Christine Denet

Laparoscopic liver resection.

This paper describes a 10‐year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours.

Small bowel adenocarcinoma in patients with Crohn's disease compared with small bowel adenocarcinoma de novo

Background: Data concerning small bowel adenocarcinoma (SBA) in Crohns disease (CD) come from case reports and small retrospective series. The aim of this study was to further describe SBA in patients with CD and compare it with SBA de novo. Methods: Twenty patients with CD with SBA recruited in French university hospitals were studied and compared with 40 patients with SBA de novo recruited from a population‐based registry. SBA occurred after a median time of 15 years of CD and was located within the inflamed areas of the ileum (n = 19) or jejunum (n = 1), whereas in patients with SBA de novo, it was distributed all along the small intestine. Median age at diagnosis of SBA was 47 years (range, 33‐72 yr) in patients with CD and 68 years (range, 41‐95 yr) in those with SBA de novo. Results: The cumulative risk of SBA, assessed in a subgroup of patients, was 0.2% and 2.2% after 10 and 25 years of ileal CD, respectively. SBA accounted for 25% and 45% of the risk of gastrointestinal carcinoma after 10 and 25 years of CD, respectively. Diagnosis was made preoperatively in 1/20 patients with CD and 22/40 patients with SBA de novo. Signet ring cells were found in 35% of patients with CD but not in patients with SBA de novo. Relative survival was not significantly different in these 2 categories of patients (54 versus 37% and 35 versus 30% in patients with and without CD at 2 and 5 yr, respectively). Conclusions: SBA in CD is different from SBA de novo. It arises from longstanding ileal inflammation and is difficult to diagnose. SBA cumulative risk increases after 10 years of CD and is likely to cause premature mortality in patients with early‐onset CD.

Pre-operative predictive factors of early recurrence after resection of adenocarcinoma of the esophagus and cardia.

OBJECTIVES To determine pre-operative predictive factors of early recurrence in patients with esophageal and cardial adenocarcinoma. PATIENTS AND METHODS We retrospectively analyzed consecutive patients who underwent resection for esophageal and cardial adenocarcinoma in our institution between October 1992 and October 2001. Patient files were studied and classified according to the occurrence of early recurrence (within one year) (group A) and patients without recurrence (group B). Pre-operative clinical, biological and radiological parameters were recorded. Both groups were compared in univariate and multivariate analysis. RESULTS One hundred patients underwent surgical resection. Tumor was located in lower esophagus in 71 cases and at the cardia in 29 cases. R0 resection was feasible in 95 cases. Hospital mortality was 2%. Survival rate at 3 years was 56%. Recurrence before 1 year occurred in 28 patients (group A) and not in 72 (group B). In univariate analysis, younger age (P=0.01), dysphagia (P=0.04) and percentage of weight loss (P<0.0004) were significantly different between both groups. Weight loss more than 10% was observed in 2 patients of group B, and in 9 patients of group A. In multivariate analysis, weight loss more than 10% was the only pre-operative factor associated with early recurrence (P=0.018). CONCLUSION Important weight loss could be a pre-operative predictive factor of early recurrence after resection of esophageal and cardial adenocarcinoma and surgery as first line treatment could be avoided in these patients.

Ambulatory groin and ventral hernia repair

OBJECTIVE Ambulatory surgery is not commonly practiced in France today. The aim of this study was to prospectively evaluate the feasibility of ambulatory hernia repair in a consecutive series of unselected patients. PATIENTS AND METHODS From June 2008 to October 2009, 257 patients (238 men and 19 women, median age 65 years) were treated in a same-day surgery unit for 270 hernias (244 groin hernias, 25 ventral hernias and one Spiegelian hernia). RESULTS For groin hernia, the techniques included the totally extraperitoneal repair (TEP) in 108 cases, the transinguinal preperitoneal (TIPP) approach in 106 cases and other alternative techniques in 30 cases; for ventral hernias, the technique was an open suture in 20 cases, an open prosthetic repair in four cases and laparoscopic repair in one case. Anesthesia was general in 145 cases, local in 121 cases and spinal in four cases. Repair was completed in a same-day surgery setting in 242 (89.6%) cases; hospital stay greater than 23 hours was planned for 21 (7.8%) patients while non-programmed hospitalizations were necessary for seven (2.6%) patients. There were two (0.7%) readmissions and nine (3.3%) benign postoperative complications. CONCLUSION These results suggest that groin and ventral hernia repair can be performed in an outpatient setting in nearly 90% of unselected patients.

Specific features of colorectal cancer in patients with metabolic syndrome: a matched case-control analysis of 772 patients

PurposeAlthough association between colorectal cancer (CRC) and metabolic syndrome (MetS) is established, specific features of CRC arising in patients presenting with MetS have not been clearly identified.MethodAll patients who underwent colectomy for CRC from January 2005 to December 2014 at Institut Mutualiste Montsouris were identified from a prospectively collected database and characteristics were compared in the entire population and in a 1:2 matched case-control analysis [variables on which matching was performed were CRC localization (right- or left-sided) and AJCC stage (0 to IV)].ResultsOut of the 772 identified patients, 98 (12.7%) presented with MetS. Entire population analysis revealed that CRC associated with MetS was more frequent in men (71.4 vs. 47.8%, p < 0.001), more often right-sided (71.4 vs. 50.4%, p < 0.001) and presented with less synchronous liver metastasis (4.1 vs. 8.7%, p = 0.002). Case-control analysis confirmed the gender association (p < 0.001) and showed HNPCC (p < 0.001) and history family of CRC (p = 0.010) to be significantly more frequent in Non-MetS patients.ConclusionsCRC associated with MetS is more frequent in men, more often right-sided, and presents with fewer synchronous metastasis. Further investigations should be designed in order to confirm these results and to enhance our knowledge of carcinogenesis related to MetS.

CO.95 - Traitement par colle biologique des fistules post-opératoires en chirurgie colorectale

Resume La morbidite des fistules apres chirurgie colorectale est elevee et leur traitement est difficile. Leur obturation par injection de colle de fibrine a ete ponctuellement publiee. Ce travail presente les resultats d’une etude prospective chez 14 patients.

P.343 Pancréatectomie gauche sans splénectomie chez l’adulte : peut-on encore réséquer les vaisseaux spléniques ?

Introduction La splenectomie de la splenopancreatectomie gauche expose a des complications tardives. Pour les eviter, la rate peut etre conservee, soit en conservant les vaisseaux spleniques, soit en les resequant. Le but de ce travail a ete d’evaluer les consequences vasculaires de la pancreatectomie sans splenectomie avec resection des vaisseaux spleniques. Patients et Methodes 35 malades consecutifs ayant eu une pancreatectomie sans splenectomie (13 fois pour maladie benigne ou « border-line » et 22 fois pour maladie maligne) entre 1993 et 2003 ont ete etudies retrospectivement. Les vaisseaux spleniques etaient conserves des que cela etait techniquement possible, quel qu’ait ete le diagnostic. En cas d’adenocarcinome la conservation splenique est en effet liee a un allongement de la survie [1]. Les vaisseaux ont ete conserves 18 fois et reseques 17 fois. Les consequences vasculaires immediates (dans les 40 jours) ont ete etudiees chez les 35 malades. Les consequences tardives (au-dela du 40eme jour) ont ete analysees chez les 21 survivants ayant encore leur rate. Aucun malade n’a ete perdu de vue. Resultats Chez les 17 malades ayant eu une resection des vaisseaux spleniques, il y a eu 7 ischemies spleniques transitoires, aucune hemorragie ni splenectomie secondaire. Chez les 18 malades ayant eu une conservation des vaisseaux spleniques il y a eu une necrose splenique secondaire sur splenomegalie, par thrombose veineuse, des hemorragies du pedicule splenique chez deux malades et trois splenectomies secondaires. Les consequences tardives ont ete exclusivement l’apparition d’une hypertension portale segmentaire. Celle-ci a ete plus frequente apres resection du pedicule splenique (10 malades) qu’apres sa conservation (11 malades) : 6 vs 3 pour les varices perigastriques, 5 vs 2 pour les varices gastriques intraparietales et 1 vs 0 pour les varices sous muqueuses endoscopiquement visibles. Chez un malade apres resection des vaisseaux spleniques une splenectomie secondaire a ete faite pour prevenir des hemorragies par varices gastriques. Conclusion Les avantages immediats de la resection des vaisseaux spleniques dans la pancreatectomie sans splenectomie sont contrebalances par un risque d’hypertension portale segmentaire tardive rapportee pour la premiere fois par Miura et al. [2]. Neanmoins, les avantages a long terme de la conservation splenique nous font proposer de conserver la rate, en resequant son pedicule si necessaire, aussi bien en cas de maladie maligne que de maladie benigne.

Traitement par colle biologique des fistules postopératoires en chirurgie colorectale

RésuméRésuméLa morbidité des fistules après chirurgie colorectale est élevée et leur traitement est difficile. Leur obturation par injection de colle de fibrine a été ponctuellement publiée. Ce travail présente les résultats d’une étude prospective chez 14 patients.Malades et méthodesDe juin 2004 à janvier 2008, les patients ayant une fistule postopératoire ont été inclus, à l’exclusion des fistules impliquant le vagin, celles de grand diamètre (> 1 cm) ou communiquant avec une cavité non drainée. Quatorze patients (10 H), d’âge moyen 63,5 ans, ont été traités; soit 11 cancers du rectum, 2 diverticulites et une tumeur stromale de la cloison recto-vaginale; trois sur 13 avaient reçu une radiothérapie préopératoire. Il s’agissait d’anastomoses colorectales (ACR), basses (n = 6) ou hautes (n = 4), dont neuf latéro-terminales, de trois anastomoses colo-anales (CA) et d’une suture rectale sans anastomose. Dix étaient des anastomoses mécaniques. Sept patients avaient d’emblée une stomie (CA + ACR basses). Le diagnostic de fistule était porté 11 fois sur l’imagerie (TDM, IRM), deux fois en endoscopie et une fois à l’examen clinique; neuf fois, il était porté précocement (< 14 jours) et cinq fois tardivement (> 57 jours). Six fois, une stomie secondaire a été nécessaire, toujours pour des fistules précoces. L’encollage a été effectué 1,5 fois en moyenne avec 1 à 3 ml de colle (Beriplast®); l’efficacité était jugée sur un scanner ou une IRM.RésultatsDouze fois sur l’imagerie, la fistule a été considérée comme obturée et la stomie a pu être retirée dans un délai moyen de 389 jours après sa mise en place, en moyenne 44 jours après le premier essai d’encollage pour les formes tardives et 168 pour les formes précoces. Dans deux cas, malgré une fermeture de la fistule, une infiltration présacrée persistait au scanner sans récidive tumorale. Le retard à la fermeture des stomies pouvait être lié à la nécessité d’une chimiothérapie postopératoire.ConclusionCette série, la plus grande rapportée d’encollage de fistules post-chirurgie colorectale coelioscopique, montre l’efficacité d’une prise en charge endoscopique. L’atout essentiel de cette technique est son absence de morbidité et une réelle efficacité, surtout en regard de l’alternative chirurgicale, notamment dans les fistules chroniques. Elle a permis une fermeture de la fistule dans 12 cas sur 14.AbstractAbstractFistula morbidity after colorectal surgery is high and such fistulae are hard to treat. There have occasionally been reports of closures using biological glue. This work presents the results of a prospective study concerning 14 patients.Patients and methodsBetween June 2004 and January 2008, all patients presenting with a postoperative fistula were included in the study, except if the fistula involved the vagina, was over 1 cm or communicated with a non-draining cavity. 14 patients (10 male) were treated, the average age being 63.5 years: 11 rectal cancers, 2 cases of diverticulitis and one stromal tumour of the recto-vaginal wall. Three out of 13 had had preoperative radiotherapy. The cases involved were 6 low and 4 high colorectal anastomoses (CRA), of which 9 were lateroterminal, 3 coloanal anastomoses (CA) and one rectal suture without anastomosis. Seven patients had spontaneous stoma (CA + low CRA). Diagnosis of the fistula was made by imaging in 11 cases (scan, MRI), twice by endoscopy and once by clinical exam; in nine cases, diagnosis was made early on (< 14 days) and in five cases it was late (> 57 days). In six cases, all diagnosed early, it was necessary to create a second stoma. Glueing was carried out one and a half times on average, using 1–3 mls of glue (Beriplast®); effectiveness was measured by CAT-scan or MRI.ResultsImaging showed the fistula to be closed in 12 cases and the stoma was removed an average of 389 days after it had been created, 44 days on average after the first glueing attempt for the later forms and 168 for the early forms. In two cases, despite closure of the fistula, presacral infiltration could be seen on the scan, without recurrence of the tumour. Late closures may have been connected with postoperative chemotherapy.ConclusionThis series, the most extensive report on gluing fistulas after colorectal laparoscopie surgery, shows that treatment by endoscopy is effective. The primary advantages of this technique are its absence of morbidity and real effectiveness, particularly considering the chronic fistula associated with the surgical alternative. Twelve of the 14 fistulae were successfully closed.