Patient management after primary rectal cancer diagnosis. Special focus on surgical treatment for non-metastatic disease.

Background: Rectal cancer is a public health priority. Primary objectives of this study were to evaluate the quality of care for non-metastatic rectal cancer using process and outcome indicators. Delay of management, length of stay and readmission rate, sphincter preservation, morbidity, number of examined lymph nodes, mortality, overall and disease-free survivals were evaluated. Secondary objectives were to estimate the relationship between possible predictive parameters for (1) anastomotic leakage (logistic regression), (2) overall or disease-free survivals (cox regression).Methods: We performed a retrospective study on 312 consecutive patients diagnosed with primary rectal cancer between 2016 and 2019. We focused on the 163 patients treated by surgery for non-metastatic cancer.Results: The treatment began within 33 days (range 0-264) after incidence, resection rate was 67%. Digestive continuity rate in lower, middle and upper rectum was 30%, 87% and 96%. Median of 14 lymph nodes (range 1-46) was analyzed. Length of stay and readmission rate were 11 days (range 3-56) and 4%, respectively. Within 90 postoperative days, clinical anastomotic leakage occurred in 9.2% of cases, major morbidity rate was 17%, mortality 1.2%. Multivariate analysis revealed that stoma decreased the risk of anastomotic leakage [hazard ratio: 0.16; 95% confidence intervals: 0.04-0.63; p = 0.008]. The 5-year overall survival after surgery was 85 ± 4%, disease-free survival 83 ± 4%. Patients with major complications, male gender and R1/R2 resection margin had a poorer prognosis.Conclusion: This work showed encouraging results in rectal cancer treatment in our institution, our results were in line with recommendations at the time.

[Clinical pathway evaluation for left colectomy in abdominal surgery]. / Evaluation d'un itinéraire clinique pour colectomie gauche en chirurgie abdominale.

At the end of 2008, a left colectomy clinical pathway was implemented at Clinique Saint-Joseph (CHC) in Liège (Belgium). A sample of 213 patients with benign or malignant pathology requiring laparoscopic left colon resection was included in this clinical pathway during the years 2009 to 2015. We focused on the compliance with the protocol, on the complication rate and the incidence of re-hospitalization within 30 days after surgery. In comparison with a historical control group, we observed that the compliance was excellent (superior to 80 %) from 2009 to 2015. The re-hospitalization did not differ though the complication rate decreased. Although the hospital stay was not our primary objective, it decreased significantly from 8 to 4 days (average). This analysis leads to the conclusion that the introduction of a clinical pathway, when it is well prepared and brings together all the implicated persons with the same goal, is directly beneficial to the patient and the quality of its management.

Fin 2008, l'itinéraire clinique (IC) «colectomie gauche¼ a été mis en place au sein de la Clinique Saint-Joseph (CHC) de Liège. Une série de 213 patients présentant une pathologie bénigne ou maligne nécessitant une résection du côlon gauche par laparoscopie a été incluse dans cet IC entre 2009 et 2015. Nous nous sommes intéressés à l'observance du protocole de l'IC ainsi qu'aux taux de complications et de ré-hospitalisations dans les 30 jours post-opératoires. Nous avons constaté, après comparaison avec un groupe témoin historique, que l'adhésion au protocole IC a été d'emblée excellente (supérieur a 80 %) tout au long de la durée de l'étude. Il n'y a pas eu de modification du taux de ré-hospitalisations et le taux de lâchage de suture a été réduit. Bien que la diminution de la durée de séjour n'était pas l'objectif premier lors de la mise en place de cet IC, elle s'est significativement réduite passant, en moyenne, de 8 à 4 jours. En conclusion, l'introduction d'un IC, pour autant qu'il soit bien préparé et rassemble dans le même objectif l'ensemble des acteurs de soins, est directement bénéfique pour le patient et la qualité de sa prise en charge.

[Contrast-enhanced ultrasound in hepatic focal nodular hyperplasia]. / Le cas clinique du mois. L'échographie avec injection de produit de contraste dans l'hyperplasie nodulaire focale du foie.

The ultrasound contrast agent is composed by microbubbles of sulfur hexafluoride. It is now recognized to the characterization of liver lesions. Focal nodular hyperplasia (FNH) is a benign lesion of the liver. It is found in the majority of cases among women with a sex ratio 1M/8F, no typical clinical presentation or malignancy is described. When the liver lesion was found in B-mode ultrasound, injection of contrast can be realized immediately by the radiologist. The study of the lesion during the arterial, portal and late phases with the contrast-enhanced ultrasound allows the diagnosis of FNH with a specificity of 97%. In arterial phase, the prescence of a central artery and scarring, centrifugal progression of enhancement, a transient unenhanced zone and in portal and late phases, isoechogenicity compared to adjacent parenchyma are the main features of FNH described in the literature.

[An unexpected finding in a 14-year-old girl]. / Le cas clinique du mois. Découverte inattendue chez une jeune fille de 14 ans.

A 14-year-old girl was admitted to the Emergency department for abdominal pain. An abdominal mass of 7-8 cm was detected and surgically resected. At anatomopathology a solid pseudopapillary neoplasm of the pancreas was observed. This tumour is rare and is included in the pancreatic cystic neoplasms. It frequently concerns 20-30-year-old girls. In all cases, the treatment consists of surgical resection, even in the rare cases with metastases. Prognosis is usually good, but careful follow-up is mandatory.

[Imaging in ankle traumas with special attention to fractures and their mechanisms]. / Mécanisme et imagerie des fractures de la cheville.

The ankle is the most frequently injured joint. The most common causes include sports injuries, highway accidents and household or workplace accidents. The therapeutic decision is based on radiological and clinical interpretation. This article aims to assist the clinician in deciding the role of radiography in diagnosis, care and treatment. It is also a reminder for the radiologist.

[Endoleak, a specific complication of the endovascular treatment of aortic aneurysms]. / Le cas clinique du mois. Les endofuites, une complication spécifique du traitement endovasculaire des pathologies aortiques.

Endoleaks represent the most common complication of endovascular aortic aneurysm repair. With the increasing use of endovascular techniques for aortic aneurysm repair, the prevalence of endoleaks has risen. While maintaining pressurization of the aneurysm sac, endoleaks expose to persistent risks of an evolution towards rupture. Long-term surveillance with imaging studies is necessary to reduce the incidence of these specific complications that may require intervention. The objective of this article is to draw the attention to the possible occurrence of these complications and to report the elements of diagnosis and treatment.

[A right supradiaphragmatic mass varying over 6 years]. / Le cas clinique du mois. Masse supra-diaphragmatique droite fluctuant pendant 6 ans.

A pleuro-pericardial cyst represents an uncommon form of congenital disease. We relate the case of an initially symptomless female patient presenting with a voluminous mediastinal mass. The fortuitous discovery of an asymptomatic mediastinal mass should always prompt consideration, among others, of the diagnosis of a pleuro-pericardial cyst.

[Screening of asymptomatic coronaropathy with adenosine stress myocardial perfusion MRI: a pilot study]. / Détection de la coronaropathie asymptomatique par etude de la perfusion myocardique sous stress a l'adénosine en résonance magnétique: résultats préliminaires.

The aim of the study was to evaluate the incidence of asymptomatic coronary heart disease in patients with cardiovascular risk factors and evaluate the diagnostic value of myocardial stress perfusion magnetic resonance as screening test in these patients. We performed a retrospective analysis of 103 consecutive asymptomatic patients with at least one clinical risk factor for cardiovascular disease, who have undergone myocardial stress perfusion magnetic resonance. For respective evaluation of ischemic myocardium and infracted myocardium, magnetic resonance imaging protocol included the study of both myocardial viability by late enhancement imaging and first-pass perfusion at rest and during maximal stress (adenosine). The reference standard was catheter coronary angiography for 10 patients and clinical follow-up for 93 patients. The incidence of coronary heart disease was 22/103 (21%), including 6/103 (6%) ischemia and 16/103 (15%) infarcts. Respective sensitivity, specificity, negative and positive predictive values for myocardial stress perfusion magnetic resonance in detecting ischemic myocardium were 100, 97, 67 and 100%. Myocardial stress perfusion magnetic resonance can be regarded and further investigated as screening test for the detection of asymptomatic coronary heart disease in high-risk subjects. Prospective studies, larger study groups and cost-effectiveness analysis are needed.

Whole-body magnetic resonance imaging: technical aspects, indications and preliminary experience.

This article reviews the interest and potential applications of whole body MR and presents a new technical concept of the technique. Preliminary experience with this new technology is presented.

Duplex ultrasound as first-line screening test for patients suspected of renal artery stenosis: prospective evaluation in high-risk group.

Our objective was to assess how far the progress in ultrasound devices has increased feasibility and accuracy of Duplex ultrasound (DUS) for the diagnosis of renal artery stenosis (RAS), in a population with high prevalence of atherosclerotic renovascular lesions. Ninety-one hypertensive patients with atherosclerotic disease were prospectively evaluated by both DUS and digital subtraction angiography (DSA) of the renal arteries. Only proximal criteria (peak systolic velocity >180 mm/s or renal-to-aortic ratio >3.5) were used for the diagnosis of significant RAS (>60% narrowing). For both techniques, two readers were involved for interobserver variability study. Two hundred one arteries were demonstrated by DSA on 182 available kidneys. The prevalence of RAS among the study group was 37%. Sixteen of the 19 accessory arteries were not seen at DUS; in 8 patients, one renal artery was not seen at DUS (feasibility 91%). On the 177 arteries assessed, in comparison with DSA, DUS yielded 96, 91, and 97% mean values of accuracy, sensitivity, and specificity, respectively. Kappa for interobserver agreement was 0.95 for DUS and 0.92 for DSA. Although still unreliable for the detection of accessory arteries, DUS is in our experience an accurate and reproducible diagnostic test for RAS.

[Stepping-table MR angiography of the upper limb arteries]. / L'angio-IRM en plusieurs stations des artères des membres supérieurs.

Stepping-table MR angiography of the upper limb arteries is reported in a patient with clinical and sonographic signs of ischemia. Advantages and limitations of the technique are discussed.

[Value of MRCP for detection of choledocholithiasis in symptomatic patients: one-year experience with a standardized high resolution breath-hold technique]. / Efficacité d'une technique standardisée de MRCP pour la détection de cholédocholithiase: expérience d'un an chez des sujets symptomatiques.

In our institution, MRCP is actually replacing diagnostic ERCP. This study is addressing its accuracy in the diagnosis of symptomatic choledocholithiasis. 137 MRCP were performed in patients with upper abdominal pain and biological anomalies (n = 48), pain with cholelithiasis at sonography (n = 69) or non-alcoholic acute pancreatitis (n = 20) on a 1.5 T system with high gradients using a standardized combination of breath-hold HASTE and RARE sequences. We included in our study 74 patients who underwent as second test ERCP (n = 36), peroperative cholangiography (n = 13), or extensive follow-up with laboratory tests and/or sonography (n = 25). All examinations were judged as diagnostic, discrepancies between direct cholangiography and MRCP being noted in 4 patients (5.4%). Lithiasis was misinterpreted on MRCP as bubbles in 2 patients after sphincterotomy or surgery. We had two false positive diagnoses on MRCP: in one patient peroperative cholangiography was negative and in the other one ERCP was negative. With a sensitivity and PPV of 92%, a specificity and NPV of 96% MRCP in our experience is shown as an accurate diagnostic tool for the detection of stone in the common bile duct replacing ERCP.

[State of the art of pancreatic cancer imaging]. / Actualités en imagerie du cancer du pancréas.

Ultrasonography and CT-scanner remain the first choice nowadays concerning detection and preoperative work-up of pancreatic cancer. MRI offers interesting options for the detection of liver metastases, and high quality of ductal and vascular examination. Actually, while we await a larger diffusion of MR systems and radiological expertise this technique is preferentially indicated as a third-step procedure when ultrasonography and CT-scanner are normal despite a real suspicion. Otherwise, MRI permits with a single non-invasive examination a complete work-up useful to prepare palliative therapy in case of unresectable tumor.

[Carotid endarterectomy without arteriography: only dedicated to urgent procedures?]. / La thrombendarteriectomie carotidienne sans arteriographie, une procedure reservee aux seules indications urgentes?

Duplex examination is presently established as a safe non-invasive and accurate method of evaluating patients with extracranial cerebrovascular disease which usually provides complete information about the extent of carotid artery narrowing Arteriography, in this indication, is an invasive procedure with a total complication rate of 3-4% with 1% of permanent stroke. If it is currently accepted that in emergency conditions (ictus ingravescens, pre-occlusive plaque) or if iodinated contrast media are contraindicated, thrombendarteriectomy can be performed without arteriography it could be extended to most cases. The authors stress the criteria to increase the number of those patients, summarize the pre-requisites to achieve this goal, and comment on the future alternative position of MRA.

Acute abdomen. Is ultrasonography useful, essential or unnecessary?

Abdominal ultrasonography in acute conditions gives sometimes the definite diagnosis or at least indicates a strategy for further examinations. This technique is constantly accurate for the upper part of the abdomen, and its classical indications are dominated by cholecystitis, biliary and urinary lithiasis, pancreatic and aortic painful circumstances. However, its role has been emphasized recently, after famous publications about the usefulness of high resolution ultrasonography for appendicitis and various gut-related acute conditions. The efficacity of abdominal ultrasonography is enhanced by color-doppler and power-doppler, to characterize some inflammatory or ischemic diseases. For the pelvis, endocavitary examination is a "must" for studying uterus and adnexae. The main drawbacks of abdominal ultrasonography are well known: its physical limitations and mainly its operator-dependence.

[Radioscopy and radiography of the thorax. Birth and maturation of an ever-current technique]. / Radioscopie et radiographie du thorax. Naissance et maturation d'une technique toujours d'actualité.

There are three milestones in the history of thoracic radiology. Thoracic radiology started in 1897 when Williams developed thoracic fluoroscopy and introduced the basic concepts of roentgenologic interpretation. At the same time, the first chest films were performed allowing decisive improvement in the diagnosis of many chest diseases. Continuous technical improvement is responsible for the fact that, even today, the conventional chest film remains a highly accurate and frequently used imaging modality. A third milestone was the development of digital radiography and its use in the chest. Computerised tomography changed thoracic imaging dramatically; in a first step mainly as a tool to visualise soft tissue abnormalities and, later on, also as a modality to study lung disease. The recent development of the digital chest radiograph has again added new perspectives to the approach and diagnosis of chest disease.