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).

Hepatic artery ligation for arterial rupture following liver transplantation: a reasonable option.

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

Conservative surgical management of Boerhaave's syndrome: experience of two tertiary referral centers.

BACKGROUND: Surgery is generally proposed for Boerhaave's syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers. METHODS: From June 1985 to November 2010, among 53 patients presenting with Boerhaave's syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S). RESULTS: Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021). CONCLUSIONS: These findings from the largest reported cohort of Boerhaave's syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.

Liver tuberculosis mistaken for malignancy. The role of needle biopsy.

Despite advances in imaging techniques rare or atypical liver lesions still pose a diagnostic challenge. In many centres percutaneous fine needle aspiration cytology or biopsy is routinely performed in order to obtain a definitive diagnosis. However because of the risk of tumour seeding along the needle tract this attitude may jeopardize the patient's chances for cure in case of malignancy. The role of percutaneous liver biopsy is reappraised in the light of an observation in which major hepatectomy was performed for suspected neoplasia only to discover at pathology that the lesion was a benign tuberculosis pseudotumour.

Tuberculosis diagnosed after major hepatectomy for suspected malignancy.

A patient with a history of surgery and adjuvant chemotherapy 2 1/2 years previously for Dukes C colonic adenocarcinoma was diagnosed with a focal liver lesion on follow-up examinations. Ultrasound and computed tomography scan revealed a 3.8 cm soft tissue mass. Positron emission tomography scan showed intense uptake, corroborating the diagnosis of a colonic liver metastasis. Major hepatectomy was performed but pathology revealed that the lesion was in fact a benign tuberculosis pseudo-tumour. In developed countries liver tuberculosis remains extremely rare, particularly the macronodular form. The diagnosis is often made only after hepatectomy for suspected malignancy. The increasing use of potent anticancer chemotherapy may favour the reactivation of quiescent tuberculosis, posing a difficult differential diagnosis with liver metastases.

[Necrotizing fasciitis]. / Fasciita necrozanta.

The management of a right foot necrotizing fasciitis and severe sepsis in an old diabetic patient is presented. The early and aggressive surgery, adequate antibiotherapy and correction of organic disfunction (cardio-circulatory, renal, respiratory) eliminated the vital risk and resulted in a satisfactory morpho-functional recovery of the foot.

[Acute surgical pathology in elderly patients]. / Aspecte ale chirurgiei de urgenta la pacientul vârstnic.

The consequence of demographic aging is an increase of surgical pathology of the elderly, concerning both number and complexity of the cases. To asses the nature of geriatric surgical pathology and the effect of co-morbidities on surgical outcome, a retrospective study was carried out on a series of 401 patients aged over 75, treated in the IIIrd Surgical Unit in the period 2002-2003. 132 patients were admitted as acute cases and 94 of them were operated: 62 required immediate surgery and 32 required delayed operations. According to the nature of the diseases, benign surgical conditions were encountered in majority of the cases (78 cases). The diagnostics requiring immediate operations were: complicated hernias, perforated peptic ulcer, lower limb acute ischemia. Delayed emergency operations were performed for: acute cholecystitis, biliary lithiasis with angiocholitis and complicated gastric cancer. Cardiovascular pathology was recorded as the most frequent co-morbidity. Hospital mortality rate of 32.9% resulted mainly from cases with mesenteric infarction and generalized peritonitis, as well as from delayed emergencies such as complicated gastric and colon cancer. The most frequent causes of death following surgery were: cardiac failure, sepsis and multiple organ failure.

[Completion gastrectomy associated with pancreaticoduodenectomy]. / Totalizarea gastrectomiei asociata cu dudenopancreatectomie cefalica.

The authors present the case of a male patient, aged 56, operated (partial gastrectomy) for peptic ulcer 20 years ago, who is admitted for epigastric pain and distension, frequent vomiting, asthenia and weight loss. Physical examination, barium meal and upper digestive endoscopy with biopsy established the diagnosis of carcinoma of the gastric stump, due to malignant transformation of adenomatous polyps, with duodenal invasion. Completion of gastrectomy and pancreaticoduodenectomy was performed, with good postoperative results. Although the extent of resection may appear excessive, our attitude was justified by the features of the lesion and good biological condition of the patient.