Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients.

INTRODUCTION: Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy. METHODS: This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis. RESULTS: Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality. CONCLUSION: The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Characteristics of Pharmacists' Interventions Related to Proton-Pump Inhibitors in French Hospitals: An Observational Study.

Methods: The study was based on a retrospective analysis of pharmacist interventions for DRPs detected during the medication order review and documented into the French Act-IP© database over a 12-year period. DRPs and PIs were analyzed, and independent factors of physician acceptance were assessed via multiple logistic regression. Results: Out of the 620,620 PIs registered, 29,694 targeted a PPI (4.8%). PPI's DRPs were mostly related to the prescription of a "drug not available at the hospital" (26.1%) and a "drug use without indication" (18.3%); PIs were mostly "drug switch" (35.9%) and "drug discontinuation" (26.1%). In all, 18,919 PIs were accepted by physicians (63.7%). Acceptance was significantly associated with patient age: less accepted for the 18-75 years group (OR = 0.59, 95 CI [0.46-0.76]), and the >75 years group (OR = 0.57, 95 CI [0.44-0.73]) vs. <18 years group; for the type of DRP, "drug use without indication" was the less accepted (OR = 0.73, 95 CI [0.63-0.85]); for the type of PI, "dose adjustment" was the less accepted (OR = 0.32, 95 CI [0.23-0.45]). Conclusion: Pharmacists contribute to preventing DRPs associated with PPI prescriptions during the medication order review process. Moreover, they often detect PPIs used without indication and they propose drug discontinuation, which contributes to the PPI deprescribing process. PIs should be further developed in the future to reduce PPI overprescription.

Crude complication rate is not an accurate marker of a surgeon's skill: A single surgeon retrospective series of 1060 procedures for colorectal endometriosis.

OBJECTIVE: To assess the relationship between the rate of postoperative bowel fistula and surgeon experience. DESIGN: Retrospective study. SETTING: Two referral centers. PATIENTS: 1060 women managed for colorectal deep endometriosis by one gynecologist surgeon from January 2005 to March 2020. INTERVENTIONS: Shaving, disc excision and segmental colorectal resection. MAIN OUTCOME MEASURES: Rate of bowel fistula stratified according to 4 time periods: P1 from 2005 to 2009, P2 from 2010 to 2014, P3 from 2015 to June 2018 and P4 from September 2018 to March 2020. RESULTS: 68 patients (6.4%) were managed during P1, 299 patients (28.2%) during P2, 422 patients (39.8%) during P3 and 271 patients (25.6%) during P4. Both diameter of rectal infiltration and rate of complex surgical procedures progressively increased from P1 to P4. Bowel fistula rate was comparable between all 4 time periods, respectively 2.9, 3.3, 4 and 4.4%. Logistic regression model revealed that risk of fistula decreased when shaving was performed when compared to segmental resection (adj OR 0.1, 95% CI 0-0.5) and increased when deep endometriosis nodules also involved sacral roots (adjOR 4.9, 95%CI 1.8-13.3) and infiltration of the vagina (adj OR 3, 95%CI 1.3-7). No statistically significant relationship was found between surgery time period and risk of fistula. CONCLUSION: Crude rates of bowel fistula following surgical management of deep endometriosis infiltrating the colon and the rectum are not an accurate marker of surgeon expertise and should be considered in conjunction with expected higher risks related to challenging procedures performed by experienced surgeons.

Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study.

BACKGROUND: Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection. METHODS: Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality. RESULTS: Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038). CONCLUSION: Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.

Differed surgery in patient with colorectal endometriosis and pregnancy intention: Is it reasonable?

The management of patients presenting deep infiltrating endometriosis involving the rectum (DIER) and pregnancy intention is controversial. Assisted Reproduction Techniques (ART) are often proposed first, but this may lead to complications and further difficulties managing DIER. A 29-years-old woman was diagnosed with pre-occlusive DIER. However, she was offered in vitro fertilization (IVF) and underwent six unsuccessful cycles with serious complications: an ectopic pregnancy and a hemoperitoneum following arterial injury during oocyte retrieval, requiring two laparotomies in emergency. The patient's symptoms worsened over time and colorectal resection with diverting colostomy was performed. The patient's quality of life was then improved. In our opinion, prior ART in patients presenting DIER delays surgery and may have harmful complications. Therefore, primary surgery followed by ART may be a valuable option in some cases and should be discussed with the patients.

Management of deep infiltrating endometriosis by laparoscopic route with robotic assistance: 3-year experience.

OBJECTIVE: To assess the feasibility of deep endometriosis surgery using robotic assistance, benefits and limits of this approach. METHOD: Case-series study enrolling patients managed for deep infiltrating endometriosis (DIE) using robotic assistance in our department between September 2011 and March 2014 (NCT02294825). Self-questionnaires including pain and digestive symptoms were filled in preoperatively and 1 year after surgery. RESULTS: Thirty-five patients were enrolled in the series. They represented 54% of patients managed for gynecological disease by laparoscopic route with robotic assistance during the study period, and 14% of patients managed for deep endometriosis in our department. Follow-up averaged 24±8 months, and no patient was lost to follow-up. Thirty-two patients had rectal involvement: rectal shaving was performed in 25 patients, disc excision in 3 and colorectal resection in 4. Three patients had bladder resection. Thirteen patients presented with deep endometriosis of the ureters: ureterolysis was performed in 11 of them, and resection of the ureter followed by reimplantation into the bladder in 2 patients. One major complication (Clavien IIIb) was recorded in a patient presenting with necrosis of the right ureter on postoperative day 5. Nine patients tried to conceive after surgery and 8 have already become pregnant (88.9%). One year after surgery, self-questionnaires revealed a significant decrease in pain symptoms and significant improvement in several item values of gastrointestinal standardized questionnaires. CONCLUSIONS: Surgical management of DIE is feasible using robotic assistance. However, data available in the literature and our own experience do not definitively support the hypothesis of the superiority of robotic assistance in the management of DIE.

Is the image "right" for everyone? Introduction to the parallax effect in laparoscopic surgery.

AIM OF THE STUDY: During minimally invasive abdominal surgery, a laparoscope is used to film the procedure, which is transmitted to a flat screen monitor. The horizontality of the image depends on the orientation in space and the visual comfort of the surgeon. Observing the screen via a lateral angle of incidence frequently results in the camera assistant making errors in determining the horizontality of the image. Thus, what is "right" for the camera assistant is not necessarily 'right' for the surgeon. We aimed to explain the impact of these errors in laparoscope manipulation, by the description of the parallax effect. PATIENTS AND METHODS: To describe this phenomenon of perceptions changing depending on the angle of view, from the basis of the parallax effect, we observed the change of position and for two observers, (the surgeon and the camera assistant) seated at two different locations, using an experimental set up (i.e., photography equipment, a screen and a pelvitrainer). RESULTS: The position of the camera assistant positioned at an angle of incidence of 45° from the surgeon, the observation of the screen with a lateral incidence changes the perception of the image viewed on the screen. For correcting the conflict between the subjective visual perception of the camera assistant and the actual image horizon, the camera assistant instinctively rotates the image, which can lead to an "incorrect" image, deleterious for the surgeon. CONCLUSIONS: This article introduces a previously unexplained concept in medical literature, called the parallax effect. The parallax effect results in the camera assistant making systematic errors in determining image horizontality on the screen.

Multiple nodule removal in multifocal colorectal endometriosis instead of "en bloc" large colorectal resection.

Surgical management of colorectal endometriosis follows the principles of two main philosophies or approaches: radical and conservative. The radical approach has recently been recommended in multifocal colorectal endometriosis, which frequently concerns patients with rectal nodules. However, an alternative conservative management could employ selective retrieval of macroscopic colorectal deep endometriosis nodules by bowel shaving and disc excision, with preservation of the mesorectum. The conservative approach is justified by the evidence that low colorectal resection may lead to postoperative functional digestive symptoms for which management is most challenging. However, there is a lack of data in the literature specifically focusing on patients with multiple excision of deep colorectal endometriosis. No data exist about the minimal length of healthy bowel that should be conserved between two successive transversal bowel sutures, and on consecutive improvement of functional outcomes. Conversely, no evidence exists on presumed reduction of recurrence rate when young patients undergo low large colorectal resection, instead of multiple selective excisions. Further comparative studies would be welcome, among which the ENDORE randomized trial which may play a central role by comparing functional outcomes related to radical and conservative approach in deep endometriosis infiltrating the rectum.

[Pharmacist's interventions on proton pump inhibitor prescriptions in a University Hospital]. / Interventions des pharmaciens sur les prescriptions d'inhibiteurs de la pompe à protons dans un centre hospitalier universitaire.

PURPOSE: In France, efforts to optimize prescribing of proton-pump inhibitors (PPIs) are rare. Various studies have shown that the prescription of these drugs is excessive. This has consequences regarding costs and iatrogenesis. The objective of this study was to describe the type of drug related problems (DRP) and pharmaceutical interventions reported by pharmacists practicing in a university hospital. METHODS: Drug related problems and pharmaceutical interventions (PI) made, were recorded on a database. They were classified according to the grid code of the French Society of Clinical Pharmacy. RESULTS AND DISCUSSION: Over a 3 years period, 132.890 prescriptions were analysed. 15.347 generated PI. Among them 701 (4.6%) concerned PPIs. Most frequently reported problems were: lack of indication or patients without a documented indication (24.4%), drug-drug interactions (22.4%) and inappropriate route or mode of administration (19.8%). Discontinuation has been proposed in 40.5% of cases, followed by substitution (22.0%) and dosage titration (17.3%). Physicians modified the prescription according to 51.3% of PI. The main PI, discontinuation therapy, is associated with over-prescription of this drug class. Nevertheless, the rate of DRP recorded (0.5%) is low compared to the high exposure of patients on PPIs and misuse (or overuse?) reported in the literature. CONCLUSION: PI made during the analysis of prescription contributes to rationalizing the use of PPIs. The action of the pharmacist must be strengthened through training of health professionals, and communication strategies to improve practices.

Deletion of extracellular matrix metalloproteinase inducer/CD147 induces altered cardiac extracellular matrix remodeling in aging mice.

Extracellular matrix metalloproteinase inducer (EMMPRIN), known for its ability to induce matrix metalloproteinase (MMP) expression, was proposed to play a role in the adverse cardiac extracellular matrix remodeling. After observing an age-associated increase in cardiac EMMPRIN expression in both mice and rats, the role and mechanism of action of EMMPRIN was investigated in the myocardial age-associated changes using 3, 12 and 24 month old EMMPRIN knock-out (KO) vs. wild-type (WT) mice, by cardiac echocardiography, Western blots, immunohistochemistry, ELISA and histology. Adilated cardiomyopathy characterized by a decreased ejection fraction and an enlargement of left ventricular chamber (LV) associated with LV hypertrophy, occurred in KO mice as soon as 12 month old. The increase in interstitial collagen deposition during aging in WT mice could not be detected in KO mice. This may be related to the reduced activation (48% reduction; P < 0.05) and signaling (smad2/3 nuclear translocation) of TGF-ß in the 12 month old KO mice which paralleled with a greater reduction in the TGF-ß known activating enzymes such as MT1-MMP and MMP-1 (33% and 37% reduction respectively, between 3 and 12 month old in KO mice; P < 0.05) as well as uPA. These findings demonstrate that EMMPRIN gene silencing is associated with an aberrant extracellular matrix remodeling, characterized by the absence of a detected age-associated fibrosis and consequently to dilated cardiopathy, indicating that a fine regulation of EMMPRIN is essential for the coordinated ECM remodeling during aging.

Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation.

BACKGROUND: Pyloric pressure and compliance have never been investigated in health nor gastroparesis. AIM: We hypothesised that pyloric pressure and/or compliance may be altered in gastroparesis. METHODS: Fasting pyloric pressure and compliance were investigated in 21 healthy volunteers (HV), 27 gastroparetic patients (GP) and 5 patients who had undergone oesophagectomy without pyloroplasty as positive controls. Under videofluoroscopic control, pyloric compliance and pressure were measured by the EndoFLIP technique. Gastric emptying half time (T1/2 ) using (13) C-octanoic acid breath test, as well as symptoms and quality of life (GIQLI score) were also monitored. RESULTS: Mean fasting pyloric compliance was measured at 25.2 ± 2.4 mm²/mmHg in HV, and was lower both in GP (16.9 ± 2.1 mm²/mmHg; P < 0.05) and patients with oesophagectomy (10.9 ± 2.9 mm²/mmHg; P < 0.05). By contrast, fasting pyloric pressure was not different among groups. Fasting pyloric compliance and pressure correlated with T1/2 in GP (R = -0.43; P = 0.04). Fasting pyloric compliance, but not pressure, correlated with symptoms and GIQLI score. Pyloric dilation in 10 GP with low fasting pyloric compliance (<10 mm²/mmHg) increased compliance from 7.4 ± 0.4 to 20.1 ± 4.9 mm²/mmHg (P < 0.01) and improved the GIQLI score from 72.5 ± 5.5 to 89.3 ± 6.1 (P = 0.04). CONCLUSION: This prospective study assessed pyloric compliance for the first time, and showed that fasting pyloric compliance is decreased in gastroparetic patients and is associated with T1/2 , symptoms and quality of life. This suggests that pyloric compliance may be a new relevant metric in gastroparetic patients, and may be useful to target patients for pyloric dilation or botulinum toxin injection.

Fully versus partially covered self-expandable metal stents in benign esophageal strictures.

Self-expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long-term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self-expandable metal stents (FCSEMS). We performed a retrospective analysis of self-expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty-two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long-term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.

An extremely uncommon variant of left hepatic artery arising from the superior mesenteric artery.

We report a new variation of the left hepatic artery arising from the superior mesenteric artery. The variant was discovered during radiological examinations in a patient presenting with ruptured hepatocellular carcinoma of the left liver lobe. Anatomical description was based on CT-scan and angiographic analysis. When present the left hepatic artery originates from the left gastric artery, with an incidence of 12-34 %. Knowledge of left hepatic artery anatomy is mandatory to optimize surgical and radiological management in complex clinical situations.

Imbalance of MMP-2 and MMP-9 expression versus TIMP-1 and TIMP-2 reflects increased invasiveness of human testicular germ cell tumours.

The histological classification of testicular germ cell tumours (TGCTs) to seminoma or non-seminomatous germ cell tumours is at present the main criterion for the clinical outcome and selection of the treatment strategy. In view of the need to identify novel prognostic biomarkers for TGCTs, we investigated the expression of the matrix metalloproteinases MMP-2 and MMP-9 in testicular tumour tissues and cell lines of both seminoma and non-seminoma origin. Immunohistochemistry and zymography analysis of tumoural tissues showed significantly higher levels of MMP-2 and MMP-9 compared with normal testis with the active forms detected only in the tumour tissues. Three cell lines representative of the different tumour types, JKT-1 seminoma, NCCIT teratocarcinoma and NTERA2/D1 embryonal carcinoma were also evaluated for their expression of these MMPs using qPCR and zymography and for their invasive properties. The more invasive non-seminomatous teratocarcinoma and embryonal cells expressed considerably more MMP-2 and MMP-9 compared with seminoma cells exhibiting lower invasiveness. Furthermore, an inverse relation was observed between invasiveness and the expression of endogenous inhibitors TIMP-1 and TIMP-2. The MMP inhibitor Marimastat inhibited invasion in all cell lines, the highest inhibition was observed in the more invasive NTERA2/D1 and NCCIT cells, which presented the highest ratio of MMP-2 and MMP-9 vs. TIMP-1 and TIMP-2. These results highlight the importance of MMP-2 and MMP-9 in the invasiveness of testicular tumours and suggest that their levels, vs. those of TIMP-1 and TIMP-2, may represent potential biomarkers for testicular malignancy.

[Incidence of adverse drug reactions in a pediatric teaching hospital: a retrospective study from 1989 to 2010]. / Étude rétrospective de l'incidence des effets indésirables médicamenteux dans un centre hospitalier universitaire mère-enfant de 1989 à 2010.

OBJECTIVE: The main objective is to describe the incidence of adverse drug reactions (ADR) coded by medical archivists from patient medical records. The secondary objective is to determine the drug classes causing ADRs according to age and to compare the incidence according to the revision of the International Classification of Diseases (ICD) used. METHODS: This is a non experimental and descriptive study of ADR in a teaching hospital. All ADR codes (i.e. codes E930 to E949 in ICD-9 version and codes Y40 to Y59 in ICD-10 version) in medical records of patients aged 18 and under have been included. The research protocol has been accepted by the institutional review board committee of CHU Sainte-Justine. RESULTS: We calculated on average 225.7±65.1 ADRs coded per year for an annual average incidence of pediatric ADRs of 1.64%±0.41% (n=4740 ADRs, average 1.3 ADR per patient) for a total of 294,480 admissions between April 1st, 1989 and March 31st, 2010. ADRs coded occurred amongst 0 to 2 years old and 12 to18 years old in a proportion of 30.5% and amongst 3 to 11 years old in a proportion of 39%. ADRs are caused by antibiotics (28%), anticancer drugs (18%), opiates (6%) and steroids (6%) which represent around 50% of all ADRs. CONCLUSION: The incidence of pediatric ADRs is increasing throughout the studied period, mainly because a more complete codification of episodes of care by medical archivists has been prioritized by the hospital administration.