Are patients at nutritional risk more prone to complications after major urological surgery?

PURPOSE: The nutritional risk score is a recommended screening tool for malnutrition. While a nutritional risk score of 3 or greater predicts adverse outcomes after digestive surgery, to our knowledge its predictive value for morbidity after urological interventions is unknown. We determined whether urological patients at nutritional risk are at higher risk for complications after major surgery than patients not at nutritional risk. MATERIALS AND METHODS: We performed a prospective observational study in consecutive patients undergoing major surgery. A priori sample calculation resulted in a study cohort of 220 patients. Interim analysis was planned after 110 patients. The nutritional risk score was assessed preoperatively by a specialized study nurse. Nutritional care was standardized in all patients. Postoperative complications were defined previously using the standardized Dindo-Clavien classification. The primary end point was 30-day morbidity. Univariate and multivariate analysis was performed to identify predictors of complications. RESULTS: The study was discontinued due to significant results after interim analysis. A total of 125 patients were included in analysis from June 2011 to June 2012 and 15 were excluded because of incomplete data. Of 51 patients at nutritional risk 38 (74%) presented with at least 1 complication compared to 28 of 59 controls (47%). Patients at nutritional risk were at threefold risk for complications on univariate and multivariate analysis (OR 3.3, 95% CI 1.3-8.0). Cystectomy was the only other predictor of morbidity (OR 10, 95% CI 2-48). CONCLUSIONS: Patients at nutritional risk are more prone to complications after major urological procedures. Whether this increased morbidity can be reversed by perioperative nutritional support should be studied.

Secretory IgA and intestinal epithelial cells at the interface between homeostasis regulation and protection against infection

RESUME DESTINE A UN LARGE PUBLICL'intestin est le siège d'intenses agressions de la part de l'ensemble des aliments ingérés, de bactéries agressives dites pathogènes mais également de bactéries dites commensales peuplant naturellement les surfaces intestinales muqueuses. Pour faire face, notre organisme arbore de nombreux niveaux de protections tant physiques, chimiques, mécaniques mais aussi immunitaires. La présence d'un type particulier de cellules, les cellules épithéliales (IEC) assurant une protection physique, ainsi que la production d'anticorps spécialisés par le système immunitaire appelés immunoglobulines sécrétoires A (SlgA) servent conjointement de première ligne de défense contre ces agressions externes. Néanmoins, comment le dialogue s'articule entre ces deux partenaires reste incomplet.Nous avons donc décidé de mimer ces interactions en modélisant les surfaces muqueuses par une monocouche de cellules différenciées en laboratoire. Des souches bactériennes isolées de l'intestin humain seules ou associées à des SlgA non-spécifiques ont été mises au contact de ce modèle cellulaire nous permettant de conclure quant à la présence effective d'une modulation du dialogue bactérie/lEC impliquant une activation de la réponse cellulaire vers un état de tolérance mutuelle. De façon surprenante, nous avons par ailleurs mis en évidence un type d'interaction nouveau entre ces anticorps et ces bactéries. Une étude biochimique nous a permis de détailler un nouveau rôle des SlgA médié par les sucres présents à leur surface dans le maintien d'une relation pacifique avec les commensaux perpétuellement présents, relations qualifiées d'homésostase intestinale.Le rôle protecteur des SlgA a par ailleurs été abordé pour avoir une meilleure appréhension de leur impact au niveau cellulaire lors d'infection par Shigella flexneri, bactérie causant la Shigellose, diarrhée sanglante responsable de la mort de plus d'un million de personnes chaque année. Basée sur le même modèle cellulaire, cette étude nous a permis de démontrer une nouvelle entrée de ce pathogène directement via les IEC. La présence d'anticorps spécifiques à la surface des bactéries restreint leur champs d'action contre les cibles intracellulaires identifiées que sont les filaments soutenant le squelette de la cellule, les fibres d'actine ainsi que les jonctions serrées, réseaux de protéines clés des interactions entre cellules. Cette ouverture au niveau cellulaire apporte un nouvel élan quant à la compréhension du rôle protecteur des SlgA lors d'attaques de l'intestin, protection semblant dépendante d'une agrégation des bactéries.Pour finir, nous avons mis en évidence la détection directe par les cellules de la présence d'anticorps libres dans l'intestin ajoutant une nouvelle réplique dans le dialogue complexe entre ces deux piliers de l'équilibre intestinal que sont les SlgA et les cellules épithéliales.RESUMELa muqueuse intestinale est dotée d'un réseau complexe de protections physico-chimiques, mécaniques ou immunologiques. Associées à un système immunitaire omniprésent, les cellules épithéliales intestinales {IEC) bordant la lumière intestinale ont la double tâche de protéger l'intérieur de l'organisme stérile contre l'invasion et la dissémination d'agents pathogènes, et de maintenir une relation pacifique avec la flore intestinale, rôles également joués par les immunoglobulines sécrétoires A (SlgA), anticorps les plus abondamment présents à la surface des muqueuses. Tant les IEC que les SlgA sont ainsi décrites comme convergeant vers le même objectif ; néanmoins, les rouages de leurs interactions restent largement inconnus.Pour répondre à cette question, des monocouches épithéliales reconstituées in vitro ont été incubées avec des souches commensales telles que des Lactobacillus ou des Bifodobacteria, seules ou complexées avec des SlgA non-spécifiques, nous permettant de décrypter l'influence des SlgA sur la détection des bactéries par les IEC, favorisant l'adhésion bactérienne et la cohésion cellulaire, augmentant l'activation de la voie NF-κΒ ainsi que la sécrétion de la cytokine thymic stromal lymphopoietin contrairement à celle de médiateurs pro-inflammatoires qui reste inchangée. Par ailleurs, une interaction Fab-indépendante est suggérée dans l'interaction SlgA/bactéries. Comme une interaction de faible affinité a été décrite comme prenant naturellement place au niveau de l'intestin, nous avons donc disséqué les mécanismes sous- jacents en utilisant un large spectre de bactérie associés à des protéines soit recombinantes soit isolées à partir de colostrum, mettant en évidence un rôle crucial des N-glycanes présents sur la pièce sécrétoire et soulignant une nouvelle propriété des SlgA dans l'homéostase intestinale.Intrinsèquement liés aux caractéristiques des SlgA, nous nous sommes également focalisés sur leur rôle protecteur lors d'infection par l'enteropathogène Shigella flexneri reproduites in vitro sur des monocouches polarisées. Nous avons tout d'abord démontré une nouvelle porte d'entrée pour ce pathogène directement via les IEC. L'agrégation des bactéries par les SlgA confère aux cellules une meilleure résistance à l'infection, retardant croissance bactérienne et entrée cellulaire, affectant par ailleurs leur capacité à cibler le cytosquelette et les jonctions serrées. La formation de tels cargos détectés de façon biaisée par les IEC apparaît comme une explication plausible au maintien de la cohésion cellulaire médiée par les SlgA.Enfin, le retrotransport des SlgA à travers les IEC a été abordé soulignant une participation active de ces cellules dans la détection de l'environnement extérieur, les impliquant possiblement dans l'activation d'un état muqueux stable.Conjointement, ces résultats indiquent que les SlgA représentent l'un des éléments-clés à la surface de la muqueuse et soulignent la complexité du dialogue établi avec l'épithélium en vue du maintien d'un fragile équilibre intestinal.ABSTRACTThe intestinal mucosa is endowed with a complex protective network melting physiochemical, mechanical and immunological features. Beyond the ubiquitous intestinal immune system, intestinal epithelial cells (IEC) lying the mucosal surfaces have also the dual task to protect the sterile core against invasion and dissemination of pathogens, and maintain a peaceful relationship with commensal microorganisms, aims also achieved by the presence of high amounts of secretory immunoglobulins A (SlgA), the most abundant immunoglobulin present at mucosal surfaces. Both IEC and SlgA are thus described to converge toward the same goal but how their interplay is orchestrated is largely unknown.To address this question, in vitro reconstituted IEC monolayers were first apically incubated with commensal bacteria such as Lactobacillus or Bifodobacteria strains either alone or in complexes with non-specific SlgA. Favoring the bacterial adhesion and cellular cohesion, SlgA impacts on the cellular sensing of bacteria, increasing NF-κΒ activation, and leading to cytokine releases restricted to the thymic stromal lymphopoietin and unaffected expression of pro-inflammatory mediators. Of main interest, bacterial recognition by SlgA suggested a Fab-independent interaction. As this low affinity, called natural coating occurs in the intestine, we further dissected the underlying mechanisms using a larger spectrum of commensal strains associated with recombinant as well as colostrum-derived proteins and pinpointed a crucial role of N-glycans of the secretory component, emphasizing an underestimated role of carbohydrates and another properties of SlgA in mediating intestinal homeostasis.As mucosal protection is also anchored in SlgA and IEC features, we focused on the cellular role of SlgA. Using IEC apical infection by the enteropathogen Shigella flexneri, we have first demonstrated a new gate of entry for this pathogen directly via IEC. Specific SlgA bacterial aggregation conferred to the cells a better resistance to infection, delaying bacterial growth and cellular entry, affecting their ability to damage both the cytoskeleton and the tight junctions. Formation of such big cargos differentially detected by IEC appears as a plausible explanation sustaining at the cellular level the antibody-mediated mucosal protection.Finally, SlgA retrotransport across IEC has been tackled stressing an active IEC sensing of the external environment possibly involved in the steady-state mucosal activation.All together, these results indicate that SlgA represents one of the pivotal elements at mucosal surfaces highlighting the complexity of the dialogue established with the epithelium sustaining the fragile intestinal balance.The Intestinal mucosa is endowed with a complex protective network melting physiochemical, mechanical and immunological features. Beyond the ubiquitous intestinal immune system, intestinal epithelial cells (IEC) lying the mucosal surfaces have also the dual task to protect the sterile core against invasion and dissemination of pathogens, and maintain a peaceful relationship with commensal microorganisms, aims also achieved by the presence of high amounts of secretory immunoglobulins A (SlgA), the most abundant immunoglobulin present at mucosal surfaces. Both IEC and SlgA are thus described to converge toward the same goal but how their interplay is orchestrated is largely unknown.To address this question, in vitro reconstituted IEC monolayers were first apically incubated with commensal bacteria such as Lactobacillus or Bifodobacteria strains either alone or in complexes with non-specific SlgA. Favoring the bacterial adhesion and cellular cohesion, SlgA impacts on the cellular sensing of bacteria, increasing NF-κΒ activation, and leading to cytokine releases restricted to the thymic stromal lymphopoietin and unaffected expression of pro-inflammatory mediators. Of main interest, bacterial recognition by SlgA suggested a Fab-independent interaction. As this low affinity, called natural coating occurs in the intestine, we further dissected the underlying mechanisms using a larger spectrum of commensal strains associated with recombinant as well as colostrum-derived proteins and pinpointed a crucial role of N-glycans of the secretory component, emphasizing an underestimated role of carbohydrates and another properties of SlgA in mediating intestinal homeostasis.As mucosal protection is also anchored in SlgA and IEC features, we focused on the cellular role of SlgA. Using IEC apical infection by the enteropathogen Shigella flexneri, we have first demonstrated a new gate of entry for this pathogen directly via IEC. Specific SlgA bacterial aggregation conferred to the cells a better resistance to infection, delaying bacterial growth and cellular entry, affecting their ability to damage both the cytoskeleton and the tight junctions. Formation of such big cargos differentially detected by IEC appears as a plausible explanation sustaining at the cellular level the antibody-mediated mucosal protection.Finally, SlgA retrotransport across IEC has been tackled stressing an active IEC sensing of the external environment possibly involved in the steady-state mucosal activation.All together, these results indicate that SlgA represents one of the pivotal elements at mucosal surfaces highlighting the complexity of the dialogue established with the epithelium sustaining the fragile intestinal balance.

Non-functioning pituitary macro-incidentalomas benefit from early surgery before becoming symptomatic.

OBJECTIVE: Pituitary incidentalomas (PIs) constitute an increasingly clinical problem. While the therapeutic management is well defined for symptomatic non-functioning PIs (NFPIs), a controversy still exists for asymptomatic macro-NFPIs between surgery and a "wait and see" approach. The aim of this study is to compare surgical results between symptomatic and asymptomatic macro-NFPIs. METHODS: We conducted a retrospective study on 76 patients with newly diagnosed symptomatic and asymptomatic macro-NFPIs operated on between 2001 and 2010. We compared age, tumor size and surgical results between these two patient groups. RESULTS: After the initial evaluation, 48 patients were found to be symptomatic. Gross total removal (GTR) rate was significantly higher in asymptomatic (82%) than in symptomatic patients (58%; p=0.03). Gross total removal was strongly associated with Knosp's classification (p=0.01). Postoperative endocrinological impairment was significantly associated with the existence of preoperative symptoms (p=0.03). It was 10 times less frequent in the asymptomatic group. In symptomatic patients, postoperative visual and endocrinological impairment were present in 49% and 78% versus 0% and 14% in asymptomatic patients respectively. CONCLUSIONS: The endocrinological and visual outcome was better in those patients who underwent surgery for asymptomatic tumors. The extent of tumor resection was also significantly greater in smaller tumors. It would therefore be appropriate to offer surgery to patients with asymptomatic macro-NFPIs.

Intestinal Spirochetosis mimicking inflammatory bowel disease in children.

ABSTRACT: BACKGROUND: Intestinal spirochetosis is an unusual infection in children and its clinical significance in humans is uncertain. The presence of these microorganisms in humans is well-known since the late 1800's and was first described in 1967 by Harland and Lee by electron microscopy. CASE PRESENTATION: This article reports the findings of one pediatric case, review of the current literature, and an overview of therapeutic options. CONCLUSION: A high degree of suspicion is required in cases presenting with abdominal pain, chronic diarrhoea and/or hematochezia associated with a normal endoscopic examination, thus emphasizing the importance of multiple biopsies throughout the colon.

The unresolved case of sacral chordoma: from misdiagnosis to challenging surgery and medical therapy resistance.

PURPOSE: A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. METHODS: Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. RESULTS: Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). CONCLUSION: Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.

Implementation of enhanced recovery after surgery (ERAS) in colorectal surgery is highly cost-effective

Objective: Enhanced Recovery After Surgery (ERAS) clinical pathways in¦colorectal surgery are known to reduce postoperative complications leading¦to shortened hospital stay. However, the implementation of such an ERAS¦pathway requires time and financial investment. This study evaluates whether¦the savings related to the reduction in the length of stay (LOS) outweigh the¦costs of implementing an ERAS pathway.¦Methods: An ERAS pathway was implemented in our institution for colorectal¦surgery. The first 50 consecutive patients subjected to this ERAS pathway¦(ERAS group) were compared to 50 consecutive patients that were operated one¦year before its introduction (control group). Primary LOS, readmission within¦30 days, and total costs based on costs per day were compared. The mean costs¦per day were: 3,263 CHF for intensive care, 1,152 CHF for intermediate care,¦and 728 CHF for basic care.¦Results: Primary LOS was shorter in the ERAS group than in the control¦group: median 7 (interquartile range 5-12·25) versus 10 (7-18) days (P =¦0·0025). The readmission within 30 postoperative days was similar in both¦groups (2 patients each). In the ERAS group, the added primary LOS was¦485 days (379 in basic care, 99 in intermediate care, 7 in intensive care) compared¦to 706 days in the control group (533 in basic care, 146 in intermediate care,¦27 in intensive care). The total costs were significantly lower for the 50 ERAS¦patients compared to the control group: 412,801 CHF versus 644,317 CHF (P <¦0·01). Investments required for the 50 first ERAS patients were approximately¦83,544 CHF, including 348 working hours as well a full-time ERAS dedicated¦nurse. The overall cost saving was approximately 2,959 CHF per patient.¦Conclusion: Implementation of an ERAS pathway significantly reduced LOS¦after colorectal surgery. The financial investment to introduce and maintain¦such a pathway is clearly inferior to the cost-saving of reduced hospital stay.

Patterns of pain-free response in 497 cases of classic trigeminal neuralgia treated with Gamma Knife surgery and followed up for least 1 year.

Object The goal of this study was to establish whether clear patterns of initial pain freedom could be identified when treating patients with classic trigeminal neuralgia (TN) by using Gamma Knife surgery (GKS). The authors compared hypesthesia and pain recurrence rates to see if statistically significant differences could be found. Methods Between July 1992 and November 2010, 737 patients presenting with TN underwent GKS and prospective evaluation at Timone University Hospital in Marseille, France. In this study the authors analyzed the cases of 497 of these patients, who participated in follow-up longer than 1 year, did not have megadolichobasilar artery- or multiple sclerosis-related TN, and underwent GKS only once; in other words, the focus was on cases of classic TN with a single radiosurgical treatment. Radiosurgery was performed with a Leksell Gamma Knife (model B, C, or Perfexion) using both MR and CT imaging targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.8 mm (range 4.5-14 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 70-90 Gy) was delivered. Using empirical methods and assisted by a chart with clear cut-off periods of pain free distribution, the authors were able to divide patients who experienced freedom from pain into 3 separate groups: patients who became pain free within the first 48 hours post-GKS; those who became pain free between 48 hours and 30 days post-GKS; and those who became pain free more than 30 days after GKS. Results The median age in the 497 patients was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.75 months (range 12-174.41 months). Four hundred fifty-four patients (91.34%) were initially pain free within a median time of 10 days (range 1-459 days) after GKS. One hundred sixty-nine patients (37.2%) became pain free within the first 48 hours (Group PF(≤ 48 hours)), 194 patients (42.8%) between posttreatment Day 3 and Day 30 (Group PF((>48 hours, ≤ 30 days))), and 91 patients (20%) after 30 days post-GKS (Group PF(>30 days)). Differences in postoperative hypesthesia were found: in Group PF(≤ 48 hours) 18 patients (13.7%) developed postoperative hypesthesia, compared with 30 patients (19%) in Group PF((>48 hours, ≤ 30 days)) and 22 patients (30.6%) in Group PF(>30 days) (p = 0.014). One hundred fifty-seven patients (34.4%) who initially became free from pain experienced a recurrence of pain with a median delay of 24 months (range 0.62-150.06 months). There were no statistically significant differences between the patient groups with respect to pain recurrence: 66 patients (39%) in Group PF(≤ 48 hours) experienced pain recurrence, compared with 71 patients (36.6%) in Group PF((>48 hours, ≤ 30 days)) and 27 patients (29.7%) in Group PF(>30 days) (p = 0.515). Conclusions A substantial number of patients (169 cases, 37.2%) became pain free within the first 48 hours. The rate of hypesthesia was higher in patients who became pain free more than 30 days after GKS, with a statistically significant difference between patient groups (p = 0.014).

Perforation colique néonatale focale spontanée en dehors de la grande prématurité : rare et potentiellement insidieuse [Focal spontaneous colic perforation in term or near-term neonates: rare and potentially insidious].

Two cases of neonatal focal spontaneous colic perforations are reported. The 1st infant, born at 36 3/7 weeks gestational age, presented on day 3 with crying, abdominal distension, and liquid stools. Clinical examination showed a slightly irritable hypothermic (35.7 °C) infant with a distended abdomen and few bowel sounds. Blood tests were normal apart from an elevated C-reactive protein level (59 mg/l). The abdomen x-ray was erroneously considered normal. The infant's condition remained stable for nearly 3 days. After reviewing the initial x-ray, pneumoperitoneum was suspected and confirmed by a cross-table lateral abdominal x-ray. The infant was started on antibiotics and operated. Macroscopically, the entire gut was normal apart from a focal sigmoid perforation, which was stitched. A transmural colic biopsy revealed focal vascular dilation but was negative for necrotising enterocolitis or Hirschsprung disease. The infant recovered quickly. She is now a healthy, normal 3-year-old. The 2nd infant, born at 38 5/7 weeks gestational age, presented between day 1 and 2 with clinical signs of infection associated with slowly progressive ileus. The chest and abdomen x-ray was mistakenly considered normal. Frank septicemia developed. After reviewing the initial x-ray, pneumoperitoneum was suspected and confirmed by a cross-table lateral abdominal x-ray. The infant was operated. Macroscopically, the small intestine was normal, the ascending and transverse colons were dilated, and the descending and sigmoid colons were narrow. Three cecal perforations were discovered and stitched. An ileostomy and multiple colic biopsies were also performed. The postoperative course was complicated by persistent septic ileus due to descending and sigmoid colon leaks, which led to colic resections with end-to-end anastomosis. Rectal aspiration biopsies were also performed. At 1 month of age, the infant was discharged from the hospital. The ileostomy was closed in two steps at 2 and 5 months of age. A normal sweat test excluded cystic fibrosis. All colic and rectal biopsies revealed nonspecific inflammatory signs and excluded necrotizing enterocolitis and Hirschsprung disease. Nonspecific irregular thinning of muscularis mucosae and muscularis propria were observed in the two resected colic segments. The boy is now a healthy 7-year-old. The incidence of neonatal focal spontaneous colic perforations at term or close to term is unknown but probably very rare. Our department is the neonatal referral center for approximately 14,000 annual births. In the last 10 years (2000-2009), out of 5115 neonatal admissions in our unit, only ten cases have presented a neonatal spontaneous intestinal perforation, seven of ten in very-low-birth-weight infants and three of ten in term or near-term neonates (one with Hirschsprung disease and the two cases reported herein). In the same period, 108 infants suffered from necrotizing enterocolitis, seven of 108 were term infants and 6 out of 7 had a congenital heart disease. The medical literature is poor on the subject of focal spontaneous colic perforations at term; no risk factor is described. The most specific clinical sign seems to be the abdominal distension. The presence of pneumoperitoneum on an abdominal x-ray is the most sensitive paraclinical sign. In case of an intestinal perforation, surgery must be performed quickly. The vital prognosis seems to be good. The objective of this study was to draw pediatricians' attention to focal spontaneous colic perforations in term or close to term newborns. In the cases reported, the diagnostic delays could have been prevented if the entity - with its radiological manifestation - had been well known.

Psychometric evaluation of the IWQOL-Lite (Spanish version) when applied to a sample of obese patients awaiting bariatric surgery

Background Obesity may have an impact on key aspects of health-related quality of life (HRQOL). In this context, the Impact of Weight Quality of Life (IWQOL) questionnaire was the first scale designed to assess HRQOL. The aim of the present study was twofold: to assess HRQOL in a sample of Spanish patients awaiting bariatric surgery and to determine the psychometric properties of the IWQOL-Lite and its sensitivity to detect differences in HRQOL across groups. Methods Participants were 109 obese adult patients (BMI¿ 35 kg/m2) from Barcelona, to whom the following measurement instruments were applied: IWQOL-Lite, Depression Anxiety Stress Scales, Brief Symptom Inventory, and self-perception items. Results Descriptive data regarding the IWQOL-Lite scores obtained by these patients are reported. Principal components analysis revealed a five-factor model accounting for 72.05% of the total variance, with factor loadings being adequate for all items. Corrected itemtotal correlations were acceptable for all items. Cronbach"s alpha coefficients were excellent both for the subscales (0.880.93) and the total scale (0.95). The relationship between the IWQOLLite and other variables supports the construct validity of the scale. Finally, sensitivity analysis revealed large effect sizes when comparing scores obtained by extreme BMI groups. Conclusions This is the first study to report the application of the IWQOL-Lite to a sample of Spanish patients awaiting bariatric surgery and to confirm that the Spanish version of the instrument has adequate psychometric properties.

Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients.

PURPOSE: Thirty to forty percent of patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis develop intra-abdominal invasive candidiasis (IC). A corrected Candida colonization index (CCI) > or =0.4 is a powerful predictor of IC. Fluconazole prevents intra-abdominal IC in this setting, but azole-resistant Candida species are emerging. The aim of this study was to explore the efficacy and safety of caspofungin for prevention of intra-abdominal IC in high-risk surgical patients. METHODS: Prospective non-comparative single-center study in consecutive adult surgical patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis. Preventive caspofungin therapy (70 mg, then 50 mg/day) was given until resolution of the surgical condition. Candida colonization index and CCI, occurrence of intra-abdominal IC and adverse events were monitored. RESULTS: Nineteen patients were studied: 16 (84%) had recurrent gastrointestinal perforation/anastomotic leakage and 3 (16%) acute necrotizing pancreatitis. The median duration of preventive caspofungin therapy was 16 days (range 4-46). The colonization index decreased significantly during study therapy, and the CCI remained <0.4 in all patients. Caspofungin was successful for prevention of intra-abdominal IC in 18/19 patients (95%, 1 breakthrough IC 5 days after inclusion). No drug-related adverse event requiring caspofungin discontinuation occurred. CONCLUSION: Caspofungin may be efficacious and safe for prevention of intra-abdominal candidiasis in high-risk surgical patients. This needs to be further investigated in randomized trials.

Chirurgie endoscopique endonasale des tumeurs de la base du crane : historique, état de l'art et perspectives d'avenir [Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches].

During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.

Transvaginal specimen extraction in colorectal surgery: current state of the art.

Aim  Background The expected benefit of transvaginal specimen extraction is reduced incision-related morbidity. Objectives A systematic review of transvaginal specimen extraction in colorectal surgery was carried out to assess this expectation. Method  Search strategy The following keywords, in various combinations, were searched: NOSE (natural orifices specimen extraction), colorectal, colon surgery, transvaginal, right hemicolectomy, left hemicolectomy, low anterior resection, sigmoidectomy, ileocaecal resection, proctocolectomy, colon cancer, sigmoid diverticulitis and inflammatory bowel diseases. Selection criteria Selection criteria included large bowel resection with transvaginal specimen extraction, laparoscopic approach, human studies and English language. Exclusion criteria were experimental studies and laparotomic approach or local excision. All articles published up to February 2011 were included. Results  Twenty-three articles (including a total of 130 patients) fulfilled the search criteria. The primary diagnosis was colorectal cancer in 51% (67) of patients, endometriosis in 46% (60) of patients and other conditions in the remaining patients. A concurrent gynaecological procedure was performed in 17% (22) of patients. One case of conversion to laparotomy was reported. In two patients, transvaginal extraction failed. In left- and right-sided resections, the rate of severe complications was 3.7% and 2%, respectively. Two significant complications, one of pelvic seroma and one of rectovaginal fistula, were likely to have been related to transvaginal extraction. The degree of follow up was specified in only one study. Harvested nodes and negative margins were adequate and reported in 70% of oncological cases. Conclusion  Vaginal extraction of a colorectal surgery specimen shows potential benefit, particularly when associated with a gynaecological procedure. Data from prospective randomized trials are needed to support the routine use of this technique.

Transobturator surgery for female stress incontinence: a comparative anatomical study of outside-in vs inside-out techniques.

OBJECTIVE To assess the specific risks of injury to neural and vascular structures inherent in two approaches to transobturator surgery for inserting a suburethral sling, i.e. the outside-in (standard technique) and inside-out approaches. MATERIALS AND METHODS The study comprised seven cadavers, providing 14 obturator regions. Five specimens had a tape inserted outside-in on one side, and inside-out on the other; of the remaining two cadavers, one had an inside-out tape and one an outside-in tape, bilaterally. After tape insertion, the cadavers were dissected. Particular attention was paid to the distances between the tape and the deep external pudendal vessels, and between the tape and the posterior branch of the obturator nerve. RESULTS With the inside-out technique, the safety margins were reduced, and the external pudendal vessels and the posterior branch of the obturator nerve were at greater risk of injury. CONCLUSION The two techniques are not equivalent, with a lower risk of injury to vascular and nerve structures with the outside-in technique.