S. Mucci

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

PurposeThe morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery.MethodsFrom 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality.ResultsPostoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04).ConclusionsColorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.

The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult

AIM OF THE STUDY The Alvarado score is a validated test in clinical adult surgery practice which can be helpful in the diagnosis of acute appendicitis. This study aimed to assess the reliability and the reproducibility of this score for patients presenting in the emergency room with acute right lower quadrant abdominal pain. MATERIAL AND METHODS A prospective monocenter study included all adults who presented in the emergency room with right lower quadrant abdominal pain. The score was calculated by assessing six symptoms and two laboratory values weighted by coefficients. The diagnosis of acute appendicitis was confirmed by the histological examination of the resected appendix. Three groups of patients with high, low, and intermediate scores were defined as described in the literature. RESULTS Of the 233 patients studied, 174 underwent surgery: three had a normal appendix on histological exam. The statistical analysis of the results showed that a score lower than 4 was significantly associated with the absence of acute appendicitis while a score higher than 6 was significantly associated with acute appendicitis which required surgical care. But a score between 4 and 6 was not discriminant. CONCLUSION The Alvarado score is a reliable, cheap and reproducible tool for the diagnosis of acute appendicitis in the emergency room; if the score is higher than 6 or lower than 4, there is no need for complementary exams. Patients with a score between 4 and 6, require serial reassessment of physical findings and score over 24 hours and/or complementary diagnostic exam such as ultrasound or CT scan.

Central pancreatectomy: Comparison of results according to the type of anastomosis

INTRODUCTION The mild pancreatic tumors are more and more treated by central pancreatectomy (CP) in alternative with the widened pancreatectomies. Indeed, their morbidity is lesser but they are however burdened by a rate of important postoperative fistulas. The purpose of our study is to compare pancreatico-jejunal anastomosis and pancreatico-gastric anastomosis. METHODS This work was realized in a bicentric retrospective way. Twenty-five CP were included and classified according to two groups according to the pancreatic anastomosis (group 1 for pancreatico-jejunal anastomosis and group 2 for the pancreatico-gastric anastomosis). CP was realized according to a protocol standardized in both centers and the complications were classified according to the classification of Clavien and Dindo and the fistulas according to the classification of Bassi. RESULTS Both groups were comparable. The duration operating and the blood losses were equivalent in both groups. There was a significant difference (P=0,014) as regards the rate of fistula. The pancreatico-gastric anastomosis complicated more often of a low-grade fistula. However, in both groups, the treatment was mainly medical. Our results were comparable with those found in the literature and confirmed the advantages of the CP with regard to the cephalic duodeno-pancreatectomy (DPC) or to the distal pancreatectomy (DP). However, in the literature, a meta-analysis did not report difference between both types of anastomosis but this one concerned only the DPC. CONCLUSIONS This work showed a less important incidence of low-grade fistula after pancreatico-jejunal anastomosis in the fall of a PM. This result should be confirmed by a later study on a more important sample of PM.

Rectal Metastasis of Prostate Cancer: About a Case

Prostate adenocarcinomas present a high risk of metastasis. We report a case of an atypical prostate cancer metastasis. A male patient presented a prostatic adenocarcinoma treated by surgery. A biological recurrence was discovered during the follow-up by an increased rate of Prostate Specific Antigen (PSA) and was treated by hormonotherapy. Several months later, there was a re-increase of the PSA rate. The CT scan showed a radiation proctitis aspect. An intermittent hormonotherapy was decided. Six months later, he presented abdominal pain. Examinations were performed and showed a rectal carcinosarcoma with prostate origins. A surgical management was realised. The outcomes were an early recurrence. A symptomatic treatment was decided. There are not any rectal localisations reported in the literature. Only loco-regional invasions of the rectum are described and no histological modification of metastasis compared to the primitive tumor has been reported. So, we report a metastasis of a prostate adenocarcinoma which transformed into a carcinosarcoma. Keywords Adenocarcinoma; Carcinosarcoma; Metastasis; Prostate; Rectal neoplasm

Pancréatite aiguë récidivante révélant un kyste hydatique du pancréas

The authors report a case of hydatid cyst of the pancreas in a 29-year-old man. Biology and computed tomography contributed to the preoperative diagnosis. The intervention consisted in a left pancreatectomy with spleen ablation. In the light of this case and the literature review, the authors discuss diagnostic issues raised by hydatid cyst of the pancreas.

Acute mesenteric ischemia of arterial origin: Importance of early revascularization

GOAL The goal of our study was to show that survival was better when early revascularization was performed rather than gastrointestinal resection in the management of acute mesenteric ischemia of arterial origin. METHODS The reports of patients managed in our center between January 2005 and May 2012 for acute mesenteric ischemia of arterial origin were analyzed retrospectively. Data on clinical, laboratory and radiologic findings, the interval before treatment, the operative findings and the surgical procedures were collected. Follow-up information included the postoperative course, and mortality at 48 h, 30 days and 1 year, the latter being compared between patients undergoing revascularization versus gastrointestinal resection. RESULTS Of 43 patients treated during this period, 20 had gastrointestinal lesions deemed to be beyond all therapeutic resources, 13 were treated with gastrointestinal resection without revascularization, while 10 underwent early revascularization. There were no statistically significant differences found in the extent of involvement between the two groups (P=0.22). Mortality at 48 h, 30 days and 1 year was 8% (n=1), 30% (n=4) and 68% (n=8) in patients who underwent enterectomy vs. 0% (n=0), 0% (n=0) and 10% (n=1) in patients who underwent revascularization procedures. The difference at 1 year was statistically significant (P=0.02). At 1 year, two patients in the revascularized group had a short bowel syndrome vs. one in the non-revascularized group. CONCLUSION Acute mesenteric ischemia of arterial origin is associated with high morbidity and mortality. Optimal management should include early revascularization.

Visceral surgeon and intraoperative cholangiography: Survey about French Wild West surgeons

Cholecystectomy is one of the most common abdominal surgical procedures. No formal agreement has been reached about the routine practice of intraoperative cholangiography (IOC). The purpose of this survey was to describe the practices and the opinions of surgeons in western France. A survey was conducted among 300 visceral surgeons practicing in western France who were asked to respond to a questionnaire with objective and subjective items. One hundred forty-eight answers were interpretable. Among these 148 surgeons, 125 (83.4%) performed IOC routinely (IOCr group) and 23 (15.4%) selectively (IOCs group). Mean age of responding surgeons was 49.3 years. Groups IOCr and IOCs were not significantly different concerning surgical experience. Surgeons in both groups responded that IOC effectively screens for intraoperative bile duct injury. In our survey, routine practice of IOC was more common than reported by our English-speaking colleagues. The routine users responded that IOC can screen for intraoperative bile duct injury or choledocholithiasis. The selective users responded that IOC has its own morbidity. IOC is commonly performed in France during laparoscopic cholecystectomy. Although it may not be indispensable, it allows rapid screening for intraoperative bile duct injury. It also provides documented proof of good surgical practice in the event of a litigation claim after bile duct injury.

Differentiated thyroid cancer with liver metastases: lessons learned from managing a series of 14 patients

Liver metastases from differentiated thyroid carcinoma (LMDTC) are rare and usually occur in disseminated metastatic disease. The aim of this study was to review the diagnosis and management of LMDTC. Between 1995 and 2011, 14 patients with a mean age of 59.7 years (+/-10.2) were treated for LMDTC. Data were retrospectively reviewed and analyzed. Seven patients had distant metastases at diagnosis, including 2 with synchronous liver lesions. The average time of onset of LMDTC from initial diagnosis was 52.2 months (+/49.5). All LMDTC were discovered during routine radiologic monitoring. Histologic analysis confirmed LMDTC in 5 patients. Eight patients received tyrosine kinase inhibitors, 1 patient underwent resection of their LMDTC after chemotherapy. Six patients (disseminated metastases, significant comorbidities) did not receive any specific treatment. The median survival after diagnosis of LMDTC was 17.4 months (+/-3.3): 23.6 months (+/-2.9) for patients who underwent chemotherapy versus 3.9 months (+/-0.9) for patients who did not receive any specific treatment (P < 0.001). Developing DTC liver metastasis is a very poor prognostic sign. Chemotherapy by TKIs, especially, hold promise in the cure of LMDTC for selected patients.

Short-Term Outcomes of Colorectal Resection for Cancer in Elderly in the Era of Enhanced Recovery

Background and aims: Early rehabilitation protocols should be assessed in elderly. We aimed to study the outcomes of colorectal surgery and the observance of the modalities of an early rehabilitation protocol in patients over 80 years. Material and Methods: All consecutive patients who underwent surgery for colorectal cancer in our center over a 19-month period were included. All of these patients were managed using the same early rehabilitation protocol. Patients older than 80 were compared to younger patients. Results: A total of 173 patients were included and 36 were ≥80 years (20.8%). Patients aged ≥80 years had a significantly higher ASA score and were operated on in emergency. In the peroperative period, patients aged ≥80 years were more likely to undergo laparotomy than patients <80 years in univariate analysis (p = 0.048), but in multivariate analysis, the choice for a laparoscopy was influenced by ASA score ≤2 (odds ratio = 3.55, 95% confidence interval = 1.67–7.58) and emergency surgery (odds ratio = 0.18, 95% confidence interval = 0.06–0.50). In the postoperative period, peristalsis stimulation and vascular catheter ablation were significantly better followed in Group 1 (p = 0.012 and 0.031). However, in multivariate analysis, age was not significantly associated with these parameters. Peristalsis stimulation was influenced by ASA score ≥2 (odds ratio = 4.27, 95% confidence interval = 1.18–15.37) and vascular catheter ablation was also influenced by ASA score ≤2 (odds ratio = 2.63, 95% confidence interval = 1.33–5.21). Emergency surgery had a strong trend to influence these parameters (p = 0.08). Conclusion: Although age or comorbidities may affect observance for certain modalities such as chewing gum use and vascular catheter ablation, an early rehabilitation protocol can be used after colorectal cancer surgery in patients ≥80 years old, where it would improve functional results and postoperative outcomes.

Does hemithyroidectomy still provide any benefit

OBJECTIVES Multinodular goiter is a common disorder, found in 5% of the general population. If only one thyroid lobe is affected, hemithyroidectomy may be preferred to total thyroidectomy, to limit the risk of complications and avoid hormone replacement therapy, but incurs a risk of subsequent completion thyroidectomy. The aim of the present study is to determine whether the arguments in favor of hemithyroidectomy are justified and whether it still provides real benefit. METHODS A retrospective observational study based on prospective data included all patients who underwent surgery for goiter or nodule in our center between September 2010 and September 2014. Rates of hormone replacement 6 months after hemithyroidectomy, postoperative complications and completion thyroidectomy during the postoperative year due to the discovery of carcinoma were analyzed. RESULTS Four hundred and ninety-three patients were studied: 335 with total thyroidectomy and158 with hemithyroidey. The rate of hormone replacement 6 months after hemithyroidectomy was 84.4%. The rate of definitive hypocalcemia was 6.3% in total thyroidectomy and zero in hemithyroidectomy (P<0.05). There was no significant difference between groups in terms of recurrent laryngeal nerve palsy (1.8% versus 1.9%; P=1) or hematoma (1.2% versus 3.5%; P=0.15). A total of 11.3% of hemithyroidectomies required completion due to discovery of carcinoma (mean interval between surgeries 3.58±2.5 months). CONCLUSIONS This study suggests that hemithyroidectomy does not in fact avoid the risk of hormone replacement and places the patient at risk of completion thyroidectomy. However, it does avoid a 6% rate of hypocalcemia. We would recommend hemithyroidectomy only in case of single toxic or euthyroid nodule with healthy contralateral lobe and/or refusal of hormone replacement by the patient.