Search

Study Objective: Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed., Design: Monocentric randomised controlled trial., Setting: Operating room., Patients: We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia., Interventions: Patients were randomised into two groups to achieve either moderate (1-3 train of four response) or deep (1-2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups., Measurements: The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption., Main Results: Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228-472) μg.h -1 in the deep NMB group compared to 494 (392-618) μg.h -1 in the moderate NMB group (P < 0.001). Lowest L-SRS was 5 (4-5) in the deep NMB group versus 3 (2-5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different., Conclusions: This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions., Trial Registration: The study was registered at ClinicalTrials.gov under NCT03910998., Competing Interests: Declaration of competing interest Philippe Richebé received honorariums as a consultant and to give lectures from the following companies: Medasense, Abbvie, Medtronic-Covidien, Biosyent, and Merck. The other authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Colorectal cancer remains the top leading cancer worldwide. Accumulating evidence suggests periodontal pathogens are involved in colorectal carcinogenesis, indicating the need for high-quality epidemiological evidence linking periodontal disease (PD) and colorectal cancer (CRC). Thus, we conducted the first population-based case-control study that was specifically designed to investigate the association between compromised oral health and sporadic CRC. A total of 348 incident cases of colon or rectal cancer, and 310 age and sex frequency-matched controls, from the Montreal island and Laval population participated in the study. Data were collected on PD and on several CRC risk factors using validated questionnaires. A life-course approach was used to document long-term history regarding lifestyle factors. Multivariable unconditional logistic regression analysis was used to estimate the rate ratio (RR) quantifying the association between CRC and PD. Results showed that the rate of new diagnosis of CRC in persons with a positive history of PD was 1.45 times higher than in those with a negative history of PD adjusting for age, sex, BMI, education, income, diabetes, family history of CRC, regular use of non-steroidal anti-inflammatory drugs, lifetime cumulative smoking, lifetime consumption of red meats, processed meats, and alcoholic drinks, and lifetime total physical activity score (adjusted RR = 1.45; 95% CI 1.04-2.01; p = 0.026). Our results support the hypothesis of an association between PD and sporadic CRC risk., (© 2021. The Author(s).)

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8-26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm 2 gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

Background: The NOL index is based on multiparametric analysis of heart rate (HR), skin conductance, wave plethysmography, and their time derivative. The aim of this study was to evaluate the NOL to detect standardized nociceptive stimuli with various remifentanil dosages under general anesthesia., Methods: A prospective, observational study at a single center (NCT02602379) included 40 ASA I to III patients undergoing laparotomy under remifentanil-desflurane anesthesia with epidural analgesia. A tetanic stimulation was applied (forearm) at remifentanil intravenous (IV) infusion of 0.005, 0.05, 0.1, and 0.15 µg/kg/min. NOL and its variations were compared with other parameters namely heart rate, mean arterial pressure, Bispectral Index, and Analgesia Nociception Index (ANI). Receiver operating characteristic (ROC) curves were plotted to assess the response to both intubation and standardized stimulus under remifentanil infusion of 0.005 µg/kg/min., Results: The post-stimulation NOL values at remifentanil doses of 0.005, 0.05, 0.1 and 0.15 µg/kg/min (39 [23-55], 15 [7-30], 8 [4-14] and 8.5 [4-15]) were significantly higher than pre-stimulation counterparts (P<0.0001). For all other parameters, there was also significant difference between pre- and post-stimulation values at all remifentanil dosages (P<0.0001). Area under the ROC curve (AUC) for the NOL during standardized stimulation was larger than for all other parameters at the exception of ANI (P=0.94). The AUC of NOL for nociception during tracheal intubation was greater (0.93 vs. 0.84 and 0.64 for ANI and HR, respectively)., Conclusions: NOL monitoring is a promising index to assess the level of nociception in patients under general anesthesia.

Background: Chronic periodontitis and tooth loss are chronic oral conditions that, in recent decades, have been implicated in the occurrence of certain types of cancer. In this review, we address the question of whether colorectal cancer is associated with these oral conditions., Results: Epidemiological studies evaluating a potential association between periodontitis, tooth loss and colorectal cancer are scarce. However, several mechanisms argue in favor of this association, notably inflammation, nutrition and possibly infection by specific bacteria, as suggested by this literature review., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Summary: In 2012 Quebec limited continuous in-hospital duty to 16 consecutive hours for all residents regardless of postgraduate (PGY) level. The new restrictions in Quebec appeared to have a profound, negative effect on the quality of life of surgical residents at McGill University and a perceived detrimental effect on the delivery of surgical education and patient care. Here we discuss the results of a nationwide survey that we created and distributed to general surgery residents across Canada to capture and compare their perceptions of the changes to duty hour restrictions.

Objective: Quebec was the first Canadian province to implement a 16-hour workday restriction. Our aim was to assess and compare Quebec's surgical residents' and professors' perception regarding the effects on the educational environment, quality of care, and quality of life., Design: The Surgical Theater Educational Environment Measure, the Postgraduate Hospital Educational Environment Measure, quality of the medical act, and quality-of-life questionnaires were administered 6 months after the work-hour restrictions., Setting: Université de Montréal Surgery Department, Montréal, Québec, Canada; Université de Sherbrooke Surgery Department, Sherbrooke, Québec, Canada; Université Laval Surgery Department, Québec, Québec, Canada; and McGill University Surgery Department, Montréal, Québec, Canada., Participants: Surgical residents and professors of all specialties within the 4 university surgery departments in Quebec through a voluntary web-based survey., Results: A total of 280 questionnaires were analyzed with response rates of 29.7% and 16.4% for residents and professors, respectively. Data were coded on a scale from 2 (strong improvement perception) to -2 (strong deterioration perception). The professors perceived a higher negative effect than the residents did on the educational environment, i.e., role of autonomy (-0.399 vs. -0.577, p < 0.001), teaching (-0.496 vs. -0.540, p < 0.001), social support (-0.345 vs. -0.535, p < 0.001), and surgical learning (-0.409 vs. -0.626, p < 0.001). The professors also observed a higher negative effect on patients' safety (-0.199 vs. -0.595, p = 0.003) and quality of care (-0.077 vs. -0.421, p = 0.014). The latter was even perceived as unchanged by residents (-0.077, 95% CI: -0.249 to 0.095). The residents perceived a negative effect on their quality of life, whereas the professors believed the contrary (0.500 vs -0.496, p < 0.001). More professors than residents believed residency should be prolonged (80.8% vs. 50.6%, p < 0.001)., Conclusions: Residents and professors perceive a mild negative effect on the educational environment and quality of care, whereas their perception on quality of life is opposite. The professors seem concerned about adequate training to the point of considering increasing training length., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Adoption of the laparoscopic approach for colorectal cancer treatment has been slow owing to initial case study results suggesting high recurrence rates at port sites. The use of laparoscopic surgery for colorectal cancer still raises a number of concerns, particularly with the technique's complexity, learning curve and longer duration. After exploring the scientific literature comparing open and laparoscopic surgery for the treatment of colorectal cancer with respect to oncologic efficacy and shortterm outcomes, the Comité de l'évolution des pratiques en oncologie (CEPO) made recommendations for surgical practice in Quebec., Methods: Scientific literature published from January 1995 to April 2012 was reviewed. Phase III clinical trials and meta-analyses were included., Results: Sixteen randomized trials and 10 meta-analyses were retrieved. Analysis of the literature confirmed that for curative treatment of colorectal cancer, laparoscopy is not inferior to open surgery with respect to survival and recurrence rates. Moreover, laparoscopic surgery provides short-term advantages, including a shorter hospital stay, reduced analgesic use and faster recovery of intestinal function. However, this approach does require a longer operative time., Conclusion: Considering the evidence, the CEPO recommends that laparoscopic resection be considered an option for the curative treatment of colon and rectal cancer; that decisions regarding surgical approach take into consideration surgeon experience, tumour stage, potential contraindications and patient expectations; and that laparoscopic resection for rectal cancer be performed only by appropriately trained surgeons who perform a sufficient volume annually to maintain competence.

Chronic graft-versus-host disease (cGVHD) frequently complicates allogeneic hematopoietic stem cell transplantation (HSCT), but small bowel involvement with obstruction is rarely observed. We report two patients who underwent allogeneic sibling HSCT and developed severe cGVHD involving the small bowel, causing unremitting obstructive symptoms and malnutrition despite maximal immunosuppression. Both patients underwent ileal resection and stricturoplasties. The first patient promptly improved, and remains asymptomatic 32 months after transplant. Three weeks after the resection of 90 cm of small bowel, the second patient developed leaking stricturoplasty and peritonitis, with a relapse of chronic myelogenous leukemia in accelerated phase. Later, an enterocutaneous fistula required additional small bowel resection and ileostomy. The patient subsequently died from pulmonary infection a few weeks after the last surgical procedure. Similar to inflammatory bowel disease, these two cases highlight that surgery may be a valuable option in patients who present with obstructive severe cGVHD refractory to aggressive immunosuppression.

Background and Objectives: Lymph node (LN) metastasis is one of the most significant prognostic factor in colorectal cancer. In fact, therapeutic decisions are based on LN status. However, multiple studies have reported on the limitations of the conventional pathological LN examination techniques, and therefore, the actual number of patients with LN positive colorectal cancer is probably underestimated. We assume that lymphatic tumor dissemination follows an orderly sequential route. We report here a simple and harmless coloration technique that was recently elaborated, and that allows us to identify the sentinel LN(s) (SLN) or first relay LNs in colorectal cancer patients. The main endpoint of this clinical trial is the feasibility of the technique., Methods: Twenty patients treated by surgery for a colic cancer were admitted in this protocol. A subserosal peritumoral injection of lymphazurin 1% was performed 10 min before completing the colic resection. A pathologist immediately examined the specimens, harvested the colored SLN, and examined them by serial cuts (200 microm) with H&E staining, followed by immunohistochemical staining (AE1-AE3 cytokeratin markers), when serial sections were classified as cancer free., Results: The preoperative identification of the SLN was impossible in at least 50 of the cases, however, SLNs were identified by the pathologist in 90% of cases. In two patients (10%) SLN was never identified. The average number of SLN was 3.9. Immunohistochemical analysis of the SLN has potentially changed the initial staging (from Dukes B to Dukes C) for 5 of the 20 patients (25%). On the other hand, there was one patient (5%) with hepatic metastasis from adenocarcinoma for whom SLN pathology was negative for metastasis (skip metastasis)., Conclusions: SLN biopsy is readily feasible with identification of SLN in at least 90% of patients with colorectal cancers. Our results indicate that 45% of patients initially staged as Dukes B had tumor cells identified in their SLN when these were subjected to our protocol. This represented a 25% upgrading rate when our complete study population is considered. However, controversy persist about the clinical significance and metastatic potential of these often very small clusters of tumor cells., (Copyright 2002 Wiley‐Liss, Inc.)

Purpose: The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer., Methods: Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent)., Results: Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24 vs. 8 percent; P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7 vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank)., Conclusion: Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment.

Aim: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection., Materials and Methods: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: "straight" coloanal anastomosis (n = 39) or colonic J-pouch (n = 44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0-20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery., Results: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3 +/- 10.1 (range, 46-86), vs. colonic J-pouch, 64.9 +/- 13.2 (range, 39-88) years); gender (females): (coloanal anastomosis, 46.2 percent vs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent, vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5 +/- 4.6, vs. colonic J-pouch, 1.1 +/- 4); bowel movements: (coloanal anastomosis, 2.1 +/- 2.3, vs. colonic J-pouch, 2.1 +/- 1.9/day); level of anastomosis: (coloanal anastomosis, 1.8 +/- 1.3, vs. colonic J-pouch, 1.5 +/- 1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent, vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent, vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent), vs. colonic J-pouch, 2/44 (4.5 percent) P = 0.08); strictures: (10.3 vs. 0 percent); leaks: (5.1 vs. 2.3 percent); bleeding: (2.6 vs. 0 percent); rectovaginal fistula: (0 vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4 +/- 2 vs. 2.4 +/- 1.3/day; P < 0.005) and urgency (36.7 vs. 7.7 percent; P < 0.05), incontinence score (2.2 +/- 3.7 vs. 0.8 +/- 1.6; P < 0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4 +/- 12.6 vs. 4.2 +/- 1.5 ml/mmHg; P < 0.05). However, these differences were less profound after two years., Conclusion: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the "straight" coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.

Review article of the actual level of knowledge about laparoscopic colorectal surgery and laparoscopic-assisted procedures. At present time laparoscopy for the cure of colorectal neoplasia should only be performed within prospective randomized trials. In the meantime it is perfectly appropriate to perform laparoscopy for palliation of metastatic disease. Patients with benign colorectal neoplasms can achieve better outcome if treated by laparoscopy rather than laparotomy. Other areas in which laparoscopy may be useful include enterolysis and possibly, treatment of rectal prolapse. Laparoscopy can be appropriately applied for the treatment of terminal ileal Crohn's disease, sigmoid diverticulitis, reversal of Hartmann's pouches and the construction of stomas.

Langendorff perfused isolated rat heart is a common model for coronary blood flow study. Left ventricular preload can both increase coronary blood flow by direct inotropic effect or decrease it by rising transmural tension. Experiments were designed to determine optimal preload conditions for observation of basal (CBF) and 5-hydroxytryptamine (5-HT) stimulated coronary blood flow (SCBF) in the isolated rat heart model. Rat hearts (n = 6) were harvested and stabilized in the Langendorff apparatus and a left ventricular balloon was inserted and inflated at different volumes (0.05 to 0.4 ml) to stimulate preload. Left ventricular systolic (LVSP), diastolic (LVDP), myocardial oxygen consumption (MVO2) and extraction (MEO2) were also measured. Under basal conditions, optimal LVSP was obtained at 0.2 ml (111 +/- 15 mmHg). MVO2 was optimal at 0.2 ml of preload and decreased thereafter while MEO2 remained stable. Optimal CBF was reached at 0.2 ml of preload. Under 5-HT stimulation, CBF increased significantly (CBF: 8.2 +/- 0.6 ml/min vs SCBF: 16.4 +/- 1.0 ml/min, p < 0.01) while left ventricular hemodynamics did not differ from basal observations. At preload volume > 0.2 ml a significant drop in SCBF was observed (0 ml: 16.4 +/- 1 ml/min vs 0.4 ml: 11 +/- 1 ml/min, p < 0.01). MVO2 and MEO2 followed the same pattern observed under basal conditions. In basal and stimulated conditions, a hyperemic flow was also seen after deflation of the balloon with preload > = 0.2 ml in both CBF and SCBF suggesting myocardial oxygen debt. We conclude that in the Langendorff model preload affects coronary flow under both basal and 5-HT stimulation. A volume > 0.2 ml for rats of 350-400 g can impede CBF and generate myocardial oxygen debt as suggested by a decreased MVO2 and a post-deflation hyperemic flow. Left ventricular preload should be maintained under 0.2 ml for optimal coronary blood flow study in the Langendorff perfused rat heart model.

We described a new technique of orotracheal intubation in the rat. This technique is performed under direct vision by transillumination to obtain a better view of the rat's small and distant vocal cords. We also emphasize overextension of the neck to allow for a more direct path to the animal's trachea. This technique is easily learned, is atraumatic, and does not depend on expensive equipment.

Chronic administration of cyclosporine (CyA) has been shown to affect local vascular tone. Pentoxifylline (PTX), a xanthine-derived vasoactive agent, has been reported to prevent CyA toxicity but its effect on CyA-related increased vascular tone remains uncertain. In vitro experiments were designed to study the effects of PTX on endothelium-dependent and independent vasorelaxation of the rat thoracic aorta. Three groups of rats (n = 10) were respectively treated for 4 weeks with CyA (30 mg/kg/day), CyA and PTX (40 mg/kg/day), and CyA and PTX (80 mg/kg/day). At the end of the period, rings (4-5 mm) of aorta were harvested and suspended in organ chambers containing Krebs Ringer solution (37 degrees C, 95% O2, 5% CO2) for assessment of endothelial and smooth muscle reactivity. Endothelium-dependent relaxation to acetylcholine was significantly enhanced in animals treated with CyA and PTX (40 mg/kg/day) compared to those exposed to CyA alone (p < 0.05). Response to histamine and adenosine diphosphate was not affected. However, the use of PTX (80 mg/kg/day) significantly deteriorated the endothelial response to the same drugs (p < 0.05) suggesting a detrimental effect of PTX at this concentration. Endothelial-independent relaxation to sodium nitroprusside was comparable in all groups. The results suggest the clinical benefit reported with the use of PTX on patients chronically exposed to CyA may partly be due to an improvement of the vascular endothelial function. However, the toxicity encountered at high dose should cautioned its use in clinical setup.

It is mandatory to preserve the vascular tone regulation of the saphenous vein in order to optimize its performance as a vascular conduit. To determine the optimal preservation solution, human saphenous vein segments (3-4 cm) were harvested, stored for 60 minutes in different preservation solutions and studied in organ chambers for endothelial and smooth muscle assessment. A 1st group (n = 10) was stored in the heparinized blood of the patient (SH), a 2nd group (n = 10) in physiologic saline solution (NaCl) and a 3rd group (n = 10) in Krebs Ringer (KR) solution. All solutions were maintained at room temperature (21 degrees C). Each preserved segment was paired to a control segment, harvested in the same patient, and studied before storage. Following 60 minutes of preservation decreased endothelial-dependent relaxation to acetylcholine and histamine was observed among the group stored in KR (p = 0.06 and p < 0.02 respectively) compared to the other groups. Endothelium-independent relaxation to sodium nitroprusside was not affected regardless of the solution used. However, veins stored in SH disclosed an increased contractility to norepinephrine (p < 0.04). When intergroup variability was considered (by variance analysis), no significant difference was seen between each group. This study suggests that KR and SH were not as efficient as NaCl in preserving saphenous endothelial function. Furthermore, storage in SH increased smooth muscle response to catecholamine. In this experimental setup, 0.9% NaCl solution is an acceptable preservation solution of the saphenous vein.

Based on the hypothesis that low-threshold calcium conductance in the thalamus might be involved in the pathophysiology of parkinsonian tremor, ethosuximide was given chronically to a monkey previously treated with MPTP and displaying exceptionally a typical rest tremor. After 5 days of daily treatment, the tremor was reduced by 60%. Diltiazem and verapamil which act on different calcium channels had no such effect. Ethosuximide also potentiated the anti-tremor effect of the dopamine D2 agonist LY-171555.