Appropriateness of colonoscopy in Europe (EPAGE II). Surveillance after polypectomy and after resection of colorectal cancer.

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for surveillance after polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resection of CRC was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: Most CRCs arise from adenomatous polyps. The characteristics of removed polyps, especially the distinction between low-risk adenomas (1 or 2, small [< 1 cm], tubular, no high-grade dysplasia) vs. high-risk adenomas (large [> or = 1 cm], multiple [> 3], high-grade dysplasia or villous features), have an impact on advanced adenoma recurrence. Most guidelines recommend a 3-year follow-up colonoscopy for high-risk adenomas and a 5-year colonoscopy for low-risk adenomas. Despite the lack of evidence to support or refute any survival benefit for follow-up colonoscopy after curative-intent CRC resection, surveillance colonoscopy is recommended by most guidelines. The timing of the first surveillance colonoscopy differs. The expert panel considered that 56 % of the clinical indications for colonoscopy for surveillance after polypectomy were appropriate. For surveillance after CRC resection, it considered colonoscopy appropriate 1 year after resection. CONCLUSIONS: Colonoscopy is recommended as a first-choice procedure for surveillance after polypectomy by all published guidelines and by the EPAGE II criteria. Despite the limitations of the published studies, colonoscopy is also recommended by most of the guidelines and by EPAGE II criteria for surveillance after curative-intent CRC resection.

Prognosis of stage II colon cancer by non-neoplastic mucosa gene expression profiling.

We have assessed the possibility to build a prognosis predictor (PP), based on non-neoplastic mucosa microarray gene expression measures, for stage II colon cancer patients. Non-neoplastic colonic mucosa mRNA samples from 24 patients (10 with a metachronous metastasis, 14 with no recurrence) were profiled using the Affymetrix HGU133A GeneChip. Patients were repeatedly and randomly divided into 1000 training sets (TSs) of size 16 and validation sets (VS) of size 8. For each TS/VS split, a 70-gene PP, identified on the TS by selecting the 70 most differentially expressed genes and applying diagonal linear discriminant analysis, was used to predict the prognoses of VS patients. Mean prognosis prediction performances of the 70-gene PP were 81.8% for accuracy, 73.0% for sensitivity and 87.1% for specificity. Informative genes suggested branching signal-transduction pathways with possible extensive networks between individual pathways. They also included genes coding for proteins involved in immune surveillance. In conclusion, our study suggests that one can build an accurate PP for stage II colon cancer patients, based on non-neoplastic mucosa microarray gene expression measures.

[Lymphadenectomy in the treatment of colon cancer]. / La chirurgie ganglionnaire dans le cancer du côlon.

Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Not Available]. / La chirurgie ganglionnaire dans le cancer du côlon.

F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Not Available]. / La chirurgie ganglionnaire dans le cancer du côlon.

F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? Case control study from a prospective survey of 11,756 patients]. / Le risque opératoire est-il majoré chez les médecins ou leurs proches? Etude cas-témoin à partir du suivi prospectif des suites opératoires de 11,756 patients.

AIM AND METHODS: Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? With the aim to answer this question, a case control study was performed from a cohort of 11,756 patients scheduled for surgery from 01/01/1987 to 12/31/2002. Fourty seven patients were physicians and 122 were a close relative to a physician. The percentage of physicians in the current series is comparable to that in the general urban population in France. Each of these patients was matched with 5 patients as controls regarding sex, age, diagnosis, procedure, and date of surgery. RESULTS: No statistically significant difference was observed between the 47 physicians and their 235 controls in the occurence of postoperative complications: 6% vs 6% (Odds ratio (OR)=1,07; CI(95%): 0,28-3,74), unplanned return to the operative room: 2% vs 2% (OR=1,00; CI: 0,11-8,8), and postoperative mortality: 0% vs 0,5% (p=0,07). No stastistically significant difference was observed between the 122 close relatives to a physician and their 610 controls in the occurence of postoperative complications: 6% vs 6% (OR=1,00; CI: 0,43-2,3), unplanned return to the operative room: 2% vs 3% (OR=0,55; CI: 0,18-3,4), and postoperative mortality: 1% vs 0,5% (OR=1,67; CI: 0,13-12,12). CONCLUSION: this study does not confirm the widespread opinion that postoperative course would be worse in physicians as patients and in their close relatives. Their recovery is not different from that to other patients if they are treated as well as other patients.

[Inguinal hernia repair: time interval between surgical repair and recurrence]. / Hernies inguinales: délais d'apparition des récidives.

This study seeks to evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia in patients undergoing re-operation. Recurrent hernia was identified in 94 (6.4%) of 1,474 patients having undergone initial hernia repair at our institution. Recurrence appeared within two years in 40 patients (42%). Recurrences were noted beyond five years in 32 patients (34%), and after 20 years in 18 patients (19%). 75% of recurrences had occurred within 15 years. We conclude that almost two-thirds of recurrences occur later than five years after the initial intervention and a quarter occur at an interval of more than fifteen years. Most studies underestimate hernia recurrence due to an insufficient period of post-operative observation.

Bilioportal fistula as a complication of choledochoduodenostomy.

A bilioportal fistula is rare. We report the case of a patient who had a bilioportal fistula 6 years after a choledochoduodenostomy. Percutaneous transhepatic opacification showed the bilioportal fistula to be associated with a thrombosed portal vein and a cavernous formation. Treatment consisted of separate percutaneous drainage of the portal and biliary tracts. Closure of the fistula was obtained by progressive proximal intrahepatic portal thrombosis. Our case contrasts with the four other cases of bilioportal fistula published in the literature in that (1) there was an absence of biliary lithiasis and (2) we did not use surgical treatment. The most likely explanation for our case of bilioportal fistula is an infectious complication related to the choledochoduodenostomy.

Infraperitoneal colorectal anastomosis: hand-sewn versus circular staples. A controlled clinical trial. French Associations for Surgical Research.

BACKGROUND: Disagreement continues among several studies as to the relative advantages and disadvantages of stapled versus sutured colorectal anastomoses. METHODS: One hundred and thirteen consecutive patients (48 men and 65 women, mean age: 67 +/- 12 years) were randomized to either hand-sewn (n = 59) or stapled (n = 54) infraperitoneal colorectal anastomosis. Both groups had similar patient demographics except that fewer patients (4 versus 15) had chronic disease (p < 0.02) and were undergoing side-to-end (11 versus 39) and more patients were undergoing end-to-end (37 versus 20) anastomosis in the stapled group (p < 0.001). RESULTS: Overall mortality was 6% (7 of 113 patients), with no difference found between the two types of anastomosis. Fewer anastomotic leaks occurred in the stapled group (11 versus 7), with an a posteriori gamma error of 11%, whereas the other early postoperative complications occurred with similar frequency in the two groups. Nine mishaps occurred in the stapled group. Stapled anastomoses took less time (median, 42 versus 30 minutes) to perform (p < 0.02). At 8 months, two strictures occurred in the hand-sewn group (n = 52) compared with eight strictures in the stapled group (n = 50) (p < 0.001). CONCLUSIONS: It was not possible to prove that lower anastomosis can be achieved with the stapling device. Routine or regular use of stapling instruments for infraperitoneal colorectal anastomosis cannot be advocated because of higher incidence of mishaps and strictures, even though the operation takes less time to perform and anastomotic leakage occurs less often.

Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research.

BACKGROUND: Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates. METHODS: One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy. RESULTS: Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p < 0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS). CONCLUSIONS: According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

Diagnosis of asymptomatic common bile duct stones: preoperative endoscopic ultrasonography versus intraoperative cholangiography--a multicenter, prospective controlled study. French Associations for Surgical Research.

BACKGROUND: In patients with symptomatic cholelithiasis, preoperative diagnosis of common bile duct (CBD) stones can modify the therapeutic strategy. The aims of this prospective, controlled multicenter study were to assess the feasibility, concordance, discordance, and indexes such as sensitivity, specificity, positive and negative predictive values, and accuracy of preoperative endoscopic ultrasonography compared with those of intraoperative cholangiography (IOC) in the diagnosis of asymptomatic CBD stones (i.e., patients undergoing cholecystectomy with no clinical or biologic evidence of CBD stones). METHODS: From October 1993 to October 1995, 240 consecutive patients with symptomatic cholelithiasis, scheduled for cholecystectomy in 14 surgical centers, were enrolled in this study. All patients were selected for this study according to a preoperative high-risk CBD stone predictive score. Each patient underwent both endoscopic ultrasonography and IOC, as well as surgical exploration of the CBD when stones were detected during one or both preoperative investigations. All patients were seen 1 months and 1 year after operation to check for residual stones. RESULTS: The feasibility of endoscopic ultrasonography was significantly higher overall than that of IOC (99% vs 90%; p < 0.001), except when IOC was through a laparotomy (97% vs 93%; p = 0.16). The number of patients available for study was 215. In 198 cases (92%), results of both investigations were in concordance (161 negative and 37 positive values). Seventeen cases (8%) were discordant. There was overall concordance between the two investigations (kappa coefficient 0.764; 95% confidence interval 0.66 to 0.87), but the percentage of discordance was in favor of IOC. Sensitivity and specificity of IOC were significantly higher than those of endoscopic ultrasonography (1.00 and 0.98 vs 0.85 and 0.93, respectively). With a prevalence of CBD stones of 19%, positive and negative predictive values of IOC were significantly higher than those of endoscopic ultrasonography (0.93 and 1.00 vs 0.75 and 0.96, respectively). CONCLUSIONS: Although endoscopic ultrasonography is feasible more often than IOC, IOC is associated with a slightly lower degree of discordance and better information indexes and remains an efficient method of investigation for CBD stones. Endoscopic ultrasonography can be suggested in preference to endoscopic retrograde cholangiography when postoperative residual stones are suspected but need not be performed routinely before cholecystectomy.

Hepatic metastases in gastrointestinal cancer: diagnostic value of biochemical investigations.

The results of biochemical estimations in 116 patients with known gastrointestinal cancer but no clinically detectable metastatic hepatic disease have been analyzed statistically. The most sensitive and the most specific tests for the presence or absence of hepatic metastasis were measurements of alkaline phosphatase and gamma-glutamyl transpeptidase. The predictive value for the absence of hepatic metastasis when the test results were normal was about 90% for alkaline phosphatase, gamma-glutamyl transpeptidase, lactate dehydrogenase, and serum aspartate aminotransferase. The best predictive value for the presence of hepatic metastasis (80%) was given by abnormal results of combined estimations of gamma-glutamyl transpeptidase and lactate dehydrogenase, and of gamma-glutamyl transpeptidase and serum aspartate aminotransferase.

Preoperative evaluation of the risk of common bile duct stones.

The patient with gallstones has an unknown risk of also having choledocholithiasis. To establish this risk preoperatively, several tests were studied in 167 patients, 37 of whom had common duct stones at exploration. With no previous or current jaundice, as well as normal alkaline phosphatase levels and a duct size of less than 12 mm, there was less than a 5% risk of choledocholithiasis; elevated bilirubin and/or alkaline phosphatase levels indicated intermediate risks (33% to 66%); and a duct size of 12 mm or greater, with any combination of other factors, indicated a 90% to 100% risk of choledocholithiasis. The surgeon should be aware of these probabilities in evaluating conditions of patients with cholelithiasis.

Choledochoduodenostomy for calculous biliary tract disease.

After the opening of the common bile duct, several controversial procedures may be used. In choledocholithiasis, our preference is to perform choledochoduodenostomy in older patients. We report the results in 77 consecutive patients with a mean age of 75 years. There were two hospital deaths (2.6%). Follow-up ranged from six months to 15 years, with an average of 6.7 years. Fifty patients are alive and well. Twenty-five patients have died. Only two patients were unavailable for follow-up. Expected mortality in the French population corresponding in age and sex was 29 deaths and the overall survival is not different, including the two postoperative deaths. Delicate technique allows anastomoses to ducts of any size, with no difference in long-term survival compared with a French population similar in age and sex.

Prophylactic antibiotherapy in abdominal surgery. First- vs third-generation cephalosporins.

To compare the efficiency of antibioprophylaxis by cefazolin sodium or cefotaxime sodium, 3137 consecutive patients undergoing abdominal surgery were included in a prospective, randomized, controlled, multicenter study. The patients were divided into four strata, according to the degree of contamination during the operation and the risk factors. Within each stratum, the patients were randomized into three groups of treatment: (1) cefazolin, (2) cefotaxime, and (3) nontreatment (control). Antibiotics were administered perioperatively in three intravenous doses of 1 g at eight-hour intervals. Patients undergoing colon surgery or with peritonitis at the time of the operation were excluded from the study. The wound abscess rate was significantly lower in the treated groups than in the control group, except in stratum 3 (contaminated surgery). The percentage of postoperative peritonitis was twice as low in the treated groups as in the control group. There was no difference between the groups receiving cefazolin or cefotaxime. The patients in the treated groups received significantly less postoperative antibiotics than the patients in the control group. In terms of cost, antibioprophylaxis by cefazolin seems to be warranted in all operations with a low anaerobic contamination.

Abdominal midline incision closure. A multicentric randomized prospective trial of 3,135 patients, comparing continuous vs interrupted polyglycolic acid sutures.

A randomized prospective multicentric study was organized to compare results between techniques using continuous sutures and interrupted sutures in closing abdominal midline incisions. The suture material employed was polyglycolic acid. This study included 3,135 patients who were randomized between the two methods of closure and who were stratified according to the type of wound: clean, clean-contaminated, and contaminated. The overall dehiscence rate was 1.6% in the continuous sutures group vs 2% in the interrupted sutures group. The dehiscence rate in the interrupted sutures group was significantly higher than in the continuous sutures group only in the stratum of contaminated wounds. The death rate was significantly higher in the interrupted sutures group. The number of needle sets was significantly less important when the continuous sutures technique was used. Continuous closure is preferable because it is more economic and expedient and also because it has the same incidence of wound dehiscence as interrupted sutures closure.

General and gastrointestinal tract surgery in France.

Forty-three state-run medical schools admit 30000 students per year but only 3500 receive their diploma after 6 years of studies. After passing a special examination, 480 of 2000 residents choose surgery and train during twelve 6-month rotations. Surgical research is organized through government agencies, individual units, or volunteer groups. In 1992, of 8268114 procedures, appendectomy represented 4.15%; hernia, 4.09%; varicose veins, 3.61%; and cholecystectomy, 1.82%. Appendectomy has decreased from 306500 per year in 1980 (34% of all gastrointestinal surgical procedures) to 159900 (15%) in 1996, whereas cholecystectomy has increased from 64700 to 95300. Emergency gastrointestinal procedures represented 15% of all surgical procedures in 1996, doubling in the last 4 years (essentially for labor and endoscopic procedures). Ambulatory procedures have increased 12-fold since 1980, essentially (75%) in private practice. About 27% of 160000 appendectomies and 77% of 95300 cholecystectomies were performed laparoscopically in 1997. One person of 4 in France has or has had cancer, mainly due to tobacco abuse. In 1993, 32000 surgical procedures were performed for gastrointestinal cancer. Of 532000 deaths (1992), about 150000 were due to cancer, 10000 to alcohol-related disease, and 22000 to trauma. Transplantation in France increased from 3180 procedures in 1993 to 2807 in 1996, essentially lungs and heart and lungs. Between 60% and 100% of health expenditures are reimbursed by the government, the remaining being covered by private insurances. Approximately 60% of 4500 French surgeons are in private practice; 25% also have part-time hospital employment. Almost 40% of surgeons work full-time in hospitals.

Chemoprevention and chemotherapy by inhibition of ornithine decarboxylase activity and polyamine synthesis: colonic, pancreatic, mammary, and renal carcinomas.

Specific, irreversible, inhibition of ODC activity with DFMO and resultant low levels of intracellular polyamines markedly suppress the induction of experimental colonic and mammary cancers and hold promise for augmenting the multidrug chemotherapy of established colonic, pancreatic, renal and mammary cancers without increasing systemic toxicity.

Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research.

BACKGROUND: This study was done to determine if certain criteria could predict the presence of common bile duct stones in patients with symptomatic gallstones. It was hoped that patients could be identified in whom intraoperative cholangiography was unnecessary. STUDY DESIGN: One hundred seventy-five patients, from 15 surgical centers, were prospectively enrolled. For each patient, the preoperative score (Huguier score) previously published was calculated according to clinical and ultrasound data: age, diameter of the common bile duct, diameter of the smallest gallstone, history of biliary colic, and acute cholecystitis. All patients underwent an open cholecystectomy and an intraoperative cholangiography. The absence or presence of a common bile duct stone was evaluated during the operation, if necessary, after an instrumental investigation of the common bile duct. RESULTS: Ultrasound was not interpretable in eight (5 percent) of 175 patients. Final analysis was made from the charts of the 167 remaining patients. Thirty (18 percent) had common bile duct stones. When the score was equal to or greater than 3.5, the risk of having a common bile duct stone was 24 percent (27 of 111). When the score was less than 3.5, this risk was 5 percent (three of 56). CONCLUSIONS: Huguier's score is well assessed and can be safely used. Intraoperative cholangiography could be avoided in 33 percent of patients when the score is less than 3.5 (56 of 167).

Stomach cancer after partial gastrectomy for benign ulcer disease. A critical analysis of epidemiological reports.

The controversy about the risk of cancer in patients surgically treated for peptic ulcer is debated in the literature. We analyzed published epidemiological studies, in an attempt to answer the following questions: 1) is there an increased risk of cancer in patients who underwent partial gastrectomy for ulcer disease?; 2) is such a risk influenced by the type of operation performed and by the original pathological lesion?; 3) are there any recommendations for peptic ulcer surgery and for a specific follow-up schedule of the patients? Twelve "prospective" studies have been published on patients operated on for peptic ulcer. These studies are based on the follow-up of a cohort over a certain period of time. Results are expressed and analyzed using the incidence ratio observed in the cohort, comparing observed with expected cases in a similar general population. The results of seven of these studies favor the hypothesis of an increased risk of stomach cancer in patients operated on for peptic ulcer disease, while those of five do not support this hypothesis. The results of two of these studies were obtained by multivariate analyses, which represent the best statistical methodology known for assessing the respective role of confounding variables. We therefore believe that the evidence is good enough to identify patients who underwent partial gastrectomy more than 20 years previously as a high-risk group for the development of carcinoma. We therefore recommend that these patients should be offered regular endoscopy, especially if they underwent a Billroth II surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)