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Resumen En la actualidad, la enfermedad de Hirschsprung se descubre excepcionalmente en la edad adulta, ante un estrenimiento persistente que se remonta siempre a la primera infancia. Se recomienda la intervencion para evitar al paciente las complicaciones digestivas graves. La preparacion debe ser draconiana en esta enfermedad, para poder tratar la zona acalasica y el colon irreversiblemente distendido, cuya longitud se estima en el estudio morfologico. En lugar de las operaciones clasicas como las descritas por Duhamel, Swenson o Soave, actualmente es posible proponer una reseccion sigmoidorrectal por via laparoscopica, seguida de un descenso transanal del colon sano y posterior anastomosis coloanal diferida unos dias; la exteriorizacion de la pieza operatoria se realiza por via anal y el plazo de confeccion de la anastomosis permite prescindir de una ostomia. De esta forma, las cicatrices son muy discretas, lo cual es de un gran interes en estos pacientes, a menudo jovenes.

Management of rectovaginal fistula (RVF) in Crohn’s disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. Thirty-two patients (median age 34 [range 21–55] years), with a median follow-up of 11.3 years (0–23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/mThis study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients.Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively).Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD.A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure.Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007).The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

International audience; Objective - The objective was to assess the efficacy and the safety of sacral nerve modulation (SNM) in men with fecal incontinence (FI) compared with those of SNM in women. Method - Prospectively collected data from patients from seven tertiary colorectal units who underwent an implant procedure between January 2010 and December 2015 were reviewed retrospectively. Outcomes and surgical revision and definitive explantation rates were compared between men and women. Results - A total of 469 patients (60 men [12.8%]; mean age = 61.4 ± 12.0 years) were included in the study, 352 (78.1%) (31 men [8.8%]) of whom received a permanent implant. The ratio of implanted/tested men was significantly lower than the ratio of implanted/tested women (p = 0.0004). After a mean follow-up of 3.4 ± 1.9 years, the cumulative successful treatment rates tended to be less favorable in men than in women (p = 0.0514): 88.6% (75.6-95.1), 75.9% (60.9-86.4), 63.9% (48.0-77.3), and 43.9% (26.7-62.7) at one, two, three, and five years, respectively, in men; 92.0% (89.1-94.2), 84.2% (80.3-87.4), 76.8% (72.3-80.7), and 63.6% (57.5-69.3) at one, two, three, and five years, respectively, in women. The revision rate for infection and the definitive explantation rate for infection were higher in men than in women (p = 0.0001 and p = 0.0024, respectively). Conclusion - Both short- and long-term success rates of SNM for FI were lower in men than in women. The revision and definitive explantation for long-term infection rates were significantly higher in men.

International audience

There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature. Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery. Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1 month postoperatively, then every 3 months during the first 2 years, and every 6 months thereafter, for a total of 5 years. A total of 28 consecutive patients (16 males) with a median age of 71.8 years (range 42.5–88.8 years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5% with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9 months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively. Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

Background Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. Methods All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. Results A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). Conclusions The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

International audience

Faecal incontinence and urinary incontinence are common and often associated. Sacral neurostimulation is a validated technique for treating each of these two types of incontinence, taken separately. The purpose of this study was to review the literature on the results of this treatment for double incontinence. A literature search was conducted using MEDLINE, PubMed, EMBASE and the Cochrane Library using the keywords "faecal incontinence", "anal incontinence", "urinary incontinence", "urgency", "urinary disorder", "neurostimulation", "sacral nerve stimulation" and "electric nerve stimulation". We limited the search to English-language articles on faecal and urinary incontinence in adults published from 1995 to the present. We identified six articles, comprising 113 patients who were followed for 3-62 months. Improved faecal incontinence was observed in 44-100 % of cases, while improved urinary incontinence was observed in 20-100 % of cases. Patient satisfaction with the correction of double incontinence, both anal and urinary, was highly variable, ranging from 20 to 100 %. As anal incontinence and urinary incontinence are often associated and are sometimes responsive to sacral neuromodulation, it seems attractive to provide such treatment for double incontinence, to improve both digestive and urinary symptoms.

Resume Nous rapportons le cas d’une luxation testiculaire intrapelvienne bilaterale associee a une fracture de l’anneau pelvien type B1-1 selon la classification de Tile modifiee AO, chez un patient de 62 ans. Le mecanisme lesionnel etait une impaction sur le reservoir d’une moto. Le patient a beneficie d’une fixation par plaque symphysaire selon une voie anterieure de Pfannenstiel, associee a une orchidopexie bilaterale par voie scrotale. L’anneau pelvien posterieur a ete stabilise par un vissage ilio-sacre, l’articulation sacro-iliaque gauche etant ouverte. L’evolution a ete favorable, sans troubles des fonctions gonadiques. Une palpation testiculaire systematique et une inspection des organes genitaux externes sur les cliches tomodensitometriques permettent de reconnaitre ces lesions urogenitales rares et de les traiter efficacement.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 45 - N° 8 - p. 992-993

Summary Introduction Pancreatic trauma (PT) is associated with high morbidity and mortality; the therapeutic options remain debated. Material and methods Retrospective study of PT treated in the University Hospital of Grenoble over a 22-year span. The decision for initial laparotomy depended on hemodynamic status as well as on associated lesions. Main pancreatic duct lesions were always searched for. PT lesions were graded according to the AAST classification. Results Of a total of 46 PT, 34 were grades II or I. Hemodynamic instability led to immediate laparotomy in 18 patients, for whom treatment was always drainage of the pancreatic bed; morbidity was 30%. Eight patients had grade III injuries, six of whom underwent immediate operation: three underwent splenopancreatectomy without any major complications while the other three who had simple drainage required re-operation for peritonitis, with one death related to pancreatic complications. Four patients had grades IV or V PT: two pancreatoduodenectomies were performed, with no major complication, while one patient underwent duodenal reconstruction with pancreatic drainage, complicated by pancreatic and duodenal fistula requiring a hospital stay of two months. The post-trauma course was complicated for all patients with main pancreatic duct involvement. Our outcomes were similar to those found in the literature. Conclusion In patients with distal PT and main pancreatic duct involvement, simple drainage is associated with high morbidity and mortality. For proximal PT, the therapeutic options of drainage versus pancreatoduodenectomy must be weighed; pancreatoduodenectomy may be unavoidable when the duodenum is injured as well. Two-stage (resection first, reconstruction later) could be an effective alternative in the emergency setting when there are other associated traumatic lesions.

International audience; BACKGROUND:Ventral rectopexy to the promontory has become one of the most strongly advocated surgical treatments for patients with full-thickness rectal prolapse and deep enterocele. Despite its challenges, laparoscopic ventral rectopexy with or without robotic assistance for selected patients can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. The aim of this prospective case-controlled study was to assess the feasibility, safety, and cost of day case robotic ventral rectopexy compared with routine day case laparoscopic ventral rectopexy.METHODS:Between February 28, 2014 and March 3, 2015, 20 consecutive patients underwent day case laparoscopic ventral rectopexy for total rectal prolapse or deep enterocele at Michallon University Hospital, Grenoble. Patients were selected for day case surgery on the basis of motivation, favorable social circumstances, and general fitness. One out of every two patients underwent the robotic procedure (n = 10). Demographics, technical results, and costs were compared between both groups.RESULTS:Patients from both groups were comparable in terms of demographics and technical results. Patients operated on with the robot had significantly less pain (p = 0.045). Robotic rectopexy was associated with longer median operative time (94 vs 52.5 min, p < 0.001) and higher costs (9088 vs 3729 euros per procedure, p < 0.001) than laparoscopic rectopexy.CONCLUSIONS:Day case robotic ventral rectopexy is feasible and safe, but results in longer operative time and higher costs than classical laparoscopic ventral rectopexy for full-thickness rectal prolapse and enterocele.

International audience

La enfermedad de Crohn se complica frecuentemente con lesiones anorrectales y perineales, cuya incidencia varia en la literatura. En todos los casos constituyen una complicacion seria, ya que tienen una repercusion importante sobre la calidad de vida. Ademas de las lesiones inflamatorias primarias como las ulceraciones, fisuras y seudoexcrecencias, de tratamiento esencialmente medico, hay que saber identificar las complicaciones secundarias, de tratamiento mixto medico y quirurgico. El cirujano puede intervenir de urgencia para drenar un absceso y, habitualmente, colocar un drenaje en seton, ya que una fistulotomia conllevaria un riesgo demasiado elevado de incontinencia por seccion del esfinter. El cirujano tambien puede intervenir en las complicaciones cronicas. Una fistula anorrectal en la enfermedad de Crohn puede tratarse con un drenaje en seton prolongado si el trayecto es alto o mediante fistulotomia secundaria si el trayecto es transesfinteriano bajo o subcutaneo. Las recidivas suelen requerir una opinion especializada, para indicar la realizacion de un descenso rectal, la inyeccion de pegamento biologico, la insercion de un plug o incluso, mas raramente, un colgajo de Martius o una graciloplastia. Las estenosis anales o rectales requieren dilataciones repetidas y, en caso de recidiva, el especialista valorara la oportunidad de una plastia. En algunos casos de enfermedad de Crohn avanzada, es posible que se proponga al paciente una ostomia y, si las lesiones son irreversibles, una amputacion abdominoperineal. El caracter cronico e invalidante de la enfermedad, asi como la variedad de tratamientos quirurgicos propuestos para una misma lesion, hacen que el paciente tenga que participar en la decision del tratamiento medicoquirurgico. La asociacion de una ostomia al tratamiento inmunosupresor y con anticuerpo antifactor de necrosis tumoral alfa puede permitir obtener mejor calidad de vida que la que se tendria tras repetidas intervenciones bajo anestesia general.

La malattia di Crohn si complica frequentemente con lesioni anorettali e perineali, l’incidenza delle quali viene diversamente valutata in letteratura. La loro presenza costituisce sempre una complicazione seria, perche le ripercussioni sulla qualita della vita sono importanti. Accanto a lesioni infiammatorie diffuse e a lesioni primarie quali ulcere, ragadi e pseudomarische con indicazione al trattamento essenzialmente medico, si dovranno identificare le complicanze secondarie, con indicazione al trattamento misto medicochirurgico. Il chirurgo interviene in urgenza per evacuare un ascesso e, di solito, per posizionare un setone, visto che una fistolotomia comporterebbe un rischio troppo elevato di incontinenza da sezione dello sfintere. Il chirurgo puo anche intervenire in caso di complicanze croniche. Una fistola anorettale su malattia di Crohn puo essere trattata con un drenaggio a setone di lunga durata quando il tramite e altoposto o con fistolotomia secondaria nel caso in cui il tramite sia transsfinterico o bassoposto, sottocutaneo. Le recidive richiedono spesso una consulenza specialistica per valutare l’indicazione a un lembo da abbassamento rettale, all’iniezione di colla biologica, all’inserimento di un plug o anche, seppur piu raramente, a un lembo di Martius o a una graciloplastica. La stenosi rettale o anale richiede dilatazioni ripetute e poi, in caso di recidiva, una plastica la cui indicazione e, anche qui, compito dello specialista. In certi casi di malattia di Crohn avanzata si deve saper proporre al paziente una stomia temporanea, ma anche, nel caso in cui le lesioni vengano giudicate irreversibili, un’amputazione addominoperineale. Il carattere cronico e invalidante della lesione, al pari della molteplicita dei trattamenti chirurgici esistenti per la medesima lesione, spingono a coinvolgere il paziente stesso nella presa in carico, che sara comunque di tipo medicochirurgico. Una stomia associata al proseguimento del trattamento con immunosoppressori e anti-tumor necrosis factor a, permette talvolta di ottenere una miglior qualita della vita rispetto a quella ottenuta con ripetuti interventi in anestesia generale.

International audience

Aim Gastrointestinal manifestations occur in up to 25% of patients with neurofibromatosis type 1. This review reports all published cases of acute intestinal obstruction due to neurofibromatosis type 1 and identifies mechanisms of obstruction, the nature of the tumour and the outcome. Method A systematic review of the literature on acute intestinal obstruction due to neurofibromatosis type 1 was performed by searching the major electronic databases. All relevant references were reviewed for possible inclusion. All the references of the relevant articles were screened for any further articles that were missed in the initial search. Results We identified 25 articles from 1972 to 2013 reporting 25 patients with von Recklinghausen's disease who underwent laparotomy for acute intestinal obstruction. Three further patients were operated on in our institution. The mean age of the patients was 44.2 years and the male/female ratio 15/13. The mechanisms of obstruction were intrinsic obstruction (16), extrinsic obstruction (8) and intussusception (4). Histology was reported to show neurofibroma (19), gastrointestinal stromal tumour (5) and adenocarcinoma (4). Among patients whose outcome was mentioned (17), 10 were asymptomatic after a mean follow-up of 1.5 years. Conclusion Acute bowel obstruction is a rare manifestation of neurofibromatosis type 1. Surgery is often necessary to treat the complication and to determine the exact nature of the tumour and the prognosis.

SummaryWe report a case of a bilateral testicular dislocation with B1-1 pelvic-ring fracture according to the modified Tile AO classification, in a patient of 62years. The mechanism of injury was impaction on the tank of a motorcycle. Symphyseal plate fixation using a Pfannenstiel approach was associated to bilateral orchidopexy through scrotal approach. The posterior pelvic ring was stabilized by iliosacral screwing because the left sacroiliac joint was open. The outcome was favorable without disorders of gonadal function. Systematic testicular palpation and careful CT analysis of the genital organs enabled identification and effective management of these rare urinary tract lesions.

Metastatic melanoma has a very poor prognosis, with a median survival for patients with stage IV disease ranging from 6 to 18 months [1]. Gastrointestinal tract involvement in melanoma is rare and often represents advanced, disseminated disease [2]. However, more than 50 % of patients with localized metastatic melanoma are amenable to surgery and have a better survival rate than patients who receive non-surgical therapy after metastasectomy. A 78-year-old man presented with a symptomatic right necrotic colonic mass and went on to have a laparoscopic right colectomy for a presumed adenocarcinoma, 41 months after a wide local excision of a malignant melanoma on his forehead. Histology of the excised specimen demonstrated a metastatic malignant melanoma to the colon with clear resection margins. Seventeen lymph nodes were identified, and all were negative for metastasis. The patient’s postoperative course was uneventful, and he was discharged on day 4. Subsequent careful skin examination, computed tomography of the thorax, abdomen and pelvis, cerebral computed tomography, and positron emission tomography demonstrated no evidence of persistent neoplastic disease. The most frequently involved portion of the gastrointestinal tract is the small bowel (in about 91 % of cases) [3]. The difficulty of achieving curative resection in cases of small bowel metastasis probably explains the low survival rates that are observed in the literature. However, prolonged survival has been reported in case of isolated metastasis to the colon. In a case series from the Mayo Clinic Scottsdale and a review of the literature published in 2003, Tessier et al. [4] found that the average time interval between diagnosis of the primary and metastatic disease to the colon was 7.47 years. The most favorable prognostic factors are a complete resection of the colonic metastasis, the absence of colonic perforation or obstruction, the absence of residual intra-abdominal disease, the absence of extra-abdominal metastases, and a disease-free interval longer than 24 months [5]. A colonic tumor in a patient with a history of resection of a malignant melanoma should be considered to be not just a colonic carcinoma, but also a metastasis of the melanoma, even several years later. We would like to emphasize the fact that surgical resection of the metastasis, if it is a single lesion, is the best strategy to improve survival.

Introduction L’exerese totale du mesorectum suivie d’anastomose colo-anale est la reference pour le traitement des cancers du bas et moyen rectum. Des sections vasculaires sont necessaires pour que l’extremite colique atteigne l’anus sans traction. Pour cela, la distance entre la symphyse pubienne et la partie distale du colon abaisse doit etre d’au moins 6 cm. L’objectif de ce travail etait de comparer le gain de longueur obtenu par deux techniques differentes de section vasculaire. Materiel et methodes Dix sujets formoles ont eu une section colique au niveau de la premiere branche arterielle sigmoidien. L’accolement de Toldt gauche et l’angle colique gauche etaient ensuite liberes. Les gains de longueur obtenus entre l’extremite distale du colon et le rebord inferieur de la symphyse pubienne etaient mesures soit apres section de l’AMI a l’origine (section haute), soit apres section de l’AMI apres la naissance de l’artere colique superieur gauche (section basse), avec ou sans section associee de la veine mesenterique inferieure (VMI) au bord inferieur du pancreas. Resultats Les gains moyens de longueur entre la section haute et basse de l’AMI etaient de −1,24 ± 5,4 cm contre −1,80 ± 5,2 cm (p = 0,026), et apres section associee de la VMI de 11,41 ± 9,39 contre 1,78 ± 4,92 (p = 0,00058). L’anastomose etait theoriquement realisable sans tension dans 100 % des cas si section haute, dans 10 % des cas si section basse. Conclusion La ligature de l’AMI a l’origine associee a la ligature de la VMI est la seule technique permettant de realiser une anastomose colo-anale sans tension apres exerese totale du mesorectum pour cancer.

L’hyperplasie congenitale des surrenales (HCS) par deficit en 21-hydroxylase a pour consequence des taux plasmatiques d’aldosterone et de cortisol tres bas et une hypersecretion d’androgenes. Les patients doivent suivre un traitement medical substitutif et freinateur afin de prevenir le risque d’insuffisance surrenal aigue et de freiner la production d’androgenes. Cependant, ces traitements sont difficiles a optimiser et une augmentation de la mortalite chez ces patients a ete demontree. Face a ce constat, nous avons developpe un modele murin de transplantation de cellules cortico-surrenaliennes en sous-cutanee dans des chambres pre-implantees. Nous avons prepare des cellules cortico-surrenaliennes humaines issues de deux patients âges de 2 et 43 ans avec une HCS qui avaient du beneficier d’une surrenalectomie bilaterale. Suite a leur mise en culture, ces cellules produisent de la 17-OH progesterone mais pas de cortisol meme sous stimulus ACTH. Le transfert du gene CYP21A2 codant pour la 21-hydroxylase a l’aide de particules lentivirales restaure la capacite de ces cellules a secreter du cortisol. Les cellules transfectees produisent aussi de l’aldosterone ce qui represente un interet non negligeable dans la perspective d’une application humaine. La transplantation de ces cellules dans les chambres pre-implantees chez les souris Scid surrenalectomisees a permis la survie de ces animaux qui, sans transplantation, decedent. La fonction des greffons a ete validee par la presence de cortisol et d’aldosterone dans le plasma. Nos resultats montrent dans un modele pre-clinique qu’une alternative a la supplementation hormonale des patients atteints d’une HCS semble possible.