Showing papers by "Jean-Jacques Tuech published in 2016"

Effect of Interval (7 or 11 weeks) Between Neoadjuvant Radiochemotherapy and Surgery on Complete Pathologic Response in Rectal Cancer: A Multicenter, Randomized, Controlled Trial (GRECCAR-6).

Abstract: Purpose A pathologic complete response (pCR; ypT0N0) of a rectal tumor after neoadjuvant radiochemotherapy (RCT) is associated with an excellent prognosis. Several retrospective studies have investigated the effect of increasing the delay after RCT. The aim of this study was to evaluate the effect of increasing the interval between the end of RCT and surgery on the pCR rate. Methods GRECCAR6 was a phase III, multicenter, randomized, open-label, parallel-group controlled trial. Patients with cT3/T4 or Tx N+ tumors of the mid or lower rectum who had received RCT (45 to 50 Gy with fluorouracil or capecitabine) were included. Patients were randomly included in the 7-week or the 11-week (11w) group. Primary end point was the pCR rate defined as a ypT0N0 specimen (NCT01648894). Results A total of 265 patients from 24 centers were enrolled between October 2012 and February 2015. The majority of the tumors were cT3 (82%). After RCT, surgery was not performed in nine patients (3.4%) because of the occurrence of distant metastasis (n = 5) or other reasons. Two patients underwent local resection of the tumor scar. A total of 47 (18.6%) specimens were classified as ypT0 (four had invaded lymph nodes [8.5%]). The primary end point (ypT0N0) was not different (7 weeks: 20 of 133, 15.0% v 11w: 23 of 132, 17.4%; P = .5983). Morbidity was significantly increased in the 11w group (44.5% v 32%; P = .0404) as a result of increased medical complications (32.8% v 19.2%; P = .0137). The 11w group had a worse quality of mesorectal resection (complete mesorectum [I] 78.7% v 90%; P = .0156). Conclusion Waiting 11 weeks after RCT did not increase the rate of pCR after surgical resection. A longer waiting period may be associated with higher morbidity and more difficult surgical resection.

Surgical Treatment of Postoperative Incisional Hernias by Intraperitoneal Insertion of Dacron Mesh and an Aponeurotic Graft

Abstract: Background: The therapeutic problems of giant incisional hernias of the abdominal wall are often difficult to resolve. The technique of repair must make up for the loss of abdominal wall substance and reestablish the interplay of the abdominal musculature. The use of prosthetic materials complies with these 2 imperatives. Hypothesis: The results of surgical treatment of postoperative incisional hernias by intraperitoneal insertion of Dacron mesh and an aponeurotic graft were evaluated. Design and Setting: Retrospective study of 250 patients in a university hospital. Results: Postoperative mortality was 0.8%. Five patients (2%) developed a subcutaneous infection that did not affect the prosthesis. Another 5 patients (2%) developed a deep-seated infection that necessitated removal of the mesh in 3 cases. Eight patients (3.2%) had recurrence of incisional hernia. Conclusion: This retrospective study shows that giant abdominal wall hernias can be efficiently treated by the intraperitoneal positioning of Dacron mesh and an aponeurotic graft.

A new internet tool to report peritoneal malignancy extent. PeRitOneal MalIgnancy Stage Evaluation (PROMISE) application

Abstract: Based on the importance of assessing the true extent of peritoneal disease, PeRitOneal MalIgnancy Stage Evaluation (PROMISE) internet application (www.e-promise.org) has been developed to facilitate tabulation and automatically calculate surgically validated peritoneal cancer index (PCI), and other surgically validated scores as Gilly score, simplified peritoneal cancer index (SPCI), Fagotti and Fagotti-modified scores. This application offers computer-assistance to produce simple, quick but precise and standardized pre, intra and postoperative reports of the extent of peritoneal metastases and may help specialized and non-specialized institutions in their current practice but also facilitate research and multicentre studies on peritoneal surface malignancies.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study.

Abstract: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. 7 (95 % CI 1.051–5.798, p = 0.038) and HIPEC duration (95 % CI 1.106–6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

Deep shaving and transanal disc excision in large endometriosis of mid and lower rectum: the Rouen technique

Abstract: Background Colorectal resection is performed in a majority of patients presenting with large endometriosis of mid and lower rectum; however, it may negatively and irreversibly impact postoperative rectal function. To avoid such unfavourable outcomes, we propose an original technique combining laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler.

Does Intraoperative Systematic Bacterial Sampling During Complete Cytoreductive Surgery (CRS) with Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC) Influence Postoperative Treatment? A New Predictive Factor for Postoperative Abdominal Infectious Complications

Abstract: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an emerging curative treatment option for patients with peritoneal carcinomatosis. It has a long-term survival benefit but is associated with high rates of morbidity, ranging from 12 % to 65 %, mainly due to infectious complications. We sought to evaluate the clinical relevance of routine intraoperative bacteriological sampling following CRS/HIPEC. Between November 2010 and December 2014, every patients receiving CRS/HIPEC were included. Three samples were routinely collected from standardized locations for intraperitoneal rinsing liquid bacteriological analysis (RLBA) after completion of HIPEC. The clinical and surgical features, bacteriological results, and short-term outcomes were retrospectively reviewed. The overall mortality and morbidity rates were 5 and 45 %, respectively. Among the 75 included patients, 40 % (n = 30) had at least one positive bacterial culture. Risk factors for a positive culture were colorectal resection (adjusted hazard ratio [HR] = 3.072, 95 % CI 1.843–8.004; p = 0.009) and blood loss >1000 mL (HR = 4.272, 95 % CI 1.080–18.141; p = 0.031). Among 26 (35 %) patients with abdominal infectious complications, 13 (17 %) experienced isolated complications. A positive RLBA result was independently associated with abdominal infectious complications (HR = 5.108, 95 % CI 1.220–16.336; p = 0.024) and isolated abdominal infectious complications (HR = 4.199, 95 % CI 1.064–15.961; p = 0.04). Forty percent of the RLBA samples obtained following CRS/HIPEC tested positive for bacteria. Bacterial sampling of rinsing liquid should be systematically performed. An aggressive and immediate antibiotic strategy needs to be evaluated.

Is the Combination of Distal Pancreatectomy and Cytoreductive Surgery With HIPEC Reasonable

Abstract: Objective:To report the morbidity and risk factors for overall complications and for pancreatic fistula (PF) after distal pancreatic resection (DP) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).Summary Background Data:The safety of DP in patients with peritoneal surface malignancies treated by CRS and HIPEC has been debated. The risk of PF and its impact on surgical outcomes are not well defined.Methods:Between 2001 and 2012, 118 patients with peritoneal surface malignancy undergoing CRS/HIPEC required DP at 7 oncological surgical centers. The incidence, clinical impact, and risk factors of PF were analyzed.Results:The indications for DP were tumoral invasion of the pancreatic gland with (n=24; 20%) or without splenic extension (n=76; 64%), invasion of the pancreatic capsule (n=10; 9%), or iatrogenic lesions during CRS (n=8; 7%). The rate of 90 days postoperative mortality was 7.6%, and the rate of severe morbidity (Clavien-Dindo III) was 44%. Pancreatic fistula was observed in 39 cases (33%), with the majority grade B (48.7%) or C (28.2%). In multivariate analysis, the risk factors for PF were a peritoneal cancer index more than 20 (risk ratio: 3.01; P=0.022) and an operative time more than 550min (risk ratio: 2.74; P=0.038). The occurrence of PF was not associated with a higher risk of 90-day mortality (5.1% vs 8.8%, not significant).Conclusions:With regard to reported morbi-mortality rates, DP associated with CRS/HIPEC may be a reasonable procedure in highly selected patients when done in high-volume centers. Therefore, distal pancreatic involvement should not be considered as a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface disease.

Conservative management using the triple approach and the Rouen technique in large deep rectovaginal endometriosis

Abstract: Background Colorectal resection is performed in numerous patients presenting with large endometriosis of mid and lower rectum; however, it may lead to low anterior rectal resection syndrome. To avoid such outcomes, we propose an original technique combining vaginal excision of infiltrated vaginal cul de sac, laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler: the Rouen technique. Methods The video presents the procedure performed in a 31-year-old nullipara referred with a large endometriotic nodule infiltrating the vaginal posterior cul de sac and the anterior wall of the mid rectum on more than 30 mm length responsible for symptomatic stenosis. The first step of the procedure is represented by the excision of vaginal infiltration using a vaginal approach. The second step includes a laparoscopic deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision is performed from rectal approach, by placing traction parachute sutures on the shaved area. Their traction induces the prolapse of shaved rectal wall that is resected using a semi-circular stapler. Results Operative time was 140 min. Immediate postoperative outcomes were uneventful. One year after the surgery, the patient reported one stool/day, without dyskesia, normal anal continence and no deep dsypareunia. To date, the Rouen technique was successfully carried out in 42 women with large deep endometriosis of the mid and lower rectum. Conclusions The Rouen technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.