Perioperative Transcutaneous Tibial Nerve Stimulation to Reduce Postoperative Ileus After Colorectal Resection: A Pilot Study.

BACKGROUND: Postoperative ileus involves an inflammatory pathway characterized by an increase of inflammation mediators in the colon wall; this could probably be prevented by sacral nerve neuromodulation. The posterior tibial nerve can be stimulated electrically to mimic neuromodulation. OBJECTIVE: The aims of this study were to assess the efficacy of transcutaneous posterior tibial nerve stimulation in reducing the delay in GI motility recovery, to assess the safety of posterior tibial nerve stimulation in a perioperative setting, and to assess the efficacy of posterior tibial nerve stimulation in reducing the occurrence of postoperative ileus. DESIGN: This was a preliminary randomized controlled study. SETTINGS: This study was conducted in 1 academic hospital in France. PATIENTS: Forty patients undergoing an elective colectomy were included and randomly assigned into 2 groups, posterior tibial nerve stimulation or placebo, according to the side of colectomy and the surgical access size. INTERVENTION: Perioperative posterior tibial nerve stimulation or placebo was performed 3 times per day according to the randomly assigned group. MAIN OUTCOME MEASURES: Delay in GI motility recovery (passage of stool and tolerance of solid food) was measured. RESULTS: Of the 40 patients included, 34 were included in the final analysis, in which 2 patients in the placebo group were allocated the incorrect device. The 6 other patients were secondarily excluded because of protocol deviation. In the intention-to-treat analysis, the mean delay in GI motility recovery was 3.6 and 3.11 days (in the placebo and tibial nerve stimulation groups; p = 0.60). Occurrence of postoperative ileus was not significantly higher in the placebo group (35.3% vs 17.6%; p = 0.42). In the per-protocol analysis, we observed the same trends except for the occurrence of postoperative ileus, which was significantly higher in the placebo group (p = 0.045). Tolerance to posterior tibial nerve stimulation was good, and all of the patients completed the protocol. LIMITATIONS: The amplitude of stimulation is set according to patient sensation, so some patients could have been aware of their group. In addition there were some inherent limitations because of the preliminary nature of the study and several deviations from the protocol. CONCLUSIONS: Posterior tibial nerve stimulation was safe in a perioperative setting and had a potential effect on GI motility recovery. The results of this study will be useful for sample size calculations in a larger prospective randomized trial. See Video Abstract at http://links.lww.com/DCR/A708.

Should pancreaticoduodenectomy be performed in the elderly?

BACKGROUND/AIMS: Pancreaticoduodenectomy (PD) is indicated in benign or malignant pancreatic head diseases. It is a difficult operation with high morbidity especially in elderly patients. The aim of our study was to determine whether pancreaticoduodenectomy is associated with higher morbidity and mortality in patients ≥ 70 years old. METHODOLOGY: During 17 years, 173 patients were operated by Whipple intervention, whatever the disease. From a prospective database, patients were divided in 2 groups (Group A ≥ 70 years old, Group B <70). RESULTS: Postoperative mortality was not significantly higher in elderly (12% vs. 4.1%; p=0.06). However, re-intervention and morbidity were more important in univariate analysis (p=0.03 and p=0.002 respectively). In multivariate analysis, age ≥ 70 years old was not an independent prognostic factor of mortality (p=0.27) and re-intervention (p=0.07). Whereas age (p=0.04) and preoperative morbidity (p=0.02) were independent prognostic factors of morbidity. CONCLUSIONS: PD requires careful patient selection. However, age should not be a limiting factor.

Impact of total thyroidectomy on quality of life at 6 months: the prospective ThyrQoL multicentre trial.

OBJECTIVE: This study is to determine the impact of complications after total thyroidectomy on health-related quality of life (HR-QoL) and to identify significant predictive factors of HR-QoL changes. HR-QoL is usually impaired in patients with thyroid diseases compared to the general population. Thyroidectomy is largely performed in the case of benign thyroid benign and can be associated with long-term complications (vocal cord palsy, hypoparathyroidism). DESIGN: The prospective ThyrQoL multicenter trial (NCT02167529) included 800 patients who underwent total thyroidectomy for benign or malignant non-extensive disease in seven French referral hospitals between 2014 and 2016. METHODS: HR-QoL was assessed using the MOS 36-item short form health survey (SF-36) self-questionnaire with a 6-month follow-up. RESULTS: We observed a significant improvement of HR-QoL 6 months after surgery (P < 0.0001). Postoperative complications were associated with a non-significant impairment of HR-QoL. In multivariable analysis, Graves' disease was associated with a significant improvement of HR-QoL (OR = 2.39 [1.49; 3.84]) and thyroid malignant disease with an impairment of HR-QoL (OR = 1.44 [0.99; 2.08]) after thyroidectomy. CONCLUSION: We observed a significant improvement of HR-QoL 6 months after total thyroid surgery for benign thyroid disease.

Feasibility criteria for total thyroidectomy in outpatient surgery.

INTRODUCTION: France is pursuing a policy of cutting healthcare costs, and outpatient surgery is one of the objectives of this policy. Thyroid surgery could be suitable for outpatient management, provided there is an appropriate patient selection process. The aim of this study was to assess the risk factors for postoperative complications in total thyroidectomy (TT). DESIGN: A single-center observational study was carried out from January 2010 to December 2015. METHOD: Correlations between, on the one hand, age, gender, obesity, history of surgery, antiplatelet and/or anticoagulation treatment, the surgeon's experience, surgery time, repeated lymph node dissection, and surgical indication (cancer, lymphocytic thyroiditis, Graves' disease or multinodular goiter) and, on the other hand, onset of postoperative complications (postoperative hypocalcemia, uni- or bi-lateral lesions of the recurrent laryngeal nerves, and premature compressive hematoma) were assessed. RESULTS: Four hundred and twenty-four consecutive TTs were included. 85 patients showed postoperative hypocalcemia (20.04%), 18 recurrent laryngeal nerve lesion (4.25%), and 4 compressive cervical hematoma (0.94%). Overall morbidity was 24.06%. Risk factors identified for postoperative hypocalcemia comprised: female gender [OR=3.2584; 95%CI (1.5500-7.7515); P=0.0036], surgery time [OR=1.0095; 95%CI (1.0020-1.0172); P=0.0129], and surgical indication for benign adenoma [OR=5.0642; 95%CI (1.7768-14.5904); P=0.0022]. None of the study variables emerged as risk factors for recurrent laryngeal nerve lesion. Repeated dissection increased the risk of re-do surgery for compressive hematoma [OR=25.1373; 95%CI (0.8468-32.2042); P=0.0347]. CONCLUSION: Surgery time, female gender, repeated dissection and total thyroidectomy for benign adenoma are risk factors that should be considered in decision-making for performing TT on an outpatient basis.

Does hemithyroidectomy still provide any benefit?

OBJECTIVES: Multinodular goiter is a common disorder, found in 5% of the general population. If only one thyroid lobe is affected, hemithyroidectomy may be preferred to total thyroidectomy, to limit the risk of complications and avoid hormone replacement therapy, but incurs a risk of subsequent completion thyroidectomy. The aim of the present study is to determine whether the arguments in favor of hemithyroidectomy are justified and whether it still provides real benefit. METHODS: A retrospective observational study based on prospective data included all patients who underwent surgery for goiter or nodule in our center between September 2010 and September 2014. Rates of hormone replacement 6 months after hemithyroidectomy, postoperative complications and completion thyroidectomy during the postoperative year due to the discovery of carcinoma were analyzed. RESULTS: Four hundred and ninety-three patients were studied: 335 with total thyroidectomy and158 with hemithyroidey. The rate of hormone replacement 6 months after hemithyroidectomy was 84.4%. The rate of definitive hypocalcemia was 6.3% in total thyroidectomy and zero in hemithyroidectomy (P<0.05). There was no significant difference between groups in terms of recurrent laryngeal nerve palsy (1.8% versus 1.9%; P=1) or hematoma (1.2% versus 3.5%; P=0.15). A total of 11.3% of hemithyroidectomies required completion due to discovery of carcinoma (mean interval between surgeries 3.58±2.5 months). CONCLUSIONS: This study suggests that hemithyroidectomy does not in fact avoid the risk of hormone replacement and places the patient at risk of completion thyroidectomy. However, it does avoid a 6% rate of hypocalcemia. We would recommend hemithyroidectomy only in case of single toxic or euthyroid nodule with healthy contralateral lobe and/or refusal of hormone replacement by the patient.

Adrenocortical carcinoma: Impact of surgical treatment.

Compared to benign adrenal lesions, secreting or otherwise, malignant adrenocortical carcinoma is rare. Overall prognosis is poor, with <50% 5-year survival. Various prognostic factors have been identified, some tumor-related and others directly linked to surgical treatment. Surgery is the only possible curative treatment, and is decided upon in a multidisciplinary medical-surgical team meeting. Surgical approach (laparotomy vs. laparoscopy) remains a matter of debate. In the light of a recent literature search, the present review reassesses the prognostic criteria of surgical resection, the quality of which determines overall and recurrence-free survival.

The simultaneous occurrence of mucinous cystadenomas in liver and pancreas.

The occurrence of mucinous cystadenomas localized to the liver and pancreas simultaneously and treated with a single surgical procedure has been described for the first time in this report. A 47-year-old woman attended the outpatient clinic complaining of abdominal pain and the appearance of an abdominal mass. On clinical examination, hepatomegaly was found. An abdominal computed tomography scan showed a large cystic lesion of the left lobe of the liver, thus causing the hepatomegaly. Moreover, the computed tomography scan showed a cystic lesion of the pancreas. Both lesions had thick walls and septa. Magnetic resonance imaging of the liver and pancreas confirmed the presence of septa within the cysts. Surgery was performed owing to the suspected malignancy. It should be emphasized that the patient had preoperatively received prophylactic treatment for hydatosis. A hepatic pericystectomy and enucleation of the pancreatic lesion were performed during the surgery. Pathology showed a mucinous cystadenoma without sign of malignancy. At the 4-year follow-up, no recurrence was found. This case is of interest for several reasons: the unusual double presentation, the treatment, and the follow-up. This case report confirms the common origin of mucinous cystic tumours of liver and pancreas.

Management of obstructed left colon carcinoma.

BACKGROUND/AIMS: The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of this retrospective study is to review the results of three surgical procedures used in our department of Visceral Surgery (subtotal colectomy, segmental resection following intraoperative irrigation, and Hartman's procedure) and to determine if there were advantages of one technique over the other. METHODOLOGY: Ninety-three patients with acute left colonic obstruction were treated by subtotal/total colectomy (n=38), segmental resection following intraoperative irrigation (n=39), and Hartman's procedure (n=16). We assessed immediate postoperative results (mortality and morbidity rates, reoperation rate and hospital stay. RESULTS: The overall mortality and morbidity rates were respectively 13% (n=12) and 30.1% (n=28). The mortality rate was 13% (n=5) in the subtotal colectomy group, 7.7% (n=3) in the intraoperative colonic irrigation and 25% (n=4) in the Hartman's procedure group. The morbidity rates were similar after subtotal or segmental resection (7.9% vs. 10.2%), bowel movements were more frequent after subtotal colectomy (range 1-5 day) than segmental colectomy (range: 1-2 per day). CONCLUSIONS: Segmental resection following intraoperative irrigation is the preferred treatment for left sided malignant colonic obstruction. Subtotal colectomy is recommended for patients with ischemic lesions and serosal tears on the cecum, and when there is a synchronous neoplasm in the proximal colon.

Assessment of pathologic response after preoperative chemoradiotherapy and surgery in pancreatic adenocarcinoma.

PURPOSE: The benefits provided by preoperative chemoradiotherapy (CRT) in pancreatic ductular adenocarcinoma (PDA) are still controversial. However, in most reports from referral centers, improvement in local control and survival appears to be provided in selected patients. The aim of this retrospective study was to analyze the radiation-induced pathologic effects of preoperative CRT in patients with resectable PDA and determine the precise long-term outcome of the responding patients. METHODS AND MATERIALS: Between November 1996 and October 2003, 61 patients underwent preoperative CRT for resectable PDA. The tumor location was the pancreatic head in 49 patients and pancreatic body in 12 patients. Of the 61 patients, 21 (34.5%) did not undergo surgery because of disease progression and 40 (65.5%) underwent pancreatic resection, including pancreaticoduodenectomy in 32 (80%) and distal pancreatectomy in 8 (20%). RESULTS: A major pathologic response was noted in 9 patients, including three complete responses, and was found only in patients with tumor of the pancreatic head. The local control rate was similar in patients with and without a major pathologic response. Survival in patients with a major response was significantly greater than in those without a response or with a minor response. CONCLUSION: Major tumor downstaging can be provided by preoperative CRT in patients with resectable cephalic PDA. Survival appears to be significantly improved in selected patients.

Rectal metastasis of prostate cancer: about a case.

UNLABELLED: Prostate adenocarcinomas present a high risk of metastasis. We report a case of an atypical prostate cancer metastasis. A male patient presented a prostatic adenocarcinoma treated by surgery. A biological recurrence was discovered during the follow-up by an increased rate of Prostate Specific Antigen (PSA) and was treated by hormonotherapy. Several months later, there was a re-increase of the PSA rate. The CT scan showed a radiation proctitis aspect. An intermittent hormonotherapy was decided. Six months later, he presented abdominal pain. Examinations were performed and showed a rectal carcinosarcoma with prostate origins. A surgical management was realised. The outcomes were an early recurrence. A symptomatic treatment was decided. There are not any rectal localisations reported in the literature. Only loco-regional invasions of the rectum are described and no histological modification of metastasis compared to the primitive tumor has been reported. So, we report a metastasis of a prostate adenocarcinoma which transformed into a carcinosarcoma. KEYWORDS: Adenocarcinoma; Carcinosarcoma; Metastasis; Prostate; Rectal neoplasm.

Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma.

PURPOSE: The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of the study was to evaluate the results of its management by emergency subtotal or total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 72 patients (mean age 74.9 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability, and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 9.7% (7 patients). An 83-year-old woman died as a result of an anastomotic dehiscence; the six other deaths resulted of cardiopulmonary complications. Postoperative morbidity was 15% (11 patients) including two fistulas, which recovered without surgery. There were eight synchronous colon carcinomas. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one-stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serous tears on the cecum. It ensures restoration of gut contiguity via a "safe" ileocolonic anastomosis and removes occasional lesions proximal to the index cancer.