Outpatient colectomy within an enhanced recovery program.

INTRODUCTION: The application of a fast-track recovery program after surgery can decrease the physiological impact of surgery and reduce the duration of hospitalisation compared to conventional care. This program has permitted us to consider the performance of colectomy on an outpatient basis. METHOD: After analyzing the recommendations for fast-track recovery, we developed and validated a specific protocol. Drawing on extensive experience in ambulatory surgery (inguinal hernia, cholecystectomy, adjustable gastric-banding), we formalized a protocol for outpatient colectomy. Patient selection criteria were the absence of serious or decompensated comorbidity, very good general condition, and full patient understanding of the procedure. Discharge was authorized if the patient met the exit criteria according to the Chung score. Postoperative surveillance was provided by regular home visits of a nurse trained in enhanced recovery, every afternoon until day 10. RESULTS: Five patients underwent this management strategy (4 men and 1 woman, mean age 64 years, range: 59-69), for indications including cancer of the rectosigmoid junction (1 case), sigmoid diverticulitis (3 cases), and volvulus. The postoperative course was simple and uncomplicated except for two patients who had dysuria and an incisional hematoma, respectively. CONCLUSION: To our knowledge, these are the first cases of colectomy performed strictly on an outpatient basis (i.e., stay<12h). We demonstrated the feasibility of outpatient colectomy when integrated into a protocol of enhanced recovery for selected patients provided that at-home monitoring was available.

[Gas gangrene of the abdominal wall due to underlying GI pathology: seven cases]. / Gangrène gazeuse extensive révélant une pathologie digestive: 7 observations.

OBJECTIVE: Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall. PATIENTS AND METHODS: Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated. RESULTS: The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%). CONCLUSION: The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

[Gastrojejunocolic fistula, report of two recent cases with original management]. / Fistule gastrojéjunocolique: prise en charge originale de deux patients.

Gastrojejunocolic fistulae, ultimate complication of anastomotic peptic ulceration, are presently uncommon. We report two recent cases of postoperative gastrojejunocolic fistulas (after duodenal ulcer surgery and total duodenopancreatectomy), which were complicated at time of diagnosis (acute peritonitis and liver cirrhosis) and required a two-stage treatment.

Experimental evaluation of lesion prediction modelling in the presence of cavitation bubbles: intended for high-intensity focused ultrasound prostate treatment.

The accuracy of high-intensity focused ultrasound (HIFU) lesion prediction modelling was evaluated for a truncated spherical transducer designed for prostate cancer treatment The modelling adapted the bio heat transfer equation (BHTE) to take into account the activity of cavitation bubbles generated during HIFU exposure. This modelling was used to predict the lesions produced by three different transducer geometries: fixed-focus, concentric-ring and 1.5D phased-array. Lesions were predicted for different ultrasound exposure conditions close to those used in prostate cancer treatment. Twenty-one in vitro and nine in vitro experiments were performed on pig liver to validate the accuracy of the predictions. A good match was found between the predicted and experimental lesion shapes. Lesion dimensions (maximum depth and length, area at the centre of the lesion or central surface area) were measured on experimental and predicted lesions. The central surface area was predicted by the model with a range of error of 0.15-6.5% for in vitro tests and 0.97-9% in vivo. For comparison, BHTE without bubbles had a range of error of 0.4-55.5% (in vitro) and 9-25.5% (in vivo). The model should be accurate enough to predict HIFU lesions under ultrasound exposure conditions used in prostate cancer treatment.

[High intensity focused ultrasonic destruction of hepatic parenchyma]. / Destruction de parenchyme hépatique par ultrasons focalisés.

OBJECTIVE: High intensity focused ultrasound (HIFU) is an effective and precise method of focal tumoral destruction since it is associated with imagery. This method is widespread for the endorectal treatment of prostatic adenocarcinomas. HIFU seem appropriate for the treatment of liver tumors but its use needs to be experimentally tested in vivo. The aim of the work is to study the feasibility, tolerance and effectiveness of the destruction of porcine liver by HIFU. MATERIAL AND METHODS: Ten pigs had liver destruction by HIFU after coeliotomy. Four to 5 2,3 cm(3) HIFU lesions were performed per animal under ultrasonographic control. The study included biological surveillance and an autopsy was performed 4 to 24 hours later for histological examination of the liver. RESULTS: The destruction of the liver was feasible in all cases and the 4 lobes of the liver could be treated. The general and biological tolerance of the procedure was excellent. Ultrasonographic features of the HIFU lesions were defined. The histological examination of the lesions showed well-circumscribed necrosis areas associated with cavitation or histological deficiencies of various degrees. CONCLUSION: This work demonstrated that liver destruction by HIFU is a feasible and effective method with low morbidity. A long-term experimental study is necessary before comtemplating its clinical use.

[Three-luminal nasojejunal tube in digestive surgery: preliminary feasibility study]. / Sonde nasojéjunale triple lumière en chirurgie digestive: étude préliminaire de faisabilité.

STUDY AIM: The benefit of enteral nutrition is an established fact for severely burned or multiple injured patients with a reduction of septic morbidity. Enteral nutrition is now possible in upper gastrointestinal tract surgery with the development of nasojejunal triple lumen tube and we report a new application with an operative placement. The aim of the study was to evaluate the nasojejunal triple lumen tube in digestive surgery. MATERIAL AND METHODS: From November 1999 to August 2001, a nasojejunal triple lumen tube was placed during surgery for high surgical risk patients (n = 17) or under radioscopic control for the treatment of post operative complications (n = 6). RESULTS: The surgical placement was possible in all cases. The radioscopic placement failed in two cases, one of which being solved with endoscopic procedure. There was no morbidity during the tube placement. Four patients were excluded because of early post operative death (n = 3) or premature removal of the tube by the patient (n = 1). The enteral nutrition was early in 18 patients and its mean duration was 18.2 days (range 3-75). Technical problems occurred in 9 patients and the replacement of the tube was necessary in 8 cases. CONCLUSION: The nasojejunal triple lumen tube is a feasible, safe and relatively well-tolerated procedure in upper gastrointestinal tract surgery.

[Cryosurgery of primary and metastatic cancers of the liver]. / Cryochirurgie des cancers primitifs et métastatiques du foie.

Cryosurgery is a method of in situ destruction of tissue by a freezing process. Results of hepatic cryosurgery are now available for more than 2100 patients and allow to assess its place in the treatment of hepatic malignancies. Mechanisms of tissue destruction and indications of cryosurgery are detailed. With a peri-operative mortality rate of 1.5%, the safety of hepatic cryosurgery is now admitted. Cryosurgery has its own morbidity: increase of transaminases levels, platelets drop, myoglobinuria and rarely renal failure or cryoshock. In selected patients, hepatic cryosurgery is feasible with a laparoscopic or percutaneous approach. Long term results do not support cryosurgery as an alternative to liver resection. This technique enlarges possibilities of surgical treatment for patients with primary and metastatic liver cancers.

Cryosurgery as a means to improve surgical treatment of patients with multiple unresectable liver metastases.

BACKGROUND: The aim of the study was to evaluate the results of cryosurgery in patients with multiple (five or more), heavily pretreated, unresectable liver metastases. MATERIALS AND METHODS: Nineteen patients with multiple unresectable liver metastases were entered into a prospective nonrandomized trial. The liver tumours were treated during surgery under ultrasound guidance. All the patients were followed-up to assess complications, treatment response and sites of recurrence. RESULTS: 140 metastases were identified in 19 patients (mean, 7; range, 5-25) and 13 patients had a synchronous liver resection. Cryosurgery was used to treat 90 metastases (mean diameter, 30 mm; range, 10-135). There were no treatment-related deaths and the overall rate of complications was 21%. During a mean follow-up of 28 months (range, 5-60), tumours recurred at the site of cryosurgery in two patients (10%), in the remaining liver in nine patients (47%) and elsewhere in five patients (26%). Three patients had no evidence of disease 48, 50 and 60 months after liver cryosurgery, respectively. CONCLUSION: Cryosurgery may be effective in the treatment of patients with multiple unresectable liver metastases and should be investigated in multimodality treatment programmes.

[Value of preoperative drainage of the bile ducts in obstructive jaundice]. / Intérêt du drainage préopératoire des voies biliaires en cas d'ictère obstructif.

Hepato-biliary surgery for obstructive jaundice is associated with high morbidity and mortality rates. Experimental and clinical studies on obstructive jaundice revealed endotoxaemia, coagulation disorders and depressed immune function. Many studies have been carried out to identify the operative risk factors. The serum bilirubin level seemed to be a significant factor. Biliary decompression via a percutaneous or endoscopic retrograde approach was therefore proposed to improve the surgical outcome. The first retrospective studies have suggested a reduction of morbidity and mortality. Subsequent randomized studies have not confirm the benefit of preoperative biliary drainage because of procedure-related complications. The article reviews the literature on preoperative biliary drainage and proposes the indications, choice of method and optimal duration of biliary drainage.

Inflammatory pseudotumor of the retroperitoneum in a child.

Inflammatory pseudotumor is a rare, benign lesion of various organs and tissues that occurs in children and young adults. A case is reported in a 12-year-old boy in a retroperitoneal location with involvement of the left ureter and a thrombosis of left iliac vein. He underwent surgical resection. A local recurrence 6 months later was surgically cured.

Combination chemotherapy with methotrexate, bleomycin, and vincristine with or without cisplatin in advanced squamous cell carcinoma of the head and neck.

A total of 185 eligible patients with advanced inoperable squamous cell carcinoma of the head and neck were randomized into two groups; the cisplatin, methotrexate, bleomycin, and vincristine (CABO) group received cisplatin (50 mg/m2; day 4), methotrexate (40 mg/m2; days 1, 15), bleomycin (10 mg; days 1, 8, and 15), and vincristine (2 mg; days 1, 8, and 15) and the ABO group received methotrexate, bleomycin and vincristine in the same doses on days 1, 8, and 15. After three courses, patients in both arms received weekly methotrexate as maintenance therapy; those 34 patients with previously untreated locoregional disease went off the study because of subsequent locoregional treatment in form of radiotherapy +/- surgery. The complete response rate was 16% in patients receiving CABO, compared with 5% among patients given ABO. The corresponding overall response rates were 50% and 28%, respectively (P = 0.003). Among patients with recurrent or metastatic disease, progression was delayed in patients receiving CABO (median, 18 weeks) compared to those receiving ABO (median, 14 weeks) (P = 0.07), but there was no difference in survival time. Myelosuppression consisted mostly of leukopenia, which was seen in 67% of the CABO patients versus 47% in the other arm. Myelosuppression-associated infection and hemorrhage led to death in two patients in the CABO treatment group and six patients in the ABO treatment group. Nausea and vomiting, mostly of grades 1 or 2, occurred in 93% of the patients given CABO and 44% of those receiving ABO. Other toxic effects--neuropathy, alopecia, stomatitis, constipation, fever/chills, diarrhea, cutaneous alterations, and renal impairment--occurred equally in the two treatment groups. This study underlines the role of cisplatin in head and neck cancer, although no impact on survival could be demonstrated. It also supports indirectly the superiority of combination chemotherapy over single-agent treatment for this disease.

Combination of chemotherapy with radiotherapy: review of previous studies and new perspectives.

A review is made of the effectiveness of various combinations of radio- and chemotherapy in head and neck cancers and it is suggested that cisplatin combined with radiotherapy is likely to produce the most favourable results.

Combination chemotherapy with cisplatin, methotrexate, bleomycin, and vincristine (CABO) in advanced squamous cell carcinoma of the head and neck.

A combination of cisplatin, methotrexate, bleomycin, and vincristine (CABO) was assessed in advanced epidermoid head and neck cancer. Among 72 patients with recurrent or metastatic disease and measurable lesions, there were 9 complete and 27 partial responses for an overall response rate of 50%. These results were adversely affected by prior surgery plus prior radiotherapy. The median response duration was 28 weeks (16-100+) in complete responders and 16 weeks (6-84) in partial responders. CABO was also administered to 56 patients with measurable, previously untreated, locoregional disease. In these patients, complete and partial response rates were 18% and 46%, respectively. Toxic effects were generally mild to moderate. In spite of its encouraging therapeutic efficacy, CABO is unlikely to be clearly superior to single-agent chemotherapy, at least in recurrent or disseminated disease. Increased effectiveness of CABO given as initial treatment suggests that chemotherapy might play an effective adjuvant role in carefully selected patients.

A randomized EORTC trial comparing intra-arterial infusion with methotrexate vs bleomycin as initial therapy in carcinoma of the oral cavity.

Either intra-arterial infusions of MTX (500 mg over 10 days) or intra-arterial infusions of BLM (95 mg over 13 days) were administered as initial treatment to 85 patients with untreated squamous cell carcinomas of the oral cavity. Tumour regression was assessed 10-15 days after the end of chemotherapy. A sequential analysis was used, and BLM demonstrated a significantly greater local efficacy after the 32nd matched pair was assessed. The same results were observed when tumour response rates were compared, ignoring the matching, on the 85 patients, (P less than 0.001). The response rate for patients with neck nodes was low (10/38). Catheter management problems, toxic effects and lethal reactions were 2.5 times more frequent in the MTX group.