Does conversion during minimally invasive rectal surgery for cancer have an impact on short-term and oncologic outcomes? Results of a retrospective cohort study.

BACKGROUND: Although minimally invasive rectal surgery (MIRS) for cancer provides better recovery for similar oncologic outcomes over open approach, conversion is still required in 10% and its impact on short-term and long-term outcomes remains unclear. The aim of our study was to evaluate the impact of conversion on postoperative and oncologic outcomes in patients undergoing MIRS for cancer. METHODS: From June 2011 to March 2020, we reviewed 257 minimally invasive rectal resections for cancer recorded in a prospectively maintained database, with 192 robotic and 65 laparoscopic approaches. Patients who required conversion to open (Conversion group) were compared to those who did not have conversion (No conversion group) in terms of short-term, histologic, and oncologic outcomes. Univariate and multivariate analyses of the risk factors for postoperative morbidity were performed. RESULTS: Eighteen patients (7%) required conversion. The conversion rate was significantly higher in the laparoscopic approach than in the robotic approach (16.9% vs 3.6%, p < 0.01). Among the 4 reactive conversions, 3 (75%) were required during robotic resections. Patients in the Conversion group had a higher morbidity rate (83.3% vs 43.1%, p = 0.01) and more severe complications (38.9%, vs 18.8%, p = 0.041). Male sex [HR = 2.46, 95%CI (1.41-4.26)], total mesorectal excision [HR = 2.89, 95%CI (1.57-5.320)], and conversion (HR = 4.87, 95%CI [1.34-17.73]) were independently associated with a higher risk of overall 30-day morbidity. R1 resections were more frequent in the Conversion group (22.2% vs 5.4%, p = 0.023) without differences in the overall (82.7 ± 7.0 months vs 79.4 ± 3.3 months, p = 0.448) and disease-free survivals (49.0 ± 8.6 months vs 70.2 ± 4.1 months, p = 0.362). CONCLUSION: Conversion to laparotomy during MIRS for cancer was associated with poorer postoperative results without impairing oncologic outcomes. The high frequency of reactive conversion due to intraoperative complications in robotic resections confirmed that MIRS for cancer is a technically challenging procedure.

Transitioning From Open to Robotic Liver Resection. Results of 46 Consecutive Procedures Including a Majority of Major Hepatectomies.

Aims. Minimally invasive liver resection is a complex and challenging operation. Although authors have reported robotic liver resection shows improved safety and efficacy compared with open liver resection, robotic major liver resections for malignant liver lesions treatment remain inadequately evaluated. The aims of the present study were to evaluate the feasibility and safety of transitioning from open to robotic liver resection in a nonuniversity hospital. Patients and Methods. From December 2015 to March 2020, 46 patients underwent totally robotic-assisted liver resections out of 446 robotic procedures. Also, we retrospectively reviewed the last 27 open right hepatectomies (ORHs) and compared then with the first 25 anatomic robotic-assisted right hepatectomies (RRHs). Results. Mean operative time, mean blood lost, rate of complications, and mean hospital stay were associated with the complexity of the procedure. The comparison between ORH and RRH showed that intraoperative complications were less frequently observed during ORH whereas RRH showed a trend in favor of less blood loss. ORH had a trend toward smaller surgical margins and higher rate of R1 resections. Recurrence occurred in 31 (59%) patients and was more frequently observed after ORH. However, the mean follow-up was significantly shorter after RRH. Conclusion. Our study demonstrated the technical feasibility and safety of transitioning from open to robotic liver resection (including major hepatectomies) in a nonuniversity setting. Higher costs remain an important drawback for robotic surgery.

Teaching robotic rectal cancer surgery at your workplace: does the presence of visiting surgeons in the operating room have a detrimental effect on outcomes?

BACKGROUND: Surgery demonstration (SD) is considered to be a mainstay of surgical education, but controversy exists concerning the patient's safety. Indeed, the presence of visiting surgeons is a source of distraction and may have an impact on surgeon's performance. This study's objective was to evaluate possible differences in outcomes between robotic sphincter-saving rectal cancer surgery (RRCS) performed during routine surgical practice versus in the presence of visiting surgeons in the operating room (OR) with direct access to the surgeon. METHODS: Retrospective case-matched studies were conducted from a prospectively collected database. 114 patients (38 with the presence of visiting surgeons) who underwent RRCS between January 2013 and September 2018 were included. Patients were matched in a 1:2 basis after propensity score analysis using five criteria: gender, body mass index, preoperative chemoradiation, type of mesorectum excision, and synchronous liver metastasis. RESULTS: There was no difference between the two groups with regard to mean operating time, estimated blood loss, conversion, and hospital stay. Also, overall (44% vs. 40%; P = 0.6), major morbidity (26% vs. 19%; P = 0.5), and unplanned reoperation (17% vs. 15%; P = 1.0) rates were not statistically different. No difference was noted with regard to the quality of mesorectum excision, or positive rate of circumferential and distal longitudinal resection margins. The mean number of harvested lymph nodes (17 vs. 14.5; P = 0.04) was lower in the SD group and the number of patients with < 12 harvested lymph nodes (31% vs. 16%; P = 0.09) was greater after SD although it did not reach statistical significance. No differences were observed in disease-free or overall survival. CONCLUSIONS: The presence of visiting surgeons in the OR seems not to interfere in the quality of rectal resection and does not compromise patient's short-term outcome and survival. However, mild differences in the extent of lymphadenectomy were observed and the surgeons performing SD may be aware of this.

Does A Longer Waiting Period After Neoadjuvant Radio-chemotherapy Improve the Oncological Prognosis of Rectal Cancer?: Three Years' Follow-up Results of the Greccar-6 Randomized Multicenter Trial.

OBJECTIVE: The aim of this study was to report the 3-year survival results of the GRECCAR-6 trial. SUMMARY BACKGROUND DATA: Current data on the effect of an extended interval between radiochemotherapy (RCT) and resection for rectal cancer on the rate of complete pathological response (pCR = ypT0N0) is controversial. Furthermore, its effect on oncological outcomes is unknown. METHODS: The GRECCAR-6 trial was a phase III, multicenter, randomized, open-label, parallel-group, controlled trial. Patients with cT3/T4 or TxN+ tumors of the mid or lower rectum who had received RCT (45-50 Gy with 5-fluorouracil or capecitabine) were included and randomized into a 7- or 11-week waiting period. Primary endpoint was the pCR rate. Secondary endpoints were 3-year overall (OS), disease-free survival (DFS), and recurrence rates. RESULTS: A total of 265 patients from 24 participating centers were enrolled. A total of 253 patients underwent a mesorectal excision. Overall pCR rate was 17% (43/253). Mean follow-up from surgical resection was 32 ±â€Š8 months. Twenty-four deaths occurred with an 89% OS at 3 years. DFS was 68.7% at 3 years (75 recurrences). Three-year local and distant recurrences were 7.9% and 23.8%, respectively. The randomization group had no impact on the 3-year OS (P = 0.8868) or DFS (P = 0.9409). Distant (P = 0.7432) and local (P = 0.3944) recurrences were also not influenced by the waiting period. DFS was independently influenced by 3 factors: circumferential radial margin (CRM) ≤1 mm [hazard ratio (HR) = 2.03; 95% confidence interval (CI), 1.17-3.51], ypT3-T4 (HR = 2.69; 95% CI, 1.19-6.08) and positive lymph nodes (HR = 3.62; 95% CI, 1.89-6.91). CONCLUSION: Extending the waiting period by 4 weeks following RCT has no influence on the oncological outcomes of T3/T4 rectal cancers.

Robotic versus laparoscopic rectal resection for sphincter-saving surgery: pathological and short-term outcomes in a single-center analysis of 130 consecutive patients.

BACKGROUND: Minimally invasive sphincter-saving rectal resection represents a challenging procedure. Robotic surgery for rectal cancer has several advantages over conventional surgery in performing precise dissection and was proved to be safe and effective in previous studies. However, comparison between laparoscopic and robotic rectal resection has drawn contradictory results. The aim of the present study was to compare robotic and laparoscopic sphincter-saving rectal resections for short-term and pathological outcomes. METHODS: Between January 2013 and May 2016, we performed a total of 258 robotic surgeries, including 146 colorectal resections (56%). For this study, we included the first 65 sphincter-saving robotic resections and compared them to the last 65 consecutive laparoscopic resections. The laparoscopic group was constituted by the last 65 consecutively operated patients who matched the inclusion criteria. RESULTS: Patients' baseline characteristics were similar in both the groups. Conversion rate was greater in the laparoscopic group (17 vs. 5%, p=0.044). Reoperation rate, overall and severe morbidity, and median hospital stay were similar in both the groups. Quality of mesorectal excision specimen was considered complete or near complete in 97 and 96% in the laparoscopic and robotic groups, respectively. There was no difference in the rates of negative circumferential radial margin, distal margin, and surgical success measured by composite criteria. CONCLUSION: The main finding of this study was that robotic proctectomy for sphincter-saving procedures offers similar quality of TME with a statistically significant lower rate of conversion when compared to laparoscopic proctectomy.

Conservative treatment of intrarectal mesh migration after ventral laparoscopic rectopexy for rectal prolapse.

OBJECTIVE: Ventral rectopexy is a validated treatment for rectal prolapse with a low morbidity rate but a risk of intrarectal mesh migration. The purpose of this study was to report the results of local transanal mesh excision for intrarectal mesh migration after ventral rectopexy. METHODS: Between January 2004 and March 2011, 312 patients underwent laparoscopic ventral rectopexy in two hospitals. Six patients were treated for intrarectal mesh migration. RESULTS: Delay between ventral rectopexy and the onset of symptoms was 53 months (4-124 months). All patients have symptoms. Imaging revealed a pelvic abscess in two cases. Intrarectal mesh migration was confirmed by anorectoscopy or clinical examination. Five patients were only treated by local transanal partial mesh excision, and one required a colostomy. Morbidity and mortality were zero. The median hospitalization time was 5 days (3-8 days). After a median postoperative follow-up period of 9 months (1-40 months), one recurrence was observed 2 months after surgery. CONCLUSION: Local transanal mesh excision for intrarectal mesh migration after laparoscopic ventral rectopexy is a feasible conservative treatment. This simple treatment produced a cure of the pelvic inflammation and closure of the fistula without compromising a more aggressive secondary treatment which was not necessary in our series.

Evidence of heterogeneity within colorectal liver metastases for allelic losses, mRNA level expression and in vitro response to chemotherapeutic agents.

A goal of oncology is to predict chemosensitivity of tumors. This approach assumes that in a patient all tumor deposits are homogeneous. We have tested the heterogeneity between several samples of the same liver metastasis (LM; intrametastatic heterogeneity) or between multiple LM (intermetastatic heterogeneity) from colorectal cancer in a single patient. In 16 untreated patients, several fragments of LM and nontumorous liver were collected. Heterogeneity to anticancer drug treatment was assessed in vitro on primary tissue cultures on poly-HEMA-coated surface with or without the topoisomerase-I inhibitor metabolite SN-38. Heterogeneity of response to SN-38 was observed in 55% of cases from one fragment to another in the same LM and in 64% of cases from one LM to another in the same patient. Allelic losses were characterized on 5q, 8p, 17p, 18q, 22q using 29 microsatellites markers. Seven patients (58%) had a perfect homogeneity for allelic losses in their LM whereas 3 (21%) had intrametastatic and 2 (18%) had intermetastatic heterogeneity. The analysis of gene expression was carried out by real time RT-PCR quantification using specific probes for TS, TOPO1, ERCC1, and CES2. Level expression of genes tested appeared heterogeneous with average variations of 57(+ or - 23)%, 52(+ or - 18)%, 53(+ or - 18)%, 56(+ or - 16)% for TS, TOPO1, ERCC1, and CES2 respectively for intermetastatic variability and 47(+ or - 26)%, 36(+ or - 14)%, 38(+ or - 19)%, and 56(+ or - 29)%, respectively for intrametastatic variability. Our results demonstrate intermetastatic and intrametastatic heterogeneity suggesting that pretherapeutic analysis of a single tumor biopsy is likely to lead to a misinterpretation of sensitivity to anticancer treatment.

Retention of Plasmodium falciparum ring-infected erythrocytes in the slow, open microcirculation of the human spleen.

The current paradigm in Plasmodium falciparum malaria pathogenesis states that young, ring-infected erythrocytes (rings) circulate in peripheral blood and that mature stages are sequestered in the vasculature, avoiding clearance by the spleen. Through ex vivo perfusion of human spleens, we examined the interaction of this unique blood-filtering organ with P falciparum-infected erythrocytes. As predicted, mature stages were retained. However, more than 50% of rings were also retained and accumulated upstream from endothelial sinus wall slits of the open, slow red pulp microcirculation. Ten percent of rings were retained at each spleen passage, a rate matching the proportion of blood flowing through the slow circulatory compartment established in parallel using spleen contrast-enhanced ultrasonography in healthy volunteers. Rings displayed a mildly but significantly reduced elongation index, consistent with a retention process, due to their altered mechanical properties. This raises the new paradigm of a heterogeneous ring population, the less deformable subset being retained in the spleen, thereby reducing the parasite biomass that will sequester in vital organs, influencing the risk of severe complications, such as cerebral malaria or severe anemia. Cryptic ring retention uncovers a new role for the spleen in the control of parasite density, opening novel intervention opportunities.

Experience With Transitioning From Laparoscopic to Robotic Right Colectomy.

BACKGROUND AND OBJECTIVES: The number of robotic colorectal procedures performed has rapidly increased, but there are only sparse data available about the robotic learning curve of expert laparoscopic colorectal surgeons. METHODS: In this retrospective study, we reviewed 101 minimally invasive right colectomies consecutively performed by a single surgeon with 20 years of clinical practice fully dedicated to laparoscopic surgery. Thus, the last 59 laparoscopic resections were compared with the first 42 robotic resections. RESULTS: The duration of the procedure was longer in the robotic group, but the conversion rate was the same in both groups. There was no difference between groups in rates of overall and severe postoperative complications, reoperation, hospital length of stay, and readmission. Number of harvested lymph nodes and oncological quality of resection defined by the pathologist were the same. CONCLUSIONS: This study suggests that the transition from the right laparoscopic colectomy with extracorporeal anastomosis to the robot-assisted right colectomy with intracorporeal anastomosis when performed by a surgeon with experience in laparoscopic colorectal surgery may not entail any increase on the morbidity rate or reduce the oncologic quality of the resection.

Mitochondrial D310 mutations in colorectal adenomas: an early but not causative genetic event during colorectal carcinogenesis.

Somatic mutations of the D310 sequence of the mitochondrial DNA are reported in human cancers, including colorectal cancers (CRC). The presence of these mutations at early or late steps of colorectal carcinogenesis is unknown. Their prevalence increased significantly with the number of cytosines in the D310 sequence of the matched normal tissue (D310 polymorphism), suggesting that this polymorphism could be a risk factor for CRC. The aim of this study was (i) to investigate the prevalence of D310 mutations in 64 colorectal adenomas and 36 liver metastases from 15 CRC patients, (ii) to assess the relation between D310 polymorphism and the risk of colorectal adenoma in a case-control study including 613 cases with colorectal adenoma and 572 polyp-free (PF) controls. D310 mutations were found in colorectal adenomas and liver metastases from CRC patients in 27 and 33%, respectively and so are an early genetic event in colorectal carcinogenesis. The frequency of the mutations increased significantly with the number of cytosines in the matched normal tissue D310 sequence (p < 0.001) but the distribution of D310 polymorphisms was not significantly different between adenoma cases (large (>9 mm) and small (<5 mm) adenomas) and PF controls (C(4)-C(7)TC(6): 47, 52 and 49%; C(8)TC(6): 44, 39 and 41%; C(9)-C(10)TC(6): 9, 9 and 10%, respectively; p > 0.05), suggesting that germline D310 polymorphism is not a risk factor for colorectal adenomas. Considering their high frequency in colorectal adenomas, mitochondrial D310 mutations could represent a biomarker for early detection of CRC although their causative role in colorectal carcinogenesis remains uncertain.

[Cystic teratoma of the pancreas]. / Tératome kystique du pancréas.

The preoperative diagnosis of cystic tumours of the pancreas can be difficult. It is usually based on morphological and biological (i.e., cyst fluid content of tumour markers) data. However, the latter can be misinterpreted in case of exceptional cystic tumours, other that cystadenomas. We report here the case of a 45-year old woman who was operated on for a benign cystic mature teratoma with endocrine component and high concentrations in cyst fluid CEA and CA 72.4 which was evocative of a malignant mucinous cystadenoma.

Is the gene encoding Chibby implicated as a tumour suppressor in colorectal cancer ?

BACKGROUND: A novel member of the Wnt signalling pathway, Chibby, was recently identified. This protein inhibits Wnt/beta-catenin mediated transcriptional activation by competing with Lef-1 (the transcription factor and target of beta-catenin) to bind to beta-catenin. This suggests that Chibby could be a tumour suppressor protein. The C22orf2 gene coding Chibby is located on chromosome 22, a region recurrently lost in colorectal cancer. Activation of the Wnt pathway is a major feature of colorectal cancer and occurs through inactivation of APC or activation of beta-catenin. All of this led us to analyse the possible implication of Chibby in colorectal carcinogenesis. METHODS: First, 36 tumour and matched normal colonic mucosa DNA were genotyped with five microsatellite markers located on chromosome 22 to search for loss of heterozygosity. Then, mutation screening of the C22orf2 coding sequence and splice sites was performed in the 36 tumour DNA. Finally, expression of Chibby was analysed by quantitative RT-PCR on 10 patients, 4 with loss of heterozygosity (LOH) on chromosome 22. RESULTS: Loss of heterozygosity involving the C22orf2 region was detected in 11 out of 36 patients (30%). Sequencing analysis revealed a known variant, rs3747174, in exon 5: T321C leading to a silent amino acid polymorphism A107A. Allelic frequencies were 0.69 and 0.31 for T and C variants respectively. No other mutation was detected. Among the 10 patients studied, expression analysis revealed that Chibby is overexpressed in 2 tumours and underexpressed in 1. No correlations were found with 22q LOH status. CONCLUSION: As no somatic mutation was detected in C22orf2 in 36 colorectal tumour DNA, our results do not support the implication of Chibby as a tumour suppressor in colorectal carcinogenesis. This was supported by the absence of underexpression of Chibby among the tumour samples with 22q LOH. The implication of other Wnt pathway members remains to be identified to explain the part of colorectal tumours without mutation in APC and beta-catenin.

[Ovarian adenocarcinoma, primary or metastasic tumour of an adenocarcinoma of the colon: the role of molecular biology]. / Adénocarcinome ovarien, tumeur primitive ou métastase d'un adénocarcinome colique: apport de la biologie moléculaire.

After the primary diagnosis of an adenocarcinoma, diagnosis of the origin of a second adenocarcinoma is a problem (primitive or metastatic). Although the clinical evolution or location sometimes makes it possible to determine the origin of the new lesion, in some cases the diagnosis cannot be confirmed. Although a pathological examination is essential for diagnosis, it may still be inconclusive, making management difficult. The use of molecular biology can help solve this problem. We report the case of a patient who presented with an ovarian adenocarcinoma of an undetermined origin one year after an adenocarcinoma of the colon. This clinical case illustrates the contribution of molecular biology in the diagnosis of the origin of an ovarian adenocarcinoma by characterizing allelic losses in 5 chromosome segments using microsatellite markers genotyping in the two lesions. The comparative analysis suggested the primitive origin of the ovarian lesion.

Primary hyperparathyroidism from parathyroid microadenoma: specific features and implications for a surgical strategy in the era of minimally invasive parathyroidectomy.

BACKGROUND: The aim of this study was to identify the specific preoperative characteristics of patients with parathyroid microadenoma and to report their outcomes after surgical treatment. STUDY DESIGN: Parathyroid microadenomas (weight < 100 mg) were identified in 62 (6%) of the 1,012 patients operated on for a parathyroid adenoma between 1995 and 2004. Presentation and outcomes after surgery were compared with those of 124 patients operated on consecutively for parathyroid adenoma (>100 mg) during the last year of the study. All patients underwent bilateral surgical exploration of the neck. Success was defined as resection of a pathologic gland combined with normocalcemia at 6 months after operation. Logistic regression was used to test the relationship between groups and potential predictive factors of microadenoma. RESULTS: There were 57 women (92%) and the median age was 57 years (range 29 to 77 years). Median preoperative calcemia and parathyroid hormone (PTH) serum levels were 2.64 mmol/L (range 2.31 to 3 mmol/L) and 79 pg/mL (range 30 to 189 pg/mL), respectively. There was no difference in the clinical presentation between patients with microadenoma and adenoma. Preoperative calcium (p < 0.001) and PTH serum levels (p = 0.014) were significantly higher in patients with adenoma. Calcium and PTH serum levels lower than 2.6 mmol/L and 60 pg/mL, respectively, predicted the presence of microadenoma with respective specificities of 0.89 and 0.87. Success rates were similar in the microadenoma and adenoma groups (92% vs 98%; p = 0.11). CONCLUSIONS: Mild preoperative elevations of calcium or PTH serum levels should warn about the risk of microadenoma. In this setting, intraoperative difficulties should be expected in identifying the pathologic gland, and bilateral neck exploration should be the preferred surgical approach.

Endoscopic management of pancreatic fistula after distal pancreatectomy and enucleation.

BACKGROUND: Preoperative endoscopic pancreatic sphincterotomy (EPS) has been proposed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) or enucleation (EN). The use of EPS as a curative treatment for POPF has been scarcely reported. We reported 10 consecutive patients who were successfully treated by EPS for a prolonged POPF. STUDY DESIGN: Ten patients underwent EPS for prolonged POPF (median duration = 40 days, range 20-114; median daily output = 80 mL, range 50-250) after 6 DPs, 2 ENs, and 2 medial pancreatectomies. RESULTS: EPS was performed in all patients, with stent insertion in 4. No patient developed a specific complication because of EPS. POPF healed within a median delay of 4 days (range 1-12). One patient underwent a repeated endoscopy to treat stent malposition. The median delay of discharge after EPS was 13 days (range 8-15). With a 20-month median follow up, 1 patient developed early transient POPF recurrence because of spontaneous stent migration. CONCLUSIONS: EPS is indicated for prolonged POPF after DP or EN because it is highly feasible, shortens healing, and is well tolerated.

Colopharyngoplasty for the treatment of severe pharyngoesophageal caustic injuries: an audit of 58 patients.

OBJECTIVE: The aim of this study was to describe the technique of colopharyngoplasty for the reconstruction of concomitant esophageal and pharyngeal caustic injuries and to evaluate the postoperative course and late functional outcomes. SUMMARY BACKGROUND DATA: Surgical treatment of esophageal and pharyngeal strictures is a difficult challenge because reconstruction at this level interferes with the mechanisms of deglutition and respiration. Several techniques have been described for the treatment of this condition but none is accepted as the gold standard. METHODS: Fifty-eight patients (34 men, median age 37 years) underwent colopharyngoplasty for caustic injuries between 1993 and 2005. Forty patients (69%) had a previous psychiatric history of depression (n = 30) or schizophrenia (n = 10). After removal of all scar tissues, the pharyngeal reconstruction was performed with the cervical end of the colic transplant employed for esophageal replacement. Laryngeal resection was associated in half of the patients. Success of the procedure was defined as recovery of nutritional autonomy and airway patency. RESULTS: Operative mortality was 2%. Postoperative complications required reoperation in 16 patients (28%). The functional outcome was evaluated in 46 patients with a follow-up of more than 6 months. The tracheostomy was withdrawn in 42 (91%) patients after a median of 42 days (range, 20-1020). The jejunostomy was removed in 32 patients (70%) after a median of 12 months (range, 2-54). Finally, the procedure was successful in 31 patients (67%). Logistic regression analysis showed that advanced age, a previous history of psychiatric disease, and early reoperation had an adverse impact on fuctional outcome. Seven patients (12%) repeated the suicide attempt. CONCLUSIONS: Colopharyngoplasty is a simple and reliable procedure that can be successfully employed to restore the digestive continuity in patients with concomitant esophageal and pharyngeal caustic injuries. Control of the underlying psychiatric disease before reconstruction is a key factor for success.