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(069). Surgery of liver metastases of colorectal cancer experience in surgical clinic “a”
AB33
Colorectal Cancer / Arab Journal of Gastroenterology 10 (2009) AB27–AB35
(066) The management of colic cancer: Surgical a department experience Am. Souadka, B. Zakri, H.O. El Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department A, Ibn Sina Hospital, Rabat, Morocco
Introduction: Colic cancer represents a real public health problem not only in western countries, but also in arabic ones, with its high incidence, high potential of hepatic metastasis and mortality. Methods: We present a large retrospective study of 193 cases of colic cancers treated at the ‘‘surgical department A’’ at Ibn Sina hospital during 12 years, from 1995 to 2006. Results: The mean age of our patients was 54 years (17–84) with a sex ratio of 1.3 man/women. The mean time between first symptoms and the medical consult was about 9 months and the principals clinical signs were: abdominal pain in 74.1% of the cases, transit disorders in 58% of cases and bleeding in 46.6% of cases. Only 29% of the patients had an abdominal mass at the initial clinical examination. We performed total colonoscopy in all cases that showed exactly the site of the cancer: 46% in left colon, 39% in right colon, 10% in the rectosigmoid junction and 5% in transverse colon. One patient had double localization at the moment of the diagnosis: rectal and colic cancer. Patients (26%) were metastatic at the moment of the diagnosis. The adenocarcinoma was the predominant histological type with 95% of cases. The 5% left were: malignant lymphoma and neuroendocrine carcinoma. The operability rate was 95% and rescalability rate was 85%. We performed curative resections at 124 patients versus 32 palliative ones. 6 synchronous hepatic metastases resections were performed. Post-operative mortality rate was 2.2% and post-operative morbidity was 14.8%. The mean following time was 23 months: 19 patients developed a local reccurrences and 9 patients developed metastases. The survival rate all stages mixed was 89% at the first year, 79% years at 3 years and 60% at 5 years for followed patients. Discussion: Our serie showed the special young age of the Moroccan population with colic cancer and the late diagnosis stage of this cancer. The management of colic cancer needs a multidisciplinary and a well establish coordination associated to an early screening to be able to propose a curative surgical treatment at the early stages to improve a long-term prognosis of this disease. doi:10.1016/j.ajg.2009.07.192
(067) Low rectal experience
cancer
management:
Surgical
a
department
Am. Souadka, B. Zakri, O.H. El Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department A, Ibn Sina Hospital, Rabat, Morocco
The management or low rectal malignancy has undergone a hilarious evolution, not only by the developpement of surgical techniques but also by the adjunction of adjuvant radiochemotherapy. The aim of this study: to report the results of our retrospective study concerning the surgical management of low rectal cancer in our department . Methods: During 16 years (from 1990 to 2006), we managed, in our department, 324 patients with low rectal cancer. Fifty four percent of them were men with an average old of 50 years old. 12% were nonoperable and 8% non-resecable. Most of the cases (59%) underwent
an abdomino-perineal resection (APR) although in the 41% left, 88% of them had an anterior (AR) resection and 11% local resetion (LR). Results: Mortality rate was 1.4%. Operative morbidity was represented by: 11 cases of postoperative peritonitis, 14 cases of acute intestinal obstruction, 7 cases of pelvic abscess, 32 cases of urinary complications, 15 cases of sexual complications, 16 cases of perineal complications and 15 cases of stomial complications. Recurrence rate reached 10.2% (9% with APR, 13.5% with AR and 9% with LR). Conclusion: The management of low rectal cancer is still difficult and heavy because the high risk or local recurrences and fonctionnel sequel. This cannot be envisaged without a multidisciplinary approach. doi:10.1016/j.ajg.2009.07.193
(068) Colonic cancer obstruction: Experience of emergency surgical department about 110 cases B. Zakri, A. Souadka, M. El Absi, M. El Ouanani, M. Eccharab, F.H. El Alami, M. Amraoui, A. Errougani, R. Chkoff Emergency Department of Surgery, Ibn Sina Hospital, Rabat, Morocco
Introduction: Management of obstructed colonic carcinomas remains a surgical challenge specially in elderly patients. The aim of our study is to assess mortality and morbidity rates of procedures performed in emergency for this pathology Methods: We reviewed the records of 110 cases of cancer in colic occlusion treated in surgical emergency department of the Avicenne hospital. They were divided into 60 men and 50 women. The average age is 53 years old. Patients (42%) had a past history of constipation. Ninety-three percent of the cases consulted at the complete occlusion state after a mean evolution time of 8 days. Results: The tumor was at the left colon in 76% of cases mostly at the recto-sigmoid junction and sigmoid colon only. In 24% of cases the tumor was at the right colon. The surgical management was represented by: 34 discharge stomas, 68 total tumor ablation, 6 internal derivation and 2 explorative laparotomies. The overall mortality is 20.75%. The internal bypass is the most blamed in the deaths of patients in our series. The disease is 23.5% dominated by infectious complications, especially anastomotic fistula. For right colic occlusions: right colectomy with immediate ileocolic anastomosis is done whenever possible. For Left colic occlusions: a discharge stomas is the best approach. Conclusion: Our study confirms that obstructed colonic cancer has a bad prognosis because of the elderly age and health state of the patients. Whereas stents are unfortunately not available at our institution, the discharge stoma remain a good, easy and quick alternative for those tired patient. doi:10.1016/j.ajg.2009.07.194
(069) Surgery of liver metastases of colorectal cancer experience in surgical clinic ‘‘a’’ S. Lahmidani, O. Malki, R. Mohcine, L. Ifrine, A. Belkouchi CHU Avicenne, Rabat, Morocco
Introduction: Advances in surgery and chemotherapy have improved the care of patients with liver metastases of colorectal origin.
Colorectal Cancer / Arab Journal of Gastroenterology 10 (2009) AB27–AB35
The objective of this work is to report the experience of the surgical clinic ‘‘A’’ to the Ibn Sina hospital in terms of resection of liver metastases of colorectal cancer and compare it to recent data from the literature. Materials and methods: It is a retrospective study of 31 patients who received resection of liver metastases of colorectal adenocarcinoma between January 1990 and December 2006. Demographic, clinical, para clinical, therapeutic and evolutive data were collected and analyzed. Results: The frequency of liver metastases of colorectal adenocarcinoma is 19%; résécabilité rate is 30%. There is a male predominance (61.3%). the average age is 52 years. the diagnosis is made by ultrasound in 87% of patients. The type of liver resection is a right or left hepatectomy (5 cases), a left lobectomy (5 cases), a bisegmentectomie (4 cases), atypical resection (7 cases), a métastasectomie (10 cases). The mortality rate is 6.4%, the morbidity rate is 19.3%. Six patients had a liver tumor recurrence, including 3 had a seconds liver resection. Discussion: Support multidisciplinary liver metastases has become essential, the surgical resection is the only treatment for a long-term survival acceptable. Only a minority of patients may benefit from curative surgery. The current challenge is to develop innovative strategies combined resection of other tumor destruction techniques as radiofrequency, embolisation portale and a new chemotherapy protocols to make résécables liver metastases that originally were not. doi:10.1016/j.ajg.2009.07.195
(070) Perineal pseudocontinent colostomy: The best alternative to iliac definitive colostomy for rectal cancer in arabic countries Am. Souadka, A. Othmani, F. Tijami, M. Boktab, H. Hachi, F. Ahyoud, A. Jalil, S. Benjelloun, A. Souadka Oncologic Surgery Department, National Institute of Oncology (INO), Rabat, Morocco
Background: This retrospective study was designed to evaluate functional results of pseudocontinent perineal colostomy (PCPC) for low rectal cancer using Schmidt’s technique. Methods: From January 1992 to December 1999, 109 PCPC for low rectal cancer were performed in our institution. There were 56 men and 53 women, with an age average of 47 years old. The PCPC was created after 96 abdominoperineal resections, 9 posterior pelvic exenterations and 2 total pelvic exenterations. Two left iliac colostomy were transformed in PCPC. Results: There was no postoperative mortality. Operative Morbidity rate was only 18.3%, essentially dominated by perineal suppuration (40%). On a functional level, 64.4% of cases had gaz incontinence and 31.2% an occasional minimal soiling. At one year surveillance, the graft was clinically well detected in 55% of cases and anorectal manometric study on 3 cases showed a hypotonic pseudosphincter. Colic irrigation rhythm was, in 74% of cases, every 24–48 h, and 15.6% of patients did not need irrigations any more 6 months after surgery. Conclusion: PCPC is a simple technique that revolutionises low rectal cancer management. It improves patient’s quality of live by preserving their body image. By its amazing functional results it may be proposed as the best alternative to definitive left iliac colostomy for Arabic and Muslim patients. doi:10.1016/j.ajg.2009.07.196
AB34
(071) Surgical management of familial adenomatous polyposis Am. Souadka, B. Zakri, O.H. el Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department, A Ibn Sina Hospital, Rabat, Morocco
Introduction: The familial adenomatous polyposis is one of the most common hereditary disease associated to colorectal cancer. Its an autosomic transmission genetic disease characterized by the presence of many adenomatous polyposis that can lead in 1% of case to an invasive colorectal cancer. Methods: We retrospectively reviewed the records of all patients with colorectal diseases during the period from January 1992 and December 2007 treated at the surgical department A and found that 22 of them had a familial adenomatous polyposis. Results: The average age was 36 years old of this series, with sex ratio of 2.14 F/M. the most frequent and constant symptoms were: intestinal bleeding and transit disorders. A total colonoscopy performed at all patients showed the several polyposis and at 8 patients the suspect aspect of degenerated FAP. A gastroesophageal endoscopy showed in two cases the presence of duodenal polyposis. All patients underwent surgical resection with: 14 total coloproctrectomy+ with ileal pouch-anal anastomosis, in 6 patients a total colectomy with ileorectal anastomosis and 2 patients an abdominoperineal resection with definitive ileostomy. Histological findings confirmed that 10 patients had a degenerated familial adenomatous polyposis: 7 of them with an invasive adenocarcinoma ant 3 others with a high grade of dysplasia. Post-operative mortality concerned one patient and 10 patients had post-operative complication with specially 2 of them of secondary peritonitis Long term follow up showed an anastomotic local recurrence in one case, the apparence of associated desmoid tumours in 3 cases and one case of anasomotic stenosis. Conclusion: Familial adenomatous polyposis is a genetic precursor of colorectal cancer. The regular surveillance and the early screening in people with this autosomic disease associated to coloproctectomy represents the more adequate option to manage these patients. doi:10.1016/j.ajg.2009.07.197
(072) Local recurrence of rectal cancer after curative resection: Analysis of 23 cases H. El koundi, Y. El khyatti, M. Chenna, O. Mouaquit, A. Boubouh, B. Serji, E.H. Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department ‘‘A’’, Ibn Sina Hospital, Rabat, Morocco
Background: Local recurrence continues to be a major problem following surgical treatment of rectal cancer, and carries an extremely poor prognosis. It occurs in 4–33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery, present patterns of these pelvic recurrence and there perioperative morbidity Materials and methods: A total of 23 consecutive patients (11 men and 12 women) with a median age of 49 years (range 34–64) and local pelvic recurrence of rectal cancer were evaluated between January 1990 and December 2000 in the Surgical department A. All patients analysed had rectal cancer either at or below the level of the peritoneal reflection. Patients with recto-sigmoid cancers were excluded from the study. Nine patients had either a rectal resection with colorectal anastomosis, 11 patients underwent an
Colorectal Cancer / Arab Journal of Gastroenterology 10 (2009) AB27–AB35
(066) The management of colic cancer: Surgical a department experience Am. Souadka, B. Zakri, H.O. El Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department A, Ibn Sina Hospital, Rabat, Morocco
Introduction: Colic cancer represents a real public health problem not only in western countries, but also in arabic ones, with its high incidence, high potential of hepatic metastasis and mortality. Methods: We present a large retrospective study of 193 cases of colic cancers treated at the ‘‘surgical department A’’ at Ibn Sina hospital during 12 years, from 1995 to 2006. Results: The mean age of our patients was 54 years (17–84) with a sex ratio of 1.3 man/women. The mean time between first symptoms and the medical consult was about 9 months and the principals clinical signs were: abdominal pain in 74.1% of the cases, transit disorders in 58% of cases and bleeding in 46.6% of cases. Only 29% of the patients had an abdominal mass at the initial clinical examination. We performed total colonoscopy in all cases that showed exactly the site of the cancer: 46% in left colon, 39% in right colon, 10% in the rectosigmoid junction and 5% in transverse colon. One patient had double localization at the moment of the diagnosis: rectal and colic cancer. Patients (26%) were metastatic at the moment of the diagnosis. The adenocarcinoma was the predominant histological type with 95% of cases. The 5% left were: malignant lymphoma and neuroendocrine carcinoma. The operability rate was 95% and rescalability rate was 85%. We performed curative resections at 124 patients versus 32 palliative ones. 6 synchronous hepatic metastases resections were performed. Post-operative mortality rate was 2.2% and post-operative morbidity was 14.8%. The mean following time was 23 months: 19 patients developed a local reccurrences and 9 patients developed metastases. The survival rate all stages mixed was 89% at the first year, 79% years at 3 years and 60% at 5 years for followed patients. Discussion: Our serie showed the special young age of the Moroccan population with colic cancer and the late diagnosis stage of this cancer. The management of colic cancer needs a multidisciplinary and a well establish coordination associated to an early screening to be able to propose a curative surgical treatment at the early stages to improve a long-term prognosis of this disease. doi:10.1016/j.ajg.2009.07.192
(067) Low rectal experience
cancer
management:
Surgical
a
department
Am. Souadka, B. Zakri, O.H. El Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department A, Ibn Sina Hospital, Rabat, Morocco
The management or low rectal malignancy has undergone a hilarious evolution, not only by the developpement of surgical techniques but also by the adjunction of adjuvant radiochemotherapy. The aim of this study: to report the results of our retrospective study concerning the surgical management of low rectal cancer in our department . Methods: During 16 years (from 1990 to 2006), we managed, in our department, 324 patients with low rectal cancer. Fifty four percent of them were men with an average old of 50 years old. 12% were nonoperable and 8% non-resecable. Most of the cases (59%) underwent
an abdomino-perineal resection (APR) although in the 41% left, 88% of them had an anterior (AR) resection and 11% local resetion (LR). Results: Mortality rate was 1.4%. Operative morbidity was represented by: 11 cases of postoperative peritonitis, 14 cases of acute intestinal obstruction, 7 cases of pelvic abscess, 32 cases of urinary complications, 15 cases of sexual complications, 16 cases of perineal complications and 15 cases of stomial complications. Recurrence rate reached 10.2% (9% with APR, 13.5% with AR and 9% with LR). Conclusion: The management of low rectal cancer is still difficult and heavy because the high risk or local recurrences and fonctionnel sequel. This cannot be envisaged without a multidisciplinary approach. doi:10.1016/j.ajg.2009.07.193
(068) Colonic cancer obstruction: Experience of emergency surgical department about 110 cases B. Zakri, A. Souadka, M. El Absi, M. El Ouanani, M. Eccharab, F.H. El Alami, M. Amraoui, A. Errougani, R. Chkoff Emergency Department of Surgery, Ibn Sina Hospital, Rabat, Morocco
Introduction: Management of obstructed colonic carcinomas remains a surgical challenge specially in elderly patients. The aim of our study is to assess mortality and morbidity rates of procedures performed in emergency for this pathology Methods: We reviewed the records of 110 cases of cancer in colic occlusion treated in surgical emergency department of the Avicenne hospital. They were divided into 60 men and 50 women. The average age is 53 years old. Patients (42%) had a past history of constipation. Ninety-three percent of the cases consulted at the complete occlusion state after a mean evolution time of 8 days. Results: The tumor was at the left colon in 76% of cases mostly at the recto-sigmoid junction and sigmoid colon only. In 24% of cases the tumor was at the right colon. The surgical management was represented by: 34 discharge stomas, 68 total tumor ablation, 6 internal derivation and 2 explorative laparotomies. The overall mortality is 20.75%. The internal bypass is the most blamed in the deaths of patients in our series. The disease is 23.5% dominated by infectious complications, especially anastomotic fistula. For right colic occlusions: right colectomy with immediate ileocolic anastomosis is done whenever possible. For Left colic occlusions: a discharge stomas is the best approach. Conclusion: Our study confirms that obstructed colonic cancer has a bad prognosis because of the elderly age and health state of the patients. Whereas stents are unfortunately not available at our institution, the discharge stoma remain a good, easy and quick alternative for those tired patient. doi:10.1016/j.ajg.2009.07.194
(069) Surgery of liver metastases of colorectal cancer experience in surgical clinic ‘‘a’’ S. Lahmidani, O. Malki, R. Mohcine, L. Ifrine, A. Belkouchi CHU Avicenne, Rabat, Morocco
Introduction: Advances in surgery and chemotherapy have improved the care of patients with liver metastases of colorectal origin.
Colorectal Cancer / Arab Journal of Gastroenterology 10 (2009) AB27–AB35
The objective of this work is to report the experience of the surgical clinic ‘‘A’’ to the Ibn Sina hospital in terms of resection of liver metastases of colorectal cancer and compare it to recent data from the literature. Materials and methods: It is a retrospective study of 31 patients who received resection of liver metastases of colorectal adenocarcinoma between January 1990 and December 2006. Demographic, clinical, para clinical, therapeutic and evolutive data were collected and analyzed. Results: The frequency of liver metastases of colorectal adenocarcinoma is 19%; résécabilité rate is 30%. There is a male predominance (61.3%). the average age is 52 years. the diagnosis is made by ultrasound in 87% of patients. The type of liver resection is a right or left hepatectomy (5 cases), a left lobectomy (5 cases), a bisegmentectomie (4 cases), atypical resection (7 cases), a métastasectomie (10 cases). The mortality rate is 6.4%, the morbidity rate is 19.3%. Six patients had a liver tumor recurrence, including 3 had a seconds liver resection. Discussion: Support multidisciplinary liver metastases has become essential, the surgical resection is the only treatment for a long-term survival acceptable. Only a minority of patients may benefit from curative surgery. The current challenge is to develop innovative strategies combined resection of other tumor destruction techniques as radiofrequency, embolisation portale and a new chemotherapy protocols to make résécables liver metastases that originally were not. doi:10.1016/j.ajg.2009.07.195
(070) Perineal pseudocontinent colostomy: The best alternative to iliac definitive colostomy for rectal cancer in arabic countries Am. Souadka, A. Othmani, F. Tijami, M. Boktab, H. Hachi, F. Ahyoud, A. Jalil, S. Benjelloun, A. Souadka Oncologic Surgery Department, National Institute of Oncology (INO), Rabat, Morocco
Background: This retrospective study was designed to evaluate functional results of pseudocontinent perineal colostomy (PCPC) for low rectal cancer using Schmidt’s technique. Methods: From January 1992 to December 1999, 109 PCPC for low rectal cancer were performed in our institution. There were 56 men and 53 women, with an age average of 47 years old. The PCPC was created after 96 abdominoperineal resections, 9 posterior pelvic exenterations and 2 total pelvic exenterations. Two left iliac colostomy were transformed in PCPC. Results: There was no postoperative mortality. Operative Morbidity rate was only 18.3%, essentially dominated by perineal suppuration (40%). On a functional level, 64.4% of cases had gaz incontinence and 31.2% an occasional minimal soiling. At one year surveillance, the graft was clinically well detected in 55% of cases and anorectal manometric study on 3 cases showed a hypotonic pseudosphincter. Colic irrigation rhythm was, in 74% of cases, every 24–48 h, and 15.6% of patients did not need irrigations any more 6 months after surgery. Conclusion: PCPC is a simple technique that revolutionises low rectal cancer management. It improves patient’s quality of live by preserving their body image. By its amazing functional results it may be proposed as the best alternative to definitive left iliac colostomy for Arabic and Muslim patients. doi:10.1016/j.ajg.2009.07.196
AB34
(071) Surgical management of familial adenomatous polyposis Am. Souadka, B. Zakri, O.H. el Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department, A Ibn Sina Hospital, Rabat, Morocco
Introduction: The familial adenomatous polyposis is one of the most common hereditary disease associated to colorectal cancer. Its an autosomic transmission genetic disease characterized by the presence of many adenomatous polyposis that can lead in 1% of case to an invasive colorectal cancer. Methods: We retrospectively reviewed the records of all patients with colorectal diseases during the period from January 1992 and December 2007 treated at the surgical department A and found that 22 of them had a familial adenomatous polyposis. Results: The average age was 36 years old of this series, with sex ratio of 2.14 F/M. the most frequent and constant symptoms were: intestinal bleeding and transit disorders. A total colonoscopy performed at all patients showed the several polyposis and at 8 patients the suspect aspect of degenerated FAP. A gastroesophageal endoscopy showed in two cases the presence of duodenal polyposis. All patients underwent surgical resection with: 14 total coloproctrectomy+ with ileal pouch-anal anastomosis, in 6 patients a total colectomy with ileorectal anastomosis and 2 patients an abdominoperineal resection with definitive ileostomy. Histological findings confirmed that 10 patients had a degenerated familial adenomatous polyposis: 7 of them with an invasive adenocarcinoma ant 3 others with a high grade of dysplasia. Post-operative mortality concerned one patient and 10 patients had post-operative complication with specially 2 of them of secondary peritonitis Long term follow up showed an anastomotic local recurrence in one case, the apparence of associated desmoid tumours in 3 cases and one case of anasomotic stenosis. Conclusion: Familial adenomatous polyposis is a genetic precursor of colorectal cancer. The regular surveillance and the early screening in people with this autosomic disease associated to coloproctectomy represents the more adequate option to manage these patients. doi:10.1016/j.ajg.2009.07.197
(072) Local recurrence of rectal cancer after curative resection: Analysis of 23 cases H. El koundi, Y. El khyatti, M. Chenna, O. Mouaquit, A. Boubouh, B. Serji, E.H. Malki, R. Mohsine, L. Ifrine, A. Belkouchi Surgical Department ‘‘A’’, Ibn Sina Hospital, Rabat, Morocco
Background: Local recurrence continues to be a major problem following surgical treatment of rectal cancer, and carries an extremely poor prognosis. It occurs in 4–33% of cases especially if surgery is sub-optimal (without total excision of the mesorectum). This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery, present patterns of these pelvic recurrence and there perioperative morbidity Materials and methods: A total of 23 consecutive patients (11 men and 12 women) with a median age of 49 years (range 34–64) and local pelvic recurrence of rectal cancer were evaluated between January 1990 and December 2000 in the Surgical department A. All patients analysed had rectal cancer either at or below the level of the peritoneal reflection. Patients with recto-sigmoid cancers were excluded from the study. Nine patients had either a rectal resection with colorectal anastomosis, 11 patients underwent an