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The evaluation of general surgery residents' operating room (OR)-training and technical skills progression may be difficult in the absence of a standardized evaluation tool. The aim of this study was to evaluate the impact of the implementation of an electronic "surgical logbook" for general surgery residents.A prospective single center study was conducted between May 2015 and October 2020. An electronic logbook was filled by all residents immediately after each surgical procedure and data were prospectively collected and analyzed.Fifty-five students (34 men/21 women) reported their participation to 6917 surgical procedures, which corresponded to 55.5% of all procedures performed in our department. Residents performed the entire procedure as the operating surgeon in 28.5% of cases (n=1963), parts of the procedure as operating surgeon in 32.5% of cases (n=2230) and as operating-assistant in 38.5% (n=2672). Residents were more likely an operating surgeon for the entire procedure when they were assisted by a fellow or a practicing physician than an associate professor or a clinical professor (P0.001). There was no significant difference in the major morbidity rate between different resident's contribution to the procedure (P=0.14).We present here a simple, useful and cost efficient tool which offers easy data collection and reporting that could help improve OR-training, OR-supervision and certification at a local or national level.

To analyze the postoperative morbidity and 1-year recurrence rate of incisional hernia repair using a biosynthetic long-term absorbable mesh in patients at higher risk of surgical infection in a contaminated surgical field.All patients undergoing incisional hernia repair in a contaminated surgical field with the use of a biosynthetic long-term absorbable mesh (Phasix®) between May 2016 and September 2018 at six participating university centers were included in this retrospective cohort and were followed-up until September 2019. Regarding the risk of surgical infection, patients were classified according to the modified Ventral Hernia Working Group classification. Preoperative, operative and postoperative data were collected. All patients' surgical site infections (SSIs) and occurrences (SSOs) and recurrence rates were the endpoints of the study.Two hundred and fifteen patients were included: 170 with mVHWG grade 3 (79%) and 45 with mVHWG grade 2 (21%). The SSI and SSO rates at 12 months were 22.3% and 39.5%, respectively. According to the Dindo-Clavien classification, 43 patients (20.0%) had at least one minor complication, and 57 patients (26.5%) had at least one major complication. Among the 121 patients (56.3%) having at least 1 year of follow-up, the clinical recurrence rate was 12.4%. Multivariate analysis showed that a concomitant gastrointestinal procedure was an independent risk factor for surgical infection (OR = 2.61), and an emergency setting was an independent risk factor for major complications (OR = 11.9).The use of a biosynthetic absorbable mesh (Phasix®) is safe in a contaminated surgical field, with satisfying immediate postoperative and 1-year results.The study is registered on Clinical Trial ID: NCT04132986.

International audience; Gastric adenocarcinoma (GA) is the 5th most common cancer in the world; in France, however, its incidence has been steadily decreasing. Twenty-five experts brought together under the aegis of the French Association of Surgery collaborated in the drafting of a series of recommendations for surgical management of GA. As concerns preoperative evaluation and work-up, echo-endoscopy aimed at clarifying lymph node status should be performed in all candidates for surgical resection and exploratory laparoscopy in cases of GA cT3/T4 and/or N+ for peritoneal carcinomatosis. On the other hand, PET-scan should not be performed systematically, but only when the other modalities for diagnosis prove insufficient. Laparotomy remains the route of choice to achieve total or partial gastrectomy with D2 lymph node lymphadenectomy for advanced lesions (> T2N0). To limit the risk of dumping syndrome and esophageal reflux and as a way of reestablishing continuity, construction of a jejunal pouch on Roux-en-Y following total gastrectomy is recommended. In cases of peritoneal carcinosis in GA with a low peritoneal cancer index (PCI) (

BackgroundThe prognostic value of the primary neoplasm responsible for pseudomyxoma peritonei (PMP) remains poorly studied. The aim of this study was to determine the prognosis for patients with extra-appendicular PMP (EA-PMP) treated optimally with complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsAll patients treated for PMP with CCRS and HIPEC between 1994 and 2016 were selected retrospectively from a French multicentre database. Patients with EA-PMP had pathologically confirmed non-neoplastic appendices and were matched in a 1 : 4 ratio with patients treated for appendicular PMP (A-PMP), based on a propensity score.ResultsSome 726 patients were identified, of which 61 (EA-PMP group) were matched with 244 patients (A-PMP group). The origins of primary tumours in the EA-PMP group included the ovary (45 patients), colon (4), urachus (4), small bowel (1), pancreas (1) and unknown (6). The median peritoneal carcinomatosis index was comparable in EA-PMP and A-PMP groups (15·5 versus 18 respectively; P = 0·315). In-hospital mortality (3 versus 2·9 per cent; P = 1·000) and major morbidity 26 versus 25·0 per cent; P = 0·869) were also similar between the two groups. Median follow-up was 66·9 months. The 5-year overall survival rate was 87·8 (95 per cent c.i. 83·2 to 92·5) per cent in the A-PMP group and 87 (77 to 96) per cent in the EA-PMP group. The 5-year disease-free survival rate was 66·0 (58·7 to 73·4) per cent and 70 (53 to 83) per cent respectively.ConclusionOverall and disease-free survival following treatment with CCRS and HIPEC is similar in patients with pseudomyxoma peritonei of appendicular or extra-appendicular origin.

Purpose: Diffuse malignant peritoneal mesothelioma (DMPM) is a severe disease with mainly locoregional evolution. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the reported treatment with the longest survival. The aim of this study was to evaluate the impact of perioperative systemic chemotherapy strategies on survival and postoperative outcomes in patients with DMPM treated with curative intent with CRS-HIPEC, using a multi-institutional database: the French RENAPE network. Patients and methods: From 1991 to 2014, 126 DMPM patients underwent CRS-HIPEC at 20 tertiary centres. The population was divided into four groups according to perioperative treatment: only neoadjuvant chemotherapy (NA), only adjuvant chemotherapy (ADJ), perioperative chemotherapy (PO) and no chemotherapy before or after CRS-HIPEC (NoC). Results: All groups (NA: n Z 42; ADJ: n Z 16; PO: n Z 16; NoC: n Z 48) were comparable regarding clinicopathological data and main DMPM prognostic factors. After a median follow-up of 61 months, the 5-year overall survival (OS) was 40%, 67%, 62% and 56% in NA, ADJ, PO and NoC groups, respectively (P Z 0.049). Major complications occurred for 41%, 45%, 35% and 41% of patients from NA, ADJ, PO and NoC groups, respectively (P Z 0.299). In multivariate analysis, NA was independently associated with worse OS (hazard ratio, 2.30; 95% confidence interval, 1.07e4.94; P Z 0.033). Conclusion: This retrospective study suggests that adjuvant chemotherapy may delay recurrence and improve survival and that NA may impact negatively the survival for patients with DMPM who underwent CRS-HIPEC with curative intent. Upfront CRS and HIPEC should be considered when achievable, waiting for stronger level of scientific evidence.

Background Peritoneal metastasis from biliary carcinoma (PMC) is associated with poor prognosis when treated with chemotherapy. Objective To evaluate the impact on survival of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), and compare with conventional palliative chemotherapy for patients with PMC. Material and methods A prospective multicenter international database was retrospectively searched to identify all patients with PMC treated with a potentially curative CRS/HIPEC (CRS/HIPEC group). The overall survival (OS) was compared to patients with PMC treated with palliative chemotherapy (systemic chemotherapy group). Survival was analyzed using Kaplan-Meier method and compared with Log-Rank test. Results Between 1995 and 2015, 34 patients were included in the surgical group, and compared to 21 in the systemic chemotherapy group. In the surgical group, median peritoneal cancer index was 9 (range 3–26), macroscopically complete resection was obtained for 25 patients (73%). There was more gallbladder localization in the surgical group compared to the chemotherapy group (35% vs. 18%, p = 0.001). Median OS was 21.4 and 9.3 months for surgical and chemotherapy group, respectively (p=0.007). Three-year overall survival was 30% and 10% for surgical and chemotherapy group, respectively. Conclusion Treatment with CRS and HIPEC for biliary carcinoma with peritoneal metastasis is feasible and may provide survival benefit when compared to palliative chemotherapy.

International audience; ObjectiveAbdominal tuberculosis is a rare disease. The clinical and radiological manifestations are non-specific and the diagnosis is difficult. Our objective was to describe the characteristics and treatment of patients presenting with abdominal tuberculosis in a low-incidence country.Patients and methodsWe reviewed the clinical, diagnostic, treatment, and outcome features of patients presenting with abdominal tuberculosis diagnosed by bacteriological and/or histological results and managed in five French university hospitals from January 2000 to December 2009.ResultsWe included 21 patients. The mean diagnostic delay was 13 months. Twelve patients (57%) came from a low-incidence area and only two had a known immunosuppressed condition. Eighteen patients (86%) presented with abdominal symptoms. The main organs involved were the peritoneum (n = 14, 66%), the mesenteric lymph nodes (n = 13, 62%), and the bowel (n = 7, 33%). Sixteen patients (76%) underwent surgery, including two in an emergency setting. Seventeen patients (81%) received six months or more of anti-tuberculosis treatment. Finally, 16 patients (76%) had a positive outcome.ConclusionNew diagnostic procedures, and especially molecular biology, may help diagnose unusual clinical presentations of tuberculosis. Invasive procedures are frequently necessary to obtain samples but also for the treatment of digestive involvement.; ObjectifsLa tuberculose abdominale est rare, le tableau clinico-radiologique aspécifique et le diagnostic difficile. Notre objectif était de décrire les caractéristiques et la prise en charge thérapeutique de patients présentant une tuberculose abdominale dans un pays où la prévalence de cette infection est faible.Patients et méthodesNous avons recueilli les données cliniques, diagnostiques, thérapeutiques et le suivi des patients atteints de tuberculose abdominale, diagnostiquée sur des arguments bactériologiques et/ou anatomopathologiques, et pris en charge dans cinq hôpitaux universitaires français de janvier 2000 à décembre 2009.RésultatsVingt et un patients ont été inclus. Le délai diagnostique moyen était de 13 mois. Douze patients (57 %) étaient originaires d’une zone de faible prévalence de la tuberculose et seulement deux patients étaient immunodéprimés. Dix-huit patients (86 %) présentaient des symptômes abdominaux. Les principaux organes atteints étaient le péritoine (n = 14, 66 %), les ganglions mésentériques (n = 13, 62 %) et le tube digestif (n = 7, 33 %). Une intervention chirurgicale a été nécessaire chez 16 patients (76 %), en urgence pour deux d’entre eux. Dix-sept patients (81 %) ont reçu au moins six mois de quadri-thérapie antituberculeuse. Au final, 16 patients (76 %) présentaient une évolution favorable.ConclusionLes nouvelles techniques diagnostiques, notamment la biologie moléculaire, peuvent être utiles pour le diagnostic des formes cliniques inhabituelles de tuberculose. Des explorations invasives sont souvent nécessaires pour obtenir des prélèvements, mais aussi pour la prise en charge thérapeutique de l’atteinte digestive.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Introduction et but de l’etude La chirurgie digestive majeure a un impact fort sur l’etat nutritionnel des patients et la presence d’une denutrition preoperatoire constitue un facteur de risque independant de complications postoperatoires. Ainsi, il est necessaire de proposer une prise en charge nutritionnelle adaptee au patient au cours de son parcours de soins afin d’ameliorer le pronostic et l’evolution clinique. L’objectif de ce travail est d’evaluer les pratiques de nutrition parenterale (NP) perioperatoire au sein des services de chirurgie digestive et hepatique du CHU de Strasbourg (hopital de Hautepierre). Materiel et methodes Cette enquete a inclus tous les patients ayant beneficie d’une chirurgie et d’une assistance nutritionnelle du 01/08/13 au 31/10/13 dans le service de chirurgie generale, hepatique, endocrinienne et transplantation et le service de chirurgie generale et digestive. Les patients ont ete recenses prospectivement et les dossiers ont ete analyses retrospectivement. La grille de recueil des donnees etait constituee de 4 parties : identification du patient/facteurs de risque de denutrition/evaluation de l’etat nutritionnel et prise en charge nutritionnelle. Les criteres de conformite ont ete analyses selon les recommandations 2010 de la Sfar et de la SFNEP sur la nutrition perioperatoire. Resultats et analyse statistique Quatre-vingt-trois patients ont ete inclus (55 % hommes-45 % femmes). Les caracteristiques des patients etaient les suivantes : âge moyen : 62 ans (extremes : 23–89) ; poids moyen : 73 kg (extremes : 44–135) ; IMC moyen : 25,7 (extremes : 15,9–41,5). La chirurgie realisee etait dans 29 % des cas pancreatique, 28 % des cas hepatique et 23 % des cas colorectale. Les resultats sont presentes dans le Tableau 1 . L’estimation des besoins caloriques du patient n’avait pas pu etre evaluee par absence de tracabilite. Conclusion Cette enquete a permis de mettre en evidence les points forts des services tel que l’evaluation de l’etat nutritionnel, l’indication de la NP, la supplementation en micronutriments et le codage de l’etat nutritionnel. Neanmoins, l’estimation des besoins energetiques et proteiques du patient et l’adequation des apports a ces besoins necessitent d’etre ameliores par l’intervention systematique de la dieteticienne, du chirurgien et du pharmacien tout au long du sejour du patient. Un algorithme de prise en charge nutritionelle et une revision des protocoles existants ont ete mis en place afin d’adapter au mieux la NP aux besoins du patient. Notre objectif a long terme est d’obtenir, grâce a cette prise en charge pluridisciplinaire, le maximum de conformite sur les differents criteres et ainsi avoir une prise en charge nutritionnelle optimale.

Objectif L’identification de la tumeur primitive neuroendocrine (TNE) de l’intestin grele est cruciale dans la planification du traitement et la resection tumorale est conseillee malgre la presence d’une maladie metastatique. De plus, une forme multifocale est presente chez environ 30 % des patients. Dans cette etude, nous avons evalue la detection de la tumeur primitive et d’une forme multifocale de TNE du grele de la TEP/TDM a la 18F-FDOPA. Materiel et methodes Nous avons inclus tous les patients consecutifs atteints d’une TNE de l’intestin grele ayant beneficie d’une resection chirurgicale et d’un bilan d’imagerie preoperatoire comprenant une TEP/TDM a la 18F-FDOPA, une TEMP/TDM des recepteurs de la somatostatine (RS) et une TDM injectee. Les performances diagnostiques des methodes d’imagerie pre operatoire pour la detection des tumeurs primitives greliques ont ete comparees aux donnees de la palpation et de l’inspection chirurgicales, considerant comme gold standard le resultat de l’analyse anatomopathologique sur la piece operatoire. Resultats Dix-sept patients ont ete prospectivement inclus et retrospectivement analyses. Neuf patients (53 %) avaient une maladie tumorale multifocale, 15 (88 %) des ganglions lymphatiques metastatiques, 3 (18 %) une carcinose peritoneale et 9 patients (53 %) des metastases hepatiques. Un total de 70 TNE de l’intestin grele a ete mis en evidence lors de l’analyse anatomopathologique. Le chirurgien a identifie la tumeur primitive chez 17/17 patients, une multifocalite chez 7/9 patients (78 %) et 47/70 (67 %) carcinoides. En preoperatoire, la TEP/TDM a la 18F-FDOPA a identifie la tumeur primitive chez 17/17 (100 %), une multifocalite chez 7/9 patients (78 %) et 37 (53 %) carcinoides. La TEP/TDM a la 18F-FDOPA a montre une meilleure sensibilite (statistiquement significative) par rapport a la SRS TEMP et a la TDM pour localiser la tumeur primitive et pour la detection de maladie multifocale. De plus, la TEP/TDM a la 18F-FDOPA a correctement identifie 14/15 patients presentant des metastases ganglionnaires, 9/9 patients avec metastases hepatiques et 1/3 patients avec carcinose peritoneale. Conclusion La TEP/TDM a la 18F-FDOPA est tres performante dans la detection de la tumeur primitive d’origine ileale et dans l’identification des patients avec une maladie carcinoide multifocale et devrait etre systematiquement incluse dans le bilan preoperatoire de TNE de l’intestin grele.

Colorectal cancer is one of the most frequent and most lethal forms of cancer in the western world. The aim of this study is to characterize by 1H high resolution magic angle spinning NMR spectroscopy (HRMAS) the metabolic fingerprint of both tumoral and healthy tissue samples obtained from a cohort of patients affected by primary colorectal adenocarcinoma. By analyzing HRMAS data using multivariate statistical analysis (PLS-DA), the two types of tissues could be discriminated with a high level of confidence. The identification of the metabolites at the origin of this discrimination revealed that adenocarcinomas are richer in taurine, glutamate, aspartate, and lactate whereas healthy tissues contain a higher amount of myo-inositol and β-glucose. The statistical model resulting from the PLS-DA analysis was subsequently used to perform a blind test on tumoral and healthy colon biopsies. The results of the classification showed that the HRMAS analysis has very high sensitivity and specificity.

Background Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death. Methods A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon. Results A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1·2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10·3 per cent). Conclusion Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.

SUMMARY. This report describes the clinical course of a patient with complications of esophageal intramural pseudodiverticulosis. The condition led to fistulization and abscess formation in the mediastinum. The initial presentation was for the septic process and appropriate antibiotic therapy led to infection control while the abscess drained spontaneously back into the esophageal lumen. A long stricture affecting the distal half of the esophagus became evident after a few months and could not be managed by repeat dilatations. After appropriate preparation, subtotal esophagectomy was offered to the patient with an initial right thoracic approach followed by laparotomy and left cervical reconstruction. A total gastric tube was used for reconstruction and placed in a substernal position. An uneventful postoperative evolution led to normal swallowing comfort.

We report the case of a 97 year old woman suffering from a voluminous diverticle of the cervical esophagus with important comorbidities and a very poor quality of life. A diverticulectomy under general anesthesia implied a high level of risk. Regional anesthesia was chosen, i.e. an intermediate cervical plexus block, with mild sedation allowing to maintain contact with the patient. The procedure was carried out without complications and the patient's and surgical staff satisfaction were optimal.

Resume Propos. – La carcinose peritoneale, en particulier d'origine digestive, a ete longtemps consideree comme une diffusion ineluctablement terminale chez les patients atteints de cancers abdominaux. Actualites et points forts. – Au cours de la derniere decennie, de nouveaux traitements locoregionaux associant chirurgie de cytoreduction, peritonectomies et chimiotherapie intraperitoneale perioperatoire (avec ou sans hyperthermie) ont ete developpes au sein d'equipes specialisees. Du fait d'une mortalite et d'une morbidite elevee mais acceptable, cette prise en charge therapeutique agressive necessite une stricte selection des patients au sein d'equipes multidisciplinaires specialisees. Elle permet d'envisager des survies prolongees ou des guerisons en cas de pseudomyxome peritoneal, de mesotheliome peritoneal et de carcinose d'origine colorectale ou gastrique. La selection des indications necessite l'utilisation de facteurs pronostiques qualitatifs et quantitatifs comme l'histopathologie tumorale, l'evaluation de l'etendue de la carcinose ou de la radicalite de la cytoreduction qui apparait etre le facteur pronostique le plus important. Perspectives et projets. – L'association d'une chirurgie de cytoreduction et d'une chimiotherapie intraperitoneale perioperatoire apparait etre une approche therapeutique adaptee chez des patients soigneusement selectionnes, presentant une carcinose peritoneale. Des etudes de phase III sont necessaires a present pour la validation et l'evaluation du type de chimiotherapie intraperitoneale.

Resume But de l'etude. – Etudier l'efficacite a long terme du traitement laparoscopique du reflux gastro-œsophagien. Patients et methodes. – Entre le 1er janvier 1992 et le 31 decembre 1996, 161 patients etaient operes pour un reflux gastro-œsophagien (RGO) par une fundoplicature laparoscopique complete ou partielle ; les techniques utilisees etaient la fundoplicature complete de Nissen-Rossetti (123 cas) ou de Nissen (26 cas) et la fundoplicature partielle de type Toupet (12 cas) ; le recul minimal etait de cinq ans. Cent quarante et un patients ont ete suivis a trois mois, deux ans et cinq ans ; il y avait quatre deces de causes non reliees a la chirurgie et 16 perdus de vue (10 %). Une pHmetrie et une manometrie ont ete realisees en preoperatoire et a trois mois de distance. A deux ans et a cinq ans la reevaluation etait realisee par un questionnaire telephonique. Resultats. – La mortalite postoperatoire etait nulle, la morbidite de 1,2 % et le taux de conversion de 5 %. La dysphagie postoperatoire etait de 23,4 % a trois mois et de 12 % a cinq ans. Les recidives a cinq ans etaient de 12 %. Conclusion. – Le taux global de satisfaction subjective etait de 91,4 % a cinq ans. L'intervention de Nissen-Rossetti enregistre les meilleurs resultats a cinq ans, en terme de dysphagie postoperatoire et de recidive.

Pseudomyxoma peritonei is a rare disease, usually diagnosed after the discover of "jelly belly" by laparotomy. With the progress of immunohistochemistry, most authors now acknowledge the appendix to be the principal origin of this disease. Pseudomyxoma peritonei need to considered as border line malignant disease because of its inevitable persistence and progression without adapted therapeutic approach: cytoreductive surgery combined with perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy) into specialized centres. The principal prognostic factors are the prior surgical history, the completeness of cytoreduction and especially the histopathologic grade.

Resume Objectif. – L’anastomose transsuturaire facilite le retablissement de la continuite digestive au fond du pelvis, mais represente une anastomose a risque. Le but de l’etude etait l’evaluation de ce risque en termes de resultats immediats et de recidive tumorale dans le cadre du traitement des cancers du rectum. Patients et methode. – Les dossiers de 301 patients operes consecutivement selon cette technique entre 1980 et 2000 ont ete analyses retrospectivement afin d’analyser les indications operatoires, l’intervention et les complications peroperatoires, les complications postoperatoires immediates et le taux de recidive. Resultats. – Parmi les 301 patients (192 hommes et 109 femmes), d’un age median de 66 ans, seuls 19 (6,3 %) ont ete operes en urgence pour occlusion. Il s’agissait d’un adenocarcinome du rectum situe dans le haut rectum dans 132 cas (43,8 %), dans le moyen rectum dans 141 cas (46,8 %) et dans le bas rectum dans 19 cas (9,4 %). Une radiotherapie preoperatoire etait realisee dans 148 cas (49 %), avec une dose de 30 Grays (Gy) entre 1987 et 1996, de 39 Gy ensuite et de 45 Gy dans 12 cas. A partir de 1990, 113 patients ont eu une chimiotherapie adjuvante pour des tumeurs de stade III et IV et quelques cas particuliers de stade II. La resection laissait une marge de securite sous la tumeur de moins de 2 cm dans 59 cas (19,6 %) et l’anastomose siegeait a 5 cm et moins de la marge anale dans 178 cas (59 %). Une stomie de derivation etait associee dans 39 cas (13 %). Un defaut de l’anastomose etait note pendant l'intervention dans 18 cas (6 %) et 23 fistules sont survenues dans les suites operatoires (7,6 %), significativement associees au niveau de l’anastomose par rapport a la marge anale ( p = 0,0009). La mortalite hospitaliere etait de 8 cas (2,6 %). Les stenoses etaient rares : 11 cas (3,6 %), significativement associees a la realisation d’une radiotherapie preoperatoire ( p = 0,02). Le taux de recidive locale etait de 12 % (37 cas) dans un delai median de 16 mois, essentiellement lie au stade initial du cancer ( p = 0,004). Conclusion. – L’anastomose transsuturaire colorectale apres resection anterieure du rectum pour cancer est une technique sure avec un faible taux de complication et de recidive tumorale, le traitement chirurgical s’inscrivant dans le cadre d’une prise en charge multimodale du cancer.

Peritoneal carcinomatosis may occur after curative surgery of any gastrointestinal carcinoma, but it is however the most frequent form of evolution after curative resection of gastric carcinoma and is present at the time of surgery in many cases. This locoregional extension of cancer has a poor prognosis, with a great mortality and a poor quality of life. It is sometimes considered of such a poor prognosis that patients do not go through any resection or palliative procedure. Techniques of radiotherapy, chemotherapy and intraperitoneal chemotherapy have been used with moderate clinical efficacy. Since the 1990s, intraoperative hyperthermic peritoneal chemotherapy combined with comprehensive cytoreductive surgery has been proposed to improve prognosis of patients with peritoneal carcinomatosis from gastric origin as well as carcinomatosis from colorectal origin or pseudomyxoma peritonei.

Introduction Les nephropathies induites par le cisplatine sont bien decrites mais peu dans le contexte de chimiotherapie hyperthermique intraperitoneale (CHIP). L’objectif est d’evaluer le risque d’insuffisance renale aigue (IRA) apres une CHIP au cisplatine et d’identifier les facteurs favorisants. Patients et methodes Etude retrospective sur une cohorte de 60 patients ayant beneficie d’une premiere CHIP au cisplatine entre juin 2006 et juin 2014. Le debit de filtration glomerulaire (DFG) pre- et postoperatoire a ete estime par la formule MDRD adaptee a la technique de dosage de la creatinine serique. La survenue d’une alteration de la fonction renale (AFR) a ete definie selon les criteres RIFLE. Des marqueurs de toxicite tubulaire ont egalement ete recueillis. Resultats Une AFR est observee chez 25 patients (41,7 %), dont 8 (13,3 %) en IRA. A 3 mois, 10 patients (16,7 %) ont presente une insuffisance renale (IR) chronique et 3 (5,0 %) une IR terminale. Le sepsis (p Discussion Dans la seule etude evaluant l’impact d’une CHIP au cisplatine mene par Mohammed Breakeit et al. [1] sur 53 patients, une IRA a ete observee chez 3,8 % des patients. Cette moindre incidence peut s’expliquer par un protocole d’hydratation a base d’albumine, sequestrant le cisplatine plasmatique, par une incidence plus faible de sepsis et de recours aux antibiotiques a potentiel nephrotoxique. Conclusion La CHIP au cisplatine expose au risque d’IRA (13,3 %). Pour diminuer le risque de nephrotoxicite, il semble interessant d’evaluer plus precisement la fonction renale et tubulaire preoperatoire, de reviser le protocole d’hydratation et d’eviter les antibiotiques a potentiel nephrotoxique. Une etude avec dosage plasmatique du cisplatine permettrait de connaitre sa pharmacocinetique au cours des CHIP.

The diagnosis of acute appendicitis relies largely on clinical experience; the performance of complementary tests is oftentimes unnecessary. We have created a score based on clinical and laboratory findings which can reliably categorize three zones of diagnostic probability : probable, doubtful, or improbable. Only the intermediate category requires complementary imaging. Alvarado first developed a scoring system based on operative findings and this has been modified and improved by others. In our experience, the scoring system of François has been most useful. This score is based on simple clinical data and findings such as age, sex, duration of symptoms, leucocytosis, palpable mass on rectal exam, and urinary symptoms. We have validated this score in a cohort of 202 patients presenting with right lower quadrant abdominal pain and found a sensitivity of 94.7% and a negative predictive value of 97.4% for patients falling into the probable and improbable categories. Management of patients with either very high or very low scores can proceed more expeditiously and with less expense. Diagnostic imaging can be reserved for those patients with intermediate scores where the diagnosis is in doubt. We have established a clinical pathway in our emergency department based on this scoring system.

Diffuse malignant peritoneal mesothelioma is a rare and lethal disease. Locoregional treatments combining cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) seem to improve prognosis.Cytoreductive surgery and HIPEC was performed in 22 patients at the Centre Hospitalier-Lyon Sud between 1989 and 2006. A retrospective analysis of survival was carried out to assess clinical and histological prognostic factors.Nineteen patients with diffuse malignant peritoneal mesothelioma were included (16 epithelial, 3 biphasic and 3 multicystic forms). Sixteen patients presented stage 3 or 4 peritoneal mesothelioma according to the Gilly classification. Optimal cytoreductive surgery was performed for 11 patients (complete macroscopic resection or residual tumor nodules less than 2.5mm). No post-operative deaths occurred but 9 patients (47%) presented grade III or IV post-operative complications. The overall median survival was 36.9 months; completeness of cytoreduction was the only significant prognostic factor.Cytoreductive surgery combined with HIPEC may improve the length of survival for patients with diffuse malignant peritoneal mesothelioma; such patients should be treated in specialized centers.

Zenker's diverticulum is an unusual condition. Its treatment requires surgery but there is no consensus regarding the various operative techniques. Through an open cervical approach, the diverticulum can be either resected or suspended with or without a concurrent myotomy of the cricopharyngeus muscle. An innovative option is endoscopic trans-oral stapled esophago-diverticulostomy.and method: We retrospectively reviewed a consecutive series of 36 patients operated on between 1988 and 2006. Median age was 77.5 years and M/F sex ratio was 1.4. Through an open neck approach, diverticulectomy without cricopharyngeal myotomy was performed in 7 patients, diverticulectomy with myotomy in 11, and diverticulopexy with myotomy in 18.Morbidity rate was 13.8%. One fistula and one recurrence occurred in both diverticulectomy groups with and without myotomy. There was no morbidity after suspension diverticulopexy which also allowed earlier oral feeding (1 vs. 6 days) and shortened hospitalization (6 vs. 13.5 days).Diverticulopexy with cricopharyngeus myotomy is an effective, reliable, and reproducible technique for the correction of Zenker's diverticula smaller than 5 cm. Diverticulectomy should be reserved for larger diverticula. Technical improvements of transoral stapled diverticulostomy are still required before it can be promoted as an alternative therapy.

Intraperitoneal chemohyperthermia (IPCH) with Cytoreductive surgery (CS) has been used in Centre Hospitalier et Universitaire Lyon Sud (CHLS) since 1989. Up to 2005, 420 patients were involved in different phase II studies for peritoneal carcinomatosis (PC) from colorectal, gastric or ovarian origin, as well as for pseudomyxoma peritonei and peritoneal mesothelioma. Encouraging results were achieved in case of optimal PC cytoreduction. The CHLS experience, as well as the Dutch randomized trial and the international registration, underline the advantage of such an aggressive combined therapy for selected patients in experienced multidisciplinary centers.

Peritoneal carcinomatosis and particularly those from digestive origin has long been considered as an automatically terminal disease in abdominal cancer patients.Over the past decade, new locoregional treatments combining cytoreductive surgery, peritonectomy procedures with perioperative intraperitoneal chemotherapy (with or without hyperthermia) have been developed by specialized teams. Because of its high but acceptable mortality and morbidity, this aggressive but comprehensive therapeutic strategy requires accurate and strict patient's selection into multidisciplinary and specialized teams. It may allow prolonged survival and cure for patients with pseudomyxoma peritonei, peritoneal mesothelioma, carcinomatosis from colorectal or gastric cancer. Qualitative and quantitative prognostic indicators are needed to assess a patient's eligibility, including tumor histopathology, assessment of carcinomatosis extent or completeness of cytoreduction which appears to be the most important.Combination of cytoreductive surgery with perioperative intraperitoneal chemotherapy appears to be an adapted therapeutic approach for patients strictly selected, with peritoneal carcinomatosis. Phase III studies are now needed for the validation and the evaluation of the type of intraperitoneal chemotherapy.

The aim of this study was to evaluate the long term efficacy of laparoscopic treatment of gastroesophageal reflux disease (GERD).Between 1(st) January 1992 and 31 December 1996, 161 patients underwent complete or partial laparoscopic fundoplication for a symptomatic GERD. One hundred and twenty three patients were submitted to Nissen-Rossetti fundoplication, 26 patients to Nissen fundoplication and 12 patients to a partial posterior Toupet fundoplication.141 patients were evaluated at 3 months, 2-years and 5-years. Since undergoing the operation, four patients died of unrelated causes, 16 patients could not be contacted for follow up (10%). pH monitoring and oesophageal manometry were performed preoperatively and at 3 months postoperatively. The patients were evaluated 2 and 5-years after surgery by specific phone questionnaire.There was no mortality, the morbidity rate was 1.2% and the conversion rate was 5%. Incidence of dysphagia 3 months after surgery was 23.4%, and 5-years after 12%; 12% of patients had recurrent symptoms at 5 years.The overall satisfaction rate at 5 years was 91.4%. Nissen-Rossetti fundoplication seems to have better results at 5-years regarding postoperative dysphagia and symptoms recurrence.

Stapled end to end anastomosis makes the restoration of digestive continuity at the level of lower pelvis easier, but carries a certain risk. The aim of this report was to evaluate this risk in terms of immediate results and tumor recurrence after surgery for rectal cancer.The data of 301 patients operated on following this technique between 1980 and 2000 have been reviewed in order to analyse the tumor characteristics, the operation and associated complications, the immediate postoperative complications and recurrence rate.Among the 301 patients (192 males and 109 females) with median age of 66 years, 19 (6.3%) received an emergency operation due to bowel obstruction. The rectal adenocarcinoma was located in the upper rectum in 132 cases (43.8%), in the middle rectum in 141 cases (46.8%) and in the lower rectum in 19 cases (9.4%). Preoperative radiotherapy was carried out in 148 cases (49%): between 1987 and 1996 with a dose of 30 Grays (Gy), later increased to 39 Gy and 45 Gy in 12 cases. From 1990, 113 patients have received adjuvant chemotherapy for stage III and IV tumors and in some position cases for stage II tumor. The excision left a safety margin under the tumor of less than 2 cm in 59 cases (19.6%), and the anastomosis was located at 5 cm or less from the anal verge in 178 cases (59%). Primary defunctioning stoma was formed in 39 cases (13%). An anastomotic defect was observed during the operation in 18 cases (6%) and 26 fistulas occured postoperatively (7.6%), significantly related to the location of the anastomosis with regard to the anal verge (P = 0.0009). The hospital mortality was 8 cases (2.6%). Cases of stenosis were uncommon : 11 cases (3.6%), significantly associated with preoperative radiotherapy (P =0.02). The local recurrence rate was 12% (37 cases) in a median time delay of 16 months, essentially related to the tumor stage (P = 0.004) and the considered period (P = 0.001).Stapled end-to-end colorectal anastomosis after excision of rectum for cancer is a reliable technique with a low rate of complication and tumor recurrence, when the surgical procedure is included in the curative therapy management of cancer.

Pseudomyxoma peritonei is a rare disease, usually diagnosed after the discover of "jelly belly" by laparotomy. With the progress of immunohistochemistry, most authors now acknowledge the appendix to be the principal origin of this disease. Pseudomyxoma peritonei need to considered as border line malignant disease because of its inevitable persistence and progression without adapted therapeutic approach: cytoreductive surgery combined with perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy) into specialized centres. The principal prognostic factors are the prior surgical history, the completeness of cytoreduction and especially the histopathologic grade.

Materials/Methods: From 2000 to 2008, 185 patients older than 65 years with T3-4 M0 rectal cancer received either a preoperative radiotherapy with conventional (45 to 50.4 Gy in 1.8-2 Gy daily fractions) or an hypofractionated (39 Gy in 3 Gy daily fractions) protocol. Fifty-five patients received concomitant chemotherapy in the conventional group and none in the hypofractionated group. Both groups were equivalent in terms of characteristics. Median follow-up was 35,7 months.