Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

Fcγ receptor expression on splenic macrophages in adult immune thrombocytopenia.

Splenic macrophages play a key role in immune thrombocytopenia (ITP) pathogenesis by clearing opsonized platelets. Fcγ receptors (FcγR) participate in this phenomenon, but their expression on splenic macrophages and their modulation by treatment have scarcely been studied in human ITP. We aimed to compare the phenotype and function of splenic macrophages between six controls and 24 ITP patients and between ITP patients according to the treatments they received prior to splenectomy. CD86, human leucocyte antigen D-related (HLA-DR) and FcγR expression were measured by flow cytometry on splenic macrophages. The major FcγR polymorphisms were determined and splenic macrophage function was assessed by a phagocytosis assay. The expression of the activation markers CD86 and HLA-DR was higher on splenic macrophages during ITP compared to controls. While the expression of FcγR was not different between ITP and controls, the phagocytic function of splenic macrophages was reduced in ITP patients treated with intravenous immunoglobulin (IVIg) within the 2 weeks prior to splenectomy. The FCGR3A (158V/F) polymorphism, known to increase the affinity of FcγRIII to IgG, was over-represented in ITP patients. Thus, these are the first results arguing for the fact that the therapeutic use of IVIg during human chronic ITP does not modulate FcγR expression on splenic macrophages but decreases their phagocytic capabilities.

Incidence, risk factors, and burden of incisional hernia repair after abdominal surgery in France: a nationwide study.

PURPOSE: Incisional hernias are common after laparotomies. The aims of this study were to assess the rate of incisional hernia repair after abdominal surgery, recurrence rate, hospital costs, and risk factors, in France. METHODS: This national, retrospective, longitudinal, observational study was based on the exhaustive hospital discharge database (PMSI). All adult patients (≥ 18 years old) hospitalised for an abdominal surgical procedure between 01-01-2013 and 31-12-2014 and hospitalised for incisional hernia repair within five years were included. Descriptive analyses and cost analyses from the National Health Insurance (NHI) viewpoint (hospital care for the hernia repair) were performed. To identify risk factors for hernia repair a multivariable Cox model and a machine learning analysis were performed. RESULTS: In 2013-2014, 710074 patients underwent abdominal surgery, of which 32633 (4.6%) and 5117 (0.7%) had ≥ 1 and ≥ 2 incisional hernia repair(s) within five years, respectively. Mean hospital costs amounted to €4153/hernia repair, representing nearly €67.7 million/year. Some surgical sites exposed patients at high risk of incisional hernia repair: colon and rectum (hazard ratio [HR] 1.2), and other sites on the small bowel and the peritoneum (HR 1.4). Laparotomy procedure and being ≥ 40 years old put patients at high risk of incisional hernia repair even when operated on low-risk sites such as stomach, duodenum, and hepatobiliary. CONCLUSION: The burden of incisional hernia repair is high and most patients are at risk either due to age ≥ 40 or the surgery site. New approaches to prevent the onset of incisional hernia are warranted.

Incisional hernia repair with a slowly absorbable P4HB mesh: what happens after the mesh disappears? A retrospective longitudinal clinical study.

PURPOSE: To analyze the incisional hernia recurrence rate at a long-term follow-up using a biosynthetic long-term absorbable mesh in patients with a higher risk of surgical infection in a contaminated surgical field. METHODS: This was a retrospective multicentric study. All patients undergoing incisional hernia repair between 2016 and 2018 at 6 participating university centers were included. Patients were classified according to the Ventral Hernia Working Group (VHWG). All consecutive patients who underwent abdominal wall repair using biosynthetic long-term absorbable mesh (Phasix®) in contaminated fields (grade 3 and 4 of the VHWG classification) were included. Patients were followed-up until September 2021. Preoperative, operative, and postoperative data were collected. All patients' surgical site infections (SSIs) and surgical site occurrences (SSOs) were recorded. The primary outcome of interest was the clinical incisional hernia recurrence rate. RESULTS: One hundred and eight patients were included: 77 with VHWG grade 3 (71.3%) and 31 with VHWG grade 4 (28.7%). Median time follow-up was 41 months [24; 63]. Twenty-four patients had clinical recurrence during the follow-up (22.2%). The SSI and SSO rates were 24.1% and 36.1%, respectively. On multivariate analysis, risk factors for incisional hernia recurrence were previous recurrence, mesh location, and postoperative enterocutaneous fistula. CONCLUSIONS: At the 3 year follow-up, the recurrence rate with a biosynthetic absorbable mesh (Phasix®) for incisional hernia repair in high-risk patients (VHWG grade 3 and 4) seemed to be suitable (22.2%). Most complications occurred in the first year, and SSI and SSO rates were low despite high-risk VHWG grading.

Diagnosis of postoperative pancreatic fistula.

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity after pancreatectomy. The International Study Group on Pancreatic Fistula (ISGPF) defines postoperative fistula by an amylase concentration in the abdominal drain of more than three times the serum value on day 3 or more after surgery. However, this definition fails to identify some clinical fistulas. This study examined the association between lipase measured in abdominal drainage fluid and PF. METHODS: Amylase and lipase levels in the abdominal drain were measured 3 days after pancreatic resection. Grade B and C fistulas were classified as clinical fistulas, regardless of whether the measured amylase concentration was considered positive or negative. The PF group included patients with a clinical fistula and/or those with positive amylase according to the ISGPF definition. RESULTS: Sixty-five patients were included. The median level of lipase was higher in patients with positive amylase than in those with negative amylase: 12,176 versus 64 units/l (P < 0·001). The lipase level was 16,500 units/l in patients with a clinical fistula and 224 units/l in those without a clinical fistula (P = 0·001). Patients with a PF had a higher lipase concentration than those without: 7852 versus 64 units/l (P < 0·001). A lipase level higher than 500 units/l yielded a sensitivity of 88 per cent and a specificity of 75 per cent for PF. For clinical fistulas the sensitivity was 93 per cent and specificity 77 per cent when the threshold for lipase was 1000 units/l. CONCLUSION: Lipase concentration in the abdominal drain correlated with PF. A threshold of 1000 units/l yielded a high sensitivity and specificity for the diagnosis of clinical PF.

Longitudinal cohort study on preoperative pain as a risk factor for chronic postoperative inguinal pain after groin hernia repair at 2-year follow-up.

PURPOSE: To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain. METHODS: Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life. RESULTS: Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia. CONCLUSION: At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.

Managing severe traumatic abdominal-wall injuries, a monocentric experience.

PURPOSE: Abdominal wall injuries (AWI) is a clinical and radiological diagnosis of fasciomuscular and at times cutaneous defects after abdominal trauma. Their severity encompasses a spectrum of parietal defects, with the most severe being a burst abdomen with eviscerated organs. With the wide use of CT scans in trauma settings, their incidence is being more recognized. Especially in severe AWI, where associated intrabdominal lesions are highly prevalent, many questions about parietal reconstruction arise concerning the timing and type of surgery, and their final hernia recurrence rate. METHOD: A list of severe AWI injuries have been retrieved, all of which were treated in our center. Type of trauma, clinical presentation, surgical technique and follow-up have been included. RESULTS: Eight cases were found with severe abdominal injuries, with an age range of 11-85 years. Road traffic accidents, crush injuries, fall from height, stab and gunshot wounds are included. Seven out of the 8 cases had associated intrabdominal traumatic lesions. Mesh augmentation due to tissue loss was used in three cases. Recurrence rate was estimated around 25%. CONCLUSION: Prompt surgical exploration is required as associated intrabdominal traumatic lesions are highly associated with severe AWI. Even when intrabdominal lesions are ruled out, fasciomuscular defects should be managed during the same hospitalization, to prevent intestinal strangulation and occlusion. Mesh augmentation should only be used when parietal defects include extensive tissue loss preventing tension-free parietal reconstruction.

Preoperative inflammation is an independent factor of worse prognosis after colorectal cancer surgery.

BACKGROUND: We know that inflammation is related to colorectal cancer prognosis and to the onset of postoperative infections. OBJECTIVE: This study aimed to understand the relationship between preoperative inflammation and the prognosis of colorectal cancer and to elucidate whether the impact of inflammation on cancer prognosis was related to an increased risk of surgical infection or was independent of it. METHODS: Patients who underwent elective colorectal cancer surgery between November 2011 and April 2014 were included in a prospective database (IMACORS). Preoperative c reactive protein was collected for each patient. Patients were followed up according to the French national guidelines. A cut-off of preoperative CRP of 5mg/L was chosen. Clinical characteristics were compared according to CRP using Chi2 and Mann-Whitney tests. The Overall Survival (OS) and Disease-Free-Survival (DFS) were compared by Kaplan-Meier curves. A Cox proportional hazards regression model was applied to perform a multivariate analysis of OS and DFS's predictors. RESULTS: A total of 254 patients were included. The median age was 68 years old. The median follow up was 41.8 months. The overall median preoperative CRP was 5mg/L. Preoperative CRP was significantly associated with N status; CRP being significantly higher among patients with colonic cancer and with patients who didn't receive a neoadjuvant treatment. Multivariate analyse revealed that preoperative CRP is an independent prognostic factor of OS and DFS respectively (HR=2.34 (1.26-4.31), P=0.006 and HR=1.83 (1.15-2.90), P=0.01). CONCLUSION: Preoperative inflammation measured by CRP is independently related with overall and disease-free survival of colorectal cancer.

What results can be expected one year after complex incisional hernia repair with biosynthetic mesh?

BACKGROUND: Incisional hernia is a frequent complication after midline laparotomy. The current standard repair includes the use of a synthetic mesh to prevent recurrence. However, the use of a synthetic mesh in a contaminated field carries a higher risk of mesh infection. In this setting biologic and biosynthetic meshes can be used as they resist to infection, but these are absorbable meshes. This raises the question of the risk of recurrence as the mesh disappears. Phasix® is a biosynthetic mesh getting absorbed in 12-18 months. The aim of this study was to assess the 1-year recurrence rate after abdominal-wall repair with a Phasix® mesh. METHODS: All patients undergoing ventral hernia repair between 2016 and 2018 at the University Hospital of Dijon using a Phasix® mesh were prospectively included in a database. They were all followed-up with a physical exam and a routine CT scan at one year. All postoperative complications were recorded. RESULTS: Twenty-nine patients were included in the study (55.2% women), with a mean BMI of 30,25 kg/m2. Nineteen meshes were sublay and 10 intraperitoneal. Complications at 1 month were mainly mild: Clavien-Dindo I and II (61.1%). No mesh was explanted. There was no chronic infection. The mean length of stay was 11.5 days. The 1-year recurrence rate was 10.3%. CONCLUSION: Patients having undergone complex ventral hernia repair with a Phasix® mesh have a 1-year recurrence rate of 10.3%. No severe surgical site occurrence was detected. A longer follow-up in a larger number of patients could confirm the place of this mesh in abdominal-wall repair.

Inflammatory markers for the early detection of post-operative infection: The same threshold for rectal and colic surgery?

INTRODUCTION: Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal? PATIENTS AND METHOD: This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve. RESULTS: An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P=0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC=0.87) corresponds to CRP on D4 for a threshold of 100mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100mg/L (AUC=0.71): sensitivity 63.6%, NPV 93.9%. CONCLUSION: Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP>100mg/L at D4.