Biosimilar versus branded enoxaparin to prevent postoperative venous thromboembolism after surgery for digestive tract cancer: Randomized trial.

Cancer and/or major surgery are two factors that predispose to post-operative thrombosis. The annual incidence of venous thromboembolic disease (VTED) in cancer patients was estimated at 0.5%-20%. Surgery increases the risk of VTED by 29% in the absence of thromboprophylaxis. Enoxaparin is a low molecular weight heparin that is safe and effective. Branded Enoxaparin and biosimilar Enoxaparin are two enoxaparin treatments. This study aimed to compare Branded Enoxaparin with biosimilar Enoxaparin in patients operated on for digestive cancer regarding the prevention of postoperative thrombosis event, to compare the tolerance of the two treatments and to identify independent predictive factors of thromboembolic incident. A randomized controlled trial conducted in a single-centre, surgical department B of Charles Nicolle Hospital, over a 5-year period from October 12th, 2015, to July 08th, 2020. We included all patients over 18 who had cancer of the digestive tract newly diagnosed, operable and whatever its nature, site, or stage, operated on in emergency or elective surgery. The primary endpoint was any asymptomatic thromboembolic event, demonstrated by systematic US Doppler of the lower limbs on postoperative day 7 to day 10. The sonographer was unaware of the prescribed treatment (Branded Enoxaparin [BE] or biosimilar Enoxaparin [BSE]). Of one hundred sixty-eight enrolled patients, six patients (4.1%) had subclinical venous thrombosis. Among those who had subclinical thrombosis, four patients (5.6%) were in the Branded Enoxaparin group and two patients (2.7%) in the Biosimilar Enoxaparin group without statistically significant difference (p = 0.435). Analysis of the difference in means using Student's t test demonstrated the equivalence of the two treatments. Our study allowed us to conclude that there was no statistically significant difference between Branded Enoxaparin and Biosimilar Enoxaparin regarding the occurrence of thromboembolic accidents postoperatively. BE and BSE are equivalent. Trial registration. Trial registration: The trial was registered on CLINICALTRIALS.GOV under the number NCT02444572.

Paraduodenal hernia: An exceptional cause of acute bowel obstruction.

Internal hernias represent only 0.2%-0.9% of all causes of bowel obstruction. A 59-year-old patient presented urgently with small bowel obstruction. Laparotomy revealed a left paraduodenal hernia with most of the small bowel herniating through a space between the inferior mesenteric vein and duodenojejunal junction.

Quality assessment of rectal cancer surgery: How are we doing?

INTRODUCTION: Surgery remains a cornerstone in the treatment of rectal cancer. Optimal surgical resection implies respect for carcinologic principles. The best way to evaluate a good quality of resection requires certainly an exhaustive evaluation of the surgical specimen by the surgeon and the pathologist. AIM: To assess the quality of resected rectal cancers. METHODS: This study included patients operated on for rectal malignant epithelial tumors, between January 1st, 2015 and December 31st, 2020, in the general surgery department B at Charles Nicolle's Hospital in Tunis. Data relevant to the pathologic examination were recorded. We performed a descriptive study and an analytic bivariate study comparing the two groups "number of lymph nodes harvested less than 12" versus "number of lymph nodes harvested higher than or equal to 12". RESULTS: Neoadjuvant therapy was performed in 39 patients (79%). Anterior resection (AR) was performed in 43 patients (43%) and abdominoperineal resection (APR) was performed in 11 patients (20%). There were no invaded margins. The mean distal surgical margin was 3±1.4 cm. Mesorectum was complete in 38 surgical specimens (70%). The median number of lymph nodes harvested was 14. Resection was considered R0 in 47 patients (87%). In bivariate analysis, there was no difference between the "number of harvested lymph nodes <12" and the "number of harvested lymph nodes ≥ 12"groups for the variables: laparotomy, laparoscopic approach, conversion to laparotomy and chemoradiotherapy. CONCLUSION: Quality of surgical resection of rectal cancer in our department was in accordance with recommendations.

Intestinal ischemia in patients with incarcerated groin hernia: proposal and validation of a score.

PURPOSE: Intestinal ischemia (II) is the most critical factor to determine in patients with incarcerated groin hernia (IGH) because II could be reversible, and it is considered as a "time sensitive condition." Although predictive factors of II were identified in several previous studies, preoperative diagnosis of II cannot be reliably made or excluded by any known parameter. The aims of this study were: to devise and to validate a clinic-biologic score, with a strong discriminatory power, for predicting the risk of II in patients with IGH. METHODS: We conducted a retrospective bicentric study including 335 patients with IGH. Logistic regression analysis was used to identify independent predictive factors of II. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second independent population of 45 patients admitted for IGH in the same departments (internal validation). RESULTS: Four independent predictive factors of II were identified: heart rate, duration of symptoms before admission, prothrombin, and neutrophil-to-lymphocyte ratio (NLR). A predictive score of II was established based on these independent predictive factors. Sensitivity was 94.50%; specificity was 92.70%. The AUC of this score was 0.97. The AUC was 0.96 when the score was applied on the second population of patients. CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score was 0.97). This score is reliable and reproducible, so it can help a surgeon to prioritize patients with II for surgery (especially at this time of COVID-19 pandemic), because ischemia could be reversible, avoiding thus intestinal necrosis.

Recurrence Factors of Groin Hernia: a systematic Review.

BACKGROUND: Groin hernia repair is a common intervention and reoperation rate for recurrence reachs 15%. Recurrence can be attributed to patients related factors  or influenced by the surgical technique. Furthermore, treating recurrence can be challenging with the risk ratio of developing a second recurrence equal to 2,7. Identifying those factors is the first step to improve hernia repair results. AIM: This systematic review aimed to identify  recurrence risk factors of groin hernia and to determine adequate treatment for recurrence. METHODS: We conducted a literature search on the Pubmed and Cochrane databases. Keywords used were: "inguinal hernia", "groin hernia", "recurrence" and  "surgical repair". Were included meta-analyses,  systematic reviews, randomized and non-randomized clinical trials, from 2008 to 2017, with their available  english full text which methodoly was evaluated. RESULTS: We identified 67 articles. Twenty-four articles were not eligible. Three articles were not available in full-text. We analyzed 40 articles. After evaluation of the methodology, six articles were excluded: these were randomized trials with a Jadad score inferior to 3. We finally selected 34 articles. The qualitative analysis of the literature revealed that heredity, female gender, obesity and smoking were general recurrence factors of groin hernia  with a level 2 of evidence. Non mesh-repair and « TEP ¼ approach for unilateral inguinal hernia favor groin hernia recurrence with a level 1 of evidence. Nor the surgical approach (laparoscopic, open), nor the mesh type, nor its fixation does affect recurrence with a level 1 of evidence. In treating  groin hernia recurrence, the inverted approach (anterior-posterior and posterior-anterior) recommended in the guidelines is questionable. CONCLUSION: This systematic review allowed us to recommand weigh loss and smoking cessation for patients undergoing groin hernia surgery. As concerns groin hernia recurrence treatment, the inverted approach (anterior-posterior and posterior-anterior) recommended in the guidelines is questionable. The choice of the adequate technique depends on the primary repair and also includes the surgeon preferences.

Predictive factor of recurrence after curative resection for stage I-II colon cancer.

BACKGROUND: Colon cancer has become a common malignant neoplasm in Tunisia. Patients with negative lymph node have a 5 years recurrence rate of 21.1%. Studies reporting the prognostic factors of recurrence for patients with stage I-II colon cancer are limited. AIM: This study aimed to determine factors predicting recurrence for patients with stage I-II colon cancer after curative resection. METHODS: This was a retrospective cohort study. Were included patients who underwent curative surgery for stage I or II colon cancer. Enrolled variables were subdivided into: Pre-operative, Intraoperative and Post-operative variables. Main outcome measures were local recurrence and distant metastasis detected during follow-up. RESULTS: Eighteen men and 17 women with median age of 61 years, ranging from 33 to 89, were enrolled in this study. Twenty-eight patients out of 35 were classified T3 and T4 colon cancer. The mean number of lymph nodes harvested was 16.23 (median= 17; range: 4-44). Ten patients (28%) had colloid component in the tumor. At a median follow-up of 23 months (range: 6-56 months), recurrence was observed in five cases (14%). Variables associated to recurrence were Carcinoembryonic antigen level (p= 0.03), serum albumin level (p=0.029) and the presence of colloid component (0.02). Multivariate logistic regression retained colloid component as the only predictive factor of recurrence (OR=1.2, 95%CI [1.019-1.412], p=0.028). CONCLUSIONS: This study showed that the percentage of mucinous component equal or greater than 25% was the only predictive factor of recurrence for curatively resected, stages I and II, colon cancer.

Laparoscopic Versus Open Complete Mesocolon Excision in Right Colon Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Laparoscopic complete mesocolon excision (LCME) for right colonic cancer improves oncological outcomes. This systematic review and meta-analysis aimed to compare intraoperative, postoperative, and oncological outcomes after LCME and open total mesocolon excision (OCME) for right-sided colonic cancers. METHODS: Literature searches of electronic databases and manual searches up to January 31, 2019, were performed. Random-effects meta-analysis model was used. Review Manager Version 5.3 was used for pooled estimates. RESULTS: After screening 1334 articles, 10 articles with a total of 2778 patients were eligible for inclusion. Compared to OCME, LCME improves results in terms of overall morbidity (OR = 1.48, 95% CI 1.21 to 1.80, p = 0.0001), blood loss (MD = 56.56, 95% CI 19.05 to 94.06, p = 0.003), hospital stay (MD = 2.18 day, 95% CI 0.54 to 3.83, p = 0.009), and local (OR = 2.12, 95% CI 1.09 to 4.12, p = 0.03) and distant recurrence (OR = 1.63, 95% CI 1.23-2.16, p = 0.0008). There was no significant difference regarding mortality, anastomosis leakage, number of harvested lymph nodes, and 3-year disease-free survival. Open approach was significantly better than laparoscopy in terms of operative time (MD = - 34.76 min, 95% CI - 46.01 to - 23.50, p < 0.00001) and chyle leakage (OR = 0.41, 95% CI 0.18 to 0.96, p = 0.04). CONCLUSIONS: This meta-analysis suggests that LCME in right colon cancer surgery is superior to OCME in terms of overall morbidity, blood loss, hospital stay, and local and distant recurrence with a moderate grade of recommendation due to the retrospective nature of the included studies.

Endogenous hyperinsulinism: diagnostic and therapeutic difficulties.

Endogenous hyperinsulinism is an abnormal clinical condition that involves excessive insulin secretion, related in 55% of cases to insulinoma. Other causes are possible such as islet cell hyperplasia, nesidioblastosis or antibodies to insulin or to the insulin receptor. Differentiation between these diseases may be difficult despite the use of several morphological examinations. We report six patients operated on for endogenous hyperinsulinism from 1st January 2000 to 31st December 2015. Endogenous hyperinsulinism was caused by insulinoma in three cases, endocrine cells hyperplasia in two cases and no pathological lesions were found in the last case. All patients typically presented with adrenergic and neuroglycopenic symptoms with a low blood glucose level concomitant with high insulin and C-peptide levels. Computed tomography showed insulinoma in one case out of two. MRI was carried out four times and succeeded to locate the lesion in the two cases of insulinoma. Endoscopic ultrasound showed one insulinoma and provided false positive findings three times out of four. Intra operative ultrasound succeeded to localize the insulinoma in two cases but was false positive in two cases. Procedures were one duodenopancreatectomy, two left splenopancreatectomy and two enucleations. For the sixth case, no lesion was radiologically objectified. Hence, a left blind pancreatectomy was practised but the pathological examination showed normal pancreatic tissue. Our work showed that even if morphological examinations are suggestive of insulinoma, other causes of endogenous hyperinsulinism must be considered and therefore invasive explorations should be carried out.

A case report of complicated appendicular hydatid cyst mimicking an appendiceal mucocele.

Retaining the etiology of a cystic lesion in the right iliac fossa can be difficult. Appendicular hydatid cyst is a very uncommon cause of a such lesion. In some cases, diagnosis is not obvious. It can radiologically mimic an appendix mucocele, a complicated ovarian cyst, an appendicular lymphangioma or an abscess. Our case highlights the difficulties encountered in this kind of situation and despite the contribution of imaging. We present a case of a 75 years-old woman presented with a right lower quadrant continuous pain. Abdominal CT-scan revealed a multilocular cystic and hydro-aeric mass. The diagnosis of an appendiceal mucocele complicated with gelatinous peritonitis was suspected. An open debulking surgery with right hemicolectomy was performed. The pathological exam has concluded to an infected appendicular hydatid cyst with thick calcified walls. The aim of this work is to report a case of an appendicular hydatid cyst that has imitated an appendicular mucocele to discuss the importance of differential diagnostic reflections and the appropriate treatment.

Mini-Invasive management of concomitant gallstones and common bile duct stones : where is the evidence ( Review article).

BACKGROUND: The ideal mini-invasive management of common bile duct stones (CBDS) with concomitant gallbladder stones is debatable. This article aims to review the management of this condition during the last decade using the mini-invasive approach. METHODS: A database research in Medline, Embase, Cochrane and Google Scholar during the period between January 2009 to December 2018 was performed. The keywords used were «ERCP¼, «common bile duct exploration¼, «endoscopic sphincterotomy¼, «laparoscopic surgery¼, «laparoscopic cholecystectomy¼, «choledocholithiasis¼, «common bile duct stones¼ «meta-analysis¼ and «randomized clinical trials¼. RESULTS: There were 14 studies comparing mini-invasive procedures. There were nine meta-analysis, three reviews articles and two randomized clinical trials. We concluded to the absence of difference between the group laparoscopic cholecystectomy (LC) with a laparoscopic exploration of CBD (LECBD) and LC with endoscopic retrograde cholangiopancreatography (ERCP) in terms of mortality, morbidity, stones extraction success rate and duration of hospital stay. LC + ERCP is superior in terms of conversion and treatment cost. Concerning LC with a preoperative ERCP versus LC with postoperative ERCP, based on the literature data, no conclusions could be drawn. Concerning LC with LECBD versus LC with preoperative ERCP, we conclude to the absence of difference in terms of mortality, morbidity and conversion rate. Given the discordance of the results, in terms of successful extraction rate of stones, operating time and duration of hospital stay we cannot conclude to the superiority of one technique. Concerning LC with LECBD versus LC with postoperative ERCP, we conclude the absence of difference in terms of mortality, morbidity, the success rate of stones extraction, duration of hospital stays and conversion rate. Concerning LC with intraoperative ERCP versus LC with preoperative ERCP, we concluded to the absence of difference in terms of mortality, morbidity and rate of success stones extraction. The LC + intraoperative ERCP was superior in terms of hospital stay duration and conversion rate. Concerning one-stage versus two-stage treatment, we concluded to the absence of difference in terms of mortality, morbidity, the success rate of stone extraction, the conversion rate and the duration of hospital stay. CONCLUSIONS: One-stage or two-stages procedures are feasible and safe with equivalent efficacy. Surgeons must be aware of the different difficulties of these procedures and should be judicious in their use of different techniques.

Management of perforated duodenal peptic ulcer treated by suture.

BACKGROUND: Laparoscopic surgery has become the gold standard for many procedures owing to its advantages such as a shorter post-operative stay, a faster recovery and less postoperative pain. However, choosing laparoscopic approach in an emergency situationsuch as in the management of a perforated duodenal peptic ulcer is still debated because of the absence of significant benefits. This study aimed to assess the management of perforated duodenal peptic ulcer treated by suture. METHODS: It's a retrospective study enrolling 81 patients operated on for duodenal perforated peptic ulcer between June 1st, 2012 and December 31st, 2016 who underwent surgery in the surgical department B of Charles Nicolle's Hospital. RESULTS: Our retrospective study showed that laparoscopic approach had shorter post-operative duration (3 [1-5] versus 4 [1-16] days, respectively, p< 0.001), shorter mortality rate (3% versus 19%, p=0.032) and more uneventful post-operative course (97% versus 74%, p=0.004) comparing to the open approach. Patients who were not admitted in the intensive care unit during the first 48 hours had 9.901 more chance to be operated by laparoscopic approach. Patients who were operated on by a senior had 3.240 times more chance to be operated by laparoscopic approach. There was no predictive variable for conversion. Mortality rate was 11%. Age was the only predictive independent factor of mortality with a cut-off point of 47 years. CONCLUSIONS: Laparoscopic approach is routinely practised in the perforated duodenal ulcer. In our study, we showed that laparoscopic approach had less post-operative complications, a lower rate of mortality and a shorter post-operative duration comparing to the open approach. The main limitation of our study was non-randomization and lack of laparoscopic expertise. The decision for either open or laparoscopic approach was then dependent on senior surgeon's availability.

Predictive factors for major amputation of lower limb in diabetic foot: about 430 patients.

BACKGROUND: Major amputation of the lower limb is defined by a leg or thigh amputation. The aim of our work was identifying predictive factors for lower limb major amputation in patients with diabetes admitted on for foot lesions through using an administrative data base. METHODS: It was a retrospective study ranging from June 1st, 2008 to December 31st, 2011, which included all the patients admitted on for an infected diabetic foot to the surgery unit B of Charles Nicolle hospital in Tunis. The main judgement criterion was the major amputation of the lower limb. We have done a descriptive and a comparative study, with univariate and multivariate analysis. RESULTS: We have enrolled 319 men and 111 women. The average age was 60.5 ± 12 years. Ninety five patients (24%) had a major amputation. Former inpatient, patient readmitted within one month post-operatively, stay in intensive care, admission in intensive care within 48hours after admission, age ≥ 65 years, presence of kidney problem, preoperative stay and length of intervention were identified as predictive factors of major amputation in the univariate analysis. Age was the only independent variable predictive for major amputation which appeared from the multivariate analysis (p=0.004).  The age cut-off ≥ 65 years has a specificity of 69 % and a sensitivity of 47% [p=0.004, OR=1.971, IC 95% : 1.239-3.132]. CONCLUSIONS: Age was the only independent predictive factor for major amputation of the lower limb in the diabetic foot with a threshold value higher or equal to 65 years. Patients aged more than 65 had 1.9 time more risk to undergo major amputation of the lower limb.

Atypical form of peritoneal tuberculosis.

It was a 48-year-old woman with a right flank mass. On examination there was a hard and painful mass of the right side, centered by a fistula orifice with a diameter of 5 mm. Abdominal computed tomography showed an intraperitoneal tissue structure in relation to the parietal peritoneum in the left hypochondria. A scanno-guided biopsy was performed. Pathological examination revealed non-specific inflammatory lesions. The evolution was marked by the appearance of a purulent fistula in the puncture site. A biopsy of the margins of the fistulous orifice of the left hypochondria was performed. Pathological examination found a granular infiltrate with caseous necrosis confirming the diagnosis of tuberculosis. The patient was put under anti-tuberculosis treatment with a good clinical and radiological evolution.

Morbidity and mortality of infected diabetic foot managed in general surgical department.

BACKGROUND: Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers. METHODS: It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality. RESULTS: This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08  23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92  33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41  16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055  0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004  0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014  1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039  1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071  0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298  0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088  0.354], p<0.001)  and Pre-operative stay (OR=1.083, 95%CI [1.033  1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48  0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76  0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558  7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038  1.147], p=0.001) was predictive of reintervention. CONCLUSIONS: Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.

Alkalin phosphatase is a predictive factor of unresecability in ampullary and periampullary tumors.

BACKGROUND: Patients with malignant obstructive jaundice should undergo surgery on the basis of results of preoperative imaging. However, about half of patients are found to be unsuitable forresection during surgical exploration. Our study aimed to determine the clinicobiologicalcharacteristics that predict the resecability of ampullary and periampullary tumors. METHODS: We retrospectively reviewed the medical records of 49 patients (45% men and 55% women) who had malignant obstructive jaundice collected in the Department B of generalsurgery, Charles Nicolle hospital between July 1, 2008 and December 31, 2013. Predictivevariables of unresecability in malignant obstructive jaundice were identified using univariate andmultivariate analysis. RESULTS: 49 patients were included in the study. The mean age was 66,3±12,9 years. Twenty patients underwent surgery. Radical resection was performed in 12 patients and surgical palliation by biliary bypass was performed in 8 patients. Twenty-nine patients unfit for surgery underwent endoscopic stenting and chemotherapy. At univariate analysis, age (p=0,016), body mass index (p=0,033), worse general health status (p=0,037), locally advanced disease (p<0,001), serum conjugated bilirubin level (p=0,055), and serum level alkaline phosphatase (ALP) (p=0,014) were associated with unresectableampullary and periampullary tumors. At multivariate analysis serum level ALP was identify as an independent factor of unresecability in malignant obstructive jaundice [OR=0,996; IC à 95% (0,992-1,000) ;p=0,048]. The area under the ROC curve was 0,745 (p=0,016). CONCLUSION: Serum level of ALP can predict resecability in malignant obstructive jaundice. Further studies are needed to identify other factors predicting resecability and prognosis of ampullary and periampullary tumors.

Surgery of the pancreatic cystic echinococcosis: systematic review.

The prevalence of pancreatic cystic echinococcosis (PCE) in the world is low ranging between 0.2% and 0.6%. The diagnosis of PCE is easy when it is associated to other location such as liver, it became difficult when PCE was isolated simulating other diagnosis such as pseudocyst, a choledochal cyst, serous or mucinous cystadenoma and cystadenocarcinoma. This systematic review aimed to provide evidence-based answer to the following questions: (I) what are the efficient tools to affirm the diagnosis of isolated PCE and (II) what are the best therapeutic strategy for the PCE? An electronic search was performed by two authors (W Dougaz, I Bouasker). Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane collaboration were consulted. The keywords used were "cyst", "echinococcosis", "hydatid cyst" and "pancreas". All abstracts were analyzed followed by extraction of the full text by the same two authors (W Dougaz, I Bouasker), all divergences were resolved by discussion with C Dziri. Recommendations were based on Oxford's classification: (I) what are the efficient tools to affirm the diagnosis of PCE? -ultrasound remains the cornerstone of diagnosis. Magnetic resonance imaging (MRI) reproduces the ultrasound defined features of CE better than computed tomography (CT). MRI with heavily T2-weighted series is preferable to CT. Pancreatic duct MRI should be promising to identify a fistula between PCE and pancreatic duct (level of evidence 3-recommendation B); (II) what are the best therapeutic strategy for the PCE? -surgery is the main treatment of PCE. Open approach is validated. The decision depends of the location of PCE: head versus body and/or tail of the pancreas (level of evidence 5-recommendation D): for the head of the pancreas, the tendency is toward conservative surgery. For body and/or tail of the pancreas, the tendency is toward radical surgery. Medical treatment (albendazole) should be prescribed 1 week before surgery and 2 months during postoperative period (level II evidence and grade C recommendation).

Prognostic factors in rectal cancer: where is the evidence?

BACKGROUND: In rectal cancer, the 5 years survival is about 53 % for all stages: it remains low in spite of the progress of diagnostic and therapeutic tools. The aim of this work was to provide evidence based answers to the following question: what are the pre, intra and post operative prognostic factors in rectal cancer? METHODS: We have carried out a search in the following data bases: Pubmed, Embase, Cochrane and Scopus. The key words used were: « rectal cancer ¼, « adenocarcinoma ¼, « overall survival ¼, « disease-free survival ¼, « prognosis ¼ and « evidence-based medicine ¼. The overall 5 years survival rate has been retained as primary outcome measure. Recurrence-free survival has been retained as secondary endpoint. Were included meta-analyses and systematic reviews of clinical trials dating back to less than six years. RESULTS:   We retrieved 270 publications, 27 articles only met the above-mentioned eligibility criteria and thereof have been retained in this work. A high operating volume, a specialized surgeon in colorectal surgery, a total mesorectal excision, an adjuvant chemotherapy given within no more than 8 weeks following the curative resection improve prognosis in rectal cancer with level I of evidence. Anastomotic leak and diabetes worsen prognosis in rectal cancer with level I of evidence. Margin of surgical resection must be RO to improve prognosis in rectal cancer with level I of evidence. CONCLUSION: The main prognostic factors found in literature which we should keep in mind are those on which surgeons can  act:  neoadjuvant treatment,  high operating volume of the surgeon,  high tie of the inferior mesenteric  artery,  mesorectal excision , RO resection,  improvement of the techniques of intersphincteric resection and techniques of anastomosis   and adjuvant chemotherapy within less than 8 weeks when appropriate.