Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

[Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis]

La saturation intrahospitalière liée à l’arrivée massive de patients atteints du COVID-19 nécessitant une prise en charge urgente conduit à reconsidérer la prise en charge des autres patients. Différer au maximum les hospitalisations et les opérations chirurgicales non urgentes est un des objectifs des chirurgiens afin de désengorger autant que possible le système de soins. Alors que la majorité des opérations programmées sont annulées, la réduction de la chirurgie d’urgence est évidemment compliquée à proposer sans altérer la qualité de la prise en charge et conduire à une perte de chance pour le patient. Cependant, l’appendicite aiguë constitue une situation spécifique bien particulière et la fréquence de cette pathologie conduit à considérer ce cas particulier. En effet, tandis que le traitement recommandé de l’appendicite aiguë non compliquée est chirurgical, l’alternative non chirurgicale par antibiothérapie seule a été largement évaluée dans la littérature au cours de travaux de qualité. Dans la mesure où la limite principale du traitement médical exclusif de l’appendicite aiguë non compliquée est le risque de récidive à distance, cette option thérapeutique représente une alternative de choix pour réduire la surcharge intrahospitalière dans ce contexte de crise sanitaire. L’objectif de ce travail est donc de mettre à disposition des médecins et des chirurgiens un guide pratique issu d’une analyse de la littérature sur le traitement médical de l’appendicite aiguë non compliquée de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans des bonnes conditions, notamment lorsque l’accès au bloc opératoire est impossible.

Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis

The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.

Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases

AIM

This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA).

METHODS

All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included.

RESULTS

From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients.

CONCLUSION

HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.

Thirty-day mortality after emergency surgery for obstructing colon cancer: survey and dedicated score from the French Surgical Association

AIM

The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score.

METHOD

From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value ≤ 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve.

RESULTS

A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age ≥ 75 (P = 0.013), American Society of Anesthesiologists (ASA) score ≥ III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80.

CONCLUSION

Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

Soft-tissue anatomy of the extant hominoids: a review and phylogenetic analysis

This paper reports the results of a literature search for information about the soft-tissue anatomy of the extant non-human hominoid genera, Pan, Gorilla, Pongo and Hylobates, together with the results of a phylogenetic analysis of these data plus comparable data for Homo. Information on the four extant non-human hominoid genera was located for 240 out of the 1783 soft-tissue structures listed in the Nomina Anatomica. Numerically these data are biased so that information about some systems (e.g. muscles) and some regions (e.g. the forelimb) are over-represented, whereas other systems and regions (e.g. the veins and the lymphatics of the vascular system, the head region) are either under-represented or not represented at all. Screening to ensure that the data were suitable for use in a phylogenetic analysis reduced the number of eligible soft-tissue structures to 171. These data, together with comparable data for modern humans, were converted into discontinuous character states suitable for phylogenetic analysis and then used to construct a taxon-by-character matrix. This matrix was used in two tests of the hypothesis that soft-tissue characters can be relied upon to reconstruct hominoid phylogenetic relationships. In the first, parsimony analysis was used to identify cladograms requiring the smallest number of character state changes. In the second, the phylogenetic bootstrap was used to determine the confidence intervals of the most parsimonious clades. The parsimony analysis yielded a single most parsimonious cladogram that matched the molecular cladogram. Similarly the bootstrap analysis yielded clades that were compatible with the molecular cladogram; a (Homo, Pan) clade was supported by 95% of the replicates, and a (Gorilla, Pan, Homo) clade by 96%. These are the first hominoid morphological data to provide statistically significant support for the clades favoured by the molecular evidence.

Ontogeny and homoplasy in the papionin monkey face

Recent molecular research has provided a consistent estimate of phylogeny for the living papionin monkeys (Cercocebus, Lophocebus, Macaca, Mandrillus, Papio, and Theropithecus). This phylogeny differs from morphological phylogenies regarding the relationships of the mangabeys (Cercocebus and Lophocebus) and baboons (Mandrillus, Papio, and Theropithecus). Under the likely assumption that the molecular estimate is correct, the incongruence between the molecular and morphological data sets indicates that the latter include numerous homoplasies. Knowledge of how these homoplasies emerge through development is important for understanding the morphological evolution of the living papionins, and also for reconstructing the phylogenetic relationships and adaptations of their fossil relatives. Accordingly, we have used geometric morphometric techniques and the molecular phylogeny to investigate the ontogeny of a key area of morphological homoplasy in papionins, the face. Two analyses were carried out. The first compared allometric vectors of Cercocebus, Lophocebus, Macaca, Mandrillus, and Papioto determine which of the facial resemblances among the genera are homoplasic and which are plesiomorphic. The second analysis focused on early post-natal facial form in order to establish whether the facial homoplasies exhibited by the adult papionins are to some degree present early in the post-natal period or whether they develop only later in ontogeny. The results of our analyses go some way to resolving the debate over which papionin genera display homoplasic facial similarities. They strongly suggest that the homoplasic facial similarities are exhibited by Mandrillus and Papio and not by Cercocebus and Lophocebus, which share the putative primitive state with Macaca. Our results also indicate that Mandrillus and Papio achieve their homoplasic similarities in facial form not through simple extension of the ancestral allometric trajectory but through a combination of an extension of allometry into larger size ranges and a change in direction of allometry away from the ancestral trajectory. Thus, the face of Mandrillus is not simply a hypermorphic version of the face of its sister taxon, Cercocebus, and the face of Papio is not merely a scaled-up version of the face of its sister taxon, Lophocebus. Lastly, our results show that facial homoplasy is not restricted to adult papionins; it is also manifest in infant and juvenile papionins. This suggests that the homoplasic facial similarities between Mandrillus and Papio are unlikely to be a result of sexual selection.

Homoplasy and the early hominid masticatory system: inferences from analyses of extant hominoids and papionins

Early hominid masticatory characters are widely considered to be more prone to homoplasy than characters from other regions of the early hominid skull and therefore less reliable for phylogenetic reconstruction. This hypothesis has important implications for current reconstructions of early hominid phylogeny, but it has never been tested. In this paper we evaluate the likely veracity of the hypothesis using craniometric data from extant primate groups for which reliable consensus molecular phylogenies are available. Datasets representing the extant large-bodied hominoid genera and the extant papionin genera were compiled from standard measurements. The data were adjusted to minimise the confounding effects of body size, and then converted into discrete character states using divergence coding. Each dataset was divided into four regional character groups: (1) palate and upper dentition, (2) mandible and lower dentition, (3) face and (4) cranial vault and base. Thereafter, the regional character groups were analysed using cladistic methods and the resulting phylogenetic hypotheses judged against the consensus molecular phylogenies for the hominoids and papionins. The analyses indicated that the regions dominated by masticatory characters-the palate and upper dentition, and the mandible and lower dentition-are no less reliable for phylogenetic reconstruction than the other regions of the skull. The four regions were equally affected by homoplasy and were, therefore, equally unreliable for phylogenetic reconstruction. This finding challenges the recent suggestion that Paranthropus is polyphyletic, which is based on the assumption that masticatory characters are especially prone to homoplasy. Our finding also suggests that, contrary to current practice, there is no a priori reason to de-emphasise the phylogenetic significance of the masticatory similarities between Homo rudolfensis and the australopiths. The corollary of this is that H. rudolfensis is unlikely to be a member of the Homo clade and should therefore be allocated to another genus.

Incidence and predictive factors of cerebrovascular events in 8,846 elderly treated hypertensive patients during a 3-year follow-up: the PRESAGE study

This epidemiological study was carried out as a 3-year follow-up project to assess the incidence of transient ischemic attacks (TIAs) and strokes; 8,846 treated hypertensive patients (mean BP, 149/84 mm Hg) aged 65 years or over (mean age, 73.7 +/- 6.3 years), devoid of symptoms of dementia and with documented vascular risk factors were recruited from January 1994 to August 1995, by 1,598 general practitioners in connection with 36 referral university neurology units throughout metropolitan France. Among these patients, 506 (5.7%) had at least one cerebrovascular event during the follow-up period: 309 (3.5%) experienced one or more isolated TIAs, and 197 (2.2%) had a stroke with or without a preceding TIA. A total of 510 TIAs were reported. The stroke subtypes were ischemia, hemorrhage, and unclassified in 70, 16, and 15% of the cases, respectively. The estimated annual stroke incidence was 7.42 per thousand. Of the 197 patients who developed strokes, 51 (26%) died. This case-fatality rate should be compared with the 4.5% mortality rate observed in the whole population during the study period. The 3 subgroups (with isolated TIAs, strokes, or no events during the study) were found to differ regarding age, sedentary lifestyle, past history of cardiovascular events, duration of hypertension, and evidence of complicated hypertension (univariate analysis). The factors identified as predictive of a stroke (multivariate analysis) were: the patient's age; sedentary lifestyle; pulse pressure (SBP-DBP); identification of TIA at baseline, and presence of arrhythmias.

[Acute vertigo]

Three questions are raised when a patient experiences sudden vertigo. Is it due to a disease of the vestibule? This would be suggested in case of a revolving nature of the vertigo, the presence of nystagmus and of vestibular ataxia. Are there associated otological (infection of the labyrinth, zoster neuritis) or neurological (ischemic vascular accidents of the cerebral trunk and of the cerebellum, cerebellar haemorrhage) signs? What is the evolution of the sudden vertigo? A single, isolated episode of vertigo will generally be related to vestibular neuritis. However, it may rather be a first episode of repeated vertigo, Ménière's disease, recurrent vertigo, migraine, or very rarely transitory ischemic accident.

Soft-tissue characters in higher primate phylogenetics

Recent research has cast doubt on the reliability of bones and teeth for reconstructing phylogenetic relationships among higher primate species and genera. Herein, we investigate whether this problem is confined to hard tissues by examining the utility of higher primate soft-tissue characters for reconstructing phylogenetic relationships at low taxonomic levels. We use cladistic methods to analyze 197 soft-tissue characters for the extant hominoids and then compare the resulting phylogenetic hypotheses with the group's consensus molecular phylogeny, which is widely considered to be accurate. We show that the soft-tissue characters yield robust phylogenetic hypotheses that are compatible with the molecular phylogeny. Given the strength of the evidence for molecular phylogeny, these results indicate that, unlike craniodental hard-tissue characters, soft tissues are reliable for reconstructing phylogenetic relationships among higher primate species and genera. Thus, in higher primates at least, some types of morphological data are more useful than others for phylogeny reconstruction.

How reliable are human phylogenetic hypotheses?

Cladistic analysis of cranial and dental evidence has been widely used to generate phylogenetic hypotheses about humans and their fossil relatives. However, the reliability of these hypotheses has never been subjected to external validation. To rectify this, we applied identical methods to equivalent evidence from two groups of extant higher primates for whom reliable molecular phylogenies are available, the hominoids and papionins. We found that the phylogenetic hypotheses based on the craniodental data were incompatible with the molecular phylogenies for the groups. Given the robustness of the molecular phylogenies, these results indicate that little confidence can be placed in phylogenies generated solely from higher primate craniodental evidence. The corollary of this is that existing phylogenetic hypotheses about human evolution are unlikely to be reliable. Accordingly, new approaches are required to address the problem of hominin phylogeny.

The human genus

A general problem in biology is how to incorporate information about evolutionary history and adaptation into taxonomy. The problem is exemplified in attempts to define our own genus, Homo. Here conventional criteria for allocating fossil species to Homo are reviewed and are found to be either inappropriate or inoperable. We present a revised definition, based on verifiable criteria, for Homo and conclude that two species, Homo habilis and Homo rudolfensis, do not belong in the genus. The earliest taxon to satisfy the criteria is Homo ergaster, or early African Homo erectus, which currently appears in the fossil record at about 1.9 million years ago.

[Post-radiotherapy multifocal meningioma]

We report one case of radio-induced meningiomas revealed by an intracranial hypertension in an 46 year-old woman. A history of cephalic irradiation during infancy for a vascular nevus, not spontaneously reported by the patient, had been discovered because of the association with a radio-induced cataract. Meningiomas are a rare, severe and late complication of cephalic radiotherapy. The history of irradiation is not always spontaneously reported by the patient.

[Parkinsonian syndrome and post-encephalitic stereotyped involuntary movements responsive to L-dopa]

In 1954, when he was five years old, a patient suffered from encephalitis with a prolonged lethargic state. Following this episode, he presented a severe parkinsonian syndrome which was associated, after a few years, with an axial dystonia and stereotyped involuntary movements of the upper limbs. These abnormal movements were particular by their coordinated appearance, their rhythmicity and their relative slowness. Treatment with L-dopa suppressed all akinetic, dystonic and dyskinetic symptoms. At age of 40 years, all the akinetic, dystonic and dyskinetic symptoms reappeared after drug withdrawal. Cerebral computed tomography, magnetic resonance imaging and fluorodeoxyglucose positron emission tomography were normal. Fluorodopa positron emission tomography revealed a significant bilateral reduction of tracer accumulation in the posterior part of both putamen, similar to that observed in patients with idiopathic Parkinson's disease. In this patient, pharmacological tests revealed that effectiveness of L-dopa was abolished by administration of a D2 antagonist, and was fully reproduced by a D2 agonist. Clinical signs, pharmacological data and past-medical history strongly suggested a limited lesion of the zona compacta of substantia nigra induced by viral agression. This complex and progressive extrapyramidal syndrome had strong similarities with the lethargic encephalitis of Von Economo and its late symptoms. Other diseases associating akinesia and dyskinesia or dystonic phenomena, like dopa-sensitive dystonia and juvenile Parkinson's disease, are very unlikely. Thus, the persistance of sporadic forms of Von Economo's encephalitis could be discussed.

Vertigo

Vertigo is one of the most frequent reasons for consultation in daily medical practice. Recent studies show that vertigo involves considerable social costs before being managed efficiently, as it is often incorrectly diagnosed. Sometimes a psychiatric symptom, the original causes are vestibular in Ménière's disease, vestibular neuritis, and benign positional vertigo. Ménière's disease to some extent resembles that of progressive autoimmune deafness. Soon, perhaps, the target of the long-suspected immune reactions will be identified and specific treatments will be developed for the rapidly progressing forms. Benign paroxysmal positional vertigo is certainly a favorite of practitioners because the treatment is so simple. Not all vertigos are so easily cured, and surgery must sometimes be performed. In most cases, retrolabyrinthine vestibular neurectomy, with its acceptable risks, is the operation of choice. New diagnostic techniques, such as dynamic posturography, are interesting, but their use is not as yet clear.

[The vestibular system: from structure to function]

The two vestibular receptors, right and left, hidden in the petrous part of the temporal bone with the cochlear receptors, receive information from angular and linear movements of the head and transform them into a nerve message sent to the nuclei of the brainstem, which are connected directly on the one hand to the oculomotor nuclei, at the origin of the oculovestibular reflex (induction of nystagmus), and on the other hand, to the spinal motor neurons, at the origin of the vestibulospinal reflex. These reflexes are associated with responses to visual and somaesthetic information for maintenance or return to the standing position, which characterises the function of equilibrium. Vertigo and disorders of balance reflect a conflict of information between these two labyrinths, or between the vestibular apparatus and the messages issued by other captors, and sometimes also dysfunction of central nervous system treatment of information or a lesion of the effector motor systems.

'Pinocchio syndrome': a peculiar form of reflex epilepsy?

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Expression and regulation of a proenkephalin beta-galactosidase fusion gene in the reproductive system of transgenic mice

A fusion gene containing 3 kilobases of human proenkephalin 5'-flanking sequences and 1 kilobase of human proenkephalin 3'-flanking sequence and the easily visualized histochemical marker, Escherichia coli beta-galactosidase, was used to study the function of cis-regulatory elements within the human proenkephalin gene in transgenic mice. Here data are presented on expression and regulation of this fusion gene in the reproductive system of three independent lines of transgenic mice. Within the male reproductive system, the fusion gene is expressed in the proximal epididymis and in developing germinal cells but not in mature or elongating spermatids. In the female reproductive system, the transgene was expressed at low basal levels, but expression was dramatically stimulated in the ovary and oviduct by hormonal stimulation and pregnancy; additionally, expression was induced at the uteroplacental junction in pregnant mice. Taken together these observations suggest that critical sequences for expression and regulation of the proenkephalin gene within the reproductive system are contained within sequences of the construct.

Contralateral disappearance of parkinsonian signs after subthalamic hematoma

A man with Parkinson's disease (PD) suddenly developed a left hemiballismus, and the CT showed a hematoma of the right subthalamic nucleus. After the ballistic movements had disappeared, akinesia and the other parkinsonian signs did not reappear on the left. This clinical case confirms the involvement of the subthalamic nucleus in the akinesia of PD, as suggested by recent experimental data.

Nuclear magnetic resonance T2 relaxation times in multiple sclerosis

An original method was used to carry out the mathematical analysis of T2 transverse magnetization decay curves and the measure of T2 relaxation times on multiple sclerosis (MS) patients. The presumably normal white matter (WM) of these patients presented higher T2 relaxation times (98.6 msec), in comparison with that found in a population sample (88 msec). In this case, magnetization decay curves remain mostly monoexponential and are characterized by a single T2. On the other hand, areas of increased signal (AIS) curves are always better fitted by a biexponential function characterized by a short (82 msec) and a long (greater than 200 msec) T2. The spreading out of long T2 varies from one AIS to another in the same patient and among different patients; values of long T2 also vary with time, but without any correlation with the clinical state. In fact, no correlation was been established between relaxation times and clinical parameters. Quantitative MRI therefore enables a different approach to interpret MRI images; results suggest that several histobiochemical parameters play a role in the pathogenesis of an AIS and that MS is a dynamic and constantly evolving disease.

[Beta-blockers and migraine. Efficacy of time-release propranolol versus placebo]

The efficacy and safety of long-acting propranolol (LA.P) 160 mg once-daily in the prophylactic treatment of migraine were tested against placebo in a multicentric, double-blind, randomized study comparing the two groups in a parallel manner over a treatment period of 12 weeks, and following a 4 week-placebo run-in period. Fifty-five out of the 74 patients who entered the trial included at the end of the run-in period. Forty-one patients completed the study. Out of the 14 patients who withdrew from the study, none discontinued because of side-effects. The statistical analysis was done according to the "intention to treat" principle. LA.P was significantly more efficient than placebo in reducing the frequency of migraine attacks (p = 0.01 by variance analysis). LA.P reduced the average number of monthly crises by 48% on day 84. There was a slight but significant reduction of the systolic blood pressure and heart rate in the erect position. There was no significant difference between LA.P and placebo regarding either the number of complaints or the number of side-effects elicited out of an 17 item questionnaire. None of the observed side effects led to a withdrawal of treatment.