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An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas. All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage. A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22–88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6–23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03–25.03), p = 0.046; OR 2.59 (1.08–6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up. This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas.All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage.A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22-88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6-23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03-25.03), p = 0.046; OR 2.59 (1.08-6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up.This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

Les dernieres RPC sur le traitement neoadjuvant du cancer du rectum dataient de 2005. Elles ont ete mises a jour en integrant les dernieres publications. Pour les tumeurs T3 ou T4, une IRM est recommandee pour preciser la marge circonferentielle. Aucun des examens d’imagerie ne peut predire avec precision le statut ganglionnaire. La RT preoperatoire diminue le taux de recidive locale mais altere le resultat fonctionnel digestif et la fonction sexuelle apres chirurgie conservatrice. Les cancers du haut rectum resecables d’emblee ne doivent pas beneficier d’un traitement neoadjuvant. Pour les tumeurs du tiers moyen et du tiers inferieur du rectum, l’indication depend de l’evaluation en imagerie. Certaines tumeurs avec une bonne marge circonferentielle peuvent etre traitees par chirurgie d’emblee. Les tumeurs mrT3d et T4 doivent beneficier d’une radiochimiotherapie. La CT associee a la RT repose sur le 5FU oral (capecitabine). L’utilisation du FU IV est une alternative possible. Il n’y a pas d’interet a ajouter une autre molecule de chimiotherapie. Apres RT courte, la chirurgie doit etre realisee au maximum 7 jours suivants l’irradiation. Apres CTRT, il ne semble pas necessaire de prolonger le delai d’attente au dela de 6-8 semaines.

Les soins peri-operatoires en chirurgie colorectale ont pour but de limiter la morbimortalite et d’aboutir au concept de rehabilitation precoce en diminuant la duree d’hospitalisation et le retentissement socio-professionnel de la chirurgie. Ces mesures encadrent les trois periodes pre, per et postoperatoire. En periode preoperatoire,l’immunonutrition est debutee 7 jours avant l’intervention, la preparation colique a base de polyethylene glycol n’est indiquee que pour la chirurgie rectale, de plus il est faisable d’administrer un solute riche en carbohydrate en preoperatoire immediat.Les futurs patients stomises doivent etre pris en charge par une stomatherapeute. En peroperatoire, le drainage urinaire se fera par catheter sous-pubien dans la chirurgie rectale, le drainage aspiratif n’est indique que pour les anastomoses sous-peritoneales. En postoperatoire, en dehors d’une chirurgie rectale a risque, le drainage urinaire ne doit pas exceder 24h, et par ailleurs il n’y a pas d’indication au maintien de la sonde nasogastrique. Le catheter cicatriciel a montre son efficacite et se rajoute a l’analgesie multimodale durant les 72 premieres heures. Il est necessaire de prendre en charge les hauts debits de stomie de maniere standardisee et d’assurer la prevention du risque embolique par heparine de bas poids moleculaire durant le premier mois postoperatoire.

Cette mini-revue detaille les principales avancees depuis les annees 2000 dans la prise en charge des cancers colorectaux. La laparoscopie est maintenant la voie d’abord de choix pour la majorite des cancers du colon ou du rectum. La preparation colique n’est plus necessaire qu’avant une proctectomie pour cancer. L’endoprothese ne doit plus etre posee en premiere intention curative en cas de cancer colique en occlusion. Le syndrome MAP (MUTYH-Associated Polyposis) a ete decouvert en 2002 et permet d’expliquer une partie des polyposes sans mutation identifiee sur APC.

Objective: Compare the feasibility and patient toler‐ ance to either a clear fluid (CF) or low residue diet (LRD) started on postoperative day (POD) 1 after elective colo‐ rectal surgery. Background: Diet advancement after surgery tradition‐ ally starts gradually with liquids, on the basis of fears that early solid intake may increase nausea, vomiting, and over‐ all complications. A randomized controlled trial comparing LRD and CF on POD 1 was performed. Methods: One hundred and eleven elective colorectal surgery patients were randomized to CF (N = 57) or LRD (N = 54). The primary end point was vomiting on POD 2. Secondary endpoints included nausea score, days to flatus, length of hospital stay (LOS), and postoperative morbidity. Results: Patient characteristics, surgical technique, intra‐ operative characteristics, and postoperative opioid use were similar between study arms. CF versus LRD results were as follows: POD2 vomiting (28 vs 14%; P = 0.09), and significant increase in mean nausea score (4.7 vs 3.5; P = 0.01), days to flatus (4.8 vs 3.7 days; P = 0.04), and LOS (7.0 vs 5.0 days; P = 0.01). LOS remained significantly shorter even after adjusting for significant covariates (lapa‐ roscopic technique, surgical site, postoperative comorbidity, stoma, and nasogastric tube) with LRD patients having an adjusted 1.4‐day decrease in LOS (P < 0.01). There was no significant difference in postoperative morbidity between study arms. Multivariate analysis of all secondary endpoints confirmed an overall significant improvement in outcomes for LRD vs CF (P < 0.01). Conclusions: LRD, rather than CF, on POD1 after colo‐ rectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increas‐ ing postoperative morbidity. Commentaires : Voila une etude qu’elle est bien et inte‐ ressante a lire... Avec une possible implication clinique immediate finalement... En postoperatoire immediat apres resection colorectale, la plupart des equipes proposent une realimentation liquide puis solide. L’etude presentee ici se propose de savoir si un regime sans residu ne serait pas fina‐ lement mieux tolere. La reponse semble oui, pour les nausees, vomissements, retour du transit et duree d’hospitalisation. Tout est significatif (sauf les vomissements) et en faveur du regime sans residu ! Pourquoi ne pas essayer chez nous ? Cotation : ☺☺☺

Objectif Le but de cette etude randomisee multicentrique etait d’evaluer le pourcentage de fistules anastomotiques symptomatiques chez les patients operes d’une resection anterieure du bas rectum, randomises avec ou sans stomie de protection.

L’exerese totale de mesorectum est un des points les plus importants dans le traitement chirurgical du cancer du rectum. Les differents montages chirurgicaux apres exerese totale de mesorectum sont decrits.

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.

La graciloplastie est une technique visant a traiter les fistules rectovaginale et uretrorectale en interposant le muscle gracilis. Cette technique est associee a une faible morbidite et un taux de succes compris entre 50 et 90 % pour les fistules rectovaginales et 80 % pour les fistules uretrorectales.

Une technique de coloproctectomie evitant la confection d’une ileostomie definitive a ete developpee pour les patients atteints d’une rectocolite hemorragique ou d’une polypose adenomateuse familiale. Apres l’exerese de l’integralite des organes malades, un reservoir utilisant l’ileon terminal est confectionne et descendu au travers du canal anal apres mucosectomie, et une anastomose ileoanale est alors realisee. Vingt et un patients (17 rectocolites hemorragiques et quatre polyposes) ont ete traites, et 20 ont ete suivis entre 2 et 34 mois (delai moyen 13,5 mois). La mortalite fut nulle, et neuf patients ont presente une complication precoce. Tous les patients sont, actuellement, en bon etat general sans retentissement sexuel ou urinaire. La continence diurne aux selles etait parfaite, et un patient avait des episodes d’incontinence la nuit. Le nombre moyen de selles etait de 3,8 par 24 heures. Dix patients avaient des exonerations sans manoeuvres. Tous les patients avaient un regime alimentaire normal, et seulement deux prenaient un ralentisseur du transit. Cette intervention semble etre une alternative a la coloproctectomie associee a une ileostomie definitive.

Inherited defects of base excision repair have not been associated with any human genetic disorder, although mutations of the genes mutM and mutY, which function in Escherichia coli base excision repair, lead to increased transversions of G:C to T:A. We have studied family N, which is affected with multiple colorectal adenomas and carcinoma but lacks an inherited mutation of the adenomatous polyposis coli gene (APC) that is associated with familial adenomatous polyposis. Here we show that 11 tumors from 3 affected siblings contain 18 somatic inactivating mutations of APC and that 15 of these mutations are G:C—>A transversions—a significantly greater proportion than is found in sporadic tumors or in tumors associated with familial adenomatous polyposis. Analysis of the human homolog of mutY, MYH, showed that the siblings were compound heterozygotes for the nonconservative missense variants Tyr165Cys and Gly382Asp. These mutations affect residues that are conserved in mutY of E. coli (Tyr82 and Gly253). Tyrosine 82 is located in the pseudo-helix-hairpin-helix (HhH) motif and is predicted to function in mismatch specificity. Assays of adenine glycosylase activity of the Tyr82Cys and Gly253Asp mutant proteins with 8-oxoG:A and G:A substrates show that their activity is reduced significantly. Our findings link the inherited variants in MYH to the pattern of somatic APC mutation in family N and implicate defective base excision repair in predisposition to tumors in humans.

La colectomie droite est le traitement curatif des tumeurs du caecum, du colon ascendant et du tiers droit du colon transverse. Qu’elle soit realisee par laparoscopie ou par laparotomie, elle doit obeir a un certain nombre de regles carcinologiques. La mortalite et la morbidite de cette intervention, en particulier le taux de fistule (inferieur a 4 %), sont faibles.

Vingt-huit patients ayant un carcinome epidermoide du canal anal ont ete traites par radiochimiotherapie neoadjuvante. La dose de radiotherapie delivree sur la tumeur, le pelvis et les ganglions inguinaux etait de 3 000 rad (30 Cy) par doses de 200 rad quotidiens, cinq jours par semaine. La chimiotherapie administree etait une association de 5-FU (1 000 mg/m2 a j1–j4 de la radiotherapie) et de mitomycine C (15 mg/m2 en bolus a j1). La chirurgie etait programmee quatre a six semaines apres la fin de la radiotherapie. Douze patients ont eu une amputation abdominoperineale et, parmi eux, sept n’avaient plus de residu tumoral, et un patient ne presentait qu’un infiltrat microscopique. Quatorze patients n’ont eu qu’une resection de la cicatrice locale apres fonte tumorale complete, et toutes les pieces etaient sterilisees. Deux patients avaient eu une reponse complete clinique mais n’ont pas ete biopsies. Aucune complication grave n’a ete observee pendant le traitement neoadjuvant, les leucopenies, les thrombopenies ou la rectite etant moderees ou severes. Apres un recul allant d’un a huit ans, 22 patients etaient vivants sans recidive. Un patient est decede d’un arret cardiaque quatre ans apres la chirurgie. Quatre patients sont morts de leur cancer. Ils avaient tous un residu tumoral sur la piece de resection, et la lesion primitive mesurait plus de 7 cm de diametre lors de l’examen initial. Un patient est decede de localisation secondaire sans recidive locale.

Le lambeau d’avancement rectal est une technique chirurgicale permettant de traiter les fistules cryptiques et crohniennes, notamment les fistules recto- ou anovaginales en obliterant l’orifice primaire anorectal. Le taux de succes varie entre 50 et 90 % selon l’etiologie. Cette technique endoanale est associee a une morbidite faible et constitue le plus souvent la premiere etape chirurgicale pour traiter les fistules complexes ou recidivantes.

Apres un premier episode de diverticulite traite medicalement, les recommandations proposent de pratiquer une colectomie prophylactique chez les patients de moins de 50 ans. Les donnees de la litterature sont contradictoires quant a la pertinence de cette attitude. Le risque de recidive est tres variable mais inferieur a 20 % dans les series les plus larges. De plus, le taux de diverticulite compliquee requerant un geste en urgence est tres faible. Ces donnees associees aux risques inherents a toute chirurgie abdominale meme par laparoscopie ne semblent pas valider l’indication systematique de colectomie apres une premiere poussee de diverticulite chez les patients de moins de 50 ans.

A 73-year-old man, who previously underwent laparotomy for pancreatic adenocarcinoma, was admitted in the emergency room for acute small bowel obstruction related to a strangulated Spieghelian hernia. On CT-scan, the hernia was located at the lateral border of the right rectus abdominis muscle below the external oblique muscle, among the transverse abdominis and internal oblique muscles layers. Spieghelian hernias (or hernia of the linea semilunaris) often occur at the level of a weak spot where the linea accurata crosses the linea semilunaris, when the posterior layer of the rectus gain changes its conformation. This weak spot is limited underneath by the inferior epigastric artery. When examining a patient with a previous history of laparotomy presenting with acute small bowel obstruction, it is mandatory to exclude a possible strangulated Spieghelian hernia before concluding to postoperative intra-abdominal adhesions. Spieghelian hernias are asymptomatic in approximately 90% of cases but entail a high risk of strangulation. Consequently, herniorrhaphy through a local approach route or open/laparoscopic mesh repair is always required.

Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short- and long-term results of the Martius flap procedure.Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined.Crohn's disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn's disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2-31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right-sided flap was associated with a higher success rate (P = 0.0442).The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.

To raise an appraisal of French urologist resident and chief resident's demographic characteristics, activity, post-residency project, career desires and factors associated with obtaining a fellowship.An electronic questionnaire was sent by email between June 2009 and January 2010 to the 288 French urologists currently in training. Items analysed included demographics, achievement of academic works and post-residency projects.Overall, we obtained 156 answers (response rate of 54%). Our population was composed by 47 (27%) fellows and 114 (73%) residents. They work 68.1 hours per week and 31 (20%) leave the hospital after an on-call night. Thirty-two (20.5%) have validated a master 2. Among the resident, 54 (47.3%) are certain to have the opportunity to be a chief resident. Regarding residents, factors significantly associated with the fact to obtain a fellowship in multivariate analysis were: to gain a master 2, working more than 65 hours per week and achieving academics works. Installation in a general hospital, a university hospital and a private clinic was considered by respectively 21.7%, 41.6% and 67.3% of young urologists.French urologist resident and chief resident's work an average 68 hours per week. The determining factors in obtaining a fellowship are the realization of a master 2, a workweek exceeding 68 hours and the achievement of academic work. After completing their academic training, a majority of young urologists are attracted by private practice.

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.

Une crise demographique menace-t-elle les specialistes des maladies digestives, medecins et chirurgiens ? Le rapport Milon du Senat notait une chute de 23 % du nombre de chirurgiens generaux entre 2000 et 2007 [1]. Le rapport Domergue, sur les choix des internes de chirurgie, n’etait guere plus optimiste [2]. Concernant la gastroenterologie, plusieurs projections demographiques annoncent une baisse sensible du nombre de praticiens sur l’ensemble du territoire a partir de cette annee, tant et si bien que la densite pourrait etre amputee d’un cinquieme d’ici a 2020 [3]. Creux de vague d’une courbe sinusoidale ou phenomene perenne ? Difficile de repondre. Une enquete menee recemment aupres de plus de 1 500 etudiants en medecine de toute la France s’est interessee au probleme [4]. Seuls 8 % des etudiants interroges declaraient envisager une specialisation en hepatogastroenterologie (HGE) ou en chirurgie digestive. Une impregnation clinique, via les stages, semblait favoriser une intention de specialisation. Pres d’un quart des etudiants evoquaient la surcharge de travail, notamment en chirurgie, pour justifier leur desinteret. Plus inquietant sans doute, presque deux tiers denoncaient un manque d’attrait pour les pathologies concernees ou un interet superieur pour une autre specialite. Ces impressions ont ete confirmees par une autre etude portant sur 1 742 etudiants en sixieme annee d’etudes (DCEM4), evaluant la vocation pour une specialisation en chirurgie. Si la chirurgie viscerale etait la quatrieme specialite chirurgicale envisagee (parmi les dix), elle etait avantderniere en termes de perception de qualite de vie et septieme en termes de revenus [5].

Son traitement repose donc en premiere intention sur la radiochimiotherapie 45 Gy avec un surdosage de 15 Gy pour les tumeurs ayant bien repondu apres un delai d’attente de 4 semaines. La chirurgie reste neanmoins necessaire pour environ 20 % des patients (tumeur n’ayant pas repondu aux 45 Gy, persistante apres les 60 Gy ou en cas de recidive a distance). Samorbidite perineale a ete reduite par les nouvelles techniques (lambeaux de grand droit, colostomie perineale...). Les questions qui restent en suspens restent cependant nombreuses