Peri-operative management of obese patients in digestive surgery: Clinical practice guidelines from the French Society of Digestive Surgery.

INTRODUCTION: The French Society of Digestive Surgery (Société Française de Chirurgie Digestive [SFCD]) has elaborated clinical practice guidelines for the management of the obese patient undergoing gastro-intestinal surgery. METHODS: The literature was analyzed according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology divided into five chapters: preoperative management, modalities of transportation and installation of the patient in the operating room, specific characteristics related to laparoscopic surgery, specific characteristics related to traditional surgery, and postoperative management. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). RESULTS: Synthesis of expert opinions and the application of the GRADE methodology produced 30 recommendations among which three were strong and nine were weak. The GRADE methodology could not be applied for 18 questions, for which only expert opinion was obtained. CONCLUSION: These clinical practice guidelines can help surgeons optimize the peri-operative management of the obese patient undergoing gastro-intestinal surgery.

Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion.

Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.

Management of abdominal compartment syndrome in acute pancreatitis.

Abdominal compartment syndrome (ACS), defined by the presence of increased intra-abdominal pressure>20mmHg in association with failure of at least one organ system, is a common and feared complication that may occur in the early phase of severe acute pancreatitis (AP). This complication can lead to patient death in the very short term. The goal of this review is to provide the surgeon and intensivist with objective information to help them in their decision-making. In the early phase of severe AP, it is essential to monitor intra-vesical pressure (iVP) to allow early diagnosis of intra-abdominal hypertension or ACS. The treatment of ACS is both medical and surgical requiring close collaboration between the surgical and resuscitation teams. Medical treatment includes vascular volume repletion, prokinetic agents, effective curarization and percutaneous drainage of large-volume ascites. If uncontrolled respiratory or cardiac failure develops or if maximum medical treatment fails, most teams favor performing an emergency xipho-pubic decompression laparotomy with laparostomy. This procedure follows the principles of abbreviated laparotomy as described for abdominal trauma.

Long-term functional outcomes of perineal gangrene: worse than expected?-an observational retrospective study.

PURPOSE: For survivors of perineal gangrene (PG), quality of life and functional prognosis of pelvic functions are probably overestimated. The aim of this study was to report long-term anal and urinary sphincter dysfunctions, sexual sequelae, and patients' quality of life after treatment of perineal gangrene. METHODS: This retrospective observational study was conducted in one university hospital over 16 years. Seventy-three patients experienced PG; 22 were subject to long-term follow-up. Three questionnaires were sent to patients to assess pelvic dysfunction and quality of life: the GIQLI, the Cleveland Incontinence Score, and the USP score for urinary dysfunction. Sexual sequelae were considered if orchiectomy or penile resection for male patients and vulvar resection for female patients were performed. RESULTS: Of the 72 patients included, seven died before discharge (9.7%) and at least 14 died during follow-up (19.4%), despite a mean age of 62 years (± 13). Among the surviving patients, seven experienced an alteration of their quality of life (44%) (GIQLI < 96). Six patients still had a colostomy, and among the remaining patients, 11 experienced minimal to mild incontinence (68.7%), while one experienced constipation (6.2%). One patient suffered from urinary incontinence (4.5%), and six suffered from dysuria (27.3%). Three male patients (14%) underwent an orchiectomy, and one female patient (100%) underwent a vulvar resection. CONCLUSION: PG leads to a high rate of anal and urinary dysfunctions. Urinary dysfunctions are taken into account and treated; however, anal incontinence is not investigated even though it could lead to decreased quality of life.

Primary Surgery for Malignant Large Bowel Obstruction: Postoperative Nasogastric Tube Reinsertion is Not Mandatory.

BACKGROUND: Malignant large bowel obstructions frequently require emergency surgery. Compliance with enhanced recovery after surgery programmes is significantly reduced due to non-removal of the nasogastric tube in the postoperative period. The first aim of the present study was to research factors associated with the failure of immediate nasogastric tube removal in patients who had undergone emergency surgery for malignant large bowel obstruction. The second aim was to assess the morbidity linked to nasogastric tube reinsertion. METHODS: This retrospective and monocentric study included all consecutive patients admitted for acute malignant large bowel obstruction who underwent emergency surgery. Patients who were not primarily operated on were excluded (n = 178; 69.3%). The group of patients requiring nasogastric tube (NGT) reinsertion was compared with the group that did not require NGT reinsertion. RESULTS: Seventy-nine patients underwent emergency surgery, of which 18 (22.8%) required nasogastric tube reinsertion. There was no difference between the two groups with regard to (a) immediate nasogastric tube removal (p = 0.87) and (b) inclusion in an enhanced recovery programme (p = 0.75). However, preoperative small bowel dilatation was associated with a reduction in the need for NGT reinsertion (p = 0.04). A left-sided tumour was also associated with the need for NGT reinsertion in uni- (p = 0.034) and multivariate analysis (OR = 8; p < 0.05). Surgical access and procedure were not significantly associated with NGT reinsertion. The postoperative course influenced NGT reinsertion, which was significantly associated with postoperative ileus (OR = 4; p < 0.05) and postoperative morbidity (OR = 4; p < 0.05). Morbidity was not linked to nasogastric tube removal. CONCLUSION: Nasogastric tube reinsertion was not affected by immediate removal of the tube. Left-sided tumours and patients at risk of postoperative ileus should be managed with caution. Immediate nasogastric tube removal is not contraindicated in the case of large bowel obstruction because it is not associated with a higher risk of NGT reinsertion.