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Chronic pelvic sepsis eventually requires salvage surgery in half of all patients. The goal of surgery is to resolve pelvic inflammation while restoring intestinal continuity. Our salvage procedure achieves this by bringing a healthy conduit into the pelvis and creating an anastomosis beyond the source of sepsis. We aimed to review our single center experience with this procedure for the treatment of chronic pelvic sepsis. All patients requiring the procedure from 2010 to 2018 were retrospectively reviewed using a prospective database. Morbidity and mortality were evaluated, and restoration of bowel continuity at 1-year rate was the endpoint. Twenty patients were included. The main indication was pelvic sepsis after anastomotic leak (AL). The median age was 60 (42–86) years and the median BMI was 26 (18–37) kg/m2. The median time carrying a stoma before the intervention was 15 months, and median time to intervention was 32 months. All patients had a diverting stoma. There were no death and overall morbidity reached 60%, and AL rate was 10%. At 1 year, 70% of the patients had their intestinal continuity restored. In expert hands, salvage surgery for chronic pelvic sepsis has acceptable morbidity rates, an acceptable rate of AL, and a bowel restoration success rate 70% at 1 year, and is a valuable option for patients failing conservative treatment.

Pre-operative chemoradiotherapy (CRT) followed by surgical resection is still the standard treatment for locally advanced low rectal cancer. Nowadays new strategies are emerging to treat patients with a complete response to pre-operative treatment, rendering the optimal management still controversial and under debate. The primary aim of this study was to obtain a snapshot of tumor regression grade (TRG) distribution after standard CRT. Second, we aimed to identify a correlation between clinical tumor stage (cT) and TRG, and to define the accuracy of magnetic resonance imaging (MRI) in the restaging setting. Between January 2017 and June 2019, a cross sectional multicentric study was performed in 22 referral centers of colon-rectal surgery including all patients with cT3-4Nx/cTxN1-2 rectal cancer who underwent pre-operative CRT. Shapiro–Wilk test was used for continuous data. Categorical variables were compared with Chi-squared test or Fisher’s exact test, where appropriate. Accuracy of restaging MRI in the identification of pathologic complete response (pCR) was determined evaluating the correspondence with the histopathological examination of surgical specimens.In the present study, 689 patients were enrolled. Complete tumor regression rate was 16.9%. The “watch and wait” strategy was applied in 4.3% of TRG4 patients. A clinical correlation between more advanced tumors and moderate to absent tumor regression was found (p = 0.03). Post-neoadjuvant MRI had low sensibility (55%) and high specificity (83%) with accuracy of 82.8% in identifying TRG4 and pCR.Our data provided a contemporary description of the effects of pre-operative CRT on a large pool of locally advanced low rectal cancer patients treated in different colon-rectal surgical centers.

AIM OF THE STUDY: The fast-track (FT) protocol consists of several measures to optimize physiologic response to the surgical stress and improve postoperative outcome. Our goal was to evaluate the compliance to our protocol and to analyze the effect of compliance to the FT protocol on postoperative outcome and postoperative hospital stay. We also aimed to identify isolated FT measures able to influence outcome. METHODS: This retrospective study involves a cohort of consecutive patients who underwent colorectal surgery within a FT protocol between 2007 and 2013. Beside basic demographics, adherence to protocol, postoperative complications, and postoperative hospital stay (POHS) were recorded. Both univariate and multivariate analyses were performed to determine the predictive value of the FT protocol compliance and of specific FT items on surgical outcome and POHS. RESULTS: There were 284 patients with a mean age of 58 years. Compliance to the FT protocol reached a median of 18 out of 19 items. The median hospital stay was 3 days (2-49). Overall complications rate was 34.9% and 7,4% when Dindo-Clavien classification > 2 was considered. Higher compliance to the FT protocol reduces the complication rate (p = 0.00004), severity of complication (p = 0.002), and POHS (p = < 0.00001). We have not been able to identify any specific isolated FT measure able to influence post-operative outcome. CONCLUSIONS: Greater adherence to the FT protocol decreases postoperative complications and POHS. Our data support a holistic effect of the FT protocol rather than specific isolated measures to improve the patient's postoperative outcome.

Background and study aim: Over the last 20 years, cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has progressively become a therapeutic option for peritoneal carcinomatosis thanks to its favourable oncologic results. The aim of this study is to analyse the overall survival and recurrence-free survival, after complete CRS and closed abdomen technique HIPEC for peritoneal carcinomatosis from colorectal cancer. Patients and methods: This retrospective study collected the data from all patients who underwent a CRS with HIPEC for colorectal cancer at “Cliniques universitaires Saint Luc” from October 2007 to December 2020. Ninety-nine patients were included. Results: The median follow-up was 34 months. Post-operative mortality and Clavien-Dindo grade III/IV morbidity rates were 2.0% and 28.3%. The overall 2-year and 5-year survival rates were 80.1% and 54.4%. Using the multivariate analysis, age at surgery, liver metastases and PCI score >13 showed a statistically significant negative impact on overall survival. The 2-year and 5-year recurrence-free survival rates were 33.9% and 22%. Using the multivariate analysis, it was found that liver metastases, the extent of carcinomatosis with PCI>7 have a statistically significant negative impact on recurrence-free survival. Conclusions: Despite a high recurrence rate, CRS followed by HIPEC to treat peritoneal carcinomatosis from colorectal origin offer encouraging oncologic results with a satisfying survival rate. When PCI>13, CRS and HIPEC does not seem to offer any survival benefit and to efficiently limit recurrence, our data are in favor of a maximum PCI of 7.

SCOPUS: ar.j, info:eu-repo/semantics/published

International audience; Introduction: During the COVID-19 pandemic, cancer patients have been regarded as having a high risk of severe events if they are infected with SARS-CoV-2, particularly those under medical or surgical treatment. The aim of this study was to assess the posttreatment risk of infection by SARS-CoV-2 in a population of patients operated on for colorectal cancer 3 months before the COVID-19 outbreak and who after hospitalization returned to an environment where the virus was circulating.Materials and methods: This French, multicenter cohort study included consecutive patients undergoing elective surgery for colorectal cancer between January 1 and March 31, 2020, at 19 GRECCAR hospitals. The outcome was the rate of COVID-19 infection in this group of patients who were followed until June 15, 2020.Results: This study included 448 patients, 262 male (58.5%) and 186 female (41.5%), who underwent surgery for colon cancer (n = 290, 64.7%), rectal cancer (n = 155, 34.6%), or anal cancer (n = 3, 0.7%). The median age was 68 years (19-95). Comorbidities were present in nearly half of the patients, 52% were at least overweight, and the median BMI was 25 (12-42). At the end of the study, 448 were alive. Six patients (1.3%) developed COVID-19 infection; among them, 3 were hospitalized in the conventional ward, and none of them died.Conclusion: The results are reassuring, with only a 1.3% infection rate and no deaths related to COVID-19. We believe that we can operate on colorectal cancer patients without additional mortality from COVID-19, applying all measures aimed at reducing the risk of infection.

PURPOSE The purpose of this study was to evaluate the prognostic value of Immunoscore in patients with stage III colon cancer (CC) and to analyze its association with the effect of chemotherapy on time to recurrence (TTR). METHODS An international study led by the Society for Immunotherapy of Cancer evaluated the predefined consensus Immunoscore in 763 patients with American Joint Committee on Cancer/Union for International Cancer Control TNM stage III CC from cohort 1 (Canada/United States) and cohort 2 (Europe/Asia). CD3+ and cytotoxic CD8+ T lymphocyte densities were quantified in the tumor and invasive margin by digital pathology. The primary end point was TTR. Secondary end points were overall survival (OS), disease-free survival (DFS), prognosis in microsatellite stable (MSS) status, and predictive value of efficacy of chemotherapy. RESULTS Patients with a high Immunoscore presented with the lowest risk of recurrence, in both cohorts. Recurrence-free rates at 3 years were 56.9% (95% CI, 50.3% to 64.4%), 65.9% (95% CI, 60.8% to 71.4%), and 76.4% (95% CI, 69.3% to 84.3%) in patients with low, intermediate, and high immunoscores, respectively (hazard ratio [HR; high v low], 0.48; 95% CI, 0.32 to 0.71; P = .0003). Patients with high Immunoscore showed significant association with prolonged TTR, OS, and DFS (all P < .001). In Cox multivariable analysis stratified by participating center, Immunoscore association with TTR was independent (HR [high v low], 0.41; 95% CI, 0.25 to 0.67; P = .0003) of patient’s sex, T stage, N stage, sidedness, and microsatellite instability status. Significant association of a high Immunoscore with prolonged TTR was also found among MSS patients (HR [high v low], 0.36; 95% CI, 0.21 to 0.62; P = .0003). Immunoscore had the strongest contribution χ2 proportion for influencing survival (TTR and OS). Chemotherapy was significantly associated with survival in the high-Immunoscore group for both low-risk (HR [chemotherapy v no chemotherapy], 0.42; 95% CI, 0.25 to 0.71; P = .0011) and high-risk (HR [chemotherapy v no chemotherapy], 0.5; 95% CI, 0.33 to 0.77; P = .0015) patients, in contrast to the low-Immunoscore group ( P > .12). CONCLUSION This study shows that a high Immunoscore significantly associated with prolonged survival in stage III CC. Our findings suggest that patients with a high Immunoscore will benefit the most from chemotherapy in terms of recurrence risk.

A 9-year-old boy presenting with recurrent rectal bleeding and prolapse refractory to therapy for constipation was referred for colonoscopy. Initial work-up (magnesium, thyroid function, food allergies, celiac disease, and stool cultures) was negative. Five large rectal polyps were evidenced just above dental line. Due to the location of the lesions, a combined endoscopic/surgical submucosal resection of the lesions was performed. [...]

We examined how the immune microenvironment molds tumor evolution at different metastatic organs in a longitudinal dataset of colorectal cancer. Through multiplexed analyses, we showed that clonal evolution patterns during metastatic progression depend on the immune contexture at the metastatic site. Genetic evidence of neoantigen depletion was observed in the sites with high Immunoscore and spatial proximity between Ki67+ tumor cells and CD3+ cells. The immunoedited tumor clones were eliminated and did not recur, while progressing clones were immune privileged, despite the presence of tumor-infiltrating lymphocytes. Characterization of immune-privileged metastases revealed tumor-intrinsic and tumor-extrinsic mechanisms of escape. The lowest recurrence risk was associated with high Immunoscore, occurrence of immunoediting, and low tumor burden. We propose a parallel selection model of metastatic progression, where branched evolution could be traced back to immune-escaping clones. The findings could inform the understanding of cancer dissemination and the development of immunotherapeutics.

Recent literature undeniably supports the idea that the microbiota has a strong influence on the healing process of an intestinal anastomosis. Understanding the mechanisms by which the bacterial community of the gut influences intestinal healing could open the door for new preventive and therapeutic approaches. Among the different mechanisms, data have shown that the production of specific reactive oxygen species (ROS) and the activation of specific formyl peptide receptors (FPRs) regulate intestinal wound healing. Evidence suggests that specific gut microbes such as Lactobacillus spp and Akkermansia muciniphila help to regulate healing processes through both ROS-dependent and FPR-dependent mechanisms. In this review, we will discuss the current knowledge and future perspectives concerning the impact of microbiota on wound healing. We will further review available evidence on whether mechanical bowel preparation and the use of specific antibiotics are beneficial or harmful procedures, an ongoing matter of debate. These practices have a profound effect on the gut microbiota composition at the level of both the mucosal and the luminal compartments. Therefore, a key question remains unanswered: should we continue to prepare the gut before surgical intervention? Current knowledge and data do not clearly support the use of one technique or another to avoid complications such as anastomotic leak. There is an urgent need for appropriate interventions with a deep microbiota analysis to investigate both the surgical technical benefits of a proper anastomosis compared with the potential effect of the gut microbes (beneficial vs harmful) on the processes of wound healing and anastomotic leakage reduction.

Early pathological descriptions of Crohn disease (CD) argued for a potential defect in lymph transport; however, this concept has not been thoroughly investigated. In mice, poor healing in response to infection-induced tissue damage can cause hyperpermeable lymphatic collecting vessels in mesenteric adipose tissue that impair antigen and immune cell access to mesenteric lymph nodes (LNs), which normally sustain appropriate immunity. To investigate whether analogous changes might occur in human intestinal disease, we established a three-dimensional imaging approach to characterize the lymphatic vasculature in mesenteric tissue from controls or patients with CD. In CD specimens, B-cell-rich aggregates resembling tertiary lymphoid organs (TLOs) impinged on lymphatic collecting vessels that enter and exit LNs. In areas of creeping fat, which characterizes inflammation-affected areas of the bowel in CD, we observed B cells and apparent innate lymphoid cells that had invaded the lymphatic vessel wall, suggesting these cells may be mediators of lymphatic remodeling. Although TLOs have been described in many chronic inflammatory states, their anatomical relationship to preestablished LNs has never been revealed. Our data indicate that, at least in the CD-affected mesentery, TLOs are positioned along collecting lymphatic vessels in a manner expected to affect delivery of lymph to LNs.

This study aims to determine which anthropometric (body mass index (BMI), waist-hip-ratio (WHR) and waist-to-height ratio (WHtR)) and radiological (visceral fat area (VFA) measured by CT scan) measurements of adiposity correlated better with postoperative outcome of colorectal cancer (CRC) surgery. We also assessed which of these measurements best predicted overall survival (OS) and disease-free survival (DFS).Data from 90 consecutive Caucasian CRC patients who underwent surgery for colorectal cancer between 2010 and 2011 with a median follow-up of 53.25 months were analysed. The correlations of different adiposity measurements and postoperative outcomes were determined using logistic regression models and multivariate analyses.Higher WHtR (p = 0.007) and VFA (p = 0.01) significantly increased the risk of overall morbidity, especially of Clavien-Dindo III or IV. The WHtR correlated best with VFA (p0.0001), which is considered the gold standard for measuring visceral fat, whereas BMI (p = 0.15) was not a good predictor of postoperative morbidity. Multivariate analyses showed consistently significant results for postoperative complications for VFA in combination with all of the other variables analysed and for WHtR, confirming that VFA and WHtR were reliable independent prognostic factors of morbidity. VFA had a significant effect on OS (p = 0.012) but did not correlate with DFS (p = 0.51).Both VFA and WHtR independently provided predictive data for potential postoperative complications after CRC surgery. In case CT scan was used for diagnostic purposes, VFA should be used in routine clinical practice.

Introduction: Complications and challenges arising from the intraoperative double-stapling technique are seldom reported in colorectal surgery literature. Partial or full-thickness rectal injuries can occur during the introduction and the advancement of the circular stapler along the upper rectum. The aim of this study is to address some of these issues by designing and optimizing a "phantom" anvil manufactured to overcome difficulties throughout the rectal introduction and advancement of the circular stapler for the treatment of benign and malignant colon disease. Methods: The design of the "phantom" anvil has been performed using computer-aided modeling techniques, finite element investigations, and 2 essential keynotes in mind. The first one is the internal shape of the anvil, which is used for the connection to the gun. The second is the shape of the cap, which makes possible the insertion of the gun through the rectum. The "phantom" anvil has 2 functional requirements, which have been taken into account. The design has been optimized to avoid colorectal injuries, neoplastic dissemination (ie, mechanical seeding) and to reduce the fecal contamination. Results: Numerical simulations show that a right combination of both top and bottom fillet radii of the shape of the anvil can reduce the stress for the considered anatomic configuration of >90%. Both the fillet radii at the top and the bottom of the device influence the local stress of the colon rectum. Conclusions: A dismountable device, which is used only for the insertion and advancement of the stapler, allows a dedicated design of its shape, keeping the remainder of the stapler unmodified. Computer-aided simulations are useful to perform numerical investigations to optimize the design of this auxiliary part for both the safety of the patient and the ease of the stapler advancement through the rectum.

Chemotherapeutic advances have enabled successful cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) expansion in treating metastatic colorectal cancer. The aims of this study were to evaluate the safety of combining liver surgery (LS) with HIPEC and CRS (which remains controversial) and its impact on overall survival (OS) rates. From 2007 to 2015, a total of 77 patients underwent CRS/HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. Twenty-five of these patients underwent concomitant LS for suspicion of liver metastases (LM; group 2), and were compared with patients who underwent CRS/HIPEC only (group 1). Demographic and clinical data were reviewed retrospectively. Among the group 2 patients, two underwent major hepatectomies, six underwent multiple wedge resections, 16 underwent single wedge resections (one with radiofrequency ablation), and one underwent radiofrequency ablation alone. For groups 1 and 2, median peritoneal cancer index was 6 and 10 (range 0–26; p = 0.08), complication rates were 15.4 and 32.0 % (Dindo–Clavien ≥3; p = 0.15), and median follow-up was 34.2 and 25.5 months (range 0–75 and 3–97), respectively. One group 2 patient died of septic shock after 66 days. Pathology confirmed LM in 21 patients in group 2 (four with benign hepatic lesions were excluded from long-term outcome analysis). Two-year OS rates were 89.5 and 70.2 % (p = 0.04), and 2-year recurrence-free survival rates were 38.3 and 13.4 % (p = 0.01) in groups 1 and 2, respectively. Simultaneous surgery for colorectal LM and PC is both feasible and safe, with low postoperative morbidity. Further longer-term studies would help determine its impact on patient survival.

AIM Nodal stage is a strong prognostic factor of oncological outcome of rectal cancer. To compensate for the variation in total number of harvested nodes, calculation of the lymph node ratio (LNR) has been advocated. The aim of the study was to compare the impact, on the long-term oncological outcome, of the LNR with other predictive factors, including the quality of total mesorectal excision (TME) and the state of the circumferential resection margin. METHOD Consecutive patients having elective surgery for nonmetastatic rectal cancer were extracted from a prospectively maintained database. Retrospective uni- and multivariate analyses were performed based on patient-, surgical- and tumour-related factors. The prognostic value of the LNR on overall survival (OS) and on overall recurrence-free survival (ORFS) was assessed and a cut-off value was determined. RESULTS From 1998 to 2013, out of 456 patients, 357 with nonmetastatic disease were operated on for rectal cancer. Neoadjuvant radiochemotherapy was administered to 66.7% of the patients. The mean number of lymph nodes retrieved was 12.8 ± 8.78 per surgical specimen. A lower lymph node yield was obtained in patients who received neoadjuvant chemoradiotherapy (11.8 vs 14.2; P = 0.014). The 5-year ORFS was 71.8% and the 5-year OS was 80.1%. Multivariate analysis confirmed LNR, the quality of TME and age to be independent prognostic factors of OS. LNR, age and perineural infiltration were independently associated with ORFS. Low- and high-risk patients could be discriminated using an LNR cut-off value of 0.2. CONCLUSION LNR is an independent prognostic factor of OS and ORFS. In line with the principles of optimal surgical management, the quality of TME and lymph node yield are essential technical requirements.

INTRODUCTION: Lipomas are the most common benign mesenchymal tumors which can be found in any part of the body. Nevertheless, their etiology and pathogenesis remain unknown. It is hypothesized that some of these lesions could result from an acute or chronic trauma. PATIENTS AND METHODS: We report a case of a 54-year-old man presenting a perineal lipoma which volume grew rapidly after he fell on his buttock, in the context of inaugural epileptic seizure. Pelvic MRI showed a voluminous fatty mass, measuring 6.6 × 5 × 9 cm without any signs of local invasion. Furthermore, we review the latest research on lipomas originating from traumatic lesion. RESULTS: The mass was completely excised in one block under general anesthaesia, using an elliptical incision and a deep dissection. We did not close the skin incision in view of the cutaneous defect. Post-operative recovery was uneventful and the patient was discharged from hospital two days after the operation. Histopathology indicated a reorganised lipoma with no evidence of malignancy. CONCLUSION: Perineal lipomas are extremely rare, pathological examination of imaging guided biopsies are needed to exclude malignancy especially a well-differentiated liposarcoma. MRI remains the first option and radical surgical excision is the gold standard treatment.

Data about single-incision laparoscopic surgery (SILS) in locally advanced colorectal cancers are scarce. This study aimed to evaluate perioperative and shortterm oncologic outcomes of SILS in pT3-T4 colorectal cancer.From 2011 to 2015 data from 249 SILS performed in our Colorectal Unit were entered into a prospective database. Data regarding patients with a pT3-T4 colorectal adenocarcinoma were compared to those with pTis-pT2. Factors influencing conversion were assessed by multivariate analysis.There were 100 consecutive patients (T3-T4 = 70, Tis-T2 = 30). Demographics were similar. Tumor size was significantly larger in the T3-T4 group [3.9cm vs 2cm; p0.001]. In T3-T4 patients we found a significant higher number of lymph nodes harvested [20 vs 13 ; p0.001]. Early (30 days) severe (Clavien-Dindo classification2) postoperative complication rate was similar between groups (8.6% vs 10% ; p = 0.999), as well as conversion rate (18.6% vs 6.7% ; p = 0.220). Finally, there were no differences in terms of hospital stay and mortality rate. On multivariate analysis, age (OR = 1.06, 95%CI: 1.012-1.113 ; p = 0.015] and stage IV (OR = 5.372, 95%CI: 1.320-21.862, p = 0.019) were independently associated with conversion.SILS for locally advanced colorectal cancer did not affect the short-term outcomes in this series and oncological clearance remained satisfactory. Age and stage IV disease are independent risk factors for conversion.

Background Enhanced recovery after surgery (ERAS) program improves immediate recovery. Beyond immediate benefits, long-term impact of ERAS implementation is not yet evident. This retrospective single-center cohort study investigates prevalence and characteristics of chronic post-surgical pain (CPSP) in patients who underwent colon surgery. Methods Two hundred and ninety-seven patients enrolled prospectively in our ERAS database were contacted by mail to question the presence of CPSP. In case of CPSP, intensity, location, and type of pain, impact of pain on quality of life and treatment taken were assessed. Post-operative pain experience during hospital stay, recall of pain, and discomfort duration when back home were assessed in all patients. Comparison between patients with and without CPSP was made to approach the risk factors of CPSP in this population. Results At 27 months after colon surgery, 25/198 patients reported CPSP (12.6%) and pain was severe in 5 patients (2.5%). CPSP had a deep abdominal component in 56% of patients and a parietal component in 20% of patients. Patients with CPSP+ differed from patients CPSP- for pre-operative pain presence (56% vs 24.8%, P = 0.004), recalled post-operative pain intensity (4 vs 3, P = 0.045), duration of discomfort after discharge (2 vs 1 weeks, P = 0.035). Pre-operative pain was found as a significant CPSP risk factor (odds ratio 1.34; 95% CI: 1.05-1.70). Conclusion CPSP prevalence after laparoscopic colon surgery seems not much affected by ERAS context. Pre-operative presence of pain emerged as an important risk factor. These findings should be confirmed in a prospective multicenter study.

Background Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited. Methods Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data. Results A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II–III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population. Conclusion Some volume effects were observed, but their effect size was limited.

Desmoid tumors are rare proliferative and invasive benign lesions. They can be sporadic, but in most instances, desmoid tumors develop in the context of Gardner's syndrome with principal localization in the abdominal cavity and abdominal wall.We report the case of a 24-year-old female presenting Gardner's syndrome with a symptomatic abdominal wall desmoid tumor. Lack of response to medical treatment led to surgical management consisting in a complete resection and parietal reconstruction with a biologic mesh. Postoperative course was uneventful and there was no evidence of recurrence at 12 months of follow-up.Conventional treatment of abdominal wall desmoid tumors consists in a wide and radical resection. However, complete resection is not always feasible because of difficulty to differentiate the desmoid tumor from adjacent tissues. The surgical approach may require different techniques to repair the parietal defect including prosthetic material such as synthetic or biologic meshes. Biological mesh is an ideal alternative to synthetic graft, mainly in case of infection.We have encountered a case of a symptomatic growing desmoid tumor of the abdominal wall in a young patient with Gardner's syndrome, successfully treated by complete resection and reconstruction with a biologic mesh to correct the parietal defect.

This retrospective study compared the fast-track colon surgery program to conventional perioperative care and assessed factors that influence postoperative length of stay.This retrospective study included 124 fast-track and 119 conventional care colon surgical patients. Exclusion criteria were primary rectal disease, stoma, American Society of Anesthesiologists score IV, and Association Française de Chirurgie index 3 or 4. Laparoscopy was the preferred approach. Variables influencing length of stay were analyzed by multivariate linear and logistic regression.Overall mortality and complication rates were not significantly different between groups (fast-track vs. controls 0 vs. 0.8 %, 30.6 vs. 38.6 % respectively). As expected, median length of stay was significantly reduced in fast-track patients (3 vs. 6 days, p0.001), but emergency readmission rate was higher (16.9 vs. 7.6 %, p = 0.026), although rehospitalization rates were similar (8 vs. 4.2 %, not significant). Independent risk factors of increased length of stay were identified as age69 years (p = 0.001), laparotomy (p = 0.011), and conventional perioperative care (p0.001).The introduction of a fast-track program reduced postoperative length of stay without increasing complication rate. This study proposes a modulation of the program according to patient age and surgical approach.

The authors report the case of a 29-year-old woman with partially calcified stage cT4N2M0 mucoid adenocarcinoma of the mid-rectum. Concomitant neoadjuvant chemoradiotherapy was administered. Preoperative CT scan and MRI demonstrated stable disease with a marked increase of its mineralized component. Histology confirmed a mucoid adenocarcinoma with ossified matrix. Osteocytes were identified in the tumor. TNM (5th edition) staging was ypT3N2M1. This case illustrates heterotopic ossification of a rectal tumor, a fairly uncommon finding. The mechanism of heterotopic bone formation within gastrointestinal adenocarcinoma has not been fully elucidated. The impact of this particular feature on patient outcome is unknown.

Although evidence suggests an inverse relationship between microsatellite instability and p53 alterations in colorectal cancer, no study has thoroughly examined the use of p53 immunohistochemistry in phenotyping colorectal cancers. We investigated the value of p53 immunohistochemistry in microsatellite instability-positive colorectal cancers prescreening and attempted to clarify the relationship between DNA mismatch repair system and p53 pathway. In a series of 104 consecutive colorectal cancers, we performed p53 immunohistochemistry, TP53 mutational analysis, DNA mismatch repair system efficiency evaluation (DNA mismatch repair system immunohistochemistry, microsatellite instability status, MLH1/MSH2 germ line, and BRAF, murine double minute 2, and p21 immunohistochemistry. Microsatellite instability high was observed in 25 of 104 colorectal cancers, with DNA mismatch repair system protein loss (24/25) and germ line (8/25) or BRAF mutations (8/25). p53 immunohistochemistry revealed 3 distinct patterns of expression: complete negative immunostaining associated with truncating TP53 mutations (P < .0001), diffuse overexpression associated with missense TP53 mutations (P < .0001), and restricted overexpression characterized by a limited number of homogenously scattered strongly positive tumor cells in 36.5% of colorectal cancers. This latest pattern was associated with wild-type TP53 and microsatellite instability high colorectal cancers (P < .0001) including all Lynch tumors (8/8), but its presence among 22% of DNA mismatch repair system-competent colorectal cancers decreased its positive predictive value (55.2% [95% confidence interval, 45%-65%]). It was also correlated with murine double minute 2 overexpression (P < .0001) and inversely with p21 loss (P = .0002), independently of microsatellite instability status. In conclusion, a restricted pattern of p53 overexpression is preferentially associated with microsatellite instability high phenotype and could, therefore, be of clinical use as signal for microsatellite instability analysis in a large-scale tumor screening. Its association with concomitant murine double minute 2 overexpression suggests an alternative mechanism of p53 pathway deregulation.

This study aimed to review the authors' 16-year experience with transanal endoscopic microsurgery (TEM). Mortality, morbidity, recurrence rate, and functional outcome were assessed. New indications and technical improvements are presented.From November 1991 to August 2008, 123 patients (72 men and 51 women; median age, 68 years; range, 21-91 years) underwent TEM for excision of 105 adenomas with low- or high-grade dysplasia, 9 invasive adenocarcinomas (5 curative and 4 palliative resections), 2 neuroendocrine tumors, and 2 extramucosal lesions. Five additional patients had excisional biopsies, allowing staging after previous endoscopic resection. Most of the resections were full-thickness rectal resections using electrocautery or, more recently, the Harmonic scalpel. The latest mucosectomies were performed using the endoscopic submucosal dissection (ESD) technique. In addition, nontumoral indications included pelvic abscess (7 patients) and rectal strictures, which were either anastomotic or chemical. Pelvic abscesses were drained transrectally, whereas rectal stenoses were treated by strictureplasty. Foreign object retrieval and collagen plug placement for anal fistulas were performed using TEM in three patients.No mortality occurred. One intraoperative rectal perforation required conversion to laparotomy. The postoperative complications included one pneumoperitoneum, which was treated medically, and one rectal perforation requiring Hartmann's procedure. In the polyp subgroup, six patients (6/91, 7%) experienced local recurrence. Pelvic abscesses were successfully treated, and stenosis did not recur after strictureplasty. Anorectal manometry showed functional alterations without significant clinical impact.The findings showed TEM to be a safe and effective procedure for local excision of rectal lesions with a low recurrence rate and minimal consequences in terms of anorectal function. In addition, TEM proved to be feasible and effective for pelvic abscess drainage and rectal stenosis treatment. New technologies such as the Harmonic scalpel and ESD increase the precision already offered by this approach.

BACKGROUND: To assess the safety and preliminary efficacy of concurrent radiotherapy, capecitabine, and cetuximab in the preoperative treatment of patients with rectal cancer. PATIENTS AND METHODS: Forty patients with rectal cancer (T3-T4, and/or N+, endorectal ultrasound) received preoperative radiotherapy (1.8 Gy, 5 days/week for 5 weeks, total dose 45 Gy, three-dimensional conformal technique) in combination with cetuximab [initial dose 400 mg/m(2) intravenous given 1 week before the beginning of radiation followed by 250 mg/m(2)/week for 5 weeks] and capecitabine for the duration of radiotherapy (650 mg/m(2) orally twice daily, first dose level; 825 mg/m(2) twice daily, second dose level). RESULTS: Four and six patients were treated at the first and second dose level of capecitabine, respectively. No dose-limiting toxicity occurred. Thirty additional patients were treated with capecitabine at 825 mg/m(2) twice daily. The most frequent grade 1/2 side-effects were acneiform rash (87%), diarrhea (65%), and fatigue (57%). Grade 3 diarrhea was found in 15%. Three grade 4 toxic effects were recorded: one myocardial infarction, one pulmonary embolism, and one pulmonary infection with sepsis. Two patients (5%) had a pathological complete response. CONCLUSIONS: Preoperative radiotherapy in combination with capecitabine and cetuximab is feasible with some patients achieving pathological downstaging.

Prognostication is an important aspect of medical practice. It relies on statistical modeling testing the correlation of variables with the outcome of interest.In contrast with the classic approach of predictive modeling, this study aimed to estimate the unique, individual, and relative contributions. This includes the quantitative contributions of patient-, tumor-, and treatment-related factors to oncologic outcome after rectal cancer resection.This was a retrospective analysis of prospectively registered data.The study included 65 hospitals participating on a voluntary basis in the Project on Cancer of the Rectum, a Belgian multidisciplinary improvement project of rectal cancer care.A total of 1470 patients presenting midrectal or low-rectal adenocarcinoma without distant metastasis were included.The study intervention was total mesorectal excision with or without sphincter preservation.The unique, individual, and relative contributions of a set of covariables to the statistical variability of the distant metastasis rate and overall survival have been calculated.The 5-year distant metastasis rate was 21% and overall survival 76%. A large amount of the variability of the outcomes (ie, 83.6% to 84.2%) could not be predicted by the prognostic factors. Unique contributions of the predictors ranged from 0.1% to 3.1%. The 3 risk factors with the highest unique contribution for distant metastasis were lymph node ratio, pathologic tumor stage, and total mesorectal quality; for overall survival they were age, lymph node ratio, and ASA score.The main weakness of this study was incomplete participation and registration in the Project on Cancer of the Rectum.Several factors influence oncologic outcomes and are present in prediction models. However, the models predict relatively little of outcome variation.

Since restorative proctocolectomy (RPC) with ileal-pouch anal anastomosis (IPAA) removes the entire diseased mucosa, it has become firmly established as the standard operative procedure of choice for familial adenomatous polyposis (FAP). Many technical controversies still persist, such as mesenteric lengthening techniques, close rectal wall proctectomy, endoanal mucosectomy vs. double stapled anastomosis, loop ileostomy omission and a laparoscopic approach. Despite the complexity of the operation, IPAA is safe (mortality: 0.5-1%), it carries an acceptable risk of non-life-threatening complications (10-25%), and it achieves good long-term functional outcome with excellent patient satisfaction (over 95%). In contrast to the high incidence in patients operated for ulcerative colitis (UC) (15-20%), the occurrence of pouchitis after IPAA seems to be rare in FAP patients (0-11%). Even after IPAA, FAP patients are still at risk of developing adenomas (and occasional adenocarcinomas), either in the anal canal (10-31%) or in the ileal pouch itself (8-62%), thus requiring lifelong endoscopic monitoring. IPAA operation does not jeopardise pregnancy and childbirth, but it does impair female fecundity and has a low risk of impairment of erection and ejaculation in young males. The latter can almost completely be avoided by a careful "close rectal wall" proctectomy technique. Some argue that low risk patients (e.g.

We performed a study to determine if colour Doppler findings may help to identify the cause of wall thickening in acute non-diverticular diseases of the colon. The study group included 66 patients admitted to the emergency department with a final diagnosis of infectious colitis (n=23), inflammatory colitis (n=10), ischaemic colitis (n=23) and malignant tumours (n=10). The following ultrasound features were assessed: maximal wall thickness, wall stratification, arterial flow in the colonic wall and arteriolar resistive index. Higher values of wall thickness were observed in malignant tumour (18.2+/-6.2 mm, p

Background & Aims: The TCF1 gene encoding hepatocyte nuclear factor 1α (HNF1), a transcription factor germline mutated in patients with maturity-onset diabetes of the young type 3, was recently found to be frequently inactivated by biallelic alterations in liver adenoma and in rare hepatocellular carcinomas. The impact of HNF1 in colorectal carcinogenesis has not been studied until now. Colorectal cancer is characterized by the existence of different molecular mechanisms known as microsatellite stable or unstable tumors. Methods: At first, a series of 10 adenomas and 29 colon cancers regardless of microsatellite instability status were screened for TCF1 mutations on the entire coding sequence. Results: Three mutations in microsatellite instability high (MSI-H) tumors were found in the exon 4 polymorphic poly-cytosin (C) 8 or (C) 9 tract and consisted of a cytosin deletion at position 291. To further characterize the prevalence of TCF1 mutations in the subgroup of MSI-H tumors, 52 additional MSI-H samples were screened for exon 4 alterations; 23% of MSI-H tumors (95% confidence interval, 14%–36%) were found to harbor frameshift at the poly-cytosin tract. The (C) 9 allele was significantly more frequently mutated than the (C) 8 allele (22% vs. 8%; P = 0.03), showing a higher instability of the longer repetition. Conclusions: These results show a role for HNF1 in MSI-H colorectal carcinogenesis.

The Malone appendicostomy is a novel option for surgical management of faecal incontinence and chronic constipation, by permitting the administration of antegrade colonic enemas for colonic evacuation. We report the case of a 54-year-old female who had undergone abdomino perineal resection for low rectal cancer followed by total perineal reconstruction with perineal colostomy, dynamic double graciloplasty and Malone appendicostomy. After 7-year follow-up, functional results and quality of life scores were satisfactory. Suddenly the patient described increasing difficulty with intubation of her appendicostomy and complete reflux of the enema liquid, which radiology referred to a calcified body of 35 mm within the Malone appendicostomy causing nearly complete obstruction of the conduit. A surgical exploration was necessary to extract the fecolith allowing full recovery with return to satisfactory Malone appendicostomy function. To our knowledge, this is the first report of a fecolith causing obstruction within a Malone appendicostomy.

A three-grade system for macroscopic evaluation of the resection plane is used to describe the quality of total mesorectal excision (TME). In several studies, two of the three grades have been combined when analysing the outcome. The aim of our study was to compare the predictive value of the three-graded with that of a two-graded TME score. The quality of TME in 1382 patients who underwent elective resection for mid or low rectal adenocarcinoma was registered by 65 hospitals in PROCARE, a Belgian multidisciplinary improvement project. Prediction of outcome based on the classic three-grade score was compared with a two-grade scoring system in which intramesorectal resection (IMR) was combined with mesorectal (MRR) or with muscularis propria resection (MPR). End-points included the local recurrence rate, distant metastasis rate (DMR), disease-free survival (DFS) and overall survival (OS). Among the 1382 resections, 63% were MRR, 27% IMR and 9% MPR. No significant differences were found in local recurrence between the different grades of TME. A two-grade score distinguishing MRR from the others was found to predict DMR, DFS and OS as well as the three-grade score. The discriminatory and predictive value of a two-grade score, differentiating MRR from the combined IMR and MPR, was as good as the classic three-grade score.

The aim of this study was to analyze the color Doppler sonographic findings in primary epiploic appendagitis. Color Doppler sonographic findings of ten patients with primary epiploic appendagitis were reviewed. The following sonographic features were analyzed: identification of a mass adjacent to the colonic wall; identification of spotty color areas with arterial flow in this mass and detection of abnormalities of the colonic wall adjacent to the infiltrated fatty tissue. A well-delineated hyperechoic mass adjacent to the colonic wall was detected in each patient with sonography. No colonic wall abnormalities were observed nor color Doppler signal in and around the hyperechoic area. Absence of flow at color Doppler sonography is an additional feature of epiploic appendagitis.

The Apc1638N mouse carries a targeted mutant allele at the endogenous adenomatous polyposis coli (Apc) gene and represents a unique in vivo model to study intestinal tumor formation and progression. Heterozygous Apc+/Apc1638N mice progressively develop 5-6 adenomas and adenocarcinomas of the small intestine within the first 6 months of life following a histologic sequence similar to that observed in human intestinal tumors. Here, we present the somatic mutation analysis of a total of 57 tumors. The results indicate that in ≤ 75% of the lesions tested the wild type copy of the Apc gene is lost and that this LOH event extends to the entire mouse chromosome 18. Unexpectedly, mutations at the K-, N- and H-ras genes have not been found in these tumors. Immunohistochemical analysis of the Apc1638N tumors failed to detect accumulation of the Tp53 protein. Also, no mutations have been found in exons 7 and 8 of the Tp53 gene. These results indicate that, although the genetic inactivation of Apc is involved in the initiating event of the human as well as murine intestinal tumorigenesis, tumor growth and progression follow different mutational pathways in these two species.

To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mortality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA).Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI.A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes.A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complications (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoperative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome.The WHR is predictive of adverse events after elective colorectal surgery. It should be used in routine clinical practice and in future risk-estimating systems.

During laparoscopic colorectal anastomosis, the rectal introduction of the circular stapler is achieved without hand assistance, increasing the risk of rectal injury. Therefore, we describe a technical adjustment facilitating rectal advancement of the stapler.Two hundred consecutive patients with benign condition underwent laparoscopic sigmoidectomy. Before any stapling, the complete circular stapler is introduced into the anus. The anvil is released in the lumen of the colon to be resected. After cross-stapling the rectum, the anvil is retrieved in the resected specimen before the final steps of the anastomosis. Feasibility, safety, and long-term results were evaluated.In 194 patients, the anastomosis was successfully performed at upper rectal level. Only, 1 rectal wall injury was observed. At a median follow-up of 44 months, 3 patients presented anastomotic stenosis and 2 small-bowel obstructions."Lost anvil" technique allows easy and safe circular stapler rectal advancement for laparoscopic colorectal anastomosis in benign diseases.

The abdominoperineal excision (APE) rate, a quality of care indicator in rectal cancer surgery, has been criticised if not adjusted for confounding factors. This study evaluates variability in APE rate between centres participating in PROCARE, a Belgian improvement initiative, before and after risk adjustment. It also explores the effect of merging the Hartmann resections (HR) rate with that of APE on benchmarking. Data of 3197 patients who underwent elective radical resection for invasive rectal adenocarcinoma up to 15 cm were registered between January 2006 and March 2011 by 59 centres, each with at least 10 patients in the registry. Variability of APE or merged APE/HR rates between centres was analysed before and after adjustment for gender, age, ASA score (3 or more), tumour level (rectal third), depth of tumour invasion (cT4) and preoperative incontinence. The overall APE rate was 21.1% (95% CI 19.7 to 22.5%). Significant variation of the APE rate was observed before and after risk adjustment (p

The specimens of 59 rectal cancers that had been scanned by preoperative endorectal ultrasound (EUS) were analysed by the pathologist in order to draw a map of the pararectal lymph nodes that should be detected by preoperative staging. 389 lymph nodes (LNs) were detected in the mesorectum, close to the tumour. Malignant LNs were larger than the non invaded: 17% of the LNs less than 6 mm in diameter were invaded whereas 23% of the LNs 6 mm or more in diameter were free of metastatic invasion. The non invaded LNs displayed three main patterns: follicle, sinusoidal and mixed types. Metastatic LNs were partially (n = 25) or totally (n = 76) invaded by tumoural cells. Diffuse involvement includes 4 different patterns: cellular proliferation, fibrosis, necrosis and cyst formation. Accuracy of EUS evaluated by a "patient by patient" comparison was 61%, with a sensitivity of 84% and a specificity of 39%. However, a comparison "lymph node by lymph node" showed a detection rate of 21% of the lymph nodes of 3 mm and more. It is concluded that a low percentage of LNs are detected by EUS in our experience. Metastatic and non metastatic LNs exhibit a great variety of morphological features and it seems difficult to reliably correlate metastatic invasion with a specific endosonic appearance. LN size remains the most reliable parameter.

A 32-year-old male patient presenting with huge varices involving the sigmoid colon and the entire rectum down to the dentate line is described. There was no familial history of gastrointestinal bleeding. No particular aetiology was identified. Marked anaemia due to recurrent bleeding required resection of the sigmoid colon and rectum. Restoration of the intestinal continuity was performed by a coloanal anastomosis. The patient did well and bleeding has not recurred. To our knowledge, no similar case of such varices requiring extensive rectal surgery to control bleeding has been described in the literature.

Transanal endoscopic microsurgery (TEM) was developed in the early 1980s as a minimally invasive technique allowing the resection of benign rectal adenomas. For this indication, TEM was reported to be safe and effective and even exceeded the results compared to classical local excision. Unsurprisingly, the indication expanded to small rectal cancer. There is still much debate, though, whether it is oncologically safe to perform TEM for rectal cancer. Much has been published about the need for proper patient selection, i.e. patients presenting a low-risk T1 rectal cancer seem to be the most adequate subgroup for this technique. Nevertheless, TEM remains controversial concerning high-risk T1 rectal adenocarcinomas and deeper infiltrating tumors. Several retrospective case series and a small prospective study suggest that radiochemotherapy before local excision reduces recurrence to a level comparable with classic radical surgery (total mesorectal excision). However, these studies are collectively limited, and prospective data from larger multicenter trials are awaited. Reports about functional results after TEM have shown that the procedure has no permanent impact on anorectal function. Even if transient anal resting pressure weakening has been repeatedly described, patients do not suffer from any long-term functional sequelae. Nor do they complain of quality of life impairment.

Background: The concept of drug titration emerged recently for intraoperative fluid administration during Fast-Track colonic surgery to avoid hypovolemia as well as excessive crystalloid administration. The Pleth Variability Index (PVI) is an oximeter-derived parameter. It allows a continuous monitoring of the respiratory variation of the perfusion index. Objective: To investigate if applying the concept of fluid titration with PVI-guided colloid administration conjointly with restricted crystalloids administration changes the amount of fluid administered. Design, settings and patients: Twenty one ASA 2 patients scheduled for Fast-Track colonic surgery were randomized in two groups: the PVI-guided the fluid management group and the the control group. Intervention and main outcome measures: After the induction of general anesthesia, the PVI group received a 10 mL.kg- 1.h-1 infusion of crystalloid during the first hour, reduced to 2 mL.kg-1.h-1 thereafter. Colloids 250 mL were administered if necessary to maintain a PVI value of 10 to 13%. In the control group, a 10 mL.kg-1.h-1 infusion of crystalloid during the first hour was followed by a 5 mL.kg-1.h-1 infusion. Boluses of 250 mL of colloids were administered if required to maintain the mean arterial pressure above 65 mmHg. Results: Intraoperative crystalloids infused volume were significantly lower in the PVI group (925+/-262 mL vs 1129+/- 160 mL; P=0.04). In contrast, the infused amounts of colloids was higher in the PVI group (725+/-521 mL vs 250+/-224 mL; P=0.01). Interestingly, total fluid amount infused intra- ant postoperatively were similar between the groups (1650+/- 807 mL vs 1379+/-186 mL; P=0.21). Conclusion: PVI-guided fluid management in Fast-Track colonic surgery is not necessarily associated with different total volume infused.

Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence.The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate.Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years.The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA.PubMed database was searched using the following search items: familial adenomatous polyposis, surgery, ileal pouch-anal anastomosis, ileo-rectal anastomosis. Papers published between 1978 and 2010 were selected.Absence of mortality, acceptable morbidity and good functional results combined to high quality of life have promoted the IPAA technique. New technical issues such as the double stapled technique, mesenteric lengthening, omission of temporary protective stoma can be addressed almost systematically for these patients. A laparoscopic approach, lessening the body image impact, has proven to be as effective and safe as the open approach to perform IPAA. Further advantages of laparoscopic IPAA rely on the lower adhesion formation resulting in less small bowel occlusion. Sexuality, fertility and childbirth are important functional issues often cited as threatened by the pelvic manoeuvres of the IPAA technique which can be prevented by close rectal wall dissection and a laparoscopic approach.IPAA offers the best available prophylaxis in FAP patients. Technical enhancements in IPAA will most probably decrease the functional risks. Thus IPAA remains the alternative to IRA for the prophylactic treatment of FAP.Nevertheless, based on the latest evidence, the choice between both procedures is still matter of debate.

Prophylactic (procto-) colectomy is the treatment of choice to reduce the risk of colorectal cancer in FAP patients with multiple adenomas. Because patients present at young age, rectum-sparing surgery is sometimes advocated, so that there is no pelvic dissection with impact on quality of life, preserved pelvic innervation and sexual function and fertility. The main disadvantage of a total colectomy with an ileorectal anastomosis (IRA) is a rectal cancer risk of 50% at the age of 50 years and a cumulative risk of 25.8% after 25 years of follow-up. Therefore, this procedure should be reserved for patients with an unaffected rectum. There should be no discussion to perform a primary IPAA in patients with multiple rectal adenomas (20) or those with a severe dysplastic or large (3 cm) rectal adenoma or a cancer elsewhere in the colon. A patient with an IRA should undergo yearly follow-up by rectoscopy.

FAP is characterized by 100-1000s of adenomatous polyps in colon and rectum, and is in 70% of the patients associated with extracolonic manifestations. Attenuated FAP (AFAP) is a less severe form of FAP, marked by the presence of100 polyps and a later onset of colorectal cancer (CRC). (A)FAP is caused by autosomal dominantly inherited mutations in the APC (Adenomatous polyposis coli) gene, a tumour suppressor gene that controls beta-catenin turnover in the Wnt pathway. De novo occurrence is reported in 30-40% of the patients. Mutations are detected in 85% of classical FAP families, while only 20%-30% of AFAP cases will exhibit a germline APC mutation. MUTYH is the second (A)FAP-related gene and is involved with base-excision repair of DNA damaged by oxidative stress. MUTYH mutations are inherited in an autosomal recessive way and account for 10%-20% of classical FAP cases without an APC mutation and for 30% of AFAP cases. Genotype-phenotype correlations exist for mutations in the APC gene, however, contradictions in the literature caution against the sole use of the genotype for decisions regarding clinical management. Once the family's specific APC mutation is identified in the proband, predictive testing for first degree relatives is possible from the age of 10 to 12 years on. For AFAP, relatives are tested at age 18 and older. Opinions about the appropriate ages at which to initiate genetic testing may vary. Physicians must have a discussion about prenatal testing with patients in childbearing age. They may either opt for conventional prenatal diagnosis (amniocentesis or chorionic villous sampling) or for preimplantation genetic diagnosis (PGD).

Thirty-one tumors, lying in the lower two-thirds of the rectum and possibly suitable for local excision, were analyzed by endorectal ultrasonography (EUS) using the Aloka scanner SSD 520. There were 18 sessile villous adenomas (group I) and 13 invasive cancers 3 cm or less (group II). Preoperative endosonographic staging (uT, uN stages) was compared with the histologic analysis of the specimens (pT, pN) and the possible contribution to therapy was evaluated. In group I, the depth of tumor infiltration was accurately assessed in 89% of cases. Malignant transformation was suspected in 4 cases (uT2) and confirmed postoperatively in 3 cases. In group II, the extent of the tumor was correctly evaluated in 84% of cases. With regard to the overall differentiation between T1 and T2/T3 tumors on one hand, and between T1/T2 and T3 lesions on the other hand, the positive predictive values were 93.3% and 100%, respectively. The negative predictive values were 93.7% and 92.8%. In group II the search for regional lymph nodes was positive in 4 cases and negative in 9 cases. An accuracy rate of 82% (sensitivity 75%, specificity 85%) was estimated by analysis of the specimens and postoperative follow-up. The exact performance could not be evaluated because a radical resection was not carried out in most cases. EUS was useful for planning the treatment of villous adenomas. A board full-thickness excision was carried out without delay for the four uT2 villous tumors, allowing safe margins to be obtained in all cases. Using EUS the choice of local excision was questioned for six small invasive cancers (uT3 and/or uN+), although radical resection was carried out for only two. As high sensitivity could not be achieved when detecting lymphatic metastasis, the choice of limited surgery based on EUS staging requires strict postoperative follow-up.

Inflammatory myofibroblastic tumor (IMT) is a rare tumor, classified by WHO of intermediate biological potential with tendency for local recurrence and small risk for distant metastasis. Histologically IMT is a mixture of inflamma- tory cells and myofibroblastic spindle cells proliferation. To our knowledge there is no MRI description of mesenteric IMT in the literature. We would like to emphasize the correlation between medical imaging and anatomical pathology based on our experience of a mesenteric IMT in a 28-year-old patient.