Ultrasonographic guidance for portal vein access during transjugular intrahepatic portosystemic shunt (TIPS) placement.

PURPOSE: The purpose of our study was to retrospectively assess the safety and efficacy of percutaneous real-time ultrasound guidance for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: Between January 2011 and November 2018, procedure details and outcome were retrospectively analyzed for 224 patients who underwent TIPS placement using real-time ultrasound guidance for portal vein puncture. There were 175 men and 49 women with a mean age of 52.7±10.6 (SD) years (range: 22-82 years). For each procedure, technical success, primary ultrasound guidance success, portosystemic pressure gradient, duration of the intervention, procedural complications, radiation exposure, mortality and morbidity rates at day 30 post-procedure were recorded for data analysis. RESULTS: Technical success rate was 100.0% with a success rate of the primary ultrasound guidance of 97.8% (219/224; 95% CI: 95.8-99.7). Mean duration of the procedure was 86.2±41.7 (SD) min (range: 22.0-267.0min). Mean dose-area product was 62.0±50.2 (SD) Gy.cm2 (range: 3.7-306.5Gy.cm2). Twelve complications (12/224; 5.4%) occurred in ten patients during TIPS procedures including 8 arterial punctures (3.6%) and 4 biliary punctures (1.8%). Four complications (4/224; 1.8%) were clinically significant. Mortality rate at day 30 after the procedure was 9.8% (22/224), without any patient dying from technical complications. CONCLUSION: Real-time ultrasound guidance is a safe technique to assist in the creation of TIPS and may allow for lower radiation exposure.

Duodenoscopy: an amplifier of cross-transmission during a carbapenemase-producing Enterobacteriaceae outbreak in a gastroenterology pathway.

Carbapenemase-producing Klebsiella pneumoniae (OXA-48 CPE) were identified in five patients who underwent an endoscopy with the same duodenoscope in October 2015. The endoscope was the only epidemiological link between these cases. A transient contamination of the duodenoscope following a failure in the disinfection process may have been the cause of transmission.

Porcine model of early onset scoliosis based on animal growth created with posterior mini-invasive spinal offset tethering: a preliminary report.

Several models of scoliosis were developed in the past 10 years. In most of them, deformations are induced in old animals and required long time observation period and a chest wall ligation ± resection. The purpose of the study was to create a scoliosis model with a size similar to an early onset scoliosis and an important growth potential without chest wall injuring. An original offset implant was fixed posteriorly and connected with a cable in seven (6 + 1 control) one-month-old Landrace pigs. The mean initial spinal length (T1-S1) was 25 cm and the mean weight was 9 kg. After 2 months observation, spinal deformities were assessed with a three dimension stereographic analysis. In four animals, the cable was sectioned and the deformities followed-up for next 2 months. No post-operative complication was observed. Mean weight growth was 10 kg/month and mean spine lengthening (T1-S1) was 7 cm/month. In 2 months, we obtained structural scoliotic curves with vertebral and disk wedging which were maximal at the apex of the curve. Mean frontal and sagittal Cobb angles was 45°. Chest wall associated deformities were similar to those observed in scoliotic deformities and were correlated to spinal deformities (p = 0.03). The cable section resulted in a partial curve regression influenced by disk elasticity and could probably be influenced by gravity loads (Decrease of the Cobb angle of 30% in the sagittal plane and 45% in the frontal plane). According to the results, the model creates a structural scoliosis and chest wall deformity that is similar to an early onset scoliosis. The spinal deformities were obtained quickly, and were consistent between animals in term of amount and characteristic.

Antireflux surgery for non-erosive and erosive reflux disease in community practice.

BACKGROUND: Antireflux surgery has been mainly evaluated in tertiary referral centres. Data regarding post-operative outcome in non-erosive reflux disease are lacking. AIM: To assess long-term outcome after antireflux surgery performed in a community practice setting. METHODS: We selected consecutively 60 non-erosive reflux disease patients and 61 erosive oesophagitis patients with symptomatic gastro-oesophageal reflux disease. After surgery, each subject answered a validated disease-specific health-related quality of life questionnaire and another questionnaire focusing on symptoms, late morbidity and drug use. RESULTS: After a 43-month median follow-up, an excellent outcome was reported by less than two-thirds of patients. Quality of life scores were lower in the non-erosive reflux disease group, especially in female patients. Non-erosive reflux disease patients reported more daily symptoms and more reflux-related symptoms (P = 0.04). Proton-pump inhibitor use was higher in non-erosive reflux disease patients (P < 0.005). Multivariate analysis identified four independent predictive factors associated with better outcome, namely male gender, abnormal preoperative acid exposure, a long duration of symptoms and surgical expertise. CONCLUSIONS: In community practice, the results of antireflux surgery are inferior to those reported by tertiary centres. Outcome seems poorer in non-erosive reflux disease especially in female patients. Nearly one-third of the non-erosive reflux disease patients continue to take proton-pump inhibitors. These results highlight the need for careful selection of patients before antireflux surgery.

[Anicteric cholestasis: imaging and diagnostic strategy]. / Une cholestase anicterique: l'apport de l'imagerie au diagnostic étiologique.

Cholestasis is due to abnormal biliary secretion, from hepatic or extra hepatic causes. The diagnostic strategy of anicteric cholestasis will be discussed, defining hepatic biologic abnormalities, and the role and sequence of imaging techniques based on clinical and biological findings. Main causes will be emphasized and illustrated with different radiological techniques (US, CT and MRI).

[Hepatoid adenocarcinoma of the stomach. A case report]. / Adénocarcinome hépatoïde de l'estomac. A propos d'un cas.

Hepatoid adenocarcinoma of the stomach is a very rare tumor with a poor prognosis. Lymph nodes involvement and/or liver metastases are frequently observed. Diagnosis should be pointed out if elevated serum level of alpha-fetoprotein (AFP) is detected with gastric tumor. Histologically, the tumor is an adenocarcinoma of intestinal type including foci of hepatoïd differenciation. Immunohistochemistry is positive for alpha-1-antitrypsin and alpha-1-antichymotripsin, and for AFP. We report a case of a 66 year-old man presenting an advanced stage of hepatoid adenocarcinoma of the stomach, treated by gastrectomy followed by chemotherapy. The patient died four months after the surgery because of progressing liver metastatic disease.

Percutaneous ethanol injection vs. resection in patients with small single hepatocellular carcinoma: a retrospective case-control study with cost analysis.

BACKGROUND: Percutaneous ethanol injection and hepatic resection are the most widely used curative therapeutic options for patients with compensated liver disease and small hepatocellular carcinoma. AIM: To compare percutaneous ethanol injection and hepatic resection in a selected group of consecutive French patients with a single hepatocellular carcinoma, smaller than or equal to 50 mm, in terms of survival, recurrence rate of malignancy and direct costs. METHODS: The analysis of two contemporary cohorts of Child-Pugh A or B patients with a single hepatocellular carcinoma of < or = 50 mm treated by percutaneous ethanol injection (n=55) or hepatic resection (n=50). RESULTS: Long-term survival was not significantly different between the two groups when the size of hepatocellular carcinoma was less than 30 mm. However, the survival of patients with hepatocellular carcinoma larger than 30 mm was higher after hepatic resection than after percutaneous ethanol injection (P=0.044). The cumulative direct costs were significantly higher in patients treated by hepatic resection than in those treated by percutaneous ethanol injection regardless of the tumour size. The calculated costs per month of survival in patients treated with percutaneous ethanol injection and hepatic resection were 999 vs. 3865 euros, respectively (P < 0.001). CONCLUSIONS: Percutaneous ethanol injection is more cost effective than hepatic resection in patients with a single hepatocellular carcinoma smaller than 30 mm. However, in patients with a larger tumour, long-term survival is higher after hepatic resection.

[Acid-sensitive esophagus: natural history and effect on the quality of life. Comparison with gastroesophageal reflux]. / OEsophage acido-sensible: histoire naturelle et retentissement sur la qualité de vie. Comparaison avec le reflux gastro-oesophagien.

UNLABELLED: The acid hypersensitive esophagus (AHE) is characterized by a normal esophageal acid exposure but a significant association between symptoms and reflux episodes. The natural history of AHE remains poorly known. We therefore conducted a follow-up study to compare the initial presentation and natural history of AHE and classical GERD. Quality of life (QOL) was also assessed. PATIENTS AND METHODS: Two groups of patients referred to our laboratory for 24-hour pH-monitoring (between 1991 and 1996) were compared. Group 1 consisted of 127 consecutive patients with AHE. Group 2 consisted of 101 patients with GERD. All patients were invited by mail to fill-in two questionnaires, the first concerning clinical course and therapeutic needs and the second QOL (questionnaire Reflux-Qual). Finally 62% and 59% of group 1 and 2 respectively did respond to both questionnaires. The corresponding follow-up periods were 4.1 and 4.3 years, respectively. RESULTS: The two groups did not differ at initial presentation with regard to age, sex, symptoms prevalence and severity of esophagitis (80% of group 1 and 75% of group 2 were endoscopy-negative patients). At an average follow-up of 4 years symptoms persisted in 80% and 71% of patients respectively. Seventy five per cent of patients in both groups continued to take antireflux drugs. QOL scores were similarly reduced in both groups (71 +/- 26 vs 70 +/- 27). CONCLUSIONS: The initial presentation and clinical outcome of AHE and GERD are similar. QOL is notably impaired and the majority of patients continue to receive antireflux medications.

Gastric emptying of solids: estimates of lag phase and constant emptying times.

There is no consensus regarding the best way to estimate the lag phase time (Tlag) and the constant emptying time (TRE) of the gastric emptying of solids. Furthermore, biphasic gastric emptying is usually described by the modified power exponential function of either Elashoff or Siegel. In an attempt to test the validity of the power exponential functions and to identify relevant parameters of biphasic gastric emptying, we followed an approach which consists of describing the power exponential function by two straight lines. The first line is horizontal and represents Tlag. The second line is tangential to the constant emptying [tangent at the maximum slope (MS) or at the half-emptying value]. Scintigraphic data of 132 patients and 15 controls were fitted by both power exponential functions. Each corresponding half-emptying time, Tlag and TRE estimated from the Elashof and Siegel power exponential functions were strongly correlated (0.93 < r < 1, P < 0.0001). The Bland and Altman statistical method demonstrated good agreement (<5% outliers). The half-emptying tangent method sometimes gave negative Tlag and should be abandoned. Tlag(MS) and TRE(MS) did not correlate and therefore were independent parameters. We conclude that the Elashoff and Siegel functions are equivalent and that the maximum slope tangent method allows a reliable description of the two independent phases of gastric emptying.

Isosorbide mononitrate and propranolol compared with propranolol alone for the prevention of variceal rebleeding.

The aim of this study was to test the effectiveness of isosorbide-5-mononitrate (IM) as an adjunct to propranolol (PR) in the prevention of variceal rebleeding. Ninety-five cirrhotic patients with variceal bleeding were randomly assigned to treatment with PR + IM (46 patients) or PR alone (49 patients). Eighteen patients in the PR + IM group and 28 in the PR group had rebleeding during the 2 years after randomization. The actuarial probability of rebleeding 2 years after randomization was lower in the PR + IM group (40.4% vs. 57.4%) but the difference was not significant (P =. 09). However, the decrease in the risk of rebleeding reached statistical significance after stratification according to age, i.e. less than 50 versus >/=50 years old, (P =.03) or by adding an additional year of follow-up (P =.05). No significant difference was found in rebleeding index and survival. The multivariate Cox analysis indicated first, that both treatment (P =.03) and age (P =. 001) were factors predictive of rebleeding and second, that PR + MI reduced the risk of rebleeding by half (relative risk: 0.51, 95% confidence interval: 0.28-0.95). Seven patients in the PR + MI group and 1 patient in the PR group had to discontinue one of the drugs because of adverse events (P =.03). These results suggest that the addition of IM improves the efficacy of PR alone in the prevention of variceal rebleeding in cirrhotic patients. However no beneficial effects were observed on other parameters reflecting the efficacy of treatment.

[Ischemic colitic in the elderly: predictive factors of gangrenous outcome]. / Colite ischémique du sujet âgé: facteurs prédictifs de l'évolution gangreneuse.

OBJECTIVE: To better characterize the presentation of gangrenous and non-gangrenous ischemic colitis in subjects older than 60 years, and to identify risk factors of gangrenous outcome. METHODS: Retrospective analysis of 80 cases of ischemic colitis (22 male, 58 female; mean age 76.9 +/- 8.7 years) with 64 and 16 non gangrenous and gangrenous forms, respectively. RESULTS: Hematochezia and diarrhea were significantly less prevalent in gangrenous colitis compared to the non-gangrenous group (31.2% vs 81.2%, P < 0.0001 and 6.2% vs 53.1%, P < 0.0001, respectively), whereas nausea and vomiting, and hyperleukcocytosis were significantly more frequent in the former group (50.0% vs 18.7%, P < 0.01 and 93.7% vs 62.5%, P < 0.02 respectively). Hypertension (P < 0.03), angina (P < 0.05), history of cancer (P < 0.03) and age older than 90 (P < 0.002) were risk factors for gangrenous outcome. After multivariate analysis, only two independent factors were identified, i.e.: hypertension and history of cancer. These factors predicted gangrenous course in 85% of cases. CONCLUSION: Patients older than 60 years suffering from ischemic colitis are at high risk of gangrenous course if they have hypertension or history of cancer.

[Do general practitioners want to manage chronic hepatitis C and take part in hepatitis C health networks? A national survey]. / Les médecins généralistes souhaitent-ils prendre en charge l'hépatite chronique virale C et participer aux réseaux ville-hôpital?

OBJECTIVES: To assess information that general practitioners had on hepatitis C and on the hepatitis C network in hospitals and private practice. METHODOLOGY: A national telephone survey of 604 general practitioners was conducted between March 18 and 23, 1998. RESULTS: Screening and management of hepatitis C was important for 89% and 97% of general practitioners. Screening was performed in relation to the relative risk (IV drug users 89%, blood transfusion before 1991 88%). General practitioners wanted more information on treatment (54%), patient counselling (42%) and the potential risks of the disease (42%). Of 604 general practitioners, 6% were involved in a hepatitis C network, while 21% were involved in another network (drug users 9%, AIDS 8%). Of the 94% general practitioners who were not part of the network, 33% were willing to join a hepatitis C network. Only 56% were aware of a hepatitis C network (press article 30%, mailing 17% or local meeting 12%). The difficulties for the involvement of general practitioners were: lack of time, topics not adapted to daily practice and geographic constraints (74%), too few patients in their practice (52%), no need (38%), the idea itself of a network and lack of information (28%). CONCLUSION: General practitioners screen patients at risk of hepatitis C. They want to be better informed about treatment, patient counselling, and the potential risks of hepatitis C. They are less involved in hepatitis C networks than in other networks (drug, AIDS). However, one third of general practitioners would like to be involved in a hepatitis C network. These results could be useful for implementing post-graduate courses and general practitioner training.

Cryoglobulinemia presenting after liver transplantation.

Essential mixed cryoglobulinemia is frequently associated with chronic hepatitis C. Three patients undergoing transplantation for end-stage chronic hepatitis C in whom cryoglobulinemia with vasculitis developed after transplantation are described. Hepatitis C virus (HCV) infection was confirmed in the 3 patients by the presence of HCV RNA detected by polymerase chain reaction. The time interval between transplantation and the first expression of vasculitis was 1, 5, and 17 months. Type II cryoglobulins were detected in the sera of all 3 patients. All patients developed cutaneous vasculitis, requiring digital amputation in 1 case. Two patients developed membranoproliferative glomerulonephritis. Plasmapheresis and the addition of cyclophosphamide led to an improvement in the renal disease in 1 case, whereas no treatment was able to reverse the renal failure in the other case. One patient developed an autoimmune hemolytic anemia 4 years after transplantation. One patient died of multiorgan failure 5 months after transplantation. We propose that HCV-associated cryoglobulinemia could become clinically significant only after orthotopic liver transplantation, possibly due in part to posttransplant increase in viremia as reflected by HCV RNA levels. These results confirm previous observations suggesting that HCV infection is important etiologically in the pathogenesis of cryoglobulinemia.

Hepatitis C virus genotypes in French blood donors.

The prevalence of different hepatitis C virus (HCV) genotypes in HCV infected individuals and the relation between the HCV genotypes and the source of the infection are controversial. The aim of this study was to determine the HCV genotypes in French blood donors. Fifty-one anti-HCV positive blood donors were studied with detectable serum HCV RNA by nested polymerase chain reaction (PCR) using primers derived from the 5' non-coding region. For genotyping HCV, we used a method based on analysis of the restriction fragment length polymorphisms (RFLP) after amplification by PCR of the HCV non-structural 5 (NS5) genome domain. Using this technique, the genotypes of 39 of the 51 blood donors (76%) were determined. Three previously described genotypes were found: 19 blood donors were infected by HCV genotype I (37%), 14 were infected by HCV genotype II (27%), 3 were infected by HCV genotype III (6%), and 3 were coinfected by two genotypes (6%). All three blood donors infected with two different genotypes were intravenous drug abusers. A past history of intravenous drug abuse was more frequent in blood donors with HCV genotype I. However, there was no difference in alanine transaminase (ALT) levels, histological lesions, and RIBA-2 patterns in blood donors infected with either HCV genotype I or HCV genotype II. These findings indicate that most HCV genotypes isolated from French blood donors belong to HCV genotype I and HCV genotype II, and that risk factors for HCV infection may differ for different genotypes of HCV.

Detection and quantitation of serum HCV-RNA by branched DNA amplification in anti-HCV positive blood donors.

The detection of serum HCV-RNA needs to be standardized. The aim of this study was to assess the effectiveness of the branched DNA amplification method in detecting and quantitating serum HCV-RNA in 54 blood donors, 33 with and 21 without increased serum alanine aminotransferase levels and with detectable serum HCV-RNA by polymerase chain reaction. HCV-RNA was detected by branched DNA signal amplification in 42/54 (77%) of the blood donors. Positivity rates were not different among the 21 blood donors with normal and the 33 blood donors with increased serum alanine aminotransferase levels (86% and 76%, respectively). Median serum HCV-RNA levels were not different among donors with or without increased serum alanine aminotransferase levels (28.6 x 10(5) Eq/ml and 14.7 x 10(5) Eq/ml, respectively). There was no significant correlation between serum alanine aminotransferase levels and serum HCV-RNA levels. These findings show that branched DNA signal amplification identifies most of the donors with true hepatitis C virus viremia and that the level of hepatitis C virus replication is not correlated to serum alanine aminotransferase levels.

Right ventricular dysfunction in patients with septic shock.

Using a rapid computerized thermodilution method, we examined the evolution of right ventricular performance in 23 patients with septic shock. Nine survived the episode of septic shock. The other 14 patients died of refractory circulatory shock. Significant right ventricular systolic dysfunction, defined as decreased ejection fraction (-39%) and right ventricular dilation (+38%) was observed in all patients with septic shock. However, in the survivors, increased right ventricular preload may prevent hemodynamic evidence of right ventricular pump failure by utilizing the Frank-Starling mechanism to maintain stroke volume. Conversely, in the nonsurvivors, right ventricular dysfunction was more prononced two days after the onset of septic shock, leading to a fall in stroke. In the last patients, a decrease in contractility appears to be the major factor accounting for decreased right ventricular performance, as evidenced by the marked increase in end-systolic volume (+27%) without significant change in pulmonary artery pressure, during the later stage of septic shock. The observed right ventricular pump failure then appears associated with an alteration in diastolic mechanical properties of this ventricle, as suggested by a leftward displacement of the individual pressure-volume curves.

Bedside evaluation of right ventricular performance using a rapid computerized thermodilution method.

In 34 patients, we assessed the reproducibility and accuracy of a new, computerized, thermodilution method that determines right ventricular ejection fraction (RVEF). We compared the results from this new algorithm with simultaneous results from the conventional plateau thermodilution method and from both first-pass and gated nuclear techniques. Using this new method improved the reproducibility of thermal determinations of RVEF. Although the thermal values were lower, the correlations between thermal and nuclear measurements were close [r = .92 (first-pass technique), r = .81 (gated technique)]. This new method seems particularly appropriate for serial monitoring of RV performance.

[Lymphostasis and the venous wall. Therapeutic implications]. / Lymphostase et paroi veineuse. Déductions thérapeutiques.

Lymph oedema have to be treated in the same way that complications of chronic venous deficiency of the lower limbs are usually treated. Isolated or linked, these two pathological conditions call for the same therapeutic method: reduction; if lymphostatic phenomena persist, it is then necessary to have recourse to lymphatic drainage and/or to compression; surgical treatment must continue to be regarded as exceptional.