Surgical management of retro-rectal tumors in the adult.

Retrorectal tumors (RRT), whether benign or malignant in nature, are rare in adults and often asymptomatic. While diagnosis is based on clinical findings, differential diagnosis depends mainly on magnetic resonance imaging (MRI). MRI provides guidance for surgical management, the first-line treatment of choice. Four surgical approaches are described: abdominal, perineal, posterior and abdomino-sacral.. This review of major reported series has made it possible to specify the indications for each surgical approach, as well as the advantages, disadvantages and complications of each one. The choice of surgical approach is determined by the nature of the RRT, its anatomical position relative to the middle of the third sacral vertebra (S3) and the presence or absence of invasion of the neighboring organs, the pelvis or sacral vertebrae. The abdominal route is chosen for tumors situated above the middle of S3, whether benign or malignant, but without invasion of neighboring organs. The perineal route is indicated for benign RRT situated below the middle of S3. The posterior route is chosen for tumors located below the middle of S3, and allows an associated resection of sacral segments in case of tumor invasion. The combined abdomino-sacral route is indicated for RRT above the middle of S3, when there is an invasion of a pelvic organ or a sacral vertebra. Intra- and post-operative complications are mainly hemorrhagic, neurological and infectious. The long-term prognosis is usually favorable, but varies according to the nature of the RRT and its management.

Intraoperative Near-Infrared Fluorescence Imaging using indocyanine green in colorectal carcinomatosis surgery: Proof of concept.

PURPOSES: This study assesses the value of using Intraoperative Near Infrared Fluorescence Imaging and Indocyanine green to detect colorectal carcinomatosis during oncological surgery. In colorectal carcinomatosis cancer, two of the most important prognostic factors are completeness of staging and completeness of cytoreductive surgery. Presently, intraoperative assessment of tumoral margins relies on palpation and visual inspection. The recent introduction of Near Infrared fluorescence image guidance provides new opportunities for surgical roles, particularly in cancer surgery. METHODS: The study was a non-randomized, monocentric, pilot "ex vivo" blinded clinical trial validated by the ethical committee of University Hospital of Saint Etienne. Ten patients with colorectal carcinomatosis cancer scheduled for cytoreductive surgery were included. Patients received 0.25 mg/kg of Indocyanine green intravenously 24 h before surgery. A Near Infrared camera was used to detect "ex-vivo" fluorescent lesions. RESULTS: There was no surgical mortality. Each analysis was done blindly. In a total of 88 lesions analyzed, 58 were classified by a pathologist as cancerous and 30 as non-cancerous. Among the 58 cancerous lesions, 42 were correctly classified by the Intraoperative Near-Infrared camera (sensitivity of 72.4%). Among the 30 non-cancerous lesions, 18 were correctly classified by the Intraoperative Near-Infrared camera (specificity of 60.0%). CONCLUSIONS: Near Infrared fluorescence imaging is a promising technique for intraoperative tumor identification. It could help the surgeon to determine resection margins and reduce the risk of locoregional recurrence.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey.

BACKGROUND: Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. METHODS: A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). RESULTS: Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. CONCLUSION: Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicentre retrospective cohort study of 566 patients.

BACKGROUND: Despite a high response rate to front-line therapy, prognosis of epithelial ovarian carcinoma (EOC) remains poor. Approaches that combine Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with this strategy. PATIENTS AND METHODS: A retrospective cohort multicentric study from French centres was performed. All consecutive patients with advanced and recurrent EOC treated with CRS and HIPEC were included. RESULTS: The study included 566 patients from 13 centres who underwent 607 procedures between 1991 and 2010. There were 92 patients with advanced EOC (first-line treatment), and 474 patients with recurrent EOC. A complete cytoreductive surgery was performed in 74.9% of patients. Mortality and grades 3 to 4 morbidity rates were 0.8% and 31.3%, respectively. The median overall survivals were 35.4 months and 45.7 months for advanced and recurrent EOC, respectively. There was no significant difference in overall survival between patients with chemosensitive and with chemoresistant recurrence. Peritoneal Cancer Index (PCI) that evaluated disease extent was the strongest independent prognostic factor for overall and disease-free survival in all groups. CONCLUSION: For advanced and recurrent EOC, curative therapeutic approach combining optimal CRS and HIPEC should be considered as it may achieve long-term survival in patients with a severe prognosis disease, even in patients with chemoresistant disease. PCI should be used for patient's selection.

Estimation of the risk for nutritional state degradation in patients with cancer: development of a screening tool based on results from a cross-sectional survey.

BACKGROUND: In routine practice, the evaluation of the nutritional status of patients with cancer is not always performed although there is frequent modification as disease progresses. The validated screening and evaluation tools currently available are time-consuming and costly. In this study we analysed factors that could be used to identify patients likely to need nutritional surveillance or intervention. PATIENTS AND METHODS: A cross-sectional survey was carried out for 2 weeks in June 2006 on 477 patients with cancer. RESULTS: 30.2% of the patients had lost more than 10% of their body weight since the start of the illness. After adjustment, the factors significantly associated with weight loss were: depressive state (OR = 3.49; P = 0.002), digestive or ENT tumours (OR = 3.20; P = <0.001), chemotherapy (OR = 2.66; P = 0.011), male gender (OR = 2.30; P = 0.001) and professional status (OR = 2.08; P = 0.02). Using a logistic model, we calculated the risk of weight loss as a function of the presence of the identified predictive factors. CONCLUSION: We report a simple screening tool, which will not replace the available evaluation methods but will enable targeting of the patients most likely, after a specific evaluation, to benefit from nutritional intervention. This remains to be validated in further prospective studies.

Cryosurgery for resectable and unresectable hepatic metastases from colorectal cancer.

AIMS: Hepatic cryosurgery is useful for patients with hepatic metastases from colorectal cancer confined to the liver but considered unresectables because of the number and location of lesions. While encouraging results were reported following cryosurgery for unresectable liver metastases we considered particularly valuable to examine the safety and effectiveness of cryosurgery in patients with resectable and unresectable metastases from colorectal cancer. METHODS: Between January 1997 and September 2005, 53 patients with liver metastases from colorectal cancer underwent hepatic cryosurgery at our institution. Hepatic metastases were resectable in 31 (58.5%) patients and unresectable in 22 (41.5%). RESULTS: A total of 136 liver metastases were treated in 53 patients. The size of treated lesions ranged from 0.5 to 10 cm (mean 2.7). There were 2 postoperative deaths (3.8%) from massive bleeding and from cryoshock. The overall morbidity rate was 66%. The median follow-up was 24.8 months. The overall survival rate at 12 months was 86.1%, at 48 months it was 27%. No significant difference was found between survival rates in patients with resectable or unresectable metastases. Among 31 patients with resectable liver metastases 7 (22.6%) patients developed recurrence at the site of cryosurgery. CONCLUSION: Survival rates were comparables between patients with resectable and unresectable metastases but a high complication rate and a substantial rate of local recurrence following cryosurgery should caution against its use to treat resectable disease.

[Management of traumatic retroperitoneal hematoma]. / Conduite à tenir devant un hématome rétro-péritonéal d'origine traumatique.

Traumatic retroperitoneal hematoma (RPH) may arise from injury to bony structures, major blood vessels, and intestinal or retroperitoneal viscera. To categorize the management of RPH, the retroperitoneum may be divided into three zones. Zone 1 (central) extends from the esophageal hiatus to the sacral promontory. Zone 2 (lateral) extends from the lateral diaphragm to the iliac crest. Zone 3 (pelvic) is confined to the retroperitoneal space of the pelvic bowl. For the traumatized patient with RPH, laparotomy is mandated by persistent hemodynamic instability despite intensive volume replacement. The judgment of whether and when to explore the retroperitoneal hematoma is guided by the mechanism of injury (blunt or penetrating) and the location of the RPH. RPH localized to the upper central area (Zone 1) after penetrating trauma implies injury to the great vessels and always requires urgent surgical exploration. RPH in other zones should be evaluated by CT and/or angiography; ongoing hemorrhage may respond to therapeutic embolization.

Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study.

PURPOSE: The three principal studies dedicated to the natural history of peritoneal carcinomatosis (PC) from colorectal cancer consistently showed median survival ranging between 6 and 8 months. New approaches combining cytoreductive surgery and perioperative intraperitoneal chemotherapy suggest improved survival. PATIENTS AND METHODS: A retrospective multicenter study was performed to evaluate the international experience with this combined treatment and to identify the principal prognostic indicators. All patients had cytoreductive surgery and perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy). PC from appendiceal origin was excluded. RESULTS: The study included 506 patients from 28 institutions operated between May 1987 and December 2002. Their median age was 51 years. The median follow-up was 53 months. The morbidity and mortality rates were 22.9% and 4%, respectively. The overall median survival was 19.2 months. Patients in whom cytoreductive surgery was complete had a median survival of 32.4 months, compared with 8.4 months for patients in whom complete cytoreductive surgery was not possible (P <.001). Positive independent prognostic indicators by multivariate analysis were complete cytoreduction, treatment by a second procedure, limited extent of PC, age less than 65 years, and use of adjuvant chemotherapy. The use of neoadjuvant chemotherapy, lymph node involvement, presence of liver metastasis, and poor histologic differentiation were negative independent prognostic indicators. CONCLUSION: The therapeutic approach combining cytoreductive surgery with perioperative intraperitoneal chemotherapy achieved long-term survival in a selected group of patients with PC from colorectal origin with acceptable morbidity and mortality. The complete cytoreductive surgery was the most important prognostic indicator.

A pancreatic-induced intramural duodenal hematoma: a case report and literature review.

Spontaneous intramural duodenal hematomas are not frequent and generally are related with an anticoagulant treatment. Pancreatic origin has seldom been described and the treatment is always controversial. We report a new case of a pancreatitis-induced intramural duodenal hematoma that was conservatively managed and we review the literature.

Laparoscopic repair of incisional hernia: a retrospective study of 159 patients.

BACKGROUND: In this long-term retrospective study, a laparoscopic technique was used for incisional hernia repair. METHODS: Over a 6-year period, we performed laparoscopic repairs with prosthetic mesh in 159 patients suffering from incisional hernia. Morbidity factors were noted and operative data were collected. In addition, early and long-term complications and recurrences were analyzed. RESULTS: There were no deaths as a result of the procedure. In 21 patients (13.8%), the operation was converted to an open procedure. Small bowel perforation occurred in three patients (1.9%). Mean hospital stay was 3.5 days. Early complications occurred in 61 patients (44%). The mean follow-up time was 49 months. There were no infections of the prosthetic mesh. Residual abdominal pain was reported in 31 patients (26%). Bowel obstructions requiring resection were found in two patients (1%), and hernia recurrence was observed in 19 patients (15.7%). CONCLUSIONS: Laparoscopic herniorraphy is a promising technique with all the advantages of minimal-invasive surgery. Nevertheless, close attention needs to be paid to the choice of the hernia and mesh size and to the fixing of the mesh.

[Port-site metastasis after laparoscopic resction of a duodenal stromal tumor]. / Métastase sur orifice de trocart après exérèse laparoscopique d'une tumeur stromale du duodénum.

Gastro-intestinal stromal tumors are rare and their evolution is dubious. This observation of port site metastasis after laparoscopic resection of a small duodenal stromal tumor would be, to our knowledge, the first case reported in the literature. Several direct and indirect mechanisms were supposed to be involved in the appearance of metastases after laparoscopic surgery, but the risk of dissemination remains badly evaluated on its frequency as well as on its mechanisms.

[Isolated pancreatic neck rupture]. / Fracture isolée de l'isthme du pancréas.

AIM OF THE STUDY: Through four cases of pancreatic neck rupture, the study aim was to emphasize the advantages of an early laparotomy when there is a doubt about a canal disruption and the risks of a later surgical management. PATIENTS AND RESULTS: Four patients were operated on for a neck disruption of the pancreas due to blunt trauma. Two patients underwent laparotomy in the first 48 hours after a radiological exploration and underwent a left pancreatectomy with spleen preservation. There were no associated injuries, no lesions of acute pancreatitis. The two other patients were, at first, medically treated and developed an acute pancreatitis with pseudocyst. They underwent laparotomy, 7 and 10 days after the trauma because of pain and hyperthermia, and a conservative treatment by cystojejunostomy was performed in difficult conditions because of the acute pancreatitis. A late pancreatic pseudocyst (4 and 6 months) occurred in two patients. CONCLUSION: When pancreatic trauma occurs, an exploration with echography, scanner, endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography can suggest a neck disruption and a canal rupture. When the canal is safe, a drainage close to the pancreas is sufficient. When the rupture of the canal is suspected or proved, an early laparotomy is necessary in order to investigate the pancreas and to perform the appropriate procedure. This surgery is easier before the occurrence of pseudocyst and acute pancreatitis.

Intraperitoneal chemohyperthermia for peritoneal carcinomatosis: original modeling, clinical tolerance and results study about 30 patients.

BACKGROUND/AIMS: The authors' objective is to report their experience of the intraperitoneal chemohyperthermia after a thermal modeling study which has allowed the optimization the intraperitoneal chemohyperthermia circuit and its running parameters and to evaluate the intraperitoneal chemohyperthermia tolerance. Intraperitoneal chemohyperthermia is considered more and more as an interesting therapeutic option in cases of some abdominal carcinomatosis, particularly of digestive origin. However, the main technical problem of this treatment is the homogenization of the temperature distribution in the abdominal cavity. METHODOLOGY: A thermal modeling has allowed us to finalize a reliable and well-tolerated intraperitoneal chemohyperthermia technique. The achievement of a physical model of the abdomen has allowed us to make an experimental study of the temperature distribution in a given liquid volume. Two steps were carried out. The first step was the characterization of the model with a thermal study carried out on the physical model and which has led to dynamic data about the heat balance leading to a knowledge model. The second step was the identification of a theoretical model of the thermal behavior which would correlate best with the experimental data. Between January 1995 and January 1998, 30 patients with peritoneal carcinomatosis were studied. Twenty-six patients underwent maximal cytoreductive surgery with abdominal evisceration, intraperitoneal chemohyperthermia. Intraperitoneal chemohyperthermia was carried out for 1 hour, at 42 degrees C, with a flow rate of 0.9 L/min in the 30 patients. The thermal modeling has shown the main purpose of a high flow rate of 0.9 L/min in the homogenization of temperature distribution. RESULTS: The 2 steps are shown to converge. This coherency between the 2 models proves that the thermal aspects of the process have been properly identified. Our initial results have shown that intraperitoneal chemohyperthermia was properly tolerated. Major intraoperative complications occurred for 1 patient. CONCLUSIONS: The experimental study with thermal modeling results should help to optimize the intraperitoneal chemohyperthermia circuit and its running parameters for human treatment, with an acceptable morbidity in 30 patients.

[Peritoneal carcinomatosis treated by cytoreductive surgery and intraperitoneal chemohyperthermia]. / Carcinoses péritonéales traitées par chirurgie de réduction tumorale et chimiohyperthermie intrapéritonéale.

STUDY AIM: The aim of this prospective non-randomized trial was to report a series of intraperitoneal carcinomatosis due to miscellaneous causes, treated by intraperitoneal hyperthermic perfusion (IPHP) and cytoreductive surgery. PATIENTS AND METHOD: From January 1995 to May 1999, 35 patients were treated by IPHP and 26 of them underwent maximal cytoreductive surgery. IPHP was performed for 60 minutes at an intraperitoneal temperature of 42 degrees C with Mitomycin C (10 mg/L) or cisplatinum (12 mg/L) at a flow rate of 0.9 L/min. RESULTS: There was one (2.8%) postoperative death due to respiratory complications on day 16. Three patients (8.5%) were admitted to the intensive care unit. A high morbidity rate (54%) was observed with intra-abdominal complications in 28.5% of patients, requiring reoperation in three patients. In patients with stages 1 and 2 peritoneal carcinomatosis (granulations less than 5 mm), the 12- and 24-month survival rates were 63.1% and 31.5%, respectively. In patients with advanced stage 3 (diffuse malignant nodules less than 2 cm) and stage 4 carcinomatosis (malignant nodules larger than 2 cm), the 12- and 24-month survival rates were 31.2% and 12%, respectively. Six patients survived for more than 30 months. CONCLUSION: IPHP appears to be an effective treatment for peritoneal carcinomatosis. IPHP combined with cytoreductive surgery is aggressive with a high morbidity rate. Rigorous patient selection is necessary. IPHP is still under evaluation. Prospective randomized trials with identical IPHP protocols are required.

[Laparoscopic excision of a duodenal neuroendocrine tumor]. / Exérèse laparoscopique d'une tumeur neuroendocrine duodénale.

A 75-year-old woman with melena was found to have a carcinoid tumor in the posterior wall of the duodenal bulb. The biology was normal. The tumor measured 10 mm in size, and endoscopic ultrasonography showed only submucosal involvement. There was no liver metastasis and no regional lymph nodes. Tumoral resection was performed laparoscopically with success. Postoperative course was uneventful. Laparoscopic resection could be an appropriate minimally invasive treatment for selected small size duodenal tumors.

Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study.

BACKGROUND: Peritoneal carcinomatosis (PC) is a common evolution of digestive cancer, associated with a poor prognosis. Yet it is poorly documented in the literature. METHODS: Three hundred seventy patients with PC from non-gynecologic malignancies were followed prospectively: the PC was of gastric origin in 125 cases, of colorectal origin in 118 cases, of pancreatic origin in 58 cases, of unknown origin in 43 cases, and of miscellaneous origins in 26 cases. A previously reported PC staging system was used to classify these 370 patients. RESULTS: Mean and median overall survival periods were 6.0 and 3.1 months, respectively. Survival rates were mainly affected by the initial PC stage (9.8 months for Stage I with malignant peritoneal granulations less than 5 mm in greatest dimension, versus 3.7 months for Stage IV with large, malignant peritoneal masses more than 2 cm in greatest dimension). The presence of ascites was associated with poor survival of patients with gastric or pancreatic carcinoma. Differentiation of the primary tumor did not influence the prognoses of patients with PC. CONCLUSIONS: A better knowledge of the natural history of PC is needed, in view of the many Phase I, II, and III trials currently being conducted to evaluate aggressive multimodal therapeutic approaches to treating patients with PC from non-gynecologic malignancies.