Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults(with video)

Background:Extrahepatic portal vein obstruction(EHPVO)results in severe portal hypertension(PHT)leading to severely compromised quality of life.Often,pharmacological and endoscopic management is unable to solve this problem.Restoring hepatic portal flow using meso-Rex bypass(MRB)may solve it.This procedure,uncommon in adult patients,is considered the treatment of choice for EHPVO in children.Methods:From 1997 to 2018,8 male and 6 female adults,with a median age of 51 years(range 22-66)underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels,Belgium.Symp-toms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings,sepsis due to portal biliopathy,and/or severe abdominal discomfort.The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein.Results:Median operative time was 500 min(range 300-730).Median follow-up duration was 22 months(range 2-169).One patient died due to hemorrhagic shock following percutaneous transluminal interven-tion for early graft thrombosis.Major morbidity,defined as Clavien-Dindo score≥III,was 35.7%(5/14).Shunt patency at last follow-up was 64.3%(9/14):85.7%(6/7)of pure venous grafts and only 42.9%(3/7)of prosthetic graft.Symptom relief was achieved in 85.7%(12/14)who became asymptomatic after MRB.Conclusions:Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications.In such patients,MRB represents the only and last resort to restore physiological portal vein flow.Although successful in a majority of patients,this procedure is associated with major morbidity and mortality and should be done in tertiary centers expe-rienced with vascular liver surgery to get the best results.

Faecal calprotectin and magnetic resonance imaging in detecting Crohn's disease endoscopic postoperative recurrence

AIM To assess magnetic resonance imaging(MRI) and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn's disease(CD).METHODS From two tertiary centers, all patients with CD who underwent ileocolonic resection were consecutively and prospectively included. All the patients underwent MRI and endoscopy within the first year after surgery or after the restoration of intestinal continuity [median = 6 mo(5.0-9.3)]. The stools were collected the day before the colonoscopy to evaluate faecal calprotectin level. Endoscopic postoperative recurrence(POR) was defined as Rutgeerts' index ≥ i2b. The MRI was analyzed independently by two radiologists blinded from clinical data.RESULTS Apparent diffusion coefficient(ADC) was lower in patients with endoscopic POR compared to those with no recurrence(2.03 ± 0.32 vs 2.27 ± 0.38 × 10^(-3) mm^2/s, P = 0.032). Clermont score(10.4 ± 5.8 vs 7.4 ± 4.5, P = 0.038) and relative contrast enhancement(RCE)(129.4% ± 62.8% vs 76.4% ± 32.6%, P = 0.007) were significantly associated with endoscopic POR contrary to the magnetic resonance index of activity(Ma RIA)(7.3 ± 4.5 vs 4.8 ± 3.7; P = 0.15) and MR scoring system(P = 0.056). ADC < 2.35 × 10^(-3) mm^2/s [sensitivity = 0.85, specificity = 0.65, positive predictive value(PPV) = 0.85, negative predictive value(NPV) = 0.65] and RCE > 100%(sensitivity = 0.75, specificity = 0.81, PPV = 0.75, NPV = 0.81) were the best cutoff values to identify endoscopic POR. Clermont score > 6.4(sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74), Ma RIA > 3.76(sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74) and a MR scoring system ≥ MR1(sensitivity = 0.54, specificity = 0.82, PPV = 0.70, and NPV = 0.70) demonstrated interesting performances to detect endoscopic POR. Faecal calprotectin values were significantly higher in patients with endoscopic POR(114 ± 54.5 μg/g vs 354.8 ± 432.5 μg/g; P = 0.0075). Faecal calprotectin > 100 μg/g demonstrated high performances to detect endoscopic POR(sensitivity = 0.67, specificity = 0.93, PPV = 0.89 and NPV = 0.77).CONCLUSION Faecal calprotectin and MRI are two reliable tools to detect endoscopic POR in patients with CD.

Gemcitabine in elderly patients with advanced pancreatic cancer

AIM： TO assess feasibility, tolerability and efficacy of gemcitabine-based chemotherapy in patients ≥ 75 years old with advanced pancreatic cancer. METHODS： All consecutive patients ≥ 75 years old with advanced pancreatic adenocarcinoma were included in this retrospective study. Necessary criteria to receive chemotherapy were： performance status 0-2, adequate biological parameters and no serious comorbidities. Other patients received best supportive care （BSC）. RESULTS： Thirty-eight patients （53% women, median age 78 years, range 75-84） with pancreatic cancer （metastatic： n = 20, locally advanced： n = 18） were studied. Among them, 30 （79%） were able to receive chemotherapy [median number： 9 infusions （1-45）]. Six patients （23%） had at least one episode of grade 3 neutropenia and one patient developed a grade 3 hemolytic-uremic syndrome. No toxic death occurred. Three patients （11%） had a partial tumor response, 13 （46%） had a stable disease and 12 （43%） had a tumor progression. Median survival was 9.1 mo （metastatic： 6.9 too, locally advanced： 11.4 too）. CONCLUSION： Tolerance and efficacy of gemcitabinebased chemotherapy is acceptable in elderly patients in good condition, with similar results to younger patients.

Prevalence and Predictive Factors of Severe Coronary Lesions in Algerian Patients Undergoing Coronary Angiography

Background: The severity of coronary lesions in patients with coronary artery disease (CAD) has important prognostic and therapeutic consequences. Clinical symptoms not always reflect the disease severity and this study aimed to evaluate coronary lesions in the Algerian population where these data are scarce. Methods: It was a prospective cross-sectional study conducted in consecutive patients with an age ≥20 years who underwent clinically-indicated coronary angiography in our center. The objective of the study was to determine the prevalence of severe coronary lesions assessed with the Gensini score. The predictive factors of severity were evaluated in a multivariate analysis. Results: A total of 507 patients were included (male, 79.7%;mean age, 58.8 years). Coronary angiography was prescribed most frequently for ST-segment elevation myocardial infarction (STMI) (46.9%) and non-STMI (38.1%). The prevalence of severe coronary lesions was 69.6% (95% CI 65.5 - 73.5). In multivariate analysis, the independent predictive factors of severe coronary lesions were male sex (odds ratio [OR] 2.00;p = 0.0141), diabetes (OR 1.92;p = 0.0070), left ventricular dysfunction (OR 1.81;p = 0.0059), age (OR 1.72;p = 0.0297) and no lipid-lowering treatment (OR, 0.47;p = 0.0388). Conclusions: Severe coronary lesions were present in two out three patients in this cohort of Algerian patients undergoing coronary angiography. Independent predictive factors of severe coronary lesions were male sex, diabetes, age, left ventricular dysfunction and no lipid-lowering treatment. It is important to identify these at-risk patients, as they should be explored at an asymptomatic stage before a cardiovascular event and receive prompt treatment with angioplasty or surgery.

Acute ulcerative jejunal diverticulitis:Case report of an uncommon entity

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations.Its reported incidence varies from 0.05% to 6%.Although there is no consensus on the management of asymptomatic jejunal diverticular disease,some complications are potentially life threatening and require early surgical treatment.We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome.Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography (CT).As a result of the clinical and biological signs of early peritonitis,an emergency surgical exploration was performed.The first jejunal loop showed clear signs of jejunal diverticulitis.Primary segmental jejunum resection with end-to-end anastomosis was performed.Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis.The patient made an excellent rapid postoperative recovery.Jejunal diverticulum is rare but may cause serious complications.It should be considered a possible etiology of acute abdomen,especially in elderly patients with unusual symptomatology.Abdominal CT is the diagnostic tool of choice.The best treatment is emergency surgical management.

对比增强超声肝纤维化分期与METAVIR评分的多中心前瞻性研究

对99例活检诊断肝纤维化病人的对比增强超声评估肝纤维化程度进行了前瞻性评价。根据每条静脉内微泡到达时间的不同，计算门静脉与肝静脉间的微泡通过时间。对比增强超声检查后6个月内每例病人均接受了肝活检。组织学纤维化分为2级：①没有或中度纤维化（METAVIR分期的F0、F1与F2）或②重度纤维化（F3与F4）。

Evaluation of Doppler-ultrasonography in the diagnosis of transjugular intrahepatic portosystemic shunt dysfunction: A prospective study

AIM To prospectively evaluate the performance of Dopplerultrasonography(US) for the detection of transjugular intrahepatic portosystemic shunt(TIPS) dysfunction within a multicenter cohort of cirrhotic patients.METHODS This study was conducted in 10 french teaching hospitals. After TIPS insertion, angiography and liver Doppler-US were carried out every six months to detect dysfunction(defined by a portosystemic gradient ≥ 12 mm Hg and/or a stent stenosis ≥ 50%). The association between ultrasonographic signs and dysfunction was studied by logistic random-effects models, and the diagnostic performance of each Doppler criterion was estimated by the bootstrap method. This study was approved by the ethics committee of Tours.RESULTS Two hundred and eighteen pairs of examinations performed on 87 cirrhotic patients were analyzed. Variables significantly associated with dysfunction were: The speed of flow in the portal vein(P = 0.008), the reversal of flow in the right(P = 0.038) and left(P = 0.049) portal branch, the loss of modulation of portal flow by the right atrium(P = 0.0005), ascites(P = 0.001) and the overall impression of the operator(P = 0.0001). The diagnostic performances of these variables were low; sensitivity was < 58% and negative predictive value was < 73%. Therefore, dysfunction cannot be ruled out from Doppler-US. CONCLUSION The performance of Doppler-US for the detection of TIPS dysfunction is poor compared to angiography. New tools are needed to improve diagnosis of TIPS dysfunction.

gastro显影葡胺在治疗粘连性小肠梗阻中的作用

Background -This study aimed to determine whether an abdominal radiograph 8 hours after ingesting oral Telebrix Gastro is a reliable marker for non-operative management in patients with adhesive small bowel obstruction. Methods -During a 5-year period (January 1, 1995, through December 31, 2000), 97 patients were admitted for small bowel occlusion due to adhesion with no indication for immediate surgery. All received 100 mL of Telebrix Gastro via gastric tube for small bowel obstruction due to adhesion. If the contrast reached the colon within 8 hours on plain abdominal radiograph, the test was considered to be negative. Results -126 cases of small bowel occlusions were analyzed due to recurring episodes for 11 patients. The test was negative in 113 cases (89.7%), and in this group, only two patients underwent surgery, the remaining being managed non-operatively. The 13 cases (10.3%) with a positive test for occlusion underwent surgery. The sensitivity, specificity and accuracy of the finding of contrast media reaching the colon as an indicator for conservative treatment were 98%, 100%, and 98%, respectively. Conclusions -A water-soluble contrast study can be of significant help in the clinical management of patients suspected of having small bowel obstruction.

Unilateral Femoral Neck Fracture after Epileptic Seizure in Young Patient: A Case Report

Femoral neck fracture occurring after an epileptic seizure is a rare and under-diagnosed injury. The majority of the reported cases in literature are old patients with osteoporosis. Younger patients present several risk factors of osteopenia and the treatment remains controversial. We present an outcome of a 23 years old patient with unilateral femoral neck fracture occurring during an epileptic seizure and we discuss the associated multiple risk factors of osteopenia and osteonecrosis of the hip. The patient was brought to the emergency department of Teaching Hospital of Kamenge (CHUK) complaining of pain in his left hip that had been progressing for one month after an epileptic seizure. There is a history of HIV infection since birth and epileptic seizures with ongoing treatments for both diseases. Despite the high risk of avascular necrosis, the treatment choice has been influenced by the patient’s age and a conservative surgery by internal fixation with Dynamic Hip Screw has been made. Unfortunately, this treatment early resulted in osteonecrosis of the hip since HIV infection itself and the highly active anti-retroviral therapy increase its risk.

Superior Mesenteric Artery Syndrome: First Chadian Observation

Introduction: The extrinsic compression of the third portion of the duodenum between the superior mesenteric artery and the aorta defines superior mesenteric artery syndrome. It determines an acute or chronic high intestinal obstruction pattern. We report the first observed case in Chad. Observation: HH was a 19 year-old woman with abdominal pain and intermittent postprandial vomiting since she was 5 years old. During last 11 months, post-prandial vomiting was more frequent, and non resolved after medical treatment. Unquantified weight loss was reported. Body mass index at hospitalization was 9.8. An injected abdominal scan demonstrated significant gastroduodenal distension, upstream of a stenosis of the third duodenal portion. Aorto-mesenteric space and angle were reduced. At laparotomy internal derivation by duodenojejunostomy was done. Postoperative situation was uneventful. Conclusion: Superior mesenteric artery syndrome determines an acute or chronic intestinal obstruction. Injected abdominal scan is fundamental for diagnosis. The treatment is firstly conservative but the need of surgery is common.

Incomplete Situs Inversus Revealed by Acute Pain of the Right Hypochondrium

Situs inversus is an abnormal placement of the thoracic and/or abdominal organs that are inverted right/left from normal. It is a rare congenital malformation often discovered in childhood. In adults, it can lead to misdiagnosis. Clinical case: A 35-year-old female patient, seen in a hepatogastroenterology consultation for acute spontaneous pain in the right hypochondrium. She had no particular clinical history. A diagnosis of hepatopathy was suspected. Abdominal and pelvic CT scans showed the left liver, stomach and spleen in the right hypochondrium, but with the heart in place, suggesting incomplete situs inversus. The evolution in our patient was spontaneously resolved with analgesics and antispasmodics, which leads us to believe that the volvulus was probably partial and without other complications. Conclusion: In developing countries, antenatal diagnosis of situs inversus is rare and is usually made during a pathology that leads the patient to a medical consultation. CT is one of the key paraclinical examinations for its diagnosis as genetic tests are not widely available.

Duplication of the Inferior Vena Cava, Azygos Continuation and Retro Aortic Renal Vein: Fortuitous Discovery

We present a rare case associating inferior vena cava’s (IVC) complex variations. Anatomical, embryological and clinical aspects are discussed. Duplication’s discovery was fortuitous during an abdominal ultrasound and was confirmed by the CT scan. The latter also highlighted azygos continuation, retro aortic renal vein and an iliac venous anomaly. These variants are important to know in order to be able to differentiate them from lymphadenopathy, para-vertebral masses, and aortic pathologies. It is necessary to report them before any retroperitoneal surgery or interventional vascular procedure.

Inventory of Radiation Protection in Hospitals of Level III in Senegal

The aim of this study was to evaluate the level of protection of employees who are exposed to radiation in a level III hospital establishment. It was a descriptive cross-sectional survey of six months’ duration, involving eight level III Hospitals (Aristide Le Dantec, Fann, Hoggy, Hear, Abass Ndao, Pikine, Touba, and Thiès) in Senegal. Sixty-one of the one hundred questionnaires were recovered (overall response rate of 61%). The population of the study was mainly female (54.1%). The average age was 38.57 with extremes ranging from 23 to 65 years old. In the places where ionizing radiation sources are handled, only at the Aristide Le Dantec Hospital did we find a “competent person in radiation protection”. This explained the lack of a classification of employees and work areas. Forty out of sixty-one (73.77%) had no knowledge of the basic principles of radiation protection (justification, optimisation, dose limitation) and had not ever taken radiation holidays. For radiovigilance, exposure time limits to ionizing radiation concerned only 29/61 or 47.54% of the study population. The inverse square law of distance was known by only 40 workers, of whom 15 had no compliance. We found the presence of dosifilms in only 7/61 or 11.47% of the workers. On the other hand, the use of lead aprons was well established and concerned 57/61 workers, i.e., 93.44%. In sum, ionizing radiation causes adverse health effects. The absence of a good radiation protection culture in Senegal requires the presence of at least 4 to 5 competent persons in radiation protection for quality training of workers in radiobiology, radiopathology and radiation protection.

Anatomical Study of MRI Optic Chiasm at the Bamako Anatomy Laboratory

Roughly quadrangular, the chiasma presents many morphological variations. The optical chiasm, odd and symmetrical structure of the optical pathways, is a required passage of the axons of neurons for the visual pathways. Any modification of its morphology evokes a pathological process, generally tumoral. The quality of MRI images rivals that of anatomical slices. So the MRI is essential for the study of the chiasma. The aim of this work was to study the morphometry of the optic chiasm in patients addressed for cerebral MRI to the imaging department of the university hospital of the POINT-G, during the period from July 29, to November 30, 2016. All patients who had a normal examination of the optic chiasma, numbering 15, were included in this study. In 86.66% of cases the chiasma had a quadrilateral form. Its average length was 8.73 mm and its average width was 13 mm. The average thickness was 4.13 mm.

移植肾动脉狭窄:血管成形术径路和方法

目的用于评价两种径路的血管成形术的方法对移植肾动脉狭窄的治疗作用。材料与方法 18例移植肾动脉狭窄并高血压患者成功进行了血管成形术。18例中,15例患者血管狭窄位于外科手术血管吻合处或吻合处远侧端移植肾动脉主干,3例位于移植肾的肾内分支动脉。同侧股动脉径路用于治疗端-侧血管吻合的患者(n=10),对侧股动脉径路,用于治疗端-端血管吻合的患者(n=6)。16例采用股动脉径路,2例经肱动脉径路。疗效以临床随访、血管造影和超声追踪为评价。结果 18例移植肾动脉狭窄患者成功地施行了血管成形术。成形术后,所有病人均治愈。1例患者因为复发动脉狭窄,而再次作血管扩张,同时放置1个支撑器。第二次血管成形术后6个月,考虑病人已治愈。结论血管成形术是移植肾动脉狭窄所致长期高血压和肾功能减退的有效的、首选治疗方法。

腕管综合征时正中神经的扩散张量成像和纤维束示踪的初步研究结果

目的是为了显示在1.5TMR设备上进行人活体正中神经扩散张量成像和纤维束示踪的可行性,并评估健康志愿者与腕管综合征病人扩散成像的潜在不同。

皮肤MRI的可行性研究

本研究的目的是评价皮肤3TMRI的质量，阐述皮肤的3TMR解剖，讨论皮肤MRI的应用前景。为3TMRI系统研制了一个7cm单码元表面接收线圈，利用三维FIESTA采集序列和自旋回波T1加权序列（SE T1）获得薄层影像。36名健康志愿者被纳入研究并接受面部和小腿部的MRI检查．所获得影像由2位放射医师2次独立进行前瞻性分析。根据皮肤层次的显示与伪影的量评价影像质量。

CT引导经皮穿刺激光凝固治疗手和足的骨样骨瘤

除了在手、足等小管状骨以外，CT引导下经皮穿刺局部消融治疗骨样骨瘤已能在很大程度上替代外科手术。本研究目的是描述CT引导经皮穿刺激光凝固法治疗的15例手和足的骨样骨瘤的技术特点和CT结果。回顾性分析1994--2004年间在本院就诊的经CT引导下行激光凝固治疗的15例病人的医疗病历。

相继2种计算方法的CT检查中支气管测量值的可变性

本研究的目的是评估相继2种MDCT采集法，即能量等高线确定（EDEC）法和半最大化全宽（FWHM）法对支气管管腔面积（LA）和管壁面积（WA）测量的可变性。2种方法均为10个连续层面上包括42支LA〉4mm^2的段及亚段支气管，这样2次采集具有最佳匹配。对于这两种方法，重复MDCT采集的95％CI在LA为-1．59～1．5mm^2．在WA为-3-31～2．96mm^2。2次重复MDCT采集中．支气管测量的变异系数（CV10，即连续10个层面上的标准差与均值的百分比）具有显著相关性（r〉0．72；P〈0．0001）。

儿童肾细胞癌不典型的影像学表现

Renal cell carcinoma is rare in children and is usually found in late childhoo d. The authors report on an exceptional case of renal cell carcinoma in a 10-ye ar-old girl. The radiological aspect is misleading and has not been previously reported in the literature. Renal cortex was thin because of congenital megalour eter, so the tumor developed entirely into excretory cavities (to the proximal ureter), while a primitive urothelial disease (tumoral or inflammatory) was first evoked. The atrophied cortex was the tumoral starting point which prolapsed int o excretory cavities, upraising the urothelial epithelium.