Score prediction of anastomotic leak in colorectal surgery: a systematic review.

OBJECTIVE: Predicting the risk of anastomotic leak (AL) is of importance when defining the optimal surgical strategy in colorectal surgery. Our objective was to perform a systematic review of existing scores in the field. METHODS: We followed the PRISMA checklist (S1 Checklist). Medline, Cochrane Central and Embase were searched for observational studies reporting on scores predicting AL after the creation of a colorectal anastomosis. Studies reporting only validation of existing scores and/or scores based on post-operative variables were excluded. PRISMA 2020 recommendations were followed. Qualitative analysis was performed. RESULTS: Eight hundred articles were identified. Seven hundred and ninety-one articles were excluded after title/abstract and full-text screening, leaving nine studies for analysis. Scores notably included the Colon Leakage Score, the modified Colon Leakage Score, the REAL score, www.anastomoticleak.com and the PROCOLE score. Four studies (44.4%) included more than 1.000 patients and one extracted data from existing studies (meta-analysis of risk factors). Scores included the following pre-operative variables: age (44.4%), sex (77.8%), ASA score (66.6%), BMI (33.3%), diabetes (22.2%), respiratory comorbidity (22.2%), cardiovascular comorbidity (11.1%), liver comorbidity (11.1%), weight loss (11.1%), smoking (33.3%), alcohol consumption (33.3%), steroid consumption (33.3%), neo-adjuvant treatment (44.9%), anticoagulation (11.1%), hematocrit concentration (22.2%), total proteins concentration (11.1%), white blood cell count (11.1%), albumin concentration (11.1%), distance from the anal verge (77.8%), number of hospital beds (11.1%), pre-operative bowel preparation (11.1%) and indication for surgery (11.1%). Scores included the following peri-operative variables: emergency surgery (22.2%), surgical approach (22.2%), duration of surgery (66.6%), blood loss/transfusion (55.6%), additional procedure (33.3%), operative complication (22.2%), wound contamination class (1.11%), mechanical anastomosis (1.11%) and experience of the surgeon (11.1%). Five studies (55.6%) reported the area under the curve (AUC) of the scores, and four (44.4%) included a validation set. CONCLUSION: Existing scores are heterogeneous in the identification of pre-operative variables allowing predicting AL. A majority of scores was established from small cohorts of patients which, considering the low incidence of AL, might lead to miss potential predictors of AL. AUC is seldom reported. We recommend that new scores to predict the risk of AL in colorectal surgery to be based on large cohorts of patients, to include a validation set and to report the AUC.

[Vaginal delivery and perineal trauma : it's time to repair]. / Accouchement par voie basse et traumatisme périnéal : quand vient le temps de la reconstruction.

Perineal injuries can occur during vaginal delivery and they are harmful to anal function, sexuality, and overall quality of life of patients. Among the feared complications, anal incontinence, often difficult to address for both patients and caregivers, has a significant impact and must be looked for during the medical history. Clinical examination of the perineum and additional tests such as endoanal ultrasound and anorectal manometry confirm the diagnosis and guide the management. Treatment often relies on multiple modalities and depends on the interval between obstetric trauma and symptom onset. When indicated, perineal reconstruction surgery restores anatomy and function.

Des lésions périnéales peuvent survenir lors d'un accouchement par voie basse et avoir des conséquences néfastes sur la fonction anale, la sexualité et la qualité de vie globale des patientes. Parmi les complications redoutées, l'incontinence anale, souvent difficile à aborder pour les patientes et les soignants, a un retentissement important et doit être recherchée lors de l'anamnèse. L'examen clinique du périnée et les examens complémentaires tels que l'échographie endoanale et la manométrie anorectale permettent de confirmer le diagnostic et d'orienter la prise en charge. Le traitement repose souvent sur plusieurs modalités et dépend du délai entre le traumatisme obstétrical et la survenue des symptômes. Lorsqu'elle est indiquée, la chirurgie de reconstruction du périnée permet de restaurer l'anatomie et de rétablir la fonction.

[Treatment of localized rectal cancer in 2024]. / Prise en charge du cancer du rectum localisé en 2024.

The management of localized rectal cancer has evolved significantly over the last two years. On one hand, intensification of treatments (radio-chemotherapy, chemotherapy, then surgery) for the most advanced tumors has shown an improvement in clinical results compared to less intense regiments. On the other hand, the possibility, as for prostate cancers, of opting for active surveillance without surgery in patients presenting a complete clinical response after a treatment phase, is now accepted. More recently, the Swiss recommendations for the surveillance of rectal cancer have been modified and now differ from those of colon cancers, by incorporating pelvic MRI and rectoscopy in addition, as well as special guidelines for tumors under active surveillance.

La prise en charge du cancer du rectum localisé a beaucoup évolué ces deux dernières années. D'un côté, l'intensification des traitements (radio-chimiothérapie, chimiothérapie, puis chirurgie) pour les tumeurs les plus avancées a montré une amélioration des résultats cliniques par rapport aux traitements moins intenses. De l'autre côté, la possibilité, comme pour les cancers de la prostate, d'opter pour une surveillance active sans chirurgie chez les patients présentant une réponse clinique complète après une phase de traitement est aujourd'hui acceptée. Plus récemment, les recommandations suisses pour la surveillance du cancer du rectum ont été modifiées et se différencient maintenant de celles des cancers du côlon, en incorporant IRM pelvienne et rectoscopie en sus, de même qu'un suivi spécial pour les tumeurs en surveillance active.

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review.

INTRODUCTION: Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. METHODS: Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021). RESULTS: One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years. CONCLUSION: The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

Predictors for selective flexure mobilization during robotic anterior resection for rectal cancer: a prospective cohort analysis.

INTRODUCTION: Splenic flexure mobilization (SFM) may be indicated during anterior resection to provide a tension-free anastomosis. However, to date, no score allows identifying patients who may benefit from SFM. METHODS: Patients who underwent robotic anterior resection for rectal cancer were identified from a prospective register. Demographic and cancer-related variables were extracted, and predictors of SFM were identified using regression models. Thereafter, 20 patients with SFM and 20 patients without SFM were randomly selected and their pre-operative CTscan were reviewed. The radiological index was defined as 1/(sigmoid length/pelvis depth). The optimal cut-off value for predicting SFM was identified using ROC curve analysis. RESULTS: Five hundred and twenty-four patients were included. SFM was performed in 121 patients (27.8%) and increased operative time by 21.8 min (95% CI: 11.3 to 32.4, p < 0.001). The incidence of postoperative complications did not differ between patient with or without SFM. Realization of an anastomosis was the main predictor for SFM (OR: 42.4, 95% CI: 5.8 to 308.5, p < 0.001). In patients with colorectal anastomosis, both sigmoid length (15 ± 5.1 cm versus 24.2 ± 80.9 cm, p < 0.001) and radiological index (1 ± 0.3 versus 0.6 ± 0.2, p < 0.001) differed between patients who had SFM and patients who did not. ROC curve analysis of the radiological index indicated an optimal cut-off value of 0.8 (sensitivity: 75%, specificity: 90%). CONCLUSION: SFM was performed in 27.8% of patients who underwent robotic anterior resection, and increased operative time by 21.8 min. For optimal surgical planning, patients requiring SFM can be identified based on pre-operative CT using the index 1/(sigmoid length/pelvis depth) with a cut-off value set at 0.8.

Isolation and Characterization of Stem Cells from the Anal Canal Transition Zone in Pigs.

BACKGROUND: Utilization of autologous stem cells has been proposed for the treatment of anal incontinence despite a lack of understanding of their mechanism of action and of the physiological healing process of anal sphincters after injury. AIMS: We aim to develop a technique allowing isolation and further study of local mesenchymal stem cells, directly from anal canal transition zone in pig. METHODS: Anal canal was resected "en bloc" from two young pigs and further microdissected. The anal canal transition zone was washed and digested with 0.1% type I collagenase for 45 min at 37 °C. The isolated cells were plated on dishes in mesenchymal stem cell medium and trypsinized when confluent. Cells were further used for flow cytometry analysis and differentiation assays. RESULTS: The anal canal transition zone localization was confirmed with H&E staining. Following culture, cells exhibited a typical "fibroblast-like" morphology typical of stem cells. Isolated cells were positive for CD90 and CD44 but negative for CD14, CD34, CD45, CD105, CD106, and SLA-DR. Following incubation with specific differentiation medium, isolated cells differentiated into adipocytes, osteoblasts, and chondrocytes, confirming in vitro multipotency. CONCLUSIONS: Herein, we report for the first time the presence of mesenchymal stem cells in the anal canal transition zone in pigs and the feasibility of their isolation. This preliminary study opens the path to the isolation of human anal canal transition zone mesenchymal stem cells that might be used to study sphincters healing and to treat anal incontinence.

Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials.

BACKGROUND: Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy. METHODS: MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I2 value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool. RESULTS: Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49-0.91, I2: 38.7%, p = 0.0098) and -0.07 (95% CI -0.12 to -0.03, I2: 53.6%, p = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect. CONCLUSION: The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

Does prophylactic negative pressure wound therapy prevent surgical site infection in abdominal surgery?

OBJECTIVE: To determine if prophylactic negative pressure wound therapy (pNPWT) allows for the prevention of surgical site infections (SSIs) in abdominal surgery. METHOD: A non-systematic review assessing the evidence was conducted in 2020. RESULTS: Retrospectve studies comparing patients with pNPWT with patients receiving standard wound dressing after abdominal surgery showed encouragning results in favour of pNPWT for reducing the incidence of SSIs, but randomised controlled trials have so far reported mixed results. CONCLUSION: New randomised controlled trials including a sufficient number of patients at risk of SSIs are needed for confirming the results of non-interventional studies.

[Colorectal cancer: technological revolution]. / Cancer colorectal : révolution technologique.

Colorectal cancer represents 4500 incidental cases in Switzerland per year, with an incidence increasing among the youngest patients. Technological innovation guides the management of colorectal cancer. Artificial intelligence in endoscopy optimizes the detection of small colonic lesions. Submucosal dissection allows treating extensive lesions at an early stage of the disease. The improvement of surgical techniques, notably robotic surgery, allows limiting complications and optimizing organ preservation. Molecular tools are leading to the development of promising targeted therapies for localized or advanced disease. The development of reference centers tends to bring together this expertise.

Le cancer colorectal représente 4500 nouveaux cas par an en Suisse. Son incidence chez les sujets de plus de 50 ans semble se stabiliser, mais chez les plus jeunes elle est en augmentation. La révolution technologique guide sa prise en charge. L'intelligence artificielle en endoscopie optimise la détection de petites lésions coliques. La dissection sous-muqueuse permet de traiter des lésions parfois étendues à un stade précoce de la maladie. L'amélioration des techniques chirurgicales, notamment par robot, vise à limiter les complications et à optimiser la conservation d'organes. Les outils moléculaires aboutissent au développement de thérapies ciblées prometteuses pour les maladies localisées ou celles avancées. Le développement des centres de référence tend à rassembler cette expertise.

A Magnetic Resonance Imaging Index to Predict Crohn's Disease Postoperative Recurrence: The MONITOR Index.

BACKGROUND & AIMS: We developed and validated a magnetic resonance imaging-based index to predict Crohn's disease (CD) postoperative recurrence (POR). METHODS: Patients with CD who underwent a postoperative evaluation for recurrence (with colonoscopy and MRI no longer than 105 days apart) were included between 2006 and 2016 in University Hospital of Nancy, France. MRI items with good levels of intra-rater and inter-rater agreement (Gwet's coefficient ≥0.5) were selected. The MRI in Crohn's Disease to Predict Postoperative Recurrence (MONITOR) index's performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and accuracy, by considering the Rutgeerts score as the gold standard. The MONITOR index was validated with a bootstrap method and an independent cohort. RESULTS: Seventy-three MRI datasets were interpreted by 2 radiologists. Seven items (bowel wall thickness, contrast enhancement, T2 signal increase, diffusion-weighted signal increase, edema, ulcers, and the length of the diseased segment) had a Gwet's coefficient ≥0.5 and were significantly associated with the Rutgeerts score, leading to their inclusion in the MONITOR index. All the items had a weighting of 1, except the "ulcers" item weighting 2.5, reflecting the higher adjusted odds ratio. The AUROC [95% confidence interval] for the prediction of endoscopic POR (Rutgeerts score >i1) was 0.80 [0.70-0.90]. The optimal threshold was a MONITOR index ≥1, giving a sensitivity of 79%, a specificity of 55%, a predictive positive value of 68%, and a predictive negative value of 68%. The bootstrap validation gave an AUROC of 0.85 [0.73-0.97]. In the validation cohort, a MONITOR index ≥1 gave a sensitivity of 87%, a specificity of 75%, a predictive positive value of 84.6%, and a predictive negative value of 75%. CONCLUSIONS: The MONITOR index is an efficient, reliable, easy-to-apply tool that can be used in clinical practice to predict the POR of CD.

The Role of Preoperative Imaging in the Detection of Lateral Lymph Node Metastases in Rectal Cancer: A Systematic Review and Diagnostic Test Meta-analysis.

BACKGROUND: Different techniques exist for the imaging of lateral lymph nodes in rectal cancer. OBJECTIVE: This study aimed to compare the diagnostic accuracy of pelvic MRI, 18 F-FDG-PET/CT, and 18 F-FDG-PET/MRI for the identification of lateral lymph node metastases in rectal cancer. DATA SOURCES: Data sources include PubMed, Embase, Cochrane Library, and Google Scholar. STUDY SELECTION: All studies evaluating the diagnostic accuracy of pelvic MRI, 18 F-FDG-PET/CT, and 18 F-FDG-PET/MRI for the preoperative detection of lateral lymph node metastasis in patients with rectal cancer were selected. INTERVENTIONS: The interventions were pelvic MRI, 18 F-FDG-PET/CT, and/or 18 F-FDG-PET/MRI. MAIN OUTCOME MEASURES: Definitive histopathology was used as a criterion standard. RESULTS: A total of 20 studies (1,827 patients) were included out of an initial search yielding 7,360 studies. The pooled sensitivity of pelvic MRI was 0.88 (95% CI, 0.85-0.91), of 18 F-FDG-PET/CT was 0.83 (95% CI, 0.80-0.86), and of 18 F-FDG-PET/MRI was 0.72 (95% CI, 0.51-0.87) for the detection of lateral lymph node metastasis. The pooled specificity of pelvic MRI was 0.85 (95% CI, 0.78-0.90), of 18 F-FDG-PET/CT was 0.95 (95% CI, 0.86-0.98), and of 18 F-FDG-PET/MRI was 0.90 (95% CI, 0.78-0.96). The area under the curve was 0.88 (95% CI, 0.85-0.91) for pelvic MRI and was 0.83 (95% CI, 0.80-0.86) for 18 F-FDG-PET/CT. LIMITATIONS: Heterogeneity in terms of patients' populations, definitions of suspect lateral lymph nodes, and administration of neoadjuvant treatment. CONCLUSIONS: For the preoperative identification of lateral lymph node metastasis in rectal cancer, this review found compelling evidence that pelvic MRI should constitute the imaging modality of choice. In contrast, to confirm the presence of lateral lymph node metastasis, 18 F-FDG-PET/MRI modalities allow discarding false positive cases because of increased specificity. PROSPERO REGISTRATION NUMBER: CRD42020200319.

Fluorescence angiography likely protects against anastomotic leak in colorectal surgery: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: Observational studies have shown that fluorescence angiography (FA) decreases the incidence of anastomotic leak (AL) in colorectal surgery, but high-quality pooled evidence was lacking. Therefore, we aimed at confirming this preliminary finding using a systematic review and meta-analysis of randomised controlled trials (RCTs) in the field. METHODS: MEDLINE, Embase and CENTRAL were searched for RCTs assessing the effect of intra-operative FA versus standard assessment of bowel perfusion on the incidence of AL of colorectal anastomosis. The systematic review complied with the PRISMA 2020 and AMSTAR2 recommendations and was registered in PROSPERO. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Heterogeneity was assessed using the Q-test and quantified using the I2 value. Certainty of evidence was assessed using the GRADE Pro tool. RESULTS: One hundred and eleven articles were screened, 108 were excluded and three were kept for inclusion. The three included RCTs compared assessment of the perfusion of the bowel during creation of a colorectal anastomosis using FA versus standard practice. In meta-analysis, FA was significantly protective against AL (3 RCTs, 964 patients, RR: 0.67, 95% CI: 0.46 to 0.99, I2: 0%, p = 0.04). The RD of AL was non-significantly decreased by 4 percentage points (95%CI: - 0.08 to 0, I2: 8%, p = 0.06) when using FA. Certainty of evidence was considered as moderate. CONCLUSION: The effect of FA on prevention of AL in colorectal surgery exists but is potentially of small magnitude. Considering the potential magnitude of effect of FA, we advise that future RCTs have an adequate sample size, include a cost-benefit analysis of the technique and better define the subpopulation who could benefit from FA.

Rectovaginal Fistula in Crohn's Disease: When and How to Operate?

Rectovaginal fistula (RVF) occurring during the course of Crohn's disease (CD) constitutes a therapeutic challenge and is characterized by a high rate of recurrence. To optimize the outcome of CD-related RVF repair, the best conditions for correct healing should be obtained. Remission of CD should be achieved with no active proctitis, the perianal CD activity should be minimized, and local septic complications should be controlled. The objective of surgical repair is to close the fistula tract with minimal recurrence and functional disturbance. Several therapeutic strategies exist and the approach should be tailored to the anatomy of the RVF and the quality of the local supporting tissues. Herein, we review the medical and surgical management of CD-related RVF.

[Hemorrhoidal disease in 2022 : how to select the most appropriate treatment ?] / Maladie hémorroïdaire en 2022 : comment choisir le traitement adapté ?

Hemorrhoidal disease is frequent and can lead to major alteration of quality of life. Conservative treatment, instrumental therapies and surgical approach play a complementary role in the management of hemorrhoidal disease. Understanding all techniques is mandatory to guide the patient and offer the best individualized treatment. Guidelines issued by scientific societies can facilitate the therapeutic decision.

La maladie hémorroïdaire est fréquente et ses répercussions sur la qualité de vie peuvent être majeures. Traitement conservateur, procédés non chirurgicaux et interventions chirurgicales jouent un rôle complémentaire dans le traitement d'une maladie hémorroïdaire symptomatique. Pour guider le patient et lui offrir la prise en charge la plus adaptée à sa situation, une connaissance des différents traitements est indispensable. Les recommandations des sociétés savantes, basées sur des avis d'experts, peuvent faciliter la décision thérapeutique.

Prophylactic Negative-pressure Wound Therapy Prevents Surgical Site Infection in Abdominal Surgery: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials and Observational Studies.

BACKGROUND: Prevention of surgical site infection (SSI) is a public health challenge. Our objective was to determine if prophylactic negative-pressure wound therapy (pNPWT) allows preventing SSI after laparotomy. METHODS: Medline, Embase, and Web of Science were searched on 6 October 2019 for original studies reporting the incidences of SSI in patients undergoing open abdominal surgery with and without pNPWT. Risk differences (RDs) between control and pNPWT patients and risk ratios (RRs) for SSI were obtained using random-effects models. RESULTS: Twenty-one studies (2930 patients, 5 randomized controlled trials [RCTs], 16 observational studies) were retained for the analysis. Pooled RD between patients with and without pNPWT was -12% (95% confidence interval [CI], -17% to -8%; I2 = 57%; P < .00001) in favor of pNPWT. That risk difference was -12% (95% CI, -22% to -1%; I2 = 69%; P = .03) when pooling only RCTs (792 patients). pNPWT was protective against the incidence of SSI with a RR of 0.53 (95% CI, .40-.71; I2 = 56%; P < .0001). The effect on pNPWT was more pronounced in studies with an incidence of SSI ≥20% in the control arm. The preventive effect of pNPWT on SSI remained after correction for potential publication bias. However, when pooling only high-quality observational studies (642 patients) or RCTs (527 patients), significance was lost. CONCLUSIONS: Existing studies suggest that pNPWT on closed wounds is protective against the occurrence of SSI in abdominal surgery, but these findings need to be confirmed by more high-quality evidence, preferentially in subgroups of patients with an incidence of SSI ≥20% in the control arm.

Multipotent mesenchymal stromal cells derived from porcine exocrine pancreas improve insulin secretion from juvenile porcine islet cell clusters.

Neonatal and juvenile porcine islet cell clusters (ICC) present an unlimited source for islet xenotransplantation to treat type 1 diabetes patients. We isolated ICC from pancreata of 14 days old juvenile piglets and characterized their maturation by immunofluorescence and insulin secretion assays. Multipotent mesenchymal stromal cells derived from exocrine tissue of same pancreata (pMSC) were characterized for their differentiation potential and ability to sustain ICC insulin secretion in vitro and in vivo. Isolation of ICC resulted in 142 ± 50 × 103 IEQ per pancreas. Immunofluorescence staining revealed increasing presence of insulin-positive beta cells between day 9 and 21 in culture and insulin content per 500IEC of ICC increased progressively over time from 1178.4 ± 450 µg/L to 4479.7 ± 1954.2 µg/L from day 7 to 14, P < .001. Highest glucose-induced insulin secretion by ICC was obtained at day 7 of culture and reached a fold increase of 2.9 ± 0.4 compared to basal. Expansion of adherent cells from the pig exocrine tissue resulted in a homogenous CD90+ , CD34- , and CD45- fibroblast-like cell population and differentiation into adipocytes and chondrocytes demonstrated their multipotency. Insulin release from ICC was increased in the presence of pMSC and dependent on cell-cell contact (glucose-induced fold increase: ICC alone: 1.6 ± 0.2; ICC + pMSC + contact: 3.2 ± 0.5, P = .0057; ICC + pMSC no-contact: 1.9 ± 0.3; theophylline stimulation: alone: 5.4 ± 0.7; pMSC + contact: 8.4 ± 0.9, P = .013; pMSC no-contact: 5.2 ± 0.7). After transplantation of encapsulated ICC using Ca2+ -alginate (alg) microcapsules into streptozotocin-induced diabetic and immunocompetent mice, transient normalization of glycemia was obtained up to day 7 post-transplant, whereas ICC co-encapsulated with pMSC did not improve glycemia and showed increased pericapsular fibrosis. We conclude that pMSC derived from juvenile porcine exocrine pancreas improves insulin secretion of ICC by direct cell-cell contact. For transplantation purposes, the use of pMSC to support beta-cell function will depend on the development of new anti-fibrotic polymers and/or on genetically modified pigs with lower immunogenicity.

Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence.

BACKGROUND: Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY: After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.

The role of perineal application of prophylactic negative-pressure wound therapy for prevention of wound-related complications after abdomino-perineal resection: a systematic review.

BACKGROUND: Closed perineal wounds often fail to heal by primary intention after abdomino-perineal resection (APR) and are often complicated by surgical site infection (SSI) and/or wound dehiscence. Recent evidence showed encouraging results of prophylactic negative-pressure wound therapy (pNPWT) for prevention of wound-related complications in surgery. Our objective was to gather and discuss the early existing literature regarding the use of pNPWT to prevent wound-related complications on perineal wounds after APR. METHODS: Medline, Embase, and Web of Science were searched for original publications and congress abstracts reporting the use of pNPWT after APR on closed perineal wounds. RESULTS: Seven publications were included for analysis. Two publications reported significantly lower incidence of SSI in pNPWT patients than in controls with a risk reduction of about 25-30%. Two other publications described similar incidences of SSI between the two groups of patients but described SSI in pNPWT patients to be less severe. One study reported significantly lower incidence of wound dehiscence in pNPWT patients than in controls. CONCLUSION: The largest non-randomized studies investigating the effect of pNPWT on the prevention of wound-related complications after APR showed encouraging results in terms of reduction of SSI and wound dehiscence that deserve further investigation and confirmation.

Surgical resection does not avoid the risk of diverticulitis recurrence-a systematic review of risk factors.

PURPOSE: Fifteen percent of patients undergoing elective sigmoidectomy will present a diverticulitis recurrence, which is associated with significant costs and morbidity. We aimed to systematically review the risk factors associated with recurrence after elective sigmoidectomy. METHODS: PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies published until May 1, 2020. Original studies were included if (i) they included patients undergoing sigmoidectomy for diverticular disease, (ii) they reported postoperative recurrent diverticulitis, and (iii) they analyzed ≥ 1 variable associated with recurrence. The primary outcome was the risk factors for recurrence of diverticulitis after sigmoidectomy. RESULTS: From the 1463 studies initially screened, six studies were included. From the 1062 patients included, 62 patients recurred (5.8%), and six variables were associated with recurrence. Two were preoperative: age (HR = 0.96, p = 0.02) and irritable bowel syndrome (33.3% with recurrence versus 12.1% without recurrence, p = 0.02). Two were operative factors: uncomplicated recurrent diverticulitis as indication for surgery (73.3% with recurrence versus 49.9% without recurrence, p = 0.049) and anastomotic level (colorectal: HR = 11.4, p = 0.02, or colosigmoid: OR = 4, p = 0.033). Two were postoperative variables: the absence of active diverticulitis on pathology (39.6% with recurrence versus 26.6% without recurrence) and persistence of postoperative pain (HR = 4.8, p < 0.01). CONCLUSION: Identification of preoperative variables that predict the occurrence of diverticulitis recurrence should help surgical decision-making for elective sigmoidectomy, while peri- and postoperative factors should be taken into account for optimal patient follow-up.

Caecal diverticulitis can be misdiagnosed as acute appendicitis: a systematic review of the literature.

AIM: Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management. METHODS: This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD. RESULTS: Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%). CONCLUSION: CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.