Preoperative assessment of the extension of rectal carcinoma: correlation of MR, surgical, and histopathologic findings

Nineteen patients with rectal carcinoma were evaluated prospectively. The extent of tumor and the relationship of the tumor to the levator ani muscle were studied as this determines the choice of the surgical procedure (abdominoperineal resection versus low anterior resection). Peroperative assessment and detailed evaluation of the pathologic specimens were correlated with magnetic resonance (MR) features. Magnetic resonance staging and surgical findings were at variance in four of 15 cases (27%). Magnetic resonance had sensitivities and specificities of 75 and 100% in the detection of perirectal growth. Magnetic resonance demonstrated invasion of adjacent pelvic side wall and sacrum in two of two cases. The comparison with TNM classification demonstrated that MR correctly staged 15 of 19 cases (79%). This study shows that MR is a good examination to evaluate the involvement of perirectal fatty tissues and adjacent structures. The low prevalence of involved lymph nodes in our cases prevents significant positive predictive values. Nevertheless, MR can help to select patients for local excision or for preoperative radiotherapy.

An international survey on the use of calcium silicate-based sealers in non-surgical endodontic treatment

OBJECTIVES

To gain insight on the current clinical usage of bioceramic root canal sealers (BRCS) by general dental practitioners (GDPs) and endodontic practitioners (EPs) and to determine if BRCS clinical application is in accordance with the best available evidence.

MATERIAL AND METHODS

An online questionnaire of 18 questions addressing BRCS was proposed to 2335 dentists via a web-based educational forum. Participants were asked about socio-demographic data, clinical practice with BRCS, and their motivation for using BRCS. Statistical analysis (chi-squared test or Fisher's exact test) was applied, as appropriate, to assess the association between the variable categories (p value < 0.05).

RESULTS

The response rate was 28.91%. Among respondents, 94.8% knew BRCS (EPs more than GDPs, p < 0.05) and 51.70% were using BRCS. The primary reason for using BRCS was their belief of its improved properties (87.7%). Among BRCS users, single-cone technique (SCT) was the most employed obturation method (63.3%) which was more applied by GDPs (p < 0.05); EPs utilized more of the thermoplasticized obturation techniques (p < 0.05). A proportion of 38.4% of BRCS users indicated the usage of SCT with BRCS regardless of the root canal anatomy (GDPs more than EPs p < 0.05) and 55.6% considered that BRCS may influence their ability to re-establish apical patency during retreatment (GDPs more than EPs p < 0.05).

CONCLUSIONS

This study highlights wide variation in the clinical use of BRCS which is not in accordance with the current literature.

CLINICAL RELEVANCE

This inconsistency among EPs and GDPs on BRCS clinical application requires further clarifications to better standardize their use and improve their future evaluation.

Current strategies for conservative endodontic access cavity preparation techniques-systematic review, meta-analysis, and decision-making protocol

OBJECTIVES

To assess related studies and discuss the clinical implications of endodontic access cavity (AC) designs.

MATERIALS AND METHODS

A systematic review of studies comparing the fracture resistance and/or endodontic outcomes between different AC designs was conducted in two electronic search databases (PubMed and Web of Science) following the PRISMA guidelines. Study selection, data extraction, and quality assessment were performed. Meta-analyses were undertaken for fracture resistance and root canal detection, with the level of significance set at 0.05 (P = 0.05).

RESULTS

A total of 33 articles were included in this systematic review. The global evaluation of the risk of bias in the included studies was assessed as moderate, and the level of evidence was rated as low. Four types of AC designs were categorized: traditional (TradAC), conservative (ConsAC), ultraconservative (UltraAC), and truss (TrussAC). Their impact on fracture resistance, cleaning/disinfection, procedural errors, root canal detection, treatment time, apical debris extrusion, and root canal filling was discussed. Meta-analysis showed that compared to TradAC, (i) there is a significant higher fracture resistance of teeth with ConsAC, TrussAC, or ConsAC/TrussAC when all marginal ridges are preserved (P < 0.05), (ii) there is no significant effect of the type of AC on the fracture resistance of teeth when one or two marginal ridges are lost (P > 0.05), and (iii) there is a significantly higher risk of undetected canals with ConsAC if not assisted by dental operating microscope and ultrasonic troughing (P < 0.05).

CONCLUSIONS

Decreasing the AC extent does not necessarily present mechanical and biological advantages especially when one or more surfaces of the tooth structure are lost. To date, the evidence available does not support the application of TrussAC. UltraAC might be applied in limited occasions.

CLINICAL RELEVANCE

Maintaining the extent of AC design as small as practical without jeopardizing the root canal treatment quality remains a pragmatic recommendation. Different criteria can guide the practitioner for the optimal extent of AC outline form which varies from case to case.

Endorectal sonography in the management of rectal villous tumours

Thirty-seven patients with rectal villous tumours were investigated by endorectal sonography to assess the integrity of the rectal muscularis propria at the tumour level. In four cases assessment of invasion was impossible. In 24 patients, endosonography revealed an ultrasonically superficial lesion not infiltrating the muscular layer. This was confirmed either, in the case of laser treatment, by the absence of malignant recurrence during the follow-up period or by histological examination after surgical resection. In nine patients, endosonography showed infiltration of the muscular layer. This was histologically confirmed in five operated patients. In the remaining four, laser destruction was performed: in two, a rectal adenocarcinoma was present 3 and 6 months later, respectively. These findings show that endosonography has a place in the management of rectal villous tumours, demonstrating invasive cancer in cases where other forms of assessment were wrongly reassuring.

Treatment of gallstones with piezoelectric lithotripsy and oral bile acids. A multicenter study

The efficacy of the combination of piezoelectric lithotripsy and oral bile acids in the treatment of gallbladder stones was assessed. Three hundred and sixty-three patients with symptomatic radiolucent gallstones in functioning gallbladder were treated in five medical centers using the same protocol with the EDAP LT 01 lithotripter. No anesthesia, analgesia or sedation was used. After one session of lithotripsy, fragmentation was observed in 89% of the patients, and satisfactory fragmentation (fragments less than or equal to 5 mm) in 29%. The satisfactory fragmentation rate was higher in patients with solitary stones less than or equal to 20 mm than in patients with solitary stones 21-35 mm or multiple stones (p less than 0.001). After multiple sessions (mean 1.6 session/patient, range 1-5) the overall rate of satisfactory fragmentation was 50%. After 12 months on oral bile acid therapy, complete clearance of the gallbladder was observed in 69% of patients with solitary stones less than or equal to 20 mm, 25% of patients with solitary stones 21-35 mm and 37% of patients with multiple stones. No complication was observed during the lithotripsy. During follow-up under bile acid therapy, there were five complications (1.4%): four patients had acute cholecystitis and one had mild, self-limited pancreatitis. We conclude that piezoelectric lithotripsy with the EDAP lithotripter is a safe and effective treatment which can be performed in outpatients. Satisfactory fragmentation and rapid disappearance of stones are obtained mainly in patients with solitary stones less than or equal to 20 mm.

Dental students' attitudes towards management of pain and anxiety during a dental emergency: educational issues

INTRODUCTION

High levels of patients' pain and anxiety characterise dental emergencies. The main objective of this study was to examine the self-reported attitudes of dental students towards these parameters in emergency conditions. A secondary objective was to determine if individual parameters (gender, personal experience of dental pain, personal dental anxiety and year of study) might affect their attitudes.

METHODS

One-hundred and eighty-seven undergraduate dental students with clinical practice completed a multiple-choice self-administered questionnaire online. The aforesaid individual parameters were collected and the students were asked to rate the frequency of their behaviour towards items representing good management of patients' pain and anxiety. The chi-square test of independence, Fisher's exact test and multiple logistic regression models were used for statistical analysis.

RESULTS

Oral assessment of anxiety before treatment was scarce and was significantly associated with the students having personally experienced dental pain (P = 0.007). Pre-, intra- and postoperative pain appeared to be managed unequally by the students. Male students were significantly less likely to inform patients about postoperative pain (P = 0.014). More clinical experience was associated with less systematic consideration for intra-operative pain (P < 0.05). Being dentally anxious showed no significant association with higher frequencies of behaviours towards patients' pain and anxiety.

CONCLUSIONS

These findings highlight the need for educational improvement regarding pain and anxiety in emergency conditions, especially concerning the assessment methods and continuity in the control of pain. Emergency dental care appears to be a very suitable field for contextual learning.

Evaluation of a new 3D-printed tooth model allowing preoperative ICDAS assessment and caries removal

INTRODUCTION

Teaching caries lesion management with operative care requires tooth models with highly realistic anatomical detail and caries lesions that can be assessed using ICDAS. This study aimed to develop and evaluate a new 3D-printed teeth model for ICDAS assessment and caries removal for pre-clinical hands-on education.

METHODS

Printable tooth with different layers for enamel, dentin and carious lesions was designed and tested by 31 dental students. They were asked to visually and radiologically assess the ICDAS severity of the simulated carious lesions, establish the therapeutic strategy according to CariesCare 4D, and perform a qualitative assessment of the models based on five-point Likert scale items.

RESULTS

Concerning carious lesions, the texture was realistic, and the shade was adequate for 94% and 97% of the participants. Ninety per cent of the participants found the model adequate to perform an ICDAS visual assessment. Seventy-four per cent of the students found the hardness adequate. Concerning the difference in shade and the noticeable hardness difference between enamel and dentin, participants have mixed agreement with a proportion of 61% and 55%, respectively. All the participants agreed these 3D-printed models provide a good caries simulation, are suitable for hands-on operative dentistry courses, and that learning outcomes better than the standard model.

CONCLUSION

The present work shows that rapid prototyping paves the way for customized educational models capable of supporting operative but also preoperative skills. 3D printing opens up new opportunities by reducing the gap between pre-clinical training and clinical reality in caries management, which can positively impact the quality of patient care.

Endodontic-related inferior alveolar nerve injuries: A review and a therapeutic flow chart

INTRODUCTION

Inferior alveolar nerve (IAN) lesions related to endodontic treatments can be explained by the anatomical proximity between the apices of the mandibular posterior teeth and the mandibular canal. The aim of this article is to review the management of inferior alveolar nerve lesions due to endodontic treatments and to establish a therapeutic flow chart.

METHODS

A review of publications reporting IAN damage related to endodontic treatment over the past 20 years has been conducted, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist; it combines an electronic search of the Pubmed^® and Google Scholar^® databasis. Forty-two full-text articles corresponding to 115 clinical cases have been selected. Two personal clinical cases were additionally reported.

RESULTS

IAN lesions due to endodontic treatments require urgent management. Early surgical removal of the excess of endodontic material, in contact with the nerve allows the best recovery prognosis (72h). Beyond this delay, irreversible nervous lesions prevail and a medical symptomatic treatment, most of the time with pregabalin, must be/can be carried out. A delayed surgical procedure shows some good benefits for patients. However, the healing prognosis remains poorly predictable.

Protective transverse loop colostomy associated with low colo-rectal anastomoses

A transverse loop colostomy to protect a low colorectal anastomosis should be carried out with minimal morbidity and mortality related to its creation and closure. A modification of the conventional technique is described.

[Anal metastases from cancer of the colon]

Two cases of anal metastases from sigmoid carcinoma are reported. The two patients were treated by local excision. The various mechanisms of tumoral spread are discussed from a review of the literature; the most frequent mechanism is cellular exfoliation. The most commonly used therapeutic approach is local excision combined, if necessary, with reconstruction of the sphincters.

[Reoperation for locoregional recurrence of cancer of the rectum]

71 recurrences after rectal resections for adenocarcinoma have been operated upon. After 43 initial anterior resections (AR), the treatment of recurrence was in 19 patients a new resection and in 18 a simple colostomy. When the initial treatment was a Mile's operation (APR in 23 patients), it has been performed 10 new exerses and 5 electrocautery. In the whole series, mortality and morbidity were respectively 17.5 per cent and 8 per cent. After AR the long term survival was 40 months when the initial tumour was classified Dukes A, and only 12 months when it was classified Dukes B or C. After APR the median long term survival was only 12 months. 75 per cent of the recurrences are observed during the first two years after initial resection. The screening includes repeated clinical examination, CEA dosage, endorectal sonography, endoscopy and CT scan. The appreciation of extirpability requires clinical examination, CT scan, MRI imaging. The aim is 1. to avoid exploratory and/or palliative operations. 2. to appreciate operating difficulties and to choose an adequate approach. The indication of systematic enlarged resections has to be appreciated related to patient's comfort and survival.

[Ogilvie's syndrome or colonic pseudo-obstruction. Apropos of 26 cases]

From twenty six personal cases, the authors make a review of the literature. 92% of their cases are met in a post operative (28%), neurological (28%), general (24%) context, or in intensive care with assisted ventilation (36%). The major symptom is the meteorism (100%) with in one out of three cases, abdominal pain, vomiting, right iliac defense, absence of bowel sounds. Radiological distension involves mostly the right colon and the coecum (28%), right and transverse colon (40), sometimes the whole colon (32%). The mean diameter of the coecum reached 12 cm (9 to 25 cm). Early coloscopy was mandatory in 20 patients, of which 14 were cured, 13 patients were operated on, for suspicion of ischemia or perforation, because incertain diagnosis, or failure of colonoscopy. Ceocostomy or right hemicolectomy (55%) were performed rather than transverse colostomy. The surgical approach must be adapted to the anatomical lesions. Total mortality was 4% in this series. Early diagnosis of pseudo obstruction, early colonoscopy with intubation must allow to avoid surgery.