Introduction : L’objectif de cette etude etait de determiner les facteurs de risque de complications graves apres resection ileocolique pour maladie de Crohn a l'ere des anti TNF α. Materiels et methodes : Une etude retrospective monocentrique a ete realisee de 1999 a 2015, en incluant tous les patients operes d’une premiere resection ileocolique pour maladie de Crohn. L’impact des caracteristiques preoperatoires et des donnees peroperatoires sur les complications graves (grade III-IV) dans les 60 jours postoperatoires a ete evalue. Resultats : 146 patients ont ete inclus dans cette etude. La morbidite postoperatoire etait de 43,8%. Il y a eu 21 complications graves (14,4%). En analyse univariee, les anti TNF  dans les 3 mois precedant la chirurgie (p = 0,0007), l’association anti TNF  et corticosteroide (p=0,006), une duree operatoire superieure a 150 minutes (p=0,01) et l’absence de drainage peroperatoire (p = 0,02) etaient associes a la survenue d’une complication grave. En analyse multivariee, les anti TNF  (OR = 4,21 ; IC 95 % = 1,23-16,87 ; p = 0,02) et la conversion (OR = 7,95 ; IC 95% = 1,68-44,89 ; p = 0,009) etaient des facteurs de risque de complications graves. Le drainage peroperatoire etait un facteur protecteur (OR = 0,23 ; IC 95 % = 0,05-0,79 ; p = 0,02). Conclusion : L’utilisation des anti TNF  dans les 3 mois preoperatoires et la conversion lors de la laparoscopie sont des facteurs de risque de complications graves apres resection ileocolique pour maladie de Crohn. La mise en place d’un drain en peroperatoire serait un facteur protecteur.

Dihydropyrimidine dehydrogenase is a crucial enzyme for the degradation of 5-fluorouracil (5FU). DPYD, which encodes dihydropyrimidine dehydrogenase, is prone to acquire genomic rearrangements because of the presence of an intragenic fragile site FRA1E. We evaluated DPYD copy number variations (CNVs) in a prospective series of 242 stage I–III colorectal tumours (including 87 patients receiving 5FU-based treatment). CNVs in one or more exons of DPYD were detected in 27% of tumours (deletions or amplifications of one or more DPYD exons observed in 17% and 10% of cases, respectively). A significant relationship was observed between the DPYD intragenic rearrangement status and dihydropyrimidine dehydrogenase (DPD) mRNA levels (both at the tumour level). The presence of somatic DPYD aberrations was not associated with known prognostic or predictive biomarkers, except for LOH of chromosome 8p. No association was observed between DPYD aberrations and patient survival, suggesting that assessment of somatic DPYD intragenic rearrangement status is not a powerful biomarker to predict the outcome of 5FU-based chemotherapy in patients with colorectal cancer.

We report a case of grade III pseudomyxoma peritonei revealed by mucusuria and abdominal mass. These symptoms are unusual; the most frequent clinical presentation is acute appendicitis or progressively increasing abdominal diameter.

Nous rapportons le cas d’un pseudomyxome de grade III, révélé par une mucusurie et syndrome de masse. Il s’agit d’une présentation inhabituelle de pseudomyxome qui est diagnostiqué le plus souvent par un syndrome appendiculaire ou l’augmentation progressive du périmètre abdominal.

Background: To test the prognostic value of tumour protein and genetic markers in colorectal cancer (CRC) and examine whether deficient mismatch repair (dMMR) tumours had a distinct profile relative to proficient mismatch repair (pMMR) tumours.Methods: This prospective multicentric study involved 251 stage I-III CRC patients. Analysed biomarkers were EGFR (binding assay), VEGFA, thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) expressions, MMR status, mutations of KRAS (codons 12-13), BRAF (V600E), PIK3CA (exons 9 and 20), APC (exon 15) and P53 (exons 4-9), CpG island methylation phenotype status, ploidy, S-phase, LOH.Results: The only significant predictor of relapse-free survival (RFS) was tumour staging. Analyses restricted to stage III showed a trend towards a shorter RFS in KRAS-mutated (P - 0.005), BRAF wt (P = 0.009) and pMMR tumours (P - 0.036). Deficient mismatch repair tumours significantly demonstrated higher TS (median 3.1 vs 1.4) and TP (median 5.8 vs 3.5) expression relative to pMMR (P < 0.001) and show higher DPD expression (median 14.9 vs 7.9, P = 0.027) and EGFR content (median 69 vs 38, P = 0.037) relative to pMMR.Conclusions: Present data suggesting that both TS and DPD are overexpressed in dMMR tumours as compared with pMMR tumours provide a strong rationale that may explain the resistance of dMMR tumours to 5FU-based therapy.

Les essais randomisés ont montré que la chimioradiothérapie néoadjuvante n’améliorait pas les chances d’un traitement conservateur [1]. La radiothérapie de contact de 50 kV peut être associée à la radiothérapie externe pour les tumeurs de stade T2-3. Elle est utile après exérèse locale pour celles T1N0 [2]. Entre 2002 et 2012, 60 patients ont été traités à Nice pour une tumeur du rectum distal. Le recul médian était de 66 mois. Dans le groupe A, 40 patients atteints de cancer de stade T2 pour 19, T3 a-b pour 18, T1 pour trois, une radiothérapie externe de 45–50 Gy en cinq semaines (avec ou sans chimiothérapie) et une radiothérapie de contact de 90 Gy en trois séances. Dix-sept cancers étaient opérables (l’âge des patients était de 75 ans), 23 inopérables (85 ans). Après réponse clinique complète, il a été fait une exérèse locale pour 13 cas, une surveillance pour 27. Dans le groupe B, chez 20 patients âgés de 72 ans, une tumeur de stade T1N0 a été traitée par exérèse locale suivie d’une radiothérapie de contact adjuvante de 50 Gy en trois séances. Dans le groupe A, une réponse clinique complète a été obtenue chez 38/40 patients (95 %). Quatre rechutes locales ont été observées, dont deux rattrapées sans ablation du rectum. La conservation du rectum a été possible dans 39 cas, la fonction rectale considérée comme bonne dans 85 % des cas. La toxicité la plus fréquente était des rectorragies de grade 2-3. Aucune rechute ganglionnaire isolée n’a été observée. Le taux de dissémination métastatique était de 21 %, ceux de survies globale et spécifique à 3 ans de 59 % et 83 %. Dans le groupe B, une rechute locale a été rattrapée par résection antérieure. La fonction rectale était habituellement bonne. Le taux de rectorragie était de 30 %, celui de dissémination métastatique de 20 %, celui de survie globale de 93 % à 5 ans. Pour les cancers de stade T2-3 ab, l’association de radiothérapie externe et de radiothérapie de contact contrôle ces tumeurs en préservant le rectum. Pour les tumeurs de stade T1, après exérèse locale première, la radiothérapie de contact est une excellente option. L’amputation abdominopérinéale doit être une exception.

Introduction: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations.Method: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum.Results: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France.Conclusion: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery. (C) 2012 Elsevier Masson SAS. All rights reserved.

L’enseignement de la chirurgie repose sur un enseignement facultaire, un enseignement au bloc opératoire et au lit du malade associé éventuellement à une formation au sein des laboratoires d’anatomie ou de chirurgie expérimentale. Celui-ci peut être complété par un apprentissage utilisant les différentes techniques de simulation. L’apprentissage par simulation, largement répandu outre-atlantique, permet, sans aucun risque pour les patients, d’intervenir sur plusieurs éléments de la formation chirurgicale. Le curriculum développé au centre de simulation de la faculté de médecine de Nice Sophia-Antipolis concerne l’ensemble des internes en chirurgie de la faculté de médecine. Chaque interne bénéficie d’une formation théorique (initiation à la check-list de bloc opératoire), une formation aux scenarii médicochirurgicaux sur mannequin haute-fidélité et une formation aux gestes techniques de chirurgie ouverte et cœlioscopique sur deux ans, suivie d’un examen de validation d’aptitude technique. Ce curriculum a été accrédité par l’American College of Surgeons, constituant le premier programme de ce type en France. Ce programme constitue un modèle, répondant aux vœux de l’Académie de chirurgie de voir l’émergence d’écoles de chirurgie. Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork, and the multidisciplinary management of acute medico surgical situations. We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the medical school participate in this curriculum. Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios, and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

Emergency management of obstructing colonic cancer depends on both tumor location and stage, general condition of the patient and surgeon's experience. Right sided or transverse colon obstructing cancers are usually treated by right hemicolectomy-extended if necessary to the transverse colon-with primary anastomosis. For left-sided obstructing cancer, in patients with low surgical risk, primary resection and anastomosis associated with on-table irrigation or manual decompression can be performed. It prevents the confection of a loop colostomy but presents the risk of anastomotic leakage. Subtotal or total colectomy allows the surgeon to encompass distended and fecal-loaded colon, and to perform one-stage resection and anastomosis. Its disadvantage is an increased daily frequency of stools. It must be performed only in cases of diastatic colon perforation or synchronous right colonic cancer. In patients with high surgical risk, Hartmann procedure must be preferred. It allows the treatment of both obstruction and cancer, and prevents anastomotic leakage but needs a second operation to reverse the colostomy. Colonic stenting is clinically successful in up to 90% in specialized groups. It is used as palliation in patients with disseminated disease or bridge to surgery in the others. If stent insertion is not possible, loop colostomy is still indicated in patients at high surgical risk.

La voie d’accouchement de la présentation du siège reste débattue dans notre pays. Au-delà des arguments médicaux, eux-mêmes discutés, existe une pression médicolégale ressentie par les praticiens. Nous présentons différentes opinions des praticiens de la médecine, du droit et de l’enseignement face à cette problématique.

Introduction: La migration est une complication fréquente des prothèses oesophagiennes auto expansibles métalliques couvertes (PMC) poséesendoscopiquement. Le but de l'étude était d'évaluer l'efficacité de la pose de clips pour amarrer les PMC à la muqueuse digestive et prévenir lamigration du matériel.

Large adrenal tumors are rarely associated with adrenal enzymatic deficiency, except in 11 beta-hydroxylase insufficiency. These tumors are exceptionally malignant. We report here the case of a patient with a congenital 21-hydroxylase deficiency (compound heterozygote for two severe mutations in the CYP21A2 gene) untreated for 20 years. His evaluation at 36 years of age showed a four-centimeter mass in the left adrenal gland, with most characteristics suggestive of malignancy (CT and positron emission tomography [PET] scan). We performed a surgical resection that established the diagnosis of adrenocortical tumor of uncertain prognosis (Weiss's score: 3). Even though malignant tumors are unusual in adrenal deficiency, our observation shows the need for a replacement therapy during adulthood, with a regular CT scan follow up in order to diagnose early isolated adrenal adenoma and remove it in case of malignancy suspicion. (C) 2009 Elsevier Masson SAS. All rights reserved.

We report the case of a 62-year-old man with short-bowel syndrome, referred for intestinal transplantation, who had esophageal varices (EV) due to superior vena cava (SVC) thrombosis. Pretransplantation work-up revealed protein S deficiency. Results of liver function tests were normal. Upper endoscopy showed grade II to III EV in the upper and middle segments of the esophagus. Computed tomography demonstrated thrombosis of the jugular, subclavian, and SVC veins and marked collateral vessels in the chest. Transient elastography yielded normal findings. A liver biopsy specimen showed a normal aspect of the liver, without fibrosis or liver cirrhosis. Presence of EV in a patient with chronic intestinal insufficiency may be related to collateral venous circulation associated with SVC thrombosis in the absence of portal hypertension. In this situation, an isolated intestinal graft is indicated.

A 34-year-old-man with short-bowel syndrome received an isolated small bowel graft. On postoperative day (POD) 11, ileal biopsy specimen demonstrated mild to moderate rejection that did not respond to corticosteroid bolus therapy. On POD 14, endoscopy and histologic examination revealed exfoliative rejection that was not controlled after 14 days of therapy with thymoglobulin. On POD 95, the patient underwent surgery again because of intestinal obstruction. The graft was removed 6 months after transplantation because of continuous severe abdominal pain with weight loss. After enterectomy, the patient developed multiple-organ failure and died on POD day 8. This case underlines the severity of exfoliative rejection and suggests that early enterectomy be performed when the diagnosis is made, before deterioration of clinical status and development of infectious and nutritional complications.

OBJECTIVES:The EBIIA (Etude épidémiologique Bactério-clinique des Infections Intra-Abdominales) study was designed to describe the clinical, microbiological and resistance profiles of community-acquired and nosocomial intra-abdominal infections (IAIs).PATIENTS AND METHODS:From January to July 2005, patients undergoing surgery/interventional drainage for IAIs with a positive microbiological culture were included by 25 French centres. The primary endpoint was the epidemiology of the microorganisms and their resistance to antibiotics. Multivariate analysis was carried out using stepwise logistic regression to assess the factors predictive of death during hospitalization.RESULTS:Three hundred and thirty-one patients (234 community-acquired and 97 nosocomial) were included. The distribution of the microorganisms differed according to the type of infection. Carbapenems and amikacin were the most active agents in vitro against Enterobacteriaceae in both community-acquired and nosocomial infections. Against Pseudomonas aeruginosa, amikacin, imipenem, ceftazidime and ciprofloxacin were the most active agents in community-acquired infections, while imipenem, cefepime and amikacin were the most active in nosocomial cases. Against the Gram-positive bacteria, vancomycin and teicoplanin were the most active in both infections. Against anaerobic bacteria, the most active agents were metronidazole and carbapenems in both groups. Empirical antibiotic therapy adequately targeted the pathogens for 63% of community-acquired and 64% of nosocomial peritonitis. The presence of one or more co-morbidities [odds ratio (OR) = 3.17; P = 0.007], one or more severity criteria (OR = 4.90; P < 0.001) and generalized peritonitis (OR = 3.17; P = 0.006) were predictive of death.CONCLUSIONS:The principal results of EBIIA are a higher diversity of microorganisms isolated in nosocomial infections and decreased susceptibility among these strains. Despite this, the adequacy of treatment is comparable in the two groups.

5542 Background: Optimal treatment of chemoresistant and recurrent ovarian cancer is debating with second line chemotherapies. For peritoneal carcinomatosis new treatment combining cytoreductive surgery with heated intraperitoneal per operative chemotherapy (HIPEC) may improve survival. Methods: Retrospective bicentric study of 246 patients with peritoneal carcinomatosis from ovarian cancer were performed to evaluate HIPEC and to identify prognostic factors. Peritoneal Cancer Index (PCI) assess tumor load and completeness cytoreductive score (CCS) was used to give quality of resection CC0 (no visible tumor), CC1 (persistent diffuse lesions < 2.5mm), CC2 (2.5mm < CC2 < 25mm) and over CC3 status. HIPEC is performed with platinum based regimen at 42°C. Endpoint was survival. Kaplan-Meier survival curve was fitted to the data. Cox's regression model was used for multivariate survival analysis. Results: The study included 268 procedures in 246 patients from 1991 to 2008. 206 procedures were performed in 184 patients with recurrence (Group 1) and 62 in chemoresistant patients (Group 2). After completion of resection the allocation of CCS was CC0 = 164, CC1 = 83, CC2 = 15, and CC3 = 5. Only 1 patient died in post operative course and procedure related morbidity rate was 12%. 5 years overall and free survival were respectively 35 % and 10%. Median overall survival was 49 months and the median disease free survival was 13 months. There was no difference between group 1 and 2 for survival. Independent prognostic factors for survival were the carcinomatosis extent, the completeness of cytoreductive surgery (HR = 2.26 IC95 [1.3–3.91]), performance status (HR = 4.3 IC95 [1.23–14.4]) and redo procedure (HR = 0.9 IC95 [0.001–0.9]). Conclusions: Hipec is a standardized and reproducible feasible method. Less extensive disease and the quality of cytoreduction remain an independent factor of better outcome. Morbidity is acceptable. To date in selected patients, HIPEC allows to reach the longest median time survival in recurrent peritoneal carcinomatosis from ovarian cancer. No significant financial relationships to disclose.

La carcinose péritonéale représente 10 % des patients atteints par une cancer colorectal au moment du diagnostic et 20 % lors de l’apparition d’une récidive. Longtemps considérée comme une évolution terminale avec un pronostic défavorable à court terme, des travaux récents ont permis d’obtenir des résultats encourageants avec une approche curative associant la chirurgie avec une chimiothérapie intrapéritonéale per-opératoire (CHIP). Le but de cette étude a été de déterminer l’existence de facteurs pronostiques chez des patients éligibles pour une CHIP. Nous avons réalisé 48 procédures (CHIP) chez 46 patients consécutifs (18 hommes et 26 femmes) de janvier 2000 à décembre 2007. Les critères d’éligibilité étaient la présence d’une carcinose péritonéale d’origine colorectale (à l’exclusion des cancers appendiculaires) sans extension extra-abdominale. L’âge était inférieur ou égal à 75 ans. L’index de carcinose péritonéale (PCI) évaluait la charge tumorale au moment de l’intervention. Le score de radicalité (CCS) représentait la qualité de la résection, CCS0 (pas de lésion visible), CCS1 (lésions < 2,5 mm), CCS2 (2,5 mm < CCS2 < 25 mm) et CCS3 > 25 mm. L’intervention a consisté en une cytoréduction la plus radicale possible, combinant des péritonectomies à des résections multiviscérales, associée à une CHIP avec de la Mitomycine C à la dose de 12 mg/m2 chez l’homme et de 10 mg/m2 chez la femme. La solution est portée à 42 °C la procédure de chimio-hyperthermie est réalisée à ventre ouvert pendant 90 minutes. L’objectif principal était la survie globale. L’analyse de la survie était réalisée selon la méthode de Kaplan Meier. L’analyse multivariée utilisait le modèle de Cox. L’âge moyen était de 52,7 ans [32 - 75]. Le PCI moyen était de 10 [1 - 21] et la répartition du CCS était 33 CCS0, 11 CCS1 et 2 CCS2. La durée moyenne d’intervention a été de 520 minutes. La mortalité post-opératoire était nulle, la morbidité de 21,7 % et la durée moyenne de séjour de 18,6 jours [7 - 57]. La survie globale à 5 ans et la survie sans récidive, selon Kaplan Meier, étaient respectivement de 40 % et 20 %. La survie médiane était de 51 mois. En analyse multivariée selon le modèle de Cox, le nombre de régions atteintes (HR = 1,7 IC 95 % [1,17 - 2,55] p < 0,006) ainsi que les localisations sous-phréniques (HR = 1,7 IC 95 % [1,17 - 2,55] p < 0,006) et mésentériques (HR = 4,03 IC 95 % [1,46 - 11,1] p < 0,007) sont des facteurs de mauvais pronostic. La CHIP est une méthode faisable et reproductible. Elle est la seule méthode de traitement curatif en cas de carcinose péritonéale. Une meilleure sélection de patients dont la maladie sera complètement réséquée doit nous permettre d’atteindre 40 % de survie à 5 ans.