Anatomic bases for liver transplantation

Summary This study gathers the anatomic implications for a good liver transplantation. During hepatic removal a left hepatic a.exists in 20% of cases; a right hepatic artery originating from the superior mesenteric a. (SMA) can be the only arterial supply in 9% of cases; the whole lesser omentum has to be removed and the SMA from 6 cm to its origin. The SMA must be freed from the celiac ganglia and its ostium removed with the celiac trunk in an aortic patch cut on the anterior side in order to avoid the renal ostia. During total hepatectomy, dissection of the portal triad is often difficult because of portal hypertension dilating accessory portal veins (parabiliary arcade) and pedicular lymphatics. Nerve plexuses are thick in front of the hepatic artery or behind the portal triad. Transection of triangular ligaments leads to the retrohepatic inferior vena cava (IVC) that must be freed from its posterior tributaries (right suprarenal vein and inferior phrenic veins flowing either into the IVC or into the hepatic veins). One big problem during hepatic replacement is the biliary anastomosis which must be well irrigated. In the recipient, dissection up to the hilum preserves hepatic and pancreatico-duodenal pedicles. The biliary tract of the graft must be cut low, behind the pancreas, and several centimeters of the gastroduodenal artery must be preserved to save hepatic and gastroduodenal pedicles.

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Bases anatomiques de la transplantation hépatique

Résumé Ce travail rassemble les notions anatomiques nécessaires au bon déroulement d'une transplantation hépatique. Le prélèvement du greffon doit enlever tout le petit omentum contenant une éventuelle a. hépatique gauche née de l'a. gastrique gauche (20%) et emporter l'a. mésentérique supérieure jusqu'à 6 cm de son origine pour ne pas oublier une a. hépatique droite née de cette dernière: son ostium est pris avec le tronc clique dans un patch aortique découpé sur la face antérieure. Lors de l'hépatectomie totale, la dissection du pédicule hépatique est rendue délicate par l'hypertension portale qui dilate les veines portes diets accessoires (arcade parabiliaire) et les lymphatiques pédiculaires. Les plexus nerveux sont riches devant l'artère hépatique et derrière le pédicule. La section des ligaments triangulaires droit et gauche amène à la veine cave inférieure (VCI) rétro-hépatique qu'il faut libérer de ses afférences postérieures (en particulier la veine surrénale principale droite toujours haut située et les veines phréniques inférieures qui s'abouchent soit dans la VCI soit dans les veines hépatiques du carrefour). Lors du remplacement, l'anastomose biliaire doit être vascularisée. Chez le receveur la dissection jusqu'au hile permet de conserver les pédicules. La voie biliaire du greffon doit être coupée bas derrière le pancréas et les premiers centimètres de l'artère gastro-duodénale conservés pour préserver les pédicules hépatique et pancréaticoduodénal.

     

Contribution to the study of the tributaries and the termination of the external jugular vein

Summary The dissection of 100 external jugular veins in 50 cadavers was the object of this anatomic study. A certain number of notions concerning the afferent veins, the mode of termination and the valvular system of this vessel were defined. 1)Afferent veins. Along its pathway toward the deep venous system, the external jugular vein successively received: the transverse cervical vein in 88 cases (88%), usually opposite the intersection of the external jugular vein with the dorsal border of the sterno- cleidomastoid muscle; the suprascapular vein in 47 cases (47%); the anterior jugular vein in 46 cases (46%); the cervical vein or anastomosis with the latter in 13 cases (13%). 2)Mode of termination. Forty-three subjects presented a symmetric mechanism. 100 anastomoses can be classed into three types: in 60 cases (60%), the external jugular vein flowed into the jugulo-subclavian venous confluence; in 36 cases (36%), in to the subclavian vein at a distance from its junction with the internal jugular vein; in 4 cases (4%) in to the trunk of the internal jugular vein. 3)Study of the valves. There were studied in 25 subjects (50 external jugular veins). The valves were found in the ostial and paraostial position in 49 out of 50 veins.

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Contribution à l'étude des afférences et de la terminaison de la veine jugulaire externe

Résumé Cette étude anatomique repose sur la dissection de 100 vv. jugulaires externes chez 50 cadavres. Elle a permis de préciser un certain nombre de notions concernant les veines afférentes, le mode de terminaison et le système valvulaire de ce vaisseau. 1)Veines afférentes. Le long de son trajet vers le sytème veineux profond, la v. jugulaire externe reçoit successivement: la v. cervicale transverse dans 88 cas (88 %), habituellement en regard du croisement de la v. jugulaire externe avec le bord dorsal du m. sterno-cléido-mastoïdien ; la v. supra-scapulaire dans 47 cas (47 %); la v. jugulaire antérieure dans 46 cas (46 %) ; la v. céphalique ou une anastomose avec celle-ci dans 13 cas (13 %). 2)Mode de terminaison. Quarante trois sujets présentent un dispositif symétrique. Les 100 abouchements peuvent être classés en trois types : dans 60 cas (60 %) la v. jugulaire externe se déverse dans le confluent veineux jugulo-subclavier ; dans 36 cas (36 %), dans la v. subclavière à distance de sa réunion avec la v. jugulaire interne ; dans 4 cas (4 %) dans le tronc de la v. jugulaire interne. 3)Etude des valvules. Recherchées chez 25 sujets (50 vv. jugulaires externes), les valvules ont été retrouvées dans 49 cas sur 50 en position ostiale ou paraostiale.

     

The ileoanal J pouch: radiographic evaluation

Endorectal ileoanal pull-through offers an attractive alternative to proctocolectomy and ileostomy for patients with ulcerative colitis, Gardner syndrome, and familial polyposis. To our knowledge, a careful radiographic analysis of the ileum, ileal pouch, and ileoanal anastomosis after ileoanal pull-through has not been reported. Thirty-two patients with ulcerative colitis, Gardner syndrome, and familial polyposis underwent colectomy, mucosal proctectomy, and endorectal ileoanal pull-through of a 15-cm ileal "J" pouch and loop ileostomy. Twenty-five (78%) of 32 of all the pouches radiographically demonstrated spiral folds extending from the middle of the pouch to the pectinate line. Other radiographic features included a mesenteric mass effect, pseudopolyps, and a central lucency that indicated intrapouch sutures. Radiographs provide useful information in the postoperative management of the ileal pull-through.     

The effects of exposure to microgravity and reconditioning of the lumbar multifidus and anterolateral abdominal muscles: implications for people with LBP

BACKGROUND CONTEXTOne of the primary changes in the neuromuscular system in response to microgravity is skeletal muscle atrophy, which occurs especially in muscles that maintain posture while being upright on Earth. Reduced size of paraspinal and abdominal muscles has been documented after spaceflight. Exercises are undertaken on the International Space Station (ISS) during and following space flight to remediate these effects. Understanding the adaptations which occur in trunk muscles in response to microgravity could inform the development of specific countermeasures, which may have applications for people with conditions on Earth such as low back pain (LBP).PURPOSEThe aim of this study was to examine the changes in muscle size and function of the lumbar multifidus (MF) and anterolateral abdominal muscles (1) in response to exposure to 6 months of microgravity on the ISS and (2) in response to a 15-day reconditioning program on Earth.DESIGNProspective longitudinal series.PATIENT SAMPLEData were collected from five astronauts who undertook seven long-duration missions on the ISS.OUTCOME MEASURESFor the MF muscle, measures included cross-sectional area (CSA) and linear measures to assess voluntary isometric contractions at vertebral levels L2 to L5. For the abdominal muscles, the thickness of the transversus abdominis (TrA), obliquus internus abdominis (IO) and obliquus externus abdominis (EO) muscles at rest and on contraction were measured.METHODSUltrasound imaging of trunk muscles was conducted at four timepoints (preflight, postflight, mid-reconditioning, and post reconditioning). Data were analyzed using multilevel linear models to estimate the change in muscle parameters of interest across three time periods.RESULTSBeta-coefficients (estimates of the expected change in the measure across the specified time period, adjusted for the baseline measurement) indicated that the CSA of the MF muscles decreased significantly at all lumbar vertebral levels (except L2) in response to exposure to microgravity (L3=12.6%; L4=6.1%, L5=10.3%; p<.001), and CSAs at L3-L5 vertebral levels increased in the reconditioning period (p<.001). The thickness of the TrA decreased by 34.1% (p<.017), IO decreased by 15.4% (p=.04), and the combination of anterolateral abdominal muscles decreased by 16.2% (p<.001) between pre- and postflight assessment and increased (TrA<0.008; combined p=.035) during the postreconditioning period. Results showed decreased contraction of the MF muscles at the L2 (from 12.8% to 3.4%; p=.007) and L3 (from 12.2% to 5%; p=.032) vertebral levels following exposure to microgravity which increased (L2, p=.046) after the postreconditioning period. Comparison with preflight measures indicated that there were no residual changes in muscle size and function after the postreconditioning period, apart from CSA of MF at L2, which remained 15.3% larger than preflight values (p<.001).CONCLUSIONSIn-flight exercise countermeasures mitigated, but did not completely prevent, changes in the size and function of the lumbar MF and anterolateral abdominal muscles. Many of the observed changes in size and control of the MF and abdominal muscles that occurred in response to prolonged exposure to microgravity paralleled those seen in people with LBP or exposed to prolonged bed rest on Earth. Daily individualized postflight reconditioning, which included both motor control training and weight-bearing exercises with an emphasis on retraining strength and endurance to re-establish normal postural alignment with respect to gravity, restored the decreased size and control of the MF (at the L3-L5 vertebral levels) and anterolateral abdominal muscles. Drawing parallels between changes which occur to the neuromuscular system in microgravity and which exercises best recover muscle size and function could help health professionals tailor improved interventions for terrestrial populations. Results suggested that the principles underpinning the exercises developed for astronauts following prolonged exposure to microgravity (emphasizing strength and endurance training to re-establish normal postural alignment and distribution of load with respect to gravity) can also be applied for people with chronic LBP, as the MF and anterolateral abdominal muscles were affected in similar ways in both populations. The results may also inform the development of new astronaut countermeasures targeting the MF and abdominal muscles.     

Antagonistic properties of the suramin analogue NF023 at heterologously expressed P2X receptors

The suramin analogue 8,8'-(carbonylbis(imino-3,1-phenylene carbonylimino)bis(1,3,5-naphthalenetrisulfonic acid) (NF023) antagonizes in a competitive fashion P2X receptor-mediated responses in certain vascular and visceral smooth muscles. In the present study, the effect of NF023 on voltage-clamped Xenopus oocytes heterologously expressing homomultimeric P2X1-P2X4 as well as heteromultimeric P2X2/P2X3 receptors has been characterized. P2X1 receptors were most sensitive to inhibition by NF023 with IC50 values of 0.24 and 0.21 microM for the rat and human homologue, respectively. P2X3 receptors have an intermediate sensitivity with IC50 values of 8.5 and 28.9 microM for rat and human subtypes, respectively and P2X2 was the least sensitive subtype (IC50 > 50 microM). P2X4 receptors were insensitive to NF023 at concentrations up to 100 microM. Coexpression of rat P2X3 with rat P2X2 resulted in receptors whose sensitivity to NF023 was identical to that obtained for homomultimeric rat P2X3 receptors (alphabeta meATP as agonist; IC50 = 1.4 and 1.6 microM, respectively). NF023 inhibited P2X1 receptors in a voltage-insensitive manner. In addition, NF023 (5 and 30 microM) caused a shift of the concentration-response curve to the right without affecting the maximal response to ATP (K(B) = 1.1 +/- 0.2 microM). Our results indicate that NF023 is a subtype-selective and surmountable antagonist at P2X1 receptors heterologously expressed in Xenopus oocytes.     

Proliferative lesions of oviduct and uterus in CD-1 mice exposed prenatally to tamoxifen

Tamoxifen (TAM) is widely used as adjuvant breast cancer therapy after surgery and as a chemopreventive agent in women of child-bearing age. However, TAM therapy has been shown to result in an increased incidence of endometrial carcinoma in women. The present study was designed to investigate the effects of TAM (5 mg/kg and 7.5 mg/kg body wt) given i.g. to pregnant CD-1 mice (1x/day, days 12 through 18 of gestation) on their female offspring. Progressive proliferative hyperplasia of the oviduct was frequently seen in TAM-exposed offspring, reaching 100% incidence by 52 weeks in both treatment groups. These females also developed progressive proliferative uterine lesions, including moderate/severe cystic endometrial hyperplasia (34-50%) and polypoid adenomas (27-30%) between 53 and 78 weeks. Deciduomas (15%) occurred at young ages (12 and 24 weeks) while leiomyomas (14%), a malignant leiomyosarcoma, and ovarian granulosa cell tumors (14%), were found between 72 and 78 weeks. Our findings thus suggest a strong association between transplacental TAM and reproductive tract abnormalities in female CD-1 mice.      

Hypoglycémie hyperinsulinémique persistante du nouveau-né et du nourrisson

Persistent hyperinsulinemic hypoglycaemia of infancy (PHHI) is the most frequent cause of hypoglycaemia in infancy. Clinical presentation is heterogeneous, with variable onset of hypoglycaemia and response to diazoxide, and presence of sporadic or familial forms. Underlying histopathological lesions can be focal or diffuse. Focal lesions are characterised by focal hyperplasia of pancreatic islet-like cells, whereas diffuse lesions implicate the whole pancreas. The distinction between the two forms is important because surgical treatment and genetic counselling are radically different. Focal lesions correspond to somatic defects which are totally cured by limited pancreatic resection, whereas diffuse lesions require a subtotal pancreatectomy exposing to high risk of diabetes mellitus. Diffuse lesions are due to functional abnormalities involving several genes and different transmission forms. Recessively inherited PHHI have been attributed to homozygote mutations for the beta-cell sulfonylurea receptor (SUR1) or the inward-rectifying potassium-channel (Kir6.2) genes. Dominantly inherited PHHI can implicate the glucokinase gene, particularly when PHHI is associated with diabetes, the glutamate dehydrogenase gene when hyperammonaemia is associated, or another locus.