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Objective: The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer., Material and Methods: In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019., Results: More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P<0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Colonoscopic screening with indigo carmine chromoendoscopy (ICC) in patients with Lynch syndrome (LS) improves the adenoma detection rate but is time consuming and poorly used in clinical practice. Narrow-band imaging (NBI), a virtual chromoendoscopy technique, highlights superficial mucosal vessels and improves adenoma characterization. We conducted a prospective multicenter trial in a back-to-back fashion to compare the third-generation NBI with ICC for detecting colonic adenomas in patients with LS., Methods: In a multicenter, prospective, noninferiority trial, 138 patients underwent a double colonoscopy, first with NBI, followed by ICC, in a back-to-back design. The primary noninferiority outcome measure was the number of patients with at least one adenoma after NBI compared with the number of patients with at least one adenoma after NBI and ICC., Results: The 138 analyzable patients were all proven mismatch repair mutation carriers for LS (MLH1 = 33%, MSH2 = 47%, MSH6 = 15%, PMS2 = 4%, and EPCAM = 1%). The mean age (SD) was 40.5 (14.7) years, and 64 (46.4%) were men. The median withdrawal time for an NBI procedure was 8 minutes (interquartile range 6-11) compared with 13 minutes (interquartile range 8-17) for ICC. At least one adenoma was detected during the initial NBI pass in 28 patients (20.3%), and 42 patients (30.4%) had at least one adenoma detected after both NBI and ICC (difference, 10.1%; 95% confidence interval, -0.1%-20.3%); this represents an increase of 50.0% of the adenoma detection rate. ICC detected additional adenomas in 25 patients (18.1%)., Discussion: Colonoscopy combining NBI and ICC detects more adenomas than third-generation NBI alone in patients with LS, respectively, 30.4% vs 20.3% (difference, 10.1%; 95% confidence interval, -0.1 to 20.3), thus failing the noninferiority assumption of NBI compared with combined NBI and ICC. Although less time consuming, colonoscopy using the third-generation NBI cannot be recommended to replace ICC in patients with LS.

Purpose: Self-expandable metallic stent (SEMS) placement is an accepted palliative therapy for management of acute malignant bowel obstruction in advanced colorectal cancer. Nevertheless, data are lacking on the effects of systemic chemotherapy combined with colorectal SEMS. The aim of this study was to investigate the safety and efficacy of palliative chemotherapy for advanced colorectal cancer combined with colorectal SEMS placement., Patients and Methods: This multicentre retrospective study included all consecutive advanced colorectal cancer patients who received first-line palliative chemotherapy combined with endoscopic stenting for colorectal cancer with obstruction. We analyzed the number of cycles and the type of combination used. The primary endpoint was overall survival. Secondary endpoints included progression-free survival, response rate, grade 3-4 toxicity and the outcomes of SEMS for malignant colorectal obstruction., Results: A total of 38 patients were included. Among them, 25 patients received oxaliplatin and 5-fluorouracil combination chemotherapy. Objective response and stabilization occurred in 38 and 24% of patients, respectively. The median overall survival and progression-free survival from the start of chemotherapy were 18 and 5months, respectively. The objective response rate and overall disease control rate were 38 and 62%, respectively. Toxicity was generally acceptable. Major complications related to stenting included perforation (8%), stent migration (5%), and reobstruction secondary to tumor ingrowths (13%)., Conclusions: Chemotherapy combined with colonic stenting as a first-line treatment seems to be a valid option in advanced colorectal cancer patients with malignant colorectal obstruction., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: In Lynch syndrome, flat and diminutive adenomas are particularly prone to malignant transformation, but they can be missed by standard colonoscopy. It is not known whether chromocolonoscopy is able to detect more adenomas than standard colonoscopy in patients with Lynch syndrome., Methods: We conducted a prospective, multicenter, randomized trial to compare standard colonoscopy with standard colonoscopy followed by pancolonic chromoscopy with indigo carmine in patients with a proven germline mutation in a mismatch-repair gene related to Lynch syndrome and who were undergoing screening or surveillance colonoscopy. Standard colonoscopy was used first to detect visible lesions. Colonoscopy with chromoscopy was then performed by a second gastroenterologist (blinded to the findings of the first colonoscopy) to detect additional lesions. The primary end point was the number of patients in whom at least one adenoma was detected., Results: A total of 78 eligible patients (median age, 45 years) were enrolled at 10 centers from July 2008 to August 2009. Significantly more patients with at least one adenoma were identified by chromocolonoscopy (32/78 (41%)) than by standard colonoscopy (18/78 (23%); P<0.001). The percentage of patients in whom at least one additional adenoma was detected during the chromoscopy was 31% (24/78). Overall, chromocolonoscopy plus colonoscopy detected a total of 55 adenomas in 32 patients (mean number of adenomas detected per patient: 0.7 vs. standard colonoscopy alone: 0.3; P<0.001)., Conclusion: The results support the proposition that chromocolonoscopy may significantly improve the detection rate of colorectal adenomas in patients undergoing screening or surveillance colonoscopy for Lynch syndrome.

Objective: Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS., Method: Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence., Results: We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed., Conclusion: We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Background: Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction., Methods: Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum., Results: In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication., Conclusions: Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.

Background and Aim: Dietary polyethylene glycol (PEG) is extraordinarily potent in the chemoprevention of experimental colon carcinogenesis. PEG is used to treat constipation in France and in the USA. French laxatives include Forlax (PEG4000), Movicol and Transipeg (PEG3350), and Idrocol (pluronic F68). This study tests the hypothesis that use of a PEG-based laxative might reduce the prevalence of colorectal tumors., Methods: In this population-based study, consecutive patients attending for routine total colonoscopy were enrolled during four months by the gastroenterologists of Indre-et-Loire. They were asked if they had previously taken a laxative or a NSAID. Age, gender, previous polyps, family history of colorectal cancer, constipation, digestive symptoms were also recorded. Tumors found during colonoscopy were categorized histologically., Results: Records from 1165 patients fulfilled the inclusion criteria, 607 women and 498 men, mean age 58.3. Among those, 813 had no tumor, 329 had adenomas, and 23 had carcinomas. In a univariate analysis, older age, male gender, lack of digestive symptom, and previous polyps were more common in patients with colorectal tumors. In contrast, previous Forlax intake was more common in tumor-free patients (odds ratio (OR) any use/no use, 0.52; 95% confidence interval, 0.27-0.94). More people used Forlax, which contains a higher dose of PEG than the other PEG-laxatives, whose ORs were smaller than one, but did not reach significance. In multivariate analysis, older age and male gender were associated with higher risk, and NSAIDs use with lower risk, of colorectal tumors., Conclusion: Forlax users had a halved risk of colorectal tumors in univariate analysis, which suggests that PEG may prevent carcinogenesis.

Objective: The aim of our study was to evaluate the feasibility of enteral jejunal nutrition for acute pancreatitis using a self-propelling spiral distal end jejunal tube., Methods: Sixteen consecutive patients with acute pancreatitis in whom Flocare tubes were placed for enteral nutrition were included in this open prospective study. All of them had pancreatic and/or peripancreatic necrosis (Balthazar >=D). The median computed topography index was 5 (range 3-10) and the median Ranson score was 2 (range 0-5). The nasoenteric Flocare tube (spiral distal end) was inserted in the stomach at the bedside. Self progression into the jejunum was assessed by X-ray at 1, 7 and 12 hours and then every 24 hours for 4 days. The rate of successful tube self-placement in the jejunum and the time to successful placement were noted., Results: Insertion was successful in 12 of 16 patients (75%). Treitz's ligament was reached in a median of 12 hours (range 1-96 hours). For the remaining patients, the tube was successfully repositioned under fluoroscopic guidance in 2 and withdrawn in 2, one for oral renutrition and one to change to a weighted jejunal tube. No tube dysfunction or recurrence of pancreatitis occurred during the entire period of enteral nutrition., Conclusions: This study suggests that the nasoenteric Flocare tube can be used effectively and safely in early enteral jejunal nutrition for severe acute pancreatitis, without endoscopic or radiological manipulation.

Objective: The aim of this retrospective study was to determine the risk factors of early complications after progressive pneumatic dilation for achalasia., Methods: Five hundred four dilations were performed in 237 consecutive achalasic patients between 1980 and 1994 with the same technique: low-pressure pneumatic dilation every other day with balloons of increasing diameter until success criteria were obtained (depending on manometric examination and esophageal x-ray transit performed 24 h after each dilation). Clinical, radiographical, endoscopical, and manometrical data as technical procedure characteristics for patients with perforations or other early complications were compared with those without complications., Results: We observed 15 complications (6% of patients): 7 perforations (3%), 3 asymptomatic esophageal mucosal tears, 4 esophageal hematomas, and 1 fever. Perforations occurred in 6 of 7 patients during the first dilation. The mean age was 68.5 yr in the group with complications versus 56.4 yr for the remainder (p < 0.05). Two deaths occurred in patients older than 90 yr. Instability of the balloon during dilations was noted in 8 of 15 cases of complications versus 57 of 222 patients (p < 0.05). No other data differed significantly., Conclusions: This study showed a low prevalence of early complications using this progressive technique. Patients with hiatal hernia, esophageal diverticulum, or vigorous achalasia may safely undergo progressive pneumatic dilation. Only patients older than 90 yr should be referred for progressive pneumatic dilation with caution. Most of perforations arose during the first dilation, but there was no predictive pretherapeutic factor of perforation.

Assessment of total and segmental colonic transit times (CTT) in man using a single type of radiopaque marker and one abdominal X-ray has been validated but not extensively studied. The aims of our prospective study were to establish normal values of this method as a function of age, gender and fiber intake in healthy subjects. Eighty-two healthy volunteers (51 men, 31 women, mean age 38 yr, range 21-61) with normal stool frequency (between 3/day and 3/week) and no history of gastrointestinal disease or medication were enrolled and ingested 10 small (3 mm edge) radiopaque markers every morning for 6 consecutive days. On the 7th day, an abdominal X-ray was performed to calculate total and segmental (right, left, rectosigmoid) CTT according to Arhan's method (CCT = 2.4 N; N = number of markers in the considered zone). During the study the number of stools was recorded and fiber intake estimated on a questionnaire. Stool frequency, total and segmental CTT were evaluated for differences due to age, gender and/or fiber intake. In volunteers, total, left and rectosigmoid CTT were closely related to stool frequency (P = 0.0001) being longer in women than in men (P < 0.02). In contrast, right CTT was independent of gender or stool frequency. Finally, in this group CTT were independent of age and fiber intake. This study confirms the influence of gender on CTT and demonstrate the ability of this simple and non-invasive method (0.08 mrad surface exposure) to assess CTT. Its use as a diagnostic tool in self-defined constipated patients would be of interest in clinical practice.

We have studied the effect of polymeric cholesterol-free enteral nutrition (EN) on serum lipid and apolipoprotein levels in 30 consecutive non-diabetic, non-hyperlipaemic gastrointestinal patients. EN-40 +/- (SEM) 2 kcal/kg/day including 35% vegetable lipids (50% highly polyunsaturated fat, 50% medium chain triglycerides)-was delivered continuously (24h) via the gastric route for at least 2 weeks (mean duration: 35 +/- 4 days). In the entire group, serum total cholesterol decreased by 10.5% (p < 0.01) on day 7 and 17.5% (p < 0.01) on day 28 (n = 12); this was accompanied by 21% and 20% decreases in LDL-cholesterol and apolipoprotein B (p < 0.05) levels respectively, on day 28. In the 19 patients who were normocholesterolaemic on day 0, serum total cholesterol decreased by 15% (p < 0.01) on day 7 and by 28% (p < 0.05) on day 28 (n = 7). Conversely, in the other 11 patients with a low (<3.7 mmol/L) pre-EN serum total cholesterol level, no significant changes were observed during EN. We conclude that continuous, cholesterol-free EN has, in normocholesterolaemic patients, a marked cholesterol-lowering effect; the respective role of the composition of the diet and the continuous delivery of nutrient within the gut have yet to be investigated.

In order to assess the relationship between increase of gamma-glutamyl transferase and diabetes, we measured serum gamma-glutamyl transferase in 48 male and 43 female insulin-dependent diabetics aged 20-60 years, 49 male and 41 female non insulin dependent diabetics aged 30-60 years, and in 114 male and 124 female controls (blood donors) aged 20-60 years. A1C haemoglobin was assayed in 124 diabetics. There is no increase of serum gamma-glutamyl transferase activity in insulin dependent diabetics of both sexes when compared with the controls. There is an increase of serum gamma-glutamyl transferase activity in non insulin dependent diabetics when compared either with controls (men p less than 0.02, women p less than 0.02) or with insulin dependent diabetics (men p less than 0.05, women p less than 0.02). There is no correlation between serum gamma-glutamyl transferase activity and fasting blood sugar (148 diabetics). In non insulin dependent diabetics of both sexes there is no correlation between A1C haemoglobin and serum gamma-glutamyl transferase activity. These results suggest that the increase observed in diabetics is not caused by diabetes itself, ie, by hyperglycemia, but by diabetes associated pathologies.