Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study

BACKGROUND

Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure.

METHODS

A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission.

RESULTS

Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002).

CONCLUSIONS

Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

Enhanced recovery after surgery (ERAS) for deep infiltrating endometriosis surgery: experience of a French center

OBJECTIVE

The objective of the study was to evaluate the implementation of an ERAS programme for deep pelvic endometriosis (DPE) surgery in terms of length of stay (LOS), postoperative complications (POC) and rehospitalisation rate.

METHODS

This was a comparative retrospective monocentric study in the Gynaecologic Department of the La Conception Hospital in Marseille, France. We compared a 'conventional' group, with classic perioperative management corresponding to patients undergoing DPE surgery between April 8, 2014 and January 23, 2018, and an 'ERAS' group after setting up the ERAS protocol from February 6, 2018 to March 6, 2020.

RESULTS

A total of 101 patients with DPE surgery were included, with 39 in the conventional group and 53 in the ERAS group. The LOS decreased by 1.91 days (p < 0.001). During the 45 postoperative days, no difference was found in rehospitalised rate (p = 1). The POC rate was 15/39 (38.5%) in the conventional group and 12/53 (22.6%) in the ERAS group (p = 0.1).

CONCLUSION

The implementation of an ERAS programme for DPE surgery is an effective strategy because it can reduce the LOS without increasing the POC rate.

Is robotic ventral mesh rectopexy for pelvic floor disorders better than laparoscopic approach at the beginning of the experience? A retrospective single-center study

PURPOSE

To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience.

METHODS

Between 2017 and 2022, the first 30 laparoscopic ventral mesh rectopexies and the first 30 robotic ventral mesh rectopexies at the beginning of the experience of 2 surgeons were retrospectively analyzed. Perioperative (demographic characteristics, surgical indication, conversion rate, operative time), and postoperative (complications, length of stay, unplanned reintervention) data were compared between groups.

RESULTS

Demographic characteristics were similar between groups. Conversion rate was lower (0 vs 17%, p = 0.05), but the operative time was significantly longer (182 [146-290] vs 150 [75-240] minutes, p < 0.0001) during robotic procedure when compared with laparoscopic approach. In terms of learning curve, the number of procedures to obtain the same operative time between the 2 approaches was 15. Postoperative results were similar between groups, in terms of pain (visual analogic scale = 2 [0-8] vs 4 [0-9], p = 0.07), morbidity (17 vs 3%, p = 0.2), and unplanned reintervention (1 vs 0%, p = 0.99). Mean length of stay was significantly reduced after robotic approach when compared with laparoscopic approach (3 [2-10] vs 5 [2-11] days, p < 0.01). Functional results were better after robotic than laparoscopic ventral mesh rectopexy, with higher satisfaction rate (93 vs 75%, p = 0.05), and reduced recurrence rate (0 vs 14%, p = 0.048).

CONCLUSION

Despite longer operative time at the beginning of the learning curve, robotic ventral mesh rectopexy was associated with similar or better perioperative results than laparoscopic ventral mesh rectopexy.

An International Registry of Peritoneal Carcinomatosis from Appendiceal Goblet Cell Carcinoma Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

PURPOSE

Peritoneal carcinomatosis from appendiceal goblet cell carcinoma (A-GCC) is a rare and aggressive form of appendiceal tumor. Cytoreductive surgery (CRS) and hyperthermic intra peritoneal chemotherapy (HIPEC) was reported as an interesting alternative regarding survival compared to surgery without HIPEC and/or systemic chemotherapy. Our aim was to evaluate the impact of CRS and HIPEC for patients presenting A-GCC through an international registry.

METHODS

A prospective multicenter international database was retrospectively searched to identify all patients with A-GCC tumor and peritoneal metastases who underwent CRS and HIPEC through the Peritoneal Surface Oncology Group International (PSOGI). The post-operative complications, long-term results, and principal prognostic factors were analyzed.

RESULTS

The analysis included 83 patients. After a median follow-up of 47 months, the median overall survival (OS) was 34.6 months. The 3- and 5-year OS was 48.5% and 35.7%, respectively. Patients who underwent complete macroscopic CRS had a significantly better survival than those treated with incomplete CRS. The 5-year OS was 44% and 0% for patients who underwent complete, and incomplete CRS, respectively (HR 9.65, p < 0.001). Lymph node involvement and preoperative chemotherapy were also predictive of a worse prognosis. There were 3 postoperative deaths, and 30% of the patients had major complications.

CONCLUSION

CRS and HIPEC may increase long-term survival in selected patients with peritoneal metastases of A-GCC origin, especially when complete CRS is achieved. Ideally, randomized control trials or more retrospective data are needed to confirm CRS and HIPEC as the gold standard in this pathology.

Half of Postoperative Deaths After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Could be Preventable: A French Root Cause Analysis on 5562 Patients

OBJECTIVE

To perform a retrospective root-cause analysis of postoperative death after CRS and HIPEC procedures.

BACKGROUND

The combination of CRS and HIPEC is an effective therapeutic strategy to treat peritoneal surface malignancies, however it is associated with significant postoperative mortality.

METHODS

All patients treated with a combination of CRS and HIPEC between January 2009 and December 2018 in 22 French centers and died in the hospital, were retrospectively analyzed. Perioperative data of the 101 patients were collected by a local senior surgeon with a sole junior surgeon. Three independent experts investigated the typical root cause of death and provided conclusions on whether postoperative death was preventable (PREV group) or not (NON-PREV group). A typical root cause of preventable postoperative death was classified on a cause-and-effect diagram.

RESULTS

Of the 5562 CRS+HIPEC procedures performed, 101 in-hospital deaths (1.8%) were identified, of which a total of 18 patients of 70 years old and above and 20 patients with ASA score of 3. Etiology of peritoneal disease was mainly colorectal. A total of 54 patients (53%) were classified in the PREV group and 47 patients (47%) in the NON-PREV group. The results of the study show that in the PREV group, WHO performance status 1-2 was more frequent and the Median Peritoneal Cancer Index was higher compared with those of the NON-PREV group. The cause of death in the PREV group was classified as: (i) preoperatively for debatable indication (59%), (ii) intraoperatively (30%) and (iii) postoperatively in 17 patients (31%). A multifactorial cause of death was found in 11 patients (20%).

CONCLUSION

More than half of the postoperative deaths after combined CRS and HIPEC may be preventable, mainly by following guidelines regarding preoperative selection of the patients and adequate intraoperative decisions.

Prognosis of poorly cohesive gastric cancer after complete cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CYTO-CHIP study)

BACKGROUND

The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC.

METHODS

All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed.

RESULTS

In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P < 0.001). In multivariable analyses, PCC (hazard ratio (HR) 1.51, 95 per cent c.i. 1.01 to 2.25; P = 0.044) was associated with poorer OS, as were pN3, Peritoneal Cancer Index (PCI), and resection with a completeness of cytoreduction score of 1, whereas HIPEC was associated with improved OS (HR 0.52; P < 0.001). The benefit of CRS-HIPEC over CRS alone was consistent, irrespective of histology, with a median OS of 16.7 versus 11.3 months (HR 0.60, 0.39 to 0.92; P = 0.018) in the PCC group, and 34.5 versus 14.3 months (HR 0.43, 0.25 to 0.75; P = 0.003) in the non-PCC group. Non-PCC and HIPEC were independently associated with improved recurrence-free survival and fewer peritoneal recurrences. In patients who underwent HIPEC, PCI values of below 7 and less than 13 were predictive of OS in PCC and non-PCC populations respectively.

CONCLUSION

In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for resectable peritoneal metastases is feasible in elderly patients

The aim is to evaluate the feasibility and the prognosis of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for resectable peritoneal metastases (RPM) in elderly patients. Patients who underwent CRS with HIPEC for RPM between 2012 and 2018 in one tertiary reference center were retrospectively included and divided according to the age: Group A (< 65 years) and Group B (≥ 65 years). Postoperative outcomes and survivals were compared. Ninety-five patients were included in Groups A (n = 65) and B (n = 30). The incidence of comorbidities was significantly higher in elderly patients (65 vs 90%, p = 0.01), but RPM characteristics were similar between groups. There was no difference between groups in terms of postoperative results: 30-day major morbidity (33 vs 23%, p = 0.4), 30-day mortality (0 vs 3%, p = 0.3), mean length of stay (26.7 ± 19.4 vs 22.4 ± 10.3 days, p = 0.3) and readmission's rate (15 vs 33%, p = 0.06). The only one significant difference was the 90-day mortality which never occurred before 65 years but in 10% of elderly patients (p = 0.03). There was no difference regarding recurrence's rate (56 vs 37%, p = 0.1), neither 1-, 3- and 5-year overall survival rates (86, 64 and 52% vs 85, 74% and not reached, p = 0.8) and disease-free survival rates (61, 28 and 28% vs 56, 45% and not reached, p = 0.6). CRS with HIPEC is feasible in elderly patients. Since the 90-day mortality appeared to be higher in elderly patients, additional criteria are necessary to improve the selection of elderly patients for this major surgery.

Second-look surgery plus hyperthermic intraperitoneal chemotherapy versus surveillance in patients at high risk of developing colorectal peritoneal metastases (PROPHYLOCHIP-PRODIGE 15): a randomised, phase 3 study

BACKGROUND

Diagnosis and treatment of colorectal peritoneal metastases at an early stage, before the onset of signs, could improve patient survival. We aimed to compare the survival benefit of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), with surveillance, in patients at high risk of developing colorectal peritoneal metastases.

METHODS

We did an open-label, randomised, phase 3 study in 23 hospitals in France. Eligible patients were aged 18-70 years and had a primary colorectal cancer with synchronous and localised colorectal peritoneal metastases removed during tumour resection, resected ovarian metastases, or a perforated tumour. Patients were randomly assigned (1:1) to surveillance or second-look surgery plus oxaliplatin-HIPEC (oxaliplatin 460 mg/m², or oxaliplatin 300 mg/m² plus irinotecan 200 mg/m², plus intravenous fluorouracil 400 mg/m²), or mitomycin-HIPEC (mitomycin 35 mg/m²) alone in case of neuropathy, after 6 months of adjuvant systemic chemotherapy with no signs of disease recurrence. Randomisation was done via a web-based system, with stratification by treatment centre, nodal status, and risk factors for colorectal peritoneal metastases. Second-look surgery consisted of a complete exploration of the abdominal cavity via xyphopubic incision, and resection of all peritoneal implants if resectable. Surveillance after resection of colorectal cancer was done according to the French Guidelines. The primary outcome was 3-year disease-free survival, defined as the time from randomisation to peritoneal or distant disease recurrence, or death from any cause, whichever occurred first, analysed by intention to treat. Surgical complications were assessed in the second-look surgery group only. This study was registered at ClinicalTrials.gov, NCT01226394.

FINDINGS

Between June 11, 2010, and March 31, 2015, 150 patients were recruited and randomly assigned to a treatment group (75 per group). After a median follow-up of 50·8 months (IQR 47·0-54·8), 3-year disease-free survival was 53% (95% CI 41-64) in the surveillance group versus 44% (33-56) in the second-look surgery group (hazard ratio 0·97, 95% CI 0·61-1·56). No treatment-related deaths were reported. 29 (41%) of 71 patients in the second-look surgery group had grade 3-4 complications. The most common grade 3-4 complications were intra-abdominal adverse events (haemorrhage, digestive leakage) in 12 (23%) of 71 patients and haematological adverse events in 13 (18%) of 71 patients.

INTERPRETATION

Systematic second-look surgery plus oxaliplatin-HIPEC did not improve disease-free survival compared with standard surveillance. Currently, essential surveillance of patients at high risk of developing colorectal peritoneal metastases appears to be adequate and effective in terms of survival outcomes.

FUNDING

French National Cancer Institute.

Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer With Peritoneal Metastases (CYTO-CHIP study): A Propensity Score Analysis

PURPOSE

Gastric cancer (GC) with peritoneal metastases (PMs) is a poor prognostic evolution. Cytoreductive surgery (CRS) yields promising results, but the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. Here we aimed to compare outcomes between CRS-HIPEC versus CRS alone (CRSa) among patients with PMs from GC.

PATIENTS AND METHODS

From prospective databases, we identified 277 patients with PMs from GC who were treated with complete CRS with curative intent (no residual nodules > 2.5 mm) at 19 French centers from 1989 to 2014. Of these patients, 180 underwent CRS-HIPEC and 97 CRSa. Tumor burden was assessed using the peritoneal cancer index. A Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used to assess the effect of HIPEC and account for confounding factors.

RESULTS

After IPTW adjustment, the groups were similar, except that median peritoneal cancer index remained higher in the CRS-HIPEC group (6 v 2; P = .003). CRS-HIPEC improved overall survival (OS) in both crude and IPTW models. Upon IPTW analysis, in CRS-HIPEC and CRSa groups, median OS was 18.8 versus 12.1 months, 3- and 5-year OS rates were 26.21% and 19.87% versus 10.82% and 6.43% (adjusted hazard ratio, 0.60; 95% CI, 0.42 to 0.86; P = .005), and 3- and 5-year recurrence-free survival rates were 20.40% and 17.05% versus 5.87% and 3.76% ( P = .001), respectively; the groups did not differ regarding 90-day mortality (7.4% v 10.1%, respectively; P = .820) or major complication rate (53.7% v 55.3%, respectively; P = .496).

CONCLUSION

Compared with CRSa, CRS-HIPEC improved OS and recurrence-free survival, without additional morbidity or mortality. When complete CRS is possible, CRS-HIPEC may be considered a valuable therapy for strictly selected patients with limited PMs from GC.

CYTO-CHIP: Cytoreductive surgery versus cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer with peritoneal metastasis: A propensity-score analysis from BIG RENAPE and FREGAT working groups

8

Background: Gastric cancer with peritoneal carcinomatosis (PC) is considered by most as an end-stage disease. Poor outcomes are achieved with palliative chemotherapy. Aggressive combination of cytroreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) are still debated in this indication. Purpose: to assess the impact of HIPEC on survival and postoperative outcomes after complete CRS compared with CRS alone (CRSa) Methods: Data from 277 consecutive patients treated for gastric cancer with PC in 19 French centers from 1989 to 2014 were collected. 180 patients who underwent CRS and HIPEC were compared to 97 treated by CRSa. Extension of PC was assessed by the Peritoneal Cancer Index (PCI). Only patients treated by complete CRS were included (CC-0 or CC-1). To assess the effect of HIPEC and to account for confounding factors, a Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used. Multivariate models and sensitivity analyses were also performed. Results: After propensity weighting, groups were similar except for the PCI that remained higher in the HIPEC group (median: 6 v 2, P = .003). However, there was no difference in the completeness of CRS (CC-0: 76.7% v 83.5 %, P = .904). HIPEC was associated with improved overall survival (OS) on both multivariate and IPTW models. On IPTW analysis, median OS was 18.8 v 12.1 months. 3- and 5-years OS were 26.21% and 19.87% v 10.82% and 6.43% (HR, 1.66; 95% CI, 1.17-2.37; P = .005). 3- and 5-years disease-free survival were 20.40% and 17.05% v 5.87% and 3.76% (P = .001). Mortality rate (7.4% v 10.1%, P = .820) and grade 3-4 morbidity (53.7% v 55.3%, P = .496) at 90 days were similar. Surgical morbidity was 37.1% v 38.8% in CRSa group. Conclusions: Compared to CRSa, HIPEC was associated with increased OS and potential disease eradication for gastric cancer with PC, without additional morbidity. This treatment, when optimal CRS can be achieved, should be considered as the gold standard since outcomes remain grim with chemotherapies. Clinical trail information: NCT03253939

Temporary successful results of ventral rectopexy for enterocele surgical correction, about 138 patients

PURPOSE

This work aimed to analyse short- and long-term results of enterocele surgical treatment by ventral rectopexy.

METHODS

All females who underwent ventral rectopexy for enterocele in our department were included. All patients underwent standardized preoperative evaluation. Data was retrospectively collected, after examination of patients or by telephone survey. Postoperative evaluation was performed by an independent observer.

RESULTS

One hundred thirty-eight females (median age = 63 years [21-86 years]) were included. They were postmenopausal and multiparous in 94 and 70% of cases, respectively. Pelvic pressure, vaginal prolapse, or the both were observed in 28, 16 or 56% of the patients, respectively. The most frequent associated symptoms were dyschezia (63%) and faecal incontinence (30%). On preoperative workup, enterocele was isolated in two cases. Rectocele, internal rectal prolapse and cervicocystoptosis were the most frequently associated pelvic floor disorders. Ventral rectopexy was performed through laparoscopy in 128 patients (93%). In the short term, all pelvic symptoms were significantly improved, except urinary incontinence. At the end of follow-up (56 months [7-125]), specific symptoms and dyschezia were still significantly improved. Secondary failure was reported in 31% of patients. By multivariate analysis, two predictive factors for long-term failure were found: diagnosis of rectocele on preoperative MRI (odd ratio = 15; 95% CI 1.4-163; p = 0.03) and conversion into open surgery (odd ratio = 8; 95% CI 1.4-43; p = 0.02).

CONCLUSION

This study suggests that ventral rectopexy is an effective treatment of enterocele, but secondary failure can be observed. Patients should be informed of the potential risk of long-term degradation.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey

BACKGROUND

Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision.

METHODS

A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE).

RESULTS

Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs.

CONCLUSION

Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Pelvic radiation disease management by hyperbaric oxygen therapy: prospective study of 44 patients

Pelvic radiation disease (PRD) occurs in 2-11% of patients undergoing pelvic radiation for urologic and gynecologic malignancies. Hyperbaric oxygen therapy (HBOT) has previously been described as a noninvasive therapeutic option for the treatment of PRD. the purpose of study was to analyze prospectively the results of HBOT in 44 consecutive patients with PRD who were resistant to conventional oral or topical treatments. Material and Methods. The median age of the cohort was 65.7 years (39-85). Twenty-seven percent of patients required blood transfusion (n = 12). The median of delay between radiotherapy and HBOT was 26 months (3-175). We evaluated the results of HBOT, using SOMA-LENT Scale. Results. SOMA-LENT score was decreased in 59% of patient. The median of SOMA-LENT score before HBOT was significantly higher, being equal to 14 (0-36), than after HBOT with the SOMA-LENT score of 12 (0-38) (P = 0.003). Tenesmus (P = 0.02), bleeding (P = 0.0001), and ulceration (P = 0.001) significantly decreased after HBOT. Regarding patients with colostomy, 33% (n = 4) benefited from colostomies closure. HBOT was generally well tolerated. Only one patient stopped precociously due to transient myopia. Conclusion. This study is in favor of the interest of HBOT in pelvic radiation disease treatment (PRD).

Splenic sarcoidosis mimicking neoplastic disease

Sarcoidosis is a multisystem granulomatous disease of unknown cause that commonly involves the spleen. Sarcoid can produce either homogeneous splenomegaly or multiple splenic nodules. Although other organ system involvement usually occurs, this is not invariable. Herein, we report on the clinical, histological, and radiological features-including sonography and MRI-of an isolated splenic sarcoidosis that mimicked neoplastic disease in a 37-year-old female. Knowledge of this atypical sonographic presentation may prevent unnecessary splenectomy.

[The lymph node of Mondor: myth or reality?]

AIM OF THE STUDY

Lymph node involvement is one of the most significant prognostic factors of patients with rectal cancer. Despite major advances in our understanding of the propagation of the rectal cancer, the lymphatic drainage of the rectum remains unclear. This study was designed to assess the number of lymph nodes located around the superior rectal artery and to assess the frequency of Mondor's lymph nodes.

PATIENTS AND METHODS

Twenty-five anatomic subjects were studied. All resections were performed using total mesorectal excision. Lymph nodes were sought in the tissue surrounding the superior rectal artery up to 2 cm under the ending of the superior rectal artery by manual dissection and were submitted for histological examination. The correlation between the number of lymph nodes, and the volume and weight of the tissue surrounding the superior rectal artery was evaluated by non-parametric Spearman test.

RESULTS

The mean number of lymph nodes per specimen was 2.7 +/- 1.4. The size of the lymph nodes varied between 1 and 7 mm. The lymph nodes were mostly smaller than 3 mm (56%). The number of lymph nodes in the superior rectal mesentery was independent of its volume and its weight. Seven subjects had a Mondor's lymph node. The mean size of Mondor's lymph node was 3.4 +/- 2.1 cm.

CONCLUSIONS

The number of NL located around the superior rectal artery is small, varying between 1 and 5. The Mondor's lymph node is an inconstant rectal NL. Its only characteristic is its location in the bifurcation or trifurcation of the superior rectal artery.

[What do we know about the lymphatic drainage of the rectum?]

Lymph node (LN) involvement is one of the most significant prognostic factors of patients with rectal cancer. However, the distribution of rectal LN is not well known. The rectal LN are mainly located around the rectal arteries. In the mesorectum, the LN are mainly located posteriorly. The number of LN by patient varies considerably. Many reasons can explain this variability. Acquired factors such as infection, inflammation or metastatic involvement facilitate the detection of LN. In contrast, preoperative radiotherapy reduces the number and size of lymph nodes. The procedure of resection affects the number of LN harvested. Extensive lymphadenectomies increase the number of LN harvested. The technique used by pathologist has equally a major influence. The fat clearing method allows detection of a greater number of LN than manual dissection particularly for small LN. Toxicity of these solutions and a time-consuming process explain that fat clearing method is rarely used in clinical practice. Detection of rectal lymph nodes is difficult and tedious but is necessary for an accurate staging of patients with rectal cancer.

Advantage of vacuum assisted closure on healing of wound associated with omentoplasty after abdominoperineal excision: a case report

Background

Primary closure of the perineum with drainage after abdominoperineal excision of the rectum for carcinoma, is widely accepted. However hematoma, perineal abscess and re-operation are significantly more frequent after primary closure than after packing of the perineal cavity. Those complications are frequently related to the patients' clinical antecedent (i.e radiotherapy, diabetes, smoking).

Case presentation

In the present report, vacuum assisted drainage was used after abdominoperineal excision for carcinoma in the very first step due to intraoperative gross septic contamination during tumor resection. The first case: A 57-years old man with a 30-years history of peri-anal Crohn's disease, the adenocarcinoma of the lowest part of the rectum and Crohn colitis with multiple area of severe dysplasia required panproctocolectomy with a perineal resection. The VAC system was used during 12 days (changed every 3 days). We observed complete healing 18 days after surgery. The second case: A 51-year-old man, with AIDS. An abdominoperineal resection was performed for recurrence epidermoid anal cancer. The patient was discharged at day 25 and complete healing was achieved 30 days later after surgery.

Conclusion

The satisfactory results showed in the present report appear to be favored by association of omentoplasty and VAC system. Those findings led us to favor VAC system in the case of pelvic exenteration associated with high risk of infection.

[Hand distal interphalangeal joints: sonographic anatomy]

PURPOSE

To determine normal anatomy of hand distal interphalangeal joints at ultrasonography, and to compare sonographic and anatomic findings.

MATERIALS AND METHODS

Right hands of three embalmed cadavers and dominant hands of 10 asymptomatic volunteers were evaluated. Distal interphalangeal joints were scanned longitudinally and transversely with a high-frequency linear-array transducer. Sonographic appearances of intra-articular and periarticular structures were analysed in consensus by two musculoskeletal radiologists. Cadaveric dissection provided anatomic comparisons.

RESULTS

Sagittal and transverse sonographic images enabled good analysis of the extensor tendon, the deep flexor tendon, and the palmar plate. The radial and ulnar collateral ligaments were identified on all coronal scans. Direct visualization of the dorsal triangular structure and of the middle phalanx head's cartilage was possible on longitudinal scans. The dorsal and palmar synovial recesses were better recognized when a small amount of fluid was present.

CONCLUSION

Ultrasonography with a high-frequency linear-array transducer provides detailed anatomical information about intra-articular and periarticular structures of the hand distal interphalangeal joints.

[What are the risk factors of anal incontinence after vaginal delivery?]

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

The number of lymph nodes is correlated with mesorectal morphometry

BACKGROUND

Lymph node involvement is one of the most significant prognostic factors of patients with rectal cancer. However, the distribution of mesorectal lymph nodes is not well known. This study was designed to assess lymph nodes in the mesorectum and to evaluate the correlation between the volume and weight of the mesorectum and the number of lymph nodes.

METHODS

The mesorectums of 20 human cadavers were studied. The volume and weight of the superior rectal mesentery, superior mesorectum and inferior mesorectum were measured. Lymph nodes were sought by manual dissection and were submitted for histological examination. The correlation between the number of lymph nodes and the volume and weight of the mesorectum was evaluated by non-parametric Spearman test.

RESULTS

A total of 178 lymph nodes were identified. The mean number of lymph nodes per specimen was 9.2 +/- 4.5. The lymph nodes were mostly smaller than 3 mm and located in the superior and posterior parts of the mesorectum. A positive correlation was found between the number of mesorectal lymph nodes and the volume and weight of the mesorectum. The number of lymph nodes in the superior rectal mesentery was independent of its volume and its weight.

CONCLUSIONS

Mesorectal lymph nodes are mainly located above the peritoneal reflection within the posterior mesorectum. The positive correlation between the volume or the weight of the mesorectum and the number of mesorectal lymph nodes should be considered as a possible means to determine the minimum number of mesorectal lymph nodes required for histological examination.

Assessment of the main pancreatic duct using computed tomography with multiplanar reconstructions

The aim of this study was to assess the morphology of the main pancreatic duct (MPD) using multiplanar reconstructions and to compare this with the morphology of the MPD of anatomic subjects.

MATERIALS AND METHODS

The morphology of the MPD was studied by means of multiplanar reconstructions obtained on the one hand from thin tomodensitometric slices and on the other hand from the dissection of anatomic subjects. This study involved 15 subjects in each group.

RESULTS

Full multiplanar reconstruction was obtained in 13 cases. In 2 cases, the isthmus did not appear in the reconstructions. The morphology of the MPD was similar in both groups. The length of the MPD was identical at the head and isthmus of the pancreas in both groups but was greater in the dissection group than in the reconstruction group in the body and tail areas of the pancreas. The diameter of the MPD was greater at the head of the pancreas in the dissection group and was identical in both groups for the other segments of the MPD.

CONCLUSIONS

Multiplanar tomodensitometric reconstruction of the main pancreatic duct is feasible. This new technique, currently under evaluation, could allow the study of canalar pathologies of the pancreas through tomodensitometry.

[Appendicitis: yes or no to laparoscopic approach?]

Whether or not there is a benefit to laparoscopy versus open surgery in the management of acute appendicitis remains a subject of controversy despite the publication of numerous randomized studies. Operative time is longer for the laparoscopic approach. The incidence of abdominal wall abscess is decreased for laparoscopy but the incidence of deep intra-abdominal abscess may be increased, especially in the case of complicated appendicitis. Post-operative pain is diminished and resumption of normal activity is quicker with the laparoscopic approach. Hospitalization is shorter but the cost of hospital care is higher; nevertheless, the global cost may be less - particularly for patients whose return to work is hastened by a laparoscopic approach. Laparoscopy diminishes the number of normal appendectomies, particularly in women of reproductive age where the diagnosis may be unclear. Laparoscopic appendectomy is practicable and has advantages over open appendectomy under certain circumstances. These advantages are most evident in the young female, the working patient, and the obese patient. Overall, the advantages of laparoscopy are, at best, modest and clinical benefit is not always demonstrable. The risk of deep abscess, particularly in patients with perforated or gangrenous appendicitis, remains an unknown and should be evaluated by further studies.

[Long term outcome following 26 surgical ampullectomies]

BACKGROUND

Pancreaticoduodenectomy (PD) is the standard surgical treatment for malignant ampullomas but is still associated with a mortality and morbidity still ranging from 0 to 10% and from 15 to 40%, respectively. Ampullectomy is an alternative to PD for benign ampulloma or, in high-risk patients, for invasive carcinoma. The aim of this study was to report early and long term results of surgical ampullectomy for presumed benign ampullomas.

PATIENTS AND METHODS

From 1981 to 2004, 26 patients from two institutions underwent surgical ampullectomy. Of the 26 patients, 8 had familial adenomatous polyposis (FAP). Surgical ampullectomy was indicated on a multisciplinary basis.

RESULTS

Final pathological examination revealed 15 adenomas, 4 in situ adenocarcinomas, 2 endocrine tumors, and 5 other benign lesions. There was no postoperative mortality. Specific morbidity was 8% (N=2). Mean follow-up was 86+/-70 months (range: 3-204). Actuarial overall 5-year survival was 92%. There were 4 local recurrences (none in patients with FAP). Four patients died during follow-up (including 3 from initial disease).

CONCLUSION

Ampullectomy is a good alternative to PD in case of benign or non-invasive malignant ampullary lesion, including in selected cases of FAP.

Anal sphincter reconstruction using a transposed gracilis muscle with a pudendal nerve anastomosis: a preliminary anatomic study

PURPOSE

Few studies have demonstrated the feasibility of cross innervating a skeletal muscle neosphincter with the pudendal nerve in an animal model. This study was designed to evaluate in humans the technical feasibility of anastomosing the nerve of the gracilis muscle and the pudendal nerve when the gracilis muscle is transposed around the anus.

METHODS

Anatomic assessment was made in 30 cases. The gracilis muscle and its principal neurovascular pedicle were dissected and the nerve to the gracilis divided at its origin. The gracilis muscle, accompanied by its nerve, was then transposed around the anus. The pudendal nerve was dissected in its extrapelvic portion and divided at its termination. Gracilis reinnervation was considered feasible when the proximal end of the nerve to the gracilis muscle and the distal end of the pudendal nerve were able to be placed into tension-free contact.

RESULTS

The mean lengths of the nerve to the gracilis and the pudendal nerve were 126.5 +/- 20.6 mm and 57.5 +/- 16.3 mm. Anastomosing the nerve of the gracilis muscle and the pudendal nerve was possible in 28 cases. There was a total mean surplus nerve length of 25.1 +/- 20.9 mm. In 26 cases, the distal end of the pudendal nerve (mean, 3.3 +/- 1.1 mm) was similar or larger than the end of the nerve to the gracilis (mean, 3 +/- 0.8 mm).

CONCLUSIONS

Anal sphincter reconstruction using transposed gracilis muscle with pudendal nerve anastomosis is anatomically achievable in cadavers, and supports the potential applications of this technique for perineal reconstruction in clinical practice.

Anatomic bases of graciloplasty using end-to-side nerve pudendal anastomosis

The objective of this study was to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve using an end-to-side nerve anastomosis. This study was carried out in 14 cases (7 adult human cadavers bilaterally). The gracilis muscle and its vascular-nervous bundle have been dissected and the nerve innervating the gracilis muscle has been cut at its origin. The gracilis muscle, accompanied by its nerve, has then been transposed around the anus. The pudendal nerve has been dissected from its extrapelvic part. The reinnervation using an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension-free contact with the extrapelvic part of the pudendal nerve. The extrapelvic part of the pudendal nerve has a common trunk in 12 cases. The width of the extrapelvic part of the pudendal nerve was 2.6+/-0.7 mm, range 1-3.5. The width of the proximal endings of the nerve innervating the gracilis muscle was 2.3+/-0.5 mm, range 2-3. The reinnervation of the gracilis muscle by the pudendal nerve has been possible in 14 cases. An average supplementary length of 17.4+/-15.4 mm was available (range 5-52). These results suggest an eventual practical aspect of this technique for the reconstruction of a functional sphincter using the gracilis muscle transposed around the anus.

[Pancreaticoduodenectomy in the era of evidence based medicine]

The aim of this comprehensive literature review was to analyse evidence based data in the field of pancreaticoduodenectomy. Pylorus preserving does reduce mortality or morbidity of the standard procedure and could increase the risk of delayed gastric emptying. Pancreaticogastrostomy does not decrease the rate of postoperative pancreatic fistula and is not superior to the pancreaticojejunal anastomosis which is more physiological. No other procedure (chemical occlusion, octreotide, stenting) has been demonstrated to prevent pancreatic fistula. Octreotide injection could be advocated in centres where there is a high rate of pancreatic fistula, when pancreatic parenchyma is soft and the main pancreatic duct thin. Intra-abdominal drainage is not beneficial and could be associated with some morbidity. Its use needs to be further evaluated. When a resection is done for pancreatic cancer, less than 5% of patients are a live five years after surgery with postoperative mortality rate of 5% in expert centres and a high morbidity rate (25-50%). Extended lymphadenectomy does not increase survival. The first trials showed that adjuvant therapies could be beneficial for pancreatic cancers, but further trials did not confirm these findings. Adjuvant therapy is not validated for pancreatic cancers and needs to be considered only in the settings of clinical trials.

[Reconstruction of the anus by the gracilis muscle reinnervated by the pudendal nerve. A preliminary anatomical study]

The aim of this study is to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve with an end-to-side nerve anastomosis.

METHODS

This study was carried out in 10 cases. The gracilis muscle and its vascular-nervous pedicle have been dissected. The nerve of the gracilis muscle has been cut at its origin. The gracilis muscle was transposed around the anus. The nerve of the gracilis muscle was transposed in the gluteal area. The pudendal nerve has been dissected from its extra-pelvic part. The reinnervation with an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension free contact with the extra-pelvic part of the pudendal nerve.

RESULTS

The reinnervation of the gracilis muscle by the pudendal nerve has been possible in all cases. The extra-pelvic part of the pudendal nerve has a common trunk in 8 cases. The width of the extra-pelvic part of the pudendal nerve was 2.8 +/- 0.8 mm (1-3.5). The width of the proximal endings of the nerve innervating the gracilis muscle was 2.5 +/- 0.5 mm (2-3). After transposition of the nerve of the gracilis muscle in the gluteal area an average supplementary length of 20.9 +/- 16.8 mm was available (range 5-52).

CONCLUSIONS

These results suggest that a reconstruction of the anal sphincter with a gracilis muscle transposed around the anus and reinnervated by the pudendal nerve with end-to-side nerve anastomosis is possible.

Correlation between invasiveness of colorectal tumor cells and adhesive potential under flow

BACKGROUND

Tumor cell adhesiveness is involved in metastatic dissemination, and adhesive behavior may be different under static and dynamic conditions.

MATERIALS AND METHODS

Patients undergoing primary colorectal cancer excision were tested for: i) serum concentration of sE-selectin, sICAM-1 and sVCAM-1, ii) expression of CD18, CD29d and E-cadherin on tumor cells and iii) efficiency of tumor cell adhesion to ECV304 monolayers under flow and resistance to detachment by shear.

RESULTS

Twenty out of 31 patients were free of detectable relapse 12 months later. Relapsing and non-relapsing patients had similar levels of soluble adhesion molecules. E-cadherin was detected on tumor cells from three non-relapsing patients, but no relapsing one. Unexpectedly, significant CD18 labeling was found on two relapsing patients and one non-relapsing patient. Cells from relapsing patients displayed significantly increased (p < 0.05 two-sided, p < 0.025 one-sided) capacity to adhere to test monolayers under flow.

CONCLUSION

Cancer invasion is related to tumor cell adhesiveness, and the flow chamber provides a practical way of measuring adhesive parameters with a potential value for relapse prediction.

[Surgical treatment of anal incontinence]

Surgery is mandatory for fecal incontinence when medical treatments and reeducation by biofeedback are ineffective. Sphincter disruption is the most frequent cause. Sphincter repair with or without overlapping is indicated in the large majority of cases. Short-term results are good but result is not ever maintained with time. In case of failure, or when the defect concerns more than 180 degrees, it is necessary to use a substitutive technique. Artificial anal sphincter is often first proposed because of its apparent technical simplicity and because it is cheaper than dynamic graciloplasty. Results are excellent. Failures are due to local infection or device disfunction. Dynamic graciloplastie may be proposed in patients with severe perineal lesions, or failure of the other methods. Its results are also excellent, except for the patients having disordered rectal perception. Sacral nerve stimulation is limited to patients with idiopathic or neurologic incontinence. Because definitive implantation is done only following positive preoperative stimulation test, short-term results are very good.

[Cephalic pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas: does pylorus preservation change morbidity and prognosis?]

STUDY AIM

To evaluate the influence of a pylorus-preserving on the morbidity and prognosis of patient with pancreaticoduodenectomy for adenocarcinoma of pancreas.

PATIENTS AND METHODS

Between 1985 and 1999, 183 patients were operated on for pancreatic adenocarcinoma. Among them, 63 patients (40 men, mean age 63 years, range 41-77 years) had curative resection and were included in this retrospective study. They were classified according to the type of resection. In the group I, the procedure included a pylorus-preserving pancreaticoduodenectomy (n = 35). In the group II, the procedure included polar inferior gastrectomy (n = 28). The prognosis was compared. Parameters for comparison were rate of local recurrence, rate of metastatic evolution and duration of survival.

RESULTS

The operative length and mortality rate (group I: 0%, group II: 3%), general (p = 0.37) and specific morbidity (p = 0.30), frequency of delayed gastric emptying were similar in the 2 groups (group I: 20%, group II: 35%, p = 0.88). The duration of naso-gastic aspiration was shorter in the group I (6 days vs 8, p = 0.01). The prognosis was the same in the 2 groups (metastasis: group I: 39%, group II: 56%, p = 0.12, local recurrence: group I: 58%, group II: 43%, p = 0.09, mean survival: group I: 18 months, group II: 19 months, p = 0.77).

CONCLUSION

These results suggest that pylorus preserving pancreatoduodenectomy could be performed for patients with adenocarcinoma of the head of the pancreas and does not compromise survival.

Short-term functional outcome following elective surgery for complicated sigmoid diverticular disease: sutured or stapled end-to-end anastomosis to the proximal rectum?

OBJECTIVE

The aim of this retrospective non-randomized study was to evaluate the short-term functional outcome following elective resectional surgery for complicated sigmoid diverticular disease, and to compare results of patients having hand-sewn or stapled end-to-end colonic anastomosis to the proximal rectum.

PATIENTS AND METHODS

Between 1983 and 1995, of 182 consecutive patients referred to our Institution for surgical treatment of complicated sigmoid diverticular disease, 137 underwent elective left hemicolectomy with primary colonic anastomosis to the proximal rectum, at a level above the peritoneal reflection. Twenty-one patients were excluded from the study because of a covering stoma (n=15), or a side-to-end (n=5) or side-to-side (n=1) anastomosis. All remaining 116 patients had an end-to-end anastomosis without covering stoma. Two groups were compared according to the type of anastomosis performed. Group I comprised the 67 patients who had a hand-sewn anastomosis, and group II the 49 patients whose anastomosis was stapled. Outcome was assessed at 6 months after surgery and compared in the two groups. Assessment included specific morbidity (anastomotic leakage, haemorrhage, fistulation and stenosis, pelvic sepsis), faecal incontinence, constipation, dyschesia, daily stool frequency, and stool consistency.

RESULTS

Preoperative patient details were comparable in both groups. There was no post-operative mortality, and the general morbidity rate was similar in both groups (P=0.85). There was no anastomotic leakage or haemorrhage, and no fistulation or pelvic sepsis in either group. One patient in group I, and two from group II, developed flatus incontinence, and a further patient from group II developed incontinence to liquid stool (P=0.17, group I vs group II). We observed better functional outcome following hand-sewn anastomosis. Three group II patients developed anastomotic stenosis compared with none in group I (P=0.04). Constipation (9% vs 28%, P=0.005) and dyschesia (18% vs 39%, P=0.03) were more frequent in group II. Excluding constipated patients (n=20), daily stool frequency was lower (mean 1.2 +/- 0.6 vs 2 +/- 1.3, P=0.0002), and more frequently of normal consistency (79% vs 43%, P=0.0001) in group I. Subgroup analysis failed to show significant differences in functional outcome in both groups in relation to the specific indications for surgery.

CONCLUSION

These retrospective data suggest for the first time in the reported literature that hand-sewn colonic anastomosis to the proximal rectum provides a better short-term functional outcome than stapled anastomosis following elective resectional surgery for complicated sigmoid diverticulosis.

[Perineal gangrene: new bacteriologic approach. Results of medico-surgical treatment (81 cases)]

STUDY OBJECTIVE

The objective of this retrospective study was to report the results of a series of 81 cases of perineal gangrene treated in the same center.

PATIENTS AND METHODS

From 1988 to 1998, 81 patients (64 males, 17 females, mean age: 58 years) with perineal gangrene were treated by a medico-surgical team, by means of a protocol combining appropriate intensive care measures based on a new bacteriologic concept of infectious agents, extensive excisions and drainage of the infraperitoneal region and hyperbaric oxygen therapy.

RESULTS

The mortality rate was 24.7%. Mean duration of intensive care stay was 19 days, mean duration of hospital stay was 31 +/- 4 days (range: 6 to 60 days). Risk factors were: age > 68 years (p = 0.001), shock (p = 0.83), subcutaneous crepitation (p = 0.25) and severity index > 10 (p = 0.003). Sequelae were anal incontinence (n = 3) and permanent colostomy (n = 5). Secondary plastic reconstruction was necessary in four patients. There were no urologic or genital sequelae.

CONCLUSION

Perineal gangrene is still a very serious disease. The time to treatment, the simplified severity index and consideration of bacteriologic combinations are the main prognostic factors.

[Malignant tumors of the ampulla of Vater. Results of radical excision. A study of 39 cases]

STUDY AIM

From 1971 to 1995, 39 patients underwent curative resection of a malignant tumor of the ampulla of Vater. The aim of this retrospective study was to report long-term results and to determine factors influencing survival in these patients.

PATIENTS AND METHODS

Data was collected from patient record analysis, correspondence with patients, their family or general physician. Kaplan-Meier method was used to compare survival data by the log-rank test. Multivariate analysis evaluated the impact of each variable on survival. Values with a P value of 0.05 or less were considered statistically significant.

RESULTS

Resection consisted of pylorus preserving pancreaticoduodenectomy (n = 21) or pancreatico-duodenectomy associated with an antrectomy (n = 18). Overall mortality rate after resection was 10% (n = 4). General and specific morbidity rates were 71% and 2.5%. During the course of the follow-up (completeness: 100%) mean survival was 80 months (median: 37 months, range: 6-227 months). Five-year survival rate was 35%. Factors favorably influencing long-term outcome were exposed protruding and well differentiated tumors (P = 0.03, P = 0.01, respectively) and negative lymph node status (P = 0.0001). Prognosis was poorer if tumor was extended into the pancreas (P = 0.04). Among proposed histoprognostic classifications (classifications of Martin, Talbot, Shiraï, Yamaguchi), an excellent correlation was obtained only with TNM classification (P = 0.0001).

CONCLUSION

Results of the present study suggest that prolonged survival can be obtained following radical resection of a malignant tumor of the ampulla of Vater, especially for exposed protruding and well differentiated tumors, without extension into the pancreas or lymph node metastasis. TNM classification provides an excellent predictive value and should be used more systematically.