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The curative treatment of locally advanced rectal cancer is currently based on chemoradiotherapy and total mesorectal excision (TME). Laparoscopy has developed considerably because of obvious clinical benefits such as reduced pain and shorter hospital stay. Recently, several prospective randomized clinical trials with long-term follow-up have showed that laparoscopy is noninferior to laparotomy with the same oncologic outcomes in terms of survival and local control rate. However, laparoscopic TME remains a challenging procedure requiring a high level of expertise and a long learning curve to ensure an adequate and safe resection. The only relative contraindication of laparoscopic rectal surgery is T4 rectal cancer extended beyond the plane of TME. In this situation, it is reasonable to consider an open resection to avoid an uncomplete resection. In obese and elderly patients, laparoscopic TME also provides the same benefits as in nonobese and younger patients but may be more difficult to achieve. This review summarizes current knowledge on the place of laparoscopic TME in the treatment of rectal cancer.

Among all procedures in colorectal surgery, restorative proctocolectomy with ileal pouch-anal anastomosis is one of the most extensive and complex. Since its first description in the late 1940s, many innovations and improvements have evolved. The two most common indications for this procedure are ulcerative colitis and familial adenomatous polyposis. In recent years, studies have proven that the laparoscopic approach for pouch surgery was safe, feasible, and associated with improved short- and long-term advantages compared with an open approach. The aim of the chapter is to detail the different steps of our surgical technique for restorative proctocolectomy with ileal pouch-anal anastomosis performed by single-port laparoscopy, which could be the next recommended surgical approach in this situation.

International audience; Background: Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn’s disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn’s disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn’s disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management.Methodology: A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis.Results: MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn’s disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn’s disease, and after obtaining luminal and perineal remission with anti-TNF ± immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn’s disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical–surgical cooperation.

Background and aims Colectomy can be required in the management of ulcerative colitis [UC]. While ileal-pouch anal anastomosis [IPAA] is the recommended reconstruction technique, ileorectal anastomosis [IRA] is still performed and might present some advantages. However, the risk of rectal neoplasia might limit its indication. The aims of our study were to determine the incidence of rectal neoplasias following IRA for UC and to identify risk factors associated with rectal carcinomas. Methods We performed a multicenter retrospective study including patients who underwent IRA for UC from 1960 to 2014 in 13 centers. Cox-proportional hazard models were used to determine carcinoma-associated risk factors. Results A total of 343 patients were included, with a median follow-up of 10.4 years after IRA. At the end of follow-up, 38 rectal neoplasias (including 19 carcinomas) were diagnosed, and 7 patients [2%] had either died from rectal carcinoma or had a metastatic disease. Incidences of rectal carcinoma after IRA for UC were estimated at 3.2% at 10 years and at 7.3% at 20 years, whereas incidences of neoplasia were estimated at 7.1% and 14% at 10 and 20 years, respectively. In multivariate analysis, age at IRA, IBD duration, primary sclerosing cholangitis [PSC] and history of prior colonic carcinoma were independently associated with the risk of rectal carcinoma following IRA. Conclusion The risk of rectal carcinoma in patients with IRA for UC remains, and this justifies long-term endoscopic surveillance. Either IPAA or end ileostomy should be considered in 'high-risk' patients i.e. those with PSC and/or with prior colonic neoplasia.

Transanal endoscopic microsurgery (TEM) is the gold standard for local excision of rectal lesions, but no study exists concerning the best material. The objective was to compare TEM using a disposable material vs a standard platform through a case-matched study. Patients who underwent TEM for rectal neoplasms were identified from prospective databases in two tertiary referral centers and matched according to four criteria (sex, tumor location, size, distance from the anal verge): TEM using a disposable material (GelPoint Applied®; group A) and TEM using a standard TEO® platform (Karl Storz, Tuttlingen, Germany; group B). A total of 74 patients were included and divided into group A (n = 33) and group B (n = 41). Full-thickness resection was less frequent in group A (85%) than B (100%; p = 0.01). Adenocarcinoma was less frequent in group A than B: 27 vs 42% (p = 0.03). No difference was noted regarding median operative time (53 vs 53 min; p = 0.6) and a peritoneal perforation rate (6 vs 20%; p = 0.17). Median length of stay was shorter in group A than B (4 vs 5 days; p

The aim of medical treatment of severe acute colitis (SAC) complicating inflammatory bowel disease (IBD) is to avoid surgery, but in 20 to 50% of the cases, colectomy remains necessary. This study aimed to determine the impact of the different lines of medical therapy (i.e., steroids, anti-TNF, or ciclosporin) on postoperative course after laparoscopic subtotal colectomy for SAC complicating IBD. All the patients who underwent laparoscopic subtotal colectomy for SAC were included and divided into two groups: those who presented with postoperative morbidity (group A) and those with an uneventful postoperative course (group B). Preoperative physical, endoscopic and radiological data, and medical treatments were compared between groups. From 2006 to 2015, 65 consecutive patients (32 males, median age = 35 [17–87] years) operated for SAC were included. Postoperative morbidity occurred in 19 patients (29%, group A) and was mainly represented by surgical morbidity (n = 15), including ileus (n = 9), stoma-related complications (n = 5), and intra-abdominal abscess (n = 4). Lichtiger score, endoscopic and radiological evaluations were similar between groups. Patients with morbidity had more frequently presented two previous episodes of SAC (26%) than those without (7%, p = 0.04). Duration of anti-TNF treatment was more frequently longer than 2 months in group A (67%) than that in group B (14%, p = 0.04). No significant differences between groups were noted regarding other preoperative medical treatments and number of lines therapy. This study suggests that postoperative course after laparoscopic subtotal colectomy for SAC is affected by prolonged preoperative anti-TNF therapy, and in the case of recurrent SAC.

Background: In patients with ileo-colonic Crohn's disease (CD), the main consequence of the development of intestinal fibrosis is the occurrence of a localized symptomatic stenosis for which treatment is mandatory. Besides medical treatment, which is still considered to be ineffective against non-inflammatory fibrotic intestinal stenosis due to CD, there are 2 options for the treatment of such stenosis: endoscopic and surgical approaches. Key Messages: Endoscopic treatment includes balloon dilatation and stenting, and can be performed only on selected patients with very short stenosis. Few reports with a small sample size are available; long-term results of endoscopic treatment remain unknown, with patients being exposed to possible early recurrence of the stenosis. For this reason, intestinal resection currently remains the first option for localized symptomatic intestinal stenosis due to CD refractory to medical therapy. Laparoscopic ileocecal resection with ileocolonic anastomosis gives good short-term results, without mortality and with very low rate of morbidity. Furthermore, when the resection is shorter than 50 cm, very few functional consequences or no consequences are reported, and quality of life is improved. However, CD recurrence is frequent and can be required to redo surgery in up to 30% of the cases. In order to reduce the theoretical risk of short bowel syndrome, some surgeons have proposed strictureplasty as a more conservative approach. The concept is to treat stenosis without intestinal resection by opening the stenosis. There are different kinds of stricturoplasty, with similar reported morbidity and long-term recurrence rates than those observed with resection. Conclusions: Because no randomized study exists, it is difficult to know what the best option for symptomatic ileal stenosis in CD is. However, for a majority of patients today, ileocecal resection is the first option, strictureplasty being reserved by most of the surgeons for recurrent cases and/or multiple stenoses. It requires more experience to perform endoscopic treatment with long-term results.

Indications for transanal endoscopic microsurgery (TEM) have been extended to technically challenging tumors, which may be associated with an increased risk of peritoneal perforation (PP). The aim of the present study was to investigate the occurrence, management and outcome of PP in patients having TEM. All the patients who had TEM for rectal adenoma or adenocarcinoma in our unit were included. Patients in whom PP occurred (Group A) were compared to those without PP (Group B). From 2007 to 2015, 194 TEM (116 men, median age 66 [range 21–100] years) were divided into Groups A (n = 28, 14%) and B (n = 166). The latter group included four patients, in whom a laparoscopy did not confirm suspicion of PP made during TEM. In 2 of 28 patients (7%), the diagnosis of PP was made postoperatively during reoperation for peritonitis. For the 26 other patients (93%), routine exploratory laparoscopy was performed with suture of the peritoneal defect on the pouch of Douglas in 24 cases and a rectal suture alone in 2 cases. Independent predictive factors for PP were: distance from the anal verge >10 cm (OR = 3.6), circumferential tumor (OR = 3.0) and anterior location (OR = 2.7). Hospital stay was significantly longer in Group A (7.5 [3–31] days) than in Group B (4 [1–38] days; p

OBJECTIVES To assess whether recent advances, such as intersphincteric resection (ISR) or local excision (LE) if a suspicion of complete tumor response after radiochemotherapy (RCT), could have modified the rate of end stoma (ES) in low rectal cancer treatment. BACKGROUND ES rate remains around 30% to 50% in patients with low rectal cancer. METHODS From 2005 to 2013, all patients with low rectal cancer undergoing laparoscopic total mesorectal excision, with or without neoadjuvant RCT, and patients undergoing LE after RCT were included. RESULTS A total of 189 patients presented a low rectal cancer; 162 (86%) underwent RCT; total mesorectal excision was performed in 172 (90%), followed by stapled colorectal anastomosis (n=26; 15%), manual coloanal anastomosis with partial (n=92; 53%) or total ISR (n=32; 19%), or ES that included abdominoperineal resection (n=21; 12%) and low Hartmann procedure (n=1; 1%). LE after RCT was performed in 19 of 189 (10%) patients with a suspicion of complete tumor response. Among them 2 of 19 (11%) underwent immediate secondary total mesorectal excision (1 abdominoperineal resection and 1 coloanal anastomosis with total ISR) because of poor pathological criteria. CONCLUSIONS Management of rectal cancer with colorectal anastomosis and coloanal anastomosis with partial ISR allowed to obtain a 38% ES rate (71/189); the additional use of total ISR decreased this rate to 22% (39/189). Selective use of LE reduced this rate to only 12% (22/189). Nowadays, recent advances lead to a paradigm shift, with only 12% ES rate in low rectal cancer.

Background Some patients with colorectal carcinoma have liver metastases (LMs) which cannot be detected by conventional imaging. This study aimed to assess whether hepatic perfusion changes induced by micrometastases can be detected by perfusion computed tomography (CT). Methods LMs were produced in rats by injecting carcinoma cells into the portal vein. Perfusion CT was performed at microscopic (day 10), interval (day 17), and macroscopic stage (day 34). Perfusion parameters were computed using a dualinput one-compartmental model. Results Micro and macro LMs presented a mean diameter of 0.5 and 2.6 mm, respectively. Compared to controls, LMs at interval (1.1 mm) and macroscopic stage induced significant perfusion changes: a decrease of 42% (P=0.004) and 41% (P=0.029) in hepatic transit time and an increase of 292% (P=0.073) and 240% (P=0.001) in portal delay, respectively. Conclusions LMs with a mean diameter between 1.1 and 2.6 mm induced significant hepatic perfusion changes, detected by CT. Such detection may help to select patients and propose chemotherapy at the time of primary tumor resection.

Anastomotic leakage (AL) after total mesorectal excision (TME) for rectal cancer is suspected to alter function. However, very few reports have been devoted to this problem. The aim of this study was to assess the influence of AL on function and quality of life (QoL) after laparoscopic TME for cancer. A total of 170 patients who underwent laparoscopic TME and sphincter-saving surgery for mid and low rectal cancer were included (67 % after neoadjuvant chemoradiotherapy). Twenty-one patients with AL were assessed for function and QoL (Short Form 36 (SF-36), Fecal Incontinence Quality of Life (FIQL), CR-29, and Wexner’s score) at the most recent follow-up. These patients were matched to 42 patients without AL according to sex, body mass index, ypTNM, radiotherapy, and type of anastomosis. After a median follow-up of 30 months, AL significantly impaired physical activity (SF-36) (p = 0.004), self-respect (FIQL) (p = 0.029), wear pad’s score (Wexner’s score) (p = 0.043), and blood and mucus in stool score (CR-29) (p = 0.001). Overall Wexner’s score did not show any significant difference in the two groups, 8.9 in AL patients vs. 11.6 in patients without AL (p = 0.1). AL significantly impairs both functional results and quality of life after laparoscopic sphincter-saving TME for rectal cancer. However, the observed difference was only limited, leading to similar outcomes on most of the tested scores. Patients with AL should be warned that if they initially experience severely impaired results, outcomes tend with time to become similar to those observed in noncomplicated patients.

Surgery of small-bowel neuroendocrine (SBNE) tumors is demanding because of the need for associated extensive node dissection and assessment of possible synchronous lesions. For this reason, possible benefit of laparoscopy in SBNE tumors has not been reported to date. From 1996, all patients operated on in Beaujon Hospital for SBNE tumors were retrospectively extracted from a prospectively maintained database of intestinal resections. Overall, 73 patients [55 % males, median age 55 years (range 27–79)] underwent small bowel resection (n = 38; 54 %), ileocolectomy (n = 25; 36 %), or both (n = 7; 10 %). In 18 patients, resection of synchronous liver metastasis was performed simultaneously. Resection was performed laparoscopically in 12 patients (16 %). Resection was R0 in 40 patients (55 %), R1 in 1 patient (1 %), and R2 in 32 patients (44 %) because of unresectable liver metastases (n = 29), nodal involvement (n = 1), or both (n = 2). Laparoscopy was associated with similar R0 (p = 0.06) and morbidity (p = 0.95) rates, but a shorter hospital stay (p = 0.003) compared with laparotomy. Median follow-up was 39 months. Progression-free survival (PFS) at 1, 3, and 5 years were 95, 83 and 75 %, respectively, for R0 patients without liver metastasis; 92, 83, and 57 %, respectively, for R0 patients with resected liver metastasis; and 82, 58 and 30 %, respectively, for R2 patients (p = 0.045). Overall survival and PFS did not show any difference when comparing the laparoscopic and open groups. Complete resection of primary SBNE tumors with or without liver metastasis is associated with good long-term survival. In selected patients, laparoscopy for SBNE tumors is feasible and associated with a shorter hospital stay than laparotomy.

Background and aims The extent of lymph node harvesting during surgery for colorectal neoplasm [dysplasia and/or cancer] complicating inflammatory bowel disease [IBD] is a matter of debate. This study aimed to assess the risk of invasive rectal cancer in patients undergoing ileal pouch-anal anastomosis [IPAA] for colonic neoplasm complicating IBD, and thus to clarify whether a systematic total mesorectal excision [TME] should be systematically performed, or not, in those patients. Methods From 1998 to 2015, all patients who underwent IPAA for colorectal neoplasm complicating IBD were included. Patients with preoperatively known rectal cancer were excluded. Pathological results were compared with preoperative endoscopic results. Results A totalof 36 patients [mean age 49 ± 14 years], comprising 10 women [31%] and 26 men [69%], underwent IPAA for colorectal neoplasm complicating IBD, with [n = 8; 22%] or without [n = 28; 78%] TME. Rectal cancer rate in pathological specimens was 0% [0/20] in patients with preoperatively known neoplasm only limited to the colon, 0% [0/8] among patients with preoperative rectal low-grade dysplasia, and 62% [5/8] among patients with preoperatively rectal high-grade dysplasia. Conclusions These results do not support systematic TME during IPAA for colonic neoplasm complicating IBD. Considering its association with postoperative sexual disorder, TME should be discussed only on a case-by-case basis.

483 Background: There are controversial data on the impact of a long waiting period between radiochemotherapy (RCT) and resection for rectal cancer on the rate of complete pathological response (pCR = ypT0N0). The impact on the oncological prognosis is also unknown. We present the 3 years survival results of the GRECCAR6 trial. Methods: The GRECCAR6 trial was a phase III, multicentre, randomized, open-label, parallel-group, controlled trial. Patients with cT3/T4 or TxN+ tumours assessed by radiological examination (MRI and/or endo-ultrasound) of the mid or lower rectum who had received RCT (45-50 Gy with intravenous 5-FU or capecitabine) were included and randomized between 7 weeks or 11 weeks of waiting period. Primary endpoint was the pCR rate. Secondary endpoints were overall, disease-free survival and rate of recurrences. Results: A total of 265 patients from 24 participating centres were enrolled between October 2012 and February 2015. Among them, 253 patients underwent surgery with mesorectal excision. The rate of pCR was 17% (43/253). Mean follow-up from surgical resection was 32±8 months. 25 deaths occurred with a 89% OS at 3 years. DFS was 67.7% at 3 years due to 77 deaths or recurrences. 3-years local and distant recurrences rates were 9.2% and 24.9%, respectively. The group of randomization had no impact on the OS (p = 0.9486) and the DFS (p = 0.8672). Distant (p = 0.8589) and local (p = 0.5780) recurrences were also not influenced by the waiting period. Patients with a pCR had an excellent prognosis with an overall survival of 94.5% versus 87.9% for the remaining patients at 3 years (p = 0.232) and a DFS of 89.6% versus 63.4% (p = 0.0025). On multivariate analysis, DFS was influenced by low rectal tumors (OR=1.74; [1.03; 2.94], p = 0.037), R1 resection (OR = 2.03; [1.18; 3.50], p = 0.011), ypT3-T4 (OR = 2.4; [1.12; 5.19], p = 0.0245) and N+ (OR = 2.85; [1.76; 4.61], p < 0.001). Conclusions: Waiting 4 weeks longer after radiochemotherapy has no influence on the oncological outcomes of T3/T4 rectal cancers. Clinical trial information: NCT01648894.

Surgical approaches for retrorectal tumors (RRT) are either abdominal, dorsal trans-sacrococcygeal, or perineal. Very few cases have been reported so far concerning a laparoscopic approach. The aim of this study was to assess the results of laparoscopy for the treatment of RRT. All patients who underwent laparoscopy for RRT between 2003 and 2012 were reviewed. Data included patient and tumor characteristics, surgical morbidity, and mortality. A total of 12 consecutive women with a median age of 55 years underwent laparoscopy for RRT. Median operative time was 145 min (range 70–215). Two conversions in laparotomy occurred, and one patient needed a temporary diverting ileostomy for rectal injury. Postoperatively, two patients presented urinary tract infections. Median length of stay was 8 days (range 4–16). Pathological examinations showed complete resections (R0) for ten benign tumors and one malignant tumor (Ewing sarcoma). One lesion was incompletely resected, a colloid sarcoma (R1 status), and was re-operated on by laparotomy after neoadjuvant chemoradiation. No local recurrence was observed after a median follow-up of 34 months (range 12–79) for benign lesions, and 28 and 71 months for the two patients who underwent resection of Ewing and colloid sarcoma, respectively. Laparoscopic resection for RRT seems feasible and safe. It allows complete excision of tumors located in the retrorectal space with low morbidity. Thus, this approach can be a valid alternative to standard Kraske or open abdominal approaches for the treatment of RRT.

Background Recent changes in adjuvant therapies improved the prognosis of metastatic colorectal cancers. Curative resection may be considered, even for both pulmonary and hepatic metastases, but prognostic factors are not well identified. Methods From 1995 to 2010, 69 patients had curative resection of pulmonary metastases of colorectal cancer; 31 had also hepatic metastases. Pulmonary and hepatic resection occurred in 2 steps (87%). We studied overall and disease-free survival and prognostic factors. Results Primary tumor location was the rectum in 10 cases (32%). Pulmonary metastases were synchronous in 5 (16%) and bilateral in 6 (19%). One patient (3%) died after pulmonary surgery. One (3%) had positive surgical margins for pulmonary metastases. Median overall survival was 44 months (5-year rate = 36%); median disease-free survival was 22 months (5-year rate = 10%). Factors linked to impaired survival were rectal primary tumor (P = 0.04) and bilateral pulmonary metastases (P = 0.02) for overall survival, and pulmonary metastase≥20 mm (P = 0.04) for disease-free survival. Conclusion When associated to adjuvant therapy, complete resection of pulmonary and hepatic metastases of colorectal cancer allows long-term survival in one third of the patients. J. Surg. Oncol. 2013 108:220–224. © 2013 Wiley Periodicals, Inc.

Summary Background & aims Short bowel syndrome (SBS) is a rare and severe condition where home parenteral nutrition (HPN) dependence can be either permanent or transient. The timing of HPN discontinuation and the survival, according to SBS characteristics, need to be further reported to help plan pre-emptive intestinal transplantation and reconstructive surgery. Methods 268 Non-malignant SBS patients have been followed in our institution since 1980. HPN dependence and survival rate were studied with univariate and multivariate analysis. Results Median follow-up was 4.4 (0.3–24) years. Actuarial HPN dependence probabilities were 74%, 64% and 48% at 1, 2 and 5 years, respectively. In multivariate analysis, HPN dependence was significantly decreased with an early ( 20 μmol/l, a remaining colon >57% (4/7) and a remnant small bowel length >75 cm. Among the 124 patients who became HPN independent, 26.5% did so more than 2 years after SBS constitution. Conclusions This study indicates that long-term HPN is required in 47% of SBS patients started on this therapy. HPN independence is significantly associated with the remnant small bowel length, remaining colon and early plasma citrulline concentration. Noteworthy, HPN dependence could be reversed until 5 years after SBS constitution.

Resume Apres chirurgie d’exerese rectale et anastomose basse, la complication aigue majeure est la survenue d’une fistule anastomotique (FA). La FA peut compromettre a long terme la conservation de l’anastomose et pejorer les resultats carcinologiques. Le but de cette mise au point etait d’identifier les elements permettant de prevenir une FA et de detailler les differentes options therapeutiques (voie endoscopique, abord chirurgical perineal, abord abdominal) en cas de FA chronique ou de stenose anastomotique. En cas de FA ou de stenose, les traitements doivent se faire sous couvert de la stomie confectionnee lors de la proctectomie. Les traitements chirurgicaux par abord local permettent un examen perineal sous anesthesie generale par le chirurgien et le drainage de la fistule. Les interventions par voie abdominale doivent etre reservees aux FA hautes et aux echecs des procedures par voie perineale. Les traitements endoscopiques peuvent etre utilises de facon complementaire aux traitements chirurgicaux, mais ont une place limitee en cas de FA. La dilatation au ballonnet est l’un des traitements de premiere ligne des stenoses anastomotiques.

Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.

Introduction Management of chronic radiation enteritis is often controversial, particularly due to the risk of short bowel syndrome. Methods One hundred and seven chronic radiation enteritis patients with short bowel syndrome were studied retrospectively between 1980 and 2009. Survival and home parenteral nutrition dependence rates were evaluated with univariate and multivariate analysis. Results The survival probabilities were 93%, 67% and 44.5% at 1, 5 and 10 years, respectively. On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR = 0.21 [0.11–0.38], p 3 (HR = 0.38 [0.20–0.73], p = 0.004) and an age of chronic radiation enteritis diagnosis >60 years (HR = 0.45 [0.22–0.89], p = 0.02). The actuarial home parenteral nutrition dependence probabilities were 66%, 55% and 43% at 1, 2 and 3 years, respectively. On multivariate analysis, this dependence was significantly decreased when there was a residual small bowel length >100 cm (HR = 0.35 [0.18–0.68], p = 0.002), adaptive hyperphagia (HR = 0.39 [0.17–0.87], p = 0.02) and the absence of a definitive stoma (HR = 0.48 [0.27–0.84], p = 0.01). Conclusion The survival of patients with diffuse chronic radiation enteritis after extensive intestinal resection was good and was mainly influenced by underlying comorbidities. Almost two-thirds of patients were able to be weaned off home parenteral nutrition.

Aim This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS). Method From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay. Results A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229 ± 66 min vs 216 ± 71 min, P = 0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P = 0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P = 0.658), including Grade 3 or Grade 4 morbidity, according to Dindo’s classification (5%vs 5%, P = 0.694). Mean hospital stay showed no difference between both groups (10 ± 7 days vs 9 ± 5 days, P = 0.849). Conclusion This large case–control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

BACKGROUND Segmental reversal of the small bowel (SRSB) is proposed in patients with short-bowel syndrome (SBS) as a rehabilitative therapy, but its effects on absorption have not been studied. OBJECTIVE We aimed to determine intestinal macronutrient absorption and home parenteral nutrition (HPN) dependence in SBS patients with intestinal failure. DESIGN We included in a retrospective study all consecutive patients who had an SRSB between 1985 and 2010 and underwent a study of macronutrient absorption. Patients were matched to SBS controls with the same digestive characteristics. Energy and macronutrient absorption were measured. The dependence on HPN was expressed by the number of infusions per week and by the calories infused daily divided by the basal energy expenditure multiplied by 1.5. RESULTS Seventeen patients who had an SRSB were matched to 17 control patients. Intestinal absorption was higher in the SRSB group for total calories (69.5% compared with 58.0%), fat (48.4% compared with 33.2%), and protein (62.7% compared with 53.4%) (P < 0.05). Median oral autonomy was 100% ± 38.4% in the SRSB group, whereas it was 79% ± 39.6% in the control group (P < 0.05). The number of calories infused was lower in the SRSB group (500 ± 283 compared with 684 ± 541; P < 0.05), as was HPN dependence (33% ± 20% compared with 48% ± 38%; P < 0.05) at the time of the study. CONCLUSION SRSB allows a gain in macronutrient absorption, which is associated with a lower HPN dependence. To our view, SRSB should be integrated in intestinal rehabilitative adult programs.

Aim Combined resection of colorectal cancer with surgery for synchronous liver metastases (LM) still remains controversial because of the possible higher morbidity rate, the necessity of an adequate abdominal approach for both resections and the impact on oncological results. However, laparoscopy may be beneficial in terms of operative results and could facilitate this combined procedure. The aim was to assess the benefit of the laparoscopic approach for colorectal cancer resection in patients undergoing simultaneous liver resection for synchronous LM. Method From 2006 to 2011, all patients with colorectal cancer and resectable synchronous LM, for which the total length of the procedure was suspected to be less than 8 h, underwent colorectal laparoscopic resection combined with open and/or laparoscopic liver surgery. In order to identify selection criteria, a comparative analysis was performed between patients with and without major postoperative morbidity. Results Fifty-one patients underwent combined surgery with laparoscopic colectomy (n = 31) and proctectomy (n = 20). The conversion rate was 8%. Liver resections included major surgery (n = 10) and minor surgery (n = 41). Extraction of the colorectal specimen was performed through an incision used for open liver resection, except in seven patients who underwent a total laparoscopic procedure. Overall and major morbidity rates were 55% and 25%, respectively. Median (range) hospital stay was 16 (6–40) days. Regarding patient and tumour characteristics, no independent criteria of major morbidity risk were identified. Conclusion This study showed that laparoscopic colorectal resection combined with liver resection for synchronous LM was feasible and safe. Moreover, laparoscopy facilitates the surgical abdominal approach for combined colorectal and liver resection.

Resume La transplantation intestinale peut etre isolee, combinee a une transplantation hepatique, ou multiviscerale. Bien qu’elle soit le traitement radical de l’insuffisance intestinale, le traitement de premiere intention de cette pathologie est la nutrition parenterale et les indications de transplantation restent debattues. Une etude recente a cependant retenu l’insuffisance hepatique associee a l’insuffisance intestinale et la presence d’une tumeur desmoide comme les deux situations mettant en jeu le pronostic vital et devant faire poser une indication de transplantation. Dans cette meme etude, la transplantation pour intestin grele extremement court et pour complications sur catheter de nutrition parenterale n’apporte pas de benefice en termes de survie et reste a evaluer de maniere plus complete. Si la greffe intestinale a vu ses resultats a court terme s’ameliorer considerablement (la survie des malades a un an est actuellement de 80 % en cas de transplantation d’intestin grele isolee contre 0 a 28 % dans les annees 1980), les resultats a long terme n’ont pas beaucoup evolue depuis les annees 1990 et l’introduction du tacrolimus, et la survie a cinq ans des malades ne depasse actuellement pas 60 %. Certaines pistes pourraient ameliorer ces resultats telles que le choix de la greffe multiviscerale, l’ajout du sirolimus ou des thymoglobulines dans le traitement immunosuppresseur d’induction, ou bien l’utilisation de nouveaux marqueurs biologiques pour une detection precoce de rejet du greffon.

Aim To evaluate the contribution of CT scanning to the management of patients with severe acute exacerbation of colitis (SAC) complicating inflammatory bowel disease (IBD), in particular, its contribution to surgical decision making. Method All patients who were admitted to our institution for SAC complicating IBD, were divided into Group A (surgical treatment) and B (medical treatment). Admission CT scan results were compared between the 2 groups. Results From 2006 to 2015, 54 patients (26 males, median age= 39 (17-71) years) presented with SAC were divided into Group A (n=41, 76%) and B (n=13, 24%). Surgical patients in Group A were more frequently with altered general status (50% vs 17%; p=0.01). Physical exam, Lichtiger score, endoscopic and laboratory results were similar between the 2 groups. There was no significant difference in CT scans between the 2 groups with respect to extension of the colitis (pan-colitis in 54% and 69%, respectively, p=0.35), median colonic thickness (10 [4-16] vs 8 [6-11] mm, p=0.15), target enhancement (88% vs 77%, p=0.38) and occurrence of toxic megacolon (2% vs 0%). Conclusion Admission CT scanning is not helpful in surgical decision making in SAC. This article is protected by copyright. All rights reserved.

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.

The single port laparoscopic method was first used in 1999 by Bresadola for cholecystectomy. Nearly a decade later, in 2008, the first single port right hemicolectomy was reported by Bucher and others in a case involving an ascending colon polyp (1,2). The continuous technological evolutional lows the first single port right hemicolectomy 17 years after the first laparoscopic hemicolectomy (1991) which was initially met with reluctance and after has gained a well-established place in the range of colorectal surgery (2). Single port access, as well as NOTES, provides, in comparison with the standard laparoscopic procedure, the aesthetic benefit, the decrease of postoperative pain and a shorter duration of hospitalization, while in terms of disadvantages, we could mention a longer surgery duration due to fewer opportunities of triangulation and vision (3,4). The reduction of postoperative pain plus the good aesthetic results with no significant increase of postoperative complications, already proved by retrospective studies, require confirmation by randomized studies envisaged by trial TRUE in France (5). Single port right hemicolectomy can be achieved with oncologic results similar to standard laparoscopic surgery, having very good postoperative results in terms of aesthetics and reduced postoperative pain (5,6,7).

Persistent perineal sinus (PPS) defined as a perineal wound remaining unhealed more than 6 months after abdominoperineal resection (APR) is a well-known complication. The aim of our study was (1) to evaluate the incidence of PPS after APR for Crohn’s disease (CD) in the era of biotherapy, (2) to determine long-term outcome of PPS, (3) to study risk factors associated with delayed perineal healing, and (4) to compare the results in this CD patient group with patients without CD. From 1997 to 2013, the records of patients who underwent APR for CD and for non-CD rectal cancer with or without radiochemotherapy at two French university hospitals were studied retrospectively. Perineal healing was evaluated by clinical examination at 1, 6, and 12 months after surgery. The cumulative probability of perineal wound unhealed at 6 and 12 months after surgery was 85 and 48%, respectively, for 81 patients who underwent APR for CD patients in contrast to 21 and 13%, respectively, for 25 non-CD patients with rectal cancer. Eight patients with CD (10%) remained with PPS after a median follow up of 4 years and spontaneous perineal healing occurred with time for all non-CD patients. Factors associated with delayed perineal healing in CD included age at surgery

Aim Rectal cancer is a malignant disease requiring multidisciplinary management. The increasing number of studies published over the past decade has called for a comprehensive update to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery (GRECCAR) and the French National Coloproctology Society (SNFCP). Method Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A Drafting Committee and a large group of expert reviewers contributed to validate the statements. Results Recommendations include the indications for neoadjuvant therapy, the quality criteria of surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement. Conclusion The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies. This article is protected by copyright. All rights reserved.

Aim To assess the results of treatment for colorectal (CRA), coloanal (CAA) or ileal pouch–anal (IPAA) anastomotic stenosis (AS). Method All patients operated on for AS from 1995 to 2014 were included. Success was defined as the absence of an additional surgical procedure for AS during 12 months after the last procedure and the absence of a stoma at the end of follow-up. Results Fifty consecutive patients presenting with AS after CRA (n = 16, 32%), CAA (n = 18, 36%) or IPAA (n = 16, 32%), performed for colorectal cancer (n = 28, 56%), familial adenomatous polyposis (n = 5, 10%), inflammatory bowel disease (n = 8, 16%), diverticulitis (n = 4, 8%), benign colorectal neoplasia (n = 3, 6%) or other (n = 2, 4%) underwent a total of 99 procedures including digital (n = 14, 14%), instrumental (n = 38, 38%) or endoscopic dilatation (n = 5, 5%), transanal AS stricturoplasty (n = 9, 10%), transanal circular stapler resection (n = 11, 11%) or transabdominal redo-anastomosis (n = 22, 22%). Overall the per-procedure success rate was 53% (52/99). Success rates were 36% (5/14) for digital dilatation, 40% (15/38) for instrumental dilatation, 20% (1/5) for endoscopic dilatation, 64% (7/11) for circular stapler resection, 89% (8/9) for stricturoplasty and 73% (16/22) for transabdominal redo-anastomosis. After a mean follow-up of 46 months, 42/50 (84%) patients had treatment that was considered successful. Multivariate analysis identified redo-anastomosis [OR = 5.1 (95% CI: 1.4–18.7), P = 0.003] as the only independent prognostic factor for success. Conclusion AS should be managed according to a step-up strategy. Conservative procedures are associated with acceptable success rates. If these fail, transabdominal redo-anastomosis is associated with the highest probability of success.

BackgroundThe effect of anastomotic leakage on oncological outcomes after total mesorectal excision (TME) is controversial. This study aimed to assess the influence of symptomatic and asymptomatic anastomotic leakage on oncological outcomes after laparoscopic TME.MethodsAll patients who underwent restorative laparoscopic TME for rectal adenocarcinoma with curative intent from 2005 to 2014 were identified from an institutional database. Asymptomatic anastomotic leakage was defined by CT performed systematically 4–8 weeks after rectal surgery, with no relevant clinical symptoms or laboratory examination findings during the postoperative course.ResultsOf a total of 428 patients, anastomotic leakage was observed in 120 (28·0 per cent) (50 asymptomatic, 70 symptomatic). After a mean follow-up of 40 months, local recurrence was observed in 36 patients (8·4 per cent). Multivariable Cox regression identified three independent risk factors for reduced local recurrence-free survival (LRFS): symptomatic anastomotic leakage (odds ratio (OR) 2·13, 95 per cent c.i. 1·29 to 3·50; P = 0·003), positive resection margin (R1) (OR 2·41, 1·40 to 4·16; P = 0·001) and pT3–4 category (OR 1·77, 1·08 to 2·90; P = 0·022). Patients with no risk factor for reduced LRFS had an estimated 5-year LRFS rate of 87·7(s.d. 3·2) per cent, whereas the rate dropped to 75·3(4·3) per cent with one risk factor, 67(7) per cent with two risk factors, and 14(13) per cent with three risk factors (P < 0·001). Asymptomatic anastomotic leakage was not significantly associated with LRFS in multivariable analysis.ConclusionSymptomatic anastomotic leakage is a risk factor for disease recurrence in patients with rectal adenocarcinoma.

BACKGROUND: Anastomotic leakage after rectal cancer surgery raises the problem of the timing of diverting stoma reversal. OBJECTIVE: The purpose of this study was to assess whether stoma reversal can be safely performed at 6 months after laparoscopic sphincter-saving surgery for rectal cancer with total mesorectal excision in patients with persistent asymptomatic anastomotic leakage. DESIGN: This was a retrospective analysis of a prospective database. SETTINGS: The study was conducted at a tertiary colorectal surgery referral center. PATIENTS: All of the patients with anastomotic leakage were treated conservatively after sphincter-saving laparoscopic total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES: The main study measure was postoperative morbidity. RESULTS: A total of 110 (26%) of 429 patients who presented with anastomotic leakage and were treated conservatively were diagnosed only on CT scan (60 symptomatic (14%) and 50 asymptomatic (12%)). During follow up, 82 (75%) of 110 anastomotic leakages healed spontaneously after a mean delay of 16 ± 6 weeks (range, 4–30 weeks). Among these patients, 7 (9%) of 82 developed postoperative symptomatic pelvic sepsis after stoma reversal. Among the 28 patients remaining, 3 died during follow-up. The remaining 25 patients (23%) presented with persistent asymptomatic anastomotic leakage with chronic sinus >6 months after rectal surgery. Stoma reversal was performed in 19 asymptomatic patients, but 3 (16%) of 19 developed postoperative symptomatic pelvic sepsis after stoma reversal (3/19 vs 7/82 patients; p = 0.217), requiring a redo surgery with transanal colonic pull-through and delayed coloanal anastomosis (n = 2) or standard coloanal anastomosis (n = 1). Regarding the 6 final patients, abdominal redo surgery was performed because of either symptoms or anastomotic leakage with a large presacral cavity. LIMITATIONS: This study was limited by its small sample size. CONCLUSIONS: In the great majority of patients with persistent anastomotic leakage at 6 months after total mesorectal excision, stoma reversal can be safely performed.

Background After sphincter-saving operation for rectal cancer, the impact of anastomotic leakage on function has been well studied. The purpose of the present work was to assess the influence of symptomatic and asymptomatic anastomotic leakage on bowel function and health-related quality of life using the Low Anterior Resection Syndrome score and the disease-specific questionnaire European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer. Methods The study was a case-matched study with multiple controls per case in a variable ratio from a prospectively maintained database conducted at a tertiary, colorectal operation referral center. A total of 46 patients with postoperative anastomotic leakage (symptomatic, n = 23, asymptomatic, n = 23) after laparoscopic, sphincter-saving operative intervention for rectal cancer were matched with all available patients without anastomotic leakage (control group, n = 89) using the following criteria: age, sex, type of neoadjuvant treatment, and type of anastomosis. The Low Anterior Resection Syndrome score and European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer were submitted to all included patients. The Low Anterior Resection Syndrome scores were categorized into 3 categories (no Low Anterior Resection Syndrome, minor Low Anterior Resection Syndrome, and major Low Anterior Resection Syndrome). Results Mean follow-up after stoma closure was 46 ± 26 months. Median (interquartile range) Low Anterior Resection Syndrome score for all included patients was 27 (16–36). Patients with symptomatic anastomotic leakage had impaired Low Anterior Resection Syndrome score: median 30 (23–39) vs 27 (15–34) in the control group (P = .02), with no Low Anterior Resection Syndrome in 4% (vs 31%), minor Low Anterior Resection Syndrome in 52% (vs 52%), and major Low Anterior Resection Syndrome in 44% (vs 17%) (P = .004). No difference was noted between the asymptomatic anastomotic leakage group and control group for median Low Anterior Resection Syndrome score (P = .70) and Low Anterior Resection Syndrome categories (no Low Anterior Resection Syndrome, minor LARS, and major Low Anterior Resection Syndrome; P = .58). Patients with symptomatic anastomotic leakage had significantly more anorectal and urinary symptoms compared with patients with no or asymptomatic anastomotic leakage. Conclusion Symptomatic anastomotic leakage impairs function and quality of life after laparoscopic, sphincter-saving operative intervention for rectal cancer.

Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age

International audience; BackgroundUlcerative colitis (UC) promotes cancer, and can be ameliorated by early appendicectomy for appendicitis. The aim of the study was to explore the effect of appendicectomy on colitis and colonic neoplasia in an animal model of colitis and a cohort of patients with UC. MethodsFive-week old IL10/Nox1(DKO) mice with nascent colitis and 8-week-old IL10/Nox1(DKO) mice with established colitis underwent appendicectomy (for experimental appendicitis or no appendicitis) or sham laparotomy. The severity and extent of colitis was assessed by histopathological examination, and a clinical disease activity score was given. From a cohort of consecutive patients with UC who underwent colectomy, the prevalence of appendicectomy and pathological findings were collected from two institutional databases. ResultsAppendicectomy for appendicitis ameliorated experimental colitis in the mice; the effect was more pronounced in the 5-week-old animals. Appendicectomy in the no-appendicitis group was associated with an increased rate of colonic high-grade dysplasia (HGD) or cancer compared with rates in sham and appendicitis groups (13 of 20 versus 0 of 20 and 0 of 20 respectively; P < 0001). Fifteen of 232 patients who underwent colectomy for UC had previously had an appendicectomy, and nine of these had colonic cancer or HGD. Thirty (138 per cent) of 217 patients with the appendix insitu had colonic neoplastic lesions. Multivariable analysis showed that previous appendicectomy was associated with colorectal neoplasia (odds ratio 1688, 95 per cent c.i. 332 to 11269). ConclusionAppendicectomy for experimental appendicitis ameliorated colitis. The risk of colorectal neoplasia appeared to increase following appendicectomy without induced appendicitis in a mouse model of colitis, and in patients with UC who had undergone appendicectomy. Surgical relevance Appendicectomy for appendicitis protects against UC. In this murine model of colitis, appendicectomy for experimental appendicitis protected against colitis, but appendicectomy without appendicitis promoted colorectal carcinogenesis. In patients with ulcerative colitis who underwent colectomy, absence of the appendix (proof of previous appendicectomy) in the resection specimen was independently associated with colorectal neoplasia. Although patients with UC and a history of appendicectomy represent a small subset, they may need closer monitoring for colorectal neoplasia. Appendicectomy reduces inflammation, increases risk for cancer

Approximately 60% of the million patients diagnosed with colorectal cancer worldwide every year will develop liver metastases (LM) during the course of their disease. Recently, surgical treatment with perioperative oxaliplatin-based chemotherapy has been established as the standard therapy for resectable LM, with an associated 5-year survival approaching 50% (Nordlinger et al. 2008). Despite these encouraging results, more than 30% of the patients will develop intrahepatic recurrence within the three years following complete surgical LM resection (D'Angelica et al. 2011). This high rate of intrahepatic recurrence might be explained, at least in part, by the presence of hepatic micrometastases, undetected during preoperative radiological staging using computed tomography (CT). Yokoyama et al. (2002) Yokoyama et al. studied such micrometastases by immunohistochemical detection and suggested that their presence in pathologic specimens after LM resection indicates widespread hepatic involvement and thus predicts an increased risk of intrahepatic recurrence. For optimization of diagnostic tools and oncological management of such micrometastases in vivo experimental models are needed. To be relevant, such experimental model should meet several requirements (de Jong et al. 2009): (i) be easy to perform and be reproducible, (ii) obtained experimental LM should be histologically accurate, as close as possible to the histological features of genuine LM, (iii) animal hosts should have a normal immune system, as immunity is a key feature in responses to cancer (Banchereau & Steinman 1998), and finally, (iv) the experimental model should resemble human clinical settings closely. In the past, we have used the association of syngenic immunocompetent BDIX rats and the DHD/K12 cell line extensively to produce several experimental models of LM (Panis et al. 1990, 1992, 1996; Caruso et al. 1993; Maggiori et al. 2011). The DHD/K12 cell line is an established transplantable carcinoma cell line originating from a 1,2-dimethylhydralazine-induced colon adenocarcinoma in the BDIX rat (Martin et al. 1983). Using this association, LM can be obtained by intraportal injection (Panis et al. 1992) or by direct injection under the liver capsule (Caruso et al. 1993), inducing in both cases poorly differentiated adenorcarcinoma consisting mainly of tumour cells organized in lobules or thick cell cords, with comparable histological features to genuine LM (Panis et al. 1990, 1992; Caruso et al. 1993). These previous models have been used to evaluate the impact of liver regeneration after portal vein occlusion (Maggiori et al. 2011) and after hepatectomy on immunosuppressive therapy (Panis et al. 1992), and to evaluate the benefit of HSV1-TK and interleukin-12 gene therapies (Caruso et al. 1993; Alves et al. 2004). More recently, we developed a model of micrometastases to assess the possibilities of early detection of such micrometastases by perfusion CT scan. However, to our knowledge, no study focused on closely mimicking the clinical setting of bilobar LM including both macroscopic metastases (i.e. potentially detectable on CT and leading to surgery) and non-detectable micrometastases (Figure 1). We consider that this new experimental model could be particularly relevant in preclinical studies concerning firstly, the development of new imaging technics for detection of ‘undetectable’ LM (i.e. elastoMRI, perfusion CT scan, etc.); and secondly, to evaluate the potential benefit of new drugs in a situation, which is close what is observed in humans: a patient with unilobar macroscopic liver metastase, and possible ‘undetectable’ controlateral LM: (i) before hepatectomy, in neodjuvant setting, (ii) after partial hepatectomy to prevent recurrence within the remnant liver. Figure 1 Experimental model (right) and corresponding clinical situation (left): single macroscopic liver metastasis (black colour) and multiple diffuse micrometastases (grey colour). Thus, the aim of this study was to develop and describe an in vivo relevant experimental model of bilobar LM including both macroscopic colorectal liver metastasis and micrometastases using immunocompetent BDIX rats and DHD/K12 cell line.

OBJECTIVE: This study aimed to assess the results of segmental reversal of the small bowel (SRSB) in patients with short bowel syndrome (SBS) who were "permanently" dependent on parenteral nutrition (PN) and to identify possible prognostic factors for weaning. SUMMARY BACKGROUND DATA: SRSB is a nontransplant surgical option for patients with SBS who require long-term PN. Few studies have reported outcomes in humans. METHODS: : All patients who were permanently dependent on PN and underwent a SRSB between 1985 and 2010 for SBS were included. The data were retrospectively retrieved. RESULTS: Thirty-eight patients underwent SRSB. The median age was 55.5 years (range, 18-76). The median length of the small bowel remnant was 49 cm (20-140), including a reversed segment of 10 cm (6-15). The median follow-up was 57.7 months (1-304). At the 5-year follow-up, 17 patients had been weaned from PN (45%). In the remaining patients, PN dependency had decreased from 7 ± 1 to 4 ± 1 days per week. The survival rate was 84%. The prognostic factors for weaning were a short time between subtotal enterectomy and SRSB (P = 0.036), a longer than typical stay in the nutrition unit (P = 0.035), and an SRSB longer than 10 cm (P = 0.024). CONCLUSIONS: SRSB has a role as a conservative alternative to small bowel transplantation in patients with SBS permanently dependent on PN. With a segmental reversal of 10 to 12 cm, almost half of the patients can be expected to be weaned from PN.

Aim A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter-saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life. Methods Anal sphincter training was performed in patients undergoing laparoscopic sphincter-saving TME for rectal cancer. Rehabilitation was performed after ileostomy closure. This group was compared with 24 matched patients. Assessment included one functional and two quality of life questionnaires (SF-36 Health Status and Faecal Incontinence Quality of Life score). Results From 2007 to 2009, 22 patients underwent laparoscopic TME. The median follow-up after stoma closure was 21.2 (range 8–46) months. The mean stool frequency per day was significantly lower after sphincter training (2.6 in the training group vs 4.0 in the control group, P = 0.025). Following rehabilitation, patients complained significantly less about dyschezia (22 vs 63%, P = 0.008). Both groups had similar continence (Wexner score 8.3 after training vs 9.9 in controls, NS). Quality of life was significantly improved by sphincter training as measured by the vitality (P = 0.004) and mental functioning (P = 0.02) subscales on the SF-36 Health Status questionnaire and by the depression and self-perception (P = 0.005) categories of the Faecal Incontinence Quality of Life score. Conclusion This study suggests that anal sphincter training following TME could decrease stool frequency and improve both general and specific quality of life.

Aim Single-incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single-incision laparoscopic surgery was assessed, including the patient outcomes. Method A meta-analysis was performed of studies comparing single-incision laparoscopic with multiport laparoscopy. Endpoints included conversion to laparotomy, operation time, postoperative morbidity, length of skin incision and length of hospital stay. The MEDLINE database was searched and only comparative studies were included in the meta-analysis. Data were retrieved from full-text manuscripts. Meta-analysis was performed according to the Mantel–Haenszel method for random effects. Results From October 2008 to December 2011, 1026 colorectal resections including 921 colonic and 105 rectal procedures using single-incision laparoscopic surgery were reported in 64 studies. Meta-analysis of the 15 comparative studies, including a total of 1075 procedures (494 single-incision and 581 multiport laparoscopies), showed no difference in conversion to open laparotomy [odds ratio (OR) 0.58 (0.24, 1.38); P = 0.22], morbidity [OR 0.84 (0.61, 1.15); P = 0.27] or operation time [weighted mean difference (WMD) −0.27 (−6.50, 5.95); P = 0.93], but a significantly shorter total skin incision [WMD −0.52 (−0.79, −0.25); P

Purpose To analyze the efficacy, toxicity, and pattern of relapse after adjuvant cisplatin-based chemotherapy followed by three-dimensional irradiation and concomitant LV5FU2 chemotherapy (high-dose leucovorin and 5-fluorouracil bolus plus continuous infusion) in the treatment of completely resected high-risk gastric cancer. Methods and Materials This was a retrospective analysis of 52 patients with high-risk gastric cancer initially treated by total/partial gastrectomy and lymphadenectomy between January 2002 and June 2007. Median age was 54 years (range, 36–75 years). Postoperative treatment consisted of 5-fluorouracil and cisplatin chemotherapy. Adjuvant chemotherapy was followed by three-dimensional conformal radiotherapy in the tumor bed and regional lymph nodes at 4500 cGy/25 fractions in association with concomitant chemotherapy. Concomitant chemotherapy consisted of a 2-h infusion of leucovorin (200 mg/m²) followed by a bolus of 5-fluorouracil (400 mg/m²) and then a 44-h continuous infusion of 5-fluorouracil (2400–3600 mg/m²) given every 14 days, for three cycles (LV5FU2 protocol). Results Five-year overall and disease-free survival were 50% and 48%, respectively. Distant metastases and peritoneal spread were the most frequent sites of relapse (37% each). After multivariate analysis, only pathologic nodal status was significantly associated with disease-free and overall survival. Acute toxicities were essentially gastrointestinal and hematologic. One myocardial infarction and one pulmonary embolism were also reported. Eighteen patients had a radiotherapy program interruption because of acute toxicity. All patients but 2 have completed radiotherapy. Conclusion Postoperative cisplatin-based chemotherapy followed by conformal radiotherapy in association with concurrent 5-fluorouracil seemed to be feasible and resulted in successful locoregional control.

Transanal endoscopic microsurgery (TEM) was introduced in 1983 as an alternative to radical proctectomy for the management of rectal adenomas unsuitable for endoscopic or standard transanal resection. Since, its indications have progressively broadened to early rectal cancer. This review article will assess the role of TEM for T1 rectal cancer management, along with its operative and long-term results.

Background: Today, there is no consensus about the best management of the remaining rectum following subtotal colectomy for acute colitis complicating inflammatory bowel disease. There are three options: intra-peritoneal rectal stump closure (Hartmann's pouch with closed stapled rectal stump), creat

Background Portal vein embolization (PVE) has been proposed to induce hypertrophy of liver before major resection. Because there are some concerns about the effect on tumor growth, experimental research is needed, requiring reliable small animal model. The aim was to assess technical feasibility of PVE model in rat and to report colorectal liver metastases (LM) tumor growth. Methods LM were induced in 40 rats by injecting DHDK12 cells into the left liver lobe. At d 7, a portography was performed through a laparotomy in 20 rats allowing the left PVE. Twenty rats without PVE served as control. All rats were sacrificed at d 30. Liver and tumor volume were calculated. Results Mortality rate was 20% (n = 8). PVE was successful in 15/19 rats (79%). Compared with control rats, the left PVE induced both significant atrophy of the left lobe (3.5 ± 0.8 versus 7.4 ± 0.9 mm3, P < 0.0001) and contralateral hypertrophy (5.8 ± 1.1 versus 3.6 ± 0.7 mm3, P < 0.0001). LM tumor volume in the left liver was significantly decreased in PVE group compared to control, 124.4 ± 95.7 mm3versus 231.1 ± 90.1 mm3, P = 0.008. Conclusion PVE is feasible in rats with a 79% success rate. Significant hypertrophy of the remnant liver and atrophy of the embolized liver were noted suggesting the efficacy of PVE. LM tumor growth decreased significantly in the embolized lobe. Our model can be used for experimental studies evaluating tumor growth and effects of new drugs against LM in a situation that mimics the human situation before partial hepatectomy.

Locally advanced rectal cancers mainly correspond to lieberkunhien adenocarcinomas and are defined by T3-T4 lesions with or without regional metastatic lymph nodes. Such tumors benefit from neoadjuvant treatment combining chemotherapy and radiotherapy, followed by surgery with total mesorectum excision. Such a strategy can decrease the rate of local relapse and lead to an easier complementary surgery. The pathologist plays an important role in the management of locally advanced rectal cancer. Indeed, he is involved in the gross examination of the mesorectum excision quality and in the exhaustive sampling of the most informative areas. He also has to perform a precise histopathological analysis, including the determination of the circumferential margin or clearance and the evaluation of tumor regression. All these parameters are major prognostic factors which have to be clearly included in the pathology report. Moreover, the next challenge for the pathologist will be to determine and validate new prognostic and predictive markers, notably by using pre-therapeutic biopsies. The goal of this mini-review is to emphasize the pathologist's role in the different steps of the management of locally advanced rectal cancers and to underline its implication in the determination of potential biomarkers of aggressiveness and response.

The ability to predict response after chemoradiotherapy in rectal adenocarcinoma may allow selecting patients to whom less invasive surgical treatment could be proposed. Tumor hypoxia has been implicated in the mechanisms of resistance to chemoradiotherapy in several malignancies. The aim was to identify morphological criteria and molecular markers of hypoxia associated with chemoradiotherapy response. Clinicopathologic data from 61 patients (35 male, 60.5 ± 10 years) undergoing rectal cancer resection after neoadjuvant chemoradiotherapy were collected. Pretreatment biopsies, available for 40 patients, were immunostained for hypoxia markers (carbonic anhydrase 9, glucose transporter 1, chemokine receptor 4) and microvascular density determination. Mean tumor size was 2.7 ± 1.6 cm. Twenty-one patients (34%) were considered as responders, that is, having significant or complete primary tumor regression without lymph node metastasis. Compared to other patients, responders had significantly more often flat tumors with or without ulceration (57% versus 18%, P = .01) and less vascular and/or neural invasions (9% versus 65%, P < .0001) or tumor necrosis (9% versus 41%, P < .01), respectively. Regarding pretreatment biopsies, carbonic anhydrase 9 expression was significantly lower in responders (7% versus 46%, P = .012). This study showed that tumor necrosis as an overexpression of carbonic anhydrase 9 was an effective molecular marker of postchemoradiotherapy response. This might suggest a key role of hypoxia in resistance mechanisms of chemoradiotherapy in rectal adenocarcinoma. This study highlighted the importance of predictive criteria to chemoradiotherapy response in proposing to selected patients an alternative treatment (eg, local resection) to more radical surgery.

Background Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. Methods Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed. Results Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31). Conclusion Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.