Nicolas Munoz-Bongrand

Splenectomy and/or cyclophosphamide as salvage therapies in thrombotic thrombocytopenic purpura: the French TMA Reference Center experience

BACKGROUND: The objective was to assess the efficacy and safety of splenectomy and cyclophosphamide as salvage therapies in severe thrombotic thrombocytopenic purpura (TTP).

Late morbidity after colon interposition for corrosive esophageal injury: risk factors, management, and outcome. A 20-years experience.

Objective:The aim of this study was to report our experience in the management of late morbidity after colonic interposition for caustic injury and to assess the influence of coloplasty dysfunction on patient outcome. Summary Background Data:Reports on coloplasty dysfunction after colon interposition for corrosive esophageal injuries are scarce in the literature. Dysfunction of the colonic substitute might jeopardize an already fragile functional result, and appropriate management can improve outcome. Methods:Long-term follow-up (>6 months) was conducted in 223 patients (125 men; median age, 35 years) who underwent colonic interposition for caustic injuries between 1987 and 2006. Statistical tests were performed on this cohort to identify risk factors for late morbidity and functional outcome. During the same period, 28 patients who underwent colon interposition for caustic injury in another center were referred for treatment of coloplasty dysfunction. Data from these patients were used together with those of our patients to describe specific coloplasty-related complications and their management. Results:With a median follow-up of 5 years (range: 6 months–20 years), late complications were recorded in 125 (55%) of our patients (stenosis 36%, reflux 11%, redundancy 5%). A delay in reconstruction <6 months (P = 0.03) and absence of thoracic inlet enlargement (P = 0.002) were independent predictive factors for cervical anastomotic stenosis. Functional failure was recorded in 52 patients (23%) and was associated with a delay in reconstruction <6 months (P = 0.009) and emergency tracheotomy (P = 0.002). Coloplasty dysfunction was responsible for half of the recorded failures. Revision surgery for coloplasty dysfunction was performed in 96 patients (68 local, 28 referred) with an overall 70% success rate. Conclusions:Late complications occurred in half of the patients after colonic interposition for corrosive injuries and accounted for half of the functional failures. Prolonged surgical follow-up and appropriate management of coloplasty dysfunction are key factors for long-term success after esophageal reconstruction for caustic injuries.

Reconstruction œsophagienne pour séquelles de brûlure caustique : coloplasties, mode d’emploi

Retrosternal coloplasty is the gold standard for esophageal reconstruction after caustic injury of the digestive tract. Complete preoperative otolaryngology evaluation and the control of the psychiatric disease are key factors for success. In the absence of controlled studies, the choice between the right and the left colon graft relies on the anatomy of the blood supply to the colon and on the individual surgeons preference. Treatment of associated pharyngeal and laryngeal injuries is mandatory at the time of esophageal reconstruction. In experienced hands mortality rates are less than 5% but specific postoperative complications (graft necrosis, leakage, anastomotic stricture) are high. The low risk of cancer development in the by-passed esophagus does not justify routine esophagectomy at the time of reconstruction. Sixty to eighty percent of patients would finally retrieve nutritional autonomy after coloplasty for caustic injury. Late acquired dysfunctions of the coloplasty (anastomotic strictures, graft redundancy) requiring revision surgery occur frequently and might jeopardize an already fragile functional result. Timely diagnosis and treatment of such complications and the necessity of continuous psychological surveillance justify the need for long term follow up in these patients.

Colopharyngoplasty for the treatment of severe pharyngoesophageal caustic injuries: an audit of 58 patients.

Objective:The aim of this study was to describe the technique of colopharyngoplasty for the reconstruction of concomitant esophageal and pharyngeal caustic injuries and to evaluate the postoperative course and late functional outcomes. Summary Background Data:Surgical treatment of esophageal and pharyngeal strictures is a difficult challenge because reconstruction at this level interferes with the mechanisms of deglutition and respiration. Several techniques have been described for the treatment of this condition but none is accepted as the gold standard. Methods:Fifty-eight patients (34 men, median age 37 years) underwent colopharyngoplasty for caustic injuries between 1993 and 2005. Forty patients (69%) had a previous psychiatric history of depression (n = 30) or schizophrenia (n = 10). After removal of all scar tissues, the pharyngeal reconstruction was performed with the cervical end of the colic transplant employed for esophageal replacement. Laryngeal resection was associated in half of the patients. Success of the procedure was defined as recovery of nutritional autonomy and airway patency. Results:Operative mortality was 2%. Postoperative complications required reoperation in 16 patients (28%). The functional outcome was evaluated in 46 patients with a follow-up of more than 6 months. The tracheostomy was withdrawn in 42 (91%) patients after a median of 42 days (range, 20–1020). The jejunostomy was removed in 32 patients (70%) after a median of 12 months (range, 2–54). Finally, the procedure was successful in 31 patients (67%). Logistic regression analysis showed that advanced age, a previous history of psychiatric disease, and early reoperation had an adverse impact on fuctional outcome. Seven patients (12%) repeated the suicide attempt. Conclusions:Colopharyngoplasty is a simple and reliable procedure that can be successfully employed to restore the digestive continuity in patients with concomitant esophageal and pharyngeal caustic injuries. Control of the underlying psychiatric disease before reconstruction is a key factor for success.

Anal carcinoma in HIV-infected patients in the era of antiretroviral therapy: a comparative study.

BACKGROUND: Before the introduction of highly active antiretroviral therapy, prognosis of anal squamous-cell carcinoma was worse when patients were infected with HIV. Since then, contradictory results have been reported. OBJECTIVE: To compare the results of chemoradiotherapy in HIV-infected and uninfected patients with anal carcinoma. DESIGN: Retrospective analysis of medical records. SETTING: Tertiary care center in France. PATIENTS: Patients with invasive anal carcinoma treated from 2001 through 2006. INTERVENTIONS: Chemoradiotherapy included 60 Gy pelvic irradiation and cisplatin-based chemotherapy. Surgery was performed for local failures or complications. MAIN OUTCOME MEASURES: Tolerance for chemoradiotherapy, tumor control, and survival were evaluated. RESULTS: A total of 46 patients (20 HIV-infected and 26 uninfected) were treated for nonmetastatic anal carcinoma. Median follow-up was 32.5 (range, 7–84) months. HIV-infected patients were more likely to be men (95% vs 23%, P < .001) and were younger (median age, 46 vs 62 years, P < .001) than uninfected patients. The viral load was less than 200 copies/mL in 15 (75%) of the HIV-infected patients. The duration of chemoradiotherapy was longer in HIV-infected than in uninfected patients (median, 103 vs 84 days, P = .027). Chemoradiotherapy failed to achieve local control in 10 (50%) HIV-infected and in 6 (23%) uninfected patients (P = .057). In HIV-infected patients, failure rates were higher in patients who required prolonged chemoradiotherapy than in those who received treatment as scheduled (7/11, 64% vs 1/7, 14%; P = .039). During follow-up, 7 (35%) of the HIV-infected and 3 (12%) of the uninfected patients died, all from anal carcinoma. The 5-year overall survival rate was 39% for HIV-infected and 84% for uninfected patients (P = .026); 5-year disease-free survival was 37% in HIV-infected and 75% in uninfected patients (P = .06). LIMITATIONS: Retrospective design, lack of data regarding precise toxicity grading, and use of cisplatin-based chemoradiotherapy. CONCLUSIONS: Even in the era of highly active antiretroviral therapy, HIV-infected patients with anal squamous-cell carcinoma show impaired tolerance to chemoradiotherapy, have a lower survival rate, and may have a higher rate of local failure compared with uninfected patients.

Crohn's disease recurrence after total proctocolectomy with definitive ileostomy

BACKGROUND Total proctocolectomy with definitive ileostomy is the ultimate treatment for refractory colonic Crohns disease (CD). Aim of the study was to report the outcome of Crohns disease patients after total proctocolectomy with definitive ileostomy. PATIENTS AND METHODS Between 1990 and 2005, 55 patients underwent total proctocolectomy with definitive ileostomy for Crohns disease in our institution. None of them received preventive post-operative treatment. We studied clinical recurrence, need for immunosuppressants (IS), anti-TNF therapy and re-operation in this retrospective cohort. RESULTS Median follow-up was 5.4 years. Probabilities of clinical Crohns disease recurrence were 4%, 27% and 39% at 1, 5 and 8 years, respectively. In multivariate analysis, clinical recurrence rate was significantly higher for patients with penetrating disease behaviour (RR 1.7 IC95% [1.5-19], p=0.05) and absence of perianal disease (RR=1.6, IC95% [1.4-10]; p=0.01). Clinical recurrences were located in terminal ileum in all cases and treated medically in 9 of 16 patients including IS or anti TNF agents in 7 cases. Probabilities of treatment with immunosuppressants or anti-TNF therapy were 4%, 15% and 15% at 1, 5 and 8 years, respectively. Nearly one third of the patients (29%) underwent surgery for mechanical complications (N=11) and/or CD recurrence (N=7). Probabilities of reoperation for Crohns disease recurrence were 0%, 10% and 18% at 1, 5 and 8 years, respectively. CONCLUSION Recurrence after total proctocolectomy with definitive ileostomy for Crohns disease is not uncommon, and in our series often required immunosuppressants or surgical procedure.

Lipome colique : cas clinique et revue de la littérature

Colonic lipoma is a rare benign tumor infrequently met in clinical practice. We report a case of symptomatic lipoma of the ascending colon in a 61-year-old woman. Diagnosis was suspected on CT scan. Colotomy with lipectomy was performed. The diagnosis was confirmed by histological examination. Reviewing the literature and combining with our experience, we discuss the clinical features, diagnosis and treatment of this uncommon disease.

Oesophagogastrectomy and pancreatoduodenectomy for caustic injury

The justification for pancreatoduodenectomy (PD) for extended duodenal and pancreatic caustic necrosis is still a matter of debate.

Primary Hyperparathyroidism from Parathyroid Microadenoma: Specific Features and Implications for a Surgical Strategy in the Era of Minimally Invasive Parathyroidectomy

BACKGROUND The aim of this study was to identify the specific preoperative characteristics of patients with parathyroid microadenoma and to report their outcomes after surgical treatment. STUDY DESIGN Parathyroid microadenomas (weight < 100 mg) were identified in 62 (6%) of the 1,012 patients operated on for a parathyroid adenoma between 1995 and 2004. Presentation and outcomes after surgery were compared with those of 124 patients operated on consecutively for parathyroid adenoma (>100 mg) during the last year of the study. All patients underwent bilateral surgical exploration of the neck. Success was defined as resection of a pathologic gland combined with normocalcemia at 6 months after operation. Logistic regression was used to test the relationship between groups and potential predictive factors of microadenoma. RESULTS There were 57 women (92%) and the median age was 57 years (range 29 to 77 years). Median preoperative calcemia and parathyroid hormone (PTH) serum levels were 2.64 mmol/L (range 2.31 to 3 mmol/L) and 79 pg/mL (range 30 to 189 pg/mL), respectively. There was no difference in the clinical presentation between patients with microadenoma and adenoma. Preoperative calcium (p < 0.001) and PTH serum levels (p = 0.014) were significantly higher in patients with adenoma. Calcium and PTH serum levels lower than 2.6 mmol/L and 60 pg/mL, respectively, predicted the presence of microadenoma with respective specificities of 0.89 and 0.87. Success rates were similar in the microadenoma and adenoma groups (92% vs 98%; p = 0.11). CONCLUSIONS Mild preoperative elevations of calcium or PTH serum levels should warn about the risk of microadenoma. In this setting, intraoperative difficulties should be expected in identifying the pathologic gland, and bilateral neck exploration should be the preferred surgical approach.

The Impact of Splenectomy in Myelofibrosis Patients before Allogeneic Hematopoietic Stem Cell Transplantation

Performing a pretransplantation splenectomy in patients with myelofibrosis (MF) is a matter of debate, as while the procedure improves hematological recovery, it may lead to severe morbidities. We retrospectively analyzed data from 85 consecutive patients who underwent transplantation in our center for MF, including 39 patients who underwent splenectomy before their transplantation. A majority of them had primary MF (78%), were considered high-risk patients (84% dynamic international prognostic scoring system intermediate-2 or higher), and had received transplants from HLA-matched sibling donors (56%) after a reduced-intensity conditioning regimen (82%). One-half of all splenectomized patients presented surgical or postsurgical morbidities, most frequently thrombosis and hemorrhage. After adjustment using Cox models, pretransplantation splenectomy was not associated with nonrelapse mortality or post-transplantation relapse but with an improved overall survival (OS) and event-free survival (EFS). We conclude that some patients with huge splenomegaly may undergo pretransplantation splenectomy without a deleterious impact on post-transplantation outcomes. OS and EFS improvement should in confirmed in controlled study.