From burden to relief: The economic and quality-of-life advantages of pseudo continent perineal colostomy in ultra-low rectal cancer patients.

BACKGROUND AND OBJECTIVE: Pseudo Continent Perineal Colostomy (PCPC) is an alternative technique to left iliac colostomy (LIC) after abdominoperineal resection for ultra low rectal cancer (ULRC). It allows placing the stoma in the perineum to preserve patients' body image. However, concerns about its impact on quality of life and management costs have limited its adoption. We aimed to compare the early outcomes and financial burden of PCPC and LIC in ULRC patients in Morocco, a low-middle-income country. METHODS: From January 2018 to December 2019, all patients who underwent abdomino-perineal resection (APR) with LIC or PCPC were prospectively enrolled. For each patient, baseline characteristics, and in hospital and 90 days morbidity with a focus on perineal complications were reported. Quality of life (QOL) was assessed using the validated EORTC-C30 and CR29 questionnaires. Financial burden to patients was reported using declarative out-of-pocket costs (OOPC) analysis. RESULTS: Among 49 patients who underwent APR, 33 received PCPC and 16 received definitive LIC. Similar rates of early perineal complications were observed between the two groups (p = 0.49). Readmission rate at POD90 was higher in the LIC-group due to perineal sepsis (p = 0.09). QOL analysis at 6 months revealed that patients with PCPC had a higher global health status (p = 0.006), a better physical functioning and reported fewer symptoms of flatulence and fecal incontinence (p = 0.001). Patients with a LIC reported more financial difficulties with higher median OOPC of stoma management up to €23 versus €0 per month for PCPC (p = 0.0024). PCPC was the only predictive factor of improved patient reported outcomes. CONCLUSIONS: PCPC is a cost-effective alternative to the standard definitive colostomy without alteration of the QOL or additional perineal complications during the first 6 months following the surgery. These findings may help convince surgeons to offer this option to patients refusing definitive LIC.

External validation of the Moroccan Arabic version of the European Organization for Research and Treatment of Cancer colorectal (CR29) module: Monocentric study.

BACKGROUND: Quality of life (QoL) outcomes are a focal endpoint of cancer treatment strategies. AIM: To externally validate the Moroccan Arabic version of the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire (QLQ) for colorectal cancer (CRC) patients (CR29). METHODS: Both Moroccan Arabic modules of QLQ-CR29 and QLQ-C30 were administered to Moroccan CRC. Psychometric properties were retested by measuring Cronbach's alpha coefficient for reliability and Intraclass correlation coefficient (ICC) to examine test-retest reproducibility. The multitrait-scaling analysis was performed to demonstrate the validity of the instrument and known-groups comparison was used to test the score's ability to discriminate between different groups of patients. RESULTS: In total, 221 patients were included in our study and 34 patients completed the questionnaire twice. The Urinary Frequency scale and Stool Frequency scale had good internal consistency with alpha Cronbach coefficients of 0.79 and 0.83 respectively, while the same coefficients were moderately lower for the Blood and Mucus in Stool scale (0.61) and the Body Image scale (0.67). The ICCs ranged from 0.88 to 1 indicating good to excellent reproducibility. In multitrait scaling analyses, the criterion for item convergent and divergent validity was satisfactory. The known-group comparison showed statistically significant differences between patients according to age, gender, stoma status, tumor location, and radiotherapy. CONCLUSION: The Moroccan Arabic version of the EORTC QLQ-CR29 is a valid and reliable tool that can be used safely for research and clinical purposes in Moroccan CRC patients.

Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in Ovarian Cancer: An Umbrella Review of Meta-Analyses.

Background: The utility of heated intraperitoneal chemotherapy (HIPEC) in the management of epithelial ovarian cancer (EOC) has been assessed in several randomised clinical trials and meta-analyses, and it is still a subject of controversy. Therefore, we performed an umbrella review of existing meta-analyses to summarise the outcomes of HIPEC and cytoreductive surgery (CRS) association in ovarian cancer. Methods: We examined the MEDLINE, Cochrane Library, Scopus, Prospero, Web of Science and Science Direct from inception to May 30, 2020, for meta-analyses of randomised controlled trials and observational studies. Analyses of overall survival, disease free survival and progression survival were performed separately for primary and recurrent ovarian cancers. Results: We identified 6 meta-analyses investigating the association of HIPEC with CRS in the management of ovarian cancer. Three year overall survival was significantly improved by the association of CRS and HIPEC for primary (HR: 0.66, 95%CI:0.56-0.78) and recurrent ovarian cancers (HR:0.50, 95%CI:0.38-0.64). This benefit was also demonstrated on disease-free survival for primary (HR: 0.54, 95%CI:0.48-0.61) and recurrent ovarian cancer (HR: 0.60, 95%CI:0.46-0.78). The pooled hazard ratios confirmed the advantage of HIPEC and CRS association with respect to CRS alone on progression free survival for primary and recurrent ovarian cancer respectively with HR: 0.50, 95%CI: 0.43-0.58 and HR: 0.59, 95%CI: 0.41-0.85. Conclusion: While waiting for the results of the current prospective studies, the present umbrella study suggests that HIPEC performed at the end of CRS may be a complementary effective asset for ovarian cancer patient management.

Current Opinion and Practice on Peritoneal Carcinomatosis Management: The North African Perspective.

Background: The status of peritoneal surface malignancy (PSM) management in North Africa is undetermined. The aim of this study was to assess and compare current practice and knowledge regarding PSM and examine satisfaction with available treatment options and need for alternative therapies in North Africa. Methods: This is a qualitative study involving specialists participating in PSM management in North Africa. The survey analyzed demographic characteristics and current knowledge and opinions regarding PSM management in different institutions. We also looked at goals and priorities, satisfaction with treatment modalities and heated intraperitoneal chemotherapy (HIPEC) usefulness according to specialty, country, years of experience, and activity sector. Results: One-hundred and three participants responded to the survey (response rate of 57%), including oncologists and surgeons. 59.2% of respondents had more than 10 years experience and 45.6% treated 20-50 PSM cases annually. Participants satisfaction with PSM treatment modalities was mild for gastric cancer (3/10 [IQR 2-3]) and moderate for colorectal (5/10 [IQR 3-5]), ovarian (5/10 [IQR 3-5]), and pseudomyxoma peritonei (5/10 [IQR 3-5]) type of malignancies. Good quality of life and symptom relief were rated as main priorities for treatment and the need for new treatment modalities was rated 9/10 [IQR 8-9]. The perceived usefulness of systemic chemotherapy in first intention was described as high by 42.7 and 39.8% of respondents for PSM of colorectal and gastric origins, while HIPEC was described as highly useful for ovarian (49.5%) and PMP (73.8) malignancies. Conclusions: The management of PSM in the North African region has distinct differences in knowledge, treatments availability and priorities. Disparities are also noted according to specialty, country, years of expertise, and activity sector. The creation of referral structures and PSM networks could be a step forward to standardized PSM management in the region.

Systematic analysis of authorship demographics in global surgery.

BACKGROUND: Global surgery has recently gained prominence as an academic discipline within global health. Authorship inequity has been a consistent feature of global health publications, with over-representation of authors from high-income countries (HICs), and disenfranchisement of researchers from low-income and middle-income countries (LMICs). In this study, we investigated authorship demographics within recently published global surgery literature. METHODS: We performed a systematic analysis of author characteristics, including gender, seniority and institutional affiliation, for global surgery studies published between 2016 and 2020 and indexed in the PubMed database. We compared the distribution of author gender and seniority across studies related to different topics; between authors affiliated with HICs and LMICs; and across studies with different authorship networks. RESULTS: 1240 articles were included for analysis. Most authors were male (60%), affiliated only with HICs (51%) and of high seniority (55% were fully qualified specialist or generalist clinicians, Principal Investigators, or in senior leadership or management roles). The proportion of male authors increased with increasing seniority for last and middle authors. Studies related to Obstetrics and Gynaecology had similar numbers of male and female authors, whereas there were more male authors in studies related to surgery (69% male) and Anaesthesia and Critical care (65% male). Compared with HIC authors, LMIC authors had a lower proportion of female authors at every seniority grade. This gender gap among LMIC middle authors was reduced in studies where all authors were affiliated only with LMICs. CONCLUSION: Authorship disparities are evident within global surgery academia. Remedial actions to address the lack of authorship opportunities for LMIC authors and female authors are required.

Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience.

Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation ("1":2005-2008), transition ("2":2009-2013) and consolidation ("3":2014-2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery.

BACKGROUND: Bowel dysfunction symptoms such as stool clustering, urgency, incomplete voiding, and fecal incontinence are frequent after colorectal surgery and known as the low anterior resection syndrome. The Wexner score is the most widely used tool for fecal incontinence assessment. We aimed to translate and test the psychometric properties of the Moroccan Arabic dialect version of the Wexner questionnaire in patients with low anterior resection syndrome after rectal surgery. METHODS: The Wexner questionnaire was translated to Moroccan Arabic and administered to a group of 158 patients, among which a subgroup of 43 patients took the test for a second time to examine test-retest reliability. Cronbach alpha coefficient was used to determine internal consistency and correlation, and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 and the low anterior resection syndrome questionnaires were assessed for convergent validity. Discriminant validity was demonstrated through the Wexner score ability to detect differences based on the patients' different clinical and pathological characteristics. RESULTS: One hundred and fifty-eight patients completed the Moroccan Arabic dialect version of the Wexner score, which showed an excellent internal consistency with a Cronbach alpha score of 0.91. Test-retest reliability was established by a Bland-Altman plot with 95% limits of agreement. The score showed positive correlation to the low anterior resection syndrome score (r = 0.748; P < .001) and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 diarrhea symptom scale (r = 0.519; P < .001). A negative correlation was also demonstrated for each one of the 5 European Organisation for the Research and Treatment of Cancer quality of life C30 functional scales, namely physical functioning (r = -0.217 ; P = .006), role functioning (r = -0.267; P = .001), emotional functioning (r = -0.266; P = .001), cognitive functioning (r = -0.283; P < .001), and social functioning (r = -0,283; P < .001). The Wexner score differed between patients according to tumor location, chemoradiotherapy, type of mesorectal excision, and anastomosis. CONCLUSION: The Moroccan Arabic dialect version of the Wexner score shows good psychometric properties and can be used for fecal incontinence assessment, particularly in colorectal cancer patients.

Psychometric validation of the Moroccan version of the EORTC QLQ-C30 in colorectal Cancer patients: cross-sectional study and systematic literature review.

BACKGROUND: Health-related quality of life is mainly impacted by colorectal cancer which justified the major importance addressed to the development and validation of assessment questionnaires. We aimed to assess the validity and reliability of the Moroccan Arabic Dialectal version of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) in patients with colorectal cancer. METHODS: We conducted a cross-sectional study using the Moroccan version of the EORTC QLQ-C30 on colorectal cancer patients from the National Oncology Institute of Rabat, in the period from February 2015 to June 2017. The QLQ-C30 was administered to 120 patients. Statistical analysis included reliability, convergent, and discriminant validity as well as known-groups comparisons. RESULTS: In total, 120 patients with colorectal cancer were included in the study with 38 (32%) patients diagnosed with colon cancers. Eighty-two patients (68%) had rectal cancer, among which 29 (24%) patients with a stoma. The mean age of diagnosis was 54 years (+/- 13.3). The reliability and validity of the Arabic dialectal Moroccan version of the EORTC QLQ-C30 were satisfactory. [Cronbach's alpha (α =0.74)]. All items accomplished the criteria for convergent and discriminant validity except for question number 5, which did not complete the minimum required correlation with its own scale (physical functioning). Patients with rectal cancer presented with bad Global health status and quality of life (GHS/QOL), emotional functioning as well as higher fatigue symptoms compared to patients with colon cancer. The difference between patients with and without stoma was significant for diarrhea and financial difficulty. CONCLUSIONS: The Moroccan Arabic Dialectal version of the QLQ-C30 is a valid and reliable measure of health-related quality of life (HRQOL) in patients with colorectal cancer.

Predictive Factors for Impaired Mental Health among Medical Students during the Early Stage of the COVID-19 Pandemic in Morocco.

The COVID-19 pandemic has great consequences on mental health. We aimed to assess medical students' psychological condition and influencing factors as a baseline evidence for interventions promoting their mental wellbeing. We conducted an online survey from April 8 to April 18, 2020 to examine the mental health of medical students by the nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder Scale, seven-item Insomnia Severity Index, and six-item Kessler psychological distress scale. Factors associated with mental health outcomes were identified by multivariable logistic regression analysis. Five hundred forty-nine students completed the survey; 341 (62.3%), 410 (74.6%), 344 (62.6%), and 379 (69%) reported anxiety, depression, insomnia, and distress, respectively. Female students, living in high COVID-19 prevalence locations, more than 25 days confinement, psychiatric consult history, and being in a preclinical level of studies had higher median scores and severe symptom levels. Multivariable logistic regression showed female gender as a risk factor for severe symptoms of anxiety (odds ratio [OR]: 1.653; 95% CI: 1.020-2.679; P = 0.042), depression (OR: 2.167; 95% CI: 1.435-3.271; P < 0.001), insomnia (OR: 1.830; 95% CI: 1.176-2.847; P = 0.007), and distress (OR: 1.994; 95% CI: 1.338-2.972; P = 0.001); preclinical level of enrollment as a risk factor for depression (OR: 0.679; 95% CI: 0.521-0.885; P = 0.004), insomnia (OR: 0.720; 95% CI: 0.545-0.949; P = 0.02), and distress (OR: 0.650; 95% CI: 0.499-0.847; P = 0.001), whereas living in high COVID-19 prevalence locations was a risk factor for severe anxiety (OR: 1.628; 95% CI: 1.090-2.432; P = 0.017) and depression (OR: 1.438; 95% CI: 1.002-2.097; P = 0.05). Currently, medical students experience high levels of mental health symptoms, especially female students, those at a preclinical level and living in regions with a high prevalence of COVID-19 cases. Screening for mental health issues, psychological support, and long-term follow-up could alleviate the burden and protect future physicians.

Methylene blue and ifosfamide-induced encephalopathy: Myth or reality?

BACKGROUND: Ifosfamide-induced encephalopathy (IIE) is a rare and serious adverse reaction. Thus far, no standard medication has been documentedto be efficient in the reversal of IIE, and while ifosfamide infusion interruption and hydration are recommended, methylene blue (MB) administration remains controversial. METHODS: We retrospectively reviewed medical records to assess cases with IIE after ifosfamide infusion. We included all patients having received an ifosfamide infusion during their hospitalization in the medical oncology unit of the National Institute of Oncology in Rabat, Morocco, between September 2016 and September 2017. We subsequently conducted a literature review to determine the role of MB in IIE by searching PubMed using the terms "Methylene Blue" and "Ifosfamide". RESULTS: A total of 88 patients received ifosfamide, and four patients had IIE. Ifosfamide infusion was stopped immediately after the IIE occurrence, and patients underwent renal function correction with hydration. All patients received MB infusion, and three patients had an improvement of their neurological status. As regards the literature review, 34 articles were reviewed and 16 items were included in the review. Overall, 38 (65.5%) patients received MB infusion and 28 (75.6%) patients responded favorably to the treatment. CONCLUSIONS: Methylene blue can be used as a treatment for IIE owing to the severity of the IIE as well as absence of standard medication. Nonetheless, side effects such as serotonergic syndrome should be investigated. More broadly, prospective studies and controlled trials are needed to explore the contribution of MB in IIE management and encourage its use.

Supraclavicular versus infraclavicular approach in inserting totally implantable central venous access for cancer therapy: A comparative retrospective study.

INTRODUCTION: The insertion of an implantable central venous access is performed according to a variety of approaches which allow the access to the subclavian vein, yet the supraclavicular technique has been underused and never compared to the other methods. The aim of this study was to testify on the efficacy and safety of the subclavian puncture without ultrasound guidance « Yoffa ¼ in comparison with the classical infraclavicular approach (ICA). MATERIAL AND METHODS: This is a retrospective study with prospective data collection on patients followed at the national oncology institute for cancer, in the period extending from May 1st 2017 to August 31st 2017. All patients had a totally implantable central venous access device inserted by the same surgeon AS for chemotherapy administration and demographic characteristics, as well as procedure details were examined. The primary outcomes were the intraoperative complications, while the secondary outcomes represented immediate postoperative and mid-term complications (at 15 months of follow up). Outcomes were compared between techniques by means of non parametric tests and the Fischer test. RESULTS: Our study included 135 patients with 70 patients undergoing the subclavian technique, while 65 were subject to the infraclavicular approach. Both groups had no statistically significant demographic characteristics. The number of vein puncture attempts exceeding once, the accidental artery puncture and operative time were more significant in the ICA group; (39,6 vs 17,6 p = 0,01) (9.2% vs 0; p = 0,01) and (27± 13 vs 23± 8min, p = 0.045) respectively. There was no statistically significant difference in the immediate and midterm complication rate between the two methods 1(1,4) vs 2 (3) p = 0.5. CONCLUSION: In case of unavailability of ultrasonographic guidance, the use of the supra-clavicular landmarks approach is linked to higher success rates and less arterial punctures, thereby proving to be a safe and reliable approach.

Validation of the Moroccan arabic version of the low anterior resection syndrome score.

BACKGROUND: Sphincter sparing surgery is oftentimes associated with bowel dysfunction complaints, namely the low anterior resection syndrome (LARS). The LARS questionnaire is widely used to assess this syndrome. The aim of this observational study is to translate this tool into arabic and test its psychometric properties in rectal cancer patients, in order to ease its use in clinical practice and future research. METHODS: The LARS questionnaire was translated to arabic and administered to a total of 143 patients. A subgroup of 42 patients took the test twice for test-retest reliability. Internal consistency was examined through cronbach's alpha. The score results were correlated to the EORTC QLQ-C30 questionnaire for convergent validity assessment, while discriminant validity was established through the ability of the LARS score to differentiate patients with different clinical and pathological criteria. RESULTS: The Moroccan Arabic version of the LARS score was completed by 143 patients. The internal consistency was demonstrated through a cronbach alpha score of 0.66. The agreement between the test and retest was established by a Bland Altman plot with 95% limits of agreement. 85.6% of patients remained in the same LARS category. The LARS score showed negative correlation with all five of the QLQ-C30 functional scales as well as positive correlation to the diarrhea symptom scale. The questionnaire score differed between patients according to their tumor location, chemoradiotherapy, type of mesorectal excision and anastomosis. CONCLUSION: The Moroccan Arabic version of the LARS score shows good psychometric properties and can be used for bowel dysfunction assessment in clinical and research settings.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score. METHODS: All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test. RESULTS: Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm. CONCLUSIONS: The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.