CT scan for early diagnosis of anastomotic leak after colorectal surgery: is rectal contrast useful?

BACKGROUND: Computed tomography (CT) scan with rectal contrast enema (RCE-CT) could increase the detection rate of anastomotic leaks (AL) in the early postoperative period following colorectal surgery, compared to CT scan without RCE. The aim of this study was to assess the benefit of RCE-CT for the early diagnosis of AL following colorectal surgery. METHODS: Patients who had a RCE-CT for suspected AL in the early postoperative period following colorectal surgery with anastomosis between January 2012 and July 2019 at the Dijon University Hospital were retrospectively included. All images were reviewed by two independent observers who were blinded to the original report. The reviewers reported for each patient whether an AL was present or not in each imaging modality (CT scan, then RCE-CT). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were then calculated to determine the diagnostic performance of each modality. RESULTS: One hundred and thirty-nine patients were included. RCE-CT had an increased NPV compared to CT scan (82% vs 77% (p = 0.02) and 84% vs 68% (p < 0.0001) for observers 1 and 2, respectively). RCE-CT had an increased sensitivity compared to CT scan (79% vs 48% (p < 0.0001) for observer 2). RCE-CT had a significant lower false-negative rate for both observers: 18% vs 23% (p = 0.02) and 16% vs 32% (p < 0.0001). CONCLUSIONS: RCE-CT improved the detection rates of AL in the early period following colorectal surgery. RCE-CT should be recommended when a CT scan is negative and AL is still suspected.

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

BACKGROUND: Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. METHODS: A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). RESULTS: Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. CONCLUSION: Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Using a heating cable within the abdomen to make hyperthermic intraperitoneal chemotherapy easier: feasibility and safety study in a pig model.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex, expensive and time-consuming procedure. Despite its good results in the treatment of peritoneal carcinomatosis, these factors have precluded the wider use of this procedure around the world. We hypothesized that HIPEC could be performed by heating the liquid within the abdomen and thus avoiding the need for an external heating circuit and a pump. The aim of this study was to assess the feasibility and safety of an internal heating device for hyperthermic intraperitoneal chemotherapy in an experimental model. METHODS: Four large-white pigs underwent one-hour open intraperitoneal hyperthermia with closed abdomen using this new device. Constant stirring of the liquid around the viscera was performed in the first three animals, but not in the fourth one. At the end of the procedure, all of the viscera were carefully examined to look for thermal injury. Any lesion or doubtful area was removed and sent to pathologic examination. RESULTS: No adverse events occurred during surgery in any of the animals. A temperature of 42 degrees C was reached in an average time of 14 min and maintained homogeneously between 42 degrees C and 43 degrees C for one hour. No visceral injury was detected in the first three animals. Three foci of thermal injury to the mucosa were detected in the absence of stirring (fourth animal). CONCLUSION: Heating the solution within the abdomen during hyperthermic intraperitoneal chemotherapy is feasible, safe and achieves perfect thermal homogeneity. This device provides a time-saving inexpensive way to perform intraperitoneal hyperthermic chemotherapy.

Cytoprotective effect against UV-induced DNA damage and oxidative stress: role of new biological UV filter.

The majority of chemical solar filters are cytotoxic, particularly on sensitive ocular cells (corneal and conjunctival cells). Consequently, a non-cytotoxic UV filter would be interesting in dermatology, but more especially in ophthalmology. In fact, light damage to the eye can be avoided thanks to a very efficient ocular antioxidant system; indeed, the chromophores absorb light and dissipate its energy. After middle age, a decrease in the production of antioxidants and antioxidative enzymes appears with accumulation of endogenous molecules that are phototoxic. UV radiations can induce reactive oxygen species formation, leading to various ocular diseases. Because most UV filters are cytotoxic for the eye, we investigated the anti-UV properties of Calophyllum inophyllum oil in order to propose it as a potential vehicle, free of toxicity, with a natural UV filter action in ophthalmic formulation. Calophyllum inophyllum oil, even at low concentration (1/10,000, v/v), exhibited significant UV absorption properties (maximum at 300nm) and was associated with an important sun protection factor (18-22). Oil concentrations up to 1% were not cytotoxic on human conjunctival epithelial cells, and Calophyllum inophyllum oil appeared to act as a cytoprotective agent against oxidative stress and DNA damage (85% of the DNA damage induced by UV radiations were inhibited with 1% Calophyllum oil) and did not induce in vivo ocular irritation (Draize test on New Zealand rabbits). Calophyllum inophyllum oil thus exhibited antioxidant and cytoprotective properties, and therefore might serve, for the first time, as a natural UV filter in ophthalmic preparations.

[Intraperitoneal chemo-hyperthermia with "overflow" open abdomen]. / La chimiohyperthermie intrapéritonéale à ventre ouvert et avec "débordement".

The authors report an original procedure of open-abdomen intraperitoneal chemo-hyperthermia. The skin edges are watertightly stapled with a soft "abdominal cavity expander", supported by a Thompson self-retaining retractor positioned over the abdomen. So, the level of the liquid can be widely raised above the level of the skin edges. The anterior wall peritoneum, the wall edges are constantly exposed to the liquid. Large amplitude movements become possible: introduction into the abdomen of two forearms, even two arms, does not induce loss of any liquid. The small bowel, the stomach can be partially exteriorized. It becomes very easy to expose all the peritoneal spaces, to maintain an homogeneous hyperthermia within the abdomen, while using only one inflow drain, and one outflow drain.

Pre-clinical study of the epinephrine-cisplatin association for the treatment of intraperitoneal carcinomatosis.

We have previously shown that intraperitoneal (i.p.) epinephrine enhances tumour penetration and anti-cancer activity of i.p.-administered cisplatin in rats with peritoneal carcinomatosis. Here, we show a direct correlation between the i.p. epinephrine concentration and cisplatin accumulation in rat peritoneal tumour nodules up to a concentration of 5 mg/l. This concentration leads to a maximal 3.7-fold increase of tumour platinum content and a maximal vasoconstriction of the peritoneal and tumour superficial microcirculation when registered by a laser doppler probe. Further, epinephrine half-life was 20.8+/-3.6 min in the peritoneal cavity of two laparotomized pigs. In these animals, epinephrine plasma concentration, heart rate and systolic blood pressure were dependent on the intraperitoneal dose of epinephrine, and life-threatening signs were not observed in either animal. In conclusion, a 5 mg/l concentration of epinephrine could be safely maintained in peritoneal fluid by regular replacement. This concentration is sufficient to maintain a constant vasoconstriction of the peritoneal and tumoral microvascular bed, and enhance the slow diffusion of cisplatin into peritoneal tumour nodules in the course of per-operative intraperitoneal chemotherapy.

[The effect of intra-abdominal temperature on the tissue and tumor diffusion of intraperitoneal cisplatin in a model of peritoneal carcinomatosis in rats]. / Effets de la température intra-abdominale sur la diffusion tissulaire et tumorale du cisplatine intrapéritonéal dans un modèle de carcinose péritonéale chez le rat.

OBJECTIVE: To evaluate the effects of hyperthermia and hypothermia on the peritoneal and on tumor penetration by intraperitoneal cisplatin. MATERIAL AND METHODS: Twenty day old peritoneal carcinomatosis was obtained after intraperitoneal injection of 1 x 10(6) DHD/K12/PROb cells into BD IX rats. Animals were treated by intraperitoneal infusion of cisplatin (25 micrograms/mL) using hyperthermic (16.6 degrees C), normothermic (37.6 degrees C) or hyperthermic (41.8 degrees C) intraperitoneal chemotherapy. RESULTS: Hyperthermia increased cisplatin concentration in tumoral and diaphragmatic tissues compared to normothermic treatment, while renal concentrations were lower. Hypothermia produced lower cisplatin concentrations in both cancer and peritoneal tissues compared to normothermic treatment. CONCLUSION: These experiments confirmed the pharmacological advantage produced by hyperthermia in cisplatin intraperitoneal chemotherapy.

New in vitro fluorimetric microtitration assays for toxicological screening of drugs.

Flow cytometry has been widely used to quantify fluorescent probes in cell culture. However, FCM is not adapted to toxicological screenings due to the cost, the length and the poor reproducibility of this technique. Moreover, several multicenter studies have preferred microtitration methodologies for drug screening. A new fluorimetric technology has been designed that is sensitive and adapted to direct screening in 96-well microplates. This fluorimeter uses cold light technology (CLF) with chemical and physical modifications of the lighting system (Rat et al., 1995). CLF allows reading of UV, visible and near infrared fluorescence by increasing light energy (from 1000 to 2300 lumens) and reducing the calorific part of light (IR > 900 nm, Joule effect). It induces a decrease in background and a 500- to 1000-fold improvement of detection limit of probes in comparison with classical fluorimeters and permits detection of pg/ml to fg/ml. CLF allows easy evaluation of cell injury induced by physical agents (UVA) or chemical toxins (CCl4). Four biological endpoints for cytotoxicity evaluation have been tested with several probes: proliferation (H33258); viability (fluorescent Neutral Red); cell-cell adhesion (calcein-AM); and mitochondrial metabolic effects (Rhodamine 123). Rh123 assay appeared more sensitive than fluorimetric or photometric detection of Neutral Red assay. Cold light fluorimetry (CLF) permits direct detection of low concentrations of probes (pg/ml to fg/ml). CLF is shown to improve classical cytotoxicity assays and, owing to its adaptability to microtitration (in 6-, 12- or 96-well plates and in Petri dishes), it is thus a promising alternative to flow cytometry for drug cytotoxicity screening.

[Surgical treatment of diverticula of the thoracic esophagus]. / Traitement chirurgical des diverticules de l'oesophage thoracique.

Pathogeny of thoracic esophageal diverticuli, divided into parabronchial and epiphrenic, appears to have been modified by development of functional esophageal motility measurement. We present 23 patients with epiphrenic diverticuli and 3 with parabronchial diverticuli (15 male and 11 female with a mean age of 61 years). Twenty-four underwent surgery: 4 isolated diverticulectomy, 7 diverticulectomy and associated myotomy, 5 myotomy alone, 3 antireflux procedure alone. Three patients required esophagectomy for carcinoma in a diverticulum, for a huge diverticulum adherent to the inferior pulmonary vein. One patient presenting with perforation of a carcinomatous diverticulum in the pleura was treated with pleurotomy and has died. No fistula has been notified. Long term results had been analysed with a mean follow up of 4 years. Special attention has been reported on development of gastro-esophageal-reflux. The finding of a thoracic diverticulum requires evaluation by barium swallow, fibroscopy and functional test which should indicate the operation required. Long term analysis should include functional manometric evaluation and a pHanalysis as long term results are reduced by the appearance of gastro-esophageal-reflux.