Feasibility and Safety of Oxaliplatin-Based Pressurized Intraperitoneal Aerosol Chemotherapy With or Without Intraoperative Intravenous 5-Fluorouracil and Leucovorin for Colorectal Peritoneal Metastases: A Multicenter Comparative Cohort Study.

BACKGROUND: This retrospective multicenter cohort study compared the feasibility and safety of oxaliplatin-based pressurized intraperitoneal aerosol chemotherapy (PIPAC-Ox) with or without intraoperative intravenous 5-fluorouracil (5-FU) and leucovorin (L). METHODS: Our study included consecutive patients with histologically proven unresectable and isolated colorectal peritoneal metastases (cPM) treated with PIPAC-Ox in seven tertiary referral centers between January 2015 and April 2020. Toxicity events and oncological outcomes (histological response, progression-free survival, and overall survival) were compared between patients who received intraoperative intravenous 5-FU/L (PIPAC-Ox + 5-FU/L group) and patients who did not (PIPAC-Ox group). RESULTS: In total, 101 patients (263 procedures) were included in the PIPAC-Ox group and 30 patients (80 procedures) were included in the PIPAC-Ox + 5-FU/L group. Common Terminology Criteria for Adverse Events v4.0 grade 2 or higher adverse events occurred in 48 of 101 (47.5%) patients in the PIPAC-Ox group and in 13 of 30 (43.3%) patients in the PIPAC-Ox + 5-FU/L group (p = 0.73). The complete histological response rates according to the peritoneal regression grading score were 27% for the PIPAC-Ox + 5-FU/L group and 18% for the PIPAC-Ox group (p = 0.74). No statistically significant differences were observed in overall or progression-free survival between the two groups. CONCLUSIONS: The safety and feasibility of PIPAC-Ox + 5-FU/L appears to be similar to the safety and feasibility of PIPAC-Ox alone in patients with unresectable cPM. Oncological outcomes must be evaluated in larger studies.

Temporary cervical sling and uterine twist before B-Lynch for massive uterine bleeding after delivery.

Massive uterine bleeding occurring after delivery is in most cases unpredictable and can have fatal consequences. This article presents the technique of combining the twisting of uterus on a 90° rotation on its axis and positioning a sling around the cervix, allowing to decrease incoming blood flow from uterine and ovarian arteries. The aim of this easy-to-use procedure is to enable surgeons and anaesthesiologists to respectively ensure the presence of an experienced surgeon and to stabilise the haemodynamic of the patient. It is a modus operandi of particular interest in resources' challenged environments.

[Vaginal microbiota and vaginosis]. / Microbiote vaginal et vaginose.

The vaginal microbiota is essentially composed of bacteria of the Lactobacillus genus. These bacteria, by their presence, prevent vaginal contamination by other potentially aggressive germs. Disturbances of the microbiota lead to a pathological state called dysbiosis, one of the most frequent pathogenic aspects of which is bacterial vaginosis. This vaginal state results in nauseating leucorrhoea induced by the proliferation of aero-anaerobic bacteria. Bacterial vaginosis is a source of different clinical impacts: increased risk of genital infection with many pathogens, loss of chance in medically assisted procreation, increased risk of premature delivery. The treatment of bacterial vaginosis must take into account the restitution of a normal microbiota.

Le microbiote vaginal est composé de bactéries du genre Lactobacillus. Ces bactéries empêchent la contamination vaginale par d'autres germes potentiellement agressifs. Les perturbations du microbiote aboutissent à un état pathologique dénommé dysbiose, dont un des aspects pathogènes le plus fréquent est la vaginose bactérienne (VB). La VB se traduit par des leucorrhées nauséabondes induites par la prolifération de bactéries aéro-anaérobies. La VB est source de différents impacts cliniques : majoration du risque infectieux génital, pertes de chance en procréation médicalement assistée, accroissement du risque d'accouchement prématuré… Le traitement de la VB doit prendre en compte la restitution d'un microbiote normal.

[Human Papillomavirus: screening of cervical and anal cancers]. / Papillomavirus humain : dépistage des cancers du col et de l'anus.

Cervical cancer is preventable through primary and secondary prevention. Vaccination against the human papillomavirus (HPV), the virus necessary for the development of precancerous lesions, can prevent most of them. Screening by cytology for these precancerous (or cancerous) lesions can be replaced by screening for certain types of HPV, high risk (HR-HPV), causing cervical cancer. The presence of HR-HPV on the cervix should raise suspicion of concomitant infection in the anus, as both epithelia are highly susceptible. This attitude is dictated by the increase incidence in anal cancer in the population, which is also HPV-dependent and therefore also potentially preventable through vaccination and screening.

Le cancer du col utérin est évitable, au travers d'une politique de prévention primaire et secondaire. Une vaccination contre le papillomavirus humain (HPV), et plus particulièrement contre les HPV dits à haut risque (HR-HPV) qui induisent le développement des états précancéreux, permet ainsi d'éviter une majeure partie de ceux-ci. Un dépistage par cytologie à la recherche de ces lésions précancéreuses (ou cancéreuses) peut être supplanté par la recherche de la présence des HR-HPV. La présence de HR-HPV sur le col doit faire suspecter une infection concomitante au niveau de l'anus car les deux épithéliums y sont très sensibles. Cette attitude est dictée par l'augmentation des cancers de l'anus dans la population, cancer lui aussi dépendant du HPV, et donc aussi potentiellement évitable au travers de la vaccination et du dépistage.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons.

OBJECTIVES: To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. METHODS: Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. RESULTS: The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. CONCLUSIONS: The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. KEY POINTS: • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

Swiss Validation of the Enhanced Recovery After Surgery (ERAS) Database.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have considerably improved postoperative outcomes and are in use for various types of surgery. The prospective audit system (EIAS) could be a powerful tool for large-scale outcome research but its database has not been validated yet. METHODS: Swiss ERAS centers were invited to contribute to the validation of the Swiss chapter for colorectal surgery. A monitoring team performed on-site visits by the use of a standardized checklist. Validation criteria were (I) coverage (No. of operated patients within ERAS protocol; target threshold for validation: ≥ 80%), (II) missing data (8 predefined variables; target ≤ 10%), and (III) accuracy (2 predefined variables, target ≥ 80%). These criteria were assessed by comparing EIAS entries with the medical charts of a random sample of patients per center (range 15-20). RESULTS: Out of 18 Swiss ERAS centers, 15 agreed to have onsite monitoring but 13 granted access to the final dataset. ERAS coverage was available in only 7 centers and varied between 76 and 100%. Overall missing data rate was 5.7% and concerned mainly the variables "urinary catheter removal" (16.4%) and "mobilization on day 1" (16%). Accuracy for the length of hospital stay and complications was overall 84.6%. Overall, 5 over 13 centers failed in the validation process for one or several criteria. CONCLUSION: EIAS was validated in most Swiss ERAS centers. Potential patient selection and missing data remain sources of bias in non-validated centers. Therefore, simplified validation of other centers appears to be mandatory before large-scale use of the EIAS dataset.

Correlation of postoperative fluid balance and weight and their impact on outcomes.

INTRODUCTION: Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes. METHODS: All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0-3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression. RESULTS: One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0-1-2-3 was 1850 (IQR 1020-2540) mL, 2890 (IQR 1610-4000) mL, 3890 (IQR 2570-5380) mL, and 4000 (IQR 1890-5760) mL respectively, and median weight gain was 2.2 (IQR 0.3-4.3) kg, 3 (1.5-4.7) kg, and 3.9 (2.5-5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01-8.9, p = 0.049). CONCLUSION: Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.

Physical Activity and Outcomes in Colorectal Surgery: A Pilot Prospective Cohort Study.

BACKGROUND: Mobilization after surgery is recommended to reduce the risk of adverse effects and to improve recovery. The aim of this study was to examine the associations between perioperative physical activity and postoperative outcomes in colorectal surgery. METHODS: The daily number of footsteps was recorded from preoperative day 5 to postoperative day 3 in a prospective cohort of patients using wrist accelerometers. Timed Up and Go Test (TUGT), 6 Min Walking Test (6MWT), and peak expiratory flow (PEF) were assessed preoperatively. ROC curves were used to assess the performance of physical activity as a diagnostic test of complications and prolonged length of stay (LOS) of more than 5 days. RESULTS: A total of 50 patients were included. Patients with complications were significantly older (67 years) than those without complications (53 years, p = 0.020). PEF was significantly lower in the group with complications (mean flow 294.3 vs. 363.6 L/min, p = 0.038) while there was no difference between groups for the other two tests (TUGT and 6MWT). The tests had no capacity to discriminate the occurrence of complications and prolonged LOS, except the 6MWT for LOS (AUC = 0.746, p = 0.004, 95% CI: 0.604-0.889). There was no difference in the mean number of preoperative footsteps, but patients with complications walked significantly less postoperatively (mean daily footsteps 1,101 vs. 1,243, p = 0.018). CONCLUSIONS: Colorectal surgery patients with complications were elderly, had decreased PEF, and walked less postoperatively. The 6MWT could be used preoperatively to discriminate patients with potentially increased LOS and foster mobilisation strategies.

Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery.

OBJECTIVES: Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. METHODS: Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. RESULTS: Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation. CONCLUSION: Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery.

BACKGROUND: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. OBJECTIVE: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. STUDY DESIGN: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. RESULTS: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients. CONCLUSION: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

INTRODUCTION: Enhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes. METHODS: Retrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification. RESULTS: A total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I-V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001). CONCLUSIONS: Compliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

Stringent fluid management might help to prevent postoperative ileus after loop ileostomy closure.

PURPOSE: The present study aimed to analyze the impact of perioperative fluid management on postoperative ileus (POI) after loop ileostomy closure. METHODS: Consecutive loop ileostomy closures over a 6-year period (May 2011-May 2017) were included. Main outcomes were POI, defined as time to first stool beyond POD 3, and postoperative complications of any grade. Critical fluid management-related thresholds including postoperative weight gain were identified through receiver operator characteristics (ROC) analysis and tested in a multivariable analysis. RESULTS: Of 238 included patients, 33 (14%) presented with POI; overall complications occurred in 91 patients (38%). 1.7 L IV fluids at postoperative day (POD) 0 was determined a critical threshold for POI (area under ROC curve (AUROC), 0.64), yielding a negative predictive value (NPV) of 93%. Further, a critical cutoff for a postoperative weight gain of 1.2 kg at POD 2 was identified (AUROC, 0.65; NPV, 95%). Multivariable analysis confirmed POD 0 fluids of > 1.7 L (OR, 4.7; 95% CI, 1.4-15.3; p = 0.01) and POD 2 weight gain of > 1.2 kg (OR, 3.1; 95% CI, 1-9.4; p = 0.046) as independent predictors for POI. CONCLUSIONS: Perioperative fluid administration of > 1.7 L and POD 2 weight gain of > 1.2 kg represent critical thresholds for POI after loop ileostomy closure.

Mutations of RAS/RAF Proto-oncogenes Impair Survival After Cytoreductive Surgery and HIPEC for Peritoneal Metastasis of Colorectal Origin.

BACKGROUND: Adequate selection of patients with peritoneal metastasis (PM) for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains critical for successful long-term outcomes. Factors reflecting tumor biology are currently poorly represented in the selection process. The prognostic relevance of RAS/RAF mutations in patients with PM remains unclear. METHODS: Survival data of patients with colorectal PM operated in 6 European tertiary centers were retrospectively collected and predictive factors for survival identified by Cox regression analyses. A simple point-based risk score was developed to allow patient selection and outcome prediction. RESULTS: Data of 524 patients with a median age of 59 years and a median peritoneal cancer index of 7 (interquartile range: 3-12) were collected. A complete resection was possible in 505 patients; overall morbidity and 90-day mortality were 50.9% and 2.1%, respectively. PCI [hazard ratio (HR): 1.08], N1 stage (HR: 2.15), N2 stage (HR: 2.57), G3 stage (HR: 1.80) as well as KRAS (HR: 1.46) and BRAF (HR: 3.97) mutations were found to significantly impair survival after CRS/HIPEC on multivariate analyses. Mutations of RAS/RAF impaired survival independently of targeted treatment against EGFR. Consequently, a simple point-based risk score termed BIOSCOPE (BIOlogical Score of COlorectal PEritoneal metastasis) based on PCI, N-, G-, and RAS/RAF status was developed, which showed good discrimination [development area under the curve (AUC) = 0.72, validation AUC = 0.70], calibration (P = 0.401) and allowed categorization of patients into 4 groups with strongly divergent survival outcomes. CONCLUSION: RAS/RAF mutations impair survival after CRS/HIPEC. The novel BIOSCOPE score reflects tumor biology, adequately stratifies long-term outcomes, and improves patient assessment and selection.

Surgical teaching does not increase the risk of intraoperative adverse events.

INTRODUCTION: Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees. METHODS: Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups. RESULTS: Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788). CONCLUSION: Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.

Respiratory Complications After Colorectal Surgery: Avoidable or Fate?

BACKGROUND: The prevention of post-operative pulmonary complications (PPC) is targeted by several enhanced recovery (ERAS) items including early mobilisation, prevention of fluid overload and omission of routine nasogastric tubes. The aim of the present study was to assess the impact of ERAS on PPC. METHODS: This was a retrospective analysis of an institutional database including consecutive colorectal ERAS procedures from May 2011 until May 2017. Multiple logistic regressions were performed to identify risk factors for PPC among demographic, surgical characteristics and items related to the ERAS protocol. RESULTS: In total, 1298 patients were included; among them 120 (9.2%) had one or more PPC. Multivariable analysis retained minimally invasive surgery [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.15-0.46] and compliance to the ERAS protocol of ≥ 70% (OR 0.53; CI 0.30-0.94) as protective factors. Emergency surgery (OR 2.70; CI 1.20-6.01), blood loss of ≥ 200 mL (OR 2.06; CI 1.20-3.53) and ASA score of ≥ 3 (OR 2.00; CI 1.12-3.57) were independent risk factors. Median length of hospital stay was significantly longer in patients who experienced respiratory complications (21 [4-183] vs. 6 [1-95] days, p ≤ 0.001). CONCLUSIONS: Minimally invasive surgery and high compliance with the ERAS protocol can help to prevent PPC.

[Screening for anal cancer : is it the same as for cervical cancer ?] / Dépistage du cancer anal : doit-on faire de même que pour le cancer du col utérin ?

Anal dysplasia is usually caused by HPV infection and can lead to squamous anal cancer. The purpose of this article is to describe the classification of these precursor lesions but above all to identify the groups of patients at risk and to clarify the screening and follow-up that must be initiated.

Les lésions de dysplasie anale sont des lésions de l'épithélium du canal anal secondaires à une infection persistante par un Papilloma Virus Humain (HPV). Certaines de ces lésions vont progresser vers le carcinome épidermoïde du canal anal. Le but de cet article est de décrire la classification de ces lésions précurseurs mais surtout de déterminer les groupes de patients à risque et de clarifier le dépistage et le suivi qui doivent être instaurés.

Minimally invasive surgery and enhanced recovery after surgery: The ideal combination?

Enhanced recovery after surgery (ERAS) and minimally invasive surgery are both in the limelight due to their potential positive effects on surgical outcome. Large randomized trials and meta-analyses validated the use of both, laparoscopy and ERAS protocol, as individual measures. A synergistic effect of both entities might contribute to even better outcomes. This review hence assessed the literature upon up-to-date studies combining both methods.

Prevalence of measured and reported multimorbidity in a representative sample of the Swiss population.

BACKGROUND: Little is known on the prevalence of multimorbidity (MM) in the general population. We aimed to assess the prevalence of MM using measured or self-reported data in the Swiss population. METHODS: Cross-sectional, population-based study conducted between 2003 and 2006 in the city of Lausanne, Switzerland, and including 3714 participants (1967 women) aged 35 to 75 years. Clinical evaluation was conducted by thoroughly trained nurses or medical assistants and the psychiatric evaluation by psychologists or psychiatrists. For psychiatric conditions, two definitions were used: either based on the participant's statements, or on psychiatric evaluation. MM was defined as presenting ≥2 morbidities out of a list of 27 (self-reported - definition A, or measured - definition B) or as the Functional Comorbidity Index (FCI) using measured data - definition C. RESULTS: The overall prevalence and (95% confidence interval) of MM was 34.8% (33.3%-36.4%), 56.3% (54.6%-57.9%) and 22.7% (21.4%-24.1%) for definitions A, B and C, respectively. Prevalence of MM was higher in women (40.2%, 61.7% and 27.1% for definitions A, B and C, respectively, vs. 28.7%, 50.1% and 17.9% in men, p < 0.001); Swiss nationals (37.1%, 58.8% and 24.8% for definitions A, B and C, respectively, vs. 31.4%, 52.3% and 19.7% in foreigners, all p < 0.001); elderly (>65 years: 67.0%, 70.0% and 36.7% for definitions A, B and C, respectively, vs. 23.6%, 50.2% and 13.8% for participants <45 years, p < 0.001); participants with lower educational level; former smokers and obese participants. Multivariate analysis confirmed most of these associations: odds ratio (95% Confidence interval) 0.55 (0.47-0.64), 0.61 (0.53-0.71) and 0.51 (0.42-0.61) for men relative to women for definitions A, B and C, respectively; 1.27 (1.09-1.49), 1.29 (1.11-1.49) and 1.41 (1.17-1.71) for Swiss nationals relative to foreigners, for definitions A, B and C, respectively. Conversely, no difference was found for educational level for definitions A and B and abdominally obese participants for all definitions. CONCLUSIONS: Prevalence of MM is high in the Lausanne population, and varies according to the definition or the data collection method.

Contribution of preoperative ultrasound-guided implantation of a magnetic seed for optimal localization and resection of vulvar angiosarcoma: A case report.

INTRODUCTION: Vulvar cancer is a rare cause of malignancy among women. It is key for surgeons to achieve negative resection margins, as it greatly impacts patient's prognosis. Unfortunately, additional surgical procedures are often performed due to the regional anatomical complexity. Based on non-palpable breast tumors, where image-guided preoperative localization tools have enhanced the complete resection rates, we aimed at evaluating the feasibility of magnetic seed technique for localizing perineal lesions. PRESENTATION OF THE CASE: We present the case of a 40-year-old female patient, who underwent iterative resections for a recurrent epithelioid angiosarcoma of the left labia major. Imaging revealed a suspicious regional involvement at 3 months of follow-up, for which another surgery was planned. We decided to target this non-palpable lesion with the Magnetic Seed technique to guide the intervention. A seed was inserted into the nodule under ultrasound guidance. Resection was then performed, with negative margins and no recurrence on last follow-up. DISCUSSION: Surgical procedures with minimal extension are recommended in vulvar cancer, to limit the aesthetic and functional complication. Unfortunately, recurrences and residual tumors remain frequent, even higher when surgical margin safety is not achieved. Many studies have suggested the benefit of image-guided localization tools in non-palpable breast tumors. By reducing the excising volume and focusing on the lesions, relapse and complications are rarer. We considered Magnetic Seed to be the most appropriated technique for perineal lesions. CONCLUSION: As for breast cancer, Magnetic Seed technique could be appropriate for non-palpable perineal lesions, optimizing resection margins with minimal procedures.