Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Endoscopic management of anastomotic leakage after colorectal cancer surgery in a Moroccan center: A case series and literature review

Endoscopic management has become an alternate treatment to a revision surgery for colorectal fistulas. Eight patients who were treated by endoscopy for postoperative anastomotic leakage to colorectal cancer were included. A univariate analysis was carried out to determine the predictive factors of success. All our patients were treated using metallic clips. The primary efficiency of this technique was 50%. In a univariate analysis, the size of the fistula and its distance from the anal margin had an influence on the efficiency of the endoscopic treatment, which was not the case for either the surgical technique or the use of neoadjuvant radiotherapy. This endoscopic treatment is effective and represents a more secure alternative than revision surgery. In our study, the use of metallic clips showed a 50% success rate, going up to 100% for the group of patients with a fistula ostium of a size ⩽1 cm, proving the necessity of using this technique.

The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries

Objective

This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre.

Methods

All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts.

Results

Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM.

Conclusions

This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.

Beware of lethal Wernicke's encephalopathy after cytoreductive surgery with HIPEC for peritoneal pseudomyxoma: Case report of morbidity and mortality review

Background

Pseudomyxoma peritonei (PMP) arising from the appendix is a rare entity. Complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only established curative treatment, and is reputedly linked to high morbidity and mortality.

We report, to our knowledge, the first case of delayed lethal Wernicke encephalopathy (WE) complicating CRS with HIPEC for an appendicular PMP. WE, caused by a thiamine deficiency, is characterized by ataxia, nystagmus and changes in consciousness.

Methods

A patient underwent complete CRS with HIPEC for a low grade mucinous appendicular tumor at the stage of PMP with a peritoneal index of 31, and was readmitted at POD 36 for persistent vomiting and vague neurological symptoms of mental confusion. The classic triad of WE appeared tardily. Although thiamine substitution was promptly applied, the patient died at POD53.

Conclusion

WE is an uncommon and severe neurological disorder with a mortality rate up to 20 % and only 16 % of treated patients can fully recover. This diagnosis should always be anticipated in patients undergoing major surgery such as CRS- HIPEC. Efficient treatment should be quickly introduced in order to avoid a lethal outcome.

•

Pseudomyxoma peritonei is a rare entity, treatment consists of complete cytoreductive surgery and hyperthermic intra peritoneal chemotherapy with positive effects established in the literature.

•

However, this combined treatment is a complex procedure and is associated with high morbidity and mortality.

•

Wernicke’s encephalopathy is a rare complication of this procedure and has been reported once in the literature.

•

Wernicke’s encephalopathy is a diagnosis to keep in mind and anticipate in patients undergoing cytoreductive surgery and hyperthermic intra peritoneal chemotherapy

Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country

Background

Morbidity and mortality reviews represent an opportunity to discuss adverse events and healthcare issues. Aim: Report the first experience of implementing a procedure of MMR, and assess its impact on quality improvement.

Methods

From July 2019 to December 2019, members of the surgical and ICU departments designed and implemented a regular procedure of MMR. Cases of severe postoperative complications after curative resection for digestive cancer were selected to be presented by a surgical resident and discussed in an interdisciplinary conference following a standardized presentation based on an analysis tool adapted from the ALARM framework. Process was assessed by the number of MMRs held, number and type of recommendations issued and implemented.

Results

Among 13 serious complications during the study period, 10 were discussed. The “Tasks” category was activated in 90% of the cases where lack or misuse of protocols was identified in 90% of the events discussed. Test results availability or accuracy were incarnated in 30% of cases. Poor communication was a contributing factor in 60% of the cases. Written medical records were defective in 40% of the cases. From 16 recommendations for improvement emitted, 87.5% (14/16) were translated into projects and successfully implemented.

Conclusions

a standardized and regular procedure of morbidity and mortality reviews in a tertiary care facility in a developing country allowed a significant improvement in patient care through quality initiatives implementation. MMRs might be a strong tool for the improvement of surgical care particularly for low-mid income countries.

•

Morbidity and mortality reviews (MMR) are an opportunity to discuss adverse events and healthcare issues.

•

Experience of implementing a procedure of MMR in a tertiary care facility in a developing country.

•

A standardized and regular procedure allowed a significant improvement in patient care through quality initiatives.

•

MMR might be a strong tool for the improvement of surgical care particularly for low-mid income countries.

Available prediction scores of conversion for laparoscopic rectal cancer surgery seem to be unsuitable for nowadays rectal cancer management

Introduction

This study aimed to externally evaluate the accuracy of four predictive scores for conversion to open surgery after rectal laparoscopic resection. None of the four scores achieved external validation previously.

Methods

This was a retrospective analysis of two prospectively maintained databases from two academic centers in France and Morocco. All consecutive patients who underwent laparoscopic resection for rectal adenocarcinoma between 2005 and 2020 were included. Logistic regression was used to assess the association between the factors present in the four scores and conversion. The accuracy of each score was assessed using the area under the curve (AUC). Observed and predicted conversion rates were compared for each score using the Chi-square goodness-of-fit test.

Results

Four hundred patients were included. There were 264 men (66%) with a mean age of 65.95 years (standard deviation 12.2). The median tumor height was 7 cm (quartiles 4–11) and 29% of patients had low rectal tumors. Conversion rate was 21.75%. The accuracy to predict conversion was low with an AUC lower than 0,62 for the four models. The observed conversion rates were significantly different from the predicted rates, except for one score.

Conclusions

The four models had low accuracy in predicting the conversion to open surgery for laparoscopic rectal resection. There is a need for new well-designed studies, analyzing more specific variables, in a multicentric design to ensure generalizability of the results for daily surgical practice.

Delivering colorectal cancer screening integrated with primary health care services in Morocco: Lessons learned from a demonstration project

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are increasing rapidly in many low-income and middle-income countries. A demonstration project was implemented in Morocco in collaboration with the Ministry of Health to assess the feasibility, acceptability, and challenges of implementing CRC screening through routine primary care facilities.

METHODS

The objective of the project was to screen 10,000 men and women aged 50 to 75 years through 10 primary health centers (PHCs) in 2 provinces. All eligible men and women attending the selected PHCs were offered the fecal immunochemical test (FIT). Stool specimens brought to the PHCs were tested immediately by trained nurses. FIT-positive individuals were referred to the National Oncology Institute for colonoscopy.

RESULTS

In total, 9763 eligible men and women were screened by FIT between June 2017 and May 2019; most (73.3%) were women. The test was positive in 460 participants (4.7%). Among the individuals who had positive FIT results, 62.6% underwent colonoscopy. The main reasons for noncompliance to colonoscopy were competing life priorities (15.4%), other health problems (13%), and fear of getting a cancer diagnosis (12.3%). As the number of referrals to colonoscopy increased, the waiting time for the procedure increased, resulting in a drop in compliance. The detection rates of advanced adenomas and CRC were 4.0 in 1000 and 0.5 in 1000 individuals screened, respectively.

CONCLUSIONS

An effective strategy to reach the target populations (especially men), a pragmatic assessment of the health system's capacity to deal with large numbers of referrals, and a formal cost-effectiveness analysis are essential before making any decision to introduce CRC screening in Morocco.

Comparison of Short-Term and Long-Term outcomes of Laparoscopy Versus Laparotomy in Rectal Cancer: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background and objective: The last randomized controlled trials ,the ACOSOG Z6051 1,2 and the ALaCaRT trial3, 4 could not show the non-inferiority of the laparoscopy in comparison to laparotomy for rectal cancer. In fact, the ten first years of practicing laparoscopy were years when surgeons developed their learning curve. Therefore, by excluding this learning bias, it is possible to end up with a more fair and correct comparison between the two techniques. It is henceforth relevant to pursue a new meta-analysis that compares the two techniques and excludes studies done during the earlier periods of laparoscopic rectal surgery. Results: Six randomized controlled trials met the eligibility criteria, involving a total of 1556 patients in the laparoscopy group and 1188 patients in the laparotomy group. Our meta-analysis was in favor of laparoscopy in a significant way for blood loss, first bowel movement and the number of harvested lymph nodes. It was non-significantly in favour of laparoscopy for 30-days mortality after surgery and length of hospital stay. It was significantly in favor of laparotomy for operative duration. No significant difference was found in anastomotic leakage) , reoperation within 30 days, number of positive CRMs and completeness of mesorectal excision between the two groups. No difference was found in recurrence, disease-free survival and overall survival between laparoscopy group and laparotomy group. Conclusion: The comparison of the randomized controlled trials published before and after 2010, showed no significant difference in outcomes between the learning period and after. Keywords: Laparoscopy, laparotomy, long-term outcomes, meta-analysis, short-term outcomes, rectal cancer

Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery

BACKGROUND

Bowel dysfunction symptoms such as stool clustering, urgency, incomplete voiding, and fecal incontinence are frequent after colorectal surgery and known as the low anterior resection syndrome. The Wexner score is the most widely used tool for fecal incontinence assessment. We aimed to translate and test the psychometric properties of the Moroccan Arabic dialect version of the Wexner questionnaire in patients with low anterior resection syndrome after rectal surgery.

METHODS

The Wexner questionnaire was translated to Moroccan Arabic and administered to a group of 158 patients, among which a subgroup of 43 patients took the test for a second time to examine test-retest reliability. Cronbach alpha coefficient was used to determine internal consistency and correlation, and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 and the low anterior resection syndrome questionnaires were assessed for convergent validity. Discriminant validity was demonstrated through the Wexner score ability to detect differences based on the patients' different clinical and pathological characteristics.

RESULTS

One hundred and fifty-eight patients completed the Moroccan Arabic dialect version of the Wexner score, which showed an excellent internal consistency with a Cronbach alpha score of 0.91. Test-retest reliability was established by a Bland-Altman plot with 95% limits of agreement. The score showed positive correlation to the low anterior resection syndrome score (r = 0.748; P < .001) and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 diarrhea symptom scale (r = 0.519; P < .001). A negative correlation was also demonstrated for each one of the 5 European Organisation for the Research and Treatment of Cancer quality of life C30 functional scales, namely physical functioning (r = -0.217 ; P = .006), role functioning (r = -0.267; P = .001), emotional functioning (r = -0.266; P = .001), cognitive functioning (r = -0.283; P < .001), and social functioning (r = -0,283; P < .001). The Wexner score differed between patients according to tumor location, chemoradiotherapy, type of mesorectal excision, and anastomosis.

CONCLUSION

The Moroccan Arabic dialect version of the Wexner score shows good psychometric properties and can be used for fecal incontinence assessment, particularly in colorectal cancer patients.

Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience

Simple Summary

Complete cytoreductive surgery (CRS) is the backbone of peritoneal surface malignancies (PSM) management and a major prognostic factor to better survival outcomes. Implementing a PSM program is a steep and complex process, particularly in low-middle income countries (LMIC), where limited resources are an additional challenge to overcome. In this study, we present the results of a mid-term audit of the implementation of a PSM program in Morocco. The latter was successfully and safely launched according to predicted initiation, transition and consolidation periods and allowed the significant improvement of short term surgical and oncological outcomes and completeness of cytoreduction procedures.

Abstract

Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation (“1”:2005–2008), transition (“2”:2009–2013) and consolidation (“3”:2014–2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Predictive Factors for Impaired Mental Health among Medical Students during the Early Stage of the COVID-19 Pandemic in Morocco

The COVID-19 pandemic has great consequences on mental health. We aimed to assess medical students’ psychological condition and influencing factors as a baseline evidence for interventions promoting their mental wellbeing. We conducted an online survey from April 8 to April 18, 2020 to examine the mental health of medical students by the nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder Scale, seven-item Insomnia Severity Index, and six-item Kessler psychological distress scale. Factors associated with mental health outcomes were identified by multivariable logistic regression analysis. Five hundred forty-nine students completed the survey; 341 (62.3%), 410 (74.6%), 344 (62.6%), and 379 (69%) reported anxiety, depression, insomnia, and distress, respectively. Female students, living in high COVID-19 prevalence locations, more than 25 days confinement, psychiatric consult history, and being in a preclinical level of studies had higher median scores and severe symptom levels. Multivariable logistic regression showed female gender as a risk factor for severe symptoms of anxiety (odds ratio [OR]: 1.653; 95% CI: 1.020–2.679; P = 0.042), depression (OR: 2.167; 95% CI: 1.435–3.271; P < 0.001), insomnia (OR: 1.830; 95% CI: 1.176–2.847; P = 0.007), and distress (OR: 1.994; 95% CI: 1.338–2.972; P = 0.001); preclinical level of enrollment as a risk factor for depression (OR: 0.679; 95% CI: 0.521–0.885; P = 0.004), insomnia (OR: 0.720; 95% CI: 0.545–0.949; P = 0.02), and distress (OR: 0.650; 95% CI: 0.499–0.847; P = 0.001), whereas living in high COVID-19 prevalence locations was a risk factor for severe anxiety (OR: 1.628; 95% CI: 1.090–2.432; P = 0.017) and depression (OR: 1.438; 95% CI: 1.002–2.097; P = 0.05). Currently, medical students experience high levels of mental health symptoms, especially female students, those at a preclinical level and living in regions with a high prevalence of COVID-19 cases. Screening for mental health issues, psychological support, and long-term follow-up could alleviate the burden and protect future physicians.

Transanal total mesorectal excision for patients with rectal cancer : a Systematic review and meta-analysis

BACKGROUND

Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME) for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours.

AIM

The objective of our meta-analysis is to evaluate short-term oncological and perioperative outcomes of transanal total mesorectal excision (TaTME) compared to laparoscopic total mesorectal excision (LaTME) for rectal cancer.

METHODS

A meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in MEDLINE (PubMed). All original studies published in English that compared TaTME with laTME were included. The quality of the included studies was assessed by the Newcastle- Ottawa Quality Assessment Scale (NOS) and Cochrane Library Handbook 5.1.0. Data analysis was conducted using the Review Manager 5.3 software.

RESULTS

Twelve studies including 835 TaTME patients and 1707 LaTME patients with rectal cancer met the inclusion criteria in this meta-analysis. No statistical significant differences were observed in regard to positive circumferential resection margin (PCRM), positive distal resection margin (PDRM), macroscopic quality of mesorectum (MQM) and harvested lymph nodes (HLN). Concerning the perioperative outcomes, the results of conversion rates, operative time, hospital stay (HS), anastomotic leakage (AL) and postoperative complications were comparable between the two groups.

CONCLUSION

Our meta-analysis provides that TaTME may be a valid alternative approach for the treatment of rectal cancer in comparison with LaTME.

Supraclavicular versus infraclavicular approach in inserting totally implantable central venous access for cancer therapy: A comparative retrospective study

INTRODUCTION

The insertion of an implantable central venous access is performed according to a variety of approaches which allow the access to the subclavian vein, yet the supraclavicular technique has been underused and never compared to the other methods. The aim of this study was to testify on the efficacy and safety of the subclavian puncture without ultrasound guidance « Yoffa » in comparison with the classical infraclavicular approach (ICA).

MATERIAL AND METHODS

This is a retrospective study with prospective data collection on patients followed at the national oncology institute for cancer, in the period extending from May 1st 2017 to August 31st 2017. All patients had a totally implantable central venous access device inserted by the same surgeon AS for chemotherapy administration and demographic characteristics, as well as procedure details were examined. The primary outcomes were the intraoperative complications, while the secondary outcomes represented immediate postoperative and mid-term complications (at 15 months of follow up). Outcomes were compared between techniques by means of non parametric tests and the Fischer test.

RESULTS

Our study included 135 patients with 70 patients undergoing the subclavian technique, while 65 were subject to the infraclavicular approach. Both groups had no statistically significant demographic characteristics. The number of vein puncture attempts exceeding once, the accidental artery puncture and operative time were more significant in the ICA group; (39,6 vs 17,6 p = 0,01) (9.2% vs 0; p = 0,01) and (27± 13 vs 23± 8min, p = 0.045) respectively. There was no statistically significant difference in the immediate and midterm complication rate between the two methods 1(1,4) vs 2 (3) p = 0.5.

CONCLUSION

In case of unavailability of ultrasonographic guidance, the use of the supra-clavicular landmarks approach is linked to higher success rates and less arterial punctures, thereby proving to be a safe and reliable approach.

Validation of the Moroccan arabic version of the low anterior resection syndrome score

Background

Sphincter sparing surgery is oftentimes associated with bowel dysfunction complaints, namely the low anterior resection syndrome (LARS). The LARS questionnaire is widely used to assess this syndrome. The aim of this observational study is to translate this tool into arabic and test its psychometric properties in rectal cancer patients, in order to ease its use in clinical practice and future research.

Methods

The LARS questionnaire was translated to arabic and administered to a total of 143 patients. A subgroup of 42 patients took the test twice for test-retest reliability. Internal consistency was examined through cronbach’s alpha. The score results were correlated to the EORTC QLQ-C30 questionnaire for convergent validity assessment, while discriminant validity was established through the ability of the LARS score to differentiate patients with different clinical and pathological criteria.

Results

The Moroccan Arabic version of the LARS score was completed by 143 patients. The internal consistency was demonstrated through a cronbach alpha score of 0.66. The agreement between the test and retest was established by a Bland Altman plot with 95% limits of agreement. 85.6% of patients remained in the same LARS category. The LARS score showed negative correlation with all five of the QLQ-C30 functional scales as well as positive correlation to the diarrhea symptom scale. The questionnaire score differed between patients according to their tumor location, chemoradiotherapy, type of mesorectal excision and anastomosis.

Conclusion

The Moroccan Arabic version of the LARS score shows good psychometric properties and can be used for bowel dysfunction assessment in clinical and research settings.

Validation of the French translation of the Dutch residency educational climate test

BACKGROUND

The learning environment is one of the most influential factors in training of medical residents. The Dutch Residency Educational Climate Test (D-RECT) is one of the strongest instruments for measuring the learning environment. However, it has not been translated in French. The objective of this study is the psychometric validation of the DRECT French version.

MATERIAL AND METHODS

After translation of the D-RECT questionnaire into French, residents of five Moroccan hospitals were invited to complete the questionnaire between July and September 2018. Confirmatory factor analysis was used to evaluate the validity of the construct using the standardized root mean square residual (SRMR), the root mean square error approximation (RMSEA), the Comparative Fit Index (CFI) and the Tucker- Lewis Index (TLI). Reliability analysis was analysed using Internal consistency and Test-retest.

RESULTS

During the study period, 211 residents completed the questionnaire. Confirmatory factor analysis showed an adequate model fit with the following indicators: SRMR = 0.058 / RMSEA = 0.07 / CFI = 0.88 / TLI = 0.87. The French translation had a good internal consistency (Cronbach alpha score >  0.7 for all subscales) and a good temporal stability (correlation score between two measurements = 0.89).

CONCLUSION

This French version has an acceptable validity of the construct, a good internal consistency and good temporal reliability, and may be used to evaluate the learning climate. Additional research is necessary in other French-speaking contexts, in order to confirm these results.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma

BACKGROUND AND OBJECTIVES

Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score.

METHODS

All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test.

RESULTS

Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm.

CONCLUSIONS

The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.

Evaluation of the Decision-Making Mode during Digestive Oncology Multidisciplinary Meetings: a Prospective Study in a Moroccan Center

Introduction: The multidisciplinary team oncology meeting (MDT) has become a standard in oncology. The objective of this study was to evaluate the value of a validated tool, the Metric for the Observation of Decision-Making, in the evaluation of the decision-making mode during the digestive cancer MDT in order to reach recommendations for improvement. Results: Eight consecutive MDTs were observed (N = 228 patients). On average, 32 patients were discussed by MDT with an average of 2 min 55 s (interval: 30 s-10 min 16 s) per patient. A decision was reached in 84.6% of the cases. Although the medical information was judged to be of good quality, the psychosocial information (average 1.29) and the patients' point of view (average 1.03) were judged to be of low quality. For teamwork, the contribution of surgeons (average 4.56) and oncologists (average 3.99) was greater than radiologists (3.12), radiotherapists (1.74) and pathologists (1.02). Conclusions: The tool made it possible to identify a disparity in the quality of the different aspects of the information and in the participation of specialists, making it possible to identify specific improvement measures. Its regular use would improve the quality of patient care. Keywords: Decision making, Quality improvement, Multidisciplinary Concertation meeting, MDT-MODe, Morocco

Evaluation of the Decision-Making Mode during Digestive Oncology Multidisciplinary Meetings: a Prospective Study in a Moroccan Center

Introduction: The multidisciplinary team oncology meeting (MDT) has become a standard in oncology. The objective of this study was to evaluate the value of a validated tool, the Metric for the Observation of Decision-Making, in the evaluation of the decision-making mode during the digestive cancer MDT in order to reach recommendations for improvement. Results: Eight consecutive MDTs were observed (N = 228 patients). On average, 32 patients were discussed by MDT with an average of 2 min 55 s (interval: 30 s-10 min 16 s) per patient. A decision was reached in 84.6% of the cases. Although the medical information was judged to be of good quality, the psychosocial information (average 1.29) and the patients' point of view (average 1.03) were judged to be of low quality. For teamwork, the contribution of surgeons (average 4.56) and oncologists (average 3.99) was greater than radiologists (3.12), radiotherapists (1.74) and pathologists (1.02). Conclusions: The tool made it possible to identify a disparity in the quality of the different aspects of the information and in the participation of specialists, making it possible to identify specific improvement measures. Its regular use would improve the quality of patient care. Keywords: Decision making, Quality improvement, Multidisciplinary Concertation meeting, MDT-MODe, Morocco

Africa Against COVID-19: Can National Solidarity Complements Health System Weaknesses? -the Moroccan Experience-

NA

Perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma: the muscular graft as a pseudosphincter

BACKGROUND AND STUDY AIM

The aim of this study was to analyze objectively the role of the muscular graft in the continence using manometric study in the patients who underwent pseudocontinent perineal colostomy after abdominoperineal resection for rectal adenocarcinoma.

PATIENTS AND METHODS

This was a retrospective study including all the patients from January 2002 to December 2009 who underwent an abdominoperineal resection followed by perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma and agreed to perform the manometric evaluation of the muscular graft.

RESULTS

Fifteen patients were included, six males and nine females, with a mean age of 50 years. According to Kirwan's classification, 2 (13.3%) patients had normal continence (Stage A) had 10 (66.6%) no soiling (stage B) and 3 (20%) patients had minimal soiling (Stage C). The manometric evaluation was performed after a median period of 12 months post-surgery. The mean maximal resting and squeeze pressures were respectively 41 cmH2O and 59 cmH2O and the mean colonic sensory volume was 12 ml.

CONCLUSION

This study showed that the musculae graft of Pseudocontinent Perineal colostomy acted as a hypotonic sphincter that pressure can increase during the voluntary squeeze. These data may help to clarify the functional outcomes of this technique after APR for ultra-low rectal adenocarcinoma.

[Adolescent binge drinking: neurocognitive consequences and gender differences]

BACKGROUND

Binge drinking by adolescents and young adults is on the increase and is having serious medical and social consequences. Over the last ten years more and more research has been done into the neurocognitive effects of binge drinking and into the possibility that these effects are gender-specific. However, so far, findings have been inconsistent.

AIM

To collect evidence for the negative impact of binge drinking on the neurocognitive functioning of adolescents and young adults and to find out whether binge drinking has a more serious effect on neurocognition in females than in males.

METHOD

We searched the literature using PubMed and Web of Science.

RESULTS

Nineteen studies satisfied our selection criteria. Eleven studies examined the binge/gender interaction.

CONCLUSION

There is considerable evidence that binge drinking does have a negative effect on neurocognition in adolescents and young adults, particularly with regard to executive functioning and memory. Females seem to be more susceptible than males to deficits in spatial working memory and impulse control.

Small bowel tumors: what is the contribution of video capsule endoscopy?

BACKGROUND

Intestinal tumors represent less than 6% of digestive tumors and, because of the limitations of intestinal investigations, these tumors are difficult to diagnose. In this context, capsule endoscopy (CE) has proven effective especially in patients with obscure digestive bleeding. The aim of the present study was to calculate the frequency, and evaluate the diagnostic and therapeutic impact of CE in cases of small bowel tumors.

PATIENTS AND METHODS

A total of 95 patients (57 males and 38 females, mean age of 56 years) with negative endoscopy and colonoscopy results were directed to undergo CE examination.

RESULTS

Of the 95 patients, 13 (13.7%) were diagnosed with small bowel tumors. The main indications for CE were obscure (occult and overt) gastrointestinal bleeding. The mean duration of symptoms before diagnosis was 10 months. The final histological diagnosis was established through surgery. In our patients, this included gastrointestinal stromal tumor (nine cases), adenocarcinoma (two cases) and carcinoid tumor (two cases).

CONCLUSION

This study revealed that the prevalence of intestinal tumors appears to be higher than expected in patients through the use of CE.

From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of "stent-guided regeneration and re-epithelialization"

BACKGROUND

Iatrogenic intestinal tract perforation and anastomotic disunion traditionally required surgical treatment. Complete anastomotic break was considered until now as an absolute contraindication for endoscopic management.

OBJECTIVE

The aim of this series was to show that endoscopic management is able to treat a spectrum of bowel wall breaks, from focal perforation to complete anastomotic disunion.

SETTING

A single-center prospective cohort study.

PATIENTS

Nine consecutive patients with nonmalignant gastrointestinal perforations were treated with endoscopic stenting between 2005 and 2008. Perforations were related to endoscopic perforations (4 cases: 2 esophageal and 2 colorectal), postoperative fistula or leakage (2 cases: 1 colorectal anastomosis and 1 esophageal), and complete anastomotic disunion (3 cases: 2 ileoanal anastomosis and 1 esophagogastric anastomosis).

INTERVENTIONS

All 9 patients underwent endoscopic installation of fully covered stents under endoscopic and radiologic guidance, sometimes associated with simultaneous endoscopic collection drainage. Oral feeding was resumed when radiologic contrast studies showed no residual leak.

RESULTS

The outcome in all 9 patients was favorable. Two migrated stents were replaced, and 2 stents were spontaneously expelled without consequence. All stents were withdrawn within an average of 5 weeks.

LIMITATIONS

Uncontrolled pilot study, small sample size.

CONCLUSION

The successful endoscopic management of bowel wall breaks ranging from perforation to complete postoperative disunion with fully covered stent could support a new concept of "stent-guided regeneration and re-epithelialization." Controlled trials are needed before this new endoscopic treatment can be proposed as a substitute for traditional treatments.

Mutational analysis of the helicase-like domain of Thermotoga maritima reverse gyrase

Reverse gyrase is a unique type IA topoisomerase that is able to introduce positive supercoils into DNA in an ATP-dependent process. ATP is bound to the helicase-like domain of the enzyme that contains most of the conserved motifs found in helicases of the SF1 and SF2 superfamilies. In this paper, we have investigated the role of the conserved helicase motifs I, II, V, VI, and Q by generating mutants of the Thermotoga maritima reverse gyrase. We show that mutations in motifs I, II, V, and VI completely eliminate the supercoiling activity of reverse gyrase and that a mutation in the Q motif significantly reduces this activity. Further analysis revealed that for most mutants, the DNA binding and cleavage properties are not significantly changed compared with the wild type enzyme, whereas their ATPase activity is impaired. These results clearly show that the helicase motifs are tightly involved in the coupling of ATP hydrolysis to the topoisomerase activity. The zinc finger motif located at the N-terminal end of reverse gyrases was also mutated. Our results indicate that this motif plays an important role in DNA binding.

Comparison of the sequences of the Aspergillus nidulans hxB and Drosophila melanogaster ma-l genes with nifS from Azotobacter vinelandii suggests a mechanism for the insertion of the terminal sulphur atom in the molybdopterin cofactor

The molybdopterin cofactor (MoCF) is required for the activity of a variety of oxidoreductases. The xanthine oxidase class of molybdoenzymes requires the MoCF to have a terminal, cyanolysable sulphur ligand. In the sulphite oxidase/nitrate reductase class, an oxygen is present in the same position. Mutations in both the ma-l gene of Drosophila melanogaster and the hxB gene of Aspergillus nidulans result in loss of activities of all molybdoenzymes that necessitate a cyanolysable sulphur in the active centre. The ma-l and hxB genes encode highly similar proteins containing domains common to pyridoxal phosphate-dependent cysteine transulphurases, including the cofactor binding site and a conserved cysteine, which is the putative sulphur donor. Key similarities were found with NifS, the enzyme involved in the generation of the iron-sulphur centres in nitrogenase. These similarities suggest an analogous mechanism for the generation of the terminal molybdenum-bound sulphur ligand. We have identified putative homologues of these genes in a variety of organisms, including humans. The human homologue is located in chromosome 18.q12.

The hxB gene, necessary for the post-translational activation of purine hydroxylases in Aspergillus nidulans, is independently controlled by the purine utilization and the nicotinate utilization transcriptional activating systems

Molybdenum-containing enzymes of the hydroxylase class (such as xanthine dehydrogenase, aldehyde oxidase and nicotinate dehydrogenase) require a terminal sulphur atom attached to the molybdenum to hydroxylate their specific substrates. The transulphurylation reaction is carried out in Drosophila melanogaster by the product of the ma-I gene. In Aspergillus nidulans, the activity of the isofunctional and homologous HxB protein is needed in at least two different metabolic contexts, when the organism grows on purines and when it grows on nicotinate as nitrogen sources. We show here that the expression of the hxB gene is not constitutive. It is induced independently and additively by the inducers of the purine and of the nicotinate utilization pathways. Each of these induction pathways is affected independently by mutations in their cognate genes, uric acid induction by mutations in the UaY protein and nicotinate and 6-nicotinate induction by those in the hxnR/aplA complex. It is, in both metabolic contexts, exquisitely sensitive to nitrogen metabolite repression and highly dependent on the AreA GATA factor.