F. Menegaux

Ischemic colitis: the ABCs of diagnosis and surgical management.

Ischemic colitis (IC) is a rare condition. As ischemia is often transient and clinical symptoms are reversible, its exact incidence is unknown. In current clinical practice, two types of IC are described according to the severity: severe IC, with transmural colonic ischemia and/or multi-organ failure (MOF), and mild IC, without MOF and spontaneous favourable evolution in most cases. Two clinical contexts are encountered: spontaneous IC (SIC) and postoperative IC (POIC), mainly after aortic surgery. As there is no specific clinico-biologic symptom of IC, emergent CT-scan and rectosigmoidoscopy are required for diagnosis confirmation, surgical decision and prognosis analysis. IC surgical treatment is not consensual but can be standardized according to organ function and the degree of ischemia: surgical treatment in case of colonic necrosis with deep ischemia and/or MOF; observation for superficial ischemia without organ dysfunction; systematic medical care. Surgery is required in 20% of cases, and consists in extended colectomy without continuity restoration and prophylactic cholecystectomy. Continuity restoration is feasible in one third of survivors, who are exposed to a high risk of severe cardiovascular events.

Evaluation of predictive models in daily practice for the identification of patients with Lynch syndrome.

The optimal strategy for identifying patients with Lynch syndrome among patients with newly diagnosed colorectal cancer (CRC) is still debated. Several predictive models (e.g., MMRpredict, PREMM1,2 and MMRpro) combining personal and familial data have recently been developed to quantify the risk that a given patient with CRC carries a Lynch syndrome‐causing mutation. Their clinical applicability to patients with CRC from the general population requires evaluation. We studied a consecutive series of 214 patients with newly diagnosed CRC characterized for tumor microsatellite instability (MSI), somatic BRAF mutation, MLH1 promoter methylation and mismatch repair (MMR) gene germline mutation status. The performances of the models for identifying MMR mutation carriers (8/214, 3.7%) were evaluated and compared to the revised Bethesda guidelines and a molecular strategy based on MSI testing in all patients followed by the exclusion of MSI‐positive sporadic cases from mutational testing by screening for BRAF mutation and MLH1 promoter methylation. The sensitivities of the three models, at the lowest thresholds proposed, were identical (75%), with similar numbers of probands eligible for further MSI testing (almost half the patients). In our dataset, the prediction models gave no better discrimination than the revised Bethesda guidelines. Both approaches failed to identify two of the eight mutation carriers (the same two patients, aged 67 and 81 years, both with no family history). Thus, like the revised Bethesda guidelines, predictive models did not identify all patients with Lynch syndrome in our series of consecutive CRC. Our results support systematic screening for MMR deficiency in all new CRC cases.

Ambulatory thyroidectomy: Recommendations from the Association Francophone de Chirurgie Endocrinienne (AFCE). Investigating current practices

BACKGROUNDnCervical hematoma with airway compromise is a severe complication that may be rapidly lethal or result in irreversible cerebral anoxia if the hematoma is not urgently decompressed. It is therefore indispensable to know the essential relevant elements as well as predictive criteria for this complication before envisioning ambulatory thyroidectomy.nnnMETHODSnThe Association francophone de chirurgie endocrinienne (AFCE) sought to answer several questions raised by the proposal of ambulatory thyroidectomy and to propose recommendations based on a review of the literature, an inquiry sent out to members of the AFCE, and an in-depth research of the medicolegal risks involved, based essentially on jurisprudence. The details scrutinized included preoperative selection criteria, the characteristics of the operation and the basic elements of postoperative surveillance.nnnCONCLUSIONSnThe standard today is at least an overnight hospital stay. In fact, hospital stay can be less than 24h because the risk of cervical compressive hematoma is very unusual beyond this interval. Ambulatory (outpatient) thyroidectomy (0 nights) is possible under certain conditions for highly selected patients according to criteria described in the literature that also define relative contra-indications. In case of life-threatening or functional complications, the surgeon stands first in the line of responsibility. The surgeon must therefore ensure that the patient and family were fully informed of the contra-indications, the normal course of postoperative events, of pertinent elements of postoperative surveillance and of the conditions under which the patient can be safely discharged. The surgeon must also realize that this type of management is time-consuming.

Surgical management of sporadic medullary thyroid cancer

Inherited and sporadic medullary thyroid cancer (MTC) is a rare carcinoma. Sporadic MTCs represent 70% of cases. Diagnosis is currently made with the routine use of serum calcitonin (CT) measurements to screen patients with nodular thyroid disease. Surgery is the only curative treatment of MTC and since cervical lymph nodes metastases are frequent and can occur at an early stage, a standardized lymph node dissection should be associated to total thyroidectomy. However, the extent of lymphadenectomy remains debated. Prognosis of MTC is related to both the stage of the disease and the extent of initial surgery. When tumor remnants persist after surgery, there are very few therapeutic alternatives, and these are generally of limited curative value.

Ischaemic colitis: Indications, extent, and results of standardized emergency surgery

BACKGROUNDnAcute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management.nnnMETHODSn191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively.nnnRESULTSnSeventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure.nnnCONCLUSIONnAn aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 6: Adrenal surgery

Treatment of primary aldosteronism (PA) aims at preventing or correcting hypertension, hypokalemia and target organ damage. Patients with lateralized PA and candidates for surgery may be managed by laparoscopic adrenalectomy. Partial adrenalectomy and non-surgical ablation have no proven advantage over total adrenalectomy. Intraoperative morbidity and mortality are low in reference centers, and day-surgery is warranted in selected cases. Spironolactone administered during the weeks preceding surgery controls hypertension and hypokalemia and may prevent postoperative hypoaldosteronism. In most cases, surgery corrects hypokalemia, improves control of hypertension and reduces the burden of pharmacologic treatment; in about 40% of cases, it resolves hypertension. However, success in controlling hypertension and reversing target organ damage is comparable with mineralocorticoid receptor antagonists. Informed patient preference with regard to surgery is thus an important factor in therapeutic decision-making.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook.

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.

Risk of recurrence in a homogeneously managed pT3-differentiated thyroid carcinoma population

BackgroundInternational guidelines for the management of differentiated thyroid cancers are based on the 7th TNM classification: pT3 tumors are defined as differentiated thyroid cancers (DTCs) measuring more than 4xa0cm in their greatest dimension that are limited to the thyroid or any tumor with minimal extrathyroidal extension (ETE; sternothyroid muscle or perithyroid soft tissues). Differences in clinicohistological features and prognosis among patients with pT3 tumors remain controversial, and studies regarding pT3 subgroups are lacking.ObjectiveTo analyze the prognosis of four subgroups of pT3 DTCs (papillary, PTC; or follicular, FTC).Design and settingThe data of patients who underwent surgery for pT3 DTC between 1978 and 2015 in a surgical department specialized in endocrine surgery were reviewed. Patients were classified into four groups as follows: the pT3a (≤u200910xa0mm with ETE), pT3b (10–40xa0mm with ETE), pT3c (>u200940xa0mm without ETE), and pT3d groups (>u200940xa0mm with ETE). Recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method.ResultsOne thousand eighty-eight patients with pT3 DTC were included, of whom 311 (29%) had pT3a; 548 (50%), pT3b; 165 (15%), pT3c; and 64 (6%), pT3d. For the 916 patients with lymph node (LN) dissection, metastatic LNs were more frequent in the pT3b and pT3d groups (61 and 61%, respectively) than in the other groups (44% pT3a and 10% pT3c; pu2009<u20090.001). During the median follow-up period of 9xa0years (range, 2–38xa0years), recurrence occurred in 169 patients with T3 tumors (16%), including 18 with pT3a (6%), 100 with pT3b (18%), 20 with pT3c (12%), and 31 with pT3d (48%). In a multivariate analysis, LN metastases (<u20090.0001), extranodal extension (pu2009=u20090.03), FTC (vs. PTC) (pu2009=u20090.006), pT3b (pu2009=u20090.016), and pT3d (pu2009=u20090.047) were associated with an increased risk of recurrence. The 5-year RFS rates were 94.5, 82.2, 91.1, and 50.3% for the pT3a, pT3b, pT3c, and pT3d groups, respectively (pu2009<u20090.01).ConclusionExcept for microcarcinoma, the risk of LN involvement is high and similar for the DTC patients with minimal ETE, regardless of the size of the tumor. The association of a tumor size of >u20094xa0cm and ETE are associated with a poor prognosis and should justify the classification of these cases as a high-risk group. Other pT3 patients with no LN metastases could be individualized as a low-risk group.

Organization in response to massive afflux of war victims in civilian practice – experimental feedback from the November 2015 Paris terrorist attacks

The arrival of a large number of war-weapon casualties at a civilian trauma center requires anticipation. A plan defining the management principles and the respective roles of the involved physicians and nurses and their interaction with each other is essential. Uni-directional patient flow associated with adequate numbers of staff physicians and nurses under the leadership of a medical director is essential to prevent the overwhelming of the trauma center. Routine and regular interaction between the pre-hospital medical flow control system and the medical director, on one hand, and between surgical teams and the medical director, on the other, are necessary to know when to apply damage control surgical techniques. Based on the feedback of a level 1 trauma center that received 53 victims of the November 13, 2015 terrorist attack in Paris, we present the factors of success, and the stumbling blocks.

Sigmoidectomy via an elective approach for sigmoid volvulus (with video)

Please cite this article in press as: Najah H, et al. Sigmoidectomy via an elective approach for sigmoid volvulus (with video). Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.003