Posterior Approach for Laparoscopic Pancreaticoduodenectomy to Prevent Replaced Hepatic Artery Injury

Background

Laparoscopic pancreaticoduodenectomy (PD) has become more popular despite its complexity and tendency for higher morbidity.1 Replaced right hepatic artery (RRHA) and replaced common hepatic artery (RCHA), both originating from the superior mesenteric artery (SMA), are the most significant and relatively common vascular anomalies in patients undergoing PD, occurring in 8.6–21 and 0.4–4.5 % of cases, respectively.2 ^, 3 An inadvertent injury to theses arteries may result in an intra- or postoperative bleeding, hepatic or bile duct ischemia, and consequent leakage or delayed stricture in the bilioenteric anastomosis.2 ^– 4 Therefore, preservation of these aberrant hepatic arteries is essential unless their resection is oncologically indicated.2 We describe a posterior approach that can be advantageous in laparoscopic PD for patients with a RRHA or RCHA.

Methods

The posterior approach was used in 81 laparoscopic PDs at the Institute Mutualiste Montsouris between 1994 and 2012.5 In brief, retropancreatic dissection is performed to complete kocherization and expose the posterolateral aspect of the SMA. The origin of the RRHA or RCHA can then be identified and dissected. After division of the pancreatic neck, the portal vein and RRHA or RCHA are separated off the pancreatic neck. In case of the RCHA, the gastroduodenal artery originating from the RCHA is divided during this dissection.

Results

The video shows a secure procedure to preserve a RCHA in laparoscopic PD by early identification and dissection of the aberrant artery via the posterior approach.

Conclusions

The posterior approach can help to prevent inadvertent RRHA or RCHA injury in laparoscopic PD.     

Quels marqueurs osseux chez les patients hémodialysés : phosphatases alcalines osseuses ou ß-CrossLaps ?

BackgroundBone turnover (BT) abnormalities are frequently observed in patients with chronic kidney disease. Bone biopsy remains the gold standard for diagnosis; however, its invasive nature has led to its decreased utilisation. The serum parathyroid hormone (PTH) level is not a reliable bone marker (BM) for BT assessment. The latest international recommendations suggest the use of total alkaline phosphatase (t-ALP) or bone-specific alkaline phosphatase (b-ALP), but not ß-CrossLaps (CTX). We compared b-ALP, t-ALP, and CTX levels in patients on haemodialysis (HD).MethodsAll HD patients at a single institution following a standard 3 × 4 to 3 × 5 hours schedule were included in the study, provided they were free from liver disease. Serum intact PTH, t-ALP, b-ALP, and CTX values were compared at baseline and after 18 months of treatment. A kinetic study was performed for pre- and postdialysis CTX values over a 2-week period. We described the longitudinal evolution of these BMs in two typical patients.ResultsA total of 98 patients on HD (46% female) were evaluated. The mean age was 69.8 ± 11 years and the mean duration of dialysis was 54.4 ± 61 months. At baseline, CTX (2.1 ± 1 μg/L) correlated well with b-ALP (18 ± 11 μg/L; r = 0.64; P < 0.001) and PTH (221 ± 165 pg/mL; r = 0.62; P < 0.001). The changes in these values at 18 months were also correlated (ΔCTX compared with Δb-ALP: r = 0.51; P < 0.001; Δb-ALP compared with ΔPTH: r = 0.37, P < 0.01). b-ALP and t-ALP (245 ± 132 U/L) were closely correlated (r = 0.78), as was their variation over 18 months (r = 0.67), but t-ALP did not correlate with PTH, and correlated poorly with CTX (r = 0.38). The CTX reduction ratio during standard dialysis was approximately 70 to 75% over each session, although predialysis values remained stable.ConclusionIn HD patients, mean CTX values are five times higher than the normal range. CTX appears to be an alternative to b-ALP for assessing BT. b-ALP remains the standard BM, despite being expensive, infrequently available in many laboratories, and not useful for patients with liver disease.     

The Mediating Effects of Alexithymia,Intolerance of Uncertainty,and Anxiety on the Relationship Between Sensory Processing Differences and Restricted and Repetitive Behaviours in Autistic Adults

Distress caused by sensory processing differences for autistic individuals may be reduced by repetitive behaviours (RRB), including repetitive motor (RMB) and insistence on sameness (ISB) behaviours. Intolerance of uncertainty (IU) and anxiety mediate the relationship between sensory processing and RRB in autistic children. We replicated this model in autistic adults, extending it to include alexithymia. Serial mediation, using data from 426 autistic adults, identified significant direct effects from sensory processing to RMB and ISB, and indirect effects through alexithymia-IU-anxiety for RMB, and IU alone, and alexithymia-IU for ISB. Different mechanisms may underpin RMB and ISB. Alexithymia alongside, IU and anxiety, should be considered when understanding the relationship between sensory processing and RRB, and when offering interventions to support autistic people.

     

Late hepatic artery pseudoaneurysm： A rare complication after resection of hilar cholangiocarcinoma

We report an unusual pathological entity of a pseudoaneurysm of the right hepatic artery, which developed two years after the resection of a type 11 hilar cholangiocarcinoma and secondary to an excessive skeletonization for regional lymphadenectomy and neoadjuvant external-beam radiotherapy. After a sudden and massive hematemesis, a multidetector computed tomographic angiography （MDCTA） showed a hepatic artery pseudoaneurysm. Angiography with embolization of the pseudoaneurysm was attempted using microcoils with adequate patency of the hepatic artery and the occlusion of the pseudoaneurysm. A new episode of hematemesis 3 wk later revealed a partial revascularization of the pseudoaneurysm. A definitive interventional radiological treatment consisting of transarterial embolization （TAE） of the right hepatic artery with stainless steel coils and polyvinyl alcohol particles was effective and welltolerated with normal liver function tests and without signs of liver infarction.     

Intrasacral rod fixation for pediatric lumbopelvic fusion

Purpose

This paper reports the authors’ 19 years experience with pediatric intrasacral rod fixation.

Methods

After insertion of two cannulated screws in S1 with and an original template guiding them into the anterior third of the endplate, two short fusion rods were inserted into the sacrum according to Jackson’s technique distally to S3. In neuromuscular scoliosis, pelvic obliquity was reduced by connecting the proximal and distal constructs, distraction or compression, and in situ rod bending. In children with high-grade spondylolisthesis, lumbosacral kyphosis was reduced by rotation of the sacrum and in situ bending.

Results

There were no direct neurological or vascular injuries. The main complication was infection (7 %). No pseudarthrosis or significant loss of correction at the lumbosacral junction was observed during follow-up.

Conclusions

Intrasacral rod fixation appears to be safe and reliable for lumbopelvic fusion in pediatric patients.

     

French Spine Surgery Society guidelines for management of spinal surgeries during COVID-19 pandemic

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019 in China, various measures have been adopted in order to attenuate the impact of the virus on the population. With regard to spine surgery, French physicians are devoted to take place in the national plan against COVID-19, the French Spine Surgery Society therefore decided to elaborate specific guidelines for management of spinal disorders during COVID-19 pandemic in order to prioritize management of patients. A three levels stratification was elaborated with Level I: Urgent surgical indications, Level II: Surgical indications associated to a potential loss of chance for the patient and Level III: Non-urgent surgical indications. We also report French experience in a COVID-19 cluster region illustrated by two clinical cases. We hope that the guidelines formulated by the French Spine Surgery Society and the experience of spine surgeons from a cluster region will be helpful in order optimizing the management of patients with urgent spinal conditions during the pandemic.