Accuracy of imaging for predicting operative approach in Crohn's disease.

BACKGROUND: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease. METHODS: Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings. RESULTS: Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE. CONCLUSION: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Flexible versus rigid single-port peritoneoscopy: a randomized controlled trial in a live porcine model followed by initial experience in human cadavers.

INTRODUCTION: We compared single incision laparoscopic surgery with flexible endoscope ("flexible SILS") and with rigid optic ("rigid SILS") for access to 11 elective sites of peritoneal carcinomatosis. MATERIALS AND METHODS: Back-to-back flexible and rigid SILS peritoneoscopy were performed in ten live pigs. SILS peritoneoscopy was performed using a flexible endoscope or a rigid optic, in random order, together with two rigid 5-mm laparoscopic forceps. Primary endpoint was access success rate to 11 elective sites of peritoneal carcinomatosis. Findings for the most favorable option were then assessed in four human cadavers. RESULTS: In the porcine model, the overall rate of access to targets was 98% with flexible SILS and 87% with rigid SILS (p < 0.001). Both flexible and rigid SILS allowed a 100% access rate to diaphragmatic domes, paracolic gutters, splenic and hepatic hilum, pelvic floor, and trigonal bladder. The rates of access to other sites by flexible versus rigid SILS, respectively, were: root of the mesentery (90 vs. 50%), origin of the inferior mesenteric vein (90 vs. 50%), inferior vena cava (100 vs. 90%), and cul-de-sac of Douglas (100 vs. 50%). No complications were observed. Procedures were performed in mean time of 26 and 24 min, respectively. These findings were confirmed for flexible SILS in four human cadavers. CONCLUSIONS: Flexible SILS is superior to rigid SILS to evaluate the peritoneal cavity in a timely manner. This suggests a need for flexible instrumentation or other technical solutions to perform thorough minimally invasive surgical evaluation of peritoneal carcinomatosis.

Primary peritonitis due to Streptococcus A: laparoscopic treatment.

Primary peritonitis is defined as peritoneal infection without an evident intraperitoneal septic focus. This is a rare condition and few cases are reported in the literature. We report a case of primary peritonitis in a 23-year-old female that was diagnosed and treated laparoscopically. The challenge for the surgeon is to consider the possibility of this diagnosis, and to avoid conversion to laparotomy in search of a hypothetical septic focus when none is apparent on laparoscopy.

Colorectal cancer complicating inflammatory bowel disease: a comparative study of Crohn's disease vs ulcerative colitis in 34 patients.

AIM: Colorectal cancer (CRC) complicating inflammatory bowel disease (IBD) accounts for 10-15% of all IBD deaths. Survival of patients with IBD-related CRC was reviewed to analyse differences between ulcerative colitis (UC) and Crohn's disease (CD). METHOD: We analysed (24 men and 10 women) patients with CD (n = 14) or UC (n = 20) with CRC, who presented between 1990 and 2007, and were followed to October, 2009. RESULTS: The mean age of patients was 56 ± 12 years for patients with UC and 49 ± 17 years for patients with CD, and the mean duration of symptoms was 22 ± 11 and 16 ± 8 years, respectively. The median duration of follow up after the diagnosis of CRC was 49 (1-157) months. Recurrence occurred in five patients with UC and in nine with CD (P = 0.02). The overall and disease free five year survivals were significantly higher in patients with UC than CD [70%vs 43% (P = 0.01) and 63%vs 31% (P = 0.01), respectively]. CONCLUSION: The results showed a poorer prognosis of CRC in patients with CD than with UC.

[Prospective study of quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using oxaliplatin for peritoneal carcinomatosis]. / Étude prospective de la qualité de vie après une CHIP par oxaliplatine pour carcinose péritonéale.

BACKGROUND: Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is now the reference technique for limited peritoneal carcinomatosis (PC). Operative mortality is actually at 3 or 4%, and decrease as morbidity. Together, they did not limit acceptation of HIPEC. However, one of the major limitation of this aggressive treatment is that patient can be afraid to impair overall quality of life (QoL). The aim of this article was to assess QoL in patients at least 12 months after HIPEC using Oxaliplatin. METHOD: Patients completed a questionnaire before and after surgery at 1, 3, 6 and 12 months. QoL was assessed with the EORTC QLQ-C30 questionnaire. RESULTATS: Between September 2006 and October 2008, 32 of 35 patients who had undergone HIPEC were interviewed. PC originated in primary lesions of the colon/rectum (N = 17), ovary (N = 3), stomach (N = 3), appendix (N = 2), mesothelium (N = 2), pseudomyxoma peritonei (N = 3) and primary carcinoma of peritoneum (N = 2). The percentage of patients completing the questionnaire at each time point was: baseline = 87% (N = 28); 1 and 3 months = 46% (N = 15); 6 months = 62% (N = 20); and 12 months = 59% (N = 19). Morbidity and mortality were respectively 35 and 5%. Median hospital stay was 19 days. QoL score had decreased considerably in 60% of patients in the early postoperative assessment period after HIPEC (1 month), as compared with baseline score. Forty five per cent had reported significant pain and limitations on physical functioning. QoL score had returned to baseline at 3 months in 53,3% of patients: 20% reported lack of energy and fatigue. Fifty-five and 73% of patients had recovered their overall QoL at 6 and 12 months, respectively. Also, psychosocial problems, diarrhea and constipation, and peripheral neuropathy of oxaliplatin were reported in 20% of survivors over the course of the first year after HIPEC. CONCLUSION: Short-term QoL with physical and functional well-being are impaired in the first few months after surgery plus HIPEC using oxaliplatin. Long-term QoL returns to baseline at 3 months; however 20% of patients still report psychosocial problems, gastrointestinal symptoms and oxaliplatin-induced neuropathy. It is useful and important for patients to see this HIPEC QoL data at the time of consultation before treatment.

[Management of ileal stenosis in patients with Crohn's disease]. / Prise en charge des sténoses iléales de maladie de Crohn.

Stenosis is the most frequent complication during Crohn's disease. The lesion can be inflammatory, or due to a fibrosing or neoplastic process. The medical treatment with anti-inflammatory drugs is usually sufficient as first line treatment; fibrous lesions require endoscopic or surgical procedures while neoplastic lesions require surgery. A multidisciplinary approach (radiologic, medical, surgical and endoscopic) is needed. In a first part, we discuss the definition of stenosis and the modalities of imaging (particularly MRI) and of treatment (particularly with TNFalpha antagonists). Then we expose the strategy for the management of the most frequent clinical situations: occlusion, ileal inflammatory stenosis, stenosis of an ileocolonic anastomosis and chronic fibrous stenosis. The treatment decision takes into account the results of radiological assessment, CRP level and the effects of the previous treatments.

Plexitis as a predictive factor of early postoperative clinical recurrence in Crohn's disease.

BACKGROUND AND AIMS: A previous study suggested that the presence of myenteric plexitis in the proximal resection margins could be predictive of early endoscopic recurrence after ileocolonic or ileal resection for Crohn's disease (CD). The aim of the present study was to assess the predictive value of plexitis for early clinical CD recurrence. METHODS: All consecutive patients with ileocolonic or ileal resection for active CD in Lariboisière Hospital (Paris) between 1995 and 2006 were included. Clinical, surgical, histological and follow-up data were extracted from medical charts. Early clinical recurrence was defined as the reappearance of CD clinical manifestations requiring a specific treatment within 2 years postsurgery. The proximal resection margin was analysed using haematein eosin saffron (HES) staining and immunochemistry targeting mastocytes (anti-CD117 antibody) and lymphocytes (anti-CD3 antibody). Eosinophils were detected by HES staining. Ten cases of ileocolonic resections for caecal carcinoma served as controls. RESULTS: Data were available from 171 postoperative follow-up periods in 164 patients with CD. Early clinical recurrence of CD occurred in 28.1%. In multivariate analysis, factors associated with postoperative recurrence were active smoking (hazard ratio (HR) = 1.94; 95% CI 1.06 to 3.60; p = 0.033), submucosal plexitis with >or=3 mastocytes (HR = 1.87; 95% CI 1.00 to 3.46; p = 0.048) and a disease-free resection margin <5 cm (HR = 0.52; 95% CI 0.27 to 1.02; p = 0.059). CONCLUSIONS: Submucosal plexitis is associated with early clinical recurrence and could be taken into account in studies searching for new treatment strategies in the immediate postoperative period.

[Adjuvant chemotherapy followed by conformal chemoradiotherapy in gastric carcinoma]. / Chimiothérapie adjuvante suivie d'une chimioradiothérapie conformationnelle dans les cancers de l'estomac.

PURPOSE: Analysis of the feasibility and results of adjuvant chemotherapy followed by conformal chemoradiotherapy after surgery for gastric carcinoma. PATIENTS AND METHODS: Twenty-six patients (R0 or R1) were treated postoperatively by three cycles of 5-fluorouracil (5-FU) and cisplatin, followed by a concomitant association of LV5FU2 chemotherapy with a conformal radiotherapy of 45 Gy. RESULTS: The tumor was classified pT3-T4 in 77% of the patients and 92.5% had a nodal involvement (pN1: 54%; pN2: 31%). FEASIBILITY: (1) Adjuvant chemotherapy: nausea/vomiting grade II/III: 12 patients (48%); neutropenia grade III/IV: two patients; completed in all patients, except one. (2) Chemoradiotherapy: nausea/vomiting grade II/III: 10 patients; diarrhea grade II/3: two patients; oesophagitis grade II/III: two patients; myocardial infarction/pulmonary embolism: two patients. All patients except one received the planned dose of 45Gy. Radiotherapy was interrupted in six cases, with a median duration of 14 days. Survival: with a median follow-up of 30 months, 65% of the patients were alive without disease; median survival was 32 months. CONCLUSION: This postoperative schedule was judged feasible. It allowed the deliverance of a more intensified chemotherapy than the classical schedule. Its clinical benefit must be evaluated in a phase III trial.

Splenic abscess secondary to a colosplenic fistula in Crohn's disease.

Colosplenic fistula associated to splenic abscesses is a rare condition in Crohn's disease (CD). Diagnosis is difficult and a computed tomography (CT) scan is helpful. Treatment includes surgical procedure. Atypical locations of fistulas and abscesses should not be overlooked in CD.

Rectal cancer surgery without mechanical bowel preparation.

BACKGROUND: : Eight randomized clinical trials and two meta-analyses recently questioned the value of preoperative mechanical bowel preparation (MBP) in colorectal surgery. However, very few patients having rectal surgery were included in these studies. The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP. METHODS: The postoperative course was assessed in 52 consecutive unselected patients who underwent rectal cancer resection and sphincter preservation without MBP. This group was compared with a group of 61 matched patients in whom MBP was performed before surgery. RESULTS: The overall morbidity rate after rectal resection was higher in patients who had MBP than in those who did not (51 versus 31 per cent; P = 0.036). The incidence of symptomatic anastomotic leakage was similar in the two groups (8 versus 10 per cent respectively; P = 1.000). Although not significant, peritonitis occurred more frequently in the absence of MBP (2 versus 6 per cent; P = 0.294). A trend towards a higher rate of infectious complications was noted in patients who had MBP (23 versus 12 per cent; P = 0.141), but MBP was associated with a significantly higher rate of infectious extra-abdominal complications (11 versus 0 per cent; P = 0.014). Mean hospital stay was significantly longer in the MBP group (12 versus 10 days; P = 0.022). CONCLUSION: Elective rectal surgery for cancer without MBP may be associated with reduced postoperative morbidity.

[Long term outcome following 26 surgical ampullectomies]. / Résultat à long terme de 26 ampullectomies chirurgicales.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard surgical treatment for malignant ampullomas but is still associated with a mortality and morbidity still ranging from 0 to 10% and from 15 to 40%, respectively. Ampullectomy is an alternative to PD for benign ampulloma or, in high-risk patients, for invasive carcinoma. The aim of this study was to report early and long term results of surgical ampullectomy for presumed benign ampullomas. PATIENTS AND METHODS: From 1981 to 2004, 26 patients from two institutions underwent surgical ampullectomy. Of the 26 patients, 8 had familial adenomatous polyposis (FAP). Surgical ampullectomy was indicated on a multisciplinary basis. RESULTS: Final pathological examination revealed 15 adenomas, 4 in situ adenocarcinomas, 2 endocrine tumors, and 5 other benign lesions. There was no postoperative mortality. Specific morbidity was 8% (N=2). Mean follow-up was 86+/-70 months (range: 3-204). Actuarial overall 5-year survival was 92%. There were 4 local recurrences (none in patients with FAP). Four patients died during follow-up (including 3 from initial disease). CONCLUSION: Ampullectomy is a good alternative to PD in case of benign or non-invasive malignant ampullary lesion, including in selected cases of FAP.

Factors that predict conversion in 69 consecutive patients undergoing laparoscopic ileocecal resection for Crohn's disease: a prospective study.

PURPOSE: This prospective study was designed to identify factors that could predict conversion in patients undergoing first laparoscopic ileocecal resection for Crohn's disease. METHODS: Between 1998 and 2004, 69 consecutive patients (32 males; mean age, 32 +/- 9 years) who had undergone a first laparoscopic ileocecal resection for Crohn's disease were included in a prospective study. Twenty-one patients (30 percent) were converted into laparotomy. Possible factors for conversion were analyzed by both univariate and multivariate analyses. RESULTS: No patient died. Four patients (9 percent; 2 in each group) required five reoperations because of intraperitoneal hemorrhage (n = 1), anastomotic fistula (n = 3), and small-bowel obstruction (n = 1). Mean hospital stay was significantly increased in converted compared with laparoscopic patients (9 +/- 4 vs. 7 +/- 3 days; P < 0.05). On univariate analysis, more than three episodes of acute flare of Crohn's disease (P = 0.02), male gender (P = 0.03), preoperative immunosuppressive drugs (P = 0.04), intra-abdominal abscess or fistula at the time of laparoscopy (P = 0.02), and resection of other intestinal segment (P = 0.02) were factors that predicted conversion. On multivariate analysis, recurrent medical episodes of Crohn's disease (odds ratio, 2; 95 percent confidence interval, 1-4), and intra-abdominal abscess or fistula at the time of laparoscopy (odds ratio, 15; 95 percent confidence interval, 4-78) were the two independent risk factors for conversion. CONCLUSIONS: This prospective study demonstrated that the severity of the disease increased significantly the conversion rate of the first laparoscopic ileocecal resection. Knowledge of these risk factors for conversion could be helpful in preoperative preparation and counseling of patients.