Periodontal disease as a risk factor for sporadic colorectal cancer: results from COLDENT study.

Colorectal cancer remains the top leading cancer worldwide. Accumulating evidence suggests periodontal pathogens are involved in colorectal carcinogenesis, indicating the need for high-quality epidemiological evidence linking periodontal disease (PD) and colorectal cancer (CRC). Thus, we conducted the first population-based case-control study that was specifically designed to investigate the association between compromised oral health and sporadic CRC. A total of 348 incident cases of colon or rectal cancer, and 310 age and sex frequency-matched controls, from the Montreal island and Laval population participated in the study. Data were collected on PD and on several CRC risk factors using validated questionnaires. A life-course approach was used to document long-term history regarding lifestyle factors. Multivariable unconditional logistic regression analysis was used to estimate the rate ratio (RR) quantifying the association between CRC and PD. Results showed that the rate of new diagnosis of CRC in persons with a positive history of PD was 1.45 times higher than in those with a negative history of PD adjusting for age, sex, BMI, education, income, diabetes, family history of CRC, regular use of non-steroidal anti-inflammatory drugs, lifetime cumulative smoking, lifetime consumption of red meats, processed meats, and alcoholic drinks, and lifetime total physical activity score (adjusted RR = 1.45; 95% CI 1.04-2.01; p = 0.026). Our results support the hypothesis of an association between PD and sporadic CRC risk.

Cholecystocolonic fistula with a giant colonic gallstone: the mainstay of treatment in an acute setting.

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8-26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm2 gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

Validation of the PMD100 and its NOL Index to detect nociception at different infusion regimen of remifentanil in patients under general anesthesia.

BACKGROUND: The NOL index is based on multiparametric analysis of heart rate (HR), skin conductance, wave plethysmography, and their time derivative. The aim of this study was to evaluate the NOL to detect standardized nociceptive stimuli with various remifentanil dosages under general anesthesia. METHODS: A prospective, observational study at a single center (NCT02602379) included 40 ASA I to III patients undergoing laparotomy under remifentanil-desflurane anesthesia with epidural analgesia. A tetanic stimulation was applied (forearm) at remifentanil intravenous (IV) infusion of 0.005, 0.05, 0.1, and 0.15 µg/kg/min. NOL and its variations were compared with other parameters namely heart rate, mean arterial pressure, Bispectral Index, and Analgesia Nociception Index (ANI). Receiver operating characteristic (ROC) curves were plotted to assess the response to both intubation and standardized stimulus under remifentanil infusion of 0.005 µg/kg/min. RESULTS: The post-stimulation NOL values at remifentanil doses of 0.005, 0.05, 0.1 and 0.15 µg/kg/min (39 [23-55], 15 [7-30], 8 [4-14] and 8.5 [4-15]) were significantly higher than pre-stimulation counterparts (P<0.0001). For all other parameters, there was also significant difference between pre- and post-stimulation values at all remifentanil dosages (P<0.0001). Area under the ROC curve (AUC) for the NOL during standardized stimulation was larger than for all other parameters at the exception of ANI (P=0.94). The AUC of NOL for nociception during tracheal intubation was greater (0.93 vs. 0.84 and 0.64 for ANI and HR, respectively). CONCLUSIONS: NOL monitoring is a promising index to assess the level of nociception in patients under general anesthesia.

Elimination of 24-hour continuous medical resident duty in Quebec.

SUMMARY: In 2012 Quebec limited continuous in-hospital duty to 16 consecutive hours for all residents regardless of postgraduate (PGY) level. The new restrictions in Quebec appeared to have a profound, negative effect on the quality of life of surgical residents at McGill University and a perceived detrimental effect on the delivery of surgical education and patient care. Here we discuss the results of a nationwide survey that we created and distributed to general surgery residents across Canada to capture and compare their perceptions of the changes to duty hour restrictions.

Perceived effects of the 16-hour workday restriction on surgical specialties: Quebec's experience.

OBJECTIVE: Quebec was the first Canadian province to implement a 16-hour workday restriction. Our aim was to assess and compare Quebec's surgical residents' and professors' perception regarding the effects on the educational environment, quality of care, and quality of life. DESIGN: The Surgical Theater Educational Environment Measure, the Postgraduate Hospital Educational Environment Measure, quality of the medical act, and quality-of-life questionnaires were administered 6 months after the work-hour restrictions. SETTING: Université de Montréal Surgery Department, Montréal, Québec, Canada; Université de Sherbrooke Surgery Department, Sherbrooke, Québec, Canada; Université Laval Surgery Department, Québec, Québec, Canada; and McGill University Surgery Department, Montréal, Québec, Canada. PARTICIPANTS: Surgical residents and professors of all specialties within the 4 university surgery departments in Quebec through a voluntary web-based survey. RESULTS: A total of 280 questionnaires were analyzed with response rates of 29.7% and 16.4% for residents and professors, respectively. Data were coded on a scale from 2 (strong improvement perception) to -2 (strong deterioration perception). The professors perceived a higher negative effect than the residents did on the educational environment, i.e., role of autonomy (-0.399 vs. -0.577, p < 0.001), teaching (-0.496 vs. -0.540, p < 0.001), social support (-0.345 vs. -0.535, p < 0.001), and surgical learning (-0.409 vs. -0.626, p < 0.001). The professors also observed a higher negative effect on patients' safety (-0.199 vs. -0.595, p = 0.003) and quality of care (-0.077 vs. -0.421, p = 0.014). The latter was even perceived as unchanged by residents (-0.077, 95% CI: -0.249 to 0.095). The residents perceived a negative effect on their quality of life, whereas the professors believed the contrary (0.500 vs -0.496, p < 0.001). More professors than residents believed residency should be prolonged (80.8% vs. 50.6%, p < 0.001). CONCLUSIONS: Residents and professors perceive a mild negative effect on the educational environment and quality of care, whereas their perception on quality of life is opposite. The professors seem concerned about adequate training to the point of considering increasing training length.

Laparoscopic versus open surgery for the treatment of colorectal cancer: a literature review and recommendations from the Comité de l'évolution des pratiques en oncologie.

BACKGROUND: Adoption of the laparoscopic approach for colorectal cancer treatment has been slow owing to initial case study results suggesting high recurrence rates at port sites. The use of laparoscopic surgery for colorectal cancer still raises a number of concerns, particularly with the technique's complexity, learning curve and longer duration. After exploring the scientific literature comparing open and laparoscopic surgery for the treatment of colorectal cancer with respect to oncologic efficacy and shortterm outcomes, the Comité de l'évolution des pratiques en oncologie (CEPO) made recommendations for surgical practice in Quebec. METHODS: Scientific literature published from January 1995 to April 2012 was reviewed. Phase III clinical trials and meta-analyses were included. RESULTS: Sixteen randomized trials and 10 meta-analyses were retrieved. Analysis of the literature confirmed that for curative treatment of colorectal cancer, laparoscopy is not inferior to open surgery with respect to survival and recurrence rates. Moreover, laparoscopic surgery provides short-term advantages, including a shorter hospital stay, reduced analgesic use and faster recovery of intestinal function. However, this approach does require a longer operative time. CONCLUSION: Considering the evidence, the CEPO recommends that laparoscopic resection be considered an option for the curative treatment of colon and rectal cancer; that decisions regarding surgical approach take into consideration surgeon experience, tumour stage, potential contraindications and patient expectations; and that laparoscopic resection for rectal cancer be performed only by appropriately trained surgeons who perform a sufficient volume annually to maintain competence.

CONTEXTE: L'adoption de la laparoscopie pour traiter le cancer colorectal se fait lentement à cause des résultats des premières études de cas qui indiquent des taux élevés de récidive aux sites d'intervention. La laparoscopie pour traiter le cancer colorectal soulève toujours de nombreuses préoccupations, particulièrement en raison de la complexité de la technique, de la courbe d'apprentissage, et de la durée de la chirurgie. Après avoir étudié des publications scientifiques comparant l'efficacité oncologique et les résultats à court terme de la laparoscopie à ceux de la chirurgie ouverte pour le traitement du cancer colorectal, le Comité de l'évolution des pratiques en oncologie (CEPO) a formulé des recommandations pour la pratique chirurgicale au Québec. MÉTHODES: Une revue des écrits scientifiques publiés entre janvier 1995 et avril 2012 a été effectuée. Seuls les essais cliniques de phase III et les méta-analyses ont été répertoriés. RÉSULTANTS: Seize essais randomisés et 10 méta-analyses ont été retenus. L'analyse des publications a confirmé que pour le traitement curatif du cancer colorectal, la laparoscopie n'est pas inférieure à la chirurgie ouverte pour ce qui est des taux de survie et de récidive. La laparoscopie offre de plus des avantages à court terme, y compris une hospitalisation de moins longue durée, une réduction de l'usage d'analgésiques et un rétablissement plus rapide de la fonction intestinale. Cette intervention prend toutefois plus de temps. CONCLUSIONS: Compte tenu des données probantes, le CEPO recommande d'envisager la résection laparoscopique comme technique curative possible du cancer colorectal et que les décisions sur la méthode chirurgicale tiennent compte de l'expérience du chirurgien, du stade de la tumeur, des contre-indications possibles et des attentes du patient. Dans le cas de la résection laparoscopique du cancer du rectum, le CEPO recommande qu'elle ne soit pratiquée que par des chirurgiens ayant reçu la formation nécessaire et qui pratiquent suffisamment d'interventions par année pour maintenir leur compétence.

Is severe intestinal chronic graft-versus-host disease an indication for surgery? A report of two cases.

Chronic graft-versus-host disease (cGVHD) frequently complicates allogeneic hematopoietic stem cell transplantation (HSCT), but small bowel involvement with obstruction is rarely observed. We report two patients who underwent allogeneic sibling HSCT and developed severe cGVHD involving the small bowel, causing unremitting obstructive symptoms and malnutrition despite maximal immunosuppression. Both patients underwent ileal resection and stricturoplasties. The first patient promptly improved, and remains asymptomatic 32 months after transplant. Three weeks after the resection of 90 cm of small bowel, the second patient developed leaking stricturoplasty and peritonitis, with a relapse of chronic myelogenous leukemia in accelerated phase. Later, an enterocutaneous fistula required additional small bowel resection and ileostomy. The patient subsequently died from pulmonary infection a few weeks after the last surgical procedure. Similar to inflammatory bowel disease, these two cases highlight that surgery may be a valuable option in patients who present with obstructive severe cGVHD refractory to aggressive immunosuppression.

Phase I study on sentinel lymph node mapping in colon cancer: a preliminary report.

BACKGROUND AND OBJECTIVES: Lymph node (LN) metastasis is one of the most significant prognostic factor in colorectal cancer. In fact, therapeutic decisions are based on LN status. However, multiple studies have reported on the limitations of the conventional pathological LN examination techniques, and therefore, the actual number of patients with LN positive colorectal cancer is probably underestimated. We assume that lymphatic tumor dissemination follows an orderly sequential route. We report here a simple and harmless coloration technique that was recently elaborated, and that allows us to identify the sentinel LN(s) (SLN) or first relay LNs in colorectal cancer patients. The main endpoint of this clinical trial is the feasibility of the technique. METHODS: Twenty patients treated by surgery for a colic cancer were admitted in this protocol. A subserosal peritumoral injection of lymphazurin 1% was performed 10 min before completing the colic resection. A pathologist immediately examined the specimens, harvested the colored SLN, and examined them by serial cuts (200 microm) with H&E staining, followed by immunohistochemical staining (AE1-AE3 cytokeratin markers), when serial sections were classified as cancer free. RESULTS: The preoperative identification of the SLN was impossible in at least 50 of the cases, however, SLNs were identified by the pathologist in 90% of cases. In two patients (10%) SLN was never identified. The average number of SLN was 3.9. Immunohistochemical analysis of the SLN has potentially changed the initial staging (from Dukes B to Dukes C) for 5 of the 20 patients (25%). On the other hand, there was one patient (5%) with hepatic metastasis from adenocarcinoma for whom SLN pathology was negative for metastasis (skip metastasis). CONCLUSIONS: SLN biopsy is readily feasible with identification of SLN in at least 90% of patients with colorectal cancers. Our results indicate that 45% of patients initially staged as Dukes B had tumor cells identified in their SLN when these were subjected to our protocol. This represented a 25% upgrading rate when our complete study population is considered. However, controversy persist about the clinical significance and metastatic potential of these often very small clusters of tumor cells.