Total mesorectal excision for cancer: histological and immunohistochemical evidence of nerve removal and risk-factor analysis.

AIM: Whether or not nerve-sparing rectal-cancer surgery can effectively prevent removal of the pelvic autonomic nerves has not been substantiated microscopically. We aimed to analyse the quality of nerve preservation in female patients by quantifying residual nerve fibres in total mesorectal excision specimens, to analyse pro-erectile function of the nerve fibres removed and to determine risk factors for pelvic denervation. METHOD: Serial transverse sections from female patients, 64 ± 18 years of age, were studied after the mesorectal fascia was inked and studied histologically [using anti-S100 and anti-neuronal nitric oxide synthase (nNOS) antibodies]. Nerve fibres located within 1 mm of the inked surface were counted and analysed according to type of surgery, tumour location, pT stage, circumferential resection margin and the necessity for a posterior colpectomy. RESULTS: Twelve specimens were analysed. Per specimen, the mean number of nerve-fibre sections outside the mesorectum was 5.3 ± 3.6 (range: 1-12). The mean number of fibres per specimen was 6.4 ± 4.1 in patients having a low-rectal tumour and 4.4 ± 2.9 in those with mid or higher rectal tumours (P = 0.42). The mean number of fibres was higher (9.2) for T4 tumours than for T2/T3 tumours (5.0 ± 3.5), but this difference was not statistically sigmificant (P = 0.25). Patients having abdominoperineal excision, a posterior colpectomy or a circumferential resection margin of less than 1 mm had significantly more nerve fibres in the specimen (10.6 ± 1.9 vs 4.4 ± 2.8; P = .041). Fibres localized at the anterolateral rectum corresponded to branches of the neurovascular bundle, expressing rich pro-erectile activity (positive anti-nNOS immunostaining). CONCLUSION: The neurovascular bundle is a key risk zone for pelvic denervation during total mesorectal excision. Abdominoperineal excision, posterior colpectomy and an invaded circumferential resection margin are associated with perineal denervation.

Internal supravesical hernia: an unusual cause of small bowel obstruction.

Internal hernia of the supravesical fossa is an unusual cause of small bowel obstruction. We report the case of a patient without previous abdominal surgery with an acute abdominal obstruction in which laparoscopic exploration revealed a strangulated internal supravesical hernia. To help clinicians with their pre-operative diagnosis and to better understand the clinical management of this unusual internal hernia, a description of the anatomy of the supravesical fossa is included in this case report.

Where does pelvic nerve injury occur during rectal surgery for cancer?

AIM: Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. METHOD: The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. RESULTS: The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. CONCLUSIONS: In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

Risk factors for surgical site infection after pancreatic surgery: a better postoperative antibiotic strategy is possible.

INTRODUCTION: Pancreatic surgery is associated with high morbidity, mainly due to infectious complications, so many centres use postoperative antibiotics (ATBpo) for all patients. However, antibiotic regimens vary according to local practices. The aims of this study were to describe the occurrence of surgical site infection (SSI) and ATBpo prescription after pancreatic surgery, and to determine the risk factors of postoperative SSI, in order to better define the clinical indications for ATBpo in this context. PATIENTS AND METHODS: All patients undergoing scheduled major pancreatic surgery from January 2007 to November 2018 were included in this retrospective study. Patients were classified into four groups according to SSI and routine ATBpo prescription: SSI+/ATBpo+, SSI-/ATBpo+, SSI+/ATBpo- and SSI-/ATBpo-. In addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of SSI and ATBpo were analysed using a logistic regression model. RESULTS: Data from 149 patients (115 pancreaticoduodenectomies and 34 splenopancreatectomies) were analysed. Thirty (20.1%) patients experienced SSI and 42 (28.2%) received ATBpo. No difference was found in routine ATBpo prescription between patients with and without SSI (26.7% vs 28.6%, respectively; P=0.9). Amongst the 107 patients who did not receive routine ATBpo, 85 (79.4%) did not develop an SSI. In-hospital mortality did not differ between infected and uninfected patients (7% vs 2%, respectively; P=0.13). The occurrence of postoperative fever differed between SSI+ and SSI- patients (73.3% vs 34.2%, respectively; P<0.001), while the prevalence of pre-operative biliary prosthesis was similar (37.9% vs 26.7%, respectively; P=0.3). CONCLUSION: Non-routine ATBpo after major pancreatic surgery resulted in 85 (56%) patients being spared unnecessary antibiotic treatment. This suggests that routine ATBpo prescription could be excessive, but further studies are needed to confirm such antibiotic stewardship. Fever appears to be a relevant clinical sign for individual-based prescription, but the presence of a biliary prosthesis does not.

Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation.

BACKGROUND: Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score. METHODS: We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy. RESULTS: Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%. CONCLUSIONS: After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.

Comparison of complete versus partial mesh removal for the treatment of chronic mesh infection after abdominal wall hernia repair.

PURPOSE: Treatment of chronic mesh infections (CMI) after parietal repair is difficult and not standardized. Our objective was to present the results of a standardized surgical treatment including maximal infected mesh removal. METHODS: Patients who were referred to our center for chronic mesh infection were analyzed according to CMI risk factors, initial hernia prosthetic cure, CMI characteristics and treatments they received to achieve a cure. RESULTS: Thirty-four patients (mean age 54 ± 13 years; range 23-72), were included. Initial prosthetic cure consisted of 26 incisional hernias and eight groin or umbilical hernias of which 21% were considered potentially contaminated because of three intestinal injuries, two stomas and two strangulated hernias. The mesh was synthetic in all cases. CMI appeared after a mean of 83 days (range 30-6740) and was characterized by chronic leaking in 52 cases (50%), an abscess in 22 cases (21%) and synchronous hernia recurrence in 17 cases (16.5%). Eighty-six reinterventions were necessary, including 36 mesh removals (42%), and 13 intestinal resections for entero-cutaneous fistula (15%). The CMI persistence rate was 81% (35 reinterventions out of 43) when mesh removal was voluntarily limited to infected and/or not incorporated material, but was 44% when mesh removal was voluntarily complete (19 reinterventions out of 43; p < 0.001). On average, 3.4 interventions (1-11) were necessary to achieve a cure, after 2.8 years (0-6). Fourteen incisional hernia recurrences occurred (41%). CONCLUSIONS: Treatment of chronic mesh infection is lengthy and resource-intensive, with a high risk of hernia recurrence. Maximal mesh removal is mandatory.

[The mesorectum: an anatomical entity that is difficult to evaluate with MRI]. / Le ligament rectal inférieur. Entité anatomique difficilement évaluable par l'imagerie.

The preoperative assessement by magnetic resonance imaging (MRI) of mesorectum involvement could improve the treatment strategy for patients with rectal cancer. However, the anatomical definition of the mesorectum remains controversial and consequently the accurracy of its analysis by preoperative imaging workup is still unsatisfactory. The aims of this study were to define the mesorectum anatomically and to assess whether it could be evaluated accurately by MRI. Total mesorectal excision was performed in 37 patients with rectal cancer. The mesorectum was inked for anatomical analysis, which was performed before and after fixation in formalin. The mesorectal thickness was measured anteriorly, posteriorly and laterally. Mesorectal involvement was defined by the shortest distance from the outermost part of the tumour to the lateral mesorectal margin. The anatomical measures were compared to those evaluated by preoperative MRI. In middle rectum, the anatomical analysis showed that the maximal mesorectal thickness was 60 and 20 mm posteriorly and anteriorly, respectively. In low rectum, the mesorectum was very thin and its maximal thickness was less than 10 mm anteriorly and posteriorly in all cases. The mesorectal involvement was less than 2 mm in 23% of cases. In terms of mesorectal involvement, there was good agreement between anatomical analysis and MRI for middle rectum. In contrast, the agreement was fair for low rectum. This anatomical analysis could explain the poor performance of MRI in the assessement of mesorectum involvement in low rectum.

[Lymph nodes and rectal cancer]. / Ganglions et cancer du rectum.

Nodal invasion is a major prognostic factor of rectal cancer. Lymphatic extension of rectal cancer usually involves the mesorectal nodes then the inferior mesenteric chain but in 14% of patients, particularly with cancer of the lower rectum, metastasic nodes can be observed in the internal or lumboaortic chains situated beyond the usual territory of nodal dissection. On average, 30 nodes are examined on a proctectomy specimen, but with wide interindividual variation. The tumor can be adequately staged if at least 15 nodes are examined with little risk of not recognizing nodal metastasis. Metastatic nodes of rectal cancer are almost always small, more than 90% measuring less than 10 mm and 70% less than 5 mm. The number of invaded nodes and the total number of examined nodes are prognostic factors for survival. Hypofrationated preoperative radiotherapy does not alter the nodal status but a long radiotherapy protocol (45 Gy over 5 weeks) reduces significantly the total number of nodes examined without changing the number of metastasic nodes. Micrometastases (measuring less than 2 mm), identified by immunohistochemistry or gene amplification, can be detected in 25 to 70% of nodes considered metastasis-free at the usual microscopic examination. The prognostic value of these micrometastases remains to be established. The first node draining the tumor (sentinel node), which can be detected rapidly with dye infusion, appears to provide a good picture of the nodal status, the risk of finding an invaded node if the sentinel node is metastasis-free is less than 5%.

Inside-out autologous vein grafts fail to restore erectile function in a rat model of cavernous nerve crush injury after nerve-sparing prostatectomy.

Some autologous tissues can restore erectile function (EF) in rats after a resection of the cavernous nerve (CN). However, a cavernous nerve crush injury (CNCI) better reproduces ED occurring after a nerve-sparing radical prostatectomy (RP). The aim was to evaluate the effect on EF of an autologous vein graft after CNCI, compared with an artificial conduit. Five groups of rats were studied: those with CN exposure, exposure+vein, crush, crush+guide and crush+vein. Four weeks after surgery, the EF of rats was assessed by electrical stimulation of the CNs. The intracavernous pressure (ICP) and mean arterial pressure (MAP) were monitored during stimulations at various frequencies. The main outcome, that is, the rigidity of the erections, was defined as the ICP/MAP ratio. At 10 Hz, the ICP/MAP ratios were 41.8%, 34.7%, 20.9%, 33.9% and 20.5%, respectively. The EF was significantly lower in rats if the CNCI was treated with a vein graft instead of an artificial guide. Contrary to cases of CN resection, autologous vein grafts did not improve EF after CNCI. In terms of clinical use, the study suggests to limit an eventual use of autologous vein grafts to non-nerve-sparing RPs.

[Anatomy of the levator ani muscle and implications for obstetrics and gynaecology]. / Anatomie du muscle élévateur de l'anus et applications en gynécologie obstétrique.

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery.

[Videoendoscopic approach for parathyroid adenomas: results of a prospective study of 100 patients]. / Exérèse vidéoendoscopique des adénomes parathyroïdiens: résultats à propos d'une série prospective de 100 patients.

STUDY AIM: The aim of this prospective study was to report the results of 100 consecutive video-endoscopic parathyroidectomies in patients suspected of having a single adenoma. PATIENTS AND METHOD: From March 1997 to September 2000, 80 females and 20 males (mean age: 49.5 years) were operated on. They were selected on the basis of the following criteria: preoperative imaging in favour of a single adenoma, absence of goiter and no prior neck dissection. The technique required three trocars; one 5 mm trocar inserted through the middle line of the neck for the 0-degree 5 mm endoscope, and two 3 mm trocars inserted laterally in order to perform a bilateral exploration. The neck was inflated to 10 mm Hg pressure with a low flow (3 L/min). RESULTS: Exploration was unilateral, bilateral and interrupted respectively in 52, 45 and 3% of the cases. The reasons for stopping were: an incidentally discovered thyroid carcinoma; moderate bleeding occurring from an anterior jugular vein after introduction of a lateral trocar; and a too-short neck. Parathyroid abnormalities were found in 86% of the patients (84 single adenomas, one double adenoma, one hyperplasia of the four glands). In 14% of the cases, the exploration was unsuccessful. A horizontal cervicotomy was required in 15% of the cases (14 negative explorations and one hyperplasia of the four glands). No intraoperative or postoperative complications occurred. The mean hospital stay was 24 hours. After 3-month follow-up, the serum calcium level was normal in 96% of the cases and cosmetic results were excellent. CONCLUSION: A video-endoscopic approach for parathyroidectomy is feasible and safe. With sufficient experience, a bilateral and complete exploration of the neck is possible. Therefore this technique represents a good alternative to the traditional cervicotomy in patients with uniglandular disease.

[The "pneumoneck" in videocervicoscopy: operative technique and anatomic limits]. / Le "pneumocou" dans la vidéocervicoscopie: technique opératoire et limites anatomiques.

The aim of this study was to describe a technic in order to create a gas space "pneumoneck" during videoendoscopic surgery of the neck and to determine the anatomical limits of this space. Data were based on a surgical experience and on the dissection of two corpses. This space was located between the two layers of the pre-tracheal lamina of the cervical fascia. This space was enclosed and favourable to detachment with insufflated gas without subcutaneous emphysema. This approach can be used for parathyroid and thyroid surgery.

[Acute pancreatitis after bilateral laparoscopic adrenalectomy in patients with ectopic ACTH syndrome]. / Pancréatite aiguë après surrénalectomie bilatérale laparoscopique pour sécrétion ectopique d'ACTH.

Two cases of acute necrotizing pancreatitis after bilateral laparoscopic adrenalectomy were observed in patients with an ectopic ACTH syndrome. Two reasons may be suspected: the difficulty of dissection in such patients and the specific morbidity in relation to hypercorticism.

[Bleeding gastroduodenal ulcer: results of surgical management]. / Ulcère gastroduodénal hémorragique: résultats du traitement chirurgical.

AIM OF THE STUDY: The aim of this retrospective study was to report the mortality and morbidity after surgery for bleeding peptic ulcer while the population is aging and while the medical treatment and endoscopic procedures are improving. PATIENTS AND METHODS: This retrospective study between 1994 and 1999 included 49 patients, 15 women, 34 men, aged 72 +/- 14 years. Patients were separated into three groups: ten with uncontrollable haemorrhages, 28 with recurrent haemorrhages and 11 with persistent haemorrhages. These patients were classified ASA II (n = 6), ASA III (n = 20), ASA IV (n = 21) and ASA V (n = 2). The surgical procedures for gastric ulcers (n = 5) were resection-oversewing (n = 2) or partial gastric resection (n = 3). The surgical procedures for duodenal ulcers (n = 44) were oversewing (n = 30), partial gastric resection (n = 10) or exploratory duodenotomy (n = 4). RESULTS: The overall postoperative mortality rate was 20.4% (10/49). The mortality rate was 40% (4/10) in patients with massive haemorrhage, 7% (2/28) in patients with recurrent haemorrhage, and 36% (4/11) in patients with persistent haemorrhage. There was no significant difference in the mortality rate in relation to the surgical procedures. The morbidity rate was 45%, including three bleeding recurrences after suture and three duodenal leakages after partial gastric resection. CONCLUSION: The morbidity and mortality rate after surgery for bleeding peptic ulcer is still high. Recurrent haemorrhages don't worsen the prognosis. Delayed surgery for persistent haemorrhage is associated with a severe prognosis.

[Perforation and rupture of the oesophagus: treatment and prognosis]. / Perforation et rupture de l'oesophage: prise en charge et pronostic.

AIM OF THE STUDY: To analyze treatment and prognosis of perforations and ruptures of the oesophagus. MATERIAL AND METHODS: This retrospective study included 40 patients (26 men and 14 women; mean age = 59 +/- 17 years) with a perforation or a rupture of the oesophagus. Seven perforations were cervical: iatrogenic (n = 6) or following ingestion of a foreign body (n = 1). Thirty-three perforations were thoracic: iatrogenic (n = 15), spontaneous rupture (n = 14), following ingestion of foreign body (n = 3) or traumatic (n = 1). All patients with cervical perforations were operated on (suture or drainage). One patient with thoracic perforation died before surgery, 2 underwent non-operative treatment and 30 were operated on. Twenty-eight underwent an oesophageal procedure: suture (n = 13), oesophagectomy (n = 11) or double exclusion (n = 4). Two uderwent surgery without oesophageal procedure (one pleural decortication, and one ablation of a pleural foreign body). RESULTS: The overall mortality rate was 17% (7/40), 21% (3/14) after spontaneous ruptures and 19% (4/21) after iatrogenic perforations (no death for other aetiologies). The mortality rate was 14% (1/7) for cervical lesions and 18% (6/33) for thoracic ones. It was 8% (1/13) after intrathoracic suture, 18% (2/11) after oesophagectomy and 50% (2/4) after double exclusion. CONCLUSION: Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Non-surgical treatment is rarely indicated. oesophagectomy is a good option in case of non suturable oesophagus or delayed operation.

[Surgical treatment of pancreatic metastases from renal carcinoma]. / Traitement chirurgical des métastases pancréatiques des cancers du rein.

OBJECTIVES: Pancreatic metastases from renal carcinoma are poorly known. The aim of this study was to report clinical and radiological manifestations, the treatment performed, and the observed survival in 7 patients with this rare entity. RESULTS: All patients were operated on. One patient had nonresectable tumor. Six patients underwent curative resection. There was one postoperative death. Follow-up after pancreatectomy ranged from 6 months to 3 years. Two patients developed extra-pancreatic metastases one year and 3 years after pancreatectomy respectively. CONCLUSIONS: Pancreatic metastases from renal carcinoma are rare and often occur several years after nephrectomy. However their resection is often possible and allows a good long-term survival. PATIENTS AND METHODS: From 1988 to 2000, 7 patients (5 men and 2 women, mean age = 66 years) with pancreatic metastases from a renal cell carcinoma were observed in the same center. One patient had synchronous metastasis; in the 6 others, metastases were diagnosed 4 to 16 years after nephrectomy, and were revealed by pain (n = 2), gastrointestinal bleeding (n = 1), faintness (n = 1) or routine follow-up (n = 2). The diagnosis of metastases was made by contrast-enhanced abdominal CT-scan.

[Intraperitoneal chemo-hyperthermia with "overflow" open abdomen]. / La chimiohyperthermie intrapéritonéale à ventre ouvert et avec "débordement".

The authors report an original procedure of open-abdomen intraperitoneal chemo-hyperthermia. The skin edges are watertightly stapled with a soft "abdominal cavity expander", supported by a Thompson self-retaining retractor positioned over the abdomen. So, the level of the liquid can be widely raised above the level of the skin edges. The anterior wall peritoneum, the wall edges are constantly exposed to the liquid. Large amplitude movements become possible: introduction into the abdomen of two forearms, even two arms, does not induce loss of any liquid. The small bowel, the stomach can be partially exteriorized. It becomes very easy to expose all the peritoneal spaces, to maintain an homogeneous hyperthermia within the abdomen, while using only one inflow drain, and one outflow drain.