Contribution of transient receptor potential canonical channels in human and experimental pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is due to progressive distal pulmonary artery (PA) obstruction, leading to right ventricular hypertrophy and failure. Exacerbated store-operated Ca2+ entry (SOCE) contributes to PAH pathogenesis, mediating human PA smooth muscle cell (hPASMC) abnormalities. The transient receptor potential canonical channels (TRPC family) are Ca2+-permeable channels contributing to SOCE in different cell types, including PASMCs. However, the properties, signaling pathways, and contribution to Ca2+ signaling of each TRPC isoform are unclear in human PAH. We studied in vitro the impact of TRPC knockdown on control and PAH-hPASMCs function. In vivo, we analyzed the consequences of pharmacological TRPC inhibition using the experimental model of pulmonary hypertension (PH) induced by monocrotaline (MCT) exposure. Compared with control-hPASMCs cells, in PAH-hPASMCs, we found a decreased TRPC4 expression, overexpression of TRPC3 and TRPC6, and unchanged TRPC1 expression. Using the siRNA strategy, we found that the knockdown of TRPC1-C3-C4-C6 reduced the SOCE and the proliferation rate of PAH-hPASMCs. Only TRPC1 knockdown decreased the migration capacity of PAH-hPASMCs. After PAH-hPASMCs exposure to the apoptosis inducer staurosporine, TRPC1-C3-C4-C6 knockdown increased the percentage of apoptotic cells, suggesting that these channels promote apoptosis resistance. Only TRPC3 function contributed to exacerbated calcineurin activity. In the MCT-PH rat model, only TRPC3 protein expression was increased in lungs compared with control rats, and in vivo "curative" administration of a TRPC3 inhibitor attenuated PH development in rats. These results suggest that TRPC channels contribute to PAH-hPASMCs dysfunctions, including SOCE, proliferation, migration, and apoptosis resistance, and could be considered as therapeutic targets in PAH.NEW & NOTEWORTHY TRPC3 is increased in human and experimental pulmonary arterial hypertension (PAH). In PAH pulmonary arterial smooth muscle cells, TRPC3 participates in the aberrant store-operated Ca2+ entry contributing to their pathological cell phenotypes (exacerbated proliferation, enhanced migration, apoptosis resistance, and vasoconstriction). Pharmacological in vivo inhibition of TRPC3 reduces the development of experimental PAH. Even if other TRPC acts on PAH development, our results prove that TRPC3 inhibition could be considered as an innovative treatment for PAH.

Involvement of SUR2/Kir6.1 channel in the physiopathology of pulmonary arterial hypertension

Aims

We hypothesized that the ATP-sensitive K⁺ channels (KATP) regulatory subunit (ABCC9) contributes to PAH pathogenesis. ABCC9 gene encodes for two regulatory subunits of KATP channels: the SUR2A and SUR2B proteins. In the KATP channel, the SUR2 subunits are associated with the K⁺ channel Kir6.1. We investigated how the SUR2/Kir6.1 channel contributes to PAH pathogenesis and its potential as a therapeutic target in PAH.

Methods and results

Using in vitro, ex vivo, and in vivo approaches, we analyzed the localization and expression of SUR2A, SUR2B, and Kir6.1 in the pulmonary vasculature of controls and patients with PAH as in experimental pulmonary hypertension (PH) rat models and its contribution to PAH physiopathology. Finally, we deciphered the consequences of in vivo activation of SUR2/Kir6.1 in the monocrotaline (MCT)-induced PH model. We found that SUR2A, SUR2B, and Kir6.1 were expressed in the lungs of controls and patients with PAH and MCT-induced PH rat models. Organ bath studies showed that SUR2 activation by pinacidil induced relaxation of pulmonary arterial in rats and humans. In vitro experiments on human pulmonary arterial smooth muscle cells and endothelial cells (hPASMCs and hPAECs) in controls and PAH patients showed decreased cell proliferation and migration after SUR2 activation. We demonstrated that SUR2 activation in rat right ventricular (RV) cardiomyocytes reduced RV action potential duration by patch-clamp. Chronic pinacidil administration in control rats increased heart rate without changes in hemodynamic parameters. Finally, in vivo pharmacological activation of SUR2 on MCT and Chronic-hypoxia (CH)-induced-PH rats showed improved PH.

Conclusion

We showed that SUR2A, SUR2B, and Kir6.1 are presented in hPASMCs and hPAECs of controls and PAH patients. In vivo SUR2 activation reduced the MCT-induced and CH-induced PH phenotype, suggesting that SUR2 activation should be considered for treating PAH.

The SOCE Machinery: An Unbalanced Knowledge between Left and Right Ventricular Pathophysiology

Right ventricular failure (RVF) is the most important prognostic factor for morbidity and mortality in pulmonary arterial hypertension (PAH) or pulmonary hypertension (PH) caused by left heart diseases. However, right ventricle (RV) remodeling is understudied and not targeted by specific therapies. This can be partly explained by the lack of basic knowledge of RV remodeling. Since the physiology and hemodynamic function of the RV differ from those of the left ventricle (LV), the mechanisms of LV dysfunction cannot be generalized to that of the RV, albeit a knowledge of these being helpful to understanding RV remodeling and dysfunction. Store-operated Ca²⁺ entry (SOCE) has recently emerged to participate in the LV cardiomyocyte Ca²⁺ homeostasis and as a critical player in Ca²⁺ mishandling in a pathological context. In this paper, we highlight the current knowledge on the SOCE contribution to the LV and RV dysfunctions, as SOCE molecules are present in both compartments. he relative lack of studies on RV dysfunction indicates the necessity of further investigations, a significant challenge over the coming years.

Orai1 Inhibitors as Potential Treatments for Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is characterized by progressive distal pulmonary artery (PA) obstruction, leading to right ventricular hypertrophy and failure. Exacerbated intracellular calcium (Ca²⁺) signaling contributes to abnormalities in PA smooth muscle cells (PASMCs), including aberrant proliferation, apoptosis resistance, exacerbated migration, and arterial contractility. Store-operated Ca²⁺ entry is involved in Ca²⁺ homeostasis in PASMCs, but its properties in PAH are unclear.

METHODS

Using a combination of Ca²⁺ imaging, molecular biology, in vitro, ex vivo, and in vivo approaches, we investigated the roles of the Orai1 SOC channel in PA remodeling in PAH and determined the consequences of pharmacological Orai1 inhibition in vivo using experimental models of pulmonary hypertension (PH).

RESULTS

Store-operated Ca²⁺ entry and Orai1 mRNA and protein were increased in human PASMCs (hPASMCs) from patients with PAH (PAH-hPASMCs). We found that MEK1/2 (mitogen-activated protein kinase kinase 1/2), NFAT (nuclear factor of activated T cells), and NFκB (nuclear factor-kappa B) contribute to the upregulation of Orai1 expression in PAH-hPASMCs. Using small interfering RNA (siRNA) and Orai1 inhibitors, we found that Orai1 inhibition reduced store-operated Ca²⁺ entry, mitochondrial Ca²⁺ uptake, aberrant proliferation, apoptosis resistance, migration, and excessive calcineurin activity in PAH-hPASMCs. Orai1 inhibitors reduced agonist-evoked constriction in human PAs. In experimental rat models of PH evoked by chronic hypoxia, monocrotaline, or Sugen/hypoxia, administration of Orai1 inhibitors (N-{4-[3,5-bis(Trifluoromethyl)-1H-pyrazol-1-yl]phenyl}-4-methyl-1,2,3-thiadiazole-5-carboxamide [BTP2], 4-(2,5-dimethoxyphenyl)-N-[(pyridin-4-yl)methyl]aniline [JPIII], or 5J4) protected against PH.

CONCLUSIONS

In human PAH and experimental PH, Orai1 expression and activity are increased. Orai1 inhibition normalizes the PAH-hPASMCs phenotype and attenuates PH in rat models. These results suggest that Orai1 should be considered as a relevant therapeutic target for PAH.

SUR1 as a New Therapeutic Target for Pulmonary Arterial Hypertension

Mutations in ABCC8 have been identified in pulmonary arterial hypertension (PAH). ABCC8 encodes SUR1, a regulatory subunit of the ATP-sensitive-potassium channel Kir6.2. However, the pathophysiological role of the SUR1/Kir6.2 channel in PAH is unknown. We hypothesized that activation of SUR1 could be a novel potential target for PAH. We analysed the expression of SUR1/Kir6.2 in the lungs and pulmonary artery (PA) in human PAH or experimental pulmonary hypertension (PH). The contribution of SUR1 in human or rat PA tone was evaluated, and we measured the consequences of in vivo activation of SUR1 in control and PH rats. SUR1 and Kir6.2 protein expression was not reduced in the lungs or human pulmonary arterial endothelial cells and smooth muscle cells (hPAECs and hPASMCs) from PAH or experimentally induced PH. We showed that pharmacological activation of SUR1 by 3 different SUR1 activators (diazoxide, VU0071063, and NN414) leads to PA relaxation. Conversely, the inhibition of SUR1/Kir6.2 channels causes PA constriction. In vivo, long- and short-term activation of SUR1 with diazoxide reversed monocrotaline-induced PH in rats. Additionally, in vivo diazoxide application (short protocol) reduced the severity of PH in chronic-hypoxia rats. Moreover, 3 weeks of diazoxide exposure in control rats had no cardiovascular effects. Finally, in vivo, activation of SUR1 with NN414 reduced monocrotaline-induced PH in rats. In PAH and experimental PH, the expression of SUR1/Kir6.2 was still presented. In vivo pharmacological SUR1 activation by two different molecules alleviated experimental PH, providing proof-of-concept that SUR1 activation should be considered for PAH and evaluated more thoroughly.

Role of Store-Operated Ca2+ Entry in the Pulmonary Vascular Remodeling Occurring in Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a severe and multifactorial disease. PAH pathogenesis mostly involves pulmonary arterial endothelial and pulmonary arterial smooth muscle cell (PASMC) dysfunction, leading to alterations in pulmonary arterial tone and distal pulmonary vessel obstruction and remodeling. Unfortunately, current PAH therapies are not curative, and therapeutic approaches mostly target endothelial dysfunction, while PASMC dysfunction is under investigation. In PAH, modifications in intracellular Ca2+ homoeostasis could partly explain PASMC dysfunction. One of the most crucial actors regulating Ca2+ homeostasis is store-operated Ca2+ channels, which mediate store-operated Ca2+ entry (SOCE). This review focuses on the main actors of SOCE in human and experimental PASMC, their contribution to PAH pathogenesis, and their therapeutic potential in PAH.

Does Biolox Delta ceramic reduce the rate of component fractures in total hip replacement?

Biolox Delta ceramic has been optimized with nano-sized, yttria-stabilized tetragonal zirconium and strontium oxide to help limit cracking propagation. Although its mechanical properties are better than those of earlier generation ceramics, existing data on this material are limited, thus the goals of this study were to determine: 1) the remaining rate of implant fracture; 2) the ideal combination of head diameter and component position. Hypothesis. We hypothesized that the use of the ceramic composite Biolox Delta had reduced the risk of implant fracture. Materials and methods. The bibliographic search (in Pubmed database with the key words «ceramic fracture» and «total hip prosthesis ») identified 46 articles on fractures in third or fourth generation ceramic components, including 5 involving Biolox Delta. Manufacturer's data and ANSM (Agence nationale de sécurité du médicament et des produits de santé) (National Agency for Safety of Drugs and Medical Products) reports were compared with the few clinical cases published in the literature. Results. According to the manufacturer (CeramTec GmbH, Plochingen, Germany), the use of Biolox Delta ceramic has reduced the rate of femoral head fractures to 0.003% compared to 0.021% with alumina ceramic. The fracture rate of liners has remained stable, at approximately 0.03%. The number of ANSM reports confirmed these tendencies. The rate of head component fractures decreases as the head diameter increases. The quality of impaction on the morse taper (cleanliness of the taper, insertion along the axis) plays an important role. Although it is generally only available for cup sizes above 50mm, a 36-mm head diameter seems to be optimal because it prevents impingement between the cup rim and the neck of the stem, without increasing micro-separation with larger diameters. Conclusion. Although Biolox Delta ceramic is more resistant to fractures than alumina ceramic, it can be fractured under suboptimal implantation conditions including edge loading. Its use requires the same precautions as other hard-on-hard bearings and requires special attention to cup position, insertion on or in morse tapers and adjustment of leg length.

LEVEL OF EVIDENCE

V expert's opinion.

Comparison of esCCO and transthoracic echocardiography for non-invasive measurement of cardiac output intensive care

BACKGROUND

The esCCO monitor (ECG- estimated Continuous Cardiac Output, Nihon Kohden(®)) is a new non-invasive tool for estimating cardiac output (CO). It derives CO from the pulse wave transit time (PWTT) estimated by the ECG and the plethysmographic wave. An initial calibration is needed to refine the relation linking pulse pressure (measured by arterial pressure cuff) to PWTT. To assess the accuracy and reliability of the esCCO system, we performed an analysis of agreement of CO values obtained by transthoracic echocardiography (TTE).

METHODS

Thirty-eight intensive care unit patients were prospectively included. CO was determined simultaneously using esCCO (CO(esCCO)) and TTE (CO(TTE)) as our reference method.

RESULTS

A total of 103 paired readings from 38 patients were collected. The correlation coefficient between CO(esCCO) and CO(TTE) was 0.61 (P<0.001). The Bland and Altman analysis corrected for repeated measures showed a bias of -1.6 litre min(-1) and limits of agreement from -4.7 to +1.5 litre min(-1), with a percentage error (2 sd/mean CO) of 49%. The correlation for CO changes was significant (R=0.63, P<0.001), but the concordance rate was poor (73%). Polar plot analysis showed an angular bias of -9° with radial limits of agreement from -54° to +36°. The bias appeared to correlate with systemic vascular resistance (R=-0.45, P<0.001).

CONCLUSIONS

In critically ill patients, the performance of the esCCO monitor was not clinically acceptable, and this monitor cannot be recommended in this setting. Moreover, the esCCO failed to trend CO data reliably.

Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: a multicenter study

INTRODUCTION

We determined whether the implementation of a bundle of 10 recommendations leads to the reduction of mortality in ICU patients with severe sepsis or septic shock.

METHODS

All patients with severe sepsis or septic shock during two consecutive phases: a 6-month quality control period (observational) and secondly a 6-month intervention period based on the implementation of a bundle of 10 recommendations adapted from the Surviving Sepsis Campaign guidelines (initial bacteriological samples and initiating antibiotics, measurement of arterial lactate, volume expansion > or =20 ml/kg, targeted mean arterial pressure > or =65 mmHg and the assessments of central venous pressure and Scv(O2); glucose control, low doses of corticosteroids, a tidal volume < or =8 ml/kg in mechanically ventilated patients with ALI; adequate use of recombinant human activated protein C) were evaluated in 15 ICUs. The primary endpoint was the 28-day mortality rate and the secondary endpoint was the compliance with the recommendations of the care bundle.

MEASUREMENT AND RESULTS

Four hundred and forty-five patients (230 and 215 in the observational and intervention periods, respectively) were included. In the two periods, the patients had similar characteristics. The 28-day mortality rate significantly decreased from 40% in the observational period to 27% in the intervention period (P=0.02). According to each recommendation, compliance with the care bundle was achieved in 9 to 100% of patients.

CONCLUSION

The implementation of a care bundle adapted from the Surviving Sepsis Campaign guidelines decreases the 28-day mortality rate in patients with severe sepsis and/or septic shock.

Laparoscopic enucleation of pancreatic neoplasm

BACKGROUND

Enucleation is an alternative procedure for treating benign and borderline neoplasms of the pancreas, which preserves healthy parenchyma and pancreatic function. This study aimed to evaluate the postoperative and long-term results after laparoscopic enucleation.

METHODS

Data collected prospectively from 23 consecutive patients who underwent laparoscopic pancreatic enucleation were analyzed.

RESULTS

Laparoscopic enucleation was achieved successfully for 21 patients (91.3%). One death (4%) occurred. A postoperative pancreatic fistula was observed in three cases (13%), and was clinically significant in one case (4%). Enucleation was performed for endocrine neoplasm in 15 patients (65%) and for cystic neoplasm in eight patients (35%). All the patients had benign tumors at the final histopathologic diagnosis. During a median follow-up period of 53 months, no patient experienced tumor recurrence or new-onset exocrine or endocrine insufficiency.

CONCLUSION

Laparoscopic enucleation is a safe and effective procedure for the radical treatment of benign and borderline pancreatic tumors. The laparoscopic approach seems to be associated with a decrease in operative time, hospital stay, and pancreatic fistula after enucleation. Laparoscopy should become the standard approach in the future for enucleation of presumed benign lesions.

Emergence of the alumina matrix composite in total hip arthroplasty

Pure alumina ceramic has been in clinical use in orthopaedics since 1971 and, currently, up to 5 million components have been implanted. Alumina offers advantages like stability, biocompatibility and low wear; however, it has limited strength. Applications are limited by design considerations. Engineers in biomaterials have worked on improving the performance of the material by optimising the manufacturing process. To fulfil surgeons' and patients' increasingly exacting requirements, ceramists have also developed a new ceramic composite, the alumina matrix composite (AMC). This material combines the great principles of the reinforcement of ceramics with its tribological qualities and presents a better mechanical resistance than alumina. The examination of the tribological situation of AMC, especially under the challenging conditions of hydrothermal ageing, shows the aptitude of this material in wear applications. The US Food and Drug Administration (FDA) has approved ceramic ball heads articulating against polyethylene inserts. Since its introduction, more than 65,000 ball heads and 40,000 inserts of AMC have been implanted. With a 6-year follow up, no complication has been reported to the manufacturer. Improved toughness and the excellent wear of AMC makes it a potentially more flexible alternative to the more traditional alumina for hip prostheses.

[Laparoscopic treatment of para-esophageal hernias]

AIM

This retrospective study aims at analyzing the functional results obtained in patients operated by laparoscopy for a para-esophageal hernia.

PATIENTS AND METHODS

From 1994 to 2004, 38 patients underwent a laparoscopic procedure for a symptomatic para-esophageal hiatal hernia of at least 3/4 of the proximal stomach: 27 females and 11 males, mean age 65 years (extreme: 22-84). There was no case on emergency, 4 patients had have at least one episode of intrathoracic volvulus. The operation consisted in gastric reduction into the abdominal cavity, excision of the sac, suture of the crura reinforced with a mesh in 6 patients and the construction of a gastric wrap. A postoperative barium swallow was performed on POD 3 in order to confirm the anatomical result.

RESULTS

Mean operating time was 157 minutes (75-480), no case was converted into laparotomy. Four postoperative complications were observed (morbidity 10.8%): one gastric perforation diagnosed on POD 1, 2 severe dysphagias linked to the wrap, and one atelectasia. There was no death in this series. Functional results were evaluated by the mean of a questionnaire in 33 patients who had a follow up more than 6 months. Thirty-three questionnaires have been sent, 3 patients were lost and one was dead. Among the 29 patients analyzed, 14 were very satisfied, 11 were satisfied and 3 were deceived by the operation. Best results are obtained in patients with GERD, dysphagia or postprandial cardiothoracic symptoms.

CONCLUSION

These results compared to the published data allow us to discuss about indications of surgery, the necessity to removal the hernia sac, and the advantages to reinforce the crura by the mean of a non absorbable mesh.

Prise en charge du cancer colique en occlusion

INTRODUCTION

Management of obstructed colonic carcinomas is a surgical challenge because it happens more often in elderly patients. The aim of our study is to assess mortality and morbidity rates of procedures performed in emergency for this pathology.

PATIENTS AND METHOD

Between January 1st, 1998 and December 31st 2003, 22 patients underwent an emergency procedure for obstructive colonic obstruction due to an adenocarcinoma. Obstruction was defined as an emesis, distension on examination, no gas or stool since 24 hours and confirmatory plain radiograph film.

RESULTS

Twenty patients (91%) underwent surgical procedure and two others received a colonic stent. Eleven patients (50%) underwent left colonic resection and intraoperative colonic cleansing was undertaken in 3 of these patients. One patient underwent a lateral colostomy, three patients (14%) underwent a right colectomy. A Hartmann's procedure was performed in six cases (27%). Morbidity occurred in 23% (50% were from anastomotic complication). Mortality rate was 27% (44% if aged more than 75 years old) (one superior mesenteric ischemia, and five heart and respiratory failures). Two-year survival rate was 61% and five year survival rate was 47%. Median survival was 24 months.

CONCLUSION

Our study confirms that obstructed colonic cancer has a bad prognosis because it happens in elderly and not healthy patients. Priority must be given to the restoration of colonic permeability.

Laparoscopic Adjustable Gastric Banding Results after 2 Years with Two Different Band Types

BACKGROUND

Laparoscopic gastric banding is the most common operation in Europe for morbid obesity. Many devices from different companies are now available. The aim of this study was to compare the results over a 2-year period of 2 types of band: the Lap-Band and the Minimizer band.

METHODS

In a non-randomized study, 2 consecutive groups were prospectively analyzed. Group A consisted of 120 patients who received the Lap-Band, and group B consisted of 68 patients who received the Minimizer band which contains eyelets. All the bands were placed above the lesser sac by the perigastric approach.

RESULTS

4 early complications were observed in group A (1 phlebitis, 1 pneumopathy and 2 early displacements of the band); and 1 in group B (1 retention of urine). After a follow-up of 2 years, the displacement rate of the band was 10.8% in group A and 0% in group B. One gastric erosion was observed in group B, but not in group A. After 2 years, the average loss of excess weight was 50% in both groups.

CONCLUSION

With the Minimizer band, we did not observe any slipping, and the efficacy with respect to weight loss was equivalent to the Lap-Band.

[Value of surgical ampullectomy in the management of benign ampullary tumors]

AIM OF THE STUDY

To report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater.

PATIENTS AND METHODS

From 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins.

RESULTS

There was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence.

CONCLUSION

Transduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.

[Clinical practice guidelines: 2004 Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach--radiotherapy]

CONTEXT

"The Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVES

To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement.

RESULTS

Adjuvant radiation therapy alone is not a standard treatment for patients with stomach adenocarcinoma. Adjuvant concomitant chemoradiotherapy is not a standard treatment for patients with stage II or III stomach adenocarcinoma R0, with Dl or D2 lymphadenectomy who have undergone surgery. Following surgical resection, adjuvant concomitant chemoradiotherapy should be proposed to patients without denutrition with a lymphadenectomy < Dl (fewer than 15 lymph nodes examined) and those with T3 and/or N+ tumours following the protocol used in the MacDonald trials (SWOG-9008) (Level of evidence B1). Adjuvant concomitant chemoradiotherapy can be administered to patients without denutrition with DI or D2 lymphadenectomy and with involvement of regional lymph nodes (N2 or N3).

[Laparoscopic pancreatectomy: report of 22 cases]

OBJECTIVE

To evaluate results of laparoscopic pancreatectomy for benign lesions of the pancreas. Peri-operative data, surgical outcomes and techniques are presented.

PATIENTS AND METHODS

Eighteen women and four men underwent laparoscopic pancreatectomy and were collected retrospectively from 1999 to 2003.

RESULTS

Laparoscopic pancreatectomy was attempted in 22 patients and completed successfully in 18: 10 enucleations, three distal pancreatectomies, four left pancreatectomies and one total pancreatectomy for endocrine and cystic tumors. Left and distal pancreatectomies were performed with preservation of the spleen. Four patients were converted (one enucleation, one whipple procedure and two left pancreatectomy). There was no mortality; the post-operative morbidity included two pancreatic leaks and one case of half splenic infarction. The median length of hospital stay was 12 days.

CONCLUSION

Patients appear to benefit from laparoscopic pancreatectomy for pancreatic benign tumors.

Resection of noncolorectal and nonneuroendocrine liver metastases: late metastases are the only chance of cure

Resection of liver colorectal metastases allows a 5-year survival in 25% to 35% of patients. The outcome of patients with noncolorectal metastases is unknown because of the heterogeneity of this group. The aim of this retrospective study was to evaluate predictive factors of survival in patients who underwent resection of noncolorectal and nonneuroendocrine (NCRNE) liver metastases. From 1980 to 1997, 284 patients underwent hepatectomy for liver metastases of whom 39 (25 men and 14 women, mean age 55 years) had curative resection for NCRNE liver metastases. No patients had extrahepatic disease. The primary tumors were gastrointestinal (n = 15), genitourinary (n = 12) and miscellaneous (n = 12). The mean number of metastases was 1.8, and the mean size of the lesions was 51 mm. The median disease-free interval was 27 months. Twenty patients had a major hepatectomy and 19 a minor resection, with simultaneous resection of the primary in 6 cases. Overall survival was evaluated using the Kaplan-Meier method. There was no operative mortality, and 8% morbidity. The survival at 1, 3, and 5 years was 81, 40, and 35%, respectively. Patients with a disease-free interval higher than 24 months had a greater survival rate than those with a disease-free interval of less than 24 months (100% vs. 10%; p = 0.0004). Survival was not significantly influenced by age, sex, type of primary tumor, number, size and localization of metastases, type of hepatectomy, or blood transfusion. Resection of NCRNE liver metastases should be justified for patients without extrahepatic disease and resectable metastases, especially for those who have a disease-free interval of more than 24 months.

[Contribution of endorectal ultrasonography in preoperative evaluation for very low rectal cancer]

Abdominoperineal resection is the standard treatment of very low rectal carcinoma. Pretherapeutic evaluation of locoregional extension relies mainly on digital rectal examination. The interest of endorectal ultrasonography to assess lateral and inferior margins is still to be determined.

AIM OF THE STUDY

To assess the ability of endorectal ultrasonography to evaluate the possibility of conservative anal sphincter surgery.

PATIENTS AND METHODS

Between April 1996 and June 1998, 34 patients (20 men, 14 women, mean age: 61 years, range: 43-80) have been treated for rectal adenocarcinoma. Endorectal ultrasonography was made with a linear probe (EUP-U33). Before treatment, the mean distance between the lower pole of the tumor and the anal verge was 3.9 cm (range: 2-5), and between the lower pole and the puborectalis sling 2.3 mm (range: 0-7). A uTN classification was made. Preoperative treatment was radiotherapy (40 Gy in 4 patients, 60 Gy in 24 patients), or radiochemotherapy (6 patients). Pre- and post-radiotherapy endorectal ultrasonography results were compared to the patholocical analysis of operative specimen.

RESULTS

Wall infiltration was correctly evaluated in 57% of patients after radiotherapy. In 26/34 cases, a safe plane existed before and after radiotherapy, and correlation of endorectal ultrasonography with histology was 96%. For patients without safe plane, correlation with histology was 75%.

CONCLUSION

For very low rectal tumors, with an aggressive sphincter conservation approach, endorectal ultrasonography allows to assess sphincter invasion with 96% fiability when safe plane exists.

[Mushroom poisoning]

Time elapsed between absorption of toxic mushrooms and occurrence of first disorders (mainly digestive), lead to distinguish 2 kinds of syndromes. Early syndromes, beginning before the 6th hour, follow a generally favourable course. Incriminated toxins induce digestive, neurosensory or neurovegetative disorders, sometimes severe but reversible. Late syndromes, beginning after the 6th hour, endanger patient's life. Incriminated toxins can lead to irreversible liver and kidneys damage. Medical treatment aims at eliminating toxins and inhibiting cellular penetration of cytolytic toxins. Symptomatic intensive care, directed by clinical and biological indications, ensure correction of plasmatic disorders and compensation for hepatic and renal severe failure.

[Dieulafoy's duodenal ulcer. Report of two cases]

Two cases of Dieulafoy's ulcer of the duodenum revealed by a severe digestive bleeding and histologically proved are reported. It is a rare localization of a rare disease which is particular by the presence of an abnormal vessel in the sub-mucosa layer of the digestive wall. Both patients were operated on and successfully treated by excision suture.

[A study of biological and histological criteria of thyroid autoimmunity in diffuse goiters with hyperthyroidism]

Hyperthyroidism is usually classified as follows: with diffuse or with toxic plurinodular goiter, respectively considered as autoimmune and non-autoimmune thyroid disorders. This classification seems partially inadequate as signs of thyroid immunity may be found in some plurinodular toxic goiter and alternatively may by lacking in some cases of Graves' disease. These observations led us to study the intensity of intrathyroidal autoimmune process (IAP) and the levels of TBIAb, TPO- and Thyroglobulin-antibodies in 105 cases with diffuse goiter, hyperthyroidism and elevated RAIU (92 women and 13 men, age 34 +/- 11, mean +/- SD). The intensity of intrathyroidal autoimmune process (IAP) was determined by one pathologist (HT) by semi quantitative method applicable to routine clinical use. Subtotal thyroidectomy was performed because of a large goiter (n = 29), a concomitant cold nodule (n = 20), a recurrent disease (n = 18), intolerance to antithyroid drugs (n = 5) or because patients chose surgical treatment (n = 33). All cases were rendered euthyroid at the time of surgery using antithyroid drugs or iodine. The results show a lack of IAP and undetectable levels of TBIAb, TPO- and Thyroglobulin-antibodies in 10%, 11%, 25% and 47% respectively. The intensity of IAP was not different in case of first episode or recurrence of hyperthyroidism and was not related to type or duration of medical treatment. Comparison of patients with or without IAP show higher levels of TPO- and thyroglobulin-antibodies but not of TBIAb in the former group (P < 0.005). TBIAb were higher when ophthalmopathy and/or dermopathy were present vs absent (p < 0.05) and were correlated with FT4 levels (p < 0.05). The negative predictive value of TBIAb, TPO- and thyroglobulin-antibodies to predict the lack of significant IAP was 42%, 65% and 64%. The total absence of clinical, biological and histological signs of thyroid autoimmunity was found in only one case (female aged 35 with first episode of hyperthyroidism and no family history of thyroid disease) (0.9%). These results suggest that routine available criteria of thyroid immunity (including IAP) have a low specificity. It follows that they are probably inadequate to screen cases of hereditary toxic familial hyperplasia, a rare entity of still unknown prevalence.

[Somatostatinoma. Apropos of a case]

Somatostatinoma are uncommon pancreatic endocrine tumors. We review the epidemiological, pathological, clinical and biological characteristics. The diagnosis of a somatostatinoma may be suggested clinically but is confirmed by histology of the resected tumor and specific immunohistochemistry marking. Malignancy is diagnosed on the presence metastases. Surgery is required with excision of the tumor, lymph nodes and metastases.

[Cysto-ileal diversion by Y loop of a compressive pseudocyst after segmental pancreatic transplantation]

We report the case of a young female patient who underwent dual segmentary pancreatic and renal transplantation in May 1990. The immediate post-operative course was marked by the peri pancreatic collections normally noted with this technique. However, a peculiarity was a long-lasting pseudocyst of the grafted tissue which could not be drained externally despite several attempts. This was compressing the splenic vein of the tissue, thereby causing a reflux. Fear of losing tissue functionality led us four and a half years later to perform an internal cysto-ileal derivation on a bowel loop. In this way, normal endocrine function of the pancreatic graft tissue has now been maintained for over a year.

[Application of three-dimensional computer graphics in oncology]

Accurate 3D tumoral volume evaluation is now possible through the combined use and progress of computer graphics technics (3D reconstruction and visualization) and medical imagery (helicoidal TDM scanner). Specific organ and pathology oriented softwares can help answer rapidly to problems posed by oncologic praticians. A new decision support for diagnosis, therapy and follow-up is emerging. First results in liver tumors and hepatic regeneration macroscopic biometrics are presented. Tumoral or organ volumic index will be usable in the follow-up. TNM staging, external conformal radiotherapy for prostatic or brain tumors, drugs cytolytic effects evaluation will take great advantage of these technologies. 3D visualization and matching CT and MRI imagery can help computed assisted surgery.

Primary extramedullary plasmacytoma of the liver. A case report

We report the first case of primary extramedullary plasmacytoma of the liver. The tumor was situated in segment VIII of the liver without extrahepatic extension. Histologically, the tumor was composed of sheets of mature plasma cells with slight atypia in association with proplasmacytes invading the hepatic parenchyma. Neither plasmoblasts nor lymphoplasmacytes were present. Immunohistochemistry demonstrated monoclonal IgG and kappa light-chain expression. In situ hybridization confirmed the monotypic expression of kappa light-chain mRNA. Bone marrow examination revealed no abnormality. After surgery, the IgG kappa spike detected in preoperative plasma samples decreased. The patient is disease free 31 months postoperatively.

[Comparative studies of the tolerability of gadodiamide, dimeglumine gadopentetate and meglumine gadoterate in MRI tests of the central nervous system]

The development of new non-ionic magnetic resonance (MR) contrast media as gadodiamide injection increased the choice of paramagnetic contrast agents available in MR of the central nervous system (CNS). The purpose of our paper was to compare at the dose of 0.1 mmol/kg b.w. the safety of gadodiamide (Gd-DTPA-BMA) to gadopentetate dimeglumine (Gd-DTPA) and to gadoterate meglumine (Gd-DOTA) in two multicentric double-blind studies. A total of 551 patients were enrolled with 143 patients in the Gd-DTPA group, 132 patients in the Gd-DOTA group and 276 patients in the Gd-DTPA-BMA group. Safety was assessed by recording the adverse events up to 24 hours after the injection. One or more adverse events were recorded in 14% of the Gd-DTPA patients, in 15.1% of the Gd-DOTA patients and in 11.6% of the Gd-DTPA-BMA patients. These reactions were related to the contrast media in 9.1%, 13.6% and 8.7% of the cases respectively. Their intensity was defined as mild in 8.4% of the patients in the Gd-DTPA group, in 13.6% of the patients in the Gd-DOTA group and in 8.3% of the patients in the Gd-DTPA-BMA group. No severe reaction or death were recorded. An injection-site reaction (heat, coldness, pain) has been observed in 43% of the cases although an adverse event other than local reactions (headache, dizziness, nausea) has been noticed in 57% of the cases. No significant statistical difference was observed between the groups. Gadodiamide is a safe and effective contrast agent in MRI of the CNS in comparison with Gd-DTPA and Gd-DOTA currently in routine use.

[Tumors of the digestive muscles. Diagnosis and treatment apropos of 10 cases]

Ten cases of digestive tract muscle tumours emphasized the difficulty in preoperative diagnosis. CT scan gave the best results by visualizing the tumour in all the cases but one. In this case jejunal localization of a small tumour was made by arteriography. In gastric and duodenal localizations, the endoscopic aspect was not particularly specific and too superficial biopsies were always negative. The prognosis depends on pathology results but the distinction between malignancy and benign tumours is not always easy to make. The course of the disease is often needed to correct an erroneous initial diagnosis of benign tumour underscoring the need for careful follow-up.

External iliac vein stenosis after segmental pancreatic transplantation: treatment by percutaneous endoprosthesis

A stenosis of the iliac vein secondary to a fluid collection in a pancreas transplant was identified by color Doppler flow sonography. The pancreatic venous drainage was reversed to the contralateral iliac veins via venous collaterals. After two unsuccessful angioplasties of the vein stenosis, a Wallstent was positioned above the venous anastomosis, and has remained patent for 8 months. The pancreatic venous drainage became normal after the procedure.

[Isotopic criteria for the assessment of the effects of lumbar sympathectomy (author's transl)]

The authors present a work intended to assess the effects of lumbar sympathectomy using radioactive microspheres. These contain 99mTe and are injected into the femoral artery. The distribution of radioactivity is then measured at the lower limb with a gamma camera linked to a computer. Seventeen patients were tested before and after lumbar sympathectomy. It appears from this short series that lumbar sympathectomy causes a redistribution of the radioactive material directed towards the extremities, mainly the feet.