Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

Evoked pressure curves from the external anal sphincter following transcranial magnetic stimulation in healthy volunteers and patients with faecal incontinence.

AIM: The hypothesis was tested that evoked pressure curves (EPCs) after transcranial magnetic stimulation (TMS) would provide additional neuropathophysiological information on the descending pathways to the external anal sphincter (EAS) in patients with faecal incontinence (FI). METHOD: Twenty-five healthy subjects and 69 patients with FI were investigated. TMS was applied to the vertex, and EPCs were recorded with a probe placed through the EAS. TMS was performed with the EAS at rest and during contraction (facilitated responses). At least three responses were recorded for each modality. Clinical data and anorectal manometric, electrophysiological perineal and transanal ultrasound recordings were compared with respect to the EPC results. RESULTS: There was no statistically significant difference between the EPCs of healthy subjects and FI patients. Twenty-three per cent of the FI patients had abnormal EPC latencies, with significantly lower voluntary contraction amplitudes (P = 0.03) and significantly higher rectal sensation (P = 0.04) than the other group. We found no significant difference between FI patients with and without abnormal EPC latencies in terms of clinical characteristics and electrophysiological and endoanal ultrasound parameters. There was no difference in the identified causes of the FI between the two groups. CONCLUSION: As abnormal EPC latencies were found in 23% of FI patients with no known central neurological disease, abnormal EPC latencies might reveal undetected lesions of descending pathways in patients with FI.

[Results of sacral neuromodulation on the urinary and fecal incontinence and sexuality in 20 women suffering from a double incontinence]. / Résultats de la neuromodulation des racines sacrées sur la continence et la sexualité dans une cohorte de 20 patientes ayant une double incontinence.

CONTEXT: Urinary and faecal incontinence (defining double incontinence) are common conditions, which are frequently associated and can altered sexuality. The effectiveness of the sacral nerve modulation (NMS) in the treatment of the urge urinary incontinence, faecal incontinence and double incontinence was shown. OBJECTIVE: The present article aims to determine the impact of SNM on female sexual function in twenty women suffering from a double incontinence. METHODS: All patients who received sacral neuromodulation for urge urinary and/or faecal incontinence between 2005 and 2010 and who still had the implant were included. Only 20 sexually active patients suffering from double incontinence were considered eligible. They completed a questionnaire on follow-up examinations. RESULTS: The initial indication of NMS was the urge urinary incontinence for 15 patients and the faecal incontinence for five patients. Ten patients (50%) were improved on two incontinence. All patients preserved sexual activity after the treatment of NMS. NMS improves the quality of sexual activity in 45% patients. The numbers of urinary and faecal episodes of incontinence are decreased respectively for 50% and 15% patients during sexual activity. The quality of sexual's life and orgasm score are significantly increased in the group of patients improved on the DI. CONCLUSION: This study confirms the effectiveness of NMS in the treatment of double incontinence which half patients are improved on the two incontinence. This study shows that improvement of urinary or faecal incontinence could have a positive impact on sexuality of these patients, especially for patients improved double incontinence. It is difficult to know if these results are related to its direct action on the neurological ways of sexual function or on its benefit on the continence.

Internal supravesical hernia: an unusual cause of small bowel obstruction.

Internal hernia of the supravesical fossa is an unusual cause of small bowel obstruction. We report the case of a patient without previous abdominal surgery with an acute abdominal obstruction in which laparoscopic exploration revealed a strangulated internal supravesical hernia. To help clinicians with their pre-operative diagnosis and to better understand the clinical management of this unusual internal hernia, a description of the anatomy of the supravesical fossa is included in this case report.

Definitive chemoradiotherapy in patients with esophageal adenocarcinoma: an alternative to surgery?

BACKGROUND AND OBJECTIVES: Definitive chemoradiotherapy (CRT) is considered curative intent treatment for locally advanced esophageal squamous cell carcinoma. Data concerning the usefulness of definitive CRT in patients with esophageal adenocarcinoma (ADC) are lacking. The aim of the study was to compare the results of definitive CRT versus surgery in patients with an ADC. METHODS: All consecutive patients with a non-metastatic ADC treated between 1994 and 2008 were retrospectively assessed. Patients were divided into two groups: surgery group (±pre-operative treatment) versus definitive CRT group. RESULTS: In surgery and definitive CRT groups, 67 and 79 patients were evaluated, respectively. A complete resection was achieved in 92.5% of patients in surgery group and a clinical complete response was observed in 49.4% of patients in definitive CRT group. Overall survival was 36.2 ± 2.0 months in surgery group versus 16.5 ± 0.8 months in definitive CRT group (P = 0.02). The predictive factors of survival were age (P < 0.01), stage (P = 0.04), WHO performance status (P < 0.01), initial weight loss (P < 0.01), and the treatment group (P < 0.01). CONCLUSIONS: The results of the study do not support definitive CRT as an alternative to surgery in esophageal ADC treatment. Definitive CRT should be reserved for patients with a major operative risk.

Botulinum A toxin as a treatment for overactive rectum with associated faecal incontinence.

AIM: Rectal hypercontractility can lead to faecal incontinence (FI). Botulinum toxin (BT) has been used successfully for the treatment of bladder overactivity. This study aimed to evaluate the therapeutic value of intrarectal injections of BT in inhibiting colorectal contractions and relieving FI in patients suffering from FI as a result of overactive rectal contractions. METHOD: A prospective open study was carried out in Rouen University Hospital. Six patients (four men and two women) with severe FI related to overactive rectal contractions underwent intrarectal submucosal injections of BT placed in three rows of 10, 1-ml injections (50 U/1 ml; Dysport(®)) starting 1 cm above the dentate line and repeated twice, at intervals of 5 cm proximally. The end-points included improvement in the FI score, in faecal incontinence quality of life (FIQL) and of manometric abnormality. RESULTS: All patients reported improvement in the FI score [18.2±1.1 at baseline vs 9.0±1.7 at 3 months (P=0.04)] and in FIQL. Rectal contractile activity was reduced. The frequency of contractions remained unaffected (28.1±6.6/h; P=0.46 vs baseline). High-amplitude contractions of >50 cmH(2)O were significantly decreased in all patients (16.6±3.9 vs 6.6±4.1/h; P=0.03). CONCLUSION: Patients with an 'overactive rectum' are a heterogeneous group, with varying causes of dysfunction. The dose of BT used was arbitrarily selected. Nevertheless, the study introduces a further therapeutic option in the treatment of FI caused by rectal overactivity.

How sacral nerve stimulation works in patients with faecal incontinence.

AIM: Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action. METHOD: A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found. RESULTS: We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity. CONCLUSION: The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.

Natural orifice total mesorectal excision using transanal port and laparoscopic assistance.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging concept which has been recently applied to the field of rectal excision. The authors describe a case of total mesorectal excision using a transanal port and laparoscopic assistance. We described a procedure performed in a 45-year-old for a rectal adenocarcinoma (1 cm wide, T1sm3) 3 cm above the dentate line. The procedure is described in the text and in a didactic video.

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients.

AIM: Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI. METHOD: Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year. RESULTS: The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome. CONCLUSION: Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

A large-scale candidate gene approach identifies SNPs in SOD2 and IL13 as predictive markers of response to preoperative chemoradiation in rectal cancer.

Neoadjuvant radiochemotherapy followed by total mesorectal excision is now the standard treatment for locally advanced rectal cancer. However, tumor response to chemoradiation varies widely among individuals and cannot be determined before the final pathologic evaluation. The aim of this study was to identify germline genetic markers that could predict sensitivity or resistance to preoperative radiochemotherapy (RT-CT) in rectal cancer. We evaluated the predictive value of 128 single-nucleotide polymorphisms (SNPs) in 71 patients preoperatively treated by RT-CT. The selected SNPs were distributed over 76 genes that are involved in various cellular processes such as DNA repair, apoptosis, proliferation or immune response. The SNPs superoxide dismutase 2 (SOD2) rs4880 (P=0.005) and interleukin-13 (IL13) rs1800925 (P=0.0008) were significantly associated with tumor response to chemoradiation. These results reinforce the idea of using germline polymorphisms for personalized treatment.

Transposed right colon segment for vaginal reconstruction after pelvic exenteration.

Vaginal reconstruction following pelvic exenteration surgery for malignant disease is an important step in the physical and psychological rehabilitation of such patients. Planning of such procedures must include a strategy for reconstruction of the vagina and the oncological surgical team must be aware of the surgical techniques available in order to optimally plan and execute such procedures. We described a procedure which involves supralevator exenteration of the pelvis along with primary colorectal anastomosis. A transposed right colon segment is used to reconstruct the vagina and an omental flap is interpositioned between the reconstructed vagina and the colorectal anastomosis. The procedure is described in the text and in a didactic video.

Artificial anal sphincter for severe fecal incontinence implanted by a transvaginal approach: experience with 32 patients treated at one institution.

PURPOSE: Our aim was to evaluate medium-term results of transvaginal implantation of an artificial anal sphincter in a large series of patients. METHODS: Women undergoing treatment for severe fecal incontinence at Rouen University Hospital, Rouen, France, from January 2003 through December 2007 were eligible for the study if the fecal incontinence had lasted for 6 months and if they had attempted other therapies without success. All patients received implantation of an artificial anal sphincter via a transvaginal approach. Incontinence was assessed with the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score). RESULTS: A total of 32 women entered the study. Their median age was 63 (range, 26-79) years. At entry, 20 (63%) had severe destruction and scarring of the perineum, which was a contraindication for implantation via a perineal approach. Nine patients (28.1%) had previously undergone implantation of an AAS which had been removed because of complications, and 5 had had a Pickrell procedure for anal agenesia. No deaths occurred during the study. The device was removed in a total of 9 patients (28.1%): in 7 because of septic adverse events within the first 6 months after the operation, in 1 because of poor function, and in 1 for psychological reasons despite good functional results. Implantation was successful in 23 patients (71.9%), and the device remained activated for a mean follow-up of 41 (range, 18-75) months, with a mean decrease in Cleveland Clinic incontinence score from 18.4 to 6.8 (P < .0001). None of the patients complained of dyspareunia. CONCLUSIONS: The transvaginal approach for implantation of an artificial anal sphincter permits treatment of women with fecal incontinence who have severe damage and scarring of the anterior perineum. This route provides an alternative for patients whose only therapeutic option would previously have been a defunctioning stoma.

[Technical considerations for KRAS testing in colorectal cancer. The pathologist's point of view]. / Aspect technique de la détermination du statut KRAS dans le cancer colorectal et mise en place en France. Point de vue de l'anatomopathologiste.

The KRAS status is now a mandatory prerequisite in order to treat metastatic colorectal patients with anti-EGFR (epidermal growth factor receptor) antibodies, such as cetuximab (Erbitux) or panitumumab (Vectibix). KRAS mutations are unambiguously linked to a lack of response to these targeted therapies and to a poor outcome. The optimal determination of the KRAS status should be based on coordination between pathologists and biologists. The pathologist must morphologically check the tumor to be analyzed and be sure that the fixatives used are valuable for molecular biology. The pathologist's involvement may also concern the DNA extraction and the KRAS mutations analyses. This involvement has to be included in a multidisciplinary setting in order to get rapid and robust tests for the clinical use. The imperative knowledge of the KRAS status in the management of metastatic disease represents a good example of this multidisciplinary coordination. In the future, the pathologist's role should be extended, considering the emergence of a more and more personalized medicine, integrating efficiency and cost-effectiveness. Thus, the pathologist may contribute to validate new molecular tests and to offer his specific techniques for translational research.

Increased expression of class III beta-tubulin in castration-resistant human prostate cancer.

BACKGROUND: Class III beta-tubulin (betaIII-tubulin) is expressed in tissues of neuronal lineage and also in several human malignancies, including non-small-cell lung carcinoma, breast and ovarian cancer. Overexpression of betaIII-tubulin in these tumours is associated with an unfavourable outcome and resistance to taxane-based therapies. At present, betaIII-tubulin expression remains largely uncharacterised in prostate cancer. METHODS: In this report, we evaluated the expression of betaIII-tubulin in 138 different human prostate tumour specimens by immunohistochemistry from patients with hormone-treated or hormone-untreated prostate cancer. betaIII-tubulin expression was also examined in various prostatic cancer cell lines including in androgen-sensitive human prostate cancer cells, LNCaP, grown in androgen-depleted medium in 2D cultures or as tumour xenografts when the host mouse was castrated. RESULTS: Whereas moderate-to-strong betaIII-tubulin expression was detected in only 3 out of 74 (4%) hormone-naive tumour specimens obtained from patients who never received hormone therapy, 6 out of 24 tumour specimens (25%) from patients treated for 3 months with neoadjuvant hormone therapy and 24 out of 40 (60%) castration-resistant tumour specimens from chronic hormone-treated patients were found to express significant levels of betaIII-tubulin. These findings were supported by in vitro and in vivo settings. CONCLUSION: Our data indicate that betaIII-tubulin expression is augmented in prostate cancer by androgen ablation and that the expression of this beta-tubulin isoform is associated with the progression of prostate cancer to the castration-resistant state, a stage largely responsible for mortality from prostate cancer.

Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience.

OBJECTIVE: Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS. METHOD: Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence. RESULTS: We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed. CONCLUSION: We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Control of pelvic symptoms in patients with rectal cancer and synchronous metastases.

OBJECTIVE: The optimal treatment strategy for rectal cancer (RC) with synchronous metastases remains an issue of debate. The aim of this study was to evaluate the impact of surgery and radiation on the control of pelvic symptoms in this setting. METHODS: Consecutive patients with RC and synchronous metastases were retrospectively assessed and divided into four treatment groups: surgical resection of rectal tumor (S); radiotherapy with/without chemotherapy followed by surgery (CRTS); chemoradiotherapy (CRT); and chemotherapy only (CT). Each group was evaluated in terms of duration of pelvic symptom-free periods (relative to overall survival). RESULTS: A total of 96 patients were evaluated: S: n=30; CRTS: n=21; CRT: n=27; and CT: n=18. After treatment, pelvic symptoms persisted in 14.7% patients (S=0%, CRTS=7.1%, CRT=31.8%, CT=25%; P=0.01). The relative pelvic symptom-free periods were 93.0% in the S group, 83.1% in the CRTS group, 53.0% in the CRT group and 53.2% in the CT group (P<0.01). On multivariate analysis, only surgical treatment correlated with a significant relative pelvic symptom-free period (P<0.01), with an adjusted hazards ratio of 2.80 [95% CI: 1.79-4.39]. CONCLUSION: Our results suggest that rectal resection was the most effective therapeutic procedure in selected patients with RC and synchronous metastases, offering the patients the longest pelvic symptom-free periods.

Does magnetic stimulation of sacral nerve roots modify colonic motility? Results of a randomized double-blind sham-controlled study.

Although sacral nerve root stimulation (SNS) can result in a symptomatic improvement of faecal incontinence, the mechanism of action remains unknown. The aim of this study was to assess whether short-term magnetic SNS can inhibit pharmacologically induced propulsive colonic contractions. Twelve healthy volunteers (median age: 43.5 years old) were studied on two separate occasions and randomized into either active (15 Hz, 100% output intensity for 5 s min(-1) for 30 min) or sham rapid rate lumbosacral magnetic stimulation (rLSMS). Colorectal motility was recorded with a manometric catheter located at the most proximal transducer in the left colon and the most distal, in the rectum. Colonic contractions were provoked by instilling Bisacodyl. The effects of rLSMS on colonic, sigmoid and rectal contractions were monitored and recorded after Bisacodyl instillation. The appearance of high-amplitude contractions propagated or not (HAC/HAPC) provoked by Bisacodyl instillation was significantly delayed during active compared to sham stimulation (P = 0.03). There was no difference in the characteristics of HAC/HAPC (i.e. frequency, amplitude, duration, velocity of propagation) or the motility index with active or sham stimulation. The perception of urgency tended to be decreased with rLSMS following Bisacodyl instillation. The catheter was expulsed within a median of 16.5 min (range 8-39) after Bisacodyl administration during active stimulation compared to 14 min (range 5-40) during sham stimulation (P = 0.03). This study suggests that rLSMS could delay the appearance of the first Bisacodyl-induced colonic contractions.