Nouveautés dans la stratégie thérapeutique de la diverticulite sigmoïdienne [Current treatment strategies for sigmoid diverticulitis]

Treatment of colonic diverticular disease has evolved over the past years. Most episodes are simple and can be successfully treated with antibiotics alone. For complicated diverticulitis, a strong trend is developing towards less invasive therapies including interventional radiology and laparoscopic lavage in an effort to avoid the morbidity and discomfort of a diverting colostomy. Based on a better understanding of the natural history of the disease, the indication to prophylactic colectomy after a few episodes of simple diverticulitis has been seriously challenged. For those patients who need a colectomy, single port laparoscopy, NOTES and transanal specimen extraction are being proposed. However larger studies are needed to confirm the hypothetical advantages of these evolving techniques.

Can 3T multiparametric magnetic resonance imaging accurately detect prostate cancer extracapsular extension?

BACKGROUND: Accurate staging is essential to determine the correct management of patients diagnosed with prostate cancer. We assess the accuracy of 3T multiparametric magnetic resonance imaging (MRI) with endorectal coil (3TemMRI) in detecting prostate cancer local extension. METHODS: We retrospectively reviewed charts from January 2008 to July 2012 from all patients undergoing radical prostatectomy. Patients were only included if 3TemMRI and radical prostatectomy were performed at our institution. Based on the presence of extracapsular extension (ECE) at 3TemMRI, prostate cancer was dichotomized into locally advanced or organ-confined disease. The accuracy of 3TemMRI local staging was then evaluated using definitive pathology as a reference. RESULTS: Overall, 177 radical prostatectomies were performed within the timeframe. After applying exclusion criteria, 60 patients were included in the final analysis. The mean patient age was 67 ± 7 (standard deviation) years. Mean prostate-specific antigen value was 12.7 ± 12.7 ng/L. Based on preoperative characteristics, we considered 38 of the 60 patients (63%) patients high risk. 3TemMRI identified an organ-confined tumour in 46 patients and locally advanced disease in 14 patients. When correlated to final pathology, 3TemMRI specificity, sensitivity, negative and positive predictive values, and accuracy in detecting locally advanced prostate cancer were 90%, 35%, 57%, 79% and 62%, respectively. INTERPRETATION: This study shows that the use of preoperative 3TemMRI can be used to identify organ-confined prostate cancer when locally advanced disease is suspected.

Doppler-guided hemorrhoidal artery ligation with rectal mucopexy technique: initial evaluation of 42 cases

The treatment of hemorrhoidal disease (HD) by conventional hemorrhoidectomy is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. Doppler-guided hemorrhoid artery ligation (DGHAL) is a minimal-invasive surgical treatment for HD that has been used as an alternative method in order to reduce these inconveniences. OBJECTIVE: To analyze the initial results of the DGHAL technique associated with rectal mucopexy in the treatment of HD. METHODS:Forty-two patients with stage I, III and IV hemorrhoids who were submitted to DGHAL were analyzed from December 2010 to August 2011. Eleven patients (26%) were stage II; 21 (50%), stage III; and 10 (24%), stage IV HD. All patients were operated by the same surgeon under spinal anesthesia and using the same equipment and technique to perform the procedure. The 42 patients underwent ligation of six arterial branches followed by rectal mucopexia by uninterrupted suture. Nine patients needed concomitant removal of perianal skin tag. In the postoperative, the following parameters were evaluated: pain, tenesmus, bleeding, itching, prolapse, mucus discharge and recurrence. The mean postoperative follow-up lasted four months (one to nine months). RESULTS: Tenesmus was the most common postoperative complaint for 85.7% of patients followed by pain, in 28.6%, perianal burning, in 12.3%, mucus discharge and perianal hematoma in 4.7%. Two patients had severe postoperative bleeding and required surgical haemostasis, one of which needed blood transfusion. Ninety-five percent of the patients declared to be satisfied with the method. CONCLUSION: Even though DGHAL has complications similar to those of other surgical methods, its results present less postoperative pain, allowing faster recovery and return to work. Studies with more cases and a longer follow-up are still necessary to assess the late recurrence.

Trattamento della malattia paranale complessa di Crohn: rescue therapy dopo fallimento dei farmaci biologici

La malattia paranale di Crohn rappresenta una condizione clinica complessa e invalidante. La chirurgia da sola è efficace nel migliorare i sintomi mediante il controllo della sepsi, ma è raramente associata alla guarigione definitiva. L'introduzione dei farmaci biologici ha aumentato le possibilità di chiusura definitiva delle fistole. Tuttavia molti pazienti non rispondono a questo trattamento bio-chirurgico combinato. Il ruolo del mucosal healing del retto ottenuto con i farmaci non è al momento ancora chiaro. L'obiettivo del presente studio è quello di identificare possibili terapia alternative per pazienti non responsivi ai biologici. Lo studio ha valutato efficacia e sicurezza della chirurgia riparativa, confezionamento di flap mucosi endorettali e posizionamento di protesi biologiche, nei pazienti non responsivi ai biologici ma che grazie ad essi abbiano ottenuto un mucosal healing del retto.

RANGE ADAPTIVE PROTON THERAPY FOR PROSTATE CANCER

Purpose: The rapid distal falloff of a proton beam allows for sparing of normal tissues distal to the target. However proton beams that aim directly towards critical structures are avoided due to concerns of range uncertainties, such as CT number conversion and anatomy variations. We propose to eliminate range uncertainty and enable prostate treatment with a single anterior beam by detecting the proton’s range at the prostate-rectal interface and adaptively adjusting the range in vivo and in real-time. Materials and Methods: A prototype device, consisting of an endorectal liquid scintillation detector and dual-inverted Lucite wedges for range compensation, was designed to test the feasibility and accuracy of the technique. Liquid scintillation filled volume was fitted with optical fiber and placed inside the rectum of an anthropomorphic pelvic phantom. Photodiode-generated current signal was generated as a function of proton beam distal depth, and the spatial resolution of this technique was calculated by relating the variance in detecting proton spills to its maximum penetration depth. The relative water-equivalent thickness of the wedges was measured in a water phantom and prospectively tested to determine the accuracy of range corrections. Treatment simulation studies were performed to test the potential dosimetric benefit in sparing the rectum. Results: The spatial resolution of the detector in phantom measurement was 0.5 mm. The precision of the range correction was 0.04 mm. The residual margin to ensure CTV coverage was 1.1 mm. The composite distal margin for 95% treatment confidence was 2.4 mm. Planning studies based on a previously estimated 2mm margin (90% treatment confidence) for 27 patients showed a rectal sparing up to 51% at 70 Gy and 57% at 40 Gy relative to IMRT and bilateral proton treatment. Conclusion: We demonstrated the feasibility of our design. Use of this technique allows for proton treatment using a single anterior beam, significantly reducing the rectal dose.

Diffusion-weighted magnetic resonance imaging detects significant prostate cancer with high probability

PURPOSE We prospectively assessed the diagnostic accuracy of diffusion-weighted magnetic resonance imaging for detecting significant prostate cancer. MATERIALS AND METHODS We performed a prospective study of 111 consecutive men with prostate and/or bladder cancer who underwent 3 Tesla diffusion-weighted magnetic resonance imaging of the pelvis without an endorectal coil before radical prostatectomy (78) or cystoprostatectomy (33). Three independent readers blinded to clinical and pathological data assigned a prostate cancer suspicion grade based on qualitative imaging analysis. Final pathology results of prostates with and without cancer served as the reference standard. Primary outcomes were the sensitivity and specificity of diffusion-weighted magnetic resonance imaging for detecting significant prostate cancer with significance defined as a largest diameter of the index lesion of 1 cm or greater, extraprostatic extension, or Gleason score 7 or greater on final pathology assessment. Secondary outcomes were interreader agreement assessed by the Fleiss κ coefficient and image reading time. RESULTS Of the 111 patients 93 had prostate cancer, which was significant in 80 and insignificant in 13, and 18 had no prostate cancer on final pathology results. The sensitivity and specificity of diffusion-weighted magnetic resonance imaging for detecting significant PCa was 89% to 91% and 77% to 81%, respectively, for the 3 readers. Interreader agreement was good (Fleiss κ 0.65 to 0.74). Median reading time was between 13 and 18 minutes. CONCLUSIONS Diffusion-weighted magnetic resonance imaging (3 Tesla) is a noninvasive technique that allows for the detection of significant prostate cancer with high probability without contrast medium or an endorectal coil, and with good interreader agreement and a short reading time. This technique should be further evaluated as a tool to stratify patients with prostate cancer for individualized treatment options.

Promising results of a cooperative group phase II trial of preoperative chemoradiation for locally advanced rectal cancer (TROG 9801)

PURPOSE: This article reports the overall survival, failure-free survival, local failure, and late radiation toxicity of a phase II trial of preoperative radiotherapy with continuous infusion 5-fluorouracil for rectal cancer after a minimum 3.5 years of follow-up. METHODS: Eligible patients were those with newly diagnosed localized adenocarcinoma of the rectum, within 12 cm of the anal verge, staged T3-T4 and deemed suitable for curative resection. Radiotherapy (50.4 Gy in 28 fractions in five weeks and three days) was given with continuous infusion 5-fluorouracil throughout the course of radiotherapy. RESULTS: A total of 82 patients were accrued in 13 months. The median follow-up time was 4.1 (range, 2.3-4.5) years. There were 55 males (67 percent) and the median age was 59 (range, 27-87) years. Patients were staged pretreatment as T3 (89 percent) and resectable T4 (11 percent). Endorectal ultrasound was performed in 70 percent and magnetic resonance imaging in another 5 percent. The four-year overall and failure-free survival rates were 82 percent (95 percent Cl: 72-89) and 69 percent (95 percent Cl: 58-78), respectively. The cumulative incidence of local failure at four years was 3.9 percent (95 percent CI: 1.3-11). Risk of failures, local and distant, has not reached a plateau phase. CONCLUSION: This regimen can be delivered safely and without leading to a significant increase in late toxicity. It provides excellent local control and favorable overall survival. There is a need for longer follow-up than has commonly been used for the proper evaluation of failures after an effective regimen of preoperative chemoradiation.

Technique and outcomes about a new laparoscopic procedure: the Pelvic Organ Prolapse Suspension (POPS)

Pelvic organ prolapse suspension (POPS) is a recent surgical procedure for one-stage treatment of multiorgan female pelvic prolapse. This study evaluates the preliminary results of laparoscopic POPS in 54 women with a mean age of 55.2 and a BMI of 28.3. Patients underwent at the same time stapled transanal rectal resection (STARR) to correct the residual rectal prolapse. We had no relapses and the preliminary results were excellent. We evaluated the patients after 1 year follow-up and we confirmed the validity of our treatment. The technique is simplier than traditional treatments with an important reduction or completely disappearance of the pre-operative symptomatology.