitro and the patient displayed no rejection of an allogeneic skin graft. However, unlike children with severe combined immunodeficiency (SCID), besides not having circulating T cells, the patient also developed peripheral lymphocytic proliferation and autoimmune primary biliary cirrhosis. We present the first female Argentine patient with mutation in CD25 associated with chronic and severe inflammatory lung disease (follicular bronchiolitis with lymphocyte hyperplasia), eczema and infections. She has no expression of CD25 on CD4(+) T cells and an extremely low amount of Tregs . The molecular study confirmed homozygous missense mutation in the alpha subunit of the IL-2 receptor (CD25αR) (c. 122 a > c; p. Y41S).