From burden to relief: The economic and quality-of-life advantages of pseudo continent perineal colostomy in ultra-low rectal cancer patients.

BACKGROUND AND OBJECTIVE: Pseudo Continent Perineal Colostomy (PCPC) is an alternative technique to left iliac colostomy (LIC) after abdominoperineal resection for ultra low rectal cancer (ULRC). It allows placing the stoma in the perineum to preserve patients' body image. However, concerns about its impact on quality of life and management costs have limited its adoption. We aimed to compare the early outcomes and financial burden of PCPC and LIC in ULRC patients in Morocco, a low-middle-income country. METHODS: From January 2018 to December 2019, all patients who underwent abdomino-perineal resection (APR) with LIC or PCPC were prospectively enrolled. For each patient, baseline characteristics, and in hospital and 90 days morbidity with a focus on perineal complications were reported. Quality of life (QOL) was assessed using the validated EORTC-C30 and CR29 questionnaires. Financial burden to patients was reported using declarative out-of-pocket costs (OOPC) analysis. RESULTS: Among 49 patients who underwent APR, 33 received PCPC and 16 received definitive LIC. Similar rates of early perineal complications were observed between the two groups (p = 0.49). Readmission rate at POD90 was higher in the LIC-group due to perineal sepsis (p = 0.09). QOL analysis at 6 months revealed that patients with PCPC had a higher global health status (p = 0.006), a better physical functioning and reported fewer symptoms of flatulence and fecal incontinence (p = 0.001). Patients with a LIC reported more financial difficulties with higher median OOPC of stoma management up to €23 versus €0 per month for PCPC (p = 0.0024). PCPC was the only predictive factor of improved patient reported outcomes. CONCLUSIONS: PCPC is a cost-effective alternative to the standard definitive colostomy without alteration of the QOL or additional perineal complications during the first 6 months following the surgery. These findings may help convince surgeons to offer this option to patients refusing definitive LIC.

Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR.

OBJECTIVES: To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications. BACKGROUND: DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA). METHODS: All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included. RESULTS: Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up. CONCLUSIONS: DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.

Correlation between KRAS and NRAS mutational status and clinicopathological features in 414 cases of metastatic colorectal cancer in Morocco: the largest North African case series.

BACKGROUND: Advances in molecular biology have improved understanding of the molecular features of carcinogenesis and progression of colorectal cancer. It is clear that the efficacy of anti-EGFR depends upon the RAS mutational status, since any mutation in RAS is associated with resistance to anti-EGFR therapy. The aim of this study is to report the largest North African description of KRAS and NRAS status in metastatic colorectal cancer and to describe the association of these mutations with clinicopathological characteristics. METHODS: This is a prospective study of all consecutive unselected metastatic colorectal cancer samples, collected from the Laboratory of Pathology at the National Institute of Oncology of Rabat, Morocco, from January 1st 2020 to December 31st 2021. The molecular analysis was performed on the Idylla™ platform (fully automated real-time polymerase chain reaction-based assay) for KRAS and NRAS mutations in exons 2, 3 and 4. These mutations were correlated to gender, primary tumor site, histological type and degree of differentiation of tumor using adequate statistical methods. RESULTS: Four hundred fourteen colorectal tumors were screened for KRAS and NRAS mutations. These mutations occurred in 51.7% of tumors for KRAS (mainly in exon 12) and in 3% of tumors for NRAS. There was a significant correlation between NRAS mutation and age of colorectal patients in this study. The low rate of invalid RAS tests (1.7% for KRAS and 3.1% for NRAS) was certainly obtained due to the strict respect of pre-analytical factors such as cold ischemia time and formalin fixation. CONCLUSION: We report the largest North African analysis of NRAS and KRAS status in colorectal metastatic patients. This study showed the ability in low middle income countries to perform a high rate of valid tests and the unusual trend towards older patients for NRAS mutations.

The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries.

Objective: This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre. Methods: All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts. Results: Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM. Conclusions: This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.

Delivering colorectal cancer screening integrated with primary health care services in Morocco: Lessons learned from a demonstration project.

BACKGROUND: Colorectal cancer (CRC) incidence and mortality rates are increasing rapidly in many low-income and middle-income countries. A demonstration project was implemented in Morocco in collaboration with the Ministry of Health to assess the feasibility, acceptability, and challenges of implementing CRC screening through routine primary care facilities. METHODS: The objective of the project was to screen 10,000 men and women aged 50 to 75 years through 10 primary health centers (PHCs) in 2 provinces. All eligible men and women attending the selected PHCs were offered the fecal immunochemical test (FIT). Stool specimens brought to the PHCs were tested immediately by trained nurses. FIT-positive individuals were referred to the National Oncology Institute for colonoscopy. RESULTS: In total, 9763 eligible men and women were screened by FIT between June 2017 and May 2019; most (73.3%) were women. The test was positive in 460 participants (4.7%). Among the individuals who had positive FIT results, 62.6% underwent colonoscopy. The main reasons for noncompliance to colonoscopy were competing life priorities (15.4%), other health problems (13%), and fear of getting a cancer diagnosis (12.3%). As the number of referrals to colonoscopy increased, the waiting time for the procedure increased, resulting in a drop in compliance. The detection rates of advanced adenomas and CRC were 4.0 in 1000 and 0.5 in 1000 individuals screened, respectively. CONCLUSIONS: An effective strategy to reach the target populations (especially men), a pragmatic assessment of the health system's capacity to deal with large numbers of referrals, and a formal cost-effectiveness analysis are essential before making any decision to introduce CRC screening in Morocco.

Available prediction scores of conversion for laparoscopic rectal cancer surgery seem to be unsuitable for nowadays rectal cancer management.

INTRODUCTION: This study aimed to externally evaluate the accuracy of four predictive scores for conversion to open surgery after rectal laparoscopic resection. None of the four scores achieved external validation previously. METHODS: This was a retrospective analysis of two prospectively maintained databases from two academic centers in France and Morocco. All consecutive patients who underwent laparoscopic resection for rectal adenocarcinoma between 2005 and 2020 were included. Logistic regression was used to assess the association between the factors present in the four scores and conversion. The accuracy of each score was assessed using the area under the curve (AUC). Observed and predicted conversion rates were compared for each score using the Chi-square goodness-of-fit test. RESULTS: Four hundred patients were included. There were 264 men (66%) with a mean age of 65.95 years (standard deviation 12.2). The median tumor height was 7 cm (quartiles 4-11) and 29% of patients had low rectal tumors. Conversion rate was 21.75%. The accuracy to predict conversion was low with an AUC lower than 0,62 for the four models. The observed conversion rates were significantly different from the predicted rates, except for one score. CONCLUSIONS: The four models had low accuracy in predicting the conversion to open surgery for laparoscopic rectal resection. There is a need for new well-designed studies, analyzing more specific variables, in a multicentric design to ensure generalizability of the results for daily surgical practice.

Psychometric validation of the Moroccan version of the EORTC QLQ-C30 in colorectal Cancer patients: cross-sectional study and systematic literature review.

BACKGROUND: Health-related quality of life is mainly impacted by colorectal cancer which justified the major importance addressed to the development and validation of assessment questionnaires. We aimed to assess the validity and reliability of the Moroccan Arabic Dialectal version of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) in patients with colorectal cancer. METHODS: We conducted a cross-sectional study using the Moroccan version of the EORTC QLQ-C30 on colorectal cancer patients from the National Oncology Institute of Rabat, in the period from February 2015 to June 2017. The QLQ-C30 was administered to 120 patients. Statistical analysis included reliability, convergent, and discriminant validity as well as known-groups comparisons. RESULTS: In total, 120 patients with colorectal cancer were included in the study with 38 (32%) patients diagnosed with colon cancers. Eighty-two patients (68%) had rectal cancer, among which 29 (24%) patients with a stoma. The mean age of diagnosis was 54 years (+/- 13.3). The reliability and validity of the Arabic dialectal Moroccan version of the EORTC QLQ-C30 were satisfactory. [Cronbach's alpha (α =0.74)]. All items accomplished the criteria for convergent and discriminant validity except for question number 5, which did not complete the minimum required correlation with its own scale (physical functioning). Patients with rectal cancer presented with bad Global health status and quality of life (GHS/QOL), emotional functioning as well as higher fatigue symptoms compared to patients with colon cancer. The difference between patients with and without stoma was significant for diarrhea and financial difficulty. CONCLUSIONS: The Moroccan Arabic Dialectal version of the QLQ-C30 is a valid and reliable measure of health-related quality of life (HRQOL) in patients with colorectal cancer.

Methylene blue and ifosfamide-induced encephalopathy: Myth or reality?

BACKGROUND: Ifosfamide-induced encephalopathy (IIE) is a rare and serious adverse reaction. Thus far, no standard medication has been documentedto be efficient in the reversal of IIE, and while ifosfamide infusion interruption and hydration are recommended, methylene blue (MB) administration remains controversial. METHODS: We retrospectively reviewed medical records to assess cases with IIE after ifosfamide infusion. We included all patients having received an ifosfamide infusion during their hospitalization in the medical oncology unit of the National Institute of Oncology in Rabat, Morocco, between September 2016 and September 2017. We subsequently conducted a literature review to determine the role of MB in IIE by searching PubMed using the terms "Methylene Blue" and "Ifosfamide". RESULTS: A total of 88 patients received ifosfamide, and four patients had IIE. Ifosfamide infusion was stopped immediately after the IIE occurrence, and patients underwent renal function correction with hydration. All patients received MB infusion, and three patients had an improvement of their neurological status. As regards the literature review, 34 articles were reviewed and 16 items were included in the review. Overall, 38 (65.5%) patients received MB infusion and 28 (75.6%) patients responded favorably to the treatment. CONCLUSIONS: Methylene blue can be used as a treatment for IIE owing to the severity of the IIE as well as absence of standard medication. Nonetheless, side effects such as serotonergic syndrome should be investigated. More broadly, prospective studies and controlled trials are needed to explore the contribution of MB in IIE management and encourage its use.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score. METHODS: All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test. RESULTS: Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm. CONCLUSIONS: The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.

Validation of the Moroccan arabic version of the low anterior resection syndrome score.

BACKGROUND: Sphincter sparing surgery is oftentimes associated with bowel dysfunction complaints, namely the low anterior resection syndrome (LARS). The LARS questionnaire is widely used to assess this syndrome. The aim of this observational study is to translate this tool into arabic and test its psychometric properties in rectal cancer patients, in order to ease its use in clinical practice and future research. METHODS: The LARS questionnaire was translated to arabic and administered to a total of 143 patients. A subgroup of 42 patients took the test twice for test-retest reliability. Internal consistency was examined through cronbach's alpha. The score results were correlated to the EORTC QLQ-C30 questionnaire for convergent validity assessment, while discriminant validity was established through the ability of the LARS score to differentiate patients with different clinical and pathological criteria. RESULTS: The Moroccan Arabic version of the LARS score was completed by 143 patients. The internal consistency was demonstrated through a cronbach alpha score of 0.66. The agreement between the test and retest was established by a Bland Altman plot with 95% limits of agreement. 85.6% of patients remained in the same LARS category. The LARS score showed negative correlation with all five of the QLQ-C30 functional scales as well as positive correlation to the diarrhea symptom scale. The questionnaire score differed between patients according to their tumor location, chemoradiotherapy, type of mesorectal excision and anastomosis. CONCLUSION: The Moroccan Arabic version of the LARS score shows good psychometric properties and can be used for bowel dysfunction assessment in clinical and research settings.

Validation of the French translation of the Dutch residency educational climate test.

BACKGROUND: The learning environment is one of the most influential factors in training of medical residents. The Dutch Residency Educational Climate Test (D-RECT) is one of the strongest instruments for measuring the learning environment. However, it has not been translated in French. The objective of this study is the psychometric validation of the DRECT French version. MATERIAL AND METHODS: After translation of the D-RECT questionnaire into French, residents of five Moroccan hospitals were invited to complete the questionnaire between July and September 2018. Confirmatory factor analysis was used to evaluate the validity of the construct using the standardized root mean square residual (SRMR), the root mean square error approximation (RMSEA), the Comparative Fit Index (CFI) and the Tucker- Lewis Index (TLI). Reliability analysis was analysed using Internal consistency and Test-retest. RESULTS: During the study period, 211 residents completed the questionnaire. Confirmatory factor analysis showed an adequate model fit with the following indicators: SRMR = 0.058 / RMSEA = 0.07 / CFI = 0.88 / TLI = 0.87. The French translation had a good internal consistency (Cronbach alpha score >  0.7 for all subscales) and a good temporal stability (correlation score between two measurements = 0.89). CONCLUSION: This French version has an acceptable validity of the construct, a good internal consistency and good temporal reliability, and may be used to evaluate the learning climate. Additional research is necessary in other French-speaking contexts, in order to confirm these results.

Predictive factors of disease-free survival after complete pathological response to neoadjuvant radiotherapy for rectal adenocarcinoma: retrospective case series.

BACKGROUND: Many data suggest that patients with low rectal adenocarcinoma who achieved ypT0N0 status have improved survival and disease-free survival (DFS) compared to all other stages however only few data are available regarding the specific prognosis factors of this subgroup. This study aimed to evaluate predictive factors for disease free survival after complete pathological response (CPR) in cases of low rectal adenocarcinoma. MATERIALS AND METHODS: From January 2005 to December 2013, all patients with low rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision and achieved CPR were included at 7 Moroccan and 1 Algerian centres. Predictive factors for disease-free survival were analysed by uni and multivariate analysis. RESULTS: Eigthy-four (12.1%) patients achieved a CPR (ypT0N0). Multivariate analysis revealed that both poorly differentiated tumors (OR, 9.23; 95 CI 1.35-62.82; P = 0.023) and the occurrence of perineal sepsis (OR, 13.51; 95 CI 1.96-93.12; P = 0.008) were independently associated with impaired DFS. CONCLUSIONS: Patients with low rectal cancer who exhibited a CPR after neoadjuvant therapy have good prognoses; however, the occurrence of perineal sepsis and/or poor initial differentiation may be associated with impaired DFS in these patients. TRIAL REGISTRATION: The study was retrospectively registered the 28th July 2018 in ClinicalTrials.gov register with the reference NCT03601689.

Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country.

INTRODUCTION: Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes. OBJECTIVE: The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC. DESIGNS AND SETTINGS: We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco. PARTICIPANTS: These operations were performed by junior residents (post-graduate year [PGY] 4-5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien-Dindo classification) were recorded and analysed. One-way analysis of variance, Student's t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05. RESULTS: One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001). CONCLUSION: LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.