Transanal NOTES total mesorectal excision (TME) in patients with rectal cancer: Is anatomy better preserved?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are spreading worldwide. Total mesorectal excision (TME), the standard treatment for patients with distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically (LAPTME) or as an open procedure. We have already reported a NOTES-inspired, transanal, "down-to-up" variant of TME (NOTESTME). The main aim of this study was to assess the quality of the resected specimen in patients who had undergone either NOTESTME or LAPTME. METHODS: All patients with distal rectal neoplasia presenting between January 2011 and December 2014 were considered for the study. Additional inclusion criteria comprised American Society of Anesthesiologists score ≤ III and the absence of previous open surgery. Assignment to either group was sequential and based on the rank of inclusion in the study. The primary endpoint was the macroscopic quality of the specimen. Secondary endpoints included nerve visualization, tumor perforation, operating time, status of margins, and number of retrieved nodes. RESULTS: Eighteen patients (6 men, 12 women) were in the NOTESTME group and 15 (7 men, 8 women) in the LAPTME group, respectively. The TME specimen was considered complete or mainly regular in 16 patients who had undergone NOTESTME (88.9 %) and in 11 patients who had undergone LAPTME (73.3 %), (p > 0.05). During the procedure, we visually identified the neurovascular bundles of Walsh in 14 patients in the NOTESTME group (77.8 %) and in only 5 patients in the LAPTME group (33.3 %), (p < 0.05). Mean operative time was 245 min (range 155-440 min) in the NOTESTME group and 275 min (range 180-400 min) in the LAPTME group (p > 0.05). A median of 11 nodes per specimen (range 8-22 nodes) was retrieved in the NOTESTME group and 12 nodes (range 6-41 nodes) in the LAPTME group, respectively (p > 0.05). Distal and radial margins were comparable in both groups. CONCLUSIONS: Compared to the LAPTME, the NOTESTME seems to be associated with a more frequent intraoperative identification of the sacral nerves. However, the difference in overall quality of the retrieved specimen, although favoring NOTESTME, did not reach statistical significance in this small series.

Sequence of genome segments 1, 2, and 3 of the grass carp reovirus (Genus Aquareovirus, family Reoviridae).

The genome segments 1, 2, and 3 of the grass carp reovirus (GCRV), a tentative species assigned to genus Aquareovirus, family Reoviridae, were sequenced. The respective segments 1, 2, and 3 were 3949, 3877, and 3702 nucleotides long. Conserved motifs 5' (GUUAUUU) and 3' (UUCAUC) were found at the ends of each segment. Each segment contains a single ORF and the negative strand does not permit identification of consistent ORFs. Sequence analysis revealed that VP2 is the viral polymerase, while VP1 might represent the viral guanylyl/methyl transferase (involved in the capping process of RNA transcripts) and VP3 the NTPase/helicase (involved in the transcription and capping of viral RNAs). The highest amino acid identities (26-41%) were found with orthoreovirus proteins. Further genomic characterization should provide insight about the genetic relationships between GCRV, aquareoviruses, and orthoreoviruses. It should also permit to precise the taxonomic status of these different viruses.

[Gastric leiomyoblastoma, 2 case reports with a selective literature review]. / Leiomyoblastome gastrique, à propos de deux observations avec revue sélective de la littérature.

The gastric Leiomyoblastoma is a smooth muscle described in 1960 by Martin and in 1962 by Stout. These rare tumors are generally benign but may have a sarcomatous evolution in 11% of cases. They are characterized by the presence of large round or polygonal cells. Thin filaments are visible on electronic microscopy. Treatment of choice is the surgical resection.

[Inguinal herniorrhaphies by the pre-peritoneal method using surgical mesh]. / Les herniorraphies inguinales par voie pré-péritonéale utilisant la crinoplaque.

During a period of 5 years, 314 patients with 427 inguinal hernias were operated. 80 males with bilateral inguinal hernia recurrent, or not, were operated with an insertion of a Crinoplaque by a pre-peritoneal approach. The operative time was 65 +/- 26 minutes. 10 patients (12.5%) had by the same incision a concomitant pelvic procedure (9 varicoceles, 1 benign prostatic hypertrophy). 4 patients (5%) developed minor parietal complications. After 1 to 4 years of follow-up, 1 patient (1,25%) showed one side recurrence, in the beginning of our experience. In conclusion, we consider the pre-peritoneal Crinoplaque insertion as a treatment of choice for bilateral recurrent, or not, inguinal hernia for its simplicity and its lower complication rate.

[Therapeutic problem posed by Gardner's syndrome, report of a Lebanese family]. / Les problèmes thérapeutiques posés par le syndrome de Gardner, à propos d'une famille libanaise.

Gardner's syndrome ie an autosomal dominant disease characterized by the association of a polyposis coli with one or more of specific extracolonic manifestations. A lebanese family is reported. Polyposis coli, desmoid tumors, gastroduodenal polyps, procreation counselling etc. are difficult problems to manage in this syndrome.

[Hypothalamo-hypophyseal and gastric metastasis of a breast neoplasm. Clinical case and a review of the literature]. / Métastases hypothalamo-hypophysaire et gastrique d'un cancer du sein. Cas clinique et revue de la littérature.

The authors report the case of a young woman with advanced breast cancer who developed diabetes insipidus due to pituitary involvement and also gastric metastases. This patient had a normal brain CT scan. Gastric metastases were diagnosed when she was operated for a perforated gastric ulcer. Although very rare, and even if the brain CT scan is normal, pituitary metastases should be diagnosed in the presence of suggestive clinical symptoms. Abdominal pain also warrants investigation in these patients in an early attempt to document any possible gastric metastases.

[Retroperitoneal duodenal rupture during closed abdominal trauma]. / Les ruptures du duodénum rétropéritonéal au cours des traumatismes fermés de l'abdomen.

Duodenal retroperitoneal wound after blunt abdominal trauma, is a well known, and a classical entity. Most of the patients are operated with delay and this lesion could easily be missed at laparotomy if not searched for. Mortality and morbidity are much higher if the diagnosis is delayed more than 24 hours. These lesions should be strongly suspected after any blunt abdominal trauma, and repeated clinical assessment is mandatory in the conscious patient. Gastrografine upper GI study and CT Scan are interesting diagnosis procedures when the patient is unconscious or should be anesthesized. At laparotomy, the presence of a central retroperitoneal hematoma should guide the surgeon to explore the duodenum. Treatment depend on the time of diagnosis, the severity of the wound, and the associated pancreatic lesions.

[Jejunogastric intussusception. Apropos of a case]. / L'invagination jéjuno-gastrique. A propos d'un cas.

Jejunogastric intussusception is a rare complication after gastric surgery. The authors report a case of acute jejunogastric intussusception diagnosed in a 57-year-old woman, 22 years after vagotomy and gastroenterostomy for duodenal ulcer. There are three types of jejunogastric intussusception: 1) the acute type, presenting as a surgical emergency, and characterized by a sudden onset of cramp-like epigastric pain, followed by nausea and vomiting, with a palpable epigastric mass. 2) the chronic recurrent type, which may progress to the acute type of may result in severe disability, and may require corrective surgery depending on the severity of the symptoms. 3) the acute post-operative type, presenting on the 4th or 5th post-operative day, and usually improving with conservative treatment.

Thoracic splenosis. Case report and literature review.

Thoracic splenosis is the autotransplantation of splenic tissue into the thoracic cavity after thoracoabdominal trauma. We report a case of thoracic splenosis in a 35-year-old woman who had had a thoracoabdominal gunshot wound 12 years earlier. A review of the literature revealed 15 cases already reported. All patients had an asymptomatic thoracic lesion discovered on a plain chest film 9 to 32 years (mean 16) after the initial accident. In 13 cases an operation was necessary to establish the diagnosis. In two cases technetium 99m and indium 111 scans established the diagnosis.

Four hundred esophageal anastomoses with a stapler.

Four-hundred esophageal anastomoses were performed with a stapler in the Department of Digestive Surgery, Hospital Beaujon in Paris, in a six year period. The experience of the 14 different surgeons in esophageal surgery was very uneven (zero to 25 years). Two-hundred and sixty-eight esophagogastrostomies (220 in the chest and 48 in the neck), 83 esophagojejunostomies and 49 esophagocolostomies were done. The overall mortality rate was 9.2%, three per cent owing to leaks. The average incidence of leakage was 7% falling to 5.5% if cervical anastomoses were excluded. The incidence of stenoses was 8%. Several points which might account for problems are discussed. Stapled anastomoses seem to reduce the mortality and the morbidity rates of esophageal anastomoses, especially for surgeons with no experience in esophageal surgery.

[Asymptomatic cholelithiasis. When is a cholecystectomy justified?]. / Lithiase vésiculaire asymptomatique. Quand la cholécystectomie est-elle justifiée?

Since the introduction of routine abdominal echography, silent gallstone has become a major medical concern. The management of a patient with silent gallstone, is very controversed, and routine cholecystectomy is not always beneficial. Aged and high operative risk patients, should be treated conservatively. Literature review can identify subgroups of patients in whom cholecystectomy is justified: patients with micro or macro-lithiasis, patients in whom oral cholecystography reveals multiple floating stones, dyskinectic, not opacified or calcified gallbladder, and patients receiving general anesthesia for other reasons than gallbladder disease.

[Jejunogastric intussusception. Apropos of a case]. / L'invagination jéjuno-gastrique. A propos d'un cas.

Jejunogastric intussusception is a rare complication after gastric surgery. The authors report a case of acute jejunogastric intussusception diagnosed in a 57-year-old woman, 22 years after vagotomy and gastroenterostomy for duodenal ulcer. There are three types of jejunogastric intussusception: 1) the acute type, presenting as a surgical emergency, and characterized by a sudden onset of cramp-like epigastric pain, followed by nausea and vomiting, with a palpable epigastric mass. 2) the chronic recurrent type, which may progress to the acute type of may result in severe disability, and may require corrective surgery depending on the severity of the symptoms. 3) the acute post-operative type, presenting on the 4th or 5th post-operative day, and usually improving with conservative treatment.

Comparaçäo da recuperaçäo anestésica utilizando-se o etomidato e o tiopental sódico / Comparison of the anesthetic recover using etomidate and soduim thiopental

Em pacientes ambulatoriais submetidos a procedimentos de pequeno porte, a regressäo anestésica deve se proceder no menor tempo possível, visando a uma menor permanência hospitalar. Compara-se a recuperaçäo anestésica quando foi utilizado por via venosa o tiopental sódico na dosagem de 6 mg.kg-1 e do etomidato 0,3 mg.kg-1 em 60 pacientes femininas (ASA I), divididas em dois grupos de 30 cada, submetidas à curetagem uterina. A medicaçäo pré-anestésica para ambos os grupos foi atropina 0,5 mg + fentanil 2 micron g.kg-1 venoso. A avaliaçäo da recuperaçäo pós-anestésica foi feita pelo método dos quatro estágios de regressäo anestésica. Para o fentanil/etomidato este valor ficou em torno de 4 min, comparado ao fentanil/tiopental que ficou em torno de 10 min em média. Esta diferença foi estatisticamente significante. A associaçäo dos medicamentos principais tiopental e o etomidato ao fentanil, nas dosagens estudadas, devem contribuir para uma alta precoce, ressalvando-se que o tempo de analgesia do etomidato é pequeno 2,5 min, em relaçäo ao do tiopental sódico de 6,7 min, em média

Bupivacaína 0,25% em anestesia peridural torácica contínua para mamoplastias / Bupivacaine at 0,25% in continous thoracic epidural anesthesia for mammaplasty

Foram observados 40 pacientes submetidas a mamoplastias sob anestesia peridural torácica contínua com bupivacaína 0,25%, procurando-se determinar as características do bloqueio, seus efeitos cardiovasculares e as alteraçöes ventilatórias causadas pela técnica anestésica. Obteve-se ótimo grau de analgesia em 37 pacientes (92,5%) e nas três restantes (7,5%), completou-se a analgesia proposta com anestesia geral e ventilaçäo controlada. O tempo médio de latência foi de 8,50 + ou - 5,50 min. O tempo médio de regressäo da analgesia com a dose de 75 mg de bupivacaína foi de 130 + ou - 25 min e com a adiçäo de mais 25 mg através do cateter num total de 100 mg de bupivacaína, foi de 170 + ou - 21 min. Em 24 pacientes (60%), houve necessidade de dose complementar através do cateter. Em 10% dos casos houve necessidade de vasopressor e em 40% dos casos atropina para corrigir a bradicardia. A diminuiçäo do volume corrente, em 75% dos casos, näo foi superior a 10% dos valores iniciais; esta queda sempre foi acompanhada de um aumento da freqüência respiratória de 15%, e o volume minuto aumentou em 10%. Säo abordados aspectos com relaçäo à analgesia epidural torácica utilizando-se a soluçäo de bupivacaína 0,25% determinando alteraçöes na fisiologia cardiocirculatória e respiratória

Prevention of coagulopathy after placement of peritoneovenous shunt with replacement of ascitic fluid by normal saline solution.

Consumptive coagulopathy may complicate the early postoperative course of peritoneovenous shunting and be responsible for diffuse bleeding or even death. Since this complications has been related to procoagulant substances in ascitic fluid getting access to the systemic circulation, it was demonstrated that the replacement of the ascitic fluid by normal saline solution during shunt insertion decreases the prevalence and severity of postoperative coagulopathy.

[Complications of colonic esophagoplasty. Radiologic aspects]. / Les complications des oesophagoplasties coliques. Aspects radiologiques.

Early or late postoperative complications in 52 patients undergoing colic esophagoplasty for benign (27 cases) or malignant (25 cases) lesions of esophagus are discussed in relation to radiologic findings. Immediate postoperative complications due to infection were mainly bronchopneumopathies (14 cases), their incidence being increased by recurrent nerve palsy, and mediastinitis (3 cases). The frequency of upper anastomotic fistulae (16 cases) emphasizes the need for routine radiologic follow up on the 7th postoperative day by upper digestive tract follow-through examination with water-soluble contrast. Stenosis of upper part of graft may be of ischemic or fibrous origin. Ischemic stenosis develops 2 weeks to 4 months after surgery as a long filiform narrowing. Fibrous stenosis occurs in upper anastomosis at a later stage, after the 3rd month, as a short regular narrowing. Other complications are rare.

Correlaçäo entre os valores do pH e concentraçäo de glicose no líquido cefalorraquídeo e sangue arterial em pacientes pediátricos / Correlation between pH values and glicose concentration in cerebrospinal fluid and arterial blood in pediatric patients

Em 30 pacientes, submetidos à anestesia raquídica, para cirurgias eletivas, foi colhida, previamente, amostra de líquor, para a verificaçäo do pH e valor da glicose, além da amostra de sangue arterial, com idêntica finalidade. Também foi colhida amostra de suco gástrico, em todos os pacientes, a fim de se verificar o valor do pH. Os valores obtidos, para o pH e glicose do líquor e sangue arterial, foram agrupados em tabelas e submetidos à análise estatística, com base no teste "t" de Student, adotando-se, como nível de significância, p < 0,05. As médias globais foram para o líquor: pH = 7,38 (7,13 a 8,50) e glicose = 62,60 (42 a 89) mg%; para o sangue arterial: pH = 7,34 (7,20 a 7,42) e glicose = 86 (68) a 130) mg% e para o suco gástrico: pH = 2,03 (1 a 5). O valor médio da relaçäo glicorraquia/glicemia foi 0,73 (0,46 a 0,92). Considerando que, em pacientes pediátricos, os valores médios dos parâmetros estudados säo escassos na literatura médica, achamos importante um trabalho desta natureza