Frédérique Peschaud

The Ratio of Metastatic to Examined Lymph Nodes Is a Powerful Independent Prognostic Factor in Rectal Cancer

Objective:The aim of the study was to evaluate the prognostic value of the ratio of metastatic to examined lymph nodes (LNR) in patients with rectal cancer. Summary Background Data:Lymph nodes ratio (LNR) has been shown to have prognostic value in patients with colon cancer. The impact of LNR on disease-free and overall survival in patients with rectal cancer is unknown. Patients and Methods:From 1998 to 2004, 307 patients underwent rectal resection for adenocarcinoma. The relationships between overall and disease-free survival at 3 years and 15 variables, including the presence or absence of metastatic lymph nodes, the total number of lymph nodes examined, and LNR, were analyzed by multivariate analysis. Patients were then assigned to 4 groups based on LNR: LNR = 0 (N0 patients), LNR = 0.01 to 0.07, LNR >0.07 to 0.2, LNR >0.2. Results:The mean number of lymph nodes examined was 22 ± 12. In the multivariate analysis, LNR was a significant prognostic factor for both disease-free (P = 0.006) and overall survival (P = 0.0003), whereas the presence or absence of metastatic lymph nodes was not. LNR remained a significant prognostic factor in the 59 patients in whom fewer than 12 lymph nodes were examined (P = 0.0058). According to LNR values, disease-free and overall survival decreased significantly with increasing LNR (P < 0.001). Conclusions:LNR is the most significant prognostic factor for both overall and disease-free survival in patients with rectal cancer, even in patients with fewer than 12 lymph nodes examined.

Accuracy of Magnetic Resonance Imaging in Rectal Cancer Depends on Location of the Tumor

PURPOSEThis study was designed to evaluate prospectively magnetic resonance imaging for the prediction of the circumferential resection margin in rectal cancer to identify in which patient magnetic resonance imaging could accurately assess the circumferential resection margin before surgery and in which patients it could not.METHODSDuring a 17-month period, a preoperative magnetic resonance imaging for the assessment of circumferential resection margin was obtained prospectively in 38 patients with mid or low rectal cancer. The agreement of magnetic resonance imaging and pathologic examination for assessment of circumferential resection margin was analyzed.RESULTSOverall, magnetic resonance imaging agreed with histologic examination of the circumferential resection margin assessment in 28 patients (73 percent; κ = 0.47). In all cases of disagreement between magnetic resonance imaging and pathology, magnetic resonance imaging overestimated the circumferential resection margin involvement. For the 11 patients with mid rectal cancer, circumferential resection margin was well predicted by magnetic resonance imaging in all cases (κ = 1). For 27 patients with low rectal tumor, overall agreement between magnetic resonance imaging and histologic assessment was 63 percent (κ = 0.35). Agreement was 22 percent (κ = 0.03) for the 9 patients with low anterior and 83 percent (κ = 0.67) for the 18 patients with low posterior rectal tumor. Univariate analysis revealed that only low and anterior rectal tumor was risk factor of overestimation of the circumferential resection margin by magnetic resonance imaging.CONCLUSIONSAlthough magnetic resonance imaging remains the best imaging tool for the preoperative assessment of the circumferential resection margin in patients with rectal cancer, it can overestimate the circumferential resection margin involvement in low and anterior tumor with the risk of overtreating the patients.

Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis.

BACKGROUND: Little detailed information is available concerning morphological and functional autonomic nerve supply to the internal anal sphincter. However, denervation of the sphincter potentially affects anal function after rectal surgery for cancer. OBJECTIVE: The aim of this study was to identify the location and type (nitrergic, adrenergic, and cholinergic) of nerve fibers in the internal anal sphincter and to provide a 3-dimensional representation of their structural relationship in the human fetus. MATERIALS AND METHODS: serial transverse sections were obtained from 14 human fetuses (7 male, 7 female, 15–31 weeks of gestation) and were studied histologically and immunohistochemically; digitized serial sections were used to construct a 3-dimensional representation of the pelvis. MAIN OUTCOMES MEASURES: The location and type of internal anal sphincter nerves were assessed qualitatively. RESULTS: Posteroinferior fibers originating from the inferior hypogastric plexus posteroinferior angle projected to the posterolateral and posterior rectal wall and internal anal sphincter, forming the inferior rectal plexus. The inferior rectal plexus contained vesicular acetylcholine transporter-positive (cholinergic), tyrosine hydroxylase-positive (adrenergic/sympathetic), and neural nitric oxide synthase-positive (nitrergic) fibers. The intrasphincteric vesicular acetylcholine transporter-positive fibers included both neural nitric oxide synthase-negative fibers and neural nitric oxide synthase-positive fibers (nitrergic-parasympathetic). LIMITATIONS: The study focused on topographic and functional anatomy, so that quantitative data were not obtained. A small number of fetal specimens were available. CONCLUSIONS: We report the precise location and distribution of the autonomic neural supply to the internal anal sphincter. This description contributes to the understanding of neurogenic postoperative sphincteric dysfunction. Three-dimensional cartography of pelvic-perineal neurotransmitters provides an anatomical and physiological basis for the selection and development of pharmacological agents to be used in the treatment of primary or postoperative continence and evacuation disorders.

Preservation of Genital Innervation in Women During Total Mesorectal Excision: Which Anterior Plane?

BackgroundErectile dysfunction, principally related to injury of the autonomic nerve fibers in men, is a major cause of postoperative morbidity after anterolateral dissection during total mesorectal excision (TME) for rectal adenocarcinoma. However, the autonomic innervation of erectile bodies is less known in women, and the anterolateral plane of dissection during TME remains unclear. The existence of the rectovaginal septum (RVS) is controversial. The purpose of the present study was to identify the RVS in the human fetus and adult female by dissection, immunohistochemistry, and three-dimensional reconstruction, and to define its relationship with erectile nerve fibers so as to determine the anterolateral plane of dissection during TME, which could reduce postoperative sexual dysfunction in women.MethodMacroscopic dissection, histologic studies, and immunohistochemistry examination with 3D reconstruction were performed in six fresh female adult cadavers and six female fetuses.ResultsThe RVS was clearly definable in all adult specimens. It was composed of multiple connective tissue, with smooth muscle fibers originating from the uterus and the vagina. It is closely applied to the vagina and has a relationship with the neurovascular bundles (NVBs) that contain erectile fibers intended for the clitoris. The NVBs are situated anteriorly to the posterior extension of rectovaginal septum. This posterior extension protects the NVBs during the anterior and anterolateral dissection for removal of rectal cancer.ConclusionsTo reduce the risk of postoperative sexual dysfunction in women undergoing TME for rectal cancer, we recommend careful dissection to the anterior mesorectum to develop a plane of dissection behind the posterior extension of the RVS if oncologically reasonable.

Management of patients over 80 years of age treated with resection for localised colon cancer: Results from a French referral centre

BACKGROUND Few data are available on management of very elderly colon cancer patients, especially concerning the parameters of therapeutic decisions and the role of geriatricians. METHODS We retrospectively reviewed the charts of patients over 80 years of age who underwent surgery for a localised colon cancer in a French academic hospital. RESULTS A total of 176 patients underwent surgery (postoperative morbidity and mortality rates: 25% and 6.7%). Adjuvant chemotherapy was discussed at a multidisciplinary team meeting for 91% of stage III patients, but only 13.5% of them were treated. Twenty-five patients relapsed: 19 were discussed at the multidisciplinary meeting and 16 were treated (5 had a metastasectomy). Despite their increase with time, geriatric assessments were infrequent, 17% (33% after 2006), and had no impact on postoperative morbi-mortality. Median overall survival and recurrence-free survival were 65.3 months and 65.1 months, respectively. Age, emergency surgery, and Charlson comorbidity index were independent prognostic factors. CONCLUSION Selected elderly colon cancer patients have significant access to surgery. However, postoperative morbi-mortality rates remain high and adjuvant chemotherapy rarely prescribed. Perioperative geriatric assessment, especially before surgery, should be routinely proposed to these patients to evaluate its impact on postoperative morbi-mortality and prescription of adjuvant treatment.

Concepts of the rectovaginal septum: implications for function and surgery.

IntroductionIn the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers’ rectoprostatic fascia or rectovesical septum (RVS). Its purpose—and, indeed, its existence—are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men.MethodsA review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested.ResultsThis manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men.ConclusionsThe RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.

LETHAL FECALOMA: LETTERS TO THE EDITOR

predict long-term clinical outcome after percutaneous coronary revascularization. Eur Heart J 2005;26:2387–2395. 5. Jia SH, Li Y, Parodo J et al. Pre-B cell colony-enhancing factor inhibits neutrophil apoptosis in experimental inflammation and clinical sepsis. J Clin Invest 2004;113:1318–1327. 6. YeSQ, Simon BA, Maloney JP et al. Pre-B-cell colony-enhancing factor as a potential novel biomarker in acute lung injury. Am J Respir Crit Care Med 2005;171:361–370. 7. Zhang YY, Gottardo L, Thompson R et al. Avisfatin promoter polymorphism is associated with low-grade inflammation and type 2 diabetes. Obesity (Silver Spring) 2006;14:2119–2126. 8. Takami S, Imai Y, Katsuya T et al. Gene polymorphism of the renin-angiotensin system associates with risk for lacunar infarction. The Ohasama Study. Am J Hypertens 2000;13:121–127. 9. Yamada A, Matsumoto K, Iwanari H et al. Rapid and sensitive enzyme-linked immunosorbent assay for measurement of HGF in rat and human tissues. Biomed Res 1995;16:105–114. 10. Ognjanovic S, Bao S, Yamamoto SY et al. Genomic organization of the gene coding for human pre-B-cell colony enhancing factor and expression in human fetal membranes. J Mol Endocrinol 2001;26:107–117.

Le ligament rectal inférieur: Entité anatomique difficilement évaluable par l’imagerie

Resume L’appreciation pre-operatoire du degre d’envahissement tumoral du mesorectum en imagerie par resonnance magnetique (IRM) permettrait d’optimiser la prise en charge des malades atteints d’un cancer du rectum. Cependant d’un point de vue anatomique, les limites precises du mesorectum ou ligament rectal superieur sont controversees, si bien que l’analyse de celui-ci par l’imagerie parait incertaine. L’objectif de ce travail est donc de definir avec precision l’anatomie du mesorectum afin de savoir si celui-ci peut reellement etre analyse par l’imagerie medicale. L’exerese totale du mesorectum jusqu’au muscle levator ani, fut realisee chez 37 patients atteint d’un cancer. La distribution anatomique du mesorectum a ete analysee sur pieces fraiches puis fixees apres marquage a l’encre de Chine. Son epaisseur etait mesuree ventralement, dorsalement et lateralement sur le moyen et le bas rectum. Le degre d’envahissement tumoral etait defini par la distance mesuree entre le processus tumoral et la limite circonferentielle du mesorectum. L’ensemble de ces mesures etait egalement evalue sur les cliches d’IRM en pre-operatoire. Au niveau du moyen rectum, son epaisseur maximale en dorsal etait de 60 mm, et en ventral de 20 mm. Au niveau du bas rectum, le mesorectum etait beaucoup plus mince puisque son epaisseur n’excedait jamais 1 cm aussi bien en ventral qu’en dorsal. Le degre d’envahissement tumoral etait inferieure a 2 mm dans 23 % de cas. Concernant le degre d’envahissement du mesorectum, il existait une bonne correlation entre la mesure anatomique et l’IRM uniquement au niveau du moyen rectum. Ces donnees anatomiques expliquent pourquoi l’IRM ne peut apprecier correctement le mesorectum au niveau du bas rectum.The preoperative assessement by magnetic resonance imaging (MRI) of mesorectum involvement could improve the treatment strategy for patients with rectal cancer. However, the anatomical definition of the mesorectum remains controversial and consequently the accurracy of its analysis by preoperative imaging workup is still unsatisfactory. The aims of this study were to define the mesorectum anatomically and to assess whether it could be evaluated accurately by MRI. Total mesorectal excision was performed in 37 patients with rectal cancer. The mesorectum was inked for anatomical analysis, which was performed before and after fixation in formalin. The mesorectal thickness was measured anteriorly, posteriorly and laterally. Mesorectal involvement was defined by the shortest distance from the outermost part of the tumour to the lateral mesorectal margin. The anatomical measures were compared to those evaluated by preoperative MRI. In middle rectum, the anatomical analysis showed that the maximal mesorectal thickness was 60 and 20 mm posteriorly and anteriorly, respectively. In low rectum, the mesorectum was very thin and its maximal thickness was less than 10 mm anteriorly and posteriorly in all cases. The mesorectal involvement was less than 2 mm in 23% of cases. In terms of mesorectal involvement, there was good agreement between anatomical analysis and MRI for middle rectum. In contrast, the agreement was fair for low rectum. This anatomical analysis could explain the poor performance of MRI in the assessement of mesorectum involvement in low rectum.

La résection anastomose colorectale protégée n’est-elle pas finalement la meilleure option thérapeutique en cas de péritonite par perforation diverticulaire Hinchey III ?

But Le traitement chirurgical optimal des peritonites purulentes (Hinchey III) par perforation diverticulaire (PPPD) reste debattu. Le but de cette etude etait de comparer les resultats postoperatoires du lavage-drainage laparoscopique (LDL) a ceux de la resectionanastomose colorectale protegee (RAP) pour PPPD. Methodes De 2010 a 2015, tous les malades operes pour PPPD ont ete inclus. Le choix entre LDL et RAP etait laisse a l’appreciation du chirurgien. Resultats 24 malades ont eu une RAP et 15 un LDL. La proportion de malades ASA>2 etait superieure dans le groupe RAP (12/24 vs 1/15, p vs 67 %, N S ; 8.3 % vs 6.7 %, NS). Les taux de complications chirurgicales et de reoperations etaient plus eleves apres LDL qu’apres RAP (53 % vs 17 %, p=0.03 ; 47 % vs 4 %, p Conclusion En cas de PPPD, pres de la moitie des malades ayant un LDL sont reoperes pour avoir une stomie. La RAP est une alternative fiable, elle limite le risque de reintervention pour complication grave sans augmenter le risque de stomie definitive. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.

Erratum to: Preservation of Genital Innervation in Women During Total Mesorectal Excision: Which Anterior Plane?

Fig. 4 Three-dimensional (3D) view of fetus intrapelvic organs with pelvic nerves. Superior infraperitoneal 3D view of a 30-week-old female fetus: intrapelvic organs with immunolabeled pelvic nerves showing the position of the inferior hypogastric plexus (IHP) on the lateral aspects of the rectum. From the IHP, efferent branches rise in distal directions: postero-inferior for the rectal wall, lateral for the levator ani muscles, and antero-inferior to form the NVBs. Some fibers from the NVBs branch medially to innervate the posterior vaginal wall. More caudally, the bundle puts out fibers in three major projections: an anterior projection for the urethral sphincter complex, an anterolateral projection (the cavernous nerve) that travels anterolaterally to the vagina to reach the corpora cavernosa, and a posterolateral projection (the spongious nerve) that continues posterolaterally to the vagina to innervate the corpus spongiosum. In inset, blue arrows show the directions of the IHP and NVB main terminal efferences. Ur urethra The online version of the original article can be found under doi:10.1007/s00268-011-1313-2.