Cytoreductive surgery associated to hyperthermic intraperitoneal chemoperfusion for desmoplastic round small cell tumor with peritoneal carcinomatosis in young patients.

PURPOSE: Desmoplastic round small cell tumor (DRSCT) is a rare intraabdominal mesenchymal tissue neoplasm in young patients and spreads through the abdominal cavity. Its prognosis is poor despite a multimodal therapy including chemotherapy, radiotherapy, and surgical cytoreduction (CS). hyperthermic intraperitoneal chemotherapy (HIPEC) is considered as an additional strategy in the treatment of peritoneal carcinomatosis; for this reason, we planned to treat selected cases of children with DRSCT using CS and HIPEC. METHODS: Peritoneal disease extension was evaluated according to Gilly classification. Surgical cytoreduction was considered as completeness of cytoreduction-0 when no macroscopic nodule was residual; HIPEC was performed according to the open technique. RESULTS: We described 3 cases: the 2 first cases were realized for palliative conditions and the last one was operated on with curative intent. There was no postoperative mortality. One patient was reoperated for a gallbladder perforation. There was no other complication related to HIPEC procedure. CONCLUSIONS: Surgical cytoreduction and HIPEC provide a local alternative approach to systemic chemotherapy in the control of microscopic peritoneal disease in DRSCT, with an acceptable morbidity, and may be considered as a potential beneficial adjuvant waiting for a more specific targeted therapy against the fusion protein.

Surgeon-dependent predictive factors for mortality after elective colorectal resection and immediate anastomosis for cancer or nonacute diverticular disease: multivariable analysis of 2,605 patients.

BACKGROUND: Multivariable analysis best identifies independent risk factors. STUDY DESIGN: We conducted a prospective evaluation of 2,605 patients through univariate analysis followed by nonconditional multiple logistic regression analysis on 39 pre-, intra-, and postoperative factors, analyzed according to preoperative factors alone, preoperative and intraoperative factors together, and all 3 combined. The purpose was to identify surgeon-dependent independent risk factors for mortality after elective colorectal surgery, with immediate anastomosis for cancer and nonacute diverticular disease. RESULTS: Overall mortality was 3.5%. Through multivariable analysis, five risk factors were found when preoperative data were analyzed alone. Four remained (age between 60 and 75 years, age greater than 75 years, male gender, and heart failure) and 4 new factors (palliative resection, total colectomy, respiratory failure, and surgeon-dependent fecal soiling [the only surgeon-dependent factor]) appeared when pre- and intraoperative factors were analyzed together. Of the latter, two remained stable when all three categories of risk factors were combined and analyzed (palliative resection and total colectomy), and the two others disappeared. Of the eight pre-, intra-, and postoperative factors combined, two new factors appeared: extrasurgical site (ESS) and surgeon-dependent, organ space surgical site (O/SSS) morbidity. CONCLUSIONS: Every effort must be made to collect specific, surgeon-dependent (technical and clinical) data, along with administrative data, for multivariable analysis of risk factors. Classification into three periods (pre-, pre- and intraoperative together, and pre-, intra-, and postoperative combined) enables determination of relevant, surgeon-dependent risk factors (fecal soiling and postoperative morbidity) for which there are direct preventive actions.

Iterative cytoreductive surgery associated with hyperthermic intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis of colorectal origin with or without liver metastases.

INTRODUCTION: The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS: The population included 43 patients who had 54 CS+HIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5-20 mm) and Gilly 4 (diffuse nodules>20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates. RESULTS: The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules <5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS + HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS + HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity = 31%). Complications included deep abscess (n = 6), wound infection (n = 5), pleural effusion (n = 5), digestive fistula (n = 4), delayed gastric emptying syndrome (n = 4), and renal failure (n = 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8-43.9). Actuarial 2- and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS + HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P = 0.73). CONCLUSION: Iterative CS + HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.

[Primary epiploic appendagitis: a nonsurgical and often misdiagnosed pathology]. / Appendagite épiploïque primitive: un diagnostic non chirurgical souvent méconnu.

INTRODUCTION: Primary epiploic appendagitis (PEA) is characterized by the association of localized abdominal pain with guarding. Depending on its localization, it may simulate acute appendicitis or diverticular sigmoiditis. Symptoms correspond to necrosis of the epiploic appendix due the torsion and vascular occlusion of the main epiploic pedicle. OBSERVATION: A 34-year-old man (BMI=29.38) was examined for persistent localized abdominal pain of the left lower quadrant three days after receiving systemic antibiotic therapy for what was diagnosed as mild diverticular sigmoiditis. Abdominal examination showed localized guarding in the left lower quadrant, with no fever, vomiting or diarrhea. Laboratory results showed no inflammatory response. Abdominal ultrasound showed no evidence of left hydronephrosis. Helical CT showed a localized zone of necrosis of the epiploic appendix of the sigmoid colon and thus confirmed the diagnosis without surgical exploration. Symptoms regressed after a week of analgesic treatment. DISCUSSION: PEA is a rare disease. It often occurs in mildly overweight adult men (around 35 years of age). The combination of acute abdomen with localized abdominal guarding and no evidence of fever or inflammation is the typical presentation. Surgical exploration (laparoscopy) can be avoided for diagnosis if helical CT shows a localized fatty zone situated outside the colon wall with a high attenuating dot point that corresponds to central necrosis of the epiploic appendix.

Povidone-iodine vs sodium hypochlorite enema for mechanical preparation before elective open colonic or rectal resection with primary anastomosis: a multicenter randomized controlled trial.

HYPOTHESIS: The anti-infective actions of povidone-iodine (PVI) and sodium hypochlorite enemas are different. DESIGN: Prospective, randomized, single-blind study. SETTING: Multicenter. PATIENTS: Five hundred seventeen consecutive patients with colorectal carcinoma or sigmoid diverticular disease undergoing elective open colorectal resection, followed by primary anastomosis. INTERVENTION: All patients received senna (1-2 packages diluted in a glass of water) at 6 pm the evening before surgery. Patients were administered two 2-L aqueous enemas of 5% PVI (n = 277) or 0.3% sodium hypochlorite (n = 240) at 9 pm the evening before surgery and at 3 hours before operation. Intravenous ceftriaxone sodium (1 g) and metronidazole (1 g) were administered at anesthetic induction. MAIN OUTCOME MEASURE: Rate of patients with 1 infective parietoabdominal complication or more. RESULTS: The percentages of patients with 1 infective parietoabdominal complication or more did not differ between the 2 groups (13.7% in the PVI-treated group vs 15.0% in the sodium hypochlorite-treated group). Tolerance was better in the PVI-treated group than in the sodium hypochlorite-treated group (79.4% vs 67.9%), with fewer patients experiencing abdominal pain (13.0% vs 24.6%) or discontinuing their preparation (3.0% vs 9.0%) (P=.02 for all). There were more patients with malaise in the PVI-treated group than in the sodium hypochlorite-treated group (9.1% vs 4.9%, P<.05). Three patients in the sodium hypochlorite-treated group had necrotic ulcerative colitis. CONCLUSION: When antiseptic enemas are chosen for mechanical preparation before colorectal surgery, PVI should be preferred over sodium hypochlorite because of better tolerance and avoidance of necrotic ulcerative colitis.

Predictive risk score for infection after inguinal hernia repair.

BACKGROUND: Identification of subgroups of patients at high and low risk for global infectious complications (GIC) after inguinal hernia repair without mesh. METHODS: A database of 1254 patients who underwent inguinal hernia repair without mesh, issued from 3 prospective multicenter randomized trials, has been established (group A). After multivariate analysis, a score for GIC was calculated and tested using data from a similar prospective randomized multicenter study (group B). RESULTS: A risk score for GIC was constructed: -4.7 + (0.95 x age > or =75 years) + (1.1 obesity) + (2.1 x urinary catheter). In case of score less than -4.2 (low-risk group), the GIC rate was 2.7%; therefore, in case of score more than -4.2 (high-risk score), the GIC rate was 14.3% (P < .001). In the low-risk group, the administration of antibiotic prophylaxis did not reduce the infectious complication rate, while in high-risk group the administration of antibiotic prophylaxis significantly reduced the rates of surgical site infection, GIC, and urinary infection by 72%, 67%, and 76.8%, respectively. CONCLUSIONS: This study demonstrates the efficacy of antibiotic prophylaxis in inguinal hernia surgery in the subgroup of high-risk patients.

Risk factors for prediction of surgical site infections in "clean surgery".

BACKGROUND: The aim of this study was to determine the risk factors of surgical site infections (SSI) in clean surgery and to identify high- and low-risk patients from whom efficacy of the antibiotic prophylaxis was analyzed. METHODS: From June 1982 to September 1996, a database was established from 3 prospective multicenter randomized studies, containing information of 5798 patients who underwent abdominal noncolorectal surgery. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). RESULTS: A total of 2374 patients underwent a clean surgery. An antibiotic prophylaxis was administered to 1943 patients (81.8%). A multivariate analysis was performed including only preoperative factors and disclosed 3 independent factors: cirrhosis (OR, 2.8; 95% CI: 1.6-12.8), other disease (OR, 2.7; 95% CI: 1.3-5.8), and preoperative urinary catheter (OR, 2.1; 95% CI: 1.1-4.6). A risk score for SSI was constructed: -4.9 + (1.5 x cirrhosis++) + (other disease++) + (0.8 x preoperative urinary catheter++) (++ = 0 if absent or 1 if present). The study included 1 group of patients having no risk factors for SSI with a score below -4.5 (S1R-) and 1 group of patients having 1 or more risk factors for SSI with a score over -4.5 (S1R+). Antibiotic prophylaxis did not reduce the infectious complication rate in the S1R- group, whereas, in the S1R+ group, it reduced significantly the rate of SSI and of parietal infectious complications by 58% and 69%, respectively. CONCLUSIONS: Antibiotic prophylaxis in clean abdominal surgery was effective in high-risk patients. Urinary catheter must be avoided.

Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection: a prospective, multicenter randomized controlled trial.

HYPOTHESIS: Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection. DESIGN: Single-blind, controlled, randomized trial. SETTING: Multicenter (N = 20) trial in France. PATIENTS: Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls. RESULTS: All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P<.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P<.02), when pancreatojejunostomy was performed (P<.02), or both (P<.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P<.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]). CONCLUSIONS: Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Risk factors for mortality and morbidity after elective sigmoid resection for diverticulitis: prospective multicenter multivariate analysis of 582 patients.

The prevalence of diverticular disease of the colon is increasing in occidental countries. It would be useful to further decrease the mortality and morbidity after elective sigmoid resection (ESR) for diverticulitis. The aim of this study was to identify modifiable preoperative and intraoperative risk factors for mortality and morbidity after ESR for diverticulitis. A database of 2615 patients who underwent a colon or rectal resection with primary anastomosis between 1985 to 1998 has been constructed from prospective randomized studies published by a French surgical group. Of those patients, 582 had undergone ESR for diverticulitis, and they constitute the population of the present study. A total of 46 potential preoperative and intraoperative risk factors for mortality and morbidity have been studied by univariate and multivariate analysis. The operative mortality for our series was 1.2%, and the overall morbidity was 24.9%. The multivariate analysis revealed two statistically significant independent risk factors of mortality: age >75 (odds-ratio=7.9; 95% confidence interval [CI 1.7-36.6]; p=0.01) and obesity (odds-ratio=5.2; 95% CI [1.1-27.9]; p=0.04). The abdominal morbidity (AM) was 6.5% (38/582). The absence of antimicrobial prophylaxis administration with ceftriaxone was the only significant risk factor for AM in multivariate analysis (p=0.003; odds-ratio=2; 95% CI [1.1-4]). The extraabdominal morbidity (EAM) was 18.4% (107/582). Both chronic pulmonary disease (p=0.008; odds-ratio=2.9; 95% CI [1.4-6]; p=0.008) and cirrhosis (odds-ratio=12; 95% CI [1.2-120]) proved to be significant risk factors for EAM. Weight control prior to surgery, routine administration of prophylactic preoperative antibiotics, and preoperative optimization of the respiratory status of patients with chronic pulmonary disease could decrease the postoperative mortality and morbidity associated with ESR for diverticulitis.

Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients.

HYPOTHESIS: Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications. DESIGN: A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). SETTING: Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). PATIENTS: From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery. MAIN OUTCOME MEASURES: The dependent variables studied included surgical site infection (SSI) (divided into parietal and deep infectious complications with or without fistulas) and global infectious complications (SSI and extraparietal and abdominal infectious complications). RESULTS: The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age (60-74 years, OR, 1.64; >or=75 years, OR, 1.45); being underweight (OR, 1.51); having cirrhosis (OR, 2.45), having a vertical abdominal incision (OR, 1.66); having a suture placed or an anastomis of the bowel (OR, 1.48) in the digestive tract; having a prolonged operative time (61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72); and being categorized as having a class 4 surgical site (ie, obese patients or having a risk factor of a healing defect) (OR, 1.66). Ceftriaxone sodium therapy was identified as a protective factor (OR, 0.43). In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis (OR, 4.75), having a suture placed or an anastomosis of the bowel (OR, 1.82) in the digestive tract, having postoperative abdominal drainage (OR, 2.15), undergoing a surgical procedure for the treatment of cancer (OR, 1.74), and receiving curative anticoagulant therapy (OR, 3.33) postoperatively. CONCLUSIONS: Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.

Budd-Chiari syndrome associated with inferior vena caval obstruction: surgical treatment; cavo-or meso-atrial shunt

Em 6 anos, 17 pacientes foram submetidos à derivaçäo entre o sistema mesentérico-esplenoportal (15 vezes) ou o sistema cava inferior com anastomose mesentérico ou portocava (duas vezes) e o átrio direito. O grupo era composto de nove homens e oito mulheres; entre estes, 14 eram adultos com idades de 19 a 61 anos e três crianças, com idades de 2 a 5 anos. Com uma exceçäo, todos apresentavam ascite. Três pacientes foram operados na urgência devido: hemorragia por ruptura de varizes do fundo gástrico, síndrome hepato-renal e um por aumento súbito das transaminases (cinco vezes o normal). As lesöes centrolobulares foram confirmadas, em todos os casos, através de biopsia pré-operatória e/ou per-operatória. A oclusäo das veias sub-hepáticas foi demonstrada em todos os casos por, no mínimo, dois dos exames seguintes: ultra-sonografia, angio tomografia, flebografia supra-hepática, ou portografia transhepática. A cavografia demonstrou obstruçäo completa de veia cava em oito casos e incompleta em nove, acarretando hipertensäo de veia cava, com gradiente porto-cava variando de -6a +6mm de mercúrio. Nas anastomoses utilizou-se próteses de politetrafluor e tileno (Gore-Tex), com uma única exceçäo, onde foi utilizada prótese de dacron. As próteses foram passadas sete vezes à frente do fígado e dez vezes por trás do lobo esquerdo. A anastomose foi feita dez vezes com a face inferior do átrio direito, abordando nove vezes por frenotomia e uma vez por esternotomia; seis vezes com face anterior do átrio direito abordado por esternotomia; e uma vez com a veia cava superior intra-pericárdica, abordada por toracotomia ântero-lateral direita. Setenta por cento dos pacientes apresentaram ascite no pós-operatório. Seis pacientes morreram no primeiro mês pós-operatório, respectivamente pelas seguintes causas: choque séptico com ascite infectada, insuficiência renal, erro de técnica, insuficiência múltipla de órgäos com isquemia do miocárdio e dois por síndromes hepato-renal...