Systemic causes are important risk factors for failure after unscheduled colorectal revision surgery.

BACKGROUND: The rates of unscheduled revision surgery (URS) after colorectal surgery and failure to rescue-surgical (FTR-s) are 2.4% and 11-17% respectively. The aim of this study was to evaluate the causes of URS lethality to reduce this rate after colorectal surgery. METHODS: From 2011 to 2021, 337 surgeons collected 547 URS. Type of procedure, time course, diagnostic and detection means, time to decision, time to complication(s), causes of URS, delay of URS, and death were recorded and allowed for multivariate systemic analysis of risk factors for death (FTR-s) after URS. Systemic causes of delay were analyzed as assessment of urgency, communication, skills, organization of the operative program, and transport. RESULTS: The two main causes of URS were infectious (66% of which 50% by fistula or anastomotic release) and vascular (18%). The rate of FTRs was 10%. The systemic causes rate of FTR-s were 35%. The FTRs were related to the patient (ASA score 3-4: RR: 6 [1-40]; age: RR: 1.05 [1-1.1]), to the surgical procedure (laparotomy: RR: 4.5 [1.6-12]) and to the systemic causes responsible for the delay in the realization of URS (RR: 4.1 [1.4-12]). CONCLUSION: By avoiding systemic causes, more than one third of the deaths from FTR-s after colorectal surgery could be avoided.

Unplanned surgery after colorectal resection: laparoscopy at the index surgery is a protective factor against mortality.

BACKGROUND: The aim of this study was to assess risk factors of mortality after unplanned surgery following colorectal resection. METHODS: All the consecutive patients who underwent colorectal resection between 2011 and 2020 in a French national cohort were retrospectively included. Perioperative data of the index colorectal resection (indication, surgical approach, pathological analysis, postoperative morbidity), and characteristics of unplanned surgery (indication, time to complication, time to surgical redo) were assessed in order to identify predictive factors of mortality. RESULTS: Among 547 included patients, 54 patients died (10%; 32 men; mean age = 68 ± 18 years, range 34-94 years). Patients who died were significantly older (75 ± 11 vs 66 ± 12 years, p = 0.002), frailer (ASA score 3-4 = 65 vs 25%, p = 0.0001), initially operated through open approach (78 vs 41%, p = 0.0001), and without any anastomosis (17 vs 5%, p = 0.003) than those alive. The presence of colorectal cancer, the time to postoperative complication and the time to unplanned surgery were not significantly associated to the postoperative mortality. After multivariate analysis, 5 independent predictive factors of mortality were identified: old age (OR 1.038; IC 95% 1.006-1.072; p = 0.02), ASA score = 3 (OR 5.9, CI95% 1.2-28.5, p = 0.03), ASA score = 4 (OR 9.6; IC95% 1.5-63; p = 0.02), open approach for the index surgery (OR 2.7; IC95% 1.3-5.7; p = 0.01), and delayed management (OR 2.6; IC95% 1.3-5.3; p = 0.009). CONCLUSION: After unplanned surgery following colorectal surgery, one out of 10 patients dies. The laparoscopic approach during the index surgery is associated with a good prognosis in the case of unplanned surgery.

SAGES SAFE CHOLE program changes surgeons practice in France-results of the FCVD implementation of SAFE CHOLE in France.

BACKGROUND: With the Society of Gastrointestinal and Endoscopic Surgeons supervision, the Safe Cholecystectomy Task Force (SAFE CHOLE) was translated into French by the the Federation of Visceral and Digestive Surgery (FCVD) and adopted to run on its national e-learning platform for surgical continuing medical education (CME). The objective of this study was to assess the impact of the SAFE CHOLE (SF) program on the knowledge and practice of French surgeons performing cholecystectomy and participating in the FCVD lead CME activity. METHODS: To obtain CME certification, each participant must fill out three FCVD validated questionnaires regarding (1) the participants' routine practice for cholecystectomy, (2) the participants' knowledge and practice after successful completion of the program, and (3) the educational value of the SC program. RESULTS: From 2021 to 2022, 481 surgeons completed the program. The overall satisfaction rate for the program was 81%, and 53% of the surgeons were practicing routine cholangiography before the SC program. Eighty percent declared having acquired new knowledge. Fifty-six percent reported a change in their practice of cholecystectomy. Of those, 46% started routinely using the critical view of safety, 12% used a time-out prior transection of vital structures, and 11% adopted routine intraoperative cholangiography. Sixty-seven percent reported performing a sub-total cholecystectomy in case the CVS was unobtainable. If faced with BDI, 45% would transfer to a higher level of care, 33% would seek help from a colleague, and 10% would proceed with a repair. Ninety percent recommended adoption of SC by all general surgeons and 98% reported improvement of patient safety. CONCLUSIONS: Large-scale implementation of the SC program in France is feasible within a broad group of diverse specialty surgeons and appears to have a significant impact on their practice. These data should encourage other surgeons and health systems to engage in this program.

Upfront Laparoscopic Management of Common Bile Duct Stones: What Are the Risk Factors of Failure?

BACKGROUND: Treatment of common bile duct stones (CBDS) includes laparoscopic cholecystectomy (LC) with either laparoscopic common bile duct exploration (LCBDE) or perioperative endoscopic retrograde cholangiopancreatography (ERCP). The main objective of this study was to identify predictive factors for the failure of upfront and exclusive surgical treatment by LCBDE. METHODS: This is a single-center, retrospective study on patients with CBDS and operated for LC between 2007 and 2019. The use of intra- or postoperative endoscopy for CBD clearance within 6 months after surgery was considered as failure of LCBDE. Predictors for the failure of LCBDE were investigated and outcomes were compared. RESULTS: Among 222 operated patients, LCBDE was successfully performed in 173 patients (78%) and 49 (22%) required ERCP with sphincterotomy (intraoperative (n=29) or postoperative (n=20)). Independent risk factors for surgical failure were male sex (OR: 2.525 (1.111-5.738); p=0.027), anesthesia induction time ≥ 4 p.m. (OR: 4.858 (1.731-13.631); p=0.003), pediculitis (OR: 4.147 (1.177-14.606); p=0.027), and thin CDB < 4mm (OR: 11.951 (3.562-40.097), p< 0.0001). Age, ASA score, cystic anatomy, presence of cholecystitis, and the surgeon's experience were not identified as predictors for surgical failure. A general anesthesia number >1 (6% vs. 33%; p < 0.0001), length of initial stay (6 [1-42] vs. 8 [2-27], p=0.012), total length of hospitalization (6 [1-45] vs. 9 [2-27]; p=0.010), and the rate of emergency readmissions (3.5% vs. 12.2%; p=0.027) were significantly higher in the LCBDE failure group. CONCLUSIONS: Upfront LCBDE for CBDS was associated with improved outcomes compared to intra-/postoperative ERCP recourse. Male sex, pediculitis, thin CBD, and surgery later than 4 p.m were associated with LCBDE failure and the need for endoscopic treatment. REGISTRATION NUMBER AND AGENCY: The present retrospective study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT04467710).

Laparoscopic Versus Open Pancreatoduodenectomy: Cost-Effectiveness Analysis.

Background and Objectives: The role of laparoscopy during a pancreatoduodenectomy (PD) is not clearly defined. The purpose of this study was thus to compare the cost-effectiveness between laparoscopic pancreatoduodenectomy (LPD) and open pancreatoduodenectomy (OPD). Materials and Methods: From 2010 to 2019, 140 patients underwent PD (60 LPD and 80 OPD). After 60-60 matching, the clinical-pathological characteristics, surgical technique, and type of rehabilitation were identical in both groups. Complications, R0 resection, and cost were compared. Results: Complication rates were 48% (12% Clavien-Dindo grade 3-4) in the LPD group and 64% (22% Clavien-Dindo grade 3-4) in the OPD group. The LPD group had significantly fewer pulmonary complications (6%) than the OPD group (20%) (P = .04). The oncological quality of the R0 resection did not differ between the two groups. The operating time was 312 ± 50 minutes in the OPD group and 392 ± 75 minutes in the LPD group (P < .001). The mean length of hospital stay was significantly shorter for the LPD group (13 ± 10) days compared to the OPD group (19 ± 8) days (P = .02). The average cost of total hospital stay was significantly lower for the LPD group compared to the OPD group (P = .02). Conclusions: Despite longer operative times, LPD had fewer (pulmonary) complications and reduced hospital costs.

Impact of recommendations and new therapies on the prognosis of colon cancer with synchronous liver metastasis.

OBJECTIVE: To assess the prognostic impact of the new therapies recommended over the past twenty years for colonic cancers with synchronous hepatic metastasis (hmCC). METHODS: From 1995 to 2016, 802 hmCC were identified in a tumor registry. An univariate and multivariate analysis looked for the impact of the different recommendations over three periods: chemotherapy without targeted therapy (p1CH), chemotherapy with targeted agent in 2nd line (p2TA2), chemotherapy with TA in 1st line (p3TA1) depending on anatomoclinical criteria and therapeutic sequences: chemotherapy then resection of the primary tumor (CR) (n = 100), resection of the primary tumor then chemotherapy (RC) (n = 541), chemotherapy alone with or without TC (onlyCH) (n = 161). RESULTS: The rates of onlyCH, CR and RC had varied respectively during these 3 periods from 12% to 26%, 6% to 21% and from 82% to 53% (p = 0.001). The medians of p1CH, p2TA2 and p3TA1 survival were 20.2, 22.7 and 23.6 months, respectively (p = 0.12). The independent factors of poor prognosis were age ≥ 75 years (1.6 [1.35; 1.9] p = 0.0001), chemotherapy only 2.3 [1.6; 3.5] p = 0.0001), p1CH 1.7 [1.4; 2.1] p<0.0001), p2TA2 1.2 [1.02;1.6] p = 0.04. The p2TA2 period had a worse prognosis than p3TA1 (1.25 [1.01; 1.5] p = 0.03). CONCLUSION: In public health point of view, the recommendation of first-line TA improved survival and increased rate of primary tumor resection after chemotherapy.

Pancreatic tuberculosis in an 18-year-old patient.

SummaryAn 18-year-old male patient presented with abdominal pain, nausea, and diarrhea. Subsequent laboratory investigations involving the patient's blood samples revealed an inflammatory syndrome. Subsequent radiographic investigations (CT scan, MRI, and endoscopic ultrasound with biopsies) led to the discovery of a heterogenic cystic lesion in the tail of the pancreas. Although the investigations orientated the diagnosis towards a pseudopapillary tumor, no certain pathological diagnosis could be obtained. After a multidisciplinary meeting, surgery was chosen as the designated therapeutic option. The patient underwent left pancreatectomy and no complications were encountered. The pathological examination revealed isolated pancreatic tuberculosis. Currently, the patient is under treatment and no longer presents any digestive symptoms.

The Cost and the Effectiveness of Cholangiography for the Diagnosis and Treatment of a Bile Duct Injury After Difficult Identification of the Cystic Duct.

BACKGROUND: This study aims to assess the cost and the effectiveness of intraoperative cholangiography (IOC) for the diagnosis and treatment of a bile duct injury (BDI) after incorrect or difficult identification of the cystic duct (DICD) during a cholecystectomy. METHODS: Between 2009 and 2015, 810 surgeons reported 1161 treatment-related adverse events related to the DICD during cholecystectomy in the French REX database; 623 patients (54%) underwent IOC, and 30% (n = 348) of DICD had a BDI. The therapeutic procedures and the treatment costs have been compared between the IOC group (CG) and the group without IOC (WCG). RESULTS: The BDI intraoperative diagnosis was significantly higher in the CG: 96% vs. 67% p = 0.001. The number of therapeutic procedure was significantly higher in the WCG OR: 6 (3-10.6). The rate of biliodigestive anastomosis (8.3%) was similar between the both groups. The average cost of cholecystectomy in the at-risk population of DICD was higher in the group that did not undergo IOC (6204 euros vs. 8831 euros). The estimated loss without IOC in the studied population was between 788,170 and 2,039,020 euros. CONCLUSION: The IOC was an assurance of quality and cost reduction in the immediate management of the BDI and should be systematic in front of a DICD during a cholecystectomy.

Outcome after pancreatectomy for neuroendocrine neoplams according to the WHO 2017 grading system: A retrospective multicentric analysis of 138 consecutive patients.

AIM: The aim of this study was to evaluate the new World Health Organization (WHO) 2017 grading system and the others clinicopathological factors in pancreatic neuroendocrine tumor (panNET) operated patients. METHODS: Histological staging was based on the WHO 2017 grading system. Outcome after surgery and predictors of overall survival (OS) and disease free survival (DFS) were evaluated. RESULTS: A total of 138 patients underwent surgical resection with a severe morbidity and mortality rates of 14.5% and 0.7% respectively. Five years OS differed according to WHO 2017: 95% among 58 patients with NETG1, 82% in 68 patients with NETG2, 35% in 7 patients with NETG3 and 0% in 5 patients with NECG3 (P<0.0001). Independent predictors of worse OS were age>60 y.o (P=0.014), synchronous metastasis (P=0.005) and WHO 2017 with significant differences between NETG1 versus NETG2 (P=0.005), NETG3 (P<0.001) and NECG3 (P<0.001). Independent predictors of worse DFS were symptomatic NET (P=0.038), pN+ status (P=0.027) and WHO 2017 with significant differences between NETG1 versus NETG3 (P=0.014) and NECG3 (P=0.009). CONCLUSION: The WHO 2017 grading system is a useful tool for patient prognosis after panNET resection and the tailoring of therapeutic strategy. Surgery could provide good results in NETG3 patients.

Results of the FUSE Evaluation Project in France.

BACKGROUND: The Federation of Visceral and Digestive Surgery (FCVD) is in charge in France of the continuing medical education of digestive surgeons. Since 2016 and in collaboration with SAGES, it has offered the Fundamental Use of Surgical Energy (FUSE) program as part of the continuing education for surgeons including eLearning and hands-on workshops. METHODS: The aim of this study was to evaluate the impact of the FUSE program on the participants by participating in a knowledge test and completing a survey. RESULTS: 485 participants fully completed the knowledge test of 18 questions. Post-test assessment showed an increase in the mean score with respect to pre-test assessment, and the surgeons who have participated to the hands-on workshops had a better score. 304 participants filled the survey of 6 questions. The majority were satisfied by the FUSE program and felt that the objectives were achieved. CONCLUSIONS: The FUSE program developed by SAGES and adopted by the FCVD in France was very much appreciated by the participants and achieved its educational objectives. Our goal is to spread it as widely as possible to all members of the operating room team.

Level of pancreatic division and postoperative pancreatic fistula after distal pancreatectomy: A retrospective case-control study of 157 patients with non-pancreatic ductal adenocarcinoma lesions.

BACKGROUND: Several studies have suggested that the level of pancreatic division during distal pancreatectomy (DP) has an impact on postoperative pancreatic fistula (POPF) occurrence. The purpose of this study was thus to investigate the level of pancreatic division as a potential risk factor for POPF after DP for non-pancreatic ductal adenocarcinoma lesions (non-PDAC) in the era of parenchyma-sparing resection. METHODS: Data from 217 patients requiring DP were collected in a prospectively maintained database from January 1997 to December 2017 and analyzed retrospectively. Only data from patients who underwent DP using a linear stapler for non-PDAC lesions were analyzed. The outcomes of DP with body/tail division (Body-Tail group) were compared to DP with neck division (Neck group). The primary outcome was POPF according to the 2016 ISGPF. RESULTS: Data from 157 patients who underwent DP using a linear stapler for non-PDAC lesions were included for analysis. Body-Tail (n = 53) and Neck (n = 104) groups were comparable concerning demographic data, period of treatment, BMI, ASA score, comorbidities, type of lesion, median lesion size, laparoscopic or open approach and spleen preservation rate. No differences were found in POPF (5.5 and 12.5%, p = 0.388) and new-onset pancreatogenic diabetes mellitus (22.5 vs. 20%; p = 0.439) in Body-Tail and Neck groups respectively. CONCLUSION: Clinically relevant POPF and postoperative diabetes do not appear to be affected by pancreatic division level. The intention to prevent POPF or pancreatogenic diabetes should not influence the decision on level of pancreatic division during DP.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND: Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD). METHODS: Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism® and R software®. RESULTS: Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS. CONCLUSIONS: Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Robotic versus laparoscopic distal pancreatectomy: a French prospective single-center experience and cost-effectiveness analysis.

BACKGROUND: Benefits and cost-effectiveness of robotic approach for distal pancreatectomy (DP) remain debated. In this prospective study, we aim to compare the short-term results and real costs of robotic (RDP) and laparoscopic distal pancreatectomy (LDP). METHODS: From 2011 until 2016, all consecutive patients underwent minimally invasive DP were included and data were prospectively collected. Patients were assigned in two groups, RDP and LDP, according to the availability of the Da Vinci® Surgical System for our Surgical Unit. RESULTS: A minimally invasive DP was performed in 38 patients with a median age of 61 years old (44-83 years old) and a BMI of 26 kg/m2 (20-31 kg/m2). RDP group (n = 15) and LDP group (n = 23) were comparable concerning demographic data, BMI, ASA score, comorbidities, malignant lesions, lesion size, and indication of spleen preservation. Median operative time was longer in RDP (207 min) compared to LDP (187 min) (p = 0.047). Conversion rate, spleen preservation failure, and perioperative transfusion rates were nil in both groups. Pancreatic fistula was diagnosed in 40 and 43% (p = 0.832) of patients and was grade A in 83 and 80% (p = 1.000) in RDP and LDP groups, respectively. Median postoperative hospital stay was similar in both groups (RDP: 8 days vs. LDP: 9 days, p = 0.310). Major complication occurred in 7% in RDP group and 13% in LDP group (p = 1.000). Ninety-days mortality was nil in both groups. No difference was found concerning R0 resection rate and median number of retrieved lymph nodes. Total cost of RDP was higher than LDP (13611 vs. 12509 €, p < 0.001). The difference between mean hospital incomes and costs was negative in RDP group contrary to LDP group (- 1269 vs. 1395 €, p = 0.040). CONCLUSION: Short-term results of RDP seem to be similar to LDP but the high cost of RDP makes this approach not cost-effective actually.

Impact of laparoscopy in patients aged over 70 years requiring distal pancreatectomy: a French multicentric comparative study.

BACKGROUND: Few data are available concerning short-term results of minimally invasive surgery in patients > 70 years old requiring distal pancreatectomy. The aim of this study was to compare short-term results after laparoscopic (LDP) versus open distal pancreatectomy (ODP) in this subgroup of patients. METHODS: All patients > 70 years who underwent distal pancreatectomy in 3 expert centers between 1995 and 2017 were included and data were retrospectively analyzed. Demographic, intraoperative data and postoperative outcomes in LDP and ODP groups were compared. RESULTS: A distal pancreatectomy was performed in 109 elderly patients; LDP group included 53 patients while ODP group included 56. There were 55 (50.5%) males and 54 (49.5%) women with a median age of 75 years (range 70-87). Fifty (45.9%) patients were 70-74, 40 (36.7%) patients were 75-79, and 19 (17.4%) patients were over 80 years. Nine (8.2%) patients required conversion to open surgery. The median operative time was not different between LDP and ODP (204 vs. 220 min, p = 0.62). The intraoperative blood loss was significantly lower in the LDP group (238 ± 312 vs. 425 ± 582 ml, p = 0.009) with no difference regarding the intraoperative transfusion rate. 90-day mortality (0 vs. 5%, p = 0.42), overall complication (45.4 vs. 51.8%, p = 0.53), major complication (18.2 vs. 12.5%, p = 0.43), grade B/C pancreatic fistula (6.8 vs. 7.1%, p = 0.71), were comparable in the 2 groups. Only postoperative confusion rate was significantly lower in the LDP group (4.5 vs. 25%, p = 0.01). Median length of stay was significantly lower in the LDP group (14 ± 10 vs. 16 ± 11 days, p = 0.04). R0 resection was performed in 94% of LDP patients and 89% in ODP patients without significant difference (p = 0.73). CONCLUSIONS: The laparoscopic approach seems to reduce blood loss, postoperative confusion, and length of stay in elderly patients requiring distal pancreatectomy.

Long-term quality of life in gastroesophageal reflux disease after NISSEN fundoplication: does it depend on preoperative responsiveness to proton pump inhibitors?

PURPOSE: In patients presenting with uncomplicated gastroesophageal reflux disease, nonresponders to medical treatment are not viewed as good candidates for surgical treatment. Considering preoperative response to medical treatment and quality of life, this study aimed to predict outcome following laparoscopic Nissen fundoplication. MATERIALS AND METHODS: In an academic center, 35 consecutive patients presenting with a gastroesophageal reflux disease requiring a laparoscopic Nissen fundoplication were prospectively included; 16 patients were nonresponders. Using Gastro-Intestinal Quality-of-Life Index score, quality of life was measured preoperatively and postoperatively at each visit (3, 6, 12, 24, 48, and 72 mo) and was compared between responders and nonresponders. RESULTS: No postoperative complication was recorded. Preoperative score was significantly lower in nonresponders (P<0.02) and digestive symptoms and dietary modifications were more important in nonresponders. The score increased in nonresponders after 48 and 72 months, but this improvement was nonsignificantly lower than in responders (P=0.4). In nonresponders, 6 years after the procedure, all symptoms improved. In responders, dysphagia and gastroesophageal reflux symptoms significantly improved. CONCLUSIONS: Laparoscopic Nissen fundoplication seems to improve the quality of life in nonresponders without equaling to responders results, especially because of digestive symptoms. Laparoscopic Nissen fundoplication may be considered as a therapeutic option in selected and informed nonresponder patients.

The best surgical approach for left colectomy: a comparative study between transverse laparotomy, midline laparotomy and laparoscopy.

AIM: To compare the early and late complications after left colectomy (LC) by left transverse laparotomy (LTL), midline laparotomy (ML) and laparoscopy (La). METHODS: From 1998 to 2003, 328 patients underwent an LC by LTL, ML or La. After matching patients for age, ASA score and indication, 159 patients were divided into three groups of 53 patients each according to the surgical approach performed. The median follow-up was 8 years. Early and late complications were compared by univariate and multivariate analysis. RESULTS: Early morbidity rates after LTL, ML and La were 52%, 45% and 21%, respectively (p = 0.002). Extra digestive complication rates after LTL, ML and La were 36%, 34% and 13.2%, respectively (p = 0.02). Respiratory complication rates were 15%, 21% and 2% (p = 0.01). The rate of wound infection was higher after LTL (15% vs. 6% and 6%, p = 0.06). Length of stay was significantly shorter after La (median: LTL, 10 days; ML, 9 days; La, 6 days; p < 0.0001). At a median follow-up of 8 years, the obstruction rate was 6.3%, regardless of the surgical approach. The rates of incisional hernia after LTL, ML and La were 8%, 23% and 3% (p = 0.004), respectively, with odds ratio (OR) = 4.47 (1.2 to 16). CONCLUSION: Our study shows that although La has a significant lower rate of complications, LTL, with fewer respiratory complications and hernia than ML, should be considered as the reference incision in case of conversion or contra-indication for laparoscopy.

Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness.

OBJECTIVE: This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients. METHOD: From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction. RESULTS: Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR. CONCLUSIONS: The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. BRIEF SUMMARY: In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.

Laparoscopic ampullectomy for an ampullarian adenoma.

Lesions involving the ampulla of Vater are rare entities (0.1-0.2 %) with high malignant potential (90 %) [1]. As a treatment, the surgical procedure known as duodenopancreatectomy was the main option, whatever the tumor's stage or nature. Yet with improvements of endoscopic diagnostic and therapeutic techniques, management of these lesions has been modified, enabling endoscopic removal of adenoma and adenocarcinoma-in situ. Thus, when endoscopic treatment is not possible, surgical ampullectomy is still an alternative option to duodenopancreatectomy [1, 2]. The continuous improvements in surgical techniques and instruments now allow the safe realization of laparoscopic ampullectomy, despite the few cases described in the literature [3, 4]. Here we present a surgical technique in a 52-year-old patient with an ampulloma. The ampulloma was discovered during a gastroscopy for abdominal pain. The endoscopic ultrasound with biopsy revealed a 15-mm adenoma with moderate-grade dysplasia. The thoracoabdominal CT scan was normal. The procedure was performed as shown. The tumor histology showed a R0 resection (5-mm surgical margin) of an adenoma with focal high-grade dysplasia. At 3-year follow-up, outcomes were unremarkable, without any complications.