Laurent Bresler

Efficacy of sacral nerve stimulation for fecal incontinence : Results of a multicenter double-blind crossover study

Background and Aims:This is the first double-blind multicenter study examining the effectiveness of sacral nerve stimulation in a significant number of fecally incontinent patients. Methods:A total of 34 consecutive patients (31 women), median age 57 years (range, 33–73 years), underwent sacral nerve stimulation for fecal incontinence. After implantation, 27 of 34 patients were randomized in a double-blind crossover design to stimulation ON or OFF for 1-month periods. While still blinded, the patients chose the period of stimulation (ON or OFF) that they had preferred. The mode of stimulation corresponding to the selected period was continued for 3 months (final period). Outcome measures were frequency of fecal incontinence and urgency episodes, delay in postponing defecation, score severity, feeling of improvement, preference for ON or OFF, quality of life, and manometric measurements. Results:In the crossover portion of the study, the self-reported frequency of fecal incontinence episodes was significantly reduced during the ON versus the OFF period (P = 0.03), and this symptomatic improvement was consistent: 1) with the patients feeling of greater improvement during the ON versus OFF period (P = 0.02); 2) with the significant preference of patients (P = 0.02) for the ON versus OFF period. In the final period of the study, the frequency of fecal incontinence episodes decreased significantly (P = 0.005) in patients with the stimulator ON. The ability to postpone defecation (P = 0.01), the score for symptom severity (P = 0.0004), and the quality of life (P < 0.05) as well as anal sphincter function significantly improved. Conclusions:The significant improvement in FI during the ON versus OFF period indicated that the clinical benefit of sacral nerve stimulation was not due to placebo.

Prospective evaluation of 100 robotic-assisted unilateral adrenalectomies.

BACKGROUND Our aim was to determine the learning curve for robotic adrenalectomy and factors that influence operative time and cost. METHODS We prospectively evaluated of 100 consecutive patients who underwent robotic, unilateral, transperitoneal adrenalectomy. RESULTS The mean operative time for robotic-assisted adrenalectomy was 95 minutes and conversion rate was 5%. Pathology was aldosteronoma (n = 39), pheochromocytoma (n = 24), nonfunctional adenoma (n = 19), Cushing adenoma or hyperplasia (n = 16), and cyst (n = 2). Morbidity and mortality rates were 10% and 0%, respectively. The mean operative time decreased by 1 minute every 10 cases. Operative time improved more for junior surgeons than for senior surgeons (P = .006) after the first 50 cases. By multiple regression analysis, surgeons experience (-18.9 +/- 5.5), first assistant level (-7.8 +/- 3.2), and tumor size (3 +/- 1.4) were independent predictors of operative time (P < .001 each). The robotic procedure was 2.3 times more costly than lateral transperitoneal laparoscopic adrenalectomy (euro4102 vs euro1799). CONCLUSIONS Surgeon experience, resident training level, and tumor size are important variables for robotic-assisted, unilateral adrenalectomy and should be taken into account when this approach is evaluated. Controlled studies need to be performed to show potential relevant clinical benefits that could balance costs.

Robotic-assisted adrenalectomy: what advantages compared to lateral transperitoneal laparoscopic adrenalectomy?

BACKGROUND This study evaluates the perioperative outcomes of robotic-assisted adrenalectomy (RA) compared with lateral transperitoneal laparoscopic adrenalectomy (LA). METHODS Prospective evaluation of 50 patients who underwent unilateral RA versus 59 patients who underwent unilateral LA. RESULTS RA was associated with lower blood loss (49 mL) but longer operative times (104 minutes) (P < .001). However, the difference in operative time was not significant after the learning curve of 20 cases. In patients with body mass index (BMI) > or = 30 kg/m(2), mean operative time was longer in the LA group (90 vs 78 minutes, P = .03) but not in the RA group. In patients with large tumors (> or = 55 mm), mean operative time was longer in the LA group (100 vs 80 minutes, P = .009) but not in the RA group. Conversion rate, morbidity, and hospital stay were similar in both groups. CONCLUSIONS After a learning curve of 20 cases, RA has similar perioperative outcomes compared to lateral transperitoneal LA. Several criteria (previous laparoscopic expertise, first assistants skill and tumor side) remain determinative on RA operative time.

Robotic-assisted pelvic organ prolapse surgery

BackgroundThis study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system.MethodsDuring a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed.ResultsAll but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45–280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results.ConclusionOur experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.

Does Robotic Adrenalectomy Improve Patient Quality of Life When Compared to Laparoscopic Adrenalectomy

The purpose of this study was to evaluate and compare perioperative quality of life in patients after laparoscopic versus robotic adrenalectomy. From November 2000 through August 2003, 33 consecutive patients underwent laparoscopic (n = 14) and robotic (n = 19) adrenalectomy. Data were obtained prospectively during management and by patient questionnaire (SF36, State-Trait Anxiety Inventory) preoperatively and postoperatively, at day 4 and at 6 weeks. Physical functioning, role limitations due to physical health problems, and bodily pain (Physical SF36 scores) were decreased at day 4 (p = 0.004) in all patients when compared to preoperative levels; and became similar to preoperative levels after 6 weeks. Patients who underwent robotic adrenalectomy had an increased score at 6 weeks of role limitations due to emotional problems (Mental SF36 score) (p = 0.03). No other significant difference was observed between patients after laparoscopic or robotic adrenalectomy. Although state anxiety was decreased postoperatively at day 4 and at 6 weeks (p = 0.01) in all patients, there was no significant difference between laparoscopic and robotic adrenalectomy. Postoperative pain was similar in both groups but had a tendency to be higher when patients underwent a left adrenalectomy (p = 0.07). Similarly, state anxiety had a tendency to be higher postoperatively at day 4 in patients after left adrenalectomies (p = 0.06). This study provides an evaluation of perioperative quality of life in patients after minimally invasive (laparoscopic and/or robotic) adrenalectomy. We observed no major difference between patients who underwent laparoscopic or robotic adrenalectomy. Thus, patients’ perioperative quality of life is not a justifiable parameter on which to base promotion of robotic adrenalectomies.

Splénectomie laparoscopique pour maladies hématologiques.Étude de 275 cas

AIM OF THE STUDY To evaluate the results of laparoscopic splenectomy for hematologic diseases by a multicenter retrospective study. PATIENTS AND METHODS Between 1991 and 1998, 275 patients (mean age: 40.4 years [18-93]) underwent splenectomy for idiopathic thrombocytopenic purpura (ITP) (n = 209, 76%), for hemolytic anemia (HA) (n = 37) including hereditary spherocytosis (n = 13) and auto-immune anemia (n = 24), lymphoma (n = 12), tumor (n = 6) and uncommon hematologic syndromes (n = 11). Laparoscopic splenectomy was attempted in every patient. The lateral approach was most commonly used with an anterior approach to the splenic hilar vessels, which were cut after hemostasis using a stapling gun; other techniques were also employed. RESULTS The mean operating time was 165 minutes (45-360); it was shorter in the case of conversion (144 minutes) and became shorter with the operators experience. Conversion was necessary in 55 patients (20%), due to hemorrhage in 2/3 of cases, related to splenic vessels (20 cases), short gastric vessels (9 cases), or injury of the spleen (8 cases). In ten cases (2%), conversion was necessary for extraction of the spleen. Conversion rate varied from 5.3 to 46.7%, depending on the surgical team. Univariate analysis of factors predisposing to conversion identified four causes: obesity; technique used to achieve hemostasis of the splenic hilar vessels; operators experience; and presence of splenomegaly. An accessory spleen was found in 44 patients (16%). The weight of the spleen was more than 350 g in 43 patients (15.6%). There were no deaths. There were no significant complications in 236 patients (85.8%) and the mean hospital stay was 6.4 days. In comparison with patients who had a conversion, bowel function returned significantly earlier, use of analgesia was reduced and hospital stay was shorter. The overall morbidity rate was 13.8% (n = 38); morbidity rate was only 10.4% (n = 22) for laparoscopic splenectomy. In these 22 patients, the complications were: subphrenic collections (n = 5, 2.2%), abdominal wall infections (n = 5), thromboembolic events (n = 2), anemia (n = 2), pneumonia (n = 1), peptic ulcer (n = 1), bowel obstruction (n = 1), splenic vein thrombosis (n = 1). Re-operations were required in 4 patients (1.8%) because of hemorrhage, pancreatitis and bowel obstruction. Morbidity rate was significantly increased in the case of conversion (27%), obesity (20%), malignant disease (30%) and splenomegaly (21.8%). Forty-four patients (16%) received perioperative or postoperative blood transfusion and 23 (8.3%) received platelet transfusion. Mean time to return to normal activity was 21 days and was shorter in the absence of conversion (18.5 days versus 35 days). In patients with ITP, the mean platelet count was 240,000 after 3 months, and the failure rate was 8.3%. CONCLUSION Laparoscopic splenectomy is a real alternative to conventional splenectomy for some hematologic diseases, particularly ITP and HA. The advantages are an uneventful postoperative course, a lower morbidity rate, a shorter hospital stay and an earlier return to normal activity. The limits of this technique are related to the operators experience, the size of the spleen, the nature of the underlying disorders and patient characteristics, mainly obesity.

Incidence of and impact of medications on colectomy in newly diagnosed ulcerative colitis in the era of biologics

Background: The cumulative incidence of colectomy and the impact of 5‐aminosalicylates (5‐ASA), azathioprine, and antitumor necrosis factor (TNF) treatment on the long‐term need for surgery are unknown in ulcerative colitis (UC) in the era of biologics. Methods: This was an observational study of a referral center cohort. The cumulative incidence of UC‐related colectomy was estimated using the Kaplan–Meier method. Independent predictors of surgery were identified using Cox proportional hazards regression with propensity scores adjustment. The electronic charts of 151 incident cases of UC from Nancy University Hospital, France, diagnosed between 2000 and 2008, were reviewed through January 2010. Results: The median follow‐up time per patient was 58 months. Twenty‐one (14%) underwent surgery. The cumulative probabilities of colectomy were respectively 1.3% and 13.5% at 1 and 5 years from the time of diagnosis. The probability of receiving oral mesalamine at 5 years was 68.1%. The corresponding figures were 48.9% for azathioprine and 29.0% for infliximab. For corticosteroids, methotrexate, and cyclosporin these figures were 75%, 8.8%, and 11.5%, respectively. Using multivariate Cox proportional hazards regression analysis after propensity score adjustment, previous use of cyclosporin was the only independent predictor for colectomy (hazard ratio = 4.41; 95% confidence interval 1.75–1.13). Conclusions: About one‐tenth of patients still require colectomy for UC at 5 years in the era of biologics. Oral 5‐ASA, azathioprine, and anti‐TNF therapy are not associated with a reduced need for colectomy. (Inflamm Bowel Dis 2012)

Effects of vitamin B12 and folate deficiencies on DNA methylation and carcinogenesis in rat liver.

Abstract Deficiencies of the major dietary sources of methyl groups, methionine and choline, lead to the formation of liver cancer in rodents. The most widely investigated hypothesis has been that dietary methyl insufficiency results in abnormal DNA methylation. Vitamin B12 and folate also play important roles in DNA methylation since these two coenzymes are required for the synthesis of methionine and S-adenosyl methionine, the common methyl donor required for the maintenance of methylation patterns in DNA. The aim of this study was to review the effects of methyl-deficient diets on DNA methylation and liver carcinogenesis in rats, and to evaluate the role of vitamin B12 status in defining carcinogenicity of a methyl-deficient diet. Several studies have shown that a methyl-deficient diet influences global DNA methylation. Evidence from in vivo studies has not clearly established a link between vitamin B12 and DNA methylation. We reported that vitamin B12 and low methionine synthase activity were the two determinants of DNA hypomethylation. Choline- or choline/methionine-deficient diets have been shown to cause hepatocellular carcinoma in 20–50% of animals after 12–24 months. In contrast, the effect of vitamin B12 withdrawal, in addition to choline, methionine and folate, induced hepatocellular carcinoma in less than 5% of

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence.

BACKGROUND Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence. METHODS One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed. RESULTS There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05). CONCLUSIONS RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.

Serum aldosterone is correlated positively to parathyroid hormone (PTH) levels in patients with primary hyperparathyroidism

BACKGROUND Primary hyperparathyroidism is associated with an increased cardiovascular morbidity and mortality. However, mechanisms underlying this association are currently unclear. As there is clear evidence of the independent role of aldosterone on the cardiovascular system, the aim of this study was to evaluate aldosterone levels in patients with primary hyperparathyroidism. METHODS A prospective study of 134 consecutive patients with primary hyperparathyroidism before and 3 months after parathyroidectomy. RESULTS Pre-operative serum aldosterone and parathyroid hormone (PTH) levels were correlated positively in all patients (.238; P = .005). In the 62 patients (46%) that were not on antihypertensive medications, this correlation was stronger (.441; P = .0003). In the 72 patients (54%) treated with at least 1 antihypertensive medication, no correlation between preoperative aldosterone and PTH serum levels was observed. By multivariate analysis, pre-operative PTH level (.409; P = .005) was an independent predictor of aldosterone. Pre-operative PTH level >100 ng/L was an independent predictor of abnormally elevated plasma aldosterone level (odds ratio 3.5; P = .01). At 3 months after parathyroidectomy, no correlation was observed between postoperative PTH and aldosterone levels. CONCLUSION Aldosterone is correlated positively to preoperative PTH levels in patients with primary hyperparathyroidism. Aldosterone might be a key mediator of cardiovascular symptoms in patients with primary hyperparathyroidism.