Transanal NOTES total mesorectal excision (TME) in patients with rectal cancer: Is anatomy better preserved?

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy are spreading worldwide. Total mesorectal excision (TME), the standard treatment for patients with distal rectal tumors, is usually performed in an "up-to-down" approach, either laparoscopically (LAPTME) or as an open procedure. We have already reported a NOTES-inspired, transanal, "down-to-up" variant of TME (NOTESTME). The main aim of this study was to assess the quality of the resected specimen in patients who had undergone either NOTESTME or LAPTME. METHODS: All patients with distal rectal neoplasia presenting between January 2011 and December 2014 were considered for the study. Additional inclusion criteria comprised American Society of Anesthesiologists score ≤ III and the absence of previous open surgery. Assignment to either group was sequential and based on the rank of inclusion in the study. The primary endpoint was the macroscopic quality of the specimen. Secondary endpoints included nerve visualization, tumor perforation, operating time, status of margins, and number of retrieved nodes. RESULTS: Eighteen patients (6 men, 12 women) were in the NOTESTME group and 15 (7 men, 8 women) in the LAPTME group, respectively. The TME specimen was considered complete or mainly regular in 16 patients who had undergone NOTESTME (88.9 %) and in 11 patients who had undergone LAPTME (73.3 %), (p > 0.05). During the procedure, we visually identified the neurovascular bundles of Walsh in 14 patients in the NOTESTME group (77.8 %) and in only 5 patients in the LAPTME group (33.3 %), (p < 0.05). Mean operative time was 245 min (range 155-440 min) in the NOTESTME group and 275 min (range 180-400 min) in the LAPTME group (p > 0.05). A median of 11 nodes per specimen (range 8-22 nodes) was retrieved in the NOTESTME group and 12 nodes (range 6-41 nodes) in the LAPTME group, respectively (p > 0.05). Distal and radial margins were comparable in both groups. CONCLUSIONS: Compared to the LAPTME, the NOTESTME seems to be associated with a more frequent intraoperative identification of the sacral nerves. However, the difference in overall quality of the retrieved specimen, although favoring NOTESTME, did not reach statistical significance in this small series.

Randomized comparative multicenter study of hydroxyethyl starch versus albumin as a plasma expander in cirrhotic patients with tense ascites treated with paracentesis.

OBJECTIVE: Large-volume paracentesis associated with plasma volume expansion with albumin is an effective, safe, but costly therapy for ascites in patients with cirrhosis. The aim of this study was to compare the use of a synthetic plasma expander, hydroxyethyl starch (HES), with that of albumin. DESIGN: Sixty cirrhotic patients with ascites were studied. Patients were randomly assigned to be infused with either albumin (8 g/l of ascites removed, n = 33) or HES (200 ml/l of ascites removed, n = 27). None of the patients was treated with diuretics or had renal impairment or hyponatremia at entry. Clinical and laboratory data were obtained before and 1, 3 and 15 days after treatment. RESULTS: There were no significant differences in clinical and laboratory parameters between the two groups at entry into the study. None of the patients developed renal impairment during the trial. One patient (HES group) presented with hyponatremia. Plasma atrial natriuretic factor and aldosterone levels did not differ between the two groups at baseline or at 1 and 3 days after paracentesis. The volume of ascites removed did not differ between the albumin (7.9 +/- 4.4 l) and HES (6.9 +/- 5.3 l) groups. However, there was a significant difference in weight loss between the albumin and HES groups (7.9 +/- 5.2 kg vs 4.7 +/- 3.4 kg; p = 0.01). Clinical and laboratory parameters indicated that HES was well tolerated except for hypoalbuminemia. CONCLUSION: HES is well tolerated in patients with cirrhosis. There is no difference between HES and albumin in the prevention of complications related to large-volume paracentesis. The lesser degree of weight loss observed with HES needs further study.

[Prolonged clinical remission of cholangitis in early human immunodeficiency virus infection after surgical biliary derivation]. / Rémission clinique prolongée d'une cholangite observée à un stade précoce de l'infection par le virus de l'immunodéficience humaine après dérivation biliaire chirurgicale.

During the acquired immunodeficiency syndrome, most cases of cholangitis develop at an advanced stage of disease. We report a case of cholangitis in a 47-year-old homosexual man, stage IIa according to Center of Disease Control classification. An isolated jaundice was the first manifestation of the disease. The number of CD4 was 380/microL. Ultrasonography and endoscopic retrograde cholangiography showed a 7 cm stenosis of the common bile duct, and cystic duct stenosis, with associated intra-hepatic biliary duct dilatation. No infectious agent was found. Cholecystectomy and hepaticojejunostomy were performed. Pathological examination of liver biopsy and a sample of the resected common bile duct was consistent with sclerosing cholangitis. The postoperative course was uneventful. During a three year follow-up period, the patient was disease free but he suddenly died of uncontrolled bleeding from duodenal ulcer. In HIV-infected patients, surgical treatment can be performed in case of symptomatic long stenosis of the common bile duct.

[Diagnostic efficiency of histological and simple microbiological tests for Helicobacter pylori detection in a community hospital]. / Rendement diagnostique de l'histologie et des tests bactériologiques simples pour le dépistage d'Helicobacter pylori dans un centre hospitalier intercommunal.

The objective of this study was to compare histology and microbiology (direct method, urease test, culture) for the detection of Helicobacter pylori in antral biopsies. Thirty-six patients, aged between 18 and 82, with a peptic ulcer (active or not), or gastritis or duodenitis were studied. Eighteen patients (50%) had a positive culture, 17 (47%) had a positive urease test, 16 (41%) had positive direct microbiology and 15 (42%) had positive histology. Correlation between histology and culture was 84%. This study confirms the good sensitivity of histology and the urease test for the detection of Helicobacter pylori. Combination of both methods could optimise detection of the organism.