Publications by authors named "Manuela Perez"

38 Publications

Sarcopenia in Children With End-Stage Liver Disease on the Transplant Waiting List.

Liver Transpl 2021 Jan 18. Epub 2021 Jan 18.

Division of Gastroenterology, Hepatology, and Nutrition, the Hospital for Sick Children, Toronto, Ontario, Canada.

Sarcopenia predicts morbidity and mortality in adults with end-stage liver disease (ESLD) and is determined by total psoas muscle area (tPMA) measurement from computed tomography (CT) imaging. Recently developed pediatric age- and sex-specific tPMA growth curves provide the opportunity to ascertain prevalence and impact of sarcopenia in children awaiting liver transplantation (LT). This retrospective single-center study evaluated sarcopenia in children between 1 and 16 years with ESLD and a clinically indicated abdominal CT less than 3 months before first isolated LT. Sarcopenia was defined as tPMA z score less than -2 measured at the intervertebral L4-5 level. Patient demographic, biochemical, and outcome data were recorded. tPMA was compared with other measures of nutritional status using univariate and multivariate logistic analyses. Outcome measures included 1-year morbidity events and mortality after LT. CT images from 25 (64% female) children with median age of 5.50 (interquartile range [IQR], 3.75-11.33) years were reviewed. Ten children (40%) had a tPMA z score less than -2. Sarcopenia was associated with lower z scores for weight (odds ratio [OR], 0.38; P = 0.02), height (OR, 0.32; P = 0.03), and nutritional support before LT (OR, 12.93; P = 0.01). Sarcopenic children had a longer duration of pediatric intensive care unit (PICU) stay (3.50 [IQR, 3.00-6.00] versus 2.00 [IQR, 2.00-3.50] days; P = 0.03). Sarcopenia was prevalent in 40% of children with ESLD awaiting LT, and lower tPMA z score was associated with deficient anthropometrics and need for nutritional support before LT. Post-LT PICU duration was increased in children with sarcopenia, reflecting adverse outcomes associated with muscle loss. Further studies are needed to elucidate the underlying mechanisms of sarcopenia in children with ESLD.
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http://dx.doi.org/10.1002/lt.25985DOI Listing
January 2021

Feasibility of Using Elastography Ultrasound in Pediatric Localized Scleroderma (Morphea).

Ultrasound Med Biol 2020 Dec 18;46(12):3218-3227. Epub 2020 Sep 18.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.

Assessment and monitoring of inflammation and tissue damage is crucial in localized scleroderma (LS), but validated diagnostic tools are lacking. We aimed to determine the feasibility of using acoustic radiation force imaging ultrasound elastography in the assessment of pediatric-onset LS lesions. Conventional ultrasound and shear-wave elastography (SWE) imaging were used to characterize changes in pre-assigned LS lesions in 13 prospectively recruited participants. Contralateral sites were used as controls. Mean SWE values were compared. LS lesions were significantly stiffer than control sites in the dermis and the hypodermis using both parametric and non-parametric tests, before and after skin-thickness normalization. We show that SWE imaging is a feasible way to discriminate between normal skin and LS lesions in the pediatric population.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2020.08.007DOI Listing
December 2020

[Acute abdominal and lumbar pain in traveler and migrant].

Rev Prat 2019 Oct;69(8):e286

Département de médecine interne et d'immunologie clinique, CHRU de Nancy-Brabois, 54511 Vandoeuvre-lès-Nancy Cedex, France.

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October 2019

[Acute abdominal pain of the elderly].

Rev Prat 2019 Oct;69(8):e285

Département de médecine interne et d'immunologie clinique, CHRU de Nancy-Brabois, 54511 Vandoeuvre-lès-Nancy Cedex, France.

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October 2019

[Acute abdominal and lumbar pain in the child and adult. Part Adult].

Rev Prat 2019 Oct;69(8):e271-e284

Département de médecine interne et d'immunologie clinique, CHRU de Nancy-Brabois, 54511 Vandoeuvre-lès-Nancy Cedex, France.

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October 2019

Concurrent, face, content, and construct validity of the RobotiX Mentor simulator for robotic basic skills.

Int J Med Robot 2020 Jun 14;16(3):e2100. Epub 2020 Mar 14.

Department of Visceral, Metabolic and Cancerology Surgery, Brabois Hospital, University Hospital of Nancy, Vandœuvre-lès-Nancy, France.

Objectives: To assess several criteria, such as concurrent, face, content, and construct validity of the RobotiX Mentor (RXM) simulator for basic robotic skills and to compare virtual and actual dry lab dome.

Methods: A prospective study was conducted from December 2017 to May 2018 using RXM and a da Vinci Si robot. 37 subjects, divided into three groups according to their initial surgical training (expert, intermediate, and novice), were evaluated in terms of six representative exercises of basic robotic specific skills as recommended by the fundamentals of robotic surgery.

Results: There was a correlation between the automatic data from the RXM and the subjective evaluation with the robot. The face and content validity, which were evaluated by the experts, were generally considered high (71.5% and 62.5%, respectively). Three levels (analysis of variance [ANOVA]; P = .01) and two levels (P = .001) of experience were clearly identified by the simulator.

Conclusion: Our study proves the concurrent validity and confirms the face, content, and construct validity of the RXM.
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http://dx.doi.org/10.1002/rcs.2100DOI Listing
June 2020

Paediatric reference values for total psoas muscle area.

J Cachexia Sarcopenia Muscle 2020 04 9;11(2):405-414. Epub 2020 Jan 9.

Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: Sarcopenia, the unintentional loss of skeletal muscle mass, is associated with poor outcomes in adult patient populations. In adults, sarcopenia is often ascertained by cross-sectional imaging of the psoas muscle area (PMA). Although children with chronic medical illnesses may be at increased risk for muscle loss because of nutritional deficiencies, physical deconditioning, endocrine anomalies, and systemic inflammation, consistent quantitative definitions for sarcopenia in children are lacking. We aimed to generate paediatric reference values for PMA at two intervertebral lumbar levels, L3-4 and L4-5.

Methods: In this cross-sectional study, we analysed abdominal computed tomography scans of consecutive children presenting to the emergency department. Participants were children 1-16 years who required abdominal cross-sectional imaging after paediatric trauma between January 1, 2005 and December 31, 2015 in a large Canadian quaternary care centre. Children with a documented chronic medical illness or an acute spinal trauma at presentation were excluded. Total PMA (tPMA) at levels L3-4 and L4-5 were measured in square millimetres (mm ) as the sum of left and right PMA. Age-specific and sex-specific tPMA percentile curves were modelled using quantile regression.

Results: Computed tomography images from 779 children were included. Values of tPMA at L4-5 were significantly larger than at L3-4 at all ages, but their correlation was high for both girls (r = 0.95) and boys (r = 0.98). Amongst girls, tPMA 50th percentile values ranged from 365 to 2336 mm at L3-4 and from 447 to 2704 mm for L4-5. Amongst boys, 50th percentile values for tPMA ranged between 394 and 3050 mm at L3-4 and from 498 to 3513 mm at L4-5. Intraclass correlation coefficients were excellent at L3-4 (0.97, 95% CI 0.94 to 0.981) and L4-5 (0.99, 95% CI 0.986 to 0.995). Weight and tPMA were correlated, stratified by sex for boys (L3-4 r = 0.90; L4-5 r = 0.90) and for girls (L3-4 r = 0.87; L4-5 r = 0.87). An online application was subsequently developed to easily calculate age-specific and sex-specific z-scores and percentiles.

Conclusions: We provide novel paediatric age-specific and sex-specific growth curves for tPMA at intervertebral L3-4 and L4-5 levels for children between the ages of 1-16 years. Together with an online tool (https://ahrc-apps.shinyapps.io/sarcopenia/), these tPMA curves should serve as a reference enabling earlier identification and targeted intervention of sarcopenia in children with chronic medical conditions.
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http://dx.doi.org/10.1002/jcsm.12514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113526PMC
April 2020

Exploration of peripancreatic lymphatic pathways in a live porcine model.

Ann Anat 2019 Sep 5;225:57-64. Epub 2019 Jul 5.

School of Surgery of Nancy, University of Lorraine, Nancy, France; IADI, INSERM U1254, University of Lorraine, Nancy, France.

Pancreatic cancer is associated with a poor prognosis, mainly due to lymph node invasion and lymph node recurrence after surgical resection, even after extended lymphadenectomy. The peripancreatic lymphatic system is highly complex and the specific lymphatic drainage of each part of the pancreas has not been established. The aim of this study was to determine the lymphatic drainage pathways specific to each part of the pancreas on live pigs using Patent Blue. The pancreases of 14 live pigs were injected in different parts of the gland. The technique was efficient and reproducible. The diffusion patterns were similar for each location and were reported. Our results in pigs allowed us to define specific nodal relay stations and lymphatic drainage for each part of the pancreas and confirm that independent anatomical-surgical pancreatic segments can be described. It is interesting to note that lymphatic drainage for the upper part of the proximal part of pancreas (duodenal lobe) occurred on the left side of the portal vein. This suggests that lymph node resection during cephalic duodenopancreatectomy in humans should be extended to the left side of the mesenteric vein, and probably to the right side of the superior mesenteric artery, as recently suggested. These results could help surgeons perform safe anatomical-segmental pancreatic resections with accurate lymphadenectomies and improve survival in patients with pancreatic cancer. Based on these results we will perform an innovative prospective study. Patent Blue will be injected into different parts of the gland in patients operated for pancreatic resection, and lymphatic diffusion of the dye will be recorded in relation to their origin from the theoretical pancreatic segments (ClinicalTrials.gov Identifier: NCT03597230).
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http://dx.doi.org/10.1016/j.aanat.2019.06.003DOI Listing
September 2019

Characterization of MP01 and MP02 and Assessment of Their Potential for the Prevention of Gastrointestinal Infections in an Experimental Canine Model.

Front Microbiol 2019 24;10:1117. Epub 2019 May 24.

Department of Nutrition and Food Science, Complutense University of Madrid, Madrid, Spain.

The aim of the present study was to evaluate the probiotic potential of MP01 and MP02, two strains isolated from canine milk. These two isolates were characterized for their survival to conditions similar to those found in the canine gastrointestinal tract, production of antimicrobial compounds, adherence to intestinal mucin, degradation of mucin, and antibiotic sensitivity. Globally, both strains exhibited a high probiotic potential. Finally, their potential for the prevention of gastrointestinal infections was evaluated in an experimental canine model using 1-month-old puppies. A group of 12 German shepherd puppies, 6 males and 6 females, received MP01 daily for 2 months and a second group of 12 puppies, 6 males and 6 females, of the same breed received MP02 during the same period of time. The same experimental approach was carried with Yorkshire puppies. Additionally, the trial included 12 dogs of each breed in the placebo groups. The results demonstrated that administration of the strains resulted in a significant preventive effect of gastrointestinal infections in such populations.
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http://dx.doi.org/10.3389/fmicb.2019.01117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543525PMC
May 2019

Quantification of Pediatric Burn Scar Stiffness Using Acoustic Radiation Force Impulse Ultrasound Elastography.

Ultrasound Med Biol 2019 08 17;45(8):1918-1923. Epub 2019 May 17.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address:

The purpose of this study was to quantify the stiffness of hypertrophic scars using acoustic radiation force impulse ultrasound elastography. Sixteen pediatric patients with hypertrophic scars resulting from burn injuries participated in this study (mean age: 5.13, standard deviation: 3.20). Values for the elastic modulus (E) of scar and control sites were obtained. Scarred areas were found to be almost four times stiffer than control sites (scar E = 39.29 kPa compared with control E = 10.19 kPa) (p = 0.0004). Correlations between scar stiffness and clinician-reported subjective scar scale scores were not observed (r = 0.30, p = 0.27 and r = 0.25, p = 0.35 respectively). We found that acoustic radiation force impulse imaging can discriminate between hypertrophic scars and normal skin and should be considered a potentially valuable tool in the armamentarium of objective scar measures. Future research should focus on evaluating the technology's ability to detect scar change over time in order to determine responsiveness to treatment.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2019.03.013DOI Listing
August 2019

Easing anxiety in preparation for pediatric magnetic resonance imaging: a pilot study using animal-assisted therapy.

Pediatr Radiol 2019 07 27;49(8):1000-1009. Epub 2019 Apr 27.

Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Children undergoing magnetic resonance imaging (MRI) can experience negative emotions both before and during their scan, causing them to move and often necessitating the use of procedural sedation. Several strategies to improve patient compliance have been attempted.

Objective: This study was designed to evaluate the effectiveness of a non-pharmacological intervention to reduce anxiety in pediatric patients preparing for MRI using animal-assisted therapy.

Materials And Methods: An animal intervention pilot study was performed in patients who agreed in advance to interact with a dog. Patients and caregivers filled out questionnaires, including questions designed to capture changes in patient emotion before and after the intervention. MRI diagnostic quality was compared to age- and gender-matched control groups with and without general anesthesia.

Results: The intervention in 21 patients comparing pre- and post-scan surveys demonstrated a statistically significant improvement in patient anxiety levels (P<0.01). Diagnostic MRI scans were achieved in 19/21 (90%), with no significant difference in exam quality or times compared against control groups. The majority of caregivers and staff members agreed strongly that patients benefited from the therapy dog's presence.

Conclusion: The use of animal-assisted therapy in a pilot group in our MRI division resulted in a beneficial effect on patients' emotional status, easing anxiety in preparation for scheduled scans, without impacting MRI quality or duration. Further randomized studies will be needed to demonstrate its significance in reducing sedation rates in children undergoing MRI.
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http://dx.doi.org/10.1007/s00247-019-04407-3DOI Listing
July 2019

Preliminary Definitions for Sacroiliac Joint Pathologies in the OMERACT Juvenile Idiopathic Arthritis Magnetic Resonance Imaging Score (OMERACT JAMRIS-SIJ).

J Rheumatol 2019 09 15;46(9):1192-1197. Epub 2019 Feb 15.

From the Institute of Medical Sciences, Faculty of Medicine, University of Toronto; Department of Diagnostic Imaging, The Hospital for Sick Children; Department of Translational Medicine, SickKids Research Institute, Peter Gilgan Center for Research and Learning; Dalla Lana School of Public Health, University of Toronto; Division of Rheumatology, The Hospital for Sick Children, University of Toronto; Department of Medical Imaging, University of Toronto; Department of Rheumatology, Center for Prognosis Studies in Rheumatologic Diseases, Toronto Western Hospital, Toronto, Ontario; Department of Rheumatology, University of Alberta; Department of Radiology and Diagnostic Imaging, University of Alberta; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds; UK National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, UK; Department of Rheumatology, Leiden University Medical Center, Leiden; Reade | Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands; University of Pennsylvania Perelman School of Medicine, Division of Rheumatology, Children's Hospital of Philadelphia and Departments of Pediatric and Epidemiology, Philadelphia, Pennsylvania; Department of Radiology, Nemours Children's Hospital and Health System, Orlando, Florida, USA; Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland; Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium; Department of Radiology, Hospital Sant Joan de Deu, Barcelona, Spain; Department of Radiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Pediatric Rheumatology Research Institute, Bad Bramstedt, Germany; Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India; State University of Campina-UNICAMP, Department of Internal Medicine, Cidade Universitaria, Sao Paulo, Brazil.

Objective: To develop definitions for the assessment of magnetic resonance imaging (MRI) pathologies of the sacroiliac joints (SIJ) in juvenile idiopathic arthritis.

Methods: An Outcome Measures in Rheumatology (OMERACT) consensus-driven methodology consisting of iterative surveys and focus group meetings within an international group of rheumatologists and radiologists.

Results: Two domains, inflammation and structural, were identified. Definitions for bone marrow edema, joint space inflammation, capsulitis, and enthesitis were derived for joint inflammation; sclerosis, erosion, fatty lesion, and ankylosis were defined for assessing structural joint changes.

Conclusion: Preliminary consensus-driven definitions for inflammation and structural elements have been derived, underpinning the ongoing development of the OMERACT Juvenile Arthritis MRI SIJ scoring system (OMERACT JAMRIS-SIJ).
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http://dx.doi.org/10.3899/jrheum.181115DOI Listing
September 2019

A radio-anatomical correlation study of the cisterna chyli.

J Anat 2018 11 12;233(5):679-684. Epub 2018 Aug 12.

Faculty of Medicine and University Hospital, Department of Anatomy, University of Lorraine, Nancy, France.

Surgical laparoscopic procedures in the retroperitoneal and supramesocolic spaces are increasingly frequent. There is a high risk of iatrogenic intraoperative injury of the retroperitoneal lymphatic structures during these procedures. A precise understanding of the anatomy of the thoracic duct (TD) and the cisterna chyli (CC) is essential for safe surgical procedures in this area. However, routine imaging procedures rarely and often incorrectly visualize the CC. The objective of this study was to evaluate the feasibility of a retrograde injection of the TD to fill the CC with a contrast agent in 16 human cadavers. Both magnetic resonance lymphography (MRI) and computed tomography (CT) studies could be performed on the same anatomical specimen, using a contrast medium which hardened, allowing gross dissection. MRI and CT detectability were evaluated, and imaging results were compared with the anatomical dissection. The CC of 12/16 cadavers were successfully injected, and four were unsuccessful due to technical difficulties, showing the effectiveness of the method. This technique can improve understanding of the anatomy of the TD and CC and provides an original option to study the complex anatomy of these structures by correlating precise cadaveric dissections with cross-sectional imaging.
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http://dx.doi.org/10.1111/joa.12869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6183002PMC
November 2018

Face and content validity of Xperience™ Team Trainer: bed-side assistant training simulator for robotic surgery.

Updates Surg 2018 Mar 20;70(1):113-119. Epub 2017 Dec 20.

School of Surgery of Nancy, IADI, INSERM, U947, CHU Nancy Brabois, Lorraine University, Nancy, France.

In robotic surgery, the coordination between the console-side surgeon and bed-side assistant is crucial, more than in standard surgery or laparoscopy where the surgical team works in close contact. Xperience™ Team Trainer (XTT) is a new optional component for the dv-Trainer platform and simulates the patient-side working environment. We present preliminary results for face, content, and the workload imposed regarding the use of the XTT virtual reality platform for the psychomotor and communication skills training of the bed-side assistant in robot-assisted surgery. Participants were categorized into "Beginners" and "Experts". They tested a series of exercises (Pick & Place Laparoscopic Demo, Pick & Place 2 and Team Match Board 1) and completed face validity questionnaires. "Experts" assessed content validity on another questionnaire. All the participants completed a NASA Task Load Index questionnaire to assess the workload imposed by XTT. Twenty-one consenting participants were included (12 "Beginners" and 9 "Experts"). XTT was shown to possess face and content validity, as evidenced by the rankings given on the simulator's ease of use and realism parameters and on the simulator's usefulness for training. Eight out of nine "Experts" judged the visualization of metrics after the exercises useful. However, face validity has shown some weaknesses regarding interactions and instruments. Reasonable workload parameters were registered. XTT demonstrated excellent face and content validity with acceptable workload parameters. XTT could become a useful tool for robotic surgery team training.
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http://dx.doi.org/10.1007/s13304-017-0509-xDOI Listing
March 2018

A comparative analysis and guide to virtual reality robotic surgical simulators.

Int J Med Robot 2018 Feb 10;14(1). Epub 2017 Nov 10.

Florida Hospital Nicholson Center, Celebration, Florida, USA.

Background: Since the US Food and Drug Administration approved robotically assisted surgical devices for human surgery in 2000, the number of surgeries utilizing this innovative technology has risen. In 2015, approximately 650 000 robot-assisted procedures were performed worldwide. Surgeons must be properly trained to safely transition to using such innovative technology. Multiple virtual reality robotic simulators are now commercially available for educational and training purposes. There is a need for comparative evaluations of these simulators to aid users in selecting an appropriate device for their purposes.

Methods: We conducted a comparison of the design and capabilities of all dedicated simulators of the da Vinci robot - the da Vinci Skills Simulator (dVSS), dV-Trainer (dVT), Robotic Skills Simulators (RoSS) and the RobotiX Mentor. This paper provides the base specifications of the hardware and software, with an emphasis on the training capabilities of each system.

Results: Each simulator contains a large number of training exercises for skills development: dVSS n = 40, dVT n = 65, RoSS n = 52, RobotiX Mentor n = 31. All four offer 3D visual images but use different display technologies. The dVSS leverages the real robotic surgical console to provide visualization, hand controls and foot pedals. The dVT, RoSS and RobotiX Mentor created simulated versions of all of these control systems. Each includes systems management services that allow instructors to collect, export and analyze the scores of students using the simulators.

Conclusions: This study provides comparative information on the four simulators' functional capabilities. Each device offers unique advantages and capabilities for training robotic surgeons. Each has been the subject of validation experiments, which have been published in the literature. But those do not provide specific details on the capabilities of the simulators, which are necessary for an understanding sufficient to select the one best suited for an organization's needs. This article provides comparative information to assist with that type of selection.
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http://dx.doi.org/10.1002/rcs.1874DOI Listing
February 2018

A guide for effective anatomical vascularization studies: useful ex vivo methods for both CT and MRI imaging before dissection.

J Anat 2018 Jan 11;232(1):15-25. Epub 2017 Oct 11.

Department of Anatomy, Faculty of Medicine and University Hospital, University of Lorraine, Nancy, France.

The objective of this study was to develop a simple and useful injection protocol for imaging cadaveric vascularization and dissection. Mixtures of contrast agent and cast product should provide adequate contrast for two types of ex vivo imaging (MRI and CT) and should harden to allow gross dissection of the injected structures. We tested the most popular contrast agents and cast products, and selected the optimal mixture composition based on their availability and ease of use. All mixtures were first tested in vitro to adjust dilution parameters of each contrast agent and to fine-tune MR imaging acquisition sequences. Mixtures were then injected in 24 pig livers and one human pancreas for MR and computed tomography (CT) imaging before anatomical dissection. Colorized latex, gadobutrol and barite mixture met the above objective. Mixtures composed of copper sulfate (CuSO ) gadoxetic acid (for MRI) and iodine (for CT) gave an inhomogeneous signal or extravasation of the contrast agent. Agar did not harden sufficiently for gross dissection but appears useful for CT and magnetic resonance imaging (MRI) studies without dissection. Silicone was very hard to inject but achieved the goals of the study. Resin is particularly difficult to use but could replace latex as an alternative for corrosion instead of dissection. This injection protocol allows CT and MRI images to be obtained of cadaveric vascularization and anatomical casts in the same anatomic specimen. Post-imaging processing software allow easy 3D reconstruction of complex anatomical structures using this technique. Applications are numerous, e.g. surgical training, teaching methods, postmortem anatomic studies, pathologic studies, and forensic diagnoses.
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http://dx.doi.org/10.1111/joa.12718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735051PMC
January 2018

Unraveling Pancreatic Segmentation.

World J Surg 2018 04;42(4):1147-1153

Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France.

Background: Limited pancreatic resections are increasingly performed, but the rate of postoperative fistula is higher than after classical resections. Pancreatic segmentation, anatomically and radiologically identifiable, may theoretically help the surgeon removing selected anatomical portions with their own segmental pancreatic duct and thus might decrease the postoperative fistula rate. We aimed at systematically and comprehensively reviewing the previously proposed pancreatic segmentations and discuss their relevance and limitations.

Methods: PubMed database was searched for articles investigating pancreatic segmentation, including human or animal anatomy, and cadaveric or surgical studies.

Results: Overall, 47/99 articles were selected and grouped into 4 main hypotheses of pancreatic segmentation methodology: anatomic, vascular, embryologic and lymphatic. The head, body and tail segments are gross description without distinct borders. The arterial territories defined vascular segments and isolate an isthmic paucivascular area. The embryological theory relied on the fusion plans of the embryological buds. The lymphatic drainage pathways defined the lymphatic segmentation. These theories had differences, but converged toward separating the head and body/tail parts, and the anterior from posterior and inferior parts of the pancreatic head. The rate of postoperative fistula was not decreased when surgical resection was performed following any of these segmentation theories; hence, none of them appeared relevant enough to guide pancreatic transections.

Conclusion: Current pancreatic segmentation theories do not enable defining anatomical-surgical pancreatic segments. Other approaches should be explored, in particular focusing on pancreatic ducts, through pancreatic ducts reconstructions and embryologic 3D modelization.
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http://dx.doi.org/10.1007/s00268-017-4263-5DOI Listing
April 2018

From dV-Trainer to Real Robotic Console: The Limitations of Robotic Skill Training.

J Surg Educ 2017 Nov - Dec;74(6):1074-1080. Epub 2017 Apr 24.

IADI/Inserm U947, Lorraine University, Nancy, France; Department of Emergency and General Surgery, CHU Nancy, Nancy, France. Electronic address:

Objectives: To investigate operators' performance quality, mental stress, and ergonomic habits through a training curriculum on robotic simulators.

Design: Forty volunteers without robotic surgery experience were recruited to practice 2 exercises on a dV-Trainer (dVT) for 14 hours. The simulator software (M-score) provided an automatic evaluation of the overall score for the surgeons' performance. Each participant provided a subjective difficulty score (validity to be proven) for each exercise. Their ergonomic habits were evaluated based on the workspace range and armrest load-validated criteria for evaluating the proficiency of using the armrest. They then repeated the same tasks on a da Vinci Surgical Skill Simulator for a final-level test. Their final scores were compared with their initial scores and the scores of 5 experts on the da Vinci Surgical Skill Simulator.

Results: A total of 14 hours of training on the dVT significantly improved the surgeons' performance scores to the expert level with a significantly reduced workload, but their ergonomic score was still far from the expert level.

Conclusion: Sufficient training on the dVT improves novices' performance, reduces psychological stress, and inculcates better ergonomic habits. Among the evaluated criteria, novices had the most difficulty in achieving expert levels of ergonomic skills. The training benefits of robotic surgery simulators should be determined with quantified variables. The detection of the limitations during robotic training curricula could guide the targeted training and improve the training effect.
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http://dx.doi.org/10.1016/j.jsurg.2017.03.006DOI Listing
August 2018

Effectiveness of an Integrated Video Recording and Replaying System in Robotic Surgical Training.

Ann Surg 2017 03;265(3):521-526

*IADI/Inserm U947, Lorraine University, Nancy, France †Department of Urology, Zhongnan Hospital, Wuhan University, Wuhan, China ‡Department of Urology, CHU Nancy, Nancy, France §Department of Emergency and General Surgery, CHU Nancy, Nancy, France.

Objective: This study evaluated the effectiveness of using a video recording and replaying system in robotic surgical training.

Summary Background Data: Robotic surgical videos are reviewed to accelerate the acquisition of robotic surgical skills. However, few professional recording and replaying systems have been used during robotic surgical training. The effectiveness of these professional video systems should be investigated and validated.

Methods: A randomized study was conducted to analyze the performance of 60 participants, who were unfamiliar with surgical robotics, in a robotic simulator. Participants were enrolled in 2 groups to perform 2 exercises on a Mimic dV-Trainer. One group was trained with the new protocol based on a recording and replaying system (controller of events on simulator and robot) and the other group was trained with the conventional method. The overall scores were automatically evaluated by the simulator. The number of additional requests for reviewing the videos or watching the trainer's demonstration and the learning curves based on the overall scores were compared between the 2 groups.

Results: The group trained with controller of events on simulator and robot presented a significantly improved learning curve in both exercises (P < 0.001) with more additional requests (P < 0.001) in comparison with the group trained with the conventional method.

Conclusions: In robotic skills training, the use of a recording and replay system is beneficial and more efficient than the conventional training method.
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http://dx.doi.org/10.1097/SLA.0000000000001699DOI Listing
March 2017

Quantitative Analysis of Subtalar Joint Motion With 4D CT: Proof of Concept With Cadaveric and Healthy Subject Evaluation.

AJR Am J Roentgenol 2017 Jan 3;208(1):150-158. Epub 2016 Nov 3.

1 Service d'Imagerie Guilloz, Hôpital Central, Centre Hospitalier Universitaire de Nancy, 29 Ave du Maréchal de Lattre de Tassigny, Nancy 54035, France.

Objective: The purpose of this study was to show the application of quantitative 4D CT for subtalar joint evaluation in healthy volunteers and cadavers.

Materials And Methods: Fifteen healthy volunteers with no history of subtalar joint trauma and three cadavers were prospectively evaluated with dynamic CT. The subtalar joint was evaluated during a pronosupination cycle. All acquisitions (cadavers and healthy volunteers) were performed using intermittent sequential mode with a 320-MDCT scanner. Angles and distances between the talus and the calcaneus were measured semiautomatically. Measurement variation was described in healthy volunteers and in cadavers, the latter before and after resection of the cervical and interosseous ligaments. The mean effective dose was below 0.1 mSv.

Results: In cadavers, mean increases in joint amplitude over 19% and of 22% were seen after partial ligament sectioning and after full ligament sectioning, respectively. The interobserver variability of the measurement ratios was considered to be excellent for three of the measurements made (ICC > 0.87) and moderate for the fourth (ICC = 0.57). The normal range of joint motion in healthy volunteers is described, with joint amplitudes varying from 6.4% to 22.8%.

Conclusion: Quantitative dynamic CT of the subtalar joint can provide a detailed analysis of joint motion, supporting its potential role in the evaluation of subtalar instability.
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http://dx.doi.org/10.2214/AJR.16.16434DOI Listing
January 2017

"Alarm-corrected" ergonomic armrest use could improve learning curves of novices on robotic simulator.

Surg Endosc 2017 01 17;31(1):100-106. Epub 2016 May 17.

IADI/Inserm U947, Lorraine University, 54000, Nancy, France.

Background: In robotic surgery, the professional ergonomic habit of using an armrest reduces operator fatigue and increases the precision of motion. We designed and validated a pressure surveillance system (PSS) based on force sensors to investigate armrest use. The objective was to evaluate whether adding an alarm to the PSS system could shorten ergonomic training and improve performance.

Study Design: Twenty robot and simulator-naïve participants were recruited and randomized in two groups (A and B). The PSS was installed on a robotic simulator, the dV-Trainer, to detect contact with the armrest. The Group A members completed three tasks on the dV-Trainer without the alarm, making 15 attempts at each task. The Group B members practiced the first two tasks with the alarm and then completed the final tasks without the alarm. The simulator provided an overall score reflecting the trainees' performance. We used the new concept of an "armrest load" score to describe the ergonomic habit of using the armrest.

Results: Group B had a significantly higher performance score (p < 0.001) and armrest load score (p < 0.001) than Group A from the fifth attempt of the first task to the end of the experiment.

Conclusions: Based on the conditioned reflex effect, the alarm associated with the PSS rectified ergonomic errors and accelerated professional ergonomic habit acquisition. The combination of the PSS and alarm is effective in significantly shortening the learning curve in the robotic training process.
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http://dx.doi.org/10.1007/s00464-016-4934-6DOI Listing
January 2017

The olfactory fascia: an evo-devo concept of the fibrocartilaginous nose.

Surg Radiol Anat 2016 Dec 3;38(10):1161-1168. Epub 2016 May 3.

Department of Anatomy, Pr M Braun, Faculty of Medicine of Nancy, 9 Avenue de la Foret de Haye CS50184, 54500, Vandoeuvre-les-Nancy, France.

Purpose: Evo-devo is the science that studies the link between evolution of species and embryological development. This concept helps to understand the complex anatomy of the human nose. The evo-devo theory suggests the persistence in the adult of an anatomical entity, the olfactory fascia, that unites the cartilages of the nose to the olfactory mucosa.

Methods: We dissected two fresh specimens. After resecting the superficial tissues of the nose, dissection was focused on the disarticulation of the fibrocartilaginous noses from the facial and skull base skeleton.

Results: Dissection shows two fibrocartilaginous sacs that were invaginated side-by-side in the midface and attached to the anterior skull base. These membranous sacs were separated in the midline by the perpendicular plate of the ethmoid. Their walls contained the alar cartilages and the lateral expansions of the septolateral cartilage, which we had to separate from the septal cartilage. The olfactory mucosa was located inside their cranial ends.

Conclusion: The olfactory fascia is a continuous membrane uniting the nasal cartilages to the olfactory mucosa. Its origin can be found in the invagination and differentiation processes of the olfactory placodes. The fibrous portions of the olfactory fascia may be described as ligaments that unit the different components of the olfactory fascia one to the other and the fibrocartilaginous nose to the facial and skull base skeleton. The basicranial ligaments, fixing the fibrocartilaginous nose to the skull base, represent key elements in the concept of septorhinoplasty by disarticulation.
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http://dx.doi.org/10.1007/s00276-016-1677-yDOI Listing
December 2016

Analysis of the position of the branches of the ulnar nerve in Guyon's canal using high-resolution MRI in positions adopted by cyclists.

Surg Radiol Anat 2016 Sep 6;38(7):793-9. Epub 2016 Jan 6.

Guilloz Imaging Department, CHU Nancy - Hôpital Central, Rue du Maréchal de Lattre de Tassigny, 54000, Nancy, France.

Purpose: To study variations in the anatomical relationships of the branches of the ulnar nerve in Guyon's canal relative to the hamulus of hamate (HH) in a grip encountered among cyclists.

Materials And Methods: Forty-seven wrist examinations were performed on a 3-T MRI (soft antenna, 16 channels) in propeller sequence in the plane perpendicular to the carpus in 28 healthy volunteers in three cycling positions (neutral, hyperextension and ulnar deviation). The positions and distance between the superficial (SB) and deep (DB) branches of the ulnar nerve with respect to the HH were determined on the section passing through the HH.

Results: The mean distances between the SB (d s) and DP (d p) and HH were 2.4 and 0.6 mm, respectively. The d s in hyperextension and ulnar deviation were 2.2 mm (P = 0.3) and 3 mm (P = 0.07), respectively. The d p in hyperextension and ulnar deviation were 0.3 mm (P = 0.02) and 0.5 mm (P = 0.15), respectively. Hyperextended, 60 % of SB and 40 % of DB were close to the HH, and 26 % of DB came directly in contact with it. In ulnar deviation, 30 % of SB and 29 % of DB approached HH, and 47 % of DB were in contact with it.

Conclusion: This study shows that SB and DB positions of the ulnar nerve vary with respect to the HH depending on the position of the wrist, and such differences may promote Guyon's canal syndrome in cyclists.
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http://dx.doi.org/10.1007/s00276-015-1612-7DOI Listing
September 2016

Face, content, construct, and concurrent validity of a novel robotic surgery patient-side simulator: the Xperience™ Team Trainer.

Surg Endosc 2016 08 10;30(8):3334-44. Epub 2015 Dec 10.

IADI/Inserm U947, Lorraine University, Nancy, 54000, France.

Objectives: To determine the face, content, construct, and concurrent validity of the Xperience™ Team Trainer (XTT) as an assessment tool of robotic surgical bed-assistance skills.

Methods: Subjects were recruited during a robotic surgery curriculum. They were divided into three groups: the group RA with robotic bed-assistance experience, the group LS with laparoscopic surgical experience, and the control group without bed-assistance or laparoscopic experience. The subjects first performed two standard FLS exercises on a laparoscopic simulator for the assessment of basic laparoscopic skills. After that, they performed three virtual reality exercises on XTT, and then performed similar exercises on physical models on a da Vinci(®) box trainer.

Results: Twenty-eight persons volunteered for and completed the tasks. Most expert subjects agreed on the realism of XTT and the three exercises, and also their interest for teamwork and bed-assistant training. The group RA and the group LS demonstrated a similar level of basic laparoscopic skills. Both groups performed better than the control group on the XTT exercises (p < 0.05). The performance superiority of the group RA over LS was observed but not statistically significant. Correlation of performance was determined between the tests on XTT and on da Vinci(®) box trainer.

Conclusions: The introduction of XTT facilitates the training of bedside assistants and emphasizes the importance of teamwork, which may change the paradigm of robotic surgery training in the near future. As an assessment tool of bed-assistance skills, XTT proves face, content, and concurrent validity. However, these results should be qualified considering the potential limitations of this exploratory study with a relatively small sample size. The training modules remain to be developed, and more complex and discriminative exercises are expected. Other studies will be needed to further determine construct validity in the future.
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http://dx.doi.org/10.1007/s00464-015-4607-xDOI Listing
August 2016

Robotic surgery simulation validity and usability comparative analysis.

Surg Endosc 2016 09 18;30(9):3720-9. Epub 2015 Nov 18.

Florida Hospital Nicholson Center, 404 Celebration Place, Celebration, FL, 34747, USA.

Background: The introduction of simulation into minimally invasive robotic surgery is relatively recent and has seen rapid advancement; therefore, a need exists to develop training curriculums and identify systems that will be most effective at training surgical skills. Several simulators have been introduced to support these aims-the daVinci skills simulator, Mimic dV-Trainer, Surgical Simulated Systems' RoSS, and Simbionix Robotix Mentor. While multiple studies have been conducted to demonstrate the validity of these systems, studies comparing the perceived value of these devices as tools for education and skills are lacking.

Methods: Subjects who qualified as medical students or physicians (n = 105) were assigned a specific order to use each of the three simulators. After completing a demographic questionnaire, participants performed one exercise on the three simulators and completed a second questionnaire regarding their experience with the device. After using all systems, they completed a final questionnaire, which detailed their comparative preferences. The subject's performance metrics were also collected from each simulator.

Results: The data confirmed the face, content, and construct validity for the dV-trainer and skills simulator. Similar validities could not be confirmed for the RoSS. >80 % of the time, participants chose the skills simulator in terms of physical comfort, ergonomics, and overall choice. However, only 55 % thought the skills simulator was worth the cost of the equipment. The dV-Trainer had the highest cost preference scores with 71 % of respondents feeling it was worth the investment.

Conclusions: Usability can affect the consistency and commitment of users of robotic surgical simulators. In a previous study, these simulators were objectively reviewed and compared in terms of their system capabilities. Collectively, this work will offer end-users and potential buyers a comparison of the perceived value and preferences of robotic simulators.
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http://dx.doi.org/10.1007/s00464-015-4667-yDOI Listing
September 2016

Impact of delay on telesurgical performance: study on the robotic simulator dV-Trainer.

Int J Comput Assist Radiol Surg 2016 Apr 8;11(4):581-7. Epub 2015 Oct 8.

Florida Hospital Nicholson Center, 404 Celebration Place, Celebration, FL, 34747, USA.

Purpose: To determine the impact of communication latency on telesurgical performance using the robotic simulator dV-Trainer®.

Methods: Surgeons were enrolled during three robotic congresses. They were randomly assigned to a delay group (ranging from 100 to 1000 ms). Each group performed three times a set of four exercises on the simulator: the first attempt without delay (Base) and the last two attempts with delay (Warm-up and Test). The impact of different levels of latency was evaluated.

Results: Thirty-seven surgeons were involved. The different latency groups achieved similar baseline performance with a mean task completion time of 207.2 s (p > 0.05). In the Test stage, the task duration increased gradually from 156.4 to 310.7 s as latency increased from 100 to 500 ms. In separate groups, the task duration deteriorated from Base for latency stages at delays ≥300 ms, and the errors increased at 500 ms and above (p < 0.05). The subjects' performance tended to improve from the Warm-up to the Test period. Few subjects completed the tasks with a delay higher than 700 ms.

Conclusion: Gradually increasing latency has a growing impact on performances. Measurable deterioration of performance begins at 300 ms. Delays higher than 700 ms are difficult to manage especially in more complex tasks. Surgeons showed the potential to adapt to delay and may be trained to improve their telesurgical performance at lower-latency levels.
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http://dx.doi.org/10.1007/s11548-015-1306-yDOI Listing
April 2016

Does anatomy explain the origin of a leak after sleeve gastrectomy? Comments & answers.

Obes Surg 2015 Apr;25(4):715-6

Department of Anatomy, Lorraine University, 2 Av. de la Forêt de Haye, 54501, Vandoeuvre-lès-Nancy, France,

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http://dx.doi.org/10.1007/s11695-014-1555-9DOI Listing
April 2015

Effect of latency training on surgical performance in simulated robotic telesurgery procedures.

Int J Med Robot 2015 Sep 19;11(3):290-295. Epub 2014 Oct 19.

Lorraine University, IADI, Nancy, France.

Background: The effect of telesurgical training was evaluated at two latency levels.

Methods: Eleven subjects were randomly assigned to two delay groups (400 and 600 ms). Each group trained with latency on a simple task of dV-Trainer® and performed a difficult task before (pre-test) and after (post-test) the training. The follow-up was conducted 1 week after the training.

Results: The difficulty decreased gradually during training for both groups, while the task completion time and the instrument motion improved only in the 600 ms group. Both groups made progress from pre- to post-test, but statistical significance was not achieved. In the follow-up, subjects maintained their highest level achieved during training.

Conclusions: Latency training is effective and this effect lasts at least 1 week. Latency training on a simple task may improve results in complex procedures. However, attention should be paid to avoiding carelessness due to confidence from training. Copyright © 2014 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/rcs.1623DOI Listing
September 2015

Comparative analysis of the functionality of simulators of the da Vinci surgical robot.

Surg Endosc 2015 Apr 15;29(4):972-83. Epub 2014 Aug 15.

Florida Hospital Nicholson Center, 404 Celebration Place, Celebration, FL, 34747, USA,

Background: The implementation of robotic technology in minimally invasive surgery has led to the need to develop more efficient and effective training methods, as well as assessment and skill maintenance tools for surgical education. Multiple simulators and procedures are available for educational and training purposes. A need for comparative evaluations of these simulators exists to aid users in selecting an appropriate device for their purposes.

Methods: We conducted an objective review and comparison of the design and capabilities of all dedicated simulators of the da Vinci robot, the da Vinci Skill Simulator (DVSS) (Intuitive Surgical Inc., Sunnyvale, CA, USA), dV-Trainer (dVT) (Mimic Technologies Inc., Seattle, WA, USA), and Robotic Surgery Simulator (RoSS) (Simulated Surgical Skills, LLC, Williamsville, NY, USA). This provides base specifications of the hardware and software, with an emphasis on the training capabilities of each system.

Results: Each simulator contains a large number of training exercises, DVSS = 40, dVT = 65, and RoSS = 52 for skills development. All three offer 3D visual images but use different display technologies. The DVSS leverages the real robotic surgeon's console to provide visualization, hand controls, and foot pedals. The dVT and RoSS created simulated versions of all of these control systems. They include systems management services which allow instructors to collect, export, and analyze the scores of students using the simulators.

Conclusions: This study is the first to provide comparative information of the three simulators functional capabilities with an emphasis on their educational skills. They offer unique advantages and capabilities in training robotic surgeons. Each device has been the subject of multiple validation experiments which have been published in the literature. But those do not provide specific details on the capabilities of the simulators which are necessary for an understanding sufficient to select the one best suited for an organization's needs.
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http://dx.doi.org/10.1007/s00464-014-3748-7DOI Listing
April 2015

Does anatomy explain the origin of a leak after sleeve gastrectomy?

Obes Surg 2014 Oct;24(10):1717-23

Department of Anatomy, Lorraine University, 2 Av. de la Forêt de Haye, 54501, Vandœuvre-lès-Nancy, France,

Background: Sleeve gastrectomy is a bariatric surgical procedure that may result in particular morbidity or mortality due to gastric fistula in the proximal part of the gastric tube. Two theories are currently proposed to explain this specific leak location. The vascular theory attributes the leaks to reduced perfusion in the gastric tube, and the mechanical theory suggests the etiology as gastric tube hyper-pressure due to pyloric conservation. The aim of this study was to map the arterial gastric vascular supply on fresh cadavers after performing sleeve gastrectomy to evaluate the effect of vascular changes on gastric leakage.

Methods: We performed sleeve gastrectomies on 11 cadaveric trunks with a detailed anatomical study of the gastric vascular supply after latex injection in the three branches arising from the celiac trunk.

Results: In 55 % of cases, the sleeve procedure changed the gastric vascular supply. In 9.1 %, it divided the three left gastric artery branches arising from the lesser curvature. Few changes were noted in the antrum or pylorus.

Conclusions: This anatomical study demonstrates that the vascular supply of the proximal part of the gastric tube can be damaged by a sleeve procedure, which can sever one or more of the branches arising from the left gastric artery. Such weakness could be exacerbated by disparities in vascular supply. The uninterrupted vascular supply of the antrum and pylorus may explain the preferential localization of the fistula to the proximal part of the gastric tube.
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http://dx.doi.org/10.1007/s11695-014-1256-4DOI Listing
October 2014