Lack of prognostic significance of conventional peritoneal cytology in colorectal and gastric cancers: results of EVOCAPE 2 multicentre prospective study.

AIM: In digestive cancers, the prognostic significance of intraperitoneal free cancer cells remains unclear (IPCC). The main objective of this study was to assess the prognostic significance of IPCC in colorectal and gastric adenocarcinoma. The secondary objectives were to evaluate the predictive significance of IPCC for the development of peritoneal carcinomatosis (PC) and to evaluate the prevalence of synchronous PC and IPCC. METHODS: This was a prospective multicentre study. All patients undergoing surgery for a digestive tract cancer had peritoneal cytology taken. Patients with gastric and colorectal cancer with no residual tumour after surgery and no evidence of PC were followed-up for 2 years. The primary end point was overall survival. RESULTS: Between 2002 and 2007, 1364 patients were enrolled and 956 were followed-up over 2 years. Prevalence of IPCC was 5.7% in colon cancer, 0.6% in rectal cancer and 19.5% in gastric cancer. The overall 2-year survival rate for patients with IPCC was 34.7% versus 86.8% for patients with negative cytology (p<0.0001). By multivariate analysis, IPCC was not an independent prognostic factor. No relationship between cytology and recurrence was found. CONCLUSION: The presence of IPCC was not an independent prognostic and didn't add any additional prognostic information to the usual prognostic factors related to the tumour (pTNM and differentiation). Moreover the presence of IPCC detected with this method didn't appear to predict development of PC. Peritoneal cytology using conventional staining doesn't seem to be a useful tool for the staging of colorectal and gastric cancers.

Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity.

GOAL: Laparoscopic sleeve gastrectomy (LSG) is performed in certain circumstances after failure of gastric banding. The goal of this study was to evaluate the impact of first-line gastric banding on the morbidity associated with secondary LSG for obesity. PATIENTS AND METHODS: The case records of 102 consecutive patients undergoing LSG were studied retrospectively. The technique of LSG was standardized. Two groups were compared: one with patients having undergone LSG after first-line gastric banding (n = 31) and the second, with patients having undergone first-line LSG (n = 71). Endpoints were overall morbidity and intra/postoperative complications including gastric leaks consecutive to staple line disruption as well as other septic or hemorrhagic complications. Multivariable analysis was performed to detect independent risk factors for morbidity. RESULTS: Overall morbidity was significantly higher in patients having undergone LSG after first-line gastric banding compared with those undergoing first-line LSG (32.2% vs. 7%, P = 0.002). Gastric leaks secondary to staple line disruption also occurred statistically significantly more often in patients with first-line gastric banding (16.1% vs. 2.8%, P = 0.043). Waiting 6 months between gastric band removal and performing LSG did not prevent the increased morbidity compared with first-line LSG. Multivariable analysis revealed that among the factors analyzed (age, gender, comorbidity, body mass index, surgeon, first-line gastric banding), the only independent risk factor for staple line disruption was first-line gastric banding with an odds ratio = 6.6 (95% confidence interval = [1.2-36.3]). CONCLUSION: Undergoing first-line gastric banding increases the risk of complications after secondary LSG. We recommend that patients who undergo LSG after a first-line gastric banding should be warned of the increased risks of morbidity or, alternatively, that LSG be performed preferentially as the initial procedure.

[Rectus abdominis muscle endometrioma: sparse tumor of scarred abdominal wall in a woman]. / L'endometriome du muscle grand droit: tumeur rare de la paroi abdominale cicatricielle chez la femme.

Muscular tumors in scared abdominal wall in a woman are unfrequent reason of counselling. In rare case these tumors are the result of ectopic graft of endometrial cells after abdominal or pelvic surgery with or without opening of uterus cavity. We report the case of a not typical abdominal wall endometrioma in the rectus abdominis muscle without variation of signs and volume related to menstruation ; Diagnosis was made by histological examination after carcinological excision because of recurrence and degeneration risk.

[Fibrolamellar hepatocellular carcinoma in a patient with chronic viral B hepatitis]. / Carcinome hépatocellulaire fibrolamellaire chez un patient suivi pour hépatite chronique virale B.

In most cases, fibrolamellar hepatocellular carcinoma has specific and distinctive histopathological features that distinguish it from hepatocellular carcinoma. Magnetic resonance imaging can provide characteristic features to obtain a diagnosis of this entity. We report a case of fibrolamellar hepatocellular carcinoma with a radiological-pathological correlation in a 37 year-old man with chronic viral hepatitis B without cirrhosis who underwent right hepatectomy.

[Is the debate on mechanical bowel preparation, before colorectal surgery, over?]. / Le débat sur la préparation mécanique du côlon avant chirurgie colorectale est-il clos?

The present "point of view" tries to assess the state of the art in 2008 on the role of mechanical bowel preparation before colorectal surgery. The case of bowel preparation has been questioned by several meta-analyses of small randomized trials, suggesting also its detrimental effect in terms of anastomotic leaks. In 2007 two large trials were published and pooling their data suggested an increased risk of deep abscesses when bowel preparation was omitted. A further meta-analysis including all published data on this topic appeared useful. This meta-analysis included almost 5 000 patients and showed bowel preparation involves no benefit in terms of surgical site infections, with more infections after bowel preparation (Odds ratio 1.40 [1.05-1.87]). Sensitivity analysis showed an increased risk of abscesses when bowel preparation was omitted but this risk is not clinically relevant since the number needed to harm was as high as 333 patients. In conclusion this meta-analysis including a huge number of patients does not confirm the detrimental effect of bowel preparation but did not show any benefit of it; these conclusions being valid only for colonic surgery, rectal surgery needing further studies.

Failure of a meta-analysis on the role of elective surgery for left colonic diverticulitis in young patients.

BACKGROUND: The timing of elective surgery of colonic diverticulitis in young patients remains controversial. The present meta-analysis aimed to answer the question whether these patients should be operated after the first attack or, more classically, after the second attack. MATERIALS AND METHODS: Electronic databases were searched for papers reporting the results of surgery according to the strategies. Major endpoint was the performance of a colostomy (during unplanned surgery or for anastomotic dehiscence complicating elective surgery). RESULTS: Fifteen papers were selected for potential inclusion in the meta-analysis. But, eventually, only three papers gave information about the timing of surgery. Pooling the data of these 3 studies showed that 160 patients underwent elective surgery after the first attack and only 5 patients underwent subsequent emergent surgery at the course of their disease. Hence, no meta-analysis could be performed. CONCLUSION: Researchers should no longer attempt (like us) to answer this question by any meta-analysis. The failure of the present meta-analysis highlights the limitations of evidence-based surgery in some particular fields.

Band and port-related morbidity after bariatric surgery: an underestimated problem.

OBJECTIVE: To evaluate the magnitude of the morbidity related to the system used for gastric banding Methods Between January 1997 and December 2004, 286 consecutive patients underwent laparoscopic gastric banding (LAGB) in one center. We used 4 models of LapBand 9.75, 10, 11 and Vanguard with pars flacida route. Recalibration of band was performed in our consultation unit without systematic radiologic control. We considered four kinds of complication: port displacement, port rupture, band rupture and others problems. RESULTS: The mean follow up was 3.3+/-2.8 years with a median 2.9 years. Complications occurred within a mean time of 2.2+/-1.9 years. For the models vanguard and size 11, there were no rupture and 15 (27.7%) displacements whereas for size 9.75 and 10 there were 39 ruptures (14.7%) and 15 (5.6%) displacements. Types of complications were related to the bands used i.e. more port displacements for the models vanguard and size 11 and more band and port ruptures for the models size 9.75 and 10. But when we considered the respective follow up according to the type of band these differences were no longer significant. Moreover rupture rate was significantly high but decreased after March 2002 because of changing of junction between port and catheter. Mean excess weight loss (35.2+/-27.7%) was not different in group whether the patients were reoperated or not. CONCLUSION: Band and port related morbidity is an important aspect of bariatric surgery. We have to pay attention to material evolution and to our follow up for calibration. Some new recent technical advancement could improve the management of these patients.

[Repair of rectocele using the Stapled TransAnal Rectal Resection (STARR) technique: intermediate results from a multicenter French study]. / Traitement de la rectocèle par résection rectale transanale à la pince mécanique: résultats à moyen terme d'une étude multicentrique en France.

BACKGROUND: Stapled transanal rectal resection is a new alternative for the treatment of outlet obstruction syndrome. The aim of this study was to assess its feasibility and safety in a multicenter context. MATERIALS AND METHOD: The study had a retrospective design and included 102 patients who were operated in 5 centers. All patients complained of symptomatic outlet obstruction. Surgical technique involved a double hemi-circumferential rectal stapling according to the technique described by Longo. Mean follow-up was 17.2 months. RESULTS: The STARR procedure was done in 100 patients (2 patients had a non relaxing sphincter preventing anal dilatation). Immediate postoperative morbidity included bleeding in 4 cases (4%) and rectal stenosis in 3 cases (3%). The main postoperative medium-term complaints were urge to defecate (34%) which was regressive in most patients and de novo incontinence to flatus (9%). Nevertheless, results were considered favorable in 85% of patients. CONCLUSION: This multicenter study, reporting the results of the largest published series, suggests that the STARR technique is feasible and safe in the medium term for the treatment of rectocele. Occurrence of adverse events such as incontinence to flatus should be better evaluated by future studies with longer follow up in order to assess the actual place of STARR in the treatment of rectocele or outlet obstruction.

[Major digestive surgery in octogenarians. A prospective study of 54 cases]. / La chirurgie digestive lourde après 80 ans. Etude rétrospective de 54 cas.

OBJECTIVE: The interest in geriatric surgery is on the increase because of the ageing of the population. Our study reviewed the results of a non- specialised unit. Method 54 octogenarians underwent digestive surgery including visceral resection. Cancer predominated the indications (80%). RESULTS: The patients exhibited cardiovascular (87%), endocrine (18.5%) or neuropsychiatric (29.6%) disorders with 75% scoring ASA III or IV. Morbidity was of 81.5% with 20% of specifically surgical complications and a 40.2% rate of cardiovascular complications. Post-surgical mortality was of 7.4% and the survival rate at 2 years was of 44.4%. The treating physicians judged that in 65% of patients the intervention had improved the initial status of the patient and had stabilised the disease in 35% of cases. The percentage of patients living at home declined from 83.3% before the intervention to 64.8% after the intervention. Only 2 out of the 9 patients having undergone stomy of the colon following colectomy continued to improve. CONCLUSION: This study underlines the interest of major surgery in octogenarians, including in units non-specialised in geriatric surgery.

Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation.

BACKGROUND: Mechanical bowel preparation is used routinely before colorectal surgery, but some randomized clinical trials have suggested that it is of no benefit. This study assesses whether such bowel preparation may safely be omitted before elective colorectal surgery. METHODS: A search of the literature was performed; the inclusion criteria were randomized clinical trials comparing bowel preparation with no preparation in colorectal surgery. The methodological quality of included trials was assessed. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications. The meta-analysis was conducted using the Peto one-step method. RESULTS: Eleven trials were retrieved, of which seven, containing 1454 patients, were included in the meta-analysis. There was no heterogeneity between the trials. Significantly more anastomotic leakage was found after mechanical bowel preparation (5.6 versus 3.2 per cent; odds ratio 1.75 (95 per cent confidence interval 1.05 to 2.90); P = 0.032). All other endpoints (wound infection, other septic complications and non-septic complications) also favoured the no-preparation regimen, but the differences were not statistically significant. Sensitivity analysis showed that these results were similar when trials of poor quality were excluded. Subgroup analysis showed that anastomotic leakage was significantly greater after bowel preparation with polyethylene glycol (PEG) compared with no preparation, but not after other types of preparation. CONCLUSION: There is good evidence to suggest that mechanical bowel preparation using PEG should be omitted before elective colorectal surgery. Other bowel preparations should be evaluated by further large randomized trials.

Two novel severe mutations in the pancreatic secretory trypsin inhibitor gene (SPINK1) cause familial and/or hereditary pancreatitis.

Mutations in the serine protease inhibitor Kazal type 1 gene (SPINK1) encoding pancreatic secretory trypsin inhibitor (PSTI) have recently been found to be associated with chronic pancreatitis. Nevertheless, knowledge of severe mutations is particularly scarce, both in terms of number and in the extent of clinical information. The aim of this study was to expand the known spectrum of such mutations. 46 unrelated families, each including at least two pancreatitis patients and carrying neither cationic trypsinogen (PRSS1) mutations nor the frequent SPINK1 N34S mutation, participated in this study. The four exons and their flanking sequences of the SPINK1 gene were screened by denaturing high performance liquid chromatography analysis (DHPLC); and mutations were identified by direct sequencing. A heterozygous microdeletion mutation (c.27delC), which occurs within a symmetric element, was identified in two families. In one family, c.27delC showed segregation with the disease across two generations, with a penetrance of up to 75%. But in the other family, however, the same mutation manifested as a low-penetrance susceptibility factor. In addition, a novel heterozygous splicing mutation, c.87+1G>A (G>A substitution at nucleotide +1 of intron 2) was found in one family with familial pancreatitis. Our results also helped to resolve the sharply differing views about PSTI's role in pancreatitis.

[The Prolene Hernia System for inguinal hernia repair]. / Le "Prolene Hernia System" dans la cure des hernies inguinales.

Prosthetic repair is now considered as a standard in hernia surgery. The authors describe herein the technique of placement of Prolene Hernia System (PHS) which has the feature of a "3 in 1 system" according to the principles of Rives and Stoppa on one hand and those of Lichtenstein on the other hand. The steps of surgical technique are described.

[Relation between activity volume and surgeon's results: myth or reality?]. / Relation entre volume d'activité et résultats du chirurgien: mythe ou réalité?

The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retrieved and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated. A new approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.

[Natural history of the pancreatic stump after duodenopancreatectomy of the pancreatic head]. / Histoire naturelle du moignon pancréatique après duodénopancréatectomie céphalique (DPC).

UNLABELLED: Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period. PATIENTS AND METHODS: Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1-6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment. RESULTS: Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid. CONCLUSIONS: During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.