Score prediction of anastomotic leak in colorectal surgery: a systematic review.

OBJECTIVE: Predicting the risk of anastomotic leak (AL) is of importance when defining the optimal surgical strategy in colorectal surgery. Our objective was to perform a systematic review of existing scores in the field. METHODS: We followed the PRISMA checklist (S1 Checklist). Medline, Cochrane Central and Embase were searched for observational studies reporting on scores predicting AL after the creation of a colorectal anastomosis. Studies reporting only validation of existing scores and/or scores based on post-operative variables were excluded. PRISMA 2020 recommendations were followed. Qualitative analysis was performed. RESULTS: Eight hundred articles were identified. Seven hundred and ninety-one articles were excluded after title/abstract and full-text screening, leaving nine studies for analysis. Scores notably included the Colon Leakage Score, the modified Colon Leakage Score, the REAL score, www.anastomoticleak.com and the PROCOLE score. Four studies (44.4%) included more than 1.000 patients and one extracted data from existing studies (meta-analysis of risk factors). Scores included the following pre-operative variables: age (44.4%), sex (77.8%), ASA score (66.6%), BMI (33.3%), diabetes (22.2%), respiratory comorbidity (22.2%), cardiovascular comorbidity (11.1%), liver comorbidity (11.1%), weight loss (11.1%), smoking (33.3%), alcohol consumption (33.3%), steroid consumption (33.3%), neo-adjuvant treatment (44.9%), anticoagulation (11.1%), hematocrit concentration (22.2%), total proteins concentration (11.1%), white blood cell count (11.1%), albumin concentration (11.1%), distance from the anal verge (77.8%), number of hospital beds (11.1%), pre-operative bowel preparation (11.1%) and indication for surgery (11.1%). Scores included the following peri-operative variables: emergency surgery (22.2%), surgical approach (22.2%), duration of surgery (66.6%), blood loss/transfusion (55.6%), additional procedure (33.3%), operative complication (22.2%), wound contamination class (1.11%), mechanical anastomosis (1.11%) and experience of the surgeon (11.1%). Five studies (55.6%) reported the area under the curve (AUC) of the scores, and four (44.4%) included a validation set. CONCLUSION: Existing scores are heterogeneous in the identification of pre-operative variables allowing predicting AL. A majority of scores was established from small cohorts of patients which, considering the low incidence of AL, might lead to miss potential predictors of AL. AUC is seldom reported. We recommend that new scores to predict the risk of AL in colorectal surgery to be based on large cohorts of patients, to include a validation set and to report the AUC.

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review.

INTRODUCTION: Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. METHODS: Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021). RESULTS: One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years. CONCLUSION: The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

Spontaneous lesser omental herniation resolved by laparoscopic surgery: case report and systematic literature review.

BACKGROUND: Despite its extremely low incidence, intra-abdominal herniation through the lesser omentum is associated with a high mortality rate and must be recognized early and treated urgently. To overcome a lack of data on the management of this condition, we collected and reviewed all the reported cases of operated lesser omental hernia and presented the case of a patient treated by laparoscopy for an isolated lesser omental hernia. METHODS: According to PRISMA guidelines and using PubMed, Cochrane Library, and Web of Science, a systematic literature review of cases of lesser omental hernia treated by surgery was performed on February 12, 2023. RESULTS: Of 482 articles, 30 were included for analysis and only 9 articles presented an isolated hernia through the lesser omentum. Among these, 4 patients were female and the median age was 38. Upper abdominal pain and vomiting were reported in 7 out of 9 patients. The small bowel was responsible for 78% (7/9) of all lesser omental herniations. All of them were treated by laparotomy. In addition, we describe the case of a 65-year-old woman without prior surgical history who was treated by laparoscopy for a spontaneous closed loop hernia through the lesser omentum without any other associated hernias. CONCLUSION: Mostly associated with prior surgery or trauma, this type of herniation could sometimes occur spontaneously without any sign of peritonitis. Due to the high mortality rate, internal abdominal hernias should always be ruled out with a CT scan in front of patients presenting with persisting acute abdominal pain and no alternative diagnosis.

Isolation and Characterization of Stem Cells from the Anal Canal Transition Zone in Pigs.

BACKGROUND: Utilization of autologous stem cells has been proposed for the treatment of anal incontinence despite a lack of understanding of their mechanism of action and of the physiological healing process of anal sphincters after injury. AIMS: We aim to develop a technique allowing isolation and further study of local mesenchymal stem cells, directly from anal canal transition zone in pig. METHODS: Anal canal was resected "en bloc" from two young pigs and further microdissected. The anal canal transition zone was washed and digested with 0.1% type I collagenase for 45 min at 37 °C. The isolated cells were plated on dishes in mesenchymal stem cell medium and trypsinized when confluent. Cells were further used for flow cytometry analysis and differentiation assays. RESULTS: The anal canal transition zone localization was confirmed with H&E staining. Following culture, cells exhibited a typical "fibroblast-like" morphology typical of stem cells. Isolated cells were positive for CD90 and CD44 but negative for CD14, CD34, CD45, CD105, CD106, and SLA-DR. Following incubation with specific differentiation medium, isolated cells differentiated into adipocytes, osteoblasts, and chondrocytes, confirming in vitro multipotency. CONCLUSIONS: Herein, we report for the first time the presence of mesenchymal stem cells in the anal canal transition zone in pigs and the feasibility of their isolation. This preliminary study opens the path to the isolation of human anal canal transition zone mesenchymal stem cells that might be used to study sphincters healing and to treat anal incontinence.

Multipotent mesenchymal stromal cells derived from porcine exocrine pancreas improve insulin secretion from juvenile porcine islet cell clusters.

Neonatal and juvenile porcine islet cell clusters (ICC) present an unlimited source for islet xenotransplantation to treat type 1 diabetes patients. We isolated ICC from pancreata of 14 days old juvenile piglets and characterized their maturation by immunofluorescence and insulin secretion assays. Multipotent mesenchymal stromal cells derived from exocrine tissue of same pancreata (pMSC) were characterized for their differentiation potential and ability to sustain ICC insulin secretion in vitro and in vivo. Isolation of ICC resulted in 142 ± 50 × 103 IEQ per pancreas. Immunofluorescence staining revealed increasing presence of insulin-positive beta cells between day 9 and 21 in culture and insulin content per 500IEC of ICC increased progressively over time from 1178.4 ± 450 µg/L to 4479.7 ± 1954.2 µg/L from day 7 to 14, P < .001. Highest glucose-induced insulin secretion by ICC was obtained at day 7 of culture and reached a fold increase of 2.9 ± 0.4 compared to basal. Expansion of adherent cells from the pig exocrine tissue resulted in a homogenous CD90+ , CD34- , and CD45- fibroblast-like cell population and differentiation into adipocytes and chondrocytes demonstrated their multipotency. Insulin release from ICC was increased in the presence of pMSC and dependent on cell-cell contact (glucose-induced fold increase: ICC alone: 1.6 ± 0.2; ICC + pMSC + contact: 3.2 ± 0.5, P = .0057; ICC + pMSC no-contact: 1.9 ± 0.3; theophylline stimulation: alone: 5.4 ± 0.7; pMSC + contact: 8.4 ± 0.9, P = .013; pMSC no-contact: 5.2 ± 0.7). After transplantation of encapsulated ICC using Ca2+ -alginate (alg) microcapsules into streptozotocin-induced diabetic and immunocompetent mice, transient normalization of glycemia was obtained up to day 7 post-transplant, whereas ICC co-encapsulated with pMSC did not improve glycemia and showed increased pericapsular fibrosis. We conclude that pMSC derived from juvenile porcine exocrine pancreas improves insulin secretion of ICC by direct cell-cell contact. For transplantation purposes, the use of pMSC to support beta-cell function will depend on the development of new anti-fibrotic polymers and/or on genetically modified pigs with lower immunogenicity.

Prevalence of Metastatic Lateral Lymph Nodes in Asian Patients with Lateral Lymph Node Dissection for Rectal Cancer: A Meta-analysis.

IMPORTANCE: Rectal cancers occupy the eighth position worldwide for new cases and deaths for both men and women. These cancers have a high tendency to form metastases in the mesorectum but also in the lateral lymph nodes. The therapeutic approach for the involved lateral lymph nodes remains controversial. OBJECTIVE: We performed a systematic review and meta-analysis to assess the prevalence of metastatic lateral lymph nodes in patients with lateral lymph node dissection (LLND) for rectal cancer, which seems to be a fundamental and necessary criterion to discuss any possible indications for LLND. METHODS: Data sources-study selection-data extraction and synthesis-main outcome and measures. We searched MEDLINE, EMBASE and COCHRANE from November 1, 2018, to November 19, 2018, for studies reporting the presence of metastatic lateral lymph nodes (iliac, obturator and middle sacral nodes) among patients undergoing rectal surgery with LLND. Pooled prevalence values were obtained by random effects models, and the robustness was tested by leave-one-out sensitivity analyses. Heterogeneity was assessed using the Q-test, quantified based on the I2 value and explored by subgroup analyses. RESULTS: Our final analysis included 31 studies from Asian countries, comprising 7599 patients. The pooled prevalence of metastatic lateral lymph nodes was 17.3% (95% CI: 14.6-20.5). The inter-study variability (heterogeneity) was high (I2 = 89%). The pooled prevalence was, however, robust and varied between 16.6% and 17.9% according to leave-one-out sensitivity analysis. The pooled prevalence of metastatic lymph nodes was not significantly different when pooling only studies including patients who received neoadjuvant treatment or those without neoadjuvant treatment (p = 0.44). Meta-regression showed that the pooled prevalence was associated with the sample size of studies (p < 0.05), as the prevalence decreased when the sample size increased. CONCLUSION: The pooled prevalence of metastatic lateral lymph nodes was 17.3% among patients who underwent rectal surgery with LLND in Asian countries. Further studies are necessary to determine whether this finding could impact the therapeutic strategy (total mesorectal excision with LLND versus total mesorectal excision with neoadjuvant radiochemotherapy).

Sacro-coxxygial hygiene, a key factor in the outcome of pilonidal sinus surgical treatment?

BACKGROUND: Surgical wound infection contributes to prolonged recovery time after pilonidal sinus excision. As a standard procedure after surgery, we recommend our patients to perform water irrigations in the intergluteal cleft 4 to 6 times a day during the post-operative period. Our hypothesis is that this should reduce healing time and complication rates. The aim of this study was to measure the importance of sacro coccygeal hygiene in the management of pilonidal sinus disease. METHODS: We retrospectively collected data after surgical management of pilonidal sinus (sinusectomy procedures) in our division over a 10-year period. Patients were divided into three groups according to their local hygiene during postoperative follow-up and scored one (G1: good hygiene) to three (G3: poor hygiene). Primary outcome was complication rates. Secondary endpoints were, healing time, follow-up, time off work, and recurrence rate. RESULTS: In G1 (N = 112), complication rate was 3.6%. In G2 (N = 109), it was 5.5%, whereas in G3 (N = 71), it reached 7.03%. However, there were no statistically significant differences between hygiene groups regarding complication rates in both univariate and multivariable analysis. Regarding secondary outcomes, there were significant differences between hygiene groups concerning median follow-up (p = 0.0001) and median time off work (p = 0.0127). CONCLUSION: Good hygiene of wound is essential for optimal, rapid healing without complications. The importance of this report is to show that thanks to our hygiene follow-up strategy with frequent perineal irrigations and regular follow-up checks, patients with at a first glance "unclean local conditions", reached similar complications, median healing time and recurrences rates to patients with medium and good wound hygiene level.

Risk of Colorectal Cancer in Patients With Acute Diverticulitis: A Systematic Review and Meta-analysis of Observational Studies.

BACKGROUND & AIMS: We performed a systematic review and meta-analysis to assess the prevalence of colorectal cancer in patients with acute diverticulitis. METHODS: We searched MEDLINE from inception through November 2nd, 2017 for studies reporting the prevalence of colorectal cancer in patients with diverticulitis, identified based on the protocol CRD42017083272. This systematic review was conducted in accordance to the MOOSE guidelines. Pooled prevalence values were obtained by random effects models and robustness was tested by leave-one out sensitivity analyses. Heterogeneity was assessed using the Q-test and quantified based on I2 value. The critical appraisal of included studies was performed using the Newcastle-Ottawa scale. RESULTS: Our final analysis included 31 studies, comprising 50,445 patients. The pooled prevalence of colorectal cancer was 1.9% (95% CI, 1.5%-2.3%). Patients with complicated diverticulitis had a significantly higher risk for colorectal cancer (prevalence, 7.9%; 95% CI, 3.9%-15.3%) than patients with uncomplicated diverticulitis (prevalence, 1.3%; 95% CI, 0.1%-2%), corresponding to a pooled prevalence ratio of 6.7 (95% CI, 2.5-18.3). Subgroup analyses did not find significant difference in prevalence when separately pooling studies according to ranking on the Newcastle-Ottawa scale, geographical location or length of follow-up. Meta-regression did not find any association between age and colorectal cancer. Among patients who underwent endoscopy, the pooled prevalence of polyps was 22.7% (95% CI, 19.6%-26.0%), of advanced adenomas was 4.4% (95% CI, 3.4%-5.8%), of adenomas was 14.2% (95% CI, 11.7%-17.1%), and of hyperplastic polyps was 9.2% (95% CI, 7.6%-11.2%). CONCLUSION: In a meta-analysis of observational studies of patients with acute diverticulitis, we found the pooled prevalence of colorectal cancer to be 1.9%. The risk of colorectal cancer was significantly higher in patients with complicated diverticulitis than in patients with uncomplicated diverticulitis.

Extracellular vesicles: Future diagnostic and therapeutic tools for liver disease and regeneration.

Extracellular vesicles are membrane fragments that can be produced by all cell types. Interactions between extracellular vesicles and various liver cells constitute an emerging field in hepatology and recent evidences have established a role for extracellular vesicles in various liver diseases and physiological processes. Extracellular vesicles originating from liver cells are implicated in intercellular communication and fluctuations of specific circulating extracellular vesicles could constitute new diagnostic tools. In contrast, extracellular vesicles derived from progenitor cells interact with hepatocytes or non-parenchymal cells, thereby protecting the liver from various injuries and promoting liver regeneration. Our review focuses on recent developments investigating the role of various types of extracellular vesicles in acute and chronic liver diseases as well as their potential use as biomarkers and therapeutic tools.

The clinical significance of extraluminal air in Hinchey 1a diverticulitis: results from a retrospective cohort study with 10-year follow-up.

BACKGROUND: Some patients with uncomplicated diverticulitis have extraluminal air. Our objective was to determine if patients with Hinchey 1a diverticulitis and isolated extraluminal air present more severe episode than patients without extraluminal air. METHODS: The present study is a monocentric observational retrospective cohort study. Computed tomographies of patients with diagnosed uncomplicated diverticulitis were retrospectively reviewed from the 01 January 2005 to the 31 December 2009. The presence of extraluminal air was determined. Leukocyte count, CRP value, and length of hospitalization were extracted from the patients' files. The follow-up period was from the time of diagnosis to the 15th of March 2019, the latest. Follow-up was censored for death and sigmoidectomy. Recurrence and emergency sigmoidectomy were documented during the follow-up period. The study was performed according to the STROBE guideline. RESULTS: Three hundred and one patients with an episode of Hinchey 1a diverticulitis were included. Extraluminal air was present in 56 patients (18.60%). Leukocyte count (12.4 ± 4.1(G/l) versus 10.7 ± 3.5(G/l), p = 0.05), CRP value (156.9 ± 95.1(mg/l) versus 89.9 ± 74.8(mg/l), p < 0.001), and length of hospital stay (10.9 ± 5.5(days) versus 8.4 ± 3.6(days), p < 0.001) were significantly higher in patients with extraluminal air than in patients without extraluminal air. Seventy-two patients (23.92%) presented a recurrence during the follow-up period. Survival estimates did not differ between patients with or without extraluminal air (p = 0.717). Eleven patients (3.65%) required emergency surgery during the follow-up period. Patients with extraluminal air had shorter emergency surgery-free survival than patients without extraluminal air (p < 0.05). CONCLUSION: The presence of extraluminal air in Hinchey 1a diverticulitis indicates a more severe episode, with higher inflammation parameters at admission, longer length of stay, and an increased risk for emergency sigmoidectomy.

Interleukin-1 Receptor Antagonist Modulates Liver Inflammation and Fibrosis in Mice in a Model-Dependent Manner.

BACKGROUND: Interleukin-1 (IL-1)ß and IL-1 receptor antagonist (IL-1Ra) have been proposed as important mediators during chronic liver diseases. We aimed to determine whether the modulation of IL-1ß signaling with IL-1Ra impacts on liver fibrosis. METHODS: We assessed the effects of IL-1ß on human hepatic stellate cells (HSC) and in mouse models of liver fibrosis induced by bile duct ligation (BDL) or carbon tetrachloride treatment (CCl-4). RESULTS: Human HSCs treated with IL-1ß had increased IL-1ß, IL-1Ra, and MMP-9 expressions in vitro. HSCs treated with IL-1ß had reduced α-smooth muscle actin expression. These effects were all prevented by IL-1Ra treatment. In the BDL model, liver fibrosis and Kuppfer cell numbers were increased in IL-1Ra KO mice compared to wild type mice and wild type mice treated with IL-1Ra. In contrast, after CCl-4 treatment, fibrosis, HSC and Kupffer cell numbers were decreased in IL-1Ra KO mice compared to the other groups. IL-1Ra treatment provided a modest protective effect in the BDL model and was pro-fibrotic in the CCl-4 model. CONCLUSIONS: We demonstrated bivalent effects of IL-1Ra during liver fibrosis in mice. IL-1Ra was detrimental in the CCl-4 model, whereas it was protective in the BDL model. Altogether these data suggest that blocking IL-1-mediated inflammation may be beneficial only in selective liver fibrotic disease.

Systematic review and meta-analysis of thrombocytopenia as a predictor of post-hepatectomy liver failure.

BACKGROUND: We performed a systematic review and meta-analysis to assess whether thrombocytopenia constituted a risk factor for post-hepatectomy liver failure (PHLF). METHODS: We searched MEDLINE and EMBASE from inception until February the 17th, 2018 for studies reporting cases of PHLF in patients with and without thrombocytopenia (defined as a platelet count below 100 or 150 (G/l)) and/or platelet counts in patients with and without PHLF. Pooled odd ratios for PHLF, as well as mean difference in platelet counts between patients with and without PHLF, were obtained by random effects models. Robustness was tested by subgroups and leave-one out sensitivity analyses. Heterogeneity was assessed using the Q-test and quantified based on I2 value. RESULTS: We included 15 studies representing 3966 patients. Pooled odds ratio for PHLF in thrombocytopenic patients was 3.71 (95% CI: 2.51 to 5.48; I2 = 0%). Pooled odds ratio was 5.53 (95% CI: 2.85 to 10.48) when pooling only studies based on preoperative platelet count, and 3.13 (95% CI: 1.75 to 5.58) when pooling studies including only patients without liver cirrhosis. The pooled mean difference in platelet counts between patients with and without PHLF was -21.2 (G/l) (95% CI: -36.1 to 6.4) in disfavor of patients with PHLF. When pooling only patients with various qualities of liver tissue, the pooled mean difference was 0.6 (G/l) (95% CI: -21.1 to 22.2). CONCLUSION: Preoperative and/or postoperative thrombocytopenia constitute significant risk factors for PHLF in cirrhotic and non-cirrhotic patients.

Xenotransplantation: back to the future?

The field of xenotransplantation has fluctuated between great optimism and doubts over the last 50 years. The initial clinical attempts were extremely ambitious but faced technical and ethical issues that prompted the research community to go back to preclinical studies. Important players left the field due to perceived xenozoonotic risks and the lack of progress in pig-to-nonhuman-primate transplant models. Initial apparently unsurmountable issues appear now to be possible to overcome due to progress of genetic engineering, allowing the generation of multiple-xenoantigen knockout pigs that express human transgenes and the genomewide inactivation of porcine endogenous retroviruses. These important steps forward were made possible by new genome editing technologies, such as CRISPR/Cas9, allowing researchers to precisely remove or insert genes anywhere in the genome. An additional emerging perspective is the possibility of growing humanized organs in pigs using blastocyst complementation. This article summarizes the current advances in xenotransplantation research in nonhuman primates, and it describes the newly developed genome editing technology tools and interspecific organ generation.

Robotic single-site versus multiport laparoscopic cholecystectomy: a case-matched analysis of short- and long-term costs.

BACKGROUND: Multiport laparoscopy is the gold-standard approach for cholecystectomy, and single-port laparoscopy has been developed to further reduce its invasiveness. A specific robotic single-port platform (da Vinci single-site, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2011, which could technically facilitate single-site cholecystectomy. Current data show its feasibility; however, detailed short- and long-term analyses of costs and comparisons relative to multiport laparoscopy are not available to date. METHODS: Patients who underwent robotic single-site cholecystectomy for benign, clinically noninflammatory disease between 2011 and 2015 were matched for disease, age, gender, BMI, ASA classification, diagnosis, and elapsed year of surgery to a cohort of multiport cholecystectomies. Demographic, perioperative, and long-term data were collected retrospectively and analyzed. Perioperative and long-term costs including re-operations due to the primary procedure until February 2017 were compared across both cohorts. RESULTS: 99 patients who underwent robotic single-site cholecystectomy were matched to 99 patients with multiport cholecystectomy. A higher rate of outpatient procedures in the robotic cohort (31.3 vs. 17.2%, p = 0.0305) was found, and demographic parameters and perioperative clinical outcomes were similar. Perioperative costs were significantly higher for the robotic single-site patients (6158.0 vs. 4288.0 USD, p < 0.0001). With similar follow-up times of 59.0 and 58.9 months, respectively (p = 0.9552), significantly more patients of the robotic Single-Site cohort underwent follow-up surgery (7.1 vs. 0.0%, p = 0.0140), and follow-up costs were significantly higher for the robotic cohort (694.7 vs. 0.0 USD, p = 0.0145). CONCLUSION: With similar early postoperative clinical results and a higher rate of re-operations, perioperative and long-term costs are significantly higher with robotic Single-Site cholecystectomy compared with multiport cholecystectomy. Considering the unclear clinical value of robotic single-site cholecystectomy and the significant short- and long-term costs, a call for further research and a debate as to who should bear the costs beyond the ones of the gold-standard treatment appear reasonable.

[Appendix tumours and their management]. / Les tumeurs de l'appendice et leur prise en charge.

An appendix tumour is found every 100 appendectomies. It can also be incidental discovery during a routine radiological examination and presents as a mucocele of the appendix. Appendix tumours are of varied histological type, and include mainly neuroendocrine tumours as well as epithelial tumours. The latter, when they secrete mucin, can give rise to peritoneal pseudomyxoma, a particular form of carcinosis harbouring serious complications. The management of appendix tumours responds to specific recommendations and, in advanced cases, requires the expertise of a university centre specialized in digestive oncology. The role of the primary care practitioner lies in the diagnosis and referral of patients with appendix tumours.

Une tumeur appendiculaire est retrouvée pour 100 appendicectomies. Elle peut aussi être découverte fortuitement lors d'un examen radiologique de routine et se présenter sous la forme d'un mucocèle de l'appendice. Les tumeurs appendiculaires sont de types histologiques variés et comprennent majoritairement les tumeurs neuroendocrines ainsi que les tumeurs épithéliales. Ces dernières, lorsqu'elles secrètent de la mucine, peuvent se présenter sous la forme d'un pseudomyxome péritonéal, une carcinose péritonéale particulière grevée d'importantes complications. La prise en charge des tumeurs appendiculaires répond à des recommandations particulières et, dans les cas avancés, nécessite l'expertise d'un centre universitaire spécialisé en oncologie digestive. Le rôle du médecin de premier recours réside dans le diagnostic et l'orientation des patients atteints d'une tumeur appendiculaire.

[Giant hernias with loss of domain: what is the best way to prepare patients?]. / Hernies géantes avec perte de droit de cité: comment preparer au mieux les patients?

Giant hernias with loss of domain induce physiological modifications that impair quality of life and make more complex their surgical management. A good preparation of patients before surgery is the key to an eventless postoperative course. The progressive pre-operative pneumoperitoneum (PPP) is one of the described abdominal augmentation protocols which can help patients to tolerate hernia content reintegration and avoid components separation technique during hernia repair. This article describes the management of these complex patients. We also report the case of a patient who follows successfully a PPP protocol.

[Cystic lesions of the pancreas from the general practitioner's point of view]. / Les lésions kystiques du pancréas sous l'angle du médecin de premier recours.

The detection rate of cystic lesions of the pancreas has increased following the widespread use of high-resolution imaging technologies. CT-scan, MRI and echo-endoscopy are diagnostic modalities. Pseudocyst is the most common lesion. It is benign and can be managed with endoscopic treatment. Mucinous cystic neoplasia and Intraductal Papillary Mucinous Neoplasia (IPMN) carry a risk for malignant transformation. The surgical treatment of these lesions has to be discussed by a multidisciplinary board. Serous cystic neoplasia and pseudopapillar and solid neoplasia are two rare types of lesion. The aim of this article is to present the diagnostic pathway and the management of these lesions from the general practitioner point of view.

[Management of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy]. / Prise en charge de la carcinose péritonéale par chirurgie cytoréductive et chimiothérapie hyperthermique intrapéritonéale.

In 2016, peritoneal carcinomatosis can be considered as a chronic disease that can be treated and sometimes cured. Hyperthermic Intra PEritoneal Chemotherapy (HIPEC) is a procedure developed in the eighties. Combined with CytoReductive (CR) surgery, this protocol underwent a considerable expansion in Washington Cancer Institute. CR combined with HIPEC was demonstrated to be the only curative treatment for PseudoMyxoma Peritonei syndrome (PMP). It is actually approved in the management of peritoneal carcinomatosis of ovarian, colorectal, or peritoneal primitive (mesothelioma) origin but is still studied for gastric cancer. CR/HIPEC is associated with an important mortality and morbidity. This article takes stock of indications to CR/HIPEC.