Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study.

BACKGROUND: The aim of this study was to analyze the effect of a personalized prehabilitation (PP) before ileocolic resection (ICR) on the postoperative anastomotic complications in patients with Crohn's Disease (CD) with high risk of post-operative complications. MATERIALS AND METHODS: All high-risk patients who required ICR with primary anastomosis for CD between January 2010 and March 2020 were retrospectively analyzed. PP included nutritional support, antibiotic therapy or drainage of an abscess, stopping or decreasing corticosteroid treatments. Patients were considered as high risk for complications when they had at least one or more of these 3 risk factors (RF) (hypoalbuminemia <30 g/L or weight loss of >10% over the last 6 months, treatment with corticosteroids before surgery (within 4 weeks before surgery), or presence of preoperative intra-abdominal sepsis (abscess or enteral fistula)) according to ECCO guidelines 2020. RESULTS: Ninety high-risk patients were included in our cohort and the anastomotic complication rate was 11.1%. Sixty-four (71.1%) had preoperative prehabilitation (median duration of 37 days), and the mean albumin level (34 g/L vs 37 g/L; p < 0.001) and the number of RF (1.21 vs 1.06; p = 0.001) were improved by PP during the preoperative period. The rate of anastomotic complications at 90 days from surgery (6.25% vs 23.1%; p = 0.031) as well as the re-operation rate (3.1% vs 19.2%; p = 0.019) were lower after PP. No difference was found on the rate of readmission and the length of stay in this subgroup analysis. Biological treatment administration within 3 months before surgery was not a risk factor for postoperative complication. CONCLUSION: PP reduces the number of preoperative risk factors before ICR in high-risk patients with CD and allows primary anastomosis with a lower complication rate than in upfront operated patients.

Registrar performance in minimally invasive distal pancreatectomy and effects on postoperative outcomes.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is nowadays an established standard procedure for non-locally advanced pancreatic lesions without celio-mesenteric vascular invasion. However, little is known about how the involvement of junior surgeons in MIDP affects postoperative outcomes. We performed a retrospective case series study in order to determine whether registrar involvement in MIDP is associated with adverse outcomes. METHODS: Data were analyzed from a prospectively created database of consecutive patients undergoing MIDP. Only data from 91 patients who underwent MIDP for non-PDAC lesions were included. Patients were divided in 3 groups: Consultant P1 (first 20 MIDP, n=20), Consultant P2 (after 20 MIDP, n=44), and Registrar group (n=27). Conversion rates and 90-day postoperative outcomes were compared. RESULTS: Conversion rates were 5%, 0%, and 14% in Consultant P1 and P2 and Registrar groups, respectively (P1 vs. P2, p = 0.312 and P1 vs. Registrar, p=0.376). Only Comprehensive Complication Index was higher in Registrar group compared to Consultant P1 group (13 vs. 3.7; p = 0.041). Comparison between Consultant P2 and Registrar groups resulted in a significant higher conversion rate (0 vs. 14%, p = 0.029), increased blood loss (77 vs. 263 ml, p = 0.018), and longer surgery duration (156 vs. 212 min, p=0.001) for registrars MIDP. However, no differences were found in clinically relevant postoperative pancreatic fistula (CR-POPF) (16 vs. 7.5%, p=0.282), Clavien-Dindo severe complication ≥3 score (11 vs. 4%, p=0.396), or length of hospital stay (9 vs. 9 days; p=0.614) between the consultant and registrar cohorts. CONCLUSIONS: With all the limitations of a retrospective study with a small sample size, junior surgeons' involvement in MIDP for non-PDAC lesions resulted in higher conversion rate, blood loss and duration of surgery without statistically significant difference on clinical outcomes compared to a consultant.

Impact of preoperative enteral nutritional support on postoperative outcome in patients with Crohn's disease complicated by malnutrition: Results of a subgroup analysis of the nationwide cohort registry from the GETAID Chirurgie group.

AIM: Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. METHOD: Malnutrition was defined as body mass index <18 kg/m2 and/or albuminaemia <30 g/L and/or weight loss >10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. RESULTS: Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). CONCLUSION: Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.

Outcomes of elective left colectomy in renal-transplanted patients: a single-center case-control study (LECoRT study).

PURPOSE: Renal-transplanted patients are reported to have a high anastomotic leakage (AL) rate after colorectal surgery. We aimed to define AL-related morbidity and mortality rates after elective left colectomy in renal-transplanted patients. METHODS: Data were prospectively collected between 2010 and 2015 from patients who underwent elective left colectomy with supra-peritoneal anastomosis in a single French referral hospital. We compared AL rate, and morbidity and mortality rates between renal-transplanted patients and controls. RESULTS: We identified 120 patients who underwent elective left colectomy during the study period. We retrospectively divided this cohort into 20 (17%) kidney-transplanted recipients (KTR-group) and the remaining 100 patients comprised the control group (C-group). There were no significant differences in sex, age, ASA score, body mass index, history of abdominal surgery and benign/malignant disease ratio between the KTR-group and the C-group. The AL rate was approximately four times higher in the KTR-group versus the C-group (25% vs 7%, p = 0.028). Intra-abdominal septic complications (p = 0.0005) and reoperation rates (p = 0.025) were also higher in the KTR-group. The laparoscopic approach was performed less in the KTR-group (35% versus 93%, p < 0.0001). CONCLUSION: Renal transplantation was identified as a risk factor of AL following elective left colectomy, as well as increased intra-abdominal septic morbidity and higher reoperation rate. Further multicentric studies are required to identify potential independent risk factors of AL after colorectal surgery in these frail populations. TRIAL REGISTRATION: The present study was declared on ClinicalTrials.gov (ID: NCT04495023).

Postoperative Morbidity After Iterative Ileocolonic Resection for Crohn's Disease: Should we be Worried? A Prospective Multicentric Cohort Study of the GETAID Chirurgie.

BACKGROUND AND AIMS: To compare perioperative characteristics and outcomes between primary ileocolonic resection [PICR] and iterative ileocolic resection [IICR] for Crohn's disease [CD]. METHODS: From 2013 to 2015, 567 patients undergoing ileocolonic resection were prospectively included in 19 centres of the GETAID chirurgie group. Perioperative characteristics and postoperative results of both groups [431 PICR, 136 IICR] were compared. Uni- and multivariate analyses of the risk factors of overall 30-day postoperative morbidity was carried out in the IICR group. RESULTS: IICR patients were less likely to be malnourished [27.2% vs 39.9%, p = 0.007], and had more stricturing forms [69.1% vs 54.3%, p = 0.002] and less perforating disease [19.9% vs 39.2%, p < 0.001]. Laparoscopy was less commonly used in IICR [45.6% vs 84.5%, p < 0.01] and was associated with increased conversion rates [27.4% vs 14.6%, p = 0.012]. Overall postoperative morbidity was 36.8% in the IICR group and 26.7% in the PICR group [p = 0.024]. There was no significant difference between IICR and PICR regarding septic intra-abdominal complications, anastomotic leakage [8.8% vs 8.4%] or temporary stoma requirement. IICR patients were more likely to present with non-infectious complications and ileus [11.8% vs 3.7%, p < 0.001]. Uni- and multivariate analyses did not identify specific risk factors of overall postoperative morbidity in the IICR group. CONCLUSIONS: Surgery for recurrent CD is associated with a slight increase of non-infectious morbidity [postoperative ileus] that mainly reflects the technical difficulties of these procedures. However, IICR remains a safe therapeutic option in patients with recurrent CD because severe morbidity including anastomotic complications is similar to patients undergoing primary resection. PODCAST: This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

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.

Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort.

OBJECTIVE: To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). SUMMARY BACKGROUND DATA: The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. METHODS: From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. RESULTS: Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009). CONCLUSIONS: Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

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.

Detection of Dysplasia or Cancer in 3.5% of Patients With Inflammatory Bowel Disease and Colonic Strictures.

BACKGROUND & AIMS: Colonic strictures complicate inflammatory bowel disease (IBD) and often lead to surgical resection to prevent dysplasia or cancer. We assessed the frequency of dysplasia and cancer among IBD patients undergoing resection of a colorectal stricture. METHODS: We analyzed data from the Groupe d'études et thérapeutiques des affections inflammatoires du tube digestif study. This was a nationwide retrospective study of 12,013 patients with IBD in France who underwent surgery for strictures at 16 centers from August 1992 through January 2014 (293 patients for a colonic stricture, 248 patients with Crohn's disease, 51% male, median age at stricture diagnosis of 38 years). Participants had no preoperative evidence of dysplasia or cancer. We collected clinical, endoscopic, surgical, and pathology data and information on outcomes. RESULTS: When patients were diagnosed with strictures, they had IBD for a median time of 8 years (3-14). The strictures were a median length of 6 cm (4-10) and caused symptoms in 70% of patients. Of patients with Crohn's disease, 3 (1%) were found to have low-grade dysplasia, 1 (0.4%) was found to have high-grade dysplasia, and 2 (0.8%) were found to have cancer. Of patients with ulcerative colitis, 1 (2%) had low-grade dysplasia, 1 (2%) had high-grade dysplasia, and 2 (5%) had cancer. All patients with dysplasia or cancer received curative surgery, except 1 who died of colorectal cancer during the follow-up period. No active disease at time of surgery was the only factor associated with dysplasia or cancer at the stricture site (odds ratio, 4.86; 95% confidence interval, 1.11-21.27; P = .036). CONCLUSIONS: In a retrospective study of patients with IBD undergoing surgery for colonic strictures, 3.5% were found to have dysplasia or cancer. These findings can be used to guide management of patients with IBD and colonic strictures.

Computed tomography findings of acute gastric volvulus.

PURPOSE: To assess the diagnostic performance of CT signs of gastric volvulus in both confirmed cases and control subjects. MATERIALS AND METHODS: We retrospectively reviewed CT findings in 10 patients with surgically confirmed acute gastric volvulus and 20 control subjects with gastric distension. Two radiologists independently evaluated CT images for risk factors of gastric volvulus, direct findings of gastric volvulus by assessing gastric dilatation, the presence of an antropyloric transition point, the respective position of the different stomach segments and of the greater and lesser curvatures, stenosis of the gastric segments through the oesophageal hiatus and for findings of gastric ischemia. The sensitivity and specificity of each finding were calculated. RESULTS: The most sensitive direct signs of gastric volvulus were an antropyloric transition point without any abnormality at the transition zone and the antrum at the same level or higher than the fundus. The presence of both these two findings as diagnostic criteria of gastric volvulus had 100% sensitivity and specificity for the diagnosis of gastric volvulus. There was no association between CT signs of ischemia and final bowel ischemia at pathology. CONCLUSION: CT is both highly sensitive and specific for diagnosing acute gastric volvulus. KEY POINTS: CT is highly reliable for diagnosing acute gastric volvulus with two findings. The two signs are gastropyloric transition zone and abnormal location of the antrum. This allows fast surgical management of this emergency.

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 approach for retrorectal tumors.

BACKGROUND: Retrorectal tumors are uncommon and may represent a surgical challenge. Laparoscopic excision has been reported in very few papers. We present our experience of nine cases operated by a transabdominal laparoscopic approach, between 2005 and 2011. METHODS: There were two males and seven females with a mean age of 35 years (range 19-48). The tumors were discovered incidentally in four cases or because of nonspecific clinical signs. All patients have had an MRI preoperatively. RESULTS: Only one patient required open conversion due to a huge tumor >7 cm of diameter. Postoperative mortality was nil. One patient developed a hematoma in the pelvic area. The median hospital stay was 4.7 days (range 4-8). Final diagnostic were as follows: four schwannomas, one ganglioneuroma, two tailgut cysts, one anterior meningocele, and one paragangliomas. During the follow-up showed no recurrences, but four of nine patients developed neurologic complications as parenthesis and sciatic pain and one patient developed retrograde ejaculation. CONCLUSIONS: Our case series shows that the laparoscopic approach is a feasible and safe option. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space to minimize the vascular and neurological injuries.

Does the surgeon's experience influence the outcome of laparoscopic treatment of common bile duct stones?

BACKGROUND: The aim of this study was to assess laparoscopic treatment of choledocholithiasis with respect to the surgeon's experience. METHODS: From January 1994 to December 2006, 130 patients underwent laparoscopic treatment for common bile duct stones found with intraoperative cholangiography. Two types of surgeons were defined: junior surgeons with fewer than ten laparoscopic common bile duct explorations performed and experienced surgeons with more than ten. The two patient populations (n = 65 in each group) were similar in regard to demographic data, clinical presentations (complicated or not), and ASA score. RESULTS: Results show that junior surgeons had significantly more patients with a common bile duct (CBD) diameter <7 mm compared to experienced surgeons (66% vs. 38%; p = 0.002). Primary closure of choledochotomy was performed by senior rather than junior surgeons significantly more often (87.5% vs. 69%; p = 0.05). Mean operating time was found to be longer for junior operators than for experienced surgeons (220 ± 71 min vs. 169 ± 71 min; p = 0.0006). There was no difference between group 1 (juniors) and group 2 (experienced surgeons) in regard to laparotomy conversion rate (9% vs. 1.5%; p = 0.1), complete common bile duct clearance (98% vs. 100%, p = ns), postoperative complications (two bile leaks in group 1 and one in group 2), and hospital stay (9 days vs. 7.5 days). In multivariate analysis, the transcystic approach was not influenced by the surgeon's experience. Experienced surgeons performed choledochotomy with primary closure more easily [RR = 3 (range = 1.1-8); p = 0.04]. Complicated presentations [RR = 2 (0.7-3); p = 0.08] and CBD diameter [RR = 2.5 (0.96-7); p = 0.06] influenced the choice of type of closure of choledochotomy without any significant value. CONCLUSION: Surgeon's experience influenced operating time and type of choledochotomy closure performed but had no influence on postoperative results of the laparoscopic treatment of common bile duct stones.

Age should be considered in the decision making of prophylactic splenic angioembolization in nonoperative management of blunt splenic trauma: a study of 208 consecutive civilian trauma patients.

BACKGROUND: A strategy of prophylactic splenic angioembolization using observation failure risk (OFR) computed tomographic (CT) scan criteria has been proposed recently. The main aim of the present study was to evaluate the relevance of the criteria in terms of delayed splenic rupture in patients with blunt splenic injury. METHODS: All patients with blunt splenic injuries admitted consecutively between January 2005 and January 2010 to our institution were included. Clinical, CT scan, and angiographic data, initial management, and outcome were noted. Patients managed expectantly were classified according to OFR CT scan criteria (high OFR was defined by at least one of the following CT scan signs: blush, pseudoaneurysm, Organ Injury Scale [OIS] grade III with a large hemoperitoneum, and OIS grade IV or 5). Initial management success was especially studied. RESULTS: Among the 208 patients included, 161 (77%) were treated by observation (35 OIS grade I, 64 OIS grade II, 33 OIS grade III, 18 OIS grade IV, and 11 OIS grade V) and 129 (80%) were men, with a mean (SD) age of 36.1 (18.7) years and a mean (SD) Injury Severity Score of 20.8 (15.4). Forty-nine patients (30%) had high OFR CT scan criteria. Thirteen patients (8%) experienced observation failure. High OFR CT scan criteria (odds ratio, 11; 95% confidence interval, 2.5-47.5) and patients 50 years and older (odds ratio, 33.9; 95% confidence interval, 6.2-185.5) were independent factors related to observation failure. The positive predictive value of OFR CT scan criteria for observation failure was 18%, and the negative predictive value was 96%. The corresponding values were 67% and 90%, respectively, in patients 50 years and older and 3% and 99%, respectively, in patients younger than 50 years. CONCLUSION: OFR CT scan criteria lack specificity to predict observation failure, mainly in patients younger than 50 years. Age should be considered when identifying patients requiring prophylactic splenic angioembolization. LEVEL OF EVIDENCE: Diagnostic study, level III.

Direct visualization of perforation sites in patients with a non-traumatic free pneumoperitoneum: added diagnostic value of thin transverse slices and coronal and sagittal reformations for multi-detector CT.

The incremental diagnostic value of adding 1.25-mm slices and coronal and sagittal reformatting to 5-mm axial reconstructions for direct visualization of the perforation site in patients with non-traumatic free pneumoperitoneum was assessed. Forty patients with non-traumatic bowel perforation and free pneumoperitoneum underwent computed tomography (CT). The perforation was gastroduodenal in 18 patients and involved the small or large bowel in 22 patients. Transverse scans were reconstructed with 5-mm thick sections at 5-mm intervals and 1.25-mm-thick sections at 1.25-mm intervals. The second data set was reformatted coronally and sagittaly with 3-mm-thick sections at 3-mm intervals. Three independent blinded readers interpreted 5-mm transverse scans, then combined 1.25-mm and 5-mm-transverse scans, and then combined transverse, coronal and sagittal scans. The rate of identification of the perforation site ranged from 43% to 53% with the combined axial, sagittal and coronal scans, from 28% to 48% with the 1.25- and 5-mm transverse scans, and from 5% to 20% only with the 5-mm thick transverse scans. The agreement between readers was significantly higher with thin slices and reformatting. The use of 1.25-mm axial slices and reformations intrinsically contained more useful diagnostic information than 5-mm axial slices alone for diagnosis of the perforation site in patients with pneumoperitoneum.

Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication.

OBJECTIVE: To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders. SUMMARY BACKGROUND DATA: Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia. METHODS: The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication. RESULTS: Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores. CONCLUSIONS: The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.