A41 FONTAN ASSOCIATED LIVER DISEASE: THE ROLE OF TRANSIENT ELASTOGRAPHY IN CHILDREN AND ADOLESCENTS

Background

Non-invasive assessment of Fontan Associated Liver Disease (FALD) is of interest, but studies have yielded inconsistent results about the correlation of severity of disease with laboratory values and imaging. Transient elastography (TE) is a non-invasive imaging modality used commonly for liver stiffness measurement (LSM) and in Fontan patients it is hypothesized to reflect not only liver fibrosis but also venous congestion.

Purpose

To better define the potential role of TE for non-invasive assessment of the severity of FALD.

Method

This was a retrospective study conducted on patients’ medical records at CHU Sainte-Justine Hospital. Patients less than 18 years of age with FALD who had at undergone at least one LSM by TE between 1998-2021 were included. The relationship between LSM and liver function tests, hepatic ultrasound findings (including a cirrhosis score), cardiac catheterization results and histological fibrosis scores were analyzed. The impact of interventions during cardiac catherization on LSM were also studied.

Result(s)

A total of 54 patients (36 boys and 18 girls) with FALD were studied. Median age at Fontan surgery was 4.6 years (IQR 4.0 ─ 5.4 years). Higher LSM values significantly correlated with longer time from Fontan, higher total and direct bilirubin and GGT levels, higher INR, longer APTT, lower Factor V, and lower absolute lymphocyte count. Greater LSM was also significantly associated with the presence of heterogenous parenchymal echogenicity, irregular liver contours and greater ultrasonographic cirrhosis scores. Higher TE values were significantly correlated with higher wedged hepatic venous pressure and Fontan pressure. After catherization interventions that addressed stenoses, there was a statistically significant reduction in mean LSM (24.9±3.63 kPa vs 15.8±4.6 kPa, p=0.005). After closure of significant pulmonary collaterals, mean LSM tended to increase, but this difference did not reach statistical significance (19.1±1.9 kPa vs 24.6±3.5 kPa, p=0.2). At liver biopsy, significant direct correlation was found between LSM and the grade of sinusoidal fibrosis and LSM. TE with values >20 kPa were found to have higher grades of sinusoidal fibrosis, while values <20kPa had higher grades of sinusoidal dilatation.

Conclusion(s)

This study showed that TE allows to identify patients with higher cholestatic parameters, more severe liver fibrosis at biopsy and sonographic signs suggestive of cirrhosis. Moreover, it confirmed that liver congestion significantly contributes to LSM values. Interestingly, catheter interventions addressing pulmonary stenoses led to the improvement of TE measurements, giving hope for the reduction of hepatic venous congestion in these patients, which might have an effect on their FALD. Finally, the LSM threshold of 20 kPa could be useful clinically as a value above which fibrosis is likely to be significant, while if below could indicate a greater contribution from hepatic congestion.

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Disclosure of Interest

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Unusual presentation of intramuscular hemangioma in abdominal oblique muscles

Intramuscular hemangiomas are rare benign tumors that are difficult to diagnose. We report a successful case of intramuscular hemangioma excision involving the external oblique muscles. The mass was excised successfully, and histopathology confirmed the diagnosis of intramuscular hemangioma with a negative margin and no malignancy.

Left paraduodenal hernia: a rare cause of recurrent abdominal pain: case report

Internal hernias are quite rare, accounting for fewer than 1% of all abdominal hernias. Moreover, the most frequent cause of internal herniation is paraduodenal hernia (PDH). Diagnosing paraduodenal hernias can be difficult due to the wide range of symptoms that can occur. It is a case report of paraduodenal hernia that was diagnosed and managed in a tertiary center. We describe the case of a 55-year-old male patient who had been experiencing nonspecific abdominal discomfort for the last 5 years and had several comorbidities and positive serology. An abdominal computed tomography (CT) revealed that he had a left PDH, which was effectively treated with laparoscopic surgical repair. The study's strength is that it was correctly identified by CT and subsequently laparoscopically corrected. A gastrografin swallow study was also performed postoperatively to ensure there was no leak. The study's flaw is that the patient was misdiagnosed for five years in other medical facilities. Because paraduodenal hernia is an uncommon diagnosis, it's important to keep it in mind as one of the differential diagnoses for persistent discomfort. It also needs accurate imaging in order to identify and successfully manage it. To demonstrate the relevance of this uncommon condition, future research is needed to report on any misdiagnosis or treatment. To conclude, nowadays the best option for paraduodenal hernia repair is laparoscopic surgery. However, because it can present with a wide variety of symptoms and diagnosis might be challenging, it demands a high index of suspicion. The gold standard for identifying paraduodenal hernia is still a CT scan of the abdomen. Patients who are stable and have no signs of intestinal obstruction might decide to have their hernia repaired to avoid future problems. To demonstrate the relevance of this uncommon condition, future research is needed to report on any misdiagnosis or treatment.

Elevation of CA 19-9 in Mirizzi Syndrome in the Absence of Malignancy: A Case Report

Patient: Male, 71-year-old

Final Diagnosis: Mirizzi syndrome

Symptoms: Epigastric pain • fatigue • jaundice

Medication: —

Clinical Procedure: Laparoscopic cholecystectomy

Specialty: Surgery

Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases

BACKGROUND

Upper gastrointestinal pathologies are common in bariatric patients. Preoperative esophagogastroduodenal endoscopy (EGD) should detect and treat pathologies that might alter the type of bariatric surgery. However, clinical consequences of these findings are often insignificant. The aim of this study was to assess the influence of preoperative endoscopy in our cohort and its clinical consequences.

METHODS

We conducted a retrospective analysis of endoscopic findings in patients under evaluation for bariatric surgery. Endoscopic findings were compared to preoperative risk factors as well as postoperative complications, and its clinical consequences were analyzed.

RESULTS

Data was available for 801 patients. Abnormal endoscopic findings were found in 65.7% of all patients. The most common conditions were gastritis (32.1%) and gastroesophageal reflux (24.8%). Malignancies were observed in 0.5% of all patients. We observed early-stage adenocarcinoma of the esophagus in two patients through our routine preoperative evaluation. Helicobacter pylori infections were detected in preoperative biopsies in only 3.7% of all patients. Patients who reported reflux symptoms had a higher rate of pathological EGDs (74.2 vs. 64.9%, p .019). We did not find any other risk factors for a pathological endoscopy. The postoperative complication rate was 11.2%. Leakage rate was 1.1%. Mortality rate was 0.4%. We did not find any correlation between the incidence of postoperative complications and preoperative endoscopic findings.

CONCLUSIONS

Relevant findings in routine preoperative endoscopy are rare but have significant influence on decision-making in bariatric patients and should be assessed as a necessary diagnostic tool.

Musicogenic reflex seizures in epilepsy with glutamic acid decarbocylase antibodies

BACKGROUND

Musicogenic reflex seizures (MRS) are a rare form of seizures described in patients with temporal lobe epilepsy (TLE), mainly of unknown etiology. Epilepsy with antibodies against glutamic acid decarboxylase (GAD-ab) is a form of autoimmune epilepsy for which no specific semiology has been described.

AIM OF THE STUDY

To retrospectively review the incidence of MRS in the general epileptic population and in the series of patients with epilepsy and GAD-ab and to describe its clinical and paraclinical characteristics.

METHODS

Patients recorded between January 2010 and January 2016 in the Database of Bellvitge Hospital Epilepsy Unit were reviewed.

RESULTS

From a group of 1510 epileptic patients, three reported MRS (0.0019%) (two patients with epilepsy and GAD-ab and one patient with cryptogenic TLE). The incidence of MRS in patients with epilepsy and GAD-ab was 2 of 22 (9%). Both patients had a normal magnetic resonance Imaging (MRI), but FDG-PET showed medial temporal lobe hypometabolism (unilateral or bilateral) in both and also in the insula in one of them. MRS (recorded via video-EEG[electroencephalography] in one patient) arose from the right temporal lobe.

CONCLUSIONS

MRS may be a distinctive seizure type in patients with epilepsy and antiGADab. Determination of GAD-ab should be carried out in all cases of MRS, even those with normal structural MRI.

Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases

BACKGROUND

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.

METHODS

60 RLAR and 55 TaTME for rectal cancer were compared in respect to patient characteristics, clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome.

RESULTS

62 surgeries addressed tumors of the lower third (53.9%). No intergroup differences in terms of patient characteristics and clinicopathological parameters were observed. Operating time did not differ between groups (p = 0.312), nor did the perioperative complication rate (p = 0.176). Circumferential resection margin was wider in the RLAR than in the TaTME group (p < 0.001), while no differences were found in the remaining oncological parameters.

CONCLUSION

Our study shows comparable results for RLAR and TaTME in rectal cancer treatment. Both procedures should be considered equally feasible for low rectal cancer cases and as an alternative to conventional anterior resections (open or laparoscopic). Furthermore, both techniques allow excellent oncological outcome especially in patients with anatomical limitations.

Ovarian ultrasonography in the mare

Ultrasonography has become indispensable in the control of equine reproduction. Mare ovary layers are inverted with respect to other species, with the follicles and corpus luteum found inside the ovary; only large follicles protrude from the organ's surface. This renders the making of diagnoses via rectal palpation of the ovaries very difficult. Ultrasound imaging, however, provides another avenue of examination. Since its first use in 1980, the diagnostic potential of ultrasonography has greatly improved. Colour Doppler ultrasonography can even asses blood flow, allowing for much better monitoring of ovarian activity. This study discusses the use of ultrasound, and in particular colour Doppler ultrasonography, in the monitoring of mare ovarian function and disease.

Use of radiofrequency then stent implantation for recanalization of complete aorta coarctation

Recanalization of a complete coarctation with isthmus occlusion was successfully accomplished in a 16-year-old patient using radiofrequency. This allowed the insertion and deployment of a covered stent to reestablish flow continuity across the isthmus. No complications were encountered. To the authors' knowledge this is the first case of radiofrequency use for complete coarctation, and among the rare cases of complete coarctation addressed primarily percutaneously to be reported.

Operating the European Drawer Rack on the ISS

The Erasmus User Centre, located at ESTEC in Noordwijk, will have overall responsibility for the preparation and execution of operations for the European Drawer Rack (EDR) facility in the European Columbus laboratory on the International Space Station (ISS). Together with the national User Support and Operations Centres (USOCs) involved in the operation of experiments on the ISS, it will form the network conducting the decentralised payload operations baselined for the European elements of the ISS.

Carotid endarterectomy for severe asymptomatic carotid stenosis: a perioperative experience at a community hospital

The purpose of this study was to evaluate the safety and feasibility of carotid endarterectomy (CEA) for severe asymptomatic carotid stenosis in a community setting with direct surgical resident participation. The medical records of all patients who had undergone CEA for severe asymptomatic carotid stenosis between 1989 and 1997 were retrospectively reviewed to ascertain perioperative morbidity and mortality. One hundred forty-seven CEAs were performed on 131 patients over the 8-year interval. Perioperative stroke and death rate was 0 per cent. However, one patient had a postoperative transient ischemic attack, and one patient had vocal cord dysfunction due to vagus nerve injury (1.3%). Three other patients had perioperative complications not directly related to CEA (2.1%). Therefore the total perioperative complication rate of (3.4%) compares favorably with results reported by several large tertiary referral centers. CEA for severe asymptomatic carotid stenosis can be safely performed in a community hospital setting with direct surgical resident participation.

Natural history and surgical outcomes for isolated discrete subaortic stenosis in children

OBJECTIVE

To document the natural history and surgical outcomes for discrete subaortic stenosis in children.

DESIGN

Retrospective review.

SETTING

Tertiary care paediatric cardiology centres.

PATIENTS

92 children diagnosed between 1985 and 1998.

MAIN OUTCOME MEASURES

Echocardiographic left ventricular outflow gradient (echograd), and aortic insufficiency (AI).

RESULTS

The mean (SEM) age at diagnosis was 5.3 (0.4) years; the mean echograd was 30 (2) mm Hg, with AI in 22% (19/87) of patients. The echograd and incidence of AI increased to 35 (3) mm Hg and 53% (36/68) (p < 0.05) 3.6 (0.3) years later. The echograd at diagnosis predicted echograd progression and appearance of AI. 42 patients underwent surgery 2.2 (0.4) years after diagnosis. Preoperatively echograd and AI incidence increased to 58 (6) mm Hg and 76% (19/25) (p < 0.05). The echograd was 26 (4) mm Hg 3.7 (0.4) years postoperatively, with AI in 82% (31/38) of patients. Surgical morbidities included complete heart block, need for prosthetic valves, and iatrogenic ventricular septal defects. Eight patients underwent reoperation for recurrent subaortic stenosis. The age at diagnosis of 44 patients followed medically and 42 patients operated on did not differ (5.5 (0.6) v 5. 0 (0.6) years, p < 0.05). However, the echograd at diagnosis in the former was less (21 (2) v 40 (5) mm Hg, p < 0.05) and did not increase (23 (2) mm Hg) despite longer follow up (4.1 (0.4) v 2.2 (0. 4) years, p < 0.05). The incidence of AI at diagnosis and at last medical follow up was also less (14% (6/44) v 34% (13/38); 40% (17/43) v 76% (19/25), p < 0.05).

CONCLUSIONS

Many children with mild subaortic stenosis exhibit little progression of obstruction or AI and need not undergo immediate surgery. Others with more severe subaortic stenosis may progress precipitously and will benefit from early resection despite risks of surgical morbidity and recurrence.

Increased risk of toxoplasmic encephalitis in human immunodeficiency virus-infected patients with pyrimethamine-related rash. ANRS 005-ACTG 154 Trial Group. Agence Nationale de Recherche sur le SIDA (ANRS-INSERM) and the NIAID-AIDS Clinical Trials Group

Although drug-induced rash is frequent in human immunodeficiency virus (HIV)-infected patients, rash due to pyrimethamine has not been described previously. In a randomized, double-blind, placebo-controlled study of pyrimethamine as primary prophylaxis for toxoplasmic encephalitis, the incidence of rash (per hundred patient-years) was 8.1 in the pyrimethamine group versus 1.5 in the placebo group (P < .0002). The 1-year incidence of toxoplasmic encephalitis after occurrence of rash was 37%, as compared with 9.6% in the pyrimethamine group without rash, with a 3.7 times higher risk for patients with pyrimethamine-induced rash (P = .001); the incidence was 13% in the placebo group. At the time of toxoplasmic encephalitis, pyrimethamine was successfully readministered to 80% of patients who discontinued it because of rash. Thus, pyrimethamine, when used for prophylaxis, does induce rash in HIV-infected patients. These patients are at higher risk for toxoplasmic encephalitis and should be carefully monitored for it.

Pyrimethamine for primary prophylaxis of toxoplasmic encephalitis in patients with human immunodeficiency virus infection: a double-blind, randomized trial. ANRS 005-ACTG 154 Group Members. Agence Nationale de Recherche sur le SIDA. AIDS Clinical Trial Group

Pyrimethamine (50 mg) with folinic acid (15 mg) given three times weekly was assessed as primary prophylaxis for toxoplasmic encephalitis (TE) in 554 human immunodeficiency virus-infected patients seropositive for Toxoplasma gondii and with < 200 CD4 cells/mm3. At 1 year, the incidence of TE was similar in pyrimethamine, 12%, and placebo, 13%, groups (relative risk [RR], 0.9; 95% confidence interval [CI], 0.6-1.4), and the survival rate was also similar, 85% and 80%, respectively (RR, 0.9; 95% CI, 0.7-1.2). Rash was the only adverse event that appeared significantly more frequently in the pyrimethamine arm (7% vs. 1%). In the on-treatment analysis, the incidence of TE was lower in the pyrimethamine arm, 4%, than in the placebo arm, 12% (P < .006). Thus, pyrimethamine cannot be recommended as a first-line regimen for primary prophylaxis of TE if the patient can take cotrimoxazole. However, it should be considered for patients who are intolerant to cotrimoxazole, especially in high-risk patients with < 100 CD4 cells/mm3.

Computerized measurement of Doppler flow velocity waveforms: validation of a new system

Manual measurement of Doppler flow velocity waveforms is time-consuming and carries unavoidable and significant intraobserver and interobserver variability. Those drawbacks limit the routine use of Doppler-derived indexes of systolic and diastolic function. This report describes a system that performs automatically all relevant measurements currently obtained from mitral, tricuspid, aortic, and pulmonary waveforms. One hundred and sixty waveforms, obtained from patients whose ages ranged from a 19-week fetus to a 21-year-old adult, were measured both manually and automatically. High correlations were found for all types of measurement: r = 0.993 for velocity measurements, r = 0.995 for time interval measurements, r = 0.881 for acceleration measurements, r = 0.867 for pressure half-time measurements, and r = 0.993 for flow integral measurements. When compared with manual measurements, automatized measurements displayed significantly lower intraobserver and interobserver variabilities for all types of measurements. Finally, the automatized measurement system cuts the time spent by a factor of more than five. Such a system of computerized measurements of Doppler flow velocity waveforms should become increasingly valuable as both a clinical and a research tool.

Usefulness of non-invasive indices in the monitoring of heart-transplanted pediatric patients

Seven patients underwent cardiac transplantation at Ste-Justine Hospital between June 1984 and October 1988 (age 3-16 years). Indices derived from M-mode echocardiography--left ventricular mass (LVM), isovolumetric relaxation time (IRT), shortening fraction (SF), velocity of circumferential fiber shortening (VCF), ejection fraction (EF), LV pre-ejection period/ejection time (PEP/ET), isometric contraction time (ICT)--and electrocardiography--summation of potentials (Sum Pot)--were used as non-invasive markers of rejection (367 studies), while rejection status was monitored by serial endomyocardial biopsy (55 biopsies). Spontaneous variation of such indices, as defined by the 90% distribution interval of their variation when biopsy was unchanged, was found to be important: -20% to +28% for IRT, -30% to +28% for LVM, -30% to 32% for Sum Pot, -32% to 42% for PEP/ET, etc. Using limits of spontaneous variation such as thresholds, none of the studied indices could consistently predict the 2 biopsy-documented episodes of rejection or the 7 episodes of improvement. Among all the studied indices, IRT was the most promising, correctly predicting 1 of the episodes of rejection and almost predicting the 2nd. Remeasurement of all M-mode tracings by an unique observer, following strict rules to maximize reproducibility, did not decrease the spontaneous variation of these indices, nor did it improve their performance as predictors of changes in the rejection status. These results warrant the continuing search for other non-invasive methods for accurate monitoring of the rejection status.

Psychiatric aspects of multiple sclerosis

A consecutive sample of 50 patients with a diagnosis of definite multiple sclerosis was evaluated by means of the Clinical Interview Schedule (CIS) and other psychopathological instruments. A global prevalence of psychopathology of 54% was found, with the prevalence of depression being 22%. Moreover, 46% of the sample presented signs indicative of neuropsychological deterioration in the Benton Visual Retention Test. The association between the presence of psychopathology and the social and neurological characteristics of the sample was also investigated, with results of low significance.

Congenital atresia and stenosis of the duodenum: the impact of a prenatal diagnosis

This review was undertaken to determine the effects of prenatal diagnosis, on the basis of ultrasonographic evidence, of a duodenal obstruction on the care and morbidity of the newborn infant. The records of 46 cases of either atresia or stenosis of the small bowel in infants treated during the last six years in a tertiary perinatal center were reviewed retrospectively. A prenatal fetal diagnosis of obstruction was made in 13 patients (12 obstructions located in the duodenum and one in the jejunum). The mean gestational age at prenatal diagnosis was 33.7 weeks (range 27 to 37 weeks). The course of those infants with the prenatal diagnosis made by ultrasound was compared with that of those infants in whom the diagnosis was established after the onset of symptoms of obstruction appeared. Such a prenatal diagnosis resulted in earlier surgical intervention (1.8 versus 3.9 days). Metabolic complications secondary to repeated vomiting were found to be less frequent. The expectant mother in whom such a fetal prenatal diagnosis has been made can be transported to a tertiary level perinatal center where neonatal and specialized surgical expertise are available. After birth, the infant can undergo immediate operation without being separated from its mother.