Performance of Diagnostic Scores in Thrombotic Microangiopathy Patients in the Intensive Care Unit: A Monocentric Study.

Early thrombotic thrombocytopenic purpura (TTP) recognition is critical as this disease is almost always lethal if not treated promptly with therapeutic plasma exchanges. Currently, as ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity is not widely available in emergency, scores have been developed to help differentiating TTP from other thrombotic microangiopathies (TMAs). The aim of this work was to study the accuracy of these diagnostic scores in the intensive care unit (ICU) setting. Performance of both Coppo and PLASMIC scores was studied in a cohort of adult TMA patients requiring admission to one university hospital ICU from 2006 to 2017. Receiver operating characteristic (ROC) curves were established, and confidence intervals of the area under the curve (AUC) were determined. Multivariate logistic regression analysis was performed to identify parameters specifically associated with TTP, to compare diagnostic scores and to elaborate more accurate diagnostic models. During the study period, 154 TMA patients required ICU admission, including 99 (64.2%) TTP and 55 (35.7%) non-TTP patients. AUC under the ROC curve in predicting TTP was 0.86 (95% confidence interval [CI]: 0.81-0.92) for the Coppo score, 0.67 (95% CI: 0.58-0.76) for the PLASMIC score, and 0.86 (95% CI: 0.81-0.92) for platelet count alone. Platelet count ≤20 G/L, determined as the best cut-off rate for thrombocytopenia, performed similarly to the Coppo score and better than the PLASMIC score to differentiate TTP from non-TTP patients, both using AUC ROC curve and logistic regression. In a monocentric cohort of TMA patients requiring ICU admission, the PLASMIC score had limited performance for the diagnosis of TTP. The performance of the Coppo score was good but similar to a single highly discriminant item: platelet count ≤20 G/L at admission.

The Nissen Sleeve Gastrectomy: Technical Considerations.

Background: Laparoscopic sleeve gastrectomy (LSG) is currently the most performed bariatric procedure worldwide. We have developed a modification to the usual surgical technique of LSG by adding a Nissen fundoplication. Objectives: Provide the technical details of this new bariatric procedure. Materials and Methods: The first step of the N-sleeve technique involves dissection and reduction within the abdominal cavity of a possible hiatal hernia and closure of the hiatal orifice. A short 3 cm Nissen valve is created to maintain a gastric fundus as small and functional as possible. After that, the stapling process begins and continues in a standard pattern until the level of the previously created valve. Stapling the stomach around the valve must maintain its natural position and preserve vascularization. Results: The following are the five major technical tips: avoid thermic injuries of the gastric wall during short gastric vessel dissection; gently handle the gastric fundus during fundoplication; take the anterior and superior part of the fundus to create the wrap 4 cm from the His angle to avoid a wrong pathway for the food (the food should not go through the wrap); check the good pathway for the food at the end of the operation with the tube by moving it through the esophagogastric junction. Conclusion: N-sleeve is a new procedure, technically more challenging than standard LSG, but in our experience, it seems to show similar outcomes in terms of weight loss, effects on comorbidities, and lower rate of leak and gastroesophageal reflux disease.