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International audience; Aim Neoadjuvant chemotherapy has proven valuable in locally advanced resectable colon cancer (CC) but its effect on oncological outcomes is uncertain. The aim of the present paper was to report 3-year oncological outcomes, representing the secondary endpoints of the PRODIGE 22 trial. Method PRODIGE 22 was a randomized multicentre phase II trial in high-risk T3, T4 and/or N2 CC patients on CT scan. Patients were randomized between 6 months of adjuvant FOLFOX (upfront surgery) or perioperative FOLFOX (four cycles before surgery and eight cycles after; FOLFOX perioperative). In wild-type RAS patients, a third arm testing perioperative FOLFOX-cetuximab was added. The primary endpoint was the tumour regression grade. Secondary endpoints were 3-year overall survival (OS), disease-free survival (DFS), recurrence-free survival (RFS) and time to recurrence (TTR). Results Overall, 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped for futility. The remaining 104 patients represented our intention-to-treat population. In the perioperative group, 96% received the scheduled four neoadjuvant cycles and all but one had adjuvant FOLFOX for eight cycles. In the control arm, 38 (73%) patients received adjuvant FOLFOX. The median follow-up was 54.3 months. Three-year OS was 90.4% in both arms [hazard ratio (HR) = 0.85], 3-year DFS, RFS and TTR were, respectively, 76.8% and 69.2% (HR=0.94), 73% and 69.2% (HR = 0.86) and 82% and 72% (HR = 0.67) in the perioperative and control arms, respectively. Forest plots did not show any subgroup with significant difference for survival outcomes. No benefit from adding cetuximab was observed. Conclusion Perioperative FOLFOX has no detrimental effect on long-term oncological outcomes and may be an option for some patients with locally advanced CC.

International audience; To evaluate whether systematic mesh implantation upon primary colostomy creation was effective to prevent PSH.Summary of background data: Previous randomized trials on prevention of PSH by mesh placement have shown contradictory results.Methods: This was a prospective, randomized controlled trial in 18 hospitals in France on patients aged ≥18 receiving a first colostomy for an indication other than infection. Participants were randomized by blocks of random size, stratified by center in a 1:1 ratio to colostomy with or without a synthetic, lightweight monofilament mesh. Patients and outcome assessors were blinded to patient group. The primary endpoint was clinically diagnosed PSH rate at 24 months of the intention-to-treat population. This trial was registered at ClinicalTrials.gov, number NCT01380860.Results: From November 2012 to October 2016, 200 patients were enrolled. Finally, 65 patients remained in the no mesh group (Group A) and 70 in the mesh group (Group B) at 24 months with the most common reason for drop-out being death (n = 41). At 24 months, PSH was clinically detected in 28 patients (28%) in Group A and 30 (31%) in Group B [P = 0.77, odds ratio = 1.15 95% confidence interval = (0.62;2.13)]. Stoma-related complications were reported in 32 Group A patients and 37 Group B patients, but no mesh infections. There were no deaths related to mesh insertion.Conclusion: We failed to show efficiency of a prophylactic mesh on PSH rate. Placement of a mesh in a retro-muscular position with a central incision to allow colon passage cannot be recommended to prevent PSH. Optimization of mesh location and reinforcement material should be performed.

Summary Background The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to cytoreductive surgery has been associated with encouraging survival results in some patients with colorectal peritoneal metastases who were eligible for complete macroscopic resection. We aimed to assess the specific benefit of adding HIPEC to cytoreductive surgery compared with receiving cytoreductive surgery alone. Methods We did a randomised, open-label, phase 3 trial at 17 cancer centres in France. Eligible patients were aged 18–70 years and had histologically proven colorectal cancer with peritoneal metastases, WHO performance status of 0 or 1, a Peritoneal Cancer Index of 25 or less, and were eligible to receive systemic chemotherapy for 6 months (ie, they had adequate organ function and life expectancy of at least 12 weeks). Patients in whom complete macroscopic resection or surgical resection with less than 1 mm residual tumour tissue was completed were randomly assigned (1:1) to cytoreductive surgery with or without oxaliplatin-based HIPEC. Randomisation was done centrally using minimisation, and stratified by centre, completeness of cytoreduction, number of previous systemic chemotherapy lines, and timing of protocol-mandated systemic chemotherapy. Oxaliplatin HIPEC was administered by the closed (360 mg/m2) or open (460 mg/m2) abdomen techniques, and systemic chemotherapy (400 mg/m2 fluorouracil and 20 mg/m2 folinic acid) was delivered intravenously 20 min before HIPEC. All individuals received systemic chemotherapy (of investigators' choosing) with or without targeted therapy before or after surgery, or both. The primary endpoint was overall survival, which was analysed in the intention-to-treat population. Safety was assessed in all patients who received surgery. This trial is registed with ClinicalTrials.gov , NCT00769405 , and is now completed. Findings Between Feb 11, 2008, and Jan 6, 2014, 265 patients were included and randomly assigned, 133 to the cytoreductive surgery plus HIPEC group and 132 to the cytoreductive surgery alone group. After median follow-up of 63·8 months (IQR 53·0–77·1), median overall survival was 41·7 months (95% CI 36·2–53·8) in the cytoreductive surgery plus HIPEC group and 41·2 months (35·1–49·7) in the cytoreductive surgery group (hazard ratio 1·00 [95·37% CI 0·63–1·58]; stratified log-rank p=0·99). At 30 days, two (2%) treatment-related deaths had occurred in each group.. Grade 3 or worse adverse events at 30 days were similar in frequency between groups (56 [42%] of 133 patients in the cytoreductive surgery plus HIPEC group vs 42 [32%] of 132 patients in the cytoreductive surgery group; p=0·083); however, at 60 days, grade 3 or worse adverse events were more common in the cytoreductive surgery plus HIPEC group (34 [26%] of 131 vs 20 [15%] of 130; p=0·035). Interpretation Considering the absence of an overall survival benefit after adding HIPEC to cytoreductive surgery and more frequent postoperative late complications with this combination, our data suggest that cytoreductive surgery alone should be the cornerstone of therapeutic strategies with curative intent for colorectal peritoneal metastases. Funding Institut National du Cancer, Programme Hospitalier de Recherche Clinique du Cancer, Ligue Contre le Cancer.

Background and Aims Intestinal epithelial cells [IECs] from inflammatory bowel disease [IBD] patients exhibit an excessive induction of endoplasmic reticulum stress [ER stress] linked to altered intestinal barrier function and inflammation. Colonic tissues and the luminal content of IBD patients are also characterized by increased serine protease activity. The possible link between ER stress and serine protease activity in colitis-associated epithelial dysfunctions is unknown. We aimed to study the association between ER stress and serine protease activity in enterocytes and its impact on intestinal functions Methods The impact of ER stress induced by Thapsigargin on serine protease secretion was studied using either human intestinal cell lines or organoids. Moreover, treating human intestinal cells with protease-activated receptor antagonists allowed us to investigate ER stress-resulting molecular mechanisms that induce proteolytic activity and alter intestinal epithelial cell biology. Results Colonic biopsies from IBD patients exhibited increased epithelial trypsin-like activity associated with elevated ER stress. Induction of ER stress in human intestinal epithelial cells displayed enhanced apical trypsin-like activity. ER stress-induced increased trypsin activity destabilized intestinal barrier function by increasing permeability and by controlling inflammatory mediators such as C-X-C chemokine ligand 8 [CXCL8]. The deleterious impact of ER stress-associated trypsin activity was specifically dependent on the activation of protease-activated receptors 2 and 4. Conclusions Excessive ER stress in IECs caused an increased release of trypsin activity that, in turn, altered intestinal barrier function, promoting the development of inflammatory process.

Background Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination. Methods From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy. Results The median follow-up was 76 months (range: 12–334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up. Discussion Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.

Ventral mesh rectopexy (VMR) is a surgical option to treat rectal prolapse with pelvic floor dysfunction (PFD). Using synthetic surgical glue to fix the mesh to the anterior rectal wall after ventral dissection could be advantageous in comparison with sutured or stapled fixation. This study aimed to evaluate the safety and efficacy of synthetic surgical glue for mesh fixation compared with suture mesh fixation in VMR. This observational cohort study is a retrospective analysis conducted in a University Hospital Pelvic Surgery Center. All consecutive female patients (n = 176) who underwent laparoscopic or laparotomic VMR between January 2009 and December 2014 were included. Two groups were defined based on mesh fixation technique of the rectal wall: VMR with synthetic glue (n = 66) and VMR with suture (n = 110). The recurrence-free survival after VMR was determined by Kaplan–Meier method and multivariate analysis by Cox regression. Short-term postoperative complications, postoperative symptom improvement, the need for complementary treatment postoperatively, and procedure length were evaluated. A total of 176 females patients (mean age, 58.6 ± 13.7 years) underwent VMR with synthetic mesh. Mean recurrence-free survivals after VMR were 17.16 (CI 95% 16.54–17.80) and 17.33 (CI 95% 16.89–17.77) months in the glue group and the suture group, respectively (p > 0.05). Cox regression identified an independent effect on the recurrence risk of the external rectal prolapse, alone, or in combination with other anatomical abnormalities (HR = 0.37; CI 95% 0.14–0.93; p = 0.03). There was no significant difference of short-term postoperative morbidity, procedure length, postoperative symptom improvement, or need for complementary treatment postoperatively between suture versus glue groups (all p > 0.05). Use of glue to fix the mesh in VMR was safe and had no impact on outcomes. External prolapse was the unique significant predictive factor for recurrence.

4110 Background: Neoadjuvant chemotherapy in a perioperative setting has proven valuable in locally advanced resectable colon cancer (CC) in terms of toxicity, postoperative morbidity and downstaging, but its effect on oncological outcomes remains uncertain. Methods: Prodige 22 was a randomized multicenter phase II trial in patients with resectable high-risk T3, T4 and/or N2 CC on baseline CT-scan. Patients were randomized to receive either 6 months of adjuvant FOLFOX after colectomy (control) or perioperative FOLFOX for 4 cycles before surgery and 8 cycles after (FOLFOX peri-op). In RAS wild-type (wt) patients a third arm testing perioperative FOLFOX-cetuximab was added. Primary endpoint was the Tumor Regression Grade. Secondary endpoints were 3-years overall (OS), disease-free survival (DFS) and time to recurrence (TTR). Results: 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped for futility. The remaining 104 patients (control, n = 52; FOLFOX peri-op n = 52) represented our intention-to-treat population. In the FOLFOX peri-op group, 96% received the schedule 4 cycles prior to surgery and all but one underwent adjuvant FOLFOX for a total of 12 cycles. In the control arm, 38 patients received adjuvant FOLFOX (1 postoperative death and 13 low-risk stage II patients). Median follow-up was 54.3 months [48.5-57.2]. Nineteen deaths and 26 disease recurrences were observed leading to a 3 years-OS of 90.3% in both arms (p = 0.7) and to a 3-years DFS of 76.8% and 69.2% in the peri-op and control arm respectively (p = 0.6). A trend to a better TTR in the peri-op arm was observed with a 3-years TTR of 82% as compared to 72% in the control arm (p = 0.3). No benefit from adding Cetuximab was observed in the 16 RAS-wt treated patients. Conclusions: In this pilot randomized study, perioperative FOLFOX chemotherapy has no detrimental effect on long term oncological outcomes and may be an option for some patients with locally advanced CC. A pooled analysis of randomized trials testing peri-operative strategies in this setting is warranted. Clinical trial information: NCT01675999 .

IF 3.061; International audience; IntroductionThis document is a summary of the French Intergroup guidelines regarding the management of rectal adenocarcinoma published in February 2016.MethodThis collaborative work, under the auspices of most of the French medical societies involved in the management of rectal cancer, is based on the previous guidelines published in 2013. Recommendations are graded into 3 categories according to the level of evidence of data found in the literature.ResultsIn agreement with the ESMO guidelines (2013), non-metastatic rectal cancers have been stratified in 4 risk groups according to endoscopy, MRI or endorectal-ultrasonography. Locally-advanced tumors are limited to groups 3 and 4 (T3 ≥4 cm or T3c–d or N1-2 or T4). These tumors are usually treated using neoadjuvant treatment and total proctectomy (TME). Adjuvant treatment depends on the pathological findings. Very early (group 1) or early (group 2) tumors are managed mainly by surgery, and organ preservation may be an option in selected cases. For metastatic tumors, the recommendations are based on less robust evidence and chemotherapy plays a major role.ConclusionSuch recommendations are constantly being optimized and each individual case must be discussed within a Multi-Disciplinary Team.

Resume En presence d’une lithiase vesiculaire asymptomatique, la cholecystectomie preventive n’est theoriquement plus indiquee depuis les recommandations de la Conference de Consensus francaise sur la lithiase vesiculaire de 1991. Pourtant, le benefice potentiel d’une cholecystectomie prophylactique (CP) lors de certaines interventions abdominales pour pathologie non biliaire reste discute. Ce debat a ete notamment relance par le developpement recent de la chirurgie bariatrique. Les gastrectomies pour cancer, les resections du grele, les resections coliques, les splenectomies pour spherocytose hereditaire et toutes les interventions de chirurgie bariatrique sont autant de situations pouvant modifier la physiologie de la lithiase biliaire et donc faire discuter de l’interet d’une CP dont la morbidite propre ne peut etre negligee. Le but de ce travail etait de rapporter les donnees epidemiologiques et physiopathologiques, et les resultats de la litterature afin d’evaluer l’interet d’une CP concomitante lors de differentes situations chirurgicales courantes.

Introduction Les protheses biologiques sont utilisees dans des indications limitees, notamment la reparation parietale en milieu contamine en raison de leur cout eleve. Leur efficacite est remise en question par plusieurs etudes recentes. Nous avons donc etudie les resultats, dont la recidive, de l’ensemble de nos patients ayant recu une prothese biologique. Materiel et methode Au total, 68 patients ayant eu une mise en place de prothese biologique de 2009 a 2015, dans un seul centre, ont ete revus retrospectivement. Resultats Le site de pose etait sur la paroi abdominale anterieure dans 72 % des cas, pelvien dans 28 %. La mediane de suivi etait de 19 mois. En postoperatoire precoce, 30 % des patients ont eu un abces de paroi ; 73 % ont presente une complication tardive dont 16 % d’infection de site operatoire. Au total, 56 % des patients ont presente une recidive d’eventration. En analyse multivariee, les facteurs de risque de recidive etaient une eventration peri-stomiale (p = 0,007) et la cure d’une recidive d’eventration (p = 0,002). Conclusion Une majorite de patients presente une recidive d’eventration a moyen terme ce qui remet en question l’utilisation des protheses biologiques. Leurs resultats devront etre confrontes a ceux des protheses semi-resorbables.

Summary Objectives In France, seton drainage followed by fistulotomy is currently the standard treatment for high cryptoglandular fistula-in-ano. Biological or synthetic glues, such as Glubran ® 2, have been recently proposed for sealing the fistula tract. The purpose of this study is to determine the healing rate with glubran 2 and to assess the functional outcome after cure of fistula-in-ano. Patients and methods From July 2006 to July 2008, 34 patients (20 males; median age 48.5 years, range 22–55 years) with high cryptoglandular anal fistulas were treated with glubran 2. Patients were seen for physical examination at 1, 3 and 6 months, then interviewed by telephone at 1 and 2 years, and in September 2009. The Fecal incontinence severity index (FISI) score was used to assess continence. Results The healing rate at 1 month was 67.6% (23 patients); the fistula failed to heal in 11 patients. All 23 patients with a healed fistula remained recurrence-free, with no continence disorders noted, during the median 34-month follow-up period (range 21–43 months). One patient was lost to follow-up after 6 months. Conclusion Glubran 2 provides an effective treatment for high fistula-in-ano, with no change in continence. In future, a randomized comparison of this agent with fibrin glues should be useful.

This study was carried out in 115 horses between 2 and 9 years old, ready to race or actively racing. The animals were divided into two groups : 23 horses with good racing results representing the control group, and 92 horses with poor racing results. The standardised exercise test started with a 10 min warm-up at a slow trot, followed by 3 periods of exercise of 3 min each. After the three periods, the horse was stopped on the treadmill for 1 min, the endoscope was inserted, and the horse performed a fourth period at maximal speed. The heart rate (HR) was measured throughout the test and blood was collected via a catheter inserted in the transverse facial artery during the last 10 seconds of each period. One hour after the exercise, a broncho-alveolar lavage (BAL) was performed. The results of this study (HR, blood lactate, PaO2) suggest that there is a significant difference in the metabolic response to exercise between poor performers and good performers. The results of the endoscopy during exercise and post-exercise BAL were used to divide poor performers into 4 groups, based on the localisation of the problem : upper respiratory airway (URA) disease, lower respiratory airway (LRA) disease, URA and LRA disease, and other diseases. These tests were also used to evaluate the metabolic response to exercise in the different situations. Post-exercise BAL may provide important information, even in horses with evidence of upper respiratory disease., Cette étude a été réalisée chez 115 chevaux âgés de deux à neuf ans, prêts à courir ou participant à des courses. Les animaux étaient divisés en deux groupes : 23 chevaux obtenant de bons résultats en course et constituant le groupe témoin, et 92 chevaux n’obtenant pas de bons résultats. L’exercice standardisé comprenait dix minutes d’échauffement au petit trot, puis trois paliers d’exercice de trois minutes chacun. Après les trois paliers, le cheval était arrêté une minute, l’endoscope était mis en place, et un quatrième palier était effectué à vitesse maximale. La fréquence cardiaque (FC) était mesurée en continu pendant le test et un échantillon de sang était prélevé par un cathéter placé dans l’artère faciale transverse pendant les dix dernières secondes de chaque palier. Une heure après l’exercice, un lavage broncho-alvéolaire (LBA) était effectué. Les résultats concernant la FC, la lactatémie et la PaO2 suggèrent qu’il existe une différence significative dans la réponse métabolique à l’exercice entre les chevaux contre-performants et les chevaux du groupe témoin. L’endoscopie à l’exercice et le LBA ont permis de répartir les chevaux contre-performants en quatre groupes selon la localisation des affections : affections des voies respiratoires supérieures (VRS), affections des voies respiratoires profondes (VRP), affections des VRS et des VRP, et autres affections. Ces examens ont aussi permis d’évaluer la réponse métabolique à l’exercice dans les différentes situations. La réalisation d’un LBA après exercice peut fournir des informations importantes et ce, même chez des chevaux présentant une affection évidente des voies respiratoires supérieures., Couroucé Anne, Fortier Guillaume, Pronost Stéphane, Corde Richard, Rossignol Fabrice, Deniau Valérie. Paramètres physiologiques et évaluation des voies respiratoires supérieures et profondes chez des chevaux trotteurs soumis à un exercice standardisé sur tapis roulant. In: Bulletin de l'Académie Vétérinaire de France tome 161 n°4, 2008. pp. 351-358.

Local recurrence (LR) after curative surgery for rectal cancer occurs in 4 to 33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). In many cases, diagnosis of LR is made at a late stage because of the high rate of asymptomatic patients, 56% in the experience of the Mayo Clinic. MRI and PETscan are most effective for assessing local and general extension, with a high diagnostic accuracy. Surgical treatment alone or with radiation (preoperative and/or intraoperative) is the only curative treatment of LR with R0 resectability rates of 30% to 45%. Morbidity and mortality rates are high, especially for total exenteration and abdomino-sacral resection. After curative surgery, 5-year global survival is between 30% and 40%. Palliative resection of macroscopic residues is not recommended. Careful patient selection for curative surgery is the best way to optimize treatment in these cases.

The determination of microsatellite instability (MSI) is an important step in the identification of familial colorectal cancer such as hereditary nonpolyposis colon cancer. It could also be of interest in the therapeutic management of sporadic cancer. International criteria for the determination of MSI have been published, recommending the use of microdissection. The aim of this work was to evaluate the impact of contaminant normal DNA in tumor samples for MSI assessment in colorectal cancer using a microdissection technique. We performed a comparative analysis of the microsatellite status between total DNA (DNA extracted from whole tumor samples) and microdissected DNA in 3 different regions from 23 cases of colorectal cancer. Six microsatellites were amplified using fluorescent polymerase chain reaction. We analyzed 9 cases with MSI and 14 cases without instability, with similar results between total DNA and microdissected DNA. Moreover, within a same tumor, the MSI phenotype was observed regardless of the region analyzed. Thus, this work shows the reproducibility of the MSI phenotype throughout a tumor. However, we observed a regional heterogeneity of the MSI profile, consisting of variations in the number and the size of unstable alleles within different regions. This result reflects the genetic heterogeneity of colorectal cancer with MSI. In the 14 cases without instability, we observed an increase of more than 60% in the loss of heterozygosity detection rate after microdissection. Thus, this work confirms the contribution of microdissection for loss of heterozygosity assessment.

PURPOSE: Abdominoperineal resection, with iliac colostomy, remains the gold standard treatment for very low-lying rectal cancer, but it alters patients' quality of life. Alternatives to iliac colostomy need to be experimented. Antegrade enemas via a cecal access (Malone operation) obtains a colonic emptying and improves continence for incontinent patients. Continence and quality of life after abdominoperineal resection and perineal colostomy associated to a Malone antegrade continence enema were studied. METHODS: After abdominoperineal resection for cancer, 18 patients had a digestive reconstruction by perineal colostomy and Malone antegrade continence enema. Patients performed antegrade enemas every 24 to 48 hours with tap water. After six months, continence (Cleveland Clinic score) and quality of life (Fecal Incontinence Quality of Life scale) were recorded. RESULTS: Morbidity was 5 percent (1 appendix necrosis). All patients could perform antegrade enemas by themselves. Mean continence score was 6.41/20 (standard error, 2.31). Fecal Incontinence Quality of Life scores were: lifestyle 3.18/4 (standard error, 0.83); coping/ behavior 2.99/4 (standard error, 0.83); depression/self-perception 3.11/4 (standard error, 0.83); embarrassment 2.84/4 (standard error, 0.63). CONCLUSIONS: After abdominoperineal resection, Malone antegrade continence enema associated to perineal colostomy provided an acceptable continence. It preserved patients' body image and resulted in a satisfying quality of life. It could become an alternative to iliac colostomy in selected patients.

L’artere hepatique commune, issue du tronc cœliaque (TC), se divise en 2 branches : l’artere hepatique propre (AHP) se divisant elle-meme en 2 branches terminales, et l’artere gastroduodenale (AGD). Cette vascularisation modale n’est retrouvee que dans 76 % des cas. Dans 10 %, une artere hepatique droite (AHD) nait directement de l’artere mesenterique superieure (AMS). Elle peut vasculariser le foie droit, le lobe droit ou l’ensemble du foie (AHD foie total). Cette variante anatomique peut compliquer la duodenopancreatectomie cephalique (DPC), seul traitement curatif des tumeurs pancreatiques cephaliques (80 % des tumeurs pancreatiques totales). Si elle nait precocement sur l’AMS, alors son trajet passe au sein de la lame retro-portale, necessairement resequee lors de la DPC pour etre en resection microscopiquement complete (R0). Cependant la ligature de l’AHD risque d’entrainer une ischemie hepatique ainsi qu’un plus haut risque de fistule anastomotique (bilio-digestive). Nous avons observe, dans notre centre, notre pratique face a une AHD lors d’une DPC. Entre janvier 2012 et janvier 2015, 83 patients ont eu une DPC. Neuf d’entre eux presentaient une AHD (11 %). Leur prise en charge a consiste en peropertatoire a une section et reimplantation dans 1 cas (11 %), ligature-section simple dans 1 cas (11 %), et conservation dans 7 cas (77 %). Aucune ischemie hepatique n’etait notee. En presence d’une AHD, le pourcentage de resection microscopiquement incomplete passait de 22 % a 33 %, ce qui n’etait pas significatif. La presence d’une AHD complique nettement la DPC et a meme longtemps ete consideree comme une contre-indication a cette chirurgie. Cependant, dans notre etude, nous constatons qu’elle ne compromet pas le resultat oncologique. En 2014, une equipe lilloise proposait meme une embolisation de l’AHD 3 semaines avant la DPC pour permettre le developpement d’une collateralite et donc sa section en securite. Aujourd’hui une AHD ne doit plus contre indiquer une DPC.

The presence of asymptomatic gallstones is no longer an indication for elective prophylactic cholecystectomy (PC) according to the recommendations of the 1991 French Consensus Conference on cholelithiasis. However, there may be potential benefits of performing prophylactic cholecystectomy during certain abdominal procedures for non-biliary disease; this remains a subject of debate. This debate has become livelier with the recent increase in bariatric surgery. Gastrectomy for cancer, small bowel resection, colonic resection, and splenectomy for hereditary spherocytosis as well as all bariatric surgical interventions can all alter the physiology of gallstone disease raising the question of the value of PC, but the specific morbidity of cholecystectomy must be kept in mind. The purpose of this study was to report epidemiological and pathophysiological data and the results from literature reports in order to assess the value of concomitant prophylactic cholecystectomy during various common surgical situations.

Le traitement chirurgical par duodeno-pancreatectomie cephalique (DPC) est, ce jour, le seul traitement curatif des tumeurs pancreatiques cephaliques (80 % des tumeurs pancreatiques). Il permet une survie globale a 5 ans de 20 % (vs 3 %) si la resection chirurgicale est microscopiquement complete (R0). La situation anatomique de la tete du pancreas explique le faible pourcentage de resecabilite (environ 20 % d’emblee). En effet, elle est au contact de structures majeures : la veine mesenterique (VMS), l’artere mesenterique (AMS) (avec la lame retro portale s’y inserant) et la veine porte en posterieur, ainsi que le tronc cœliaque en superieur. L’engainement de ces vaisseaux par une tumeur la rend alors non resecable. Nous avons recueilli dans notre centre tous les patients ayant presente une tumeur pancreatique cephalique entre janvier 2012 et janvier 2015. Les limites vasculaires a la resecabilite etaient observees. Trois cent quarante et un patients etaient recenses, avec 80 (23 %) operes d’emblee d’une DPC. Cent quatre patients (30 %) presentaient des limites vasculaires a leur resecabilite (tumeur localement avancee) ; principalement par engainement de l’AMS dans 42 % des cas (n = 43), et de la VMS dans 35 % des cas (n = 36). Quatre-vingt trois patients (80 %) ont alors recu un traitement neo adjuvant au terme duquel 3 seulement (3,5 %) ont pu etre operes. Chez 9 patients (10,8 %), nous avons associe une resection segmentaire veineuse (mesenterico porte) pour autoriser la DPC. Au total, 83 patients etaient operes d’une DPC (24 %) : 18 (soit 22,5 %) etaient R1 (resection microscopiquement incomplete) : 8 sur la lame retro portale, 8 sur les vaisseaux mesenteriques et 3 sur la tranche pancreatique. Ce pourcentage etait statistiquement plus eleve en cas de resection veineuse associee a la DPC (77 % vs 16 %) (p = 0,001). Les tumeurs pancreatiques cephaliques voient leur incidence augmenter de facon considerable. Des propositions apparaissent pour ameliorer leur resecabilite, notamment en cas de contacts vasculaires, avec des resultats pour l’instant discordants.

Background Recommended strategies to screen for Lynch syndrome in colorectal cancer are not applied in daily practice and most of Lynch cases remain undiagnosed. Aims We investigated in routine conditions a strategy that uses simplified clinical criteria plus detection of MisMatch Repair deficiency in tumours to identify Lynch carriers. Methods Colorectal cancer patients that met at least one of three clinical criteria were included: (1) colorectal cancer before 50 years, (2) personal history of colorectal or endometrial cancer, (3) first-degree relative history of colorectal or endometrial cancer. All tumours underwent an MisMatch Repair test combining microsatellite instability analysis and MisMatch Repair immunohistochemistry. Patients with an MisMatch Repair-deficient tumour were offered germline testing. Results Of the 307 patients fulfilling the clinical criteria, 46 (15%) had a MisMatch Repair-deficient tumour. Amongst them 27 were identified as Lynch carriers (20 with germline mutation: 12 MLH1, 7 MSH2, 1 MSH6; 7 highly suspected cases despite failure of genetic testing). The simplified clinical criteria selected a population whose MisMatch Repair-deficient status was highly predictive (59%) of Lynch syndrome. Conclusion This bio-clinical strategy based on simplified clinical criteria combined with an MisMatch Repair test efficiently detected LS cases and is easy to use in clinical practice, outside expert centres.

International audience; BACKGROUND: In human pathology, the "creeping fat" (CF) of the mesentery is unique to Crohn's disease (CD). CF is usually referred to as an ectopic extension of mesenteric adipose tissue (MAT). However, since no animal model developing CF has ever been established, very little is known about this type of fat-depot expansion and its role in the development of the disease. METHODS: We developed and standardized an experimental protocol in mice that reproducibly induces CF development when a severe colonic inflammation is obtained by intracolonic instillation of DNBS. RESULTS: Macro-microscopic observations revealed a fatty appearance of CF. Yet when compared to MAT from the same animals, CF contains very little triglycerides, few adipocytes, and we observed a very low expression and protein levels of both adipose markers (hormone-sensitive lipase, perilipin) and adipocytokines (leptin, adiponectin). The decreased expression of perilipin in CF was also observed by immunohistochemistry. Conversely, the expression of proinflammatory and fibrous markers (Pref-1) was much higher in CF than in MAT. These observations were fully consistent with those made on CF recovered from five CD patients and compared with subcutaneous and mesenteric fat from the same patients. CONCLUSIONS: Altogether, this work reports an original experimental mice model of CF. In this model we establish for the first time that CF only occurs in severe colonic inflammation and shows an inflammatory, fibrous but not an adipose pattern.

Abdominoperineal resection has a high rate of postoperative morbidity of the perineal wound. This study aimed to determine the effects of perineal colostomy on perineal morbidity after abdominoperineal resection.All patients who underwent an abdominoperineal resection for rectal adenocarcinoma between 1993 and 2007 were studied. Two groups were identified and compared who had undergone either an iliac colostomy or a perineal colostomy.The analysis included 110 patients (iliac colostomy group, n = 41; perineal colostomy group, n = 69). There were fewer instances of pelviperineal morbidity (P = .008) and fewer instances of wound dehiscence (P = .02) in the perineal colostomy group, which resulted in a shorter time to healing (35.3 vs 45.1 d, respectively; P = .04). There was no specific postoperative morbidity in any patient and no difference between the 2 groups regarding long-term perineal morbidity. The benefits from perineal colostomy were statistically significant in patients who received radiation therapy in terms of pelviperineal morbidity (P = .01) and healing time (50.8 vs 35.9 days, respectively; P = .02), whereas no difference was found in patients who had not received radiation therapy.Perineal colostomy is a safe and functionally acceptable procedure for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. In the present study, there was no additional morbidity related to perineal colostomy, and this procedure was associated with a decrease in perineal morbidity and healing time compared with primary perineal closure, in particular, after radiotherapy treatment.

International audience; AIMS: The aim of the present study was to assess the clinical fate of, and to gain new insights into, branch duct and mixed (predominantly main duct type) forms of intraductal papillary mucinous neoplasia of the pancreas (IPMN). METHODS: During a 17-year period, 99 successive IPMN patients (52 men, 47 women; mean age, 64 years) were included and divided into two groups for further comparison: one group had branch duct IPMN, whereas the other had mixed IPMN. RESULTS: Patients from the mixed IPMN group (n = 52) displayed a greater rate of symptoms (83% vs 55%, P = 0.004), pancreatic resection (67% vs 38%, P = 0.007), malignancy (35% vs 13%, P = 0.017) and death (15% vs 4%, P = 0.09) than those from the branch duct IPMN group. A 38-month follow up of non-operated, symptom-free patients confirmed that more than 85% of branch duct IPMN patients were asymptomatic without evidence of malignancy. Borderline lesions and carcinoma are found in up to 50% of symptomatic resected branch duct IPMN cases. CONCLUSION: Patients with the mixed form of IPMN as well as with symptomatic branch duct IPMN should require pancreatic resection because of symptoms and the risk for malignancy. In silent branch duct IPMN without radiological signs of malignancy, a non-operative watch-and-wait strategy can be discussed.

The prognosis of patients with colorectal cancer is largely determined by the tumor stage. In this respect, colorectal cancer with lymph node metastases has the worst prognosis. Accordingly, there is considerable clinical interest in understanding the genetic mechanisms underlying metastasis formation. The short arm of chromosome 8 is often lost in colorectal cancer and has been associated with the advanced stages. A common region of deletion has been identified in 8p21, and we investigate here the localization of the putative tumor suppressor gene. A series of 683 sporadic microsatellite stability colorectal tumor samples has been genotyped on 12 microsatellite loci encompassing the common deleted region. Allelic losses were identified in 50% of the cases and 10 break points have been evidenced between D8S1734 and D8S1810, reducing the region of interest to D8S1771-D8S131. Among the 21 genes mapped in this interval, 14 candidate genes have been retained for the sequencing analysis of 48 tumors with 8p allelic loss. No mutation was found, suggesting more complex mechanisms of inactivation or side effects of chromosome arm 8q duplication, which might be up-regulating oncogenes not located within the deleted region.

Purpose Adjuvant systemic chemotherapy administered after surgical resection of colorectal cancer metastases may reduce the risk of recurrence and improve survival, but its benefit has never been demonstrated. Two phase III trials (Fédération Francophone de Cancérologie Digestive [FFCD] Trial 9002 and the European Organisation for Research and Treatment of Cancer/National Cancer Institute of Canada Clinical Trials Group/Gruppo Italiano di Valutazione Interventi in Oncologia [ENG] trial) used a similar design and showed a trend favoring adjuvant chemotherapy, but both had to close prematurely because of slow accrual, thus lacking the statistical power to demonstrate the predefined difference in survival. We report here a pooled analysis based on individual data from these two trials. Patients and Methods After complete resection of colorectal liver or lung metastases, patients were randomly assigned to chemotherapy (CT arm; fluorouracil [FU] 400 mg/m2 administered intravenously [IV] once daily plus dl-leucovorin 200 mg/m2 [FFCD] × 5 days or FU 370 mg/m2 plus l-leucovorin 100 mg/m2 IV × 5 days [ENG] for six cycles at 28-day intervals) or to surgery alone (S arm). Results A total of 278 patients (CT, n = 138; S, n = 140) were included in the pooled analysis. Median progression-free survival was 27.9 months in the CT arm as compared with 18.8 months in the S arm (hazard ratio = 1.32; 95% CI, 1.00 to 1.76; P = .058). Median overall survival was 62.2 months in the CT arm compared with 47.3 months in the S arm (hazard ratio = 1.32; 95% CI, 0.95 to 1.82; P = .095). Adjuvant chemotherapy was independently associated with both progression-free survival and overall survival in multivariable analysis. Conclusion This pooled analysis shows a marginal statistical significance in favor of adjuvant chemotherapy with an FU bolus–based regimen after complete resection of colorectal cancer metastases.

Local recurrence (LR) after curative surgery for rectal cancer occurs in 4 to 33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). In many cases, diagnosis of LR is made at a late stage because of the high rate of asymptomatic patients, 56% in the experience of the Mayo Clinic. MRI and PETscan are most effective for assessing local and general extension, with a high diagnostic accuracy. Surgical treatment alone or with radiation (preoperative and/or intraoperative) is the only curative treatment of LR with R0 resectability rates of 30% to 45%. Morbidity and mortality rates are high, especially for total exenteration and abdomino-sacral resection. After curative surgery, 5-year global survival is between 30% and 40%. Palliative resection of macroscopic residues is not recommended. Careful patient selection for curative surgery is the best way to optimize treatment in these cases.

PURPOSE: Abdominal rectopexy is the preferred surgical technique for the treatment of total rectal prolapse. In many reported series, its results are impaired by induced constipation. Lateral rectal ligaments preservation could prevent constipation but increase recurrence rates. We report anatomic and functional results of abdominal Orr- Loygue ventral rectopexy with dissection limited to anterior and posterior rectal wall. METHODS: Consecutive patients with total rectal prolapse or intra-anal rectal prolapse associated to fecal incontinence or outlet obstruction were treated by abdominal rectopexy. Recurrences, correction of symptoms, and induced constipation were prospectively analyzed. RESULTS: Seventy-three patients were treated between 1993 and 2004. Recurrence was observed in 3 of 73 patients (4.1 percent) after a mean follow-up period of 28.6 (range, 6–84) months. Overall patient satisfaction (correction of prolapse, incontinence, and/or outlet obstruction) after the procedure was classified in three categories: Cured: n = 45 (61.6 percent); Improved: n = 24 (32.9 percent); Failure: n = 4 (5.5 percent). Postoperative constipation appeared in 2 of 36 (5.5 percent) preoperatively nonconstipated patients and worsened in 2 of 37 (5.4 percent) preoperatively constipated patients. CONCLUSIONS: Orr-Loygue abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments is a safe and effective procedure for the treatment of complete rectal prolapse, or internal prolapse associated with fecal incontinence or outlet obstruction. Preservation of lateral ligaments seems to prevent postoperative constipation without increasing the risk of prolapse recurrence

Proctectomy followed by straight coloanal anastomosis (CAA) often results in poor functional outcome known as the anterior resection syndrome. It is now based on evidence that a colonic J-pouch CAA improves outcome in the first 2 years. We assessed the very late functional outcome of CAA patients with or without a pouch. These results show that the functional benefit of the J-pouch anastomoses is sustained over the very long term.

Antegrade colonic enema, via a caecal access [Malone antegrade continence enema (MACE)], is proposed to selected patients suffering from incontinence and/or constipation when other therapeutic modalities have failed. We compared complication rates after three MACE techniques: appendicostomy, caecal neoappendicostomy, and ileal neoappendicostomy in 28 adult patients having 31 MACE operations. Stenoses and leakages occurred more frequently after appendicostomy and caecal flap than after ileal neoappendicostomy. This latter technique appears to reduce morbidity for adult patients.

Proctectomy followed by straight coloanal anastomosis (CAA) often results in poor functional outcome known as the anterior resection syndrome. It is now based on evidence that a colonic J-pouch CAA improves outcome in the first 2 years. We assessed the very late functional outcome of CAA patients with or without a pouch. These results show that the functional benefit of the J-pouch anastomoses is sustained over the very long term.

Sporadic early onset colorectal carcinoma (EOCRC) which has by definition no identified hereditary predisposition is a growing problem that remains poorly understood. Molecular analysis could improve identification of distinct sub-types of colorectal cancers (CRC) with therapeutic implications and thus can help establish that sporadic EOCRC is a distinct entity. From 954 patients resected for CRC at our institution, 98 patients were selected. Patients aged 45-60 years were excluded to help define "young" and "old" groups. Thirty-nine cases of sporadic EOCRC (patients ≤ 45 years with microsatellite stable tumors) were compared to both microsatellite stable tumors from older patients (36 cases, patients>60 years) and to groups of patients with microsatellite instability. Each group was tested for TP53, KRAS, BRAF, PIK3CA mutations and the presence of a methylator phenotype. Gene expression profiles were also used for pathway analysis. Compared to microsatellite stable CRC from old patients, sporadic EOCRC were characterized by distal location, frequent synchronous metastases and infrequent synchronous adenomas but did not have specific morphological characteristics. A familial history of CRC was more common in sporadic EOCRC patients despite a lack of identified hereditary conditions (p = 0.013). Genetic studies also showed the absence of BRAF mutations (p = 0.022) and the methylator phenotype (p = 0.005) in sporadic EOCRC compared to older patients. Gene expression analysis implicated key pathways such as Wnt/beta catenin, MAP Kinase, growth factor signaling (EGFR, HGF, PDGF) and the TNFR1 pathway in sporadic EOCRC. Wnt/beta catenin signaling activation was confirmed by aberrant nuclear beta catenin immunostaining (p = 0.01). This study strongly suggests that sporadic EOCRC is a distinct clinico-molecular entity presenting as a distal and aggressive disease associated with chromosome instability. Furthermore, several signaling pathways including the TNFR1 pathway have been identified as potential biomarkers for both the diagnosis and treatment of this disease.

Objective The aim of this study was to analyze the profile of tumor recurrence for patients operated on for cancer of oesophagogastric junction or oesophagus by Ivor-Lewis oesophagectomy. Methods Patients undergoing potentially curative Ivor-Lewis oesophageal resection between January 1999 to December 2008 at a single center institution were retrospectively analyzed. Their clinical records, details of surgical procedure, postoperative course, pathological findings, recurrence and long term survival were reviewed retrospectively. Univariate and multivariate survival analyses were performed. Results One hundred and twenty patients were analyzed. Fifty three patients (44%) presented recurrence during median follow-up of 58 months. Five-year relapse free survival (RFS) rate was 51% (95%CI = [46; 65%]). On multivariate analysis, pT stage > 2 (HR = 2.42, 95%CI = [1.22; 4.79] p = 0.011), positive lymph node status (HR = 3.69; 95% CI = [1.53; 8.96] p = 0.004) and lymph node ratio > 0.2 (HR = 2.57; 95%CI = [1.38; 4.76] p = 0.003) were associated with a poorer RFS and their combination was correlated to relapse risk. Moreover, preoperative tumor stenosis was associated with an increased risk of local recurrence (HR = 3.46; 95% CI = [1.38; 8.70] p = 0.008) whereas poor or undifferentiated tumor was associated with an increased risk of distant recurrence (HR = 3.32; 95% CI = [1.03; 10.04] p = 0.044). Conclusion pT stage > 2, positive lymph node status and lymph node ratio > 0.2 are independent prognostic factors of recurrence after Ivor-Lewis surgery for cancer. Their combination is correlated with an increasing risk of recurrence that may argue favorably, in addition with preoperative tumor stenosis assessment, for adjuvant treatment or reinforced follow-up.

Introduction Les complications perineales apres amputation (AAP) restent un probleme frequent du fait d’abces, de desunions cutanees et de retards de cicatrisation survenant dans environ 40 % des cas. De nombreuses etudes ont etudie l’interet de realiser un lambeau musculo-cutane pour combler le defect perineal, mais aucune n’a evalue les procedes de reconstruction alternatifs a la colostomie iliaque : colostomie perineale pseudo-continente ou en association au procede de Malone. Le but de cette etude etait de comparer la morbidite post-operatoire, en particulier perineale, des AAP avec colostomie iliaque (CI) a celle des AAP avec colostomie perineale (CP). Materiels et Methodes Nous avons realise une etude retrospective unicentrique. Tous les patients ayant eu une AAP pour adenocarcinome du bas rectum entre 1993 et 2007 ont ete inclus. Les patients ont ete selectionnes a partir d’une base de donnees maintenue prospectivement. Les dossiers medicaux ont ete revus. Les variables categorielles ont ete comparees par le test du Chi 2 et les variables numeriques par le t-test. Une valeur de p ® Inc.). Resultats Cent dix malades (46 femmes) d’âge moyen 63,5 ± 12,5 ans ont ete inclus dans l’etude. Soixante-neuf ont eu une CP et 41 une CI. Les deux groupes etaient comparables pour les principales caracteristiques cliniques. Soixante et onze pourcent des malades ont eu une radiotherapie preoperatoire (NS) et 23 % une resection multiviscerale (NS). Il n’y a eu aucun deces post-operatoire. Il n’y a pas eu de difference de morbidite intra-abdominale globale entre les deux groupes. La morbidite perineale globale a ete significativement plus frequente apres CI qu’apres CP (34 % vs 13 %, p = 0,008). Deux malades ont eu un abces pelvien, 1 a eu une hemorragie severe et 4 ont eu un abces perineal dans le groupe CI. Un malade a eu une hemorragie post-operatoire et 3 ont eu un abces perineal dans le groupe CP. Onze malades (26 %) ont eu une desunion cutanee dans le groupe CI vs 6 (8 %) dans le groupe CP (p = 0,02). La duree de cicatrisation du perinee a ete significativement plus longue dans le groupe CI que dans le groupe CP (45,1 ± 26 vs 35,3 ± 18 jours, p = 0,048). Enfin, la morbidite perineale tardive n’etait pas differente entre les deux groupes : 4 sinus perineaux et 1 eventration perineale dans le groupe CI vs 1 sinus et 1 eventration perineale dans le groupe CP. Conclusion La realisation d’une colostomie perineale represente une alternative a la stomie iliaque apres APR. Cette etude suggere qu’elle en diminue egalement la morbidite perineale. Elle pourrait donc representer une alternative simple au lambeau musculo-cutane evitant ainsi un sacrifice parietal.

Introduction Le lien de causalite entre prolapsus rectal intra-anal et incontinence anale n’est pas demontre. De ce fait la meilleure technique chirurgicale dans ce cas est debattue (Delorme, hemimucosectomie anterieure, STARR, rectopexie). La rectopexie anterieure semble entrainer moins de constipations que les techniques classiques de Wells ou de Orr-Loygue. Ce travail a evalue l’amelioration de la continence anale apres rectopexie anterieure pour prolapsus rectal intra-anal. Patients et Methodes Patientes souffrant d’incontinence anale, sans rupture sphincterienne echographique. Prolapsus intra-anal avec ou sans rectocele objective par defecographie dynamique. Rectopexie anterieure sans dissection des faces laterales rectales, avec prothese unique inter rectovaginale suturee au promontoire sans tension. Recueil prospectif pre et postoperatoire des scores d’incontinence (Cleveland), de constipation, de satisfaction des patientes operees. Resultats Quarante patientes consecutives ont ete incluses, avec un suivi moyen de 38 mois. Le score d’incontinence preoperatoire moyen etait de 13,2 (± 4,25), contre 3 (± 3,44) en postoperatoire (P Conclusion Ces resultats suggerent qu’un prolapsus intra-anal peut etre responsable d’incontinence anale. Pour ces patientes, une rectopexie anterieure est une technique efficace, induisant peu de constipations.

Introduction Plusieurs options chirurgicales peuvent etre proposees chez les patients presentant une incontinence anale (IA) et une rupture sphincterienne. La sphincteroplastie est la plus largement pratiquee, mais sa morbidite est significative et a moyen terme son efficacite est reduite. Conaghan et Farouk ont observe de bons resultats de la neuromodulation sacree (NMS) pour des patientes presentant une rupture du sphincter externe [1]. Recemment nous avons rapporte l’utilisation de la STP par TENS dans le traitement de l’incontinence anale idiopathique [2]. Cette etude a ete concue pour determiner si les indications STP par TENS pouvaient etre etendues aux patients presentant une incontinence anale et une lesion sphincterienne. Patients et Methodes De juillet 2004 a septembre 2007 nous avons propose ce traitement aux patients qui consultaient pour IA en rapport avec une rupture sphincterienne et qui relevait d’une reparation sphincterienne. Nous avons informe les patients qu’il s’agissait d’un traitement en evaluation et que a tout moment, ils pouvaient opter pour la solution chirurgicale prealablement prevue. L’evaluation pre-therapeutique incluait un examen medical detaille un examen des cahiers de selles, une echographie endo-anale, une manometrie ano-rectale. Le score de Wexner et la version francaise de la qualite de vie de l’incontinence fecale ont ete employes pour mesurer la severite de l’incontinence avant, et apres traitement. En fin de traitement les patients representaient leur satisfaction vis-a-vis de ce traitement sur une echelle analogique de 10 cm (EVA). Une unite TENS (Schwa-medico) delivrait un courant de 200-μs, 10-Hz tous les jours pendant 4 semaines au domicile des patients. Les patients etaient revus a 1 mois, 3 mois 6 mois puis tous les ans. Resultats Nous avons ainsi traite par STP 21 patients (19 femmes) d’âge median de 57,4 ans (48 - 71). Tous les patients avaient un defect du sphincter externe mesure entre 40° et 110°. 7 avaient un defect associe du sphincter interne mesure entre 140° et 180°. L’etiologie de l’incontinence etait 16 fois obstetricale et 3 fois traumatique (fistule), 2 fois traumatique et obstetricale (hemorroidectomie, viol). 12 des 21 patients traitees par STP ont rapporte une diminution des episodes d’incontinence et une amelioration de qualite de la vie, l’EVA median etait de 6,5 (4 - 9). Les 12 patients qui ont repondu a la STP (amelioration du Wexner d’au moins 30 % et ou diminution du nombre d’accident d’IA de 50 %) ont prefere poursuivre le traitement (quotidiennement pendant 3 mois puis 5 jours par semaines) que de subir une reparation sphincterienne et ce sur un recul median de 21 mois (15 - 34). Conclusion Notre etude suggere que dans cette indication, la STP par TENS doit probablement etre essayee avant la NMS. Remerciements, financements, autres Remerciements au Dr Laurent Abramowitz (GREP).

Introduction Le traitement chirurgical des fistules anales hautes doit tenir compte de deux logiques opposees : respecter les sphincters, garant d’une guerison sans sequelle sur la continence, eradiquer le trajet fistuleux, garant d’une guerison sans recidive. Actuellement, la technique du drainage par seton puis la section progressive des sphincters est la methode la plus employee en France, elle a comme avantages d’etre simple, de ne presenter qu’un faible taux de recidives, mais a comme inconvenient d’avoir un taux de morbidite non negligeable sur la continence. Depuis la mise sur le marche de colles et de bouchons, les techniques « d’epargne sphincterienne » connaissent un regain d’interet. Nous avons voulu evaluer le cyanoacrylate (colle chimique) [1] dans le traitement des fistules hautes tant sur le taux de cicatrisation que sur les resultats fonctionnels. Patients et Methodes De juillet 2006 a juillet 2008 nous avons propose ce traitement aux patients qui presentaient une fistule anale cryptoglandulaire haute. Apres un drainage sur seton lâche, le trajet fistuleux etait curete et lave. La colle etait injectee lentement par l’intermediaire d’un catheter prealablement place dans le trajet. Lorsqu’une bulle de colle apparaissait a l’orifice interne, le catheter etait lentement retire, la colle etait injectee jusqu’a la sortie du catheter. Une antibiotherapie orale, avec 1 g de ciprofloxacine et 1 g de metronidazole, etait prescrite en postoperatoire pendant sept jours. Les bains etaient contre-indiques pendant 15 jours. Les patients ont ete revus a un, trois et six mois, a 1 et 2 ans ils etaient contactes par telephone, on recherchait une recidive, une incontinence anale, des suintements. Resultats 34 patients consecutifs (20 hommes) ont ainsi ete traites. A un mois 23 (67,4 %) patients etaient gueris. Il n’a pas ete observe de recidive sur un suivi median de 15,5 mois (3 a 27 mois), 11 patients ont presente un echec. Un patient a ete reencolle 2 fois sans succes. Six fois, nous avons observe des complications : trois fois, un cone de colle trop important etait responsable de douleurs au niveau de l’orifice secondaire, l’excision de l’excedent de colle a permis la regression immediate des symptomes ; deux fois, des douleurs anales ont cedees a des antalgiques ; enfin une fois, une ulceration creusante au niveau de l’orifice interne etait responsable de douleurs imposant la prescription de morphiniques, la cicatrisation a ete longue : dix semaines. Aucun des 23 patients cicatrises n’a presente des troubles de la continence. Conclusion Le traitement par cyanoacrylate est peu onereux, simple, permet une reprise rapide des activites, le taux de cicatrisation est satisfaisant sans alteration de la continence. Des complications mineures ont ete observees au debut de notre experience et peuvent etre evitees. Une complication connue et imputable au produit, rare mais severe doit nous inciter a evaluer avec le patient les avantages attendus par rapport au risque.