Vestigial retrorectal cystic tumors in adults: a review of 30 cases.

OBJECTIVES: Retrorectal tumors are uncommon. This is a report on a series of vestigial retrorectal cystic tumors in adults that were surgically removed at two medical centers in France. We also assessed the significance of imaging and, in particular, magnetic resonance imaging (MRI) in the management of these lesions. METHODS: The medical files of adult patients operated on for vestigial retrorectal cystic tumors over the past 15 years were retrospectively studied and, in particular, the radiological studies, the treatment and the histopathology. RESULTS: Thirty patients underwent surgery for vestigial retrorectal cystic tumor. A preoperative diagnosis was possible in almost all cases. The surgical procedure was justified by preoperative imaging and included the transanal approach (three cases), posterior approach (23 cases), anterior approach (two cases) and combined posterior and anterior approach (two cases). Imaging can identify a multilobular lesion that may require the use of a coccygeal approach to achieve complete resection. During a mean follow-up of 3.2 years (range 0.5-15 years), two patients had a local recurrence (successfully surgically removed), and a further two patients were lost to follow-up. Only one lesion was malignant. CONCLUSIONS: Preoperative imaging, and especially magnetic resonance imaging, enables both a specific diagnosis and the selection of the optimal surgical procedure for the treatment of vestigial retrorectal cystic tumors in adults.

[Nicorandil-associated anal ulceration]. / Ulcérations anales induites par le nicorandil.

BACKGROUND: Nicorandil is a potassium-channel activator used in the treatment of angina pectoris. The first cases of anal ulcerations induced by nicorandil were published in 2002. CASE REPORT: A 71-year-old man presented with a 2-year history of anal ulcerations occurring within a few months of initiation of treatment with Nicorandil. Histological tests on a biopsy sample showed granulation tissue with non-specific chronic inflammation. Nicorandil was stopped and this resulted in complete healing of the ulcers after three months. DISCUSSION: Nicorandil can induce chronic and extensive anal ulcerations. The pathogenesis is unknown. Patients are usually treated with high doses of nicorandil. Dermatologists should be aware of this rare side-effect which heals after withdrawal of the drug.

[Abdominal management of rectocele and elytrocele: place of the laparoscopic approach]. / Traitement des rectocèles et des élytrocèles par voie abdominale: apport de la laparoscopie.

AIM OF THE STUDY: To report the results of abdominal promontory rectopexy and douglassectomy in the management of rectocele and enterocele. PATIENTS AND METHODS: Between 1992 and 2002, 72 patients were operated by one colorectal surgeon. Laparotomy was used in 37 cases between 1992 and 2001 and the laparoscopic approach in 35 cases from 1995 to 2002. Promontory rectal fixation required only one mesh secured between the anterolateral right side of the rectum and the lumbosacral ligament. The same mesh was used to fix the vagina or the cervix. Combined therapeutic or prophylactic urinary interventions are frequent in the series. RESULTS: The follow-up was more than one year in 63 patients with a mean value of 58 months with no patient lost. Recurrence of posterior vaginal prolapse was noted in only two cases. Dyschesia and urinary incontinence were improved respectively in 80 and 70% of the cases and a significant improvement in anal incontinence was observed in 95% of the patients. CONCLUSION: The abdominal way allows a suitable treatment in patients with advanced stage rectocele and enterocele and evidence of pelvic organ prolapse. The laparoscopic approach is superior in terms of morbidity and functional results.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]. / Les lymphangiomes kystiques du mésentère et du méso-côlon. Prise en charge diagnostique et thérapeutique.

STUDY AIM: Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas. MATERIAL AND METHODS: 15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%). RESULTS: Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection. CONCLUSION: Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

Adjuvant intraperitoneal 5-fluorouracil in high-risk colon cancer: A multicenter phase III trial.

OBJECTIVE: To evaluate the results of a prospective multicenter randomized study of adjuvant intraperitoneal 5-fluorouracil (5-FU) administered during 6 days shortly after resection of stages II and III colon cancers. SUMMARY BACKGROUND DATA: Systemic adjuvant chemotherapy improves the survival of patients with stage III colon cancer receiving treatment for 6 months. Intraperitoneal chemotherapy theoretically combines peritoneal and hepatic effects. METHODS: After resection, 267 patients were randomized into two groups. Patients in group 1 (n = 133) underwent resection followed by intraperitoneal administration of 5-FU (0.6 g/m2/day) for 6 days (day 4 to day 10). These patients also received intravenous 5-FU (1 g) during surgery. Patients in group 2 underwent resection alone (n = 134). RESULTS: In group 1, 103 patients received the total dose, 18 received a partial dose as a result of technical or tolerance problems, and 12 did not receive the chemotherapy. Rates of surgical death and complications were similar in both groups. Tolerance to treatment was excellent or fair in 97% of the patients and poor in 3%. After a median follow-up of 58 months, 5-year overall survival rates were 74% in group 1 and 69% in group 2; disease-free survival rates were 68% and 62%, respectively. Survival curves were superimposed until 3 years after treatment and began diverging thereafter. Among patients receiving the full treatment, the 5-year disease-free survival rate was improved in the treatment group in patients with stage II cancers but was unchanged in patients with stage III cancers. CONCLUSIONS: Chemotherapy with intraperitoneal 5-FU administered during a short period after surgery was well tolerated but was not sufficient to reduce the risk of death significantly. However, it reduced the risk of recurrence in stage II cancers. These results suggest that it should be associated with systemic chemotherapy to reduce both local and distant recurrences.

Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial.

PURPOSE: The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery. PATIENTS AND METHODS: Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study. RESULTS: A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27). CONCLUSION: A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.

[Laparoscopic appendectomy. Review based on an homogeneous series of 906 cases]. / Appendicectomie par voie coelioscopique. Réflexions à partir d'une série homogène de 906 cas.

PURPOSE: The aim of this retrospective study is to present the results of a large homogeneous series of laparoscopic appendicectomy. Special attention is drawn to the reasons for conversion and postoperative complications. METHODS: From May 1990 to December 1997, 906 patients were operated by laparoscopy for acute appendicitis, by one surgeon, using the same technique. Acute peritonitis and abscesses were found in 63 patients. RESULTS: There was no post-operative mortality. The overall conversion rate was 2.3 per cent, but was 25 per cent for abscesses with severe inflammatory adhesions, and 0 per cent for diffuse peritonitis. Post-operative complications were more frequent in the early period. The overall morbidity rate was 0.1 per cent, including essentially intraabdominal abscesses. CONCLUSION: A recent critical review of twelve randomized controlled trials on laparoscopic appendicectomy failed to draw any definitive conclusion because of a statistical lack of power. The present study with a large number of patients shows that laparoscopic treatment is safe. The limit of the method essentially concerns abscesses with sclerous inflammation.

The role of radiotherapy in the conservative treatment of rectal carcinoma--the Lyon experience.

The purpose of this study was to present the Lyon experience using radiotherapy alone or with surgery, with intent to cure rectal cancer and to avoid rectal amputation. Two groups of patients were treated between 1980 and 1996: Group I with radiotherapy alone with contact x-ray for T1 N0 (101 patients) or with a combination of external beam radiation therapy (EBRT), contact x-ray and 192 iridium implant in inoperable T2-3 N0-1 patients (43 patients); Group II with preoperative EBRT either as a pilot study (158 patients) or in a randomized trial (210 patients). With contact x-ray alone it was possible to control T1 N0 in 90% of cases, and with the combined approach 70% of the inoperable patients were controlled. In Group II, anterior resection was performed in 60% to 70% of the patients. Local recurrence was seen in 11% of cases. Surgery is the basic treatment used for rectal cancer but radiotherapy is playing an increasing role in the conservative treatment of this cancer.

[Magnetic resonance study of complex anal fistulae. Preliminary results apropos of 28 cases]. / Exploration par résonance magnétique des fistules anales complexes. Résultats préliminaires à propos de vingt-huit cas.

PURPOSE: To evaluate the use of Magnetic Resonance Imaging (MRI) for the treatment of problematical anal fistulas and follow-up of cases treated by long-term seton drainage with two or three-stage fistulotomy. METHOD: prospective study on 24 patients with surgical treatment between July 1993 and March 1995 selected for MRI among 100 anal suppurations according to following criteria: high trans-sphincteric or supra-sphincteric fistula with one or more previous definitive attempts at treatment (15), and/or severe anal or rectal fibrosis (11). Patients with Crohn's disease were not included. For 14 of these patients who had a long-term seton drainage, MRI tried to assess the quality of the surgical drainage and the course of residual abscess. RESULTS: the overall accuracy of MRI for visualization of internal opening, primary and secondary tract was 84% when compared with surgical data. The sensitivity and specificity were 100% for the detection of horse shoe fistulous tracts (8). For the 14 patients followed by MRI, only one false positive was noted and in 5 cases the results of MRI modified the previous staged procedure (prolonged seton drainage or new excision). For the 20 patients treated for more than 6 months, the mean follow-up was 18 months and median was 14 months. Only one recurrence was noted with no loss of follow-up. CONCLUSION: this study confirms the high degree of accuracy of MRI for mapping of high complex fistula in ano. MRI is very helpful for the survey of healing in cases treated with seton drainage and two or three stage fistulotomy to preserve continence.

[Anus abscess. Value of systematic search of cases involving the primary orifice. Apropos of a series of 235 patients]. / Abcès de l'anus. Intérêt de la recherche systématique en urgence de l'orifice primaire. A propos d'une série de 235 patients.

Based on our experience with 235 patients we emphasize the importance of examining, in the acute phase, the cryptic orifice and the trajectory of the fistula when treating anal abscesses. Fistulotomy can then performed in one or two operations. In specialized units, this attitude can give favourable results in nearly three-fourths of the cases and would avoid a large percentage of recurrent cases of suppuration.

[A further case of hepatocytic adenoma following oestrogenprogestogen treatment. Review of the literature (author's transl)]. / L'adénome hépatocytaire sous traitement cestro-progestatif. Revue de la littérature à propos d'une observation.

A young woman taking contraceptive hormone treatment for many years developed a hepatocytic adenoma discovered after a massive hemorrhage into the tumor. The patient recovered after a hepatectomy. A total of 160 such cases have been reported in the published literature, and recovery occurred after excision of the lesion in the majority of cases. Stopping the oestrogen-progestogen therapy seems to avoid recurrence but it is still not known whether this is sufficient to produce regression of a benign tumoral lesion.