Operative start time may impact the quality of mesorectal excision in minimally invasive rectal surgery: retrospective analysis of 137 patients.

INTRODUCTION: Timing of major elective operations is a potentially important outcome variable. This study examined the impact of operative start time (OST) on pathologic and short-term outcomes of minimally invasive rectal surgery (MIRS). METHODS: All rectal tumors patients who underwent MIRS from May 2012 to April 2016 were identified. Peroperative outcomes and the oncological quality of surgical excision were compared between patients with OST before 13.00h and after. RESULTS: A total of 137 patients were included in the study (71 Romarobot-assisted and 66 conventional laparoscopic). Ninety-nine (72%) patients were operated before 13.00h and 38 after 13.00h. The majority of cases were low/middle rectal tumors (69%). Patient's baseline characteristics were quite similar in both groups. The rate of severe complication (p=0.460) or reoperation (p=0.614) was the same. Pathologic criteria (T or N stage, number of harvested lymph nodes, and presence of any positive margin) were the same between groups except for the quality of mesorectal excision (ME) that was significantly poorer for cases beginning after 13.00h (complete 91% vs 74%; p=0.016). The OST was found to be the only parameter associated with a poor quality of ME [OR 2.55 (1.08 - 6.36)]. CONCLUSION: Perioperative outcome after MIRS does not appear to be influenced by OST. Poorer quality of ME was observed and may thus raise important questions about the timing and sequence of case scheduling.

Cystic duct remnant calculi after cholecystectomy.

UNLABELLED: Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered. PATIENTS AND METHODS: Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow. RESULTS: There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P<0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P<0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P<0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P<0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy. CONCLUSION: Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy.

Pathology underrates colon cancer extranodal and nodal metastases; ex vivo radioimmunodetection helps staging.

PURPOSE: Colorectal carcinoma is frequently accompanied by small lymph nodes metastases that often escape pathologic examination. We evaluated whether ex vivo radioimmunodetection with the Affinity Enhancement System (AES) could improve detection of mesocolonic metastases. EXPERIMENTAL DESIGN: A bivalent 111In-labeled hapten was injected (16 patients) 4 days after a bispecific antibody (anticarcinoembryonic antigen, antihapten). Surgery was done 1 to 3 days later, and radioactive uptake in the mesocolon was recorded. Extensive pathologic examination of the mesocolon (reference method) was done after fat dissolution. This method visualizes all lymph nodes but is not in routine use. RESULTS: The reference method disclosed 705 nodes. There was no significant difference between the number of node metastases detected by AES or by the reference method (16 versus 17). Better detection would have been obtained by AES than by routine pathology (P<0.01). In addition 12 extranodal metastases were found in this study of which eight were detected by AES. The prognostic importance of such extranodal metastases has been underlined in the literature. Routine pathology combined with AES would have disclosed all node metastases and 86% of total metastases versus 35% by routine pathology alone. CONCLUSIONS: Ex vivo radioimmunodetection could improve nodal and extranodal metastases detection in patients with colorectal cancer. Its value for improving pathologic analysis, together with the effect of these small metastases on prognosis, should be further evaluated. The benefit of adjuvant chemotherapy for patients upstaged with radioimmunodection should also be assessed because adjuvant chemotherapy improves the 5-year survival of stage III patients.

[Epidermoid carcinomas of anal canal treated with radiation therapy and concomitant chemotherapy (5-fluorouracil and cisplatin)]. / Carcinomes épidermoïdes du canal anal traités par association concomitante de radiothérapie et de chimiothérapie. Evaluation des résultats fonctionnels.

PURPOSE: To evaluate our results after radiation therapy and concomitant chemotherapy in terms of local control, survival and toxicity in patients with anal cancer. METHODS AND PATIENTS: Between November 1990 and January 2002, 60 patients (pts) were treated with radiation therapy and concomitant chemotherapy. The T-stage according to the 2001 UICC classification were: 2 T1, 26 T2, 25 T3, and 7 T4. There were 20 pts with nodal involvement at presentation. The treatment started with external beam RT (median dose: 45 Gy) and concomitant chemotherapy using 5-fluorouracil and cisplatin during the first week and the fifth week of external beam RT (EBRT). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 58 pts and by interstitial (192)Ir brachytherapy in 2 pts. Mean follow-up were 78.5 months. RESULTS: At the end of RT with concomitant chemotherapy local tumor clinical complete response rate was 83%. Out of 10 non responders or local progression, 5 (50%) were salvaged with abdominoperineal resection (APR). Out of 5 local tumor relapses, 3 were salvaged with APR. The overall local tumor control (LC) rate with or without salvage local treatment were 88%. LC rate with a good anal function scoring (score 0 and 1) was 70%. Among 43 pts who preserved their anus, 98% had a good anal function scoring. The 5-year disease-free survival was 75%. After multivariate analysis, 2 independent predicting factors significantly influenced the disease-free survival: HIV-positive pts (negative vs positive, P=0.032) and clinical tumor response after the first course of radiotherapy (<50% vs >or=50%, P=0.00032). Acute grade 2 or 3 toxicities were low: haematological toxicity in 4 pts and intestinal complication corresponding to diarrhea in 10 pts. Late severe complication was observed in 3 pts: 2 pts with painful necrosis of the anus requiring colostomy and 1 pt with grade 3 rectal bleeding. CONCLUSION: We confirm the good results with RT and concomitant chemotherapy. The clinical tumor response after the first course of RT and concomitant chemotherapy is probably the most important predictive factor on the disease-free survival. For patients with T3 or T4 lesion and tumor regression

Reversal of abnormal collagen production in Crohn's disease intestinal biopsies treated with regenerating agents.

BACKGROUND: Crohn's disease (CD) is characterised by inflammation, muscle layer overgrowth, and collagenous fibrosis of the intestinal tract, with no effective therapy against collagen accumulation. AIMS: We quantified production of collagen in resection specimens from normal and CD patients and investigated the effect of regenerating agents (RGTAs) on collagen production. RGTAs are chemically substituted dextrans engineered to mimic the growth factor protecting effects of heparan sulphates. RGTAs have been shown to enhance tissue repair in various in vivo models and to modulate in vitro collagen phenotype differentially according to their structure. PATIENTS: We studied intestinal biopsies from two groups of CD patients: treated with glucocorticoids (CD-GC group: 10 patients) or not treated (CD group: seven patients), and from seven control patients. METHODS: After 24 hours of ex vivo incubation with (3H) proline, collagen I, III, and V were extracted by pepsin and quantitatively separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Biosynthesis of each collagen type was quantified on radiolabelled isolated collagen. RESULTS: Total intestinal collagen production in CD patients compared with controls was increased up to 3.5-fold overall (p<0.001). In particular, collagen III biosynthesis was enhanced by 6.2-fold (p<0.001) in CD patients. In the CD-GC group, collagen production abnormalities were less marked. RGTAs added to the incubation medium in the CD group decreased total collagen production by 50% and decreased collagen III synthesis by 76%. CONCLUSION: This finding offers a rationale for using RGTAs in the treatment of intestinal fibrosis in CD, thus opening up a potential new therapeutic field for this family of drugs.

[Epidermoid carcinomas of the anal canal treated with definitive radiation therapy in a series of 305 patients]. / Carcinomes épidermoïdes du canal anal traités par irradiation à visée curative: à propos de 305 patients.

PURPOSE: To identify prognostic factors and treatment toxicity in a serie of epidermoid cancers of the anal canal without evident metastasis. PATIENTS AND METHODS: Between June 1972 and January 1997, 305 patients (pts) were treated with curative-intent radiation therapy (RT). The T-stages according to the 1987 UICC classification were: 26 T1, 141 T2, 104 T3, and 34 T4. There were 49 pts with nodal involvement at presentation. Pretreatment anal function scoring according to our in-house system was: 22 scored 0, 182 scored 1, 74 scored 2, 7 scored 3, 11 scored 4, and 9 not available pts. The treatment started with external beam RT (EBRT) in 303 pts (median dose: 45 Gy). After a rest period of 4 to 6 weeks, a boost of 20 Gy was delivered by EBRT in 279 pts and by interstitial 192Ir brachytherapy (Bcy) in 17 pts. Seven pts received only one course of EBRT (mean dose: 49.5 Gy) and 2 pts were treated with interstitial 192Ir Bcy alone (55 and 60 Gy, respectively). Concomitant chemotherapy (5-fluoro-uracil and either mitomycin C or cisplatin) was delivered to 19 pts. Mean follow-up was 103 months. RESULTS: At the end of RT local tumor clinical complete response (cCR) rate was 80%. Out of 61 non responders or local progressive tumors 27 (44%) were salvaged with abdominoperineal resection (APR). The rate of local tumor relapse (LR) was 12%. Out of 37 LTR, 20 (54%) were salvaged with APR and one with interstitial 192Ir Bcy. The orevall local tumor control (LC) rate with or without salvage local treatment was 84%. LC rate with a good anal function scoring (score 0 and 1) was 56.5%. Among 181/186 available pts who preserved their anus, 94% had a good anal function scoring. For a subgroup of 15 pts with length tumor <2 cm-N0, the LC rate after the end of RT was 100%, the LC rate with or without local salvage treatment was 100%, and among 13 available pts who preserved their anus, the anal function scoring was good in 12 pts (92%). The 10-years disease-free survival was 74%. After multivariate analysis, 3 independent predicting factors significantly influenced the disease-free survival: gap duration between 2 courses of RT (>38 days vs < or =38 days, P =0.0025), pretreatment anal function scoring (0 vs 1 vs 2 vs 3 vs 4, P =4.4 10(-6)), and cCR after the end of RT (no complete response vs complete response, P =2.5 10(-14)). CONCLUSION: We confirm excellent results with RT in T1 and T2 lesions. However, chemoradiotherapy should be prefered to improve survival free of colostomy with a good anal sphincter function for tumors more than or equal to 2 cm in length and locally advanced tumors.

[Radiotherapy of carcinomas of the anal canal. Tenon Hospital experience]. / Traitement des cancers du canal anal par irradiation. Expérience de l'hôpital Tenon.

Since 1980, curative-intent radiation therapy of epidermoid carcinoma of the anal canal is the standard first line treatment. The combined concomitant chemotherapy and radiation therapy is presently established for locally advanced tumors more than 4 cm in length and/or with nodal involvement. We report the Tenon hospital experience since 1972 concerning the long term results after radiation therapy, the modifications of the radiation technique, and the evolution of treatment strategy.

Intravenous chemotherapy, early debulking surgery, and consolidation intraperitoneal chemotherapy in advanced ovarian carcinoma.

OBJECTIVE: The efficacy of a cisplatin-anthracycline combination, early debulking surgery, and intraperitoneal chemotherapy has been demonstrated through separate studies. We evaluated a multimodal treatment strategy integrating these therapeutic options. METHODS: Women with stage III or IV ovarian carcinoma received six cycles of cisplatin/epirubicin alternating with leucovorin and 5-fluorouracil. Patients with a residual disease (RD) measuring more than 2 cm after the initial laparotomy underwent an early debulking surgery after the first three cycles of chemotherapy. A second-look laparotomy (SLL) was performed after six cycles of intravenous chemotherapy. Intraperitoneal chemotherapy with cisplatin, VP16, and mitoxantrone was then administered in patients with no or RD < 2 cm after SLL. RESULTS: A total of 87 patients were included. After initial laparotomy, 11 patients (12%) had no macroscopic residual disease, 38 (44%) had a RD < or =2 cm, and 38 (44%) had a RD > 2 cm. After early debulking surgery, an additional 18 patients (21%) had a RD < 2 cm. Seventy-five patients were evaluable for response to intravenous chemotherapy: the overall response rate was 80%, and 30 patients achieved a pathological complete response (40%). Eight percent of the patients had stable disease and 12% had a progression. Sixty-eight patients received intraperitoneal chemotherapy after second-look laparotomy. With a 72-month median follow-up, median overall survival and progression-free survival were, respectively, 37 and 19 months. Five-year survival was 41%. CONCLUSION: The prognosis of patients with advanced ovarian carcinoma may be improved by a sequential treatment strategy including intravenous chemotherapy, early debulking surgery, and intraperitoneal chemotherapy.

Teleconsultation before chemotherapy for recently operated on patients.

BACKGROUND: Some operated on cancer patients require specialized complementary chemotherapy. Often, this takes place in another institution, where the patient consults the medical oncologist before hospitalization. The aim of this study was to analyze the potential benefit of a videoconference consultation within this framework. METHODS: Sixteen operated on cancer patients hospitalized in the Surgical Unit received a teleconsultation in the presence of their surgeon and with the chemotherapist at some distance. During this period, the modalities of chemotherapy proposed, the duration of the teleconsultation, the economy of transport, and so on were noted. Twenty-four hours later each patient filled in a questionnaire aimed at, one, evaluating the quality of the image on an visual analogue scale (VAS) and the potential inconvenience involved; and two, evaluating the index of patient satisfaction on VAS. Furthermore, the last 12 patients filled in a questionnaire adapted to each of them, according to the information they had received. Each correct answer was noted 1, and each incorrect answer was noted 0. A memorization percentage was deduced. RESULTS: The average age of the 16 patients was 63.4 years (range 46 to 78). The average duration of the teleconsultation was 27 minutes (12 to 40). The index of image satisfaction was 61.3%. As for the last 12 patients, 9.8 questions (7 to 12) enabled the calculation at 24 hours of the percentage of data retained by the patient (memorization index) based on the modalities and consequences of the chemotherapy. The percentage of correct answers was 80.5%. Fourteen of the 16 patients considered that teleconsultation had its advantages. Two patients would have preferred a classic consultation. The global satisfaction index was 79.9%. The average cost of functioning per patient was 187.76 FF A saving in transport of 509.92 FF was recorded per patient. CONCLUSIONS: In the context of this original study, teleconsultation neither altered the doctor-patient relationship nor the quality of the message transmitted. Furthermore, it encourages closer links between complementary teams working at a distance and multidisciplinarity in cancerology.

[Telecommunications and networks: perspectives and issues]. / Télécommunications et réseaux: perspectives et enjeux.

The transmission of images, audio, video and computed data provides new facilities in medicine. The uses of telemedicine include teleeducation, training, consulting, diagnostic or therapeutic assistance between remote medical teams, or consultation for remote patients without the need of displacement. Network, telemedicine technologies, perspectives for teaching, medical teams and patients, national legislation, current and new ethical problems raising from telemedicine applications are successively reviewed.

[Surgical treatment of Crohn's disease of the large intestine: do rectal complications influence the results of ileorectal anastomosis?]. / Traitement chirurgical de la maladie de Crohn du gros intestin: l'atteinte rectale influence-t-elle les résultats de l'anastomose iléorectale?

STUDY AIM: The purpose of this retrospective study was to compare the morbidity and long-term outcome of patients undergoing total colectomy and ileorectal anastomosis (IRA) performed for Crohn's colitis with or without associated proctitis. PATIENTS AND METHODS: Thirty-nine patients with a mean age of 35 years (17-72 years) underwent total colectomy with IRA. Patients were retrospectively classified into two groups; group 1 (28) without rectal involvement; group 2 (11) with proctitis. Follow-up data were obtained during 1998, by reviewing all patients. Mean postoperative follow-up was 10.6 years (1.5-22). RESULTS: There were no postoperative deaths. Six (15%) patients experienced postoperative complications, with no difference between the two groups. Sixteen patients (41%) developed recurrence requiring surgery: 9 in group 1 (32%) and 7 in group 2 (64%) (p > 0.05). The IRA had to be removed or was no longer functional in 12 patients: 6 in group 1 (21.5%) and 6 in group 2 (54.5%) (p < 0.05). CONCLUSION: Moderate proctitis does not increase the morbidity of total colectomy with IRA for Crohn's disease. The risk of reoperation and secondary protectomy is higher when proctitis was present, but the IRA was still functional in one-half of patients after more than 10 years of follow-up.

[Posterior rectopexy in total rectal prolapse-]. / Rectopexie selon orr-loygue dans le prolapsus total du rectum.

STUDY AIM: The aim of this retrospective study was to report the results of posterior Orr-Loygue rectopexy in 55 patients operated on for rectal prolapse. PATIENTS AND METHOD: From 1986 to 1997, 114 patients were operated on for rectal prolapse and 55 had an Orr-Loygue operation. There were 47 women and 8 men (mean age: 55 years). Twenty-five patients (45%) had fecal incontinence, 26 (47%) described preoperative 'constipation'. The procedure was performed under general anesthesia, through laparotomy in 51 patients, through laparoscopy in 4 patients. Resection of sigmoid colon was associated to rectopexy in four patients. RESULTS: Mortality rate was 0 and morbidity rate 12%. Mean hospital stay duration was 13.5 days. Mean follow-up was 63 months and at the end of the study, four patients (7%) had recurrence, 5/25 patients had still incontinence; 55% of the patients had unchanged postoperative bowel function, 22% described improvement (including the four patients with resection-rectopexy) but 38% (21/55) suffered from postoperative 'constipation'. The rate of 'constipation' induced or majored by rectopexy was 22% but the functional trouble described appeared often complex. CONCLUSION: Posterior Orr-Loygue rectopexy is the operation recommended for patients in good general condition, especially if fecal incontinence is associated. In the course of the procedure, preservation of pelvic nerves and hypogastric plexus, and positioning of the strips not too tight between the anterolateral rectal walls and promontory must be emphasized. Posterior Orr-Loygue rectopexy is contraindicated when general anesthesis is too risky and when bowel dysfunction and/or rectal exoneration dysfunction are present.

Long-term functional results of colonic J pouch versus straight coloanal anastomosis.

BACKGROUND: There are very few studies evaluating the long-term functional outcome of coloanal anastomoses. This retrospective study aimed to compare long-term functional results of straight and colonic J pouch anastomoses. METHODS: Thirty-seven patients, 25 with a straight anastomosis and 12 with a J pouch anastomosis, responded to a standardized telephone questionnaire. The mean time since surgery was 10 (range 4-18) years. RESULTS: The mean daily stool frequency was similar in both groups of patients (1.1 in patients with a reservoir, 1.5 in patients with a straight anastomosis). In both groups, two-thirds of patients had perfect continence or limited gas incontinence. Faecal incontinence was reported by two patients with a straight anastomosis and one patient with a pouch. Nocturnal stools and fragmentation were slightly more frequent in patients with a straight anastomosis. Half of the patients regularly used medication. Thirty-five of the 37 patients reported satisfaction with functional results. CONCLUSION: Long-term functional results of coloanal anastomoses are satisfactory and, unlike early results, similar for both types of anastomosis. The functional benefit of a reservoir, seen in the first year after operation, is less evident with increasing time.