Patient management after primary rectal cancer diagnosis. Special focus on surgical treatment for non-metastatic disease.

Background: Rectal cancer is a public health priority. Primary objectives of this study were to evaluate the quality of care for non-metastatic rectal cancer using process and outcome indicators. Delay of management, length of stay and readmission rate, sphincter preservation, morbidity, number of examined lymph nodes, mortality, overall and disease-free survivals were evaluated. Secondary objectives were to estimate the relationship between possible predictive parameters for (1) anastomotic leakage (logistic regression), (2) overall or disease-free survivals (cox regression).Methods: We performed a retrospective study on 312 consecutive patients diagnosed with primary rectal cancer between 2016 and 2019. We focused on the 163 patients treated by surgery for non-metastatic cancer.Results: The treatment began within 33 days (range 0-264) after incidence, resection rate was 67%. Digestive continuity rate in lower, middle and upper rectum was 30%, 87% and 96%. Median of 14 lymph nodes (range 1-46) was analyzed. Length of stay and readmission rate were 11 days (range 3-56) and 4%, respectively. Within 90 postoperative days, clinical anastomotic leakage occurred in 9.2% of cases, major morbidity rate was 17%, mortality 1.2%. Multivariate analysis revealed that stoma decreased the risk of anastomotic leakage [hazard ratio: 0.16; 95% confidence intervals: 0.04-0.63; p = 0.008]. The 5-year overall survival after surgery was 85 ± 4%, disease-free survival 83 ± 4%. Patients with major complications, male gender and R1/R2 resection margin had a poorer prognosis.Conclusion: This work showed encouraging results in rectal cancer treatment in our institution, our results were in line with recommendations at the time.

[Clinical pathway evaluation for left colectomy in abdominal surgery]. / Evaluation d'un itinéraire clinique pour colectomie gauche en chirurgie abdominale.

At the end of 2008, a left colectomy clinical pathway was implemented at Clinique Saint-Joseph (CHC) in Liège (Belgium). A sample of 213 patients with benign or malignant pathology requiring laparoscopic left colon resection was included in this clinical pathway during the years 2009 to 2015. We focused on the compliance with the protocol, on the complication rate and the incidence of re-hospitalization within 30 days after surgery. In comparison with a historical control group, we observed that the compliance was excellent (superior to 80 %) from 2009 to 2015. The re-hospitalization did not differ though the complication rate decreased. Although the hospital stay was not our primary objective, it decreased significantly from 8 to 4 days (average). This analysis leads to the conclusion that the introduction of a clinical pathway, when it is well prepared and brings together all the implicated persons with the same goal, is directly beneficial to the patient and the quality of its management.

Fin 2008, l'itinéraire clinique (IC) «colectomie gauche¼ a été mis en place au sein de la Clinique Saint-Joseph (CHC) de Liège. Une série de 213 patients présentant une pathologie bénigne ou maligne nécessitant une résection du côlon gauche par laparoscopie a été incluse dans cet IC entre 2009 et 2015. Nous nous sommes intéressés à l'observance du protocole de l'IC ainsi qu'aux taux de complications et de ré-hospitalisations dans les 30 jours post-opératoires. Nous avons constaté, après comparaison avec un groupe témoin historique, que l'adhésion au protocole IC a été d'emblée excellente (supérieur a 80 %) tout au long de la durée de l'étude. Il n'y a pas eu de modification du taux de ré-hospitalisations et le taux de lâchage de suture a été réduit. Bien que la diminution de la durée de séjour n'était pas l'objectif premier lors de la mise en place de cet IC, elle s'est significativement réduite passant, en moyenne, de 8 à 4 jours. En conclusion, l'introduction d'un IC, pour autant qu'il soit bien préparé et rassemble dans le même objectif l'ensemble des acteurs de soins, est directement bénéfique pour le patient et la qualité de sa prise en charge.

[An unexpected finding in a 14-year-old girl]. / Le cas clinique du mois. Découverte inattendue chez une jeune fille de 14 ans.

A 14-year-old girl was admitted to the Emergency department for abdominal pain. An abdominal mass of 7-8 cm was detected and surgically resected. At anatomopathology a solid pseudopapillary neoplasm of the pancreas was observed. This tumour is rare and is included in the pancreatic cystic neoplasms. It frequently concerns 20-30-year-old girls. In all cases, the treatment consists of surgical resection, even in the rare cases with metastases. Prognosis is usually good, but careful follow-up is mandatory.

[Contrast-enhanced ultrasound in hepatic focal nodular hyperplasia]. / Le cas clinique du mois. L'échographie avec injection de produit de contraste dans l'hyperplasie nodulaire focale du foie.

The ultrasound contrast agent is composed by microbubbles of sulfur hexafluoride. It is now recognized to the characterization of liver lesions. Focal nodular hyperplasia (FNH) is a benign lesion of the liver. It is found in the majority of cases among women with a sex ratio 1M/8F, no typical clinical presentation or malignancy is described. When the liver lesion was found in B-mode ultrasound, injection of contrast can be realized immediately by the radiologist. The study of the lesion during the arterial, portal and late phases with the contrast-enhanced ultrasound allows the diagnosis of FNH with a specificity of 97%. In arterial phase, the prescence of a central artery and scarring, centrifugal progression of enhancement, a transient unenhanced zone and in portal and late phases, isoechogenicity compared to adjacent parenchyma are the main features of FNH described in the literature.

[Imaging in ankle traumas with special attention to fractures and their mechanisms]. / Mécanisme et imagerie des fractures de la cheville.

The ankle is the most frequently injured joint. The most common causes include sports injuries, highway accidents and household or workplace accidents. The therapeutic decision is based on radiological and clinical interpretation. This article aims to assist the clinician in deciding the role of radiography in diagnosis, care and treatment. It is also a reminder for the radiologist.

[A right supradiaphragmatic mass varying over 6 years]. / Le cas clinique du mois. Masse supra-diaphragmatique droite fluctuant pendant 6 ans.

A pleuro-pericardial cyst represents an uncommon form of congenital disease. We relate the case of an initially symptomless female patient presenting with a voluminous mediastinal mass. The fortuitous discovery of an asymptomatic mediastinal mass should always prompt consideration, among others, of the diagnosis of a pleuro-pericardial cyst.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]. / Le cas clinique du mois. Les endofuites, une complication spécifique du traitement endovasculaire des pathologies aortiques.

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

Usefulness of thromboendarterectomy in association with coronary artery bypass grafting.

Thromboendarterectomy is sometimes performed in association with coronary artery bypass graft surgery (CABG). Right coronary arteries and severely narrowed coronary arteries mainly undergo thromboendarterectomy, but perioperative acute myocardial infarctions (AMI) are possible complications. One hundred seventy-six consecutive patients with rest and stress thallium-201 scintigraphy and angiography were studied before and after surgery. To compare patients with and without thromboendarterectomy, 48 patients who had undergone thromboendarterectomy and whose characteristics matched closely those of patients who had not were selected. Twenty patients had previous AMI before CABG in each group. Analysis accounted for the severity of vessel lesion (complete or incomplete) and for the patency of the graft and of the native coronary artery. In these 96 patients, graft patency was lower than in the overall group and similar among patients with and without thromboendarterectomy among the 56 patients without previous AMI. In patients with previous AMI and thromboendarterectomy, however, reperfusion was achieved more often through the native vessel than through the graft. New AMI or residual ischemia occurred in 32% of the areas undergoing thromboendarterectomy and in only 5% of the standard grafts (p less than 0.001). Best results were obtained in patients with incomplete occlusion after AMI. Patients without previous AMI had worse results. Thus, thromboendarterectomy can yield 64 to 75% good results in selected subgroups when CABG is otherwise impossible, but should be avoided in mildly or moderately stenotic arteries perfusing noninfarcted myocardium.

Prevention of aorta-coronary bypass graft occlusion. Beneficial effect of ticlopidine on early and late patency rates of venous coronary bypass grafts: a double-blind study.

The efficacy of coronary bypass grafting obviously being linked to graft patency, it is compulsory to look for any innovation that could improve the patency rate. Ticlopidine, an antiplatelet drug, was tested against placebo in a double-blind trial: 173 patients (475 grafts) subjected to venous coronary artery bypass grafting were randomly treated with ticlopidine (250 mg twice daily) or placebo from the second postoperative day for 12 months. Graft patency was assessed by digital angiography on days 10 (99.4% of the patients), 180 (98.2%), and 360 (91.7%). The effect of treatment on platelet aggregation and bleeding time were measured concomitantly; a clear-cut effect was demonstrated at each interval. Intention-to-treat graft-by-graft analysis shows that ticlopidine significantly reduced the graft occlusion rate on day 10 (7.1% versus 13.4%, p less than 0.05), day 180 (15.0% versus 24.0%, p less than 0.02), and day 360 (15.9% versus 26.1%, p less than 0.01). Sequential grafts to the left anterior descending coronary artery, with side-to-side anastomosis to diagonal branch(es), are less frequently occluded than individual grafts. On the contrary, grafts to endarterectomized vessels occlude more frequently. Individual patient-by-patient analysis shows that patency of all grafts at each study time, is more frequent in the ticlopidine group. The difference is significant when one considers patients without sequential or endarterectomized grafts. The difference is also present at each study time: day 10 (84.4% versus 66.7%, p less than 0.05), day 180 (74.4% versus 52.3%, p less than 0.05) and day 360 (75.0% versus 52.5%, p less than 0.05). Results are even more impressive if one excludes from analysis the four patients in the ticlopidine group in whom administration of the drug was delayed. This supports previous suggestions that early therapy is necessary. These results show that graft occlusion occurs mainly in the first 6 postoperative months. The incidence of occlusion is significantly reduced by ticlopidine therapy.

[Use of the echotomography in the exploration of aneurisms of the abdominal aorta (author's transl)]. / Application de l'échotomographie à l'exploration des anévrismes de l'aorte abdominale.

Twenty-six cases of abdominal aortic aneurysm were shown by echotomography, at of a series of 80 subjects in whom a pulsatile abdominal mass was perceived clinically or suspected. There seems to exist an excellent correlation between the results echotomography and arteriography concerning either the lesion itself or the ocasional complications such as partial thrombosis, dissection and rupture.

[Stepping-table MR angiography of the upper limb arteries]. / L'angio-IRM en plusieurs stations des artères des membres supérieurs.

Stepping-table MR angiography of the upper limb arteries is reported in a patient with clinical and sonographic signs of ischemia. Advantages and limitations of the technique are discussed.

[State of the art of pancreatic cancer imaging]. / Actualités en imagerie du cancer du pancréas.

Ultrasonography and CT-scanner remain the first choice nowadays concerning detection and preoperative work-up of pancreatic cancer. MRI offers interesting options for the detection of liver metastases, and high quality of ductal and vascular examination. Actually, while we await a larger diffusion of MR systems and radiological expertise this technique is preferentially indicated as a third-step procedure when ultrasonography and CT-scanner are normal despite a real suspicion. Otherwise, MRI permits with a single non-invasive examination a complete work-up useful to prepare palliative therapy in case of unresectable tumor.

[Radioscopy and radiography of the thorax. Birth and maturation of an ever-current technique]. / Radioscopie et radiographie du thorax. Naissance et maturation d'une technique toujours d'actualité.

There are three milestones in the history of thoracic radiology. Thoracic radiology started in 1897 when Williams developed thoracic fluoroscopy and introduced the basic concepts of roentgenologic interpretation. At the same time, the first chest films were performed allowing decisive improvement in the diagnosis of many chest diseases. Continuous technical improvement is responsible for the fact that, even today, the conventional chest film remains a highly accurate and frequently used imaging modality. A third milestone was the development of digital radiography and its use in the chest. Computerised tomography changed thoracic imaging dramatically; in a first step mainly as a tool to visualise soft tissue abnormalities and, later on, also as a modality to study lung disease. The recent development of the digital chest radiograph has again added new perspectives to the approach and diagnosis of chest disease.

Percutaneous catheter drainage of abdominal abscess after abdominal surgery. Results in 121 cases.

One hundred and twenty-one peritoneal, retroperitoneal and pelvic abscesses were treated percutaneously using CT or US guidance. The lesions developed after abdominal surgery. Sixty-three abscesses (52%) were situated in the peritoneal cavity, 31 (26%) in the retroperitoneal cavity and 27 (22%) in the pelvis. A definitive treatment was obtained in 74% of peritoneal abscesses, 67% of retroperitoneal abscesses and 82% of pelvic abscesses. Failure most commonly occurred with multiloculated lesions or lesions associated with fistulous communication. There was a low rate of complication (1%). percutaneous drainage avoids the risks inherent in surgery and anesthesia, saves considerable time and meets greater patient acceptance. If a total cure is not systematic, a beneficial temporizing effect may however be obtained by percutaneous drainage. This procedure should be indicated for the initial treatment of postsurgical abscesses.