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Aims Neoadjuvant radiochemotherapy (RCT) followed by surgical resection is the treatment for locally advanced mid-rectal or low rectal cancer. The aim of this study was to evaluate postoperative histological prognostic factors in a series of surgical specimens after neoadjuvant RCT. Methods and results One hundred and thirteen patients were included. Macroscopic and microscopic examinations were performed according to CAP recommendations, with additional criteria such as tumour budding, the presence of calcifications, and response to neoadjuvant therapy assessed according to Modified Rectal Cancer Regression Grade (m-RCRG). The 3-year disease-free survival (DFS) was 67.6%. In univariate analysis, ypTN stage, tumour budding, circumferential margin, invaded margin and vascular and perineural invasion were prognostic factors. In multivariate analysis, the presence of calcifications (P = 0.04) and an involved circumferential margin (P = 0.03) were the only independent factors for worse DFS. mRCRG was not correlated with DFS. Among the 50 m-RCRG1 tumours, DFS was better in ypT0 patients than in other ypT stages (P = 0.003). Conclusions The presence of calcifications in the tumour bed is described for the first time as a prognostic factor in rectal cancer. The prognostic value of budding was demonstrated in this study after neoadjuvant RCT. ypT stage appears to be a more reliable predictor of oncological outcome than histological tumour regression grade, which needs to be standardized for better reproducibility.

International audience; AIMS: The incidence of oesogastric (OG) signet ring cell adenocarcinoma (SRC) is increasing in Western countries. The differential characteristics between oesophageal and gastric SRC tumours are unknown. We aimed to investigate the role of tumour location on prognosis in OG SRC.METHODS: Among 924 OG SRC resected in 21 centres from 1997 to 2010, consecutive patients who had oesophageal tumours (group OESO, n = 136) were matched to randomly selected patients who had gastric tumours (group GASTRIC, n = 363). Matching variables were gender, age, American Society of Anaesthesiologists score, malnutrition, pretherapeutic clinical TNM stage and neoadjuvant treatment. Patients and tumour characteristics were compared between groups and prognostic factors were identified.RESULTS: The two groups were well matched. Tumours in group GASTRIC were more advanced at surgical exploration, with higher rates of linitis plastica (P < 0.001), peritoneal carcinomatosis (P = 0.001), and advanced pTNM stages (P = 0.034). Radicality of resection and recurrence rates were similar (P > 0.480). Recurrences were more frequently distant (P < 0.001) and peritoneal (P < 0.001) in group GASTRIC. After adjustment on confounding variables, gastric location (P = 0.034) was independently associated with a better prognosis than oesophageal location.CONCLUSION: Gastric and oesophageal SRC tumours are distinct diseases. Despite similar pretherapeutic factors, gastric tumours were more advanced with a greater propensity for the peritoneal surface at the diagnosis and recurrence and associated with a better prognosis.

The onset of secondary hemorrhagic complications with the development of pancreatic pseudocysts is rare but has a high mortality rate. Management of the hemorrhagic complications of pancreatic pseudocysts is surgical despite the contribution of arterial embolization. We report the observation of a 59-year-old patient who had presented an episode of acute pancreatitis 1 month before consulting for abdominal pain associated with an episode of melena. The CT showed a pancreatic pseudocyst complicated by an intracystic tear, a splenic artery aneurysm in the Wirsung canal, and rupture of the spleen. These three lesions were treated simultaneously with left splenopancreatectomy starting with the splenic vessels. The simultaneous onset of three hemorrhagic complications of a pseudocyst is exceptional and has never been described to our knowledge.

Resume Les metastases de cancers colorectaux a developpement endobiliaire sont rares. Nous rapportons le cas d’un malade âge de 36 ans opere 5 ans auparavant d’un cancer du sigmoide par sigmoidectomie et ayant consulte pour la survenue depuis un mois de douleurs de l’hypochondre droit sans fievre ni ictere. L’echographie, l’imagerie abdominale par tomodensitometrie et par resonance magnetique ainsi que la tomographie par emission de positons ont permis de poser le diagnostic de metastase endobiliaire traitee par hepatectomie droite curative. Une revue de la litterature prolonge cette observation sur les metastases endobiliaires. Ces tumeurs peuvent mimer au plan clinique, radiologique et meme anatomopathologique le cholangiocarcinome des voies biliaires intrahepatiques. L’objectif principal du bilan d’imagerie est d’etablir la resecabilite de ces lesions. La survie rapportee des rares malades atteints de metastases endobiliaires resequees semble meilleure que celle des malades porteurs de metastases hepatiques parenchymateuses.

The French Research Group of Rectal Cancer Surgery (GRECCAR); International audience; Background: Neoadjuvant radiochemotherapy (RCT) is now part of the armamentarium of cancer of the lower and middle rectum. It is recommended in current clinical practice prior to surgical excision if the lesion is classified T3/T4 or N+. Histological complete response, defined by the absence of persistent tumor cell invasion and lymph node (ypT0N0) after pathological examination of surgical specimen has been shown to be an independent prognostic factor of overall survival and disease-free survival. Surgical excision is usually performed between 6 and 8 weeks after completion of CRT and pathological complete response rate ranges around 12%. In retrospective studies, a lengthening of the interval after RCT beyond 10 weeks was found as an independent factor increasing the rate of pathological complete response (between 26% and 31%), with a longer disease-free survival and without increasing the operative morbidity. The aim of the present study is to evaluate in 264 patients the rate of pathological complete response rate of rectal cancer after RCT by lengthening the time between RCT and surgery.Methods/design: The current study is a multicenter randomized trial in two parallel groups comparing 7 and 11 weeks of delay between the end of RCT and cancer surgery of rectal tumors.At the end of the RCT, surgery is planified and randomization is performed after patient’s written consent for participation. The histological complete response (ypT0N0) will be determined with analysis of the complete residual tumor and double reading by two pathologists blinded of the group of inclusion. Patients will be followed in clinics for 5 years after surgery. Participation in this trial does not change patient’s management in terms of treatment, investigations or visits. Secondary endpoints will include overall and disease free survival, rate of sphincter conservation and quality of mesorectal excision. The number of patients needed is 264.

Background Standard operative management of colorectal cancer (CRC) with adherent adjacent organs is en bloc resection to obtain clear resection margins. We analyzed early and long-term outcomes after multivisceral resection for clinically suspected T4 CRC and identified factors predicting survival. Methods All patients operated on for clinically suspected T4 CRC between 2000 and 2010 were identified retrospectively. Data concerning demographics, surgery, pathologic examination and oncologic outcome were analyzed. Results One hundred fifty-two patients underwent partial or total en bloc resection of ≥1 adherent organ. An R0 resection was achieved in 136 patients (89.5%). Malignant invasion of the adherent organ was histologically confirmed in 98 patients (64.5%). Five-year overall survival and disease-free survival rates were 77.4% and 58.1%, respectively. On univariate analysis, margin positivity, pT4 stage, and lymph node invasion were predictors of a worse disease-free survival. The presence of liver metastases and concomitant hepatectomy were both factors of poor overall and disease-free survival. On multivariate analysis, resection of ≥2 adjacent organs was a predictor of better overall survival. This finding may be explained by the significantly higher rate of tumors with microsatellite instability (MSI) in the group with resection of multiple organs. Conclusion The oncologic outcome of multivisceral resection for clinically suspected colorectal T4 tumors was good, especially in MSI patients and patients without liver metastases. The number of organs requiring resection should not contraindicated radical surgery as in this study it was associated with a good prognosis.

Background & Aims Patients with colorectal tumors with microsatellite instability (MSI) have better prognoses than patients with tumors without MSI, but have a poor response to 5-fluorouracil–based chemotherapy. A dominant-negative form of heat shock protein (HSP)110 (HSP110DE9) expressed by cancer cells with MSI, via exon skipping caused by somatic deletions in the T 17 intron repeat, sensitizes the cells to 5-fluorouracil and oxaliplatin. We investigated whether HSP110 T 17 could be used to identify patients with colorectal cancer who would benefit from adjuvant chemotherapy with 5-fluorouracil and oxaliplatin. Methods We characterized the interaction between HSP110 and HSP110DE9 using surface plasmon resonance. By using polymerase chain reaction and fragment analysis, we examined how the size of somatic allelic deletions in HSP110 T 17 affected the HSP110 protein expressed by tumor cells. We screened 329 consecutive patients with stage II–III colorectal tumors with MSI who underwent surgical resection at tertiary medical centers for HSP110 T 17 . Results HSP110 and HSP110DE9 interacted in a 1:1 ratio. Tumor cells with large deletions in T 17 had increased ratios of HSP110DE9:HSP110, owing to the loss of expression of full-length HSP110. Deletions in HSP110 T 17 were mostly biallelic in primary tumor samples with MSI. Patients with stage II–III cancer who received chemotherapy and had large HSP110 T 17 deletions (≥5 bp; 18 of 77 patients, 23.4%) had longer times of relapse-free survival than patients with small or no deletions (≤4 bp; 59 of 77 patients, 76.6%) in multivariate analysis (hazard ratio, 0.16; 95% confidence interval, 0.012–0.8; P = .03). We found a significant interaction between chemotherapy and T 17 deletion ( P = .009). Conclusions About 25% of patients with stages II–III colorectal tumors with MSI have an excellent response to chemotherapy, due to large, biallelic deletions in the T 17 intron repeat of HSP110 in tumor DNA.

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP. The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases. Among the 118 IPAA patients, 57 (48.3 %) had pouch adenomas a median of 15 years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p = 0.016] and presence of advanced duodenal adenomas (OR, 4.35; p = 0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5 %). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p = 0.007). After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.

Background and Objectives Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders. Gastrointestinal manifestations in EDS have been described but their frequency, nature and impact are poorly known. We aimed to assess digestive features in a national cohort of EDS patients. Methods A questionnaire has been sent to 212 EDS patients through the French patient support group, all of which had been formally diagnosed according to the Villefranche criteria. The questionnaire included questions about digestive functional symptoms, the GIQLI (Gastrointestinal Quality of Life Index), KESS scoring system and the Rome III criteria. Results Overall, 135 patients (64% response rate) completed the questionnaire and 134 were analyzable (123 women; 91%). Mean age and Body Mass Index were respectively 35±14.7 years and 24.3±6.1 kg/m2. The most common EDS subtype was hypermobility form (n=108; 80.6%). GIQLI and KESS median values were respectively 63.5 (27-117) and 19 [13.5-22]. Eighty four percent of patients had functional bowel disorders (FBD) according to the Rome III criteria. An irritable bowel syndrome according to the same criteria was observed in 64 patients (48%) and 48 patients (36%) reported functional constipation. A gastro-esophageal reflux disease (GERD) was reported in 90 patients (68.7%), significantly associated with a poorer GIQLI (60.5±16.8 versus 75.9±20.3; p

Objective: To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA). Background: Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed. Methods: All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy. Results: Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14–44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6–136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397). Conclusions: The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

INTRODUCTION After curatively intended surgery for colorectal liver metastases, liver recurrences occur in more than 60% of patients, despite the administration of adjuvant systemic chemotherapy. The aim of this study was to assess the benefit of combined adjuvant hepatic arterial infusion (HAI) and intravenous (IV) 5-FU compared with standard modern adjuvant IV chemotherapy in patients at high risk of hepatic recurrence. PATIENTS AND METHODS From January 2000 to December 2009, 98 patients, who had undergone curative resection of at least 4 colorectal liver metastases, were selected from a prospective database. Among them, 44 (45%) had received postoperative HAI combined with systemic 5-FU (HAI group) and 54 (55%) had received "modern" systemic chemotherapy (IV group). RESULTS The 2 groups were similar in terms of age, sex, the stage of the primary, and the administration of preoperative chemotherapy. The median number of HAI cycles received per patient was 7 [range, 1-12]. Twenty-nine patients (66%) had received at least 6 cycles of HAI oxaliplatin, and 22 patients (50%) had received the full planned treatment. For the remaining 22 patients (50%), HAI chemotherapy had been discontinued because of toxicity (n = 8), HAI catheter dysfunction (n = 6), an early recurrence (n = 6), and patient's refusal (n = 2). After a median follow-up of 60 months (51-81 months), 3-year overall survival was slightly higher in the HAI group (75% vs 62%, P = 0.17). Three-year disease-free survival was significantly longer in patients in the HAI group than those in the IV group (33% vs 5%, P < 0.0001). In the multivariate analysis, adjuvant HAI chemotherapy and an R0 resection margin status were the only independent predictive factors for prolonged disease-free survival. CONCLUSIONS Postoperative HAI oxaliplatin combined with systemic chemotherapy after curatively intended surgery of colorectal liver metastases is feasible and may significantly improve disease-free survival of patients at high risk of hepatic recurrence compared with adjuvant modern systemic chemotherapy alone. These results should be confirmed in a randomized study.

Objectifs Peu de donnees existent concernant les taux de readmissions en France apres une intervention chirurgicale programmee. Notre objectif etait d’evaluer les taux de readmissions apres une chirurgie urologique programmee sur une periode de 3 ans en France, et d’identifier les facteurs predictifs de readmissions, notamment le volume d’activite urologique de chaque etablissement, le volume d’activite de chirurgie ambulatoire et le statut administratif de l’etablissement. Methodes Les donnees concernant les hospitalisations pour une chirurgie urologique programmee entre janvier 2010 et novembre 2012 en France ont ete extraites du Programme de medicalisation des systemes d’information ( Tableau 1 ). Le critere de jugement principal etait le taux de readmissions dans les 30 jours apres l’intervention chirurgicale initiale. Des facteurs predictifs de readmissions ont ete recherches parmi lesquels le sexe, l’âge, la duree de sejour initial, le groupe homogene de malades (GHM), la pathologie concernee, le volume d’activite chirurgicale urologique globale et ambulatoire de l’etablissement et le statut administratif de l’etablissement. Resultats Apres exclusion des deces et des patients transferes durant le sejour initial, 423 393 patients ont ete inclus dans la cohorte. Le taux global de readmissions a 30 jours etait de 18,4 %. Le Tableau 2 presente les differents facteurs de risque de readmissions apres analyse univariee. Apres analyse multivariee, la prise en charge en clinique privee etait associee a un risque plus important de readmissions a 30 jours (clinique versus CHU : OR = 1,64 [IC 95 % : 1,23–2,16], clinique versus GH et PSPH : OR = 1,43 [IC 95 % : 1,16–1,76]). Les autres facteurs de risque independants de readmissions etaient le sexe masculin (OR = 1,82 [IC 95 % : 1,79–1,86]) et un GHM eleve (GHM3–4 versus GHM1–2 : OR = 3,69 [IC 95 % : 2,96–4,61]). Conclusion Le taux de readmissions global apres une chirurgie urologique est de 18,4 %, particulierement eleve compare a une moyenne nationale de 5,9 %, toutes chirurgies confondues. Ces donnees sont a mettre en perspective a un moment ou les pouvoirs publics pronent un developpement exponentiel de la chirurgie ambulatoire.

Introduction The surgical approach for the treatment of tumors of the upper third of the rectum remains controversial. Several publications have shown that partial excision of the mesorectum (PME) with division of the mesorectum and rectum 5 cm below the tumor could be a reasonable approach although total mesorectal excision (TME) is still considered the gold standard for all rectal cancers in many studies. We aimed to assess the specifics risks of anterior resection with PME and colorectal anastomosis (CRA) in rectal cancer. Patients and Methods Files of all of the patients who underwent a PME between 2000 and 2011 were reviewed in consecutive order. Complications that occurred within 3 months after surgery, oncological outcome, local and distant recurrences, and survival were assessed. Results One hundred seventy-two patients had a PME with CRA of whom 49 (28.5%) had a dysfunctional stoma. Grade III to IV complications occurred in 18 (10.5%) patients and 2 (1.2%) died. Thirteen (7.6%) developed an anastomotic leakage, and 5 (2.9%) resulted with a permanent stoma. Mean follow-up was 151 months (range, 0-151 months). The 5-year local recurrence rate was 5.3%. The 5-year overall and disease-free survival assessed in the 147 patients without synchronous metastasis were 93.2% and 79.7%, respectively. Conclusion Partial excision of the mesorectum can be performed safely, in 1 stage in many patients, with a low risk of definitive stoma. The local recurrence and the survival rates that we observed indicate that the prognosis is not altered compared with TME. Therefore, PME can be recommended in the treatment of upper and some mid rectal tumors.

Summary Background and objective Infliximab, a monoclonal antibody directed against tumor necrosis factor α (TNFα), is commonly used during flares and on a regular basis to maintain the remission of inflammatory bowel diseases (IBD). It is usually administered in 2-hours infusion and 2 hours of monitoring after as recommended. However, recent reports suggest that infliximab infusions over a shorter period (30 minutes to 1 hour) are well tolerated. We aimed to compare the tolerability of 1-hour and 2-hours infliximab infusions in patients with IBD in our institution. Methods We analyzed data from all patients treated with infliximab between 1999 and September 2010. Infliximab was administered in 1-hour infusion and 1 hour monitoring since 2009. Only the early adverse events were analyzed. Results Adverse events during infusion were compared between one group of patients who had 1-hour infusion (989 infusions) and the other who had 2-hours infusion (2102 infusions). The incidence of adverse events was 10.6% in the 2-hours infusion group versus 6.3% in the 1-hour infusion group (P = 0.36). Conclusions These results suggest that the occurrence of infliximab infusion-related adverse events is similar across the two groups, regardless of the infusion cycle. One-hour infusion could then be proposed safely for all patients.

OBJECTIVE: To report postoperative morbidity after low anterior resection (LAR) and coloanal anastomosis (CAA) for rectal cancer and identify possible risk factors of complications. BACKGROUND: Coloanal anastomosis after total mesorectal excision (TME) is associated with significant morbidity. Precise data on the specific morbidity and the risk factors are lacking. METHODS: We analyzed retrospectively 483 consecutive LARs with TME and CAA carried out in a single center between 1996 and 2005. All complications occurring up to 3 months after LAR and up to 3 months after closure of the diverting stoma were graded according to the Dindo classification. RESULTS: Of 483 patients, 164 (33.9%) suffered at least 1 complication, leading to death in 2 (0.4%) patients. Grade III/IV complications occurred in 69 of 483 (14.2%) patients. Thirty-four (7.0%) patients developed leakage of the CAA and 3 patients had leakage of the small bowel anastomosis after stoma closure. Ileostomy closure was carried out after a mean of 88.7 days (36-630) after LAR. The stoma was not closed in 4 of 456 (0.6%) patients. In multivariate analysis, male sex (P = 0.0216) and postoperative transfusion (P = 0.0025) were associated with complications. Medical complications were furthermore associated with previous thrombembolic events (P = 0.0012) and associated surgery at the time of LAR (P = 0.0010). Circumferential tumor localization was predictive of surgical complications (P = 0.0015). The only factor associated with a risk of leakage was transfusion (P = 0.0216). CONCLUSIONS: In this series morbidity occurred in 34% and dehiscence of the CAA in 7.0%. Transfusion requirement was an independent risk factor for postoperative complications and anastomotic leakage.

In locally advanced rectal cancer (LARC) patients, major response to neoadjuvant radiotherapy (NR) has been associated with favorable long-term outcomes. Positive pathologic nodal status was recently proven to be associated with poor prognosis even after total regression of primary tumor (ypT0). The aim of this study was to evaluate the rate of lymph node (LN) involvement in patients with complete (ypT0) or major (TRG1: very few viable tumor cells) response.Included were patients with complete or major response after radiotherapy followed by surgery and histological examination of the whole specimen.From 1996 to 2010, 245 patients with LARC were treated by NR. We collected clinical data for 53 patients (21.6 %) with ypT0 (n = 26, 49 %) or TRG1 (n = 27, 51 %) response. Sphincter-preserving surgery was performed in 40 patients (75 %). Overall, nine patients (16.9 %) presented LN involvement: 2 (7.7 %) in the ypT0 group and 7 (25.9 %) in the TRG1 group (NS). Patients with ypT3 tumors had significantly more invaded LN than patients with ypT1-T2 tumors (6 of 13 [46 %] vs 1 of 14 [7 %], p = .032). After median follow-up of 30 months (range, 1-160 months), 5-year disease-free and overall survivals were 88.2 and 89.0 %, respectively.There was a clear cutoff between patients with ypT0-T2 (3 of 40, 7.5 %) and ypT3 (6 of 13, 46 %) concerning the incidence of metastatic LN in patients achieving pathologic complete or major response after NR. In patients with good clinical response, local full-thickness resection of the residual tumor could be a first step, followed by standard rectal resection in cases of ypT3.

BACKGROUND: Ability to identify patients with familial adenomatous polyposis who have a high risk of developing desmoid tumors may affect decisions in clinical practice. OBJECTIVES: Our aim was to assess several risk factors for desmoid tumor development in an international cohort of patients with familial adenomatous polyposis and to evaluate the clinical relevance of risk factors. DESIGN: This was a retrospective cohort study. SETTING AND PATIENTS: Polyposis registries in The Netherlands, France, Denmark, Finland, and Italy provided information on familial adenomatous polyposis patients with desmoid tumors. MAIN OUTCOME MEASURES: We used univariate and multivariable analyses of data from registries in The Netherlands, France, Denmark, and Finland to test whether gender, APC mutation site, previous colorectal surgery, colorectal cancer, and family history for desmoid tumors contribute to risk of developing desmoid tumors at any location, or specifically at an intra-abdominal location. The effect of family history was tested with a generalized linear mixed model. RESULTS: Of 2260 patients with familial adenomatous polyposis from 912 families in The Netherlands, France, Denmark, and Finland, 220 patients (10%) had desmoid tumors (101 men). In 387 patients with desmoid tumors (including 167 patients from the Italian registry), the median age at diagnosis of the first desmoid tumor was 31 years (range, 4 months-74 years). Desmoid locations were intra-abdominal (53%), abdominal wall (24%), extremities (9%), and unknown sites or combinations of sites (14%). Multivariable analysis of risk factors for desmoids at any location showed surgery (OR, 2.58; P = .0004), an APC mutation 3' of codon 1444 (OR, 3.0; P < .0001), and a positive family history (P < .0001) to be independently associated with desmoid development. When only intra-abdominal location was analyzed, APC mutation site was not associated with desmoid development. LIMITATIONS: Selection bias may have occurred. CONCLUSIONS: A positive family history for desmoid tumors, abdominal surgery, and APC mutation site are significant risk factors for development of desmoid tumors. The results may have implications for determining the optimal management of FAP patients and guide future studies.

Background and aim Fistulae are one of the most frequent complications of Crohn's disease (CD) and occur in 30–40% of patients. Conversely, free perforation is a rare complication and is one of the indications for emergency surgery of CD because of secondary peritonitis. We report a case of a spontaneous fistula rupture secondary to a road traffic accident. Methods Case report. Results A 22 year-old man, with no personal significant medical history, was admitted in the emergency room after a road traffic accident. He underwent abdominal CT, which revealed pelvis fractures, abnormal bowel wall of the terminal ileum (wall thickening and mucosal enhancement), peritoneal effusion within the pelvis, mesenteric nodes and extra-luminal gas within an area of mesenteric inflammation: these features were suggestive of ileum perforation associated with inflammatory bowel disease, most likely CD. Laparoscopic assessment was decided and an ileocaecal resection with ileocolonic anastomosis was performed. Histological analysis revealed terminal ileitis with ulcers, non caseating granulomas and submucosal fibrosis, a transparietal fistula and a caecoappendicular inflammation, confirming CD. Post surgical outcome was uneventful and the patient was discharged at day 9. Conclusion Our patient presented this rare complication revealing CD. The involvement of the terminal ileum and fistulae were characteristics of CD. Rupture of the fistula was favored by the trauma and responsible for the peritonitis. A resection with primary anastomosis was possible. To our knowledge, it is the first case described for the rupture of an ileal fistula secondary to traumatism in a patient with CD.

Heat shock proteins (HSPs) are necessary for cancer cell survival. We identified a mutant of HSP110 (HSP110ΔE9) in colorectal cancer showing microsatellite instability (MSI CRC), generated from an aberrantly spliced mRNA and lacking the HSP110 substrate-binding domain. This mutant was expressed at variable levels in almost all MSI CRC cell lines and primary tumors tested. HSP110ΔE9 impaired both the normal cellular localization of HSP110 and its interaction with other HSPs, thus abrogating the chaperone activity and antiapoptotic function of HSP110 in a dominant-negative manner. HSP110ΔE9 overexpression caused the sensitization of cells to anticancer agents such as oxaliplatin and 5-fluorouracil, which are routinely prescribed in the adjuvant treatment of people with CRC. The survival and response to chemotherapy of subjects with MSI CRCs was associated with the tumor expression level of HSP110ΔE9. HSP110 may thus constitute a major determinant for both prognosis and treatment response in CRC.

Summary Purpose Mucinous cystadenomas are tumors arising mostly from the ovaries and pancreas. They can also arise from the kidneys, lungs, liver and appendix, but are rarely seen in the mesocolon. Recently, they have been included in an updated classification of mesenteric cysts and cystic tumors. The WHO classification (ICD 10) divides them into three subcategories according to their malignant behavior. Methods This report of two cases of mucinous cystadenoma of the mesocolon discusses the diagnostic and therapeutic modalities as well as the pathophysiological pathway(s) of development of these neoplasms. Results and conclusion The diagnosis of mucinous cystadenomas of the mesocolon is challenging due to the absence of specific clinical, biological and radiological features, and is often made during or after laparotomy. Preoperative biopsy is not useful and may even lead to misdiagnosis or peritoneal spillage. Surgery is the only curative treatment, but the modalities of resection are still a subject of debate.

Pancreaticoduodenectomy is an alternative to pancreas-sparing duodenectomy for radical treatment of duodenal lesions. The aims of this study were to assess the results of pylorus-preserving pancreaticoduodenectomy (PPPD) for severe duodenal polyposis in familial adenomatous polyposis in terms of morbidity, long-term influence on functional results, the recurrence rate of cancer or jejunal polyps, and survival.All patients operated on for a PPPD between 1992 and 2009 were included. Clinical data, endoscopic findings, and pathologic examinations were evaluated.A total of 19 patients underwent PPPD for severe duodenal polyposis (17 Spigelman IV, 1 Spigelman III, and 1 invasive carcinoma). Postoperative mortality was nil. The postoperative morbidity rate was 42%, including 4 pancreatic fistulae (21%) and 2 delayed gastric emptying (11%). Pathologic examination found 7 invasive carcinomas, of which only 1 was known before resection. One third of patients operated on without a preoperative diagnosis of malignancy already had an invasive duodenal carcinoma. After a mean follow-up of 58 months, 16 patients were alive. Thirteen patients underwent endoscopic follow-up, and new adenomas were found in 4 (31%). All were treated successfully during the same endoscopic procedure. PPPD did not modify the functional result after coloproctectomy.PPPD remains a safe and efficient therapeutic option for severe duodenal polyposis in familial adenomatous polyposis patients.

Summary Objective Describe the workload of French residents in surgery presently in training and analyze the factors influencing the quality of this training. Methods Mail questionnaire sent between June and September 2009 to French surgical residents. Items analyzed included demographics, hospital working time per week, post-call time off, planning of a fellowship after internship and academic endeavors. Received practical and theoretical instruction/training were evaluated. Results Mean hospital working time was 67 hours per week. Factors influencing working time were gender, geographical localization, and post-call off-duty. Post-call off-duty was observed by 35% of the residents. Gender and planned fellowship after internship significantly influenced this rate. The mean grade given to practical instruction was more than 6/10 for all surgical specialties. The theoretical instruction mean grade was equal or lower than the practical education mean grade for all surgical specialties. Conclusion This study confirmed the high workload of French residents in surgery. Restricted work hours regulations are largely disregarded.

MYH associated polyposis is a hereditary syndrome responsible for early colorectal cancer with a distinct genetic pathway from the Familial Adenomatous Polyposis or the Hereditary Non Polyposis Colorectal Cancer syndrome. We have studied a family with three members bearing a biallelic mutation in MYH at c.1185_1186dup. One patient who developed colon cancer had loss of expression of MLH1 on tumoral tissue and microsatellite instability (MSI) phenotype. Analysis of MLH1 based on his blood sample revealed no germline mutation or large genomic deletion. No methylation of the promoter was identified in tumoral DNA. No transversion mutations were identified in APC or KRAS in tumor DNA of this patient. Loss of expression of MLH1 was due to a transversion in intron 7 at position +5 (c.588 + 5G > T) leading to a complete deletion of exon 7 at the RNA level. This observation demonstrates that MLH1 can be a target of MYH transversions leading to MSI phenotype.

Introduction Total proctocolectomy, ensuring eradication of all diseased colorectal mucosa is the treatment of choice for ulcerative colitis, familial adenomatous polyposis. Before the era of ileal pouch anal anastomosis, definitive ileostomy was required. The aim of this study is to define both early and late morbidity and the functional result of continent ileostomy. Methods All patients’ chart who had a continent ileostomy in our department were reviewed. The functional result was evaluated in 43 patients. Results Forty-nine patients (34 women) with a mean age of 42 years (range: 17–69) underwent a continent ileostomy, 32 following a restorative proctocolectomy. The mean follow-up was 20.5 (range: 3–34) years. Seventeen patients (35%) experienced an early postoperative complication requiring reintervention in two patients. There was no mortality, and conversion to an end ileostomy was not required. Twenty-two patients developed late complications requiring 50 reoperations. The mean number of catheterisations per 24 h was 4.4. The SF36 questionnaire showed values close to those of the general population. Conclusion Continent ileostomy carries a significant risk of non-severe complications. In selected patients, it represents a valuable alternative to an end ileostomy, in particular when restorative proctocolectomy has failed.

OBJECTIVES Many factors influence the career specialty decisions made by medical students. The aim of this study was to broaden consideration of the determinants of specialty choice in a large population of medical students in their sixth year of study. METHODS A total of 2588 students distributed across all of the 39 medical schools in France participated in a National Practice Examination in December 2008, after which an electronic questionnaire was administered. Study criteria were: population characteristics; demographics, and motivation for and drawbacks to medical specialty choice. RESULTS A total of 1780 students (1111 women, 62%) responded to the questionnaire (69% response rate). The mean age of respondents was 23.8 years (22-35 years). Of these, 1555 students (87%) stated their preferred medical specialty. Surgical and medical specialties were the two specialties selected most frequently by students (n = 729, 47%). General practice was chosen by 20%. Gender influenced the choice of specialty: 88% of future paediatricians, 82% of gynaecologists and 77% of general practitioners (GPs) were women (p0.05). Main motivating factors included interesting diseases, opportunities for private practice and patient contact. Main drawbacks limiting the choice of other specialties were poor quality of life, an exclusively hospital-based career and loss of patient contact. Gender was the criterion most associated with significant differences in factors of motivation for or discouragement from a career. Patient contact and opportunities for private practice were significantly highlighted by future GPs compared with students opting for the medical or surgical specialties (p0.0001). CONCLUSIONS Students' career choices regarding specialties or general practice result from the interplay among several factors. Career interest in general practice is particularly low. Initiatives to address the factors affecting student career choices regarding less favoured specialties and to deal with the growing feminisation of the profession, which will lead to irreversible changes in clinical practice, are required.

To investigate the baseline level of knowledge of evidence based medicine (EBM) concepts in a sample of French medical students in their sixth year of training.An "electronic-questionnaire" was proposed to 3125 sixth-year students from all 39 French medical schools in 2009.Overall, 1870 students (58.2% response rate) completed the questionnaire (women=1168; 63%). The concept of EBM was known by 1716 students (92%). Most students (n=1382; 74%) read at least one French medical article per year, but 1051 students (56%) never read international articles. Just over half of students (1030; 55%) knew of web-based medical information databases. Treatment guidelines were considered to be important by most students (97%). Only 24.3% and 29% of students said that they write or speak English. In multivariate analysis, studying in a Parisian University and/or knowledge of what a journal's "impact factor" is were both associated with a ranking in the top 20% of the National Ranking Exam practice session.Only the most successful students showed interest in obtaining more knowledge of EBM. The lack of education about EBM in this sample suggests a lack of efficacy in the current heterogeneous EBM teaching programs.

To prospectively compare the results of the pathologic examination including thin 3- to 4-mm thick serial slices of the surgical specimen in a well-defined anatomic part of the liver with those of 4 different liver imaging techniques. BACKGROUNDS SUMMARY DATA: Liver metastases (LM) of neuroendocrine origin are frequent and accuracy of pretherapeutic liver imaging in detecting small-sized LM is questioned, but no study has compared the different techniques used to image large liver specimens and meticulous pathologic examination.Eleven patients with a metastatic endocrine tumor were selected before undergoing a right hepatectomy or a left hepatectomy passing along the median hepatic vein. Before the hepatectomy, patients underwent somatostatin receptor scintigraphy, computed tomography, magnetic resonance imaging, and ultrasonography (US). An intraoperative assessment (palpation and US) was also performed. Liver specimens were systematically cut into thin serial slices, 3- to 4-mm thick. A final histologic count of the total number of LM was obtained and compared with findings from each imaging technique.Compared with the final histologic count of LM, fewer than 50% of the LM were detected preoperatively. The accuracy was 24% for somatostatin receptor scintigraphy, 38% for computed tomography and US, and 49% for magnetic resonance imaging (the only imaging technique that detected half the number of LM). The size of the smallest LM was not greater than 2 mm in 54% of the patients.Half the number of LM from neuroendocrine tumors are undetectable on preoperative imaging.

Background Redo surgery (RS) in patients with failed anastomosis is a rare procedure, and data about this surgery are lacking. The aim of this study was to examine the operative results and long-term outcomes of RS. Methods All patients who underwent RS between 1999 and 2008 were included. Data were analyzed from a prospective colorectal database. Failure of the procedure was defined as the inability to perform the RS or the inability to close the defunctioning stoma. Results Thirty-three patients (22 men) underwent the first surgery at a mean age of 53.4 years. Twenty-four had a colorectal anastomosis (CRA) and nine a coloanal anastomosis (CAA). The reasons for performing RS were stricture ( n = 17), prior Hartmann procedure for complication on initial anastomosis ( n = 6), chronic fistula ( n = 5) or miscellaneous ( n = 5). RS was impossible for 2 patients due to extensive adhesions. The mean operating time was 279 min (133–480) and the overall postoperative morbidity rate was 55%. The rate of anastomotic leakage and/or isolated pelvic abscess was 27%. After a mean delay of 3.9 months (0.3–16), 26 patients (79%) had a stoma closure. The mean number of stools per day was 3.2. The failure rates after new handsewn CAA and new stapled CRA were 33% (4/12) and 5% (1/19), respectively ( P = .0385). The type of the former anastomosis influenced the success rate of restoring the intestinal continuity: failure rate after prior CAA was 56% and 8% after prior CRA ( P = .0031). Conclusion Redo surgery for failure of previous CRA or CAA is feasible but requires a demanding surgical procedure with high short-term morbidity.

This article was written to define the situations in which early second-look surgery with a combined treatment should be indicated in patients at high risk of developing peritoneal carcinomatosis (PC). Through a review of the literature, this is a definition of the second-look concept and of the different groups of patients at risk, in different situations (after resection of the primary, after initial cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy, and after the discovery of isolated carcinoembryonic antigen elevation or isolated peritoneal uptake on positron emission tomography scan). Systematic second-look surgery for early treatment of asymptomatic PC is probably beneficial in patients presenting a high risk of developing PC after resection of their primary. The benefit seems considerably lower for the other groups of high-risk patients.

Complete cytoreductive surgery (CCRS) with intraperitoneal chemotherapy (IPC) is becoming the gold-standard treatment for resectable peritoneal carcinomatosis, when feasible. However, this approach has not yet been evaluated for isolated peritoneal re-recurrences after previous IPC. The aim of this study was to evaluate the postoperative course and long-term outcome after repeat (re-)CCRS + IPC. From 1996 to 2007, 25 re-CCRS + IPC were performed in 20 patients with isolated peritoneal re-recurrences, among 393 CCRS + IPC performed during the same period in the department. Selection was based on the supposedly limited extent of the peritoneal disease and an interval of more than 12 months between the first CCRS + IPC procedure and recurrence. After a re-CCRS, we used re-IPC modalities (method and/or drug) that were systematically different from those of the first IPC. The origins of the tumors were pseudomyxoma (n = 12), colorectal cancer (n = 4), mesothelioma (n = 3), and carcinoid tumor (n = 1). At laparotomy, mean peritoneal index was 7.6 ± 4.8. Among the 25 procedures, hyperthermic intraperitoneal chemotherapy was used in 15 cases and early postoperative intraperitoneal chemotherapy in 10 cases. The postoperative mortality rate was 4% (n = 1) and six grade 3–4 postoperative complications occurred. The overall 5- and 10-year actuarial survival rates were 72.5% and 58%, respectively. The 5-year disease-free survival rate was 19%. The long-term outcome was not different, whatever the type of primary tumor. Re-CCRS + IPC is feasible and yields prolonged survival in highly selected patients. Also, the switch to another type of IPC or regimen may have contributed to this prolonged survival.

Background Desmoid tumours (DTs) are the primary cause of death of patients with familial adenomatous polyposis (FAP) following restorative proctocolectomy. The aim of this study was to identify risk factors for DT in a French population. Methods Clinical data for 442 patients with FAP from 1983 to 2004 were reviewed retrospectively. Results A total of 124 DTs were documented in 50 patients (25 female). DT sites were mesenteric (73 tumours), abdominal wall (44) and extra-abdominal (seven). Female patients developed DT earlier than males. Although DTs appeared after colectomy in 34 patients, the type of surgery did not influence the risk of DT. An identified point mutation in the adenomatous polyposis coli (APC) gene after codon 1444 was a significant risk factor (hazard ratio 3·3 (95 per cent confidence interval 1·5 to 7·3)). Belonging to a family affected by DT did not increase the individual's risk in this population. Conclusion No risk factor for life-threatening mesenteric DT could meaningfully modify the management of patients with FAP.

The objective of this study was to evaluate the histological profile obtained from primary resection of hepatocellular carcinoma (HCC) as a selection tool for liver transplantation (LT). The natural history of HCC depends on its histological features. The clinical effectiveness of resection as a selection tool for salvage or de principe LT has been previously advocated. Between 1987 and 2006, 20 patients underwent a resection prior to LT. Long-term survival of these 20 patients was compared to that of 73 patients who underwent primary LT. Histological features of the resected specimen were compared to those of the recurrences. Feasibility, morbidity, and mortality of LT following primary resection were also analyzed. Mean follow-up was 3.8 +/- 4.4 and 2.7 +/- 4.5 years from resection and LT, respectively; 6 patients died. The mean 1-, 3-, 5-, and 10-year overall survival rates were 71%, 61%, 55%, and 45% and 74%, 66%, 66%, and 40% after primary transplantation and primary resection, respectively (not significant). At LT, 14 patients had a recurrence, but histological study of the recurrence was not possible in 2 (complete necrosis). For 9 patients (75%), histological features of both primary and recurrent tumors were exactly the same. Four patients had recurrence following LT; in each case, primary and recurrent nodules shared the same histological markers of poor prognosis. De principe transplantation was proposed to 6 patients because of poor prognosis histological features on the resected specimen. All these patients are alive without recurrence with a mean follow-up of 55 months. In conclusion, the natural history of HCC can be predicted on the basis of the histological profile of the resected specimen, which may be used as a selection tool for LT. De principe LT in patients within Milan criteria with poor prognosis histological features may be an optimal strategy.

Some patients have isolated lumboaortic and/or iliac lymph node recurrences (ILNR) of colorectal cancer. Current guidelines recommend the use of chemotherapy. The aim of our study was to assess the carcinological results of lymphadenectomy for ILNR and to identify prognostic factors that may be used to select patients for this aggressive surgical approach.Medical notes, pathological findings, and surgical procedure of patients who underwent lymphadenectomy for ILNR of colorectal cancer between 1998 and 2005 were reviewed.Ten patients (four women) underwent lymphadenectomy for ILNR. Lymphadenectomy was performed after a mean of 37 +/- 16.6 months after colon or rectal resection. Two patients developed a postoperative complication. Mean number of lymph nodes removed was 5.7 +/- 3.3. After a median follow-up of 30.7 months, four patients were alive, including two patients without recurrence at 95 and 96 months after colectomy and two with local and distant recurrences at 114 and 70 months. Among the three patients with microsatellite-unstable (MSI) tumors, two were free of disease at 61 and 81 months, respectively, and one died of recurrent disease 20 months after lymphadenectomy.Lymphadenectomy for ILNR of colorectal cancer is a feasible therapeutic option for selected patients. These preliminary results suggest that resection should be proposed for MSI patients because cure is possible, but to be confirmed, the findings require larger studies.

Endobiliary metastasis of colorectal cancers are rare. We report a 36 years-old patient, operated on 5 years ago for a left colon cancer with a left colectomy. He consulted for pain in the upper right quadrant without fever nor jaundice. Ultra-sound, CTscan, RMI and PET led to the diagnosis of endobiliary metastasis and the patient underwent a right hepatectomy. A review of the literature of the endobiliary metastasis follows this case-report. These tumours can mimic intrahepatic cholangiocarcinoma in clinical presentation, imaging or even histological examinations. The main goal of the imaging explorations is to establish the resecability of such tumours. Patients with endobiliary metastasis seem to have better survival than patients with intrahepatic metastasis.

Introduction Le taux de transfusions (TR) des patients operes d’un cancer colorectal (CCR) varie selon la localisation du cancer. Il est estime entre 13 et 34 %. La majorite des etudes sont anciennes et ne prennent pas en compte la periode peri-operatoire. Le but de cette etude est d’evaluer le risque de transfusion peri-operatoire et ses facteurs associes. Materiel et methodes Nous avons realise l’analyse retrospective de tous les patients operes d’un CCR en 2013. L’exhaustivite des TR a ete recueillie en collaboration avec l’Etablissement francais du sang (EFS) en incluant celles faites 1 semaine avant et 2 mois apres la chirurgie. Les resultats sont exprimes en mediane (extremes). La correlation entre le taux de TR et les variables d’interet etait etudiee en analyse univariee. Une analyse multivariee a ete realisee par un modele de regression logistique. Resultats Deux cent seize dossiers de patients ont ete analyses : les patients ASA 1-2 representaient 74,5 % de la population. L’âge moyen etait de 67 ans. Le taux d’hemoglobine (Hb) pre operatoire etait de 12,6 g/dL (5,1–18,3) et 51 % des patients etaient anemiques (Hb Discussion Malgre les progres chirurgicaux et le respect des recommandations sur l’abaissement des seuils transfusionnels, le taux de TR peri-operatoire pour CCR reste eleve a 25 %. Le mecanisme de l’anemie peri-operatoire chez les patients atteints de CCR est probablement d’origine multifactorielle. La carence martiale pourrait occuper une place non negligeable dans ce contexte inflammatoire et justifier la supplementation en fer preoperatoire chez les patients a risque afin de reduire le taux de TR peri-operatoire.

109 Background: Salvage esophagectomy (SE) has traditionally conferred a high rate of mortality and morbidity in small, monocenter, and old publications. The aim of this large multicenter study was to assess the impact of SE following definitive chemoradiotherapy (SALV) on clinical outcomes. Methods: Data from consecutive adult patients undergoing resection for esophageal cancer in 30 European centers from 2000–2010 were collected. Among this population, the first step was to compare SALV (n=308) and neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS group, n=540) groups. The second step was to focus on the SALV group and to compare patients that benefited from SE for persistent (PERS group, n=234) versus recurrent (REC group, n=74) disease. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. Results: Comparison of SALV and NCRS groups: In-hospital mortality was similar in both groups (8.4% vs. 9.3%). The only significant differences in complications were seen for anastomotic leak (17.2% vs. 10.7%; P=0.007) and surgical site infection, which were both increased in the SALV group. At 3 years, the groups had similar overall (43.3% vs. 40.1%; P=0.542) and disease-free (39.2% vs. 32.8%; P=0.232) survivals, along-with similar overall (46.8% vs. 47.9%; P=0.829), locoregional (18.8% vs. 15.9%; P=0.544), distant (24.3% vs. 28.1%; P=0.949) and mixed (13.0% vs. 13.5%; P=0.888) tumor recurrence. Comparison of PERS and REC groups: There were no significant differences between the groups in the incidence of in-hospital mortality or major complications, apart from reoperation, which was increased in the PERS group (17.9% vs. 8.1%; P=0.042). Overall (23.4% vs 39.2%, p=0.054) and disease free survivals (21.1% vs37.8%, p=0.070) were lower in the PERS group. Conclusions: The results of this large multi-center study suggest that SE can offer acceptable short and long-term outcomes in experienced centers. Randomized controlled trials are required to validate the SE strategy as a viable option in complete esophageal cancer responders.

The aim of this study was to determine the frequency of MYH mutations in one large population of polyposis patients without APC mutation identified.Familial adenomatous polyposis (FAP) is the most known inherited colorectal cancer syndrome. In 70% to 80% of polyposis patients, an APC mutation is found. Patients with polyposis but no APC mutation are considered as APC-muted patients and followed as their relatives accordingly. Biallelic mutation of MYH has been found to responsible of colorectal polyposis and cancer in an autosomal recessive pattern of inheritance.Between 1978 and 2004, 433 patients were operated for polyposis. A mutation on APC was identified in 322 patients. Among the remaining patients, 44 were identified as possible MYH-muted patients and contacted, and 31 signed informed consent. Clinical data were obtained from the patients' medical notes. Germline mutation of MYH was searched by sequencing the whole gene. To confirm the deleterious effects of biallelic MYH mutation, transversions on K-ras and APC were searched.There were 9 women and 22 men with a mean age of 53.9 years (range, 22-68 years) at the time of diagnosis. The mean number of polyps was 62.8 (range, 11-266). Eighteen patients (58.1%) had a colorectal cancer. We found biallelic MYH mutation in 6 patients (19.3%; 95% confidence interval, 5.2%-33.5%) and 5 (83.3%) had transversions in K-ras and/or APC.MYH is a new gene responsible for about 1.4% of all adenomatous polyposis and about 20% of adenomatous polyposis without APC mutation identified. Search for MYH biallelic mutation in these patients should be systematic as it changes their and relatives'surveillance.

Reoperative surgery for thyroid disease is rare. However, it is sometimes indicated for nodular recurrence after partial surgery for initially benign thyroid disease or for a completion total thyroidectomy when a final diagnosis of well-differentiated thyroid cancer (WDTC) is confirmed on a permanent section of a partially removed thyroid gland. This surgery can expose the patient to postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. The aims of our study were to describe the population subjected to reoperative thyroid surgery and to evaluate postoperative morbidity to find the risk factor.The present study is a retrospective analysis of our experience with completion thyroidectomy: 685 consecutive patients underwent this procedure in a 14-year period, for a recurrent uninodular (85 patients) or multinodular (333 patients) goiter, recurrent thyrotoxicosis (42 patients), or a completion thyroidectomy for WDTC after partial resection of the thyroid gland (225 patients). The operative technique was standardized with identification of the RLN and parathyroid glands before removal of the thyroid gland. L-thyroxin treatment was started the day after surgery. Postoperative rates of suffocating hematoma, wound infection, RLN palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism were studied and compared to the same parameters in patients who underwent primary bilateral thyroid gland resection during the same period.The transient morbidity rate was 8%, with 5% hypoparathyroidism, 1.2% RLN palsy, 0.9% suffocating hematoma, and 0.2% wound infection. These results were higher than those from cases of primary thyroid resection for bilateral disease. Within the secondary surgery group, postoperative complications depended on the mean weight of the resected thyroid gland, hyperthyroidism, and the bilaterality of thyroid exploration during the previous surgery. The permanent morbidity rate was 3.8%, including 1.5% RLN palsy and 2.5% hypoparathyroidism. Permanent complication rates were higher than those for primary thyroid resection. Incidental carcinoma was found in 92 patients (13%): 10% (42 of 418) in patients with recurrent euthyroid nodular disease, 7% (3 of 42) in patients with recurrent hyperthyroidism, and 21% (47 of 225) in patients who underwent a completion thyroidectomy for cancer.Because reoperative thyroid surgery can lead to potential complications, especially permanent RLN palsy or hypoparathyroidism, it should be reserved for patients who need it. The importance of respecting specific technical rules should be emphasized.