Use of perfusion device for free flap salvage after ischemia in swine.

INTRODUCTION: In free flap reconstruction, improving flap tolerance to warm ischemia (WI) is fundamental. WI is the result of a venous or arterial thrombosis, which can only be addressed through surgical revision. No additional treatments have shown superior efficacy at salvaging free flaps after or during WI. Custom perfusion machines (PM), used to reduce the intensity of lesions of the flap stored in cold ischemia, have not been evaluated for WI flap salvage. This proof-of-concept study assessed whether the Lifeport® perfusion machine could improve the salvage procedure's success rates after one hour of venous WI. METHODS: Five different groups were evaluated with four porcine latissimus dorsi free flaps included in each group. Depending on the group, the flaps were subjected to one hour of WI followed by revascularization, static hypothermic submersion, or dynamic Lifeport® perfusion. Additionally, two flap perfusion liquids were evaluated: KPS-1® and IGL-1®. Biopsies were performed before in vivo warm ischemia of the flap, after in vivo warm ischemia of the flap, and after one and two hours of preservation. Interstitial edema, muscular cell size and muscular diffuse necrosis were quantified by histological assessment. RESULTS: Static submersion did not demonstrate any efficacy for venous flap salvage. Dynamic perfusion on Lifeport® machine showed a significant improvement in tissue parameters. Thrombi and fibrine, present during the WI period, were no longer visible inside vessels and the perfusion machine flow evacuated the inflammatory cells and their substrates from the flap. The flap weights did not increase during perfusion time, confirming the benefits of the Lifeport® perfusion machine. CONCLUSION: Evaluating Lifeport® advantages on human free flap salvage is necessary to confirm the benefits for the tissue and to increase post-operative results after congestive free flap revision surgery.

PD-L1 expression in the microenvironment and the response to checkpoint inhibitors in head and neck squamous cell carcinoma.

In head and neck squamous cell carcinoma (HNSCC), data from studies using checkpoint-inhibiting antibodies that target programmed death 1 (PD-1) or its ligand the programmed death ligand 1 (PD-L1) demonstrated outstanding clinical activity. Translational investigations also suggested some correlations between therapeutic response and PD-L1 expression in tumor tissue. We comprehensively summarize results that have evaluated PD-L1 expression in HNSCC. We discuss flaws and strength of current PD-1/PD-L1 detection, quantification methods and the evaluation of PD-L1 as a prognostic and theragnostic biomarker. Understanding tumor microenvironment may help understanding resistance to checkpoint inhibitors, designing clinical trials that can exploit drug combinations.

Dietary calcium impairs tomato lycopene bioavailability in healthy humans.

Lycopene (LYC) bioavailability is relatively low and highly variable, because of the influence of several factors. Recent in vitro data have suggested that dietary Ca can impair LYC micellarisation, but there is no evidence whether this can lead to decreased LYC absorption efficiency in humans. Our objective was to assess whether a nutritional dose of Ca impairs dietary LYC bioavailability and to study the mechanism(s) involved. First, in a randomised, two-way cross-over study, ten healthy adults consumed either a test meal that provided 19-mg (all-E)-LYC from tomato paste or the same meal plus 500-mg calcium carbonate as a supplement. Plasma LYC concentration was measured at regular time intervals over 7 h postprandially. In a second approach, an in vitro digestion model was used to assess the effect of increasing Ca doses on LYC micellarisation and on the size and zeta potential of the mixed micelles produced during digestion of a complex food matrix. LYC bioavailability was diminished by 83 % following the addition of Ca in the test meal. In vitro, Ca affected neither LYC micellarisation nor mixed micelle size but it decreased the absolute value of their charge by 39 %. In conclusion, a nutritional dose of Ca can impair dietary LYC bioavailability in healthy humans. This inhibition could be due to the fact that Ca diminishes the electrical charge of micelles. These results call for a thorough assessment of the effects of Ca, or other divalent minerals, on the bioavailability of other carotenoids and lipophilic micronutrients.

Guidelines of the French Society of Otorhinolaryngology (SFORL), short version. Diagnosis of local recurrence and metachronous locations in head and neck oncology.

Surveillance is fundamental to the management of head and neck cancer. The present guidelines of the French ENT society (SFORL) were drawn up by a group of experts in the field, and are intended to specify the modalities of management, based on a review of the literature and, where data are lacking, to provide expert opinion. The present paper deals with guidelines for the diagnosis of local and regional recurrence and metachronous head and neck locations. Locoregional recurrence usually occurs within 3 years of primary treatment and is mainly related to the characteristics of the primary tumor and the treatment measures taken. Laryngeal location, safe primary resection margins, low level of lymph node invasion, unimodal primary treatment and early diagnosis of recurrence are factors of good prognosis. Systematic imaging surveillance may be considered for patients for whom a curative technique exists and when surveillance is difficult. The role of PET-scanning remains to be determined. Metachronous locations are frequent, even in the late course; prolonged surveillance is appropriate. The best preventive measure is cessation of alcohol abuse and smoking. Patient education is primordial.

Chitosan solutions as injectable systems for dermal filler applications: Rheological characterization and biological evidence.

A new generation of dermal filler for wrinkle filler based on chitosan was compared to current hyaluronic acid-based dermal fillers by using a new rheological performance criterion based on viscosity during injection related to Newtonian viscosity. In addition an in vivo evaluation was performed for preclinical evidence of chitosan use as dermal filler. In this way, biocompatibility and dermis reconstruction was evaluated on a pig model.

[Implantable doppler probe for microsurgical free flap monitoring in cervico-facial reconstructive surgery]. / Le micro-doppler implantable dans la surveillance des lambeaux microanastomosés en chirurgie reconstructrice cervico-faciale.

AIM OF THE STUDY: The use of free flaps in head and neck reconstructive surgery requires postoperative monitoring, usually by conventional clinical tests. Nevertheless, clinical testing is not applicable to buried free flaps that are more frequently used in the head and neck area. The purpose of this study was to describe the use and to evaluate the implantable doppler system in this setting. PATIENTS AND METHOD: Among 162 patients who underwent free flap reconstruction in our department, between June 2008 and October 2012, 23 patients had postoperative monitoring using implantable doppler system. Probe placement, monitoring parameters and postoperative course was analyzed. RESULTS: Our series included 15 forearm free flaps, seven fibular flaps and one scapular flap. Indications for reconstruction were following the removal of a malignant tumor in 18 cases, a benign tumor in two cases and an osteoradionecrosis in three cases. Free flap monitoring by conventional clinical tests was not possible in 19 patients. Doppler signal was detected continuously during seven days in 82% of cases. A loss of signal was observed in three cases. Surgical exploration was required in one patient. CONCLUSION: Implantable doppler for free flap monitoring is a safe, reliable and efficient technique and cost is reasonable. The use of implantable doppler system seems particularly useful in head and neck reconstruction for buried free flaps, which are not accessible to conventional clinical tests.

Mastoid osteoma: report of two cases.

INTRODUCTION: Mastoid osteoma is a rare benign tumour. In this article, the authors report two new cases of mastoid osteoma and discuss the modalities of diagnosis and management. CASE REPORTS: Both patients presented with a retroauricular mass that had been slowly increasing in size over several years. The patients consulted for the cosmetic deformity induced by the lesion or moderate tenderness. The diagnosis was based on the clinical presentation and non-contrast CT. The osteoma was surgically resected in one patient. DISCUSSION/CONCLUSION: Mastoid osteoma is a rare, slowly growing, and usually asymptomatic benign tumour. Diagnosis is based on clinical findings and CT. Surgery is indicated for symptomatic or cosmetically unacceptable osteomas.

[Current findings on gastrointestinal stromal tumors: seven observations of malignant tumors]. / Actualités sur les tumeurs stromales gastro-intestinales: à partir de sept observations de tumeurs malignes.

PURPOSE: Gastrointestinal stromal tumors (GIST) are rare neoplasms, 1-3% of malignant gastrointestinal tumors. They are immature proliferations of spindled and/or epithelioid cells, developed in the muscular layer of the digestive tract, showing uncompleted or partial muscular, nervous or mixed differentiation. Immunohistologic knowledge about these tumors has recently progressed because of the discovery of specific markers (coexpression vimentin-CD117, oncogenes): GIST can now be distinguished from the other mesenchymal tumors. METHODS: Retrospective study of seven patients with GIST who received the same treatment. RESULTS: For our seven patients the mean age was 49 years with a male predominance (sex-ratio 4/3). The tumoral localisations are principally the small bowel (four cases), the rectum (two cases) and the stomach (one case). The treatment consisted of a first surgery, adapted to the tumoral localisation and extension, associated to chemotherapy in case of metastasis or local recurrence. The study of the histological grading for the seven patients showed tumors with poor prognoses. Six patients developed recurrence in a 2-year period; for the survey we are too close for a proper view. CONCLUSIONS: A review of the literature on stromal tumors finds older patients (59 years) with an equal sex ratio. Against the results of our series, the most frequent location is the stomach (50%). But the main problem is the better understanding of the particular evolution of these tumors. The bad short-date prognosis imposes carrying out larger studies, in order to confirm the principal hypothesis of histogenesis and to improve the survey by an optimal treatment.

Brachial plexopathy associated with diffuse edematous scleroderma.

Peripheral nervous system (PNS) involvement is rare in systemic sclerosis (SSc), usually restricted to peripheral nerve entrapment. To our knowledge, only one case of scleroderma with brachial plexus involvement has been reported previously. We report here on a 61-year-old woman with past history of limited cutaneous SSc who developed motor deficiency in the left arm concomitant with diffuse edematous scleroderma without evidence for trauma or compression of the brachial plexus. After six months intravenous pulse cyclophosphamide therapy, dramatic improvement of skin and neurological involvement was observed.

[Hepatic brucelloma: 2 cases and a review of the literature]. / Brucellome hépatique: deux nouveaux cas et revue de la littérature.

We report two new cases of hepatic brucelloma in addition to the 22 previously reported cases in the literature. Our analysis of these cases reveals certain characteristics. Hepatic brucelloma is a rare localization that follows previously undetected acute brucellosis. Brucelloma is a result of caseification of a granulomatous reaction induced by persistent Brucella in macrophages. Clinical manifestations can mimic malignant liver tumors or pyogenic, amebic liver abscess. Diagnosis is based on the association of characteristic imaging features (central calcification and peripheral necrotic areas), positive serology and hepatic granulomas. Brucella is rarely isolated in the blood or liver. Awareness of this clinical variant can prevent unnecessary laparotomy. Treatment should begin with rifampicine (900 mg per day) and doxycyclin (200 mg per day) for 3 months. If medical treatment is unsuccessful, percutaneous or surgical drainage should be performed. A cure should be achieved in all cases.

[Role of suindac in the treatment of familial adenomatous polyposis coli]. / Place du sulindac dans le traitement de la polypose adénomateuse colique familiale.

Familial adenomatous polyposis is a rare genetic disease characterized by the development of colorectal adenomatous polyps. Extracolonic digestive and extra-digestive manifestations can also appear. Inevitably, colorectal cancer occurs if a colectomy is not performed. Sulindac is an indolic non-steroidal anti-inflammatory indole drug which decreases colonic tumoral proliferation. The different trials published since 1983 have shown that sulindac caused regression of colorectal adenomatous polyps, but it does not affect the other manifestations of familial adenomatous polyposis. However, colorectal polyps recurred after cessation of this therapy; the effect of long-term sulindac therapy is unknown; and sulindac may cause, as a non-steroidal anti-inflammatory drug, digestive side-effects. Moreover, treatment with sulindac does not completely eliminate the risk of cancer. For patients with familial adenomatous polyposis, total colectomy and ileal pouch-anal anastomosis is the recommended procedure for most patients. However, sulindac is useful for patients who have had subtotal colectomy and ileorectal anastomosis, if these patients have only a few rectal stump polyps and accept regular and strict follow-up of the rectal stump. Sulindac is also indicated for patients who have not undergone colectomy because surgery is contraindicated or has been refused.

Blind loop syndrome: an unusual cause of panniculitis.

We describe a 52-year-old woman with panniculitis and blind loop syndrome. She had undergone a gastrectomy for peptic ulcer 4 years before. Tender erythematous nodules on her palms and soles were associated with diarrhea and weight loss. A biopsy specimen revealed septal and lobular panniculitis. A glucose hydrogen breath test was consistent with bacterial overgrowth. These results were consistent with panniculitis associated with a blind loop syndrome. Only four cases of this association have been reported previously.

Biclonal immunoglobulin M dysglobulinaemia: evolving aspects in a case of primary Sjögren's syndrome.

The observation of suggestive clinical symptoms in a patient suffering from a Gougerot-Sjögren syndrome led to a search for a cryoglobulin. Unusual physico-chemical features of this cryoglobulin were discovered, using standard electrophoresis, immunoelectrophoresis, immunofixation and electroimmunotransfer. The main unusual finding was that the cryoprecipitate was made up of a biclonal IgM kappa associated to polyclonal IgG. Therefore, we suggest that this new form of cryoglobulin be classified as a subtype IIb, thus distinguishing two subtypes in the usual classification.

[Portal hypertension caused by intra-hepatic block in chronic lymphoid leukemia]. / Hypertension portale par bloc intra-hépatique au cours d'une leucémie lymphoïde chronique.

A 83-year-old woman with chronic lymphoid leukemia--well controlled for 14 years with chemotherapy--was admitted for ascitis due to portal hypertension. Liver biopsy showed major portal infiltration with monomorphic little lymphocytes. Portal hypertension during chronic lymphoid leukemia might be caused by this periportal lymphoid infiltration or by intraportal venous thrombosis due to thrombophilia or by increasing of hepatic blood flow. Our observation showed that hepatic localizations of the disease may induce acute symptoms even when the lymphoid leukemia seems to be under control both in terms of blood parameters and lymphadenopathy.

[Role of hepatitis C virus in the genesis of hepatic lesions observed in alcoholic patients with liver cirrhosis]. / Rôle du virus de l'hépatite C dans la genèse des lésions hépatiques observées chez des malades alcooliques atteints de cirrhose.

The aim of study was to assess the role of hepatitis C virus (HCV) infection in 164 alcoholic cirrhotic patients. We studied the prevalence of anti-HCV antibodies using ELISA and RIBA first and second generation tests. Twenty-two % of the patients had anti-HCV antibodies detected by ELISA 2, RIBA 2 test was positive in 10% of the patients and indeterminate in 3%. We compared epidemiological, biological and histological characteristics according to the results of the tests. By comparing ELISA 2-RIBA 2 positive patients to ELISA 2 negative patients, we observed, in the former, a) a higher serum aminotransferase activity, b) a lower serum gammaglutamyl transpeptidase activity, and c) a lower histological score of alcoholic hepatitis. In addition, in a group of ELISA 2 positive RIBA 2 negative patients, the values were intermediate between those of the two former groups. However, most of these patients had a negative third generation ELISA test. The whole results suggest that HCV is likely to play a role in the pathogenesis of liver damage in a high number of alcoholic cirrhotic patients.

Pathogenesis of liver cirrhosis in alcoholic patients: histological evidence for hepatitis C virus responsibility.

Hepatitis C virus (HCV) has been proposed to be a cofactor in the pathogenesis of cirrhosis in patients with chronic alcoholism. The demonstration of a different liver histological pattern in anti-HCV positive patients might provide additional evidence. We studied 164 patients with chronic alcoholism, and histologically proven cirrhosis. For all of them, serum samples were collected at the time of a liver biopsy and stored at -80 degrees C. Testing for anti-HCV antibodies was done using the Ortho Diagnostic Systems Anti-HCV ELISA test. Only reproducible results were considered positive. A semi-quantitative assessment of seven histological parameters was made independently on liver biopsy samples. In the study group, 29 patients (18%) had anti-HCV antibodies. When compared with anti-HCV negative patients, both groups had similar ALT and AST seric activities. Anti-HCV positive patients had a greater score of mononuclear cells infiltrate (0.71 +/- 0.57 vs 0.41 +/- 0.52; p less than 0.05) and a lesser score of alcoholic hepatitis (0.19 +/- 0.57 vs 0.74 +/- 0.74; p less than 0.005). The scores for steatosis, perisinusoidal and perinodular fibrosis, and hepatocellular necrosis were similar in the two groups. In anti-HCV positive patients, with a clearly positive recombinant immunobinding assay (RIBA, Chiron-Ortho Diagnostic Systems), a greater score for hepatic necrosis and a lesser one for fibrosis were demonstrated. Among the seven patients with active cirrhosis, six were anti-HCV positive. Therefore, HCV is likely to play a role in the pathogenesis of liver damage in a few patients with alcoholic cirrhosis, especially, those with active cirrhosis.