La disponibilité des lits de réanimation a été un enjeu majeur de la gestion de la crise Covid-19, imposant aux acteurs régionaux de construire une réponse coordonnée et novatrice pour apporter une ...réponse en termes de recherche de place. Dans la région Île-de-France, la mise en place du dispositif a été constituée par deux mesures : la refonte du répertoire opérationnel des ressources (ROR) et la création d’une cellule d’appui régionale (Covidréa) comportant des cellules médicale et administrative. Les opérateurs de la cellule médicale étaient des chirurgiens volontaires sous la supervision d’un médecin urgentiste, chargés des actions de recherche et de régulation des demandes. La cellule administrative a vérifié la pertinence des informations du ROR sur un rythme pluriquotidien. La mobilisation des acteurs locaux (anesthésistes et réanimateurs) a permis d’obtenir des données actualisées du ROR quasiment en temps réel. La crise sanitaire Covid-19 a mis en lumière les faiblesses des systèmes d’information, particulièrement la connaissance de la disponibilité en lits de réanimation en temps réel. Une démarche collective pour construire de nouveaux outils de pilotage adaptés au quotidien, dans le cadre des tensions hivernales (bronchiolite, grippe) ou saisonnières (canicule), et la gestion des situations sanitaires exceptionnelles est impérative. Il est nécessaire d’intégrer cette fonction dans la mission des Samu départementaux en temps ordinaire et des Samu zonaux en temps de crise, en particulier dans la logique de construction du futur service d’accès aux soins (SAS).
The availability of intensive care unit (ICU) beds was a major stake in the management of the COVID-19 crisis, requiring the regional actors to build a coordinated and innovative response in terms of finding a bed. In the Ilede- France region, the implementation of the system was made up of two measures: the overhaul of the operational resource directory (ROR) and the creation of a regional support unit (COVID-ICU) including medical and administrative units. The operators of the medical cell were volunteer surgeons under the supervision of an emergency physician, in charge of research and demand medical regulation actions. The administrative unit verified the relevance of the information from the ROR on a multi-daily basis. The mobilization of local actors (anesthesiologists and intensivists) made it possible to obtain updated information almost in real time. The COVID-19 health crisis highlighted the weaknesses of the information systems, particularly the knowledge of the availability of ICU beds in real time. A collective approach to build new management tools adapted to daily life, in the context of winter (bronchiolitis, flu) or seasonal (heat wave) tensions, and the management of exceptional health situations is mandatory. It is necessary to integrate this function into the mission of the departmental Samu in ordinary times and the zonal Samu in times of crisis, especially in the logic of building the future French access to care service (SAS).
Lynch syndrome (hereditary non-polyposis colorectal cancer) is characterised by the development of colorectal cancer, endometrial cancer and various other cancers, and is caused by a mutation in one ...of the mismatch repair genes: MLH1, MSH2, MSH6 or PMS2. The discovery of these genes, 15 years ago, has led to the identification of large numbers of affected families. In April 2006, a workshop was organised by a group of European experts in hereditary gastrointestinal cancer (the Mallorca-group), aiming to establish guidelines for the clinical management of Lynch syndrome. 21 experts from nine European countries participated in this workshop. Prior to the meeting, various participants prepared the key management issues of debate according to the latest publications. A systematic literature search using Pubmed and the Cochrane Database of Systematic Reviews reference lists of retrieved articles and manual searches of relevant articles was performed. During the workshop, all recommendations were discussed in detail. Because most of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, many of them were based on expert opinion. The guidelines described in this manuscript may be helpful for the appropriate management of families with Lynch syndrome. Prospective controlled studies should be undertaken to improve further the care of these families.
Analyser les résultats du système de gestion et d’analyse des publications scientifiques (SIGAPS) au sein de l’Assistance publique–Hôpitaux de Paris (AP–HP) et comparer la production scientifique ...entre les différentes disciplines médicales et chirurgicales du CHU de Paris.
Toutes les publications importées par SIGAPS depuis PubMed entre 2006 et 2008 ont été incluses. Les données suivantes ont été prises en compte et analysées : service hospitalier d’origine, nombre d’articles publiés, nombre de titulaires dans l’unité, score SIGAPS.
Au total, 38 709 publications ont été analysées. Les 747 services étaient composés de 5719 titulaires (1895 33,1 % PU–PH, MCU ou PHU ; 2772 48,4 % PH et 1052 18,4 % CCA ou AHU). Le nombre moyen de titulaires par service était de 7,7±6,7 (min-max : 1–69). La moyenne du nombre total de publications par service était de 51,8±49,4 (min-max : 1–453). Le score SIGAPS moyen était plus important en médecine qu’en chirurgie (621,2±670,1 vs. 401±382,2 ; p=0,01) mais pas le nombre moyen d’article par titulaires entre ces deux filières (8,1±8,3 en médecine vs. 6,6±6,2 ; p=0,08). Le nombre de moyen de publication par temps plein était de 7,9±7,8 (1–45), soit un nombre moyen de 2,7±2,6 par temps plein et par an.
L’AP–HP a une production scientifique relativement importante mais avec un nombre moyen de 2,7 articles par temps plein par an. Il n’existait pas de différence notable entre les disciplines médicales et chirurgicales.
To analyze the results of the bibliometric system (SIGAPS score) of scientific publications in the Assistance publique–Hôpitaux de Paris (AP–HP) and to compare the scientific production among the various medical and surgical specialties of the academic hospitals of Paris.
All the publications imported from Pubmed between 2006 and 2008 were included. The following data were taken into account and analysed: the hospital department of origin, the number of articles published, the number of full-time physicians, the SIGAPS score.
Thirty-eight thousand, seven hundred and nine publications were included. The departments were consisted of 747 full-time practitioners 5719 (1895 Professors 33.1%, 2772 Assistant Professors 48.4% and 1052 fellows 18.4%). The average number of full-time practitioner by department was 7.7±6.7 (range 1–69). The average total number of articles published in a department was 51.8±49.4 (range 1–453). The average SIGAPS score was more important in medicine than in surgery (621.2±670.1 vs. 401±382.2; P=0.01) but not the average number of article per practitioner (8.1±8.3 vs. 6.6±6.2; P=0.0797). The mean number of publication by full-time practitioner was 7.9±7.8 (1–45), or an average of 2.7±2.6 for each full-time practitioner each year.
Academic hospitals in Paris have a reasonably scientific output but with a mean of 2.7 articles per full-time practitioner per year. No major differences between medical and surgical disciplines were observed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Patients treated with chemotherapy for microsatellite unstable (MSI) and/or mismatch repair deficient (dMMR) cancer metastatic colorectal cancer (mCRC) exhibit poor prognosis. We aimed to evaluate ...the relevance of distinguishing sporadic from Lynch syndrome (LS)-like mCRCs.
MSI/dMMR mCRC patients were retrospectively identified in six French hospitals. Tumour samples were screened for MSI, dMMR, RAS/RAF mutations and MLH1 methylation. Sporadic cases were molecularly defined as those displaying MLH1/PMS2 loss of expression with BRAFV600E and/or MLH1 hypermethylation and no MMR germline mutation.
Among 129 MSI/dMMR mCRC patients, 81 (63%) were LS-like and 48 (37%) had sporadic tumours; 22% of MLH1/PMS2-negative mCRCs would have been misclassified using an algorithm based on local medical records (age, Amsterdam II criteria, BRAF and MMR statuses when locally tested), compared to a systematical assessment of MMR, BRAF and MLH1 methylation statuses. In univariate analysis, parameters associated with better overall survival were age (P < 0.0001), metastatic resection (P = 0.001) and LS-like mCRC (P = 0.01), but not BRAFV600E. In multivariate analysis, age (hazard ratio (HR) = 3.19, P = 0.01) and metastatic resection (HR = 4.2, P = 0.001) were associated with overall survival, but not LS. LS-like patients were associated with more frequent liver involvement, metastatic resection and better disease-free survival after metastasectomy (HR = 0.28, P = 0.01). Median progression-free survival of first-line chemotherapy was similar between the two groups (4.2 and 4.2 months; P = 0.44).
LS-like and sporadic MSI/dMMR mCRCs display distinct natural histories. MMR, BRAF mutation and MLH1 methylation testing should be mandatory to differentiate LS-like and sporadic MSI/dMMR mCRC, to determine in particular whether immune checkpoint inhibitors efficacy differs in these two populations.
•Metastatic colorectal cancers with sporadic or inherited MMR deficiency display distinct natural histories.•A algorithm combining MMR protein expression, BRAF mutation and MLH1 methylation is mandatory to properly determine the mechanism of MMR deficiency.•A better characterisation of dMMR CRCs is needed to determine whether therapeutic agents efficacy differs depending on the origin of the MMR deficiency.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Peutz-Jeghers syndrome (PJS, MIM175200) is an autosomal dominant condition defined by the development of characteristic polyps throughout the gastrointestinal tract and mucocutaneous pigmentation. ...The majority of patients that meet the clinical diagnostic criteria have a causative mutation in the STK11 gene, which is located at 19p13.3. The cancer risks in this condition are substantial, particularly for breast and gastrointestinal cancer, although ascertainment and publication bias may have led to overestimates in some publications. Current surveillance protocols are controversial and not evidence-based, due to the relative rarity of the condition. Initially, endoscopies are more likely to be done to detect polyps that may be a risk for future intussusception or obstruction rather than cancers, but surveillance for the various cancers for which these patients are susceptible is an important part of their later management. This review assesses the current literature on the clinical features and management of the condition, genotype-phenotype studies, and suggested guidelines for surveillance and management of individuals with PJS. The proposed guidelines contained in this article have been produced as a consensus statement on behalf of a group of European experts who met in Mallorca in 2007 and who have produced guidelines on the clinical management of Lynch syndrome and familial adenomatous polyposis.
Purpose
Perineal hernia (PH) is a tardive complication following abdomino-perineal resection (APR). Many repair methods are described and evidences are lacking. The aim of this study was to report PH ...management, analyze surgery outcomes and review the available literature.
Methods
We retrospectively included all consecutive PH repair after APR performed between 2001 and 2017. We recorded data on APR surgery, PH symptoms and repair, and follow-up (recurrence and morbidity). Literature review included published articles on PubMed between 1960 and 2017.
Results
24 PH repairs were included. The approach was perineal
N
= 16, abdominal
N
= 5 and combined
N
= 3. A biological mesh was used for 17, a synthetic for 5 and a flap for 2 patients. The median follow-up was 25 months. Overall morbidity was 37.5% (
N
= 9): 37.5% for the perineal, 20% for the abdominal, and 66.7% for the combined approach. Complications occurred in 35.3% of biological and 20% of synthetic mesh repairs. Recurrence rate was 41.7%, similar for biological (
n
= 8, 47.1%) and synthetic meshs (
n
= 2; 40%). No recurrence occurred in the flap group. Depending of the approach, we found 50% for perineal (
n
= 8) and 40% of the abdominal cohort (
N
= 2). Among twelve studies, recurrence rates ranged from 0 to 66.7%. Abdominal or laparoscopic approach with synthetic mesh was associated with less recurrences (0 and 12.5% respectively) and complications (37.5% and 9.5%).
Conclusions
Recurrences following PH repair are high irrespective of the repair technique. More studies are necessary to identify PH risk factors and decide the appropriate perineal reconstruction.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Aim
To compare the functional results and quality of life after delayed colo‐anal anastomosis (DCAA) or immediate colo‐anal anastomosis (ICAA) following redo rectal surgery.
Method
Twenty‐six ...patients with DCAA between 2014 and 2018 were studied retrospectively (group A). Two control groups were used: 26 ICAA after redo surgery (group B) and 52 colo‐anal anastomosis (CAA) after anterior resection (group C). Control groups were matched for age, sex, pelvic radiotherapy and time to surgery. Low Anterior Resection Syndrome (LARS) and Gastrointestinal Quality of Life Index (GIQLI) scores were used to assess function and quality of life.
Results
The indications for surgery were comparable for groups A and B: anastomotic failure with chronic sepsis (38% vs 50%, P = 0.40), vaginal fistula (42% vs 42%, P = 1) and urinary fistula (20% vs 8%, P = 0.22) as well as the number of previous abdominal operations (1.3 ± 0.9 vs 1.1 ± 0.6, P = 0.19). The median LARS score in the first 2 years was 30 interquartile range (IQR) 14–41 for group A, 23 (IQR 0–41) for group B and 22 (IQR 11–37) for group C. After 2 years, the median LARS score improved in each group A, 21 (IQR 11–35); B, 18 (IQR 5–26); C, 13 (IQR 9–20), but was still high in group A. There was a tendency toward more major LARS in group A than in group B (46% vs 27%; P = 0.149). There was no difference in the mean GIQLI score between groups A and B (120 ± 16 vs 117 ± 19; P = 0.53) at the end of the follow‐up period. Time after stoma closure (< 2 years) and previous radiotherapy were risk factors for major LARS in all populations.
Conclusion
ICAA should be the procedure of choice where possible in redo surgery as it has better functional outcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Aim
The presence of tumour deposits (TDs) in colorectal cancer (CRC) is associated with poor prognosis. The seventh edition of TNM subclassified a new nodal stage, N1c, characterized by the presence ...of TDs without any concurrent positive lymph node (LN). It is not clear if the N1c category is or is not equal to LN metastasis. We aimed to examine the prevalence, characteristics and prognostic significance of this new subcategory.
Method
Consecutive patients who underwent surgery for CRC in two centres (2011–2014) were analysed. N1 cM0 patients were matched against non‐N1 cM0 (N0, N1a and N1b) patients for 3‐year overall survival (OS) and disease‐free survival (DFS).
Results
We identified 1122 patients with 648 (57.8%) colonic cancers. In 57 patients (5.1%), N1c status was associated with rectal cancers rectum = 33/57 (57.9%) vs colon = 24/57 (42.1%); P = 0.029, a higher pathological tumour stage pT3‐T4 N1c = 55/843 (6.5% vspT3‐T4 non‐N1c = 2/279 (0.7%); P < 0.0001 and vascular emboli n = 35 (61.4%) vs n = 552 (51.8%); P = 0.0305. Synchronous metastasis was observed in 23 cases (40%). After a mean follow‐up of 31 months, 3‐year OS for M0 patients, was 89.4%, 89.1%, 86.6% and 81.8% for N0, N1a, N1b and N1c tumours, respectively. DFS was significantly worse for N1c than for N0 (P = 0.0169), with N1c status having a significant effect on DFS in colonic cancers (P = 0.014). The presence of more than one TD was associated with a significantly worse DFS (P = 0.021).
Conclusion
Our results indicate that N1c CRC patients should be included among high‐risk patients for whom it is widely accepted that adjuvant chemotherapy should be considered.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Aim Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap ...technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short‐ and long‐term results of the Martius flap procedure.
Method Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF‐12 score), quality of sexual life Female Sexual Function Index (FSFI) score and anal continence (Wexner score) were determined.
Results Crohn’s disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn’s disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2–31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right‐sided flap was associated with a higher success rate (P = 0.0442).
Conclusion The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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