Should the Surgical Management of Buschke-Lowenstein Tumors Be Aggressive? About 10 Cases.

AIMS: Buschke-Lowenstein tumor (BLT) of the anal margin is a histologically benign tumor whose degeneration can lead to a deadly local evolution because of difficult and late diagnosis. The objective of this study was to report our experience and propose a therapeutic strategy for these rare tumors. METHODS: From 1996 to 2014, 10 men with a median age of 45 years (25-64) were treated for a BLT of the anal margin with a first local excision possibly followed by rectal amputation. RESULTS: Local perianal excision was curative in 6 cases without recurrence. The median follow-up time was 94.5 months (5-175). In 4 patients, local excision was followed by an early recurrence, justifying a complementary abdominoperineal excision (APE) of the rectum. Two patients who benefited from complementary resection are currently free from recurrence. Even if the postoperative course was uneventful, 2 died from recurrence and disease progression within 5 and 11 postoperative months each. CONCLUSION: Macroscopic surgical evaluation of local tumoral invasion and extensive radical resection appears to be associated with long-term survival without recurrence. When recurrence occurs, APE of the rectum seems to be the only curative alternative. Based on low level of evidence, surgical excision is currently the only standard treatment for these lesions.

Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort.

BACKGROUND: Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI. METHODS: A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate. RESULTS: A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with ß-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI. CONCLUSIONS: This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.

Technical and functional results of the artificial bowel sphincter for treatment of severe fecal incontinence: is there any benefit for the patient?

BACKGROUND: Fecal incontinence is a socially devastating problem that can be cured by the artificial bowel sphincter in selected cases. OBJECTIVE: This study evaluates short- and long-term morbidity and functional results of the artificial bowel sphincter. DESIGN: This study is a retrospective evaluation of consecutive patients. SETTINGS: This study was conducted at 2 academic colorectal units. PATIENTS: Between May 2003 and July 2010, all consecutive patients who underwent artificial bowel sphincter implantation for severe fecal incontinence were included in the study. INTERVENTION: The artificial bowel sphincter was implanted through 2 incisions made in the perineum and suprapubic area. MAIN OUTCOME MEASURES: Patients were reviewed at months 1, 6, and 12, and then annually. Mortality, morbidity (early infection within the first 30 days after implant, and late thereafter), and reoperations including explantations were analyzed. Anal continence was evaluated by means of the Cleveland Clinic Florida score. Mean follow-up was 38 months (range, 12-98). RESULTS: Between May 2003 and July 2010, 21 consecutive patients with a mean age of 51 years (range, 23-71) underwent surgery. There was no mortality. All patients presented with at least 1 complication. Infection or cutaneous ulceration occurred in 76% of patients, perineal pain in 29%, and rectal evacuation disorders in 38%. The artificial bowel sphincter was definitely explanted from 17 patients (81%). The artificial sphincter was able to be activated in 17 patients (81%), and continence was satisfactory at 1 year in those who still had their sphincter in place (n = 12). CONCLUSION: There is a very high rate of morbidity and explantation after implantation of an artificial bowel sphincter for fecal incontinence. Four of 21 patients who still had an artificial sphincter in place had satisfactory continence at a mean follow-up of 38 months.

Sacral nerve stimulation for fecal incontinence improves symptoms, quality of life and patients' satisfaction: results of a monocentric series of 119 patients.

PURPOSE: Sacral nerve stimulation (SNS) is validated as an efficient treatment for fecal incontinence (FI). However, long-term results are scarce in the literature. The goal of this study was to assess the impact of SNS on FI symptoms and quality of life, based on a retrospective analysis of prospectively collected data. METHODS: From 2001 to 2009, 119 patients (six men, mean age 61 years) underwent SNS testing for FI after an extensive diagnostic workup. Permanent implantation was realized when FI symptoms improved during testing, and follow-up visits were performed every 12 months thereafter. This follow-up evaluated morbidity and efficacy, based on clinical data and self-administered questionnaires including Jorge and Wexner FI score, urinary incontinence score (urinary distress inventory-6, UDI-6), gastrointestinal quality of life index (GIQLI), and auto-evaluation scale. RESULTS: A permanent stimulator was implanted after a positive test in 102 patients (91 %). Ten patients were explanted during follow-up (pain in one case and absence of efficacy in nine), and 29 had the stimulator and/or the electrode changed. The mean follow-up was 48 months (range 12-84): there was a significant improvement of FI score (9 ± 1 vs 14 ± 3, p < 0.0001), UDI-6 score (8 ± 4 vs 11 ± 5, p < 0.05), and GIQLI index (p < 0.002). The improvement was present at 12 months follow-up and remained stable. Eighty percent of patients were satisfied with the treatment at the last point of follow-up. None of the pretreatment variables were predictive of SNS efficacy. CONCLUSIONS: SNS improved FI and quality of life, and this efficacy remained over time. Although a complete disappearance of FI was rare, most patients were satisfied.

Outcome and cost analysis of sacral nerve modulation for treating urinary and/or fecal incontinence.

BACKGROUND: Sacral nerve modulation (SNM) is an established treatment for urinary and fecal incontinence in patients for whom conservative management has failed. OBJECTIVE: This study assessed the outcome and cost analysis of SNM compared to alternative medical and surgical treatments. METHODS: Clinical outcome and cost-effectiveness analyses were performed in parallel with a prospective, multicenter cohort study that included 369 consecutive patients with urge urinary and/or fecal incontinence. The duration of follow-up was 24 months, and costs were estimated from the national health perspective. Cost-effectiveness outcomes were expressed as incremental costs per 50% of improved severity scores (incremental cost-effectiveness ratio). RESULTS: The SNM significantly improved the continence status (P < 0.005) and quality of life (P < 0.05) of patients with urge urinary and/or fecal incontinence compared to alternative treatments. The average cost of SNM for urge urinary incontinence was ∈8525 (95% confidence interval, ∈6686-∈10,364; P = 0.001) more for the first 2 years compared to alternative treatments. The corresponding increase in cost for subjects with fecal incontinence was ∈6581 (95% confidence interval, ∈2077-∈11,084; P = 0.006). When an improvement of more than 50% in the continence severity score was used as the unit of effectiveness, the incremental cost-effectiveness ratio for SNM was ∈94,204 and ∈185,160 at 24 months of follow-up for urinary and fecal incontinence, respectively. CONCLUSIONS: The SNM is a cost-effective treatment for urge urinary and/or fecal incontinence.

Initial management of extensive mesenteric venous thrombosis: retrospective study of nine cases.

BACKGROUND: The development of mesenteric venous thrombosis (MVT) does not necessarily require surgical intervention. The aim of this study was to assess the efficacy of avoiding early operative intervention, which can lead to significant sacrifice of the small bowel. METHODS: Patients with MVT were identified using the inpatient registry for the years between 2003 and 2007. Each patient's past medical history, history of prior deep venous thrombosis or hypercoagulable state, clinical and biologic presentation, and computed tomography (CT) results were analyzed. The proportion of ischemic bowel observed on the CT scans was compared with the length of the bowel resected. RESULTS: Nine patients were admitted for extensive MVT during the time period evaluated (six men, three women). All CT scans demonstrated signs of severe bowel ischemia, with a mean ischemic bowel proportion of 21% (range 5-45%). Four patients received medical management alone. Five patients underwent surgery. The mean admission time for these patients prior to the operation was 14.8 days (6-36 days). Surgery was required only in cases of intestinal perforation. The mean length of the bowel resections was 33 cm (20-45 cm). At 6 months after admission, none of the patients required parenteral nutrition. The mean follow-up evaluation period was 27 months (15-38 months). One patient died secondary to amyotrophic lateral sclerosis during the follow-up. CONCLUSIONS: Initial nonsurgical management comprised of inpatient observation on a surgical ward along with systemic anticoagulation must be considered an alternative treatment strategy for MVT. This strategy delays surgery and therefore avoids short bowel syndrome.

Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study.

BACKGROUND: Despite improvements in treatment, secondary peritonitis still is associated with high morbidity and mortality rates. Better knowledge of real-life clinical practice might improve management. METHODS: Prospective, observational study (January-June 2005) of 841 patients with non-postoperative secondary peritonitis. RESULTS: Peritonitis originated in the colon (32% of patients), appendix (31%), stomach/duodenum (18%), small bowel (13%), or biliary tract (6%). Most patients (78%) presented with generalized peritonitis and 26% with severe peritonitis (Simplified Acute Physiology Score [SAPS] II score>38). Among the 841 patients, 27.3% underwent laparoscopy alone; 11% underwent repeat surgery, percutaneous drainage, or both. A SAPS II score>38 and the presence of Enterococcus spp. were predictive of abdominal and non-surgical infections (odds ratio [OR]=1.84; p=0.013 and OR=2.93; p<0.0001, respectively). A SAPS II score>38 also was predictive of death (OR=10.5; p<0.0001). The overall mortality rate was high (15%). Patients receiving inappropriate initial antimicrobial therapy had significantly higher morbidity and mortality rates than patients receiving appropriate therapy (44 vs. 30%; p=0.004 and 23% vs. 14%; p=0.015, respectively). The SAPS II score and rates of severe peritonitis, morbidity, and mortality were significantly lower in patients with appendiceal peritonitis. CONCLUSIONS: Patients with non-postoperative peritonitis should be considered high risk and should receive appropriate initial therapy. The presence of Enterococcus spp. in peritoneal cultures significantly increased morbidity but not the mortality rate. Appendiceal peritonitis that was less severe and had a better prognosis than peritonitis originating in other sites should be considered a special case in future studies.

Prevalence of anal incontinence in adults and impact on quality-of-life.

OBJECTIVE: To investigate the prevalence of anal incontinence in the general population and in patients consulting gastroenterologist and gynecologist practices in the Rhône Alpes area. METHODS: For the first study a questionnaire was sent to a sample of 2800 people selected randomly from the electoral roll. Another study of patients selected randomly among patients attending gynecology and gastroenterology consultations was performed. A Jorge & Wexner score above or equal to 5 was used to define anal incontinence. RESULTS: For the first study, a total of 706 questionnaires was analyzed: the prevalence of anal incontinence was 5.1% [95% CI: 3.6-7.0] and the scores of each dimension of the SF-12 Health Survey were significantly lower among incontinent people than among continent people. The prevalence was significantly higher for women (7.5% [5.0-10.7]) than for men (2.4% [1.1-4.7]). Eighty-four physicians returned 835 valid questionnaires. The prevalence was 13.1% [10.1-16.6] among patients attending gastroenterology consultations and 5.0% [3.1-7.6] among those attending gynecology consultations. For 84.8% of the incontinent patients, the physician was unaware of the patient's disorder. CONCLUSION: The prevalence figures we obtained coincide with data in the literature. This disorder is common and affects the patient's quality-of-life, but remains underestimated and under-diagnosed.

A rare retrorectal presentation of a bronchogenic cyst: A case report.

INTRODUCTION: Bronchogenic cysts are rare abnormalities and a retrorectal presentation is exceptional. Its natural history is not known, but malignant transformation is quite rare. Retrorectal bronchogenic cysts are usually asymptomatic. PRESENTATION OF THE CASE: We present the case of a 36-year-old young man with a past medical history of HIV seropositivity who underwent a procedure to excise a sacral coccyx cyst at another surgical center in February 2009. A histological examination confirmed it was a sacral cyst that was resected in sano. The patient presented with a recurrence of the cyst, and this report describes the combined surgical procedure using a double sacrococcygeal and abdominal approach. DISCUSSION: A complete excision without cyst rupture is recommended to reduce the risk of local recurrence and malignant transformation, as previously reported. Resection can ben performed using multiple approaches depending on the cyst's location CONCLUSION: Herein, we report the case of a retrorectal bronchogenic cyst in a 36 years old man who was initially treated for a pilonidal cyst. A double surgical approach (abdominal and Kraske) resulted in complete resectioning with no reccurrence.

Acute Cholecystitis-Optimal Timing for Early Cholecystectomy: a French Nationwide Study.

BACKGROUND: The recommended treatment for acute calculous cholecystitis combines antibiotics and cholecystectomy. To reduce morbidity and mortality, guidelines recommend early cholecystectomy. However, the optimal timing for surgery on first admission remains controversial. This study aims to determine the best timing for cholecystectomy in patients presenting with acute calculous cholecystitis. STUDY DESIGN: The French national health-care database was analyzed to identify all patients undergoing cholecystectomy for acute cholecystitis during the same hospital stay between January 2010 and December 2013. Data regarding patients, procedures, and hospitals characteristics were collected. The relationship between surgery's timing and clinical outcome was evaluated by multiple logistic regressions. RESULTS: Overall, 42,452 patients from 507 hospitals were included in the study. Postoperative complications requiring invasive treatment occurred in 961 patients (2.3 %), and the mortality rate was 1.1 %. Adverse postoperative outcomes-intensive care admission, reoperation, and postoperative sepsis-were significantly lower when surgery was performed between days 1 and 3 (3-3.3, 0.5-0.6, and 3.8-4.1 %, respectively) when compared to surgery performed on the day of admission (5.6, 1.2, and 5.2 %, p < 0.001) or from day 5 onward (4.5, 1, and 6.5 %, respectively; p < 0.001). Mortality was also significantly lower in patients undergoing cholecystectomy between days 1 and 3 after admission (0.8-1 %) when compared to patients operated on the day of admission or after day 3 (1.4 % on day 0, 1.2 % on day 4, and 1.9 % from day 5: all p < 0.001). CONCLUSION: For patients with acute calculous cholecystitis, all efforts should be made to perform cholecystectomy within 3 days after hospital admission in order to decrease morbidity and mortality.

Influence of rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence.

BACKGROUND: Anal sphincter defects have been shown to increase pressure asymmetry within the anal canal in patients with fecal incontinence. However, this correlation is far from perfect, and other factors may play a role. The goal of this study was to assess the impact of rectal prolapse on anal pressure asymmetry in patients with anal incontinence. METHODS: 44 patients, (42 women, mean age: 64 (11) years), complaining of anal incontinence, underwent anal vector manometry, endo-anal ultrasonography (to assess sphincter defects) and pelvic viscerogram (for the diagnosis of rectal prolapse). Resting and squeeze anal pressures, and anal asymmetry index at rest and during voluntary squeeze were determined by vector manometry. RESULTS: Ultrasonography identified 19 anal sphincter defects; there were 9 cases of overt rectal prolapse, and 14 other cases revealed by pelvic viscerogram (recto-anal intussuception). Patients with rectal prolapse had a significantly higher anal sphincter asymmetry index at rest, whether patients with anal sphincter defects were included in the analysis or not (30 (3) % versus 20 (2) %, p < 0.005). Among patients without rectal prolapse, a higher anal sphincter asymmetry index during squeezing was found in patients with anal sphincter defects (27 (2) % versus 19 (2) %, p < 0.03). CONCLUSIONS: In anal incontinent patients, anal asymmetry index may be increased in case of anal sphincter defect and/or rectal prolapse. In the absence of anal sphincter defect at ultrasonogaphy, an increased anal asymmetry index at rest may point to the presence of a rectal prolapse.

Frequency of anal incontinence and results of pelvic viscerography in 291 women with pelvic organ prolapse.

OBJECTIVES: To determine the prevalence of anal incontinence in a population of 291 women with pelvic organ prolapse and evaluate the results of pelvic viscerogram in this situation. MATERIALS AND METHODS: Each patient answered a standardized questionnaire on medical, obstetric and surgical past histories and answers were logged in a database. The viscerograms were performed by a single specialized radiologist. RESULTS: All patients but one were parous. The prevalence of anal incontinence was 26.1%. Stress urinary incontinence and urge urinary incontinence were significantly associated with anal incontinence. No obstetric or surgical risk factor for anal incontinence was demonstrated. Viscerography demonstrated rectoceles (n=86, 29.1%), enteroceles (n=77, 26.5%), cystoceles (n=174, 59.8%), and intra-anal rectal prolapse (n=106, 36.4%). A significant association was found between intra-anal rectal prolapse and anal incontinence. CONCLUSION: Anal incontinence is frequent in patients with pelvic organ prolapse, even more so in the presence of urinary incontinence, and should be investigated by pelvic viscerography. Pelvic floor dysfunction is frequently associated with enteroceles, rectoceles and rectal prolapse. Pelvic viscerograms should be systematically performed in the diagnostic work-up in patients with pelvic organ prolapse when surgical treatment is considered.

Contribution of magnetic resonance cholangiopancreatography to the management of patients with suspected common bile duct stones.

OBJECTIVES: To evaluate the value of magnetic resonance cholangiography (MRC) as a systematic first-line investigation in the management of patients with suspected common bile duct stones. METHODS: Ninety-nine consecutive patients with clinical suspicion of choledocolithiasis were prospectively explored by MRC. All MRCs were interpreted by two radiologists with knowledge of the patient's clinical condition and laboratory results. In case of discrepancy, a third opinion was obtained to reach consensus. The definitive diagnosis was established on the basis of endoscopic exploration of the common bile duct (n=40), clinical and biological follow-up at 6 Months (n=55) or other investigations (n=4). The clinician's level of confidence, management options implemented, and impact of management decisions were used to assess the contribution of MRC. The diagnostic accuracy of MRC for common bile duct stones was also determined. RESULTS: At the observed level of confidence (85.9%), MRC identified a differential diagnosis in 7.1% of patients avoiding unnecessary endoscopic exploration in 59.6%. Systematic first-line MRC enabled appropriate management in 83.8% of patients. The sensitivity, specificity, and positive and negative predictive values of MRC for the diagnosis of common bile duct stones were 95.7%, 98.7%, 95.7% and 98.7%, respectively, with excellent inter-observer agreement (kappa=0.915). CONCLUSION: Magnetic resonance cholangiography can be used to efficiently screen patients who may need further invasive exploration of the common bile duct. It specifically identifies patients requiring therapeutic ERCP.

Clinical characteristics and quality of life in a cohort of 621 patients with faecal incontinence.

AIM: The aim of this study was to study a cohort of patients with faecal incontinence (FI) to gain a better insight into the clinical and epidemiological characteristics of this pathology and its repercussions on quality of life (QL). MATERIALS AND METHODS: Consecutive patients with FI seen at tertiary centres filled in a self-questionnaire. The severity of FI, constipation and urinary incontinence (UI) was evaluated, respectively, by the Jorge and Wexner score, the Knowles-Eccersley-Scott Symptom score and the Urological Distress Inventory score. ROME II criteria were used to assess the existence of an associated irritable bowel syndrome. The repercussion on QL was evaluated by the Gastrointestinal Quality of Life index score and the Ditrovie score. The psychological status was assessed by the Hospital Anxiety and Depression scale. RESULTS: Six hundred twenty-one patients (114 men), mean age 58 +/- 15 years (range: 20-92), with FI, filled in the questionnaire. The mean Jorge and Wexner score was 11 +/- 4. Twenty-seven presented with an irritable bowel syndrome. Thirty-eight percent had an associated constipation. A UI was associated in 48% women and 25% men. QL was significantly altered, and anxiety and depression were frequent. CONCLUSIONS: FI symptoms are frequently severe, QL very altered and anxiety and depression common. FI is frequently associated with other digestive and perineal symptoms, which argue in favour of a multi-disciplinary management of FI.

Portal venous gas detected on computed tomography in emergency situations: surgery is still necessary.

BACKGROUND: Portal venous gas (PVG) has been reported to be associated with lethal surgical diagnosis. Recent studies tend to confirm the clinical significance of gas in the portal vein; however, some patients are managed without surgical treatment. The aim of this study was to assess both the diagnoses and the treatment of patients with PVG in an emergency surgical setting. MATERIALS AND METHODS: We performed a retrospective chart review of 15 patients with PVG in the emergency setting detected by computed tomography (CT) between July 1999 and July 2004. Characteristics assessed included age, sex, clinical presentation, first CT diagnosis of both PVG and the underlying pathology, American Society of Anesthesiologists (ASA) score, surgical findings, final clinical diagnosis, duration of hospitalization, and evolution of the illness/mortality. All patients were examined one month after operation. RESULTS: This series of 5 women and 10 men ranged in age from 38 to 90 years at the time they underwent emergency surgical treatment. The mean preoperative ASA score was 4.20. Computed tomography diagnosed the underlying pathology in all cases: bowel obstruction (4 cases), bowel necrosis (9 cases), and diffuse peritonitis (2 cases). The mean length of hospital stay was 12.4 days. The mortality rate was 46.6%; (7 patients). CONCLUSIONS: A wide range of pathologies can generate PVG. Computed tomography can detect both the presence of gas and the underlying pathology. In emergency situations, all the diagnosed causal pathologies required a surgical procedure without delay. We report that the prognosis was related to the pathology itself and was not influenced by the presence of PVG.