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).

Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer.

BACKGROUND: A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients. METHODS: This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients. RESULTS: Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively). CONCLUSIONS: Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

Rectovaginal fistula in Crohn's disease treatment: a low long-term success rate and a high definitive stoma risk after a conservative surgical approach.

BACKGROUND: Management of rectovaginal fistula (RVF) in Crohn's disease (CD) is challenging. Available studies are heterogeneous and retrospective, with short-term follow-up. The aim of this study was to assess the overall long-term medico-surgical treatment results in women with RVF due to CD. METHODS: A retrospective study was conducted on consecutive patients operated on for RVF in CD from September 1996 to November 2019 at a tertiary teaching hospital. All surgeries were classified as preliminary, closure, or salvage procedures. Primary outcome was fistula remission defined as the combination of fistula closure and no stoma, at least 6 months since last procedure. RESULTS: Thirty-two patients (median age 34 [range 21-55] years), with a median follow-up of 11.3 years (0-23.7) after first surgery, were included. Altogether, 138 procedures were performed; 36 (26%) preliminary, 80 (58%) closure, and 13 (9%) salvage procedures. RVF remission was obtained in 7/32 patients (22%). At the end of follow-up, a stoma was present in 13/32 patients (41%). The percentage of time on biologics was 86% for patients in remission, versus 36% for the others (p = 0.0057). After univariate analysis, only anti-TNF-α was significantly related to successful closure techniques (p = 0.007). CONCLUSIONS: The RVF remission rate in CD was low in the long term. However, patients underwent a succession of interventions, and the stoma rate was high. Combination of biologics with surgical management was crucial.

Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience.

BACKGROUND: There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature. METHODS: Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery. Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1 month postoperatively, then every 3 months during the first 2 years, and every 6 months thereafter, for a total of 5 years. RESULTS: A total of 28 consecutive patients (16 males) with a median age of 71.8 years (range 42.5-88.8 years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5% with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9 months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively. CONCLUSIONS: Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

Prospective evaluation of functional outcomes after laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease in consecutive male patients.

BACKGROUND: To date, there has been no consensus concerning the vascular approach during sigmoid colectomy for diverticular disease. The aim of this study was to determine the functional impact of elective laparoscopic sigmoidectomy performed with high ligation of the inferior mesenteric artery for diverticulitis in consecutive male patients. METHODS: Twenty-five consecutive patients of median age 53 years were enrolled in a prospective single-centre pilot study at a tertiary teaching hospital. Main outcome measures were functional results. Patients were asked to complete standardized, validated questionnaires to evaluate preoperative and 6 months postoperative bowel symptomatology (Jorge-Wexner Incontinence Score and KESS score), urinary function (IPSS), and sexual function (IIEF). Secondary outcomes were surgical data, morbidity, and quality of life (SF-36). RESULTS: There were no significant differences between preoperative and 6 months postoperative total scores for bowel symptomatology, urinary function, and sexual function. There were no perioperative deaths. The morbidity rate was 12% including three minor and no major events. Quality of life demonstrated statistically better general health (p < 0.01) and better medical status over the prior 4 weeks at 6 months after surgery, compared to baseline. This single-centre prospective study has a limited number of patients, relatively short follow-up time, and includes only male patients. CONCLUSION: Laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease does not induce functional disorders at 6 months after surgery. The benefit of the operation for quality of life is even greater for general health and medical status.

Biomechanical behaviour of human bile duct wall and impact of cadaveric preservation processes.

Biliary diseases are the third most common cause of surgical digestive disease. There is a close relationship between the mechanical performance of the bile duct and its physiological function. Data of biomechanical properties of human main bile duct are scarce in literature. Furthermore, mechanical properties of soft tissues are affected by these preservation procedures. The aim of the present work was, on the one hand, to observe the microstructure of the human bile duct by means of histological analysis, on the other hand, to characterize the mechanical behavior and describe the impact of different preservation processes. A mechanical study in a controlled environment consisting of cyclic tests was made. The results of the mechanical tests are discussed and explained using the micro-structural observations. The results show an influence of the loading direction, which is representative of an anisotropic behavior. A strong hysteresis due to the viscoelastic properties of soft tissues was also observed. Embalming and freezing preservation methods had an impact on the biomechanical properties of human main bile duct, with fiber network deterioration. That may further provide a useful quantitative baseline for anatomical and surgical training using embalming and freezing.

Level of inferior mesenteric artery ligation in low rectal cancer surgery: high tie preferred over low tie.

BACKGROUND: There is no demonstrated benefit of high-tie versus low-tie vascular transections in low rectal cancer surgery. The aim of this study was to compare the effects of high tie and low tie of the inferior mesenteric artery on colonic length. METHODS: This study was conducted in a surgical anatomy research laboratory. Anatomical dissections were performed on 11 human cadavers. We performed full left colonic mobilization, section of the descending-sigmoid junction, and high and low ligation of the inferior mesenteric artery. Distance from the proximal colon limb to the lower edge of the pubis symphysis was recorded after each step of vascular division. Three measurements were successively performed: before vascular section, after inferior mesenteric artery ligation, and after inferior mesenteric artery and vein section. RESULTS: Before vascular section, the mean distance between colonic end and lower edge of the symphysis pubis was - 1.9 ± 3.5 cm. After combined artery and vein section, the mean distance was + 10.7 ± 4.6 cm for high tie and + 1.5 ± 3 cm for low tie. A limitation of this study is the use of embalmed anatomical specimens, rather than live patients, and the small number of specimens. This study also does not evaluate colon limb vascularization or the impact of proximal lymph node dissection on survival rates. CONCLUSIONS: High tie of the inferior mesenteric artery at its aortic origin allows a gain of extra length of about 9 cm over low tie.

Laparoscopic delayed coloanal anastomosis without diverting ileostomy for low rectal cancer surgery: 85 consecutive patients from a single institution.

BACKGROUND: Surgical treatment for low rectal cancer septic complications often requires an ileostomy for fecal diversion. Delayed coloanal anastomosis (CAA) has been performed for several years to reduce septic complications and to avoid ileostomy. The aim of this study was to report the technical, functional and oncological results of delayed CAA in patients operated on for low rectal cancer focusing on pelvic septic complications. METHODS: All consecutive patients operated on for low rectal cancer suitable for total mesorectal excision and two-step delayed CAA at a single institution between May 2000 and September 2013 were included in the study. Patients' characteristics, operative and postoperative outcomes, long-term technical, functional and oncological results from a prospectively maintained database, were retrospectively analyzed. RESULTS: A total of 85 consecutive patients (69 men), of median age 63 years (range 42-83 years) were included. Median delay between the first and the second step of the operation was 6 days (range 2-13 days). Twenty-one patients (25%) developed pelvic sepsis, nine of them (10.6%) developed an anastomotic leak. Twenty-three patients had a definitive stoma at the end of follow-up. Seventeen patients (29%) experienced a poor functional result. Thirty-three patients (38%) presented with recurrence at a median follow-up of 59 months (range 12-135 months). Seven (8.2%) developed a local recurrence, 18 a distant metastasis (21.1%) and 8 (9.4%) both a local and distant recurrence. CONCLUSIONS: In our series, laparoscopic total mesorectal excision with delayed coloanal anastomosis was associated with septic complications and oncologic results similar to those reported after total mesorectal excision with conventional anastomosis and ileostomy, nearly one-third of patients experience a poor functional result. A randomized trial comparing these two options for low rectal cancer is under way.

Early experience with ambulatory robotic ventral rectopexy.

OBJECTIVE OF THE STUDY: Ventral rectopexy can be performed robotically with only limited trauma for the patient, making its performance in an ambulatory setting potentially interesting. The aim of this study is to report our preliminary experience with ambulatory robotic ventral rectopexy in consecutive patients. PATIENTS AND METHODS: Ten consecutive patients underwent robotic ventral rectopexy for total rectal prolapse (n=8) or symptomatic enterocele (n=2) between February 2014 and April 2015. Patients were selected for outpatient treatment based on criteria of patient motivation, favorable social conditions, and satisfactory general condition. Patient characteristics, technical results and cost were reported. RESULTS: The mean operating time was 94minutes (range: 78-150). The average operating room occupancy time was 254minutes (222-339). There were no operative complications, conversion to laparotomy, or postoperative complication. The average duration of hospital stay was 11 (8-32) hours. Two patients required hospitalization: one for persistent pain and the other for urinary retention. The average maximum pain score recorded on postoperative day 1 was 2/10 on a visual analog scale (range: 0-5/10). Estimated average cost (excluding amortization of the purchase of the robot) was €9088 per procedure. CONCLUSIONS: Ambulatory management of robotic ventral rectopexy is feasible and safe.

Emergency surgery for obstructing colonic cancer: a comparison between right-sided and left-sided lesions.

PURPOSE: Few studies compare management and outcomes of obstructive colonic cancer, depending on the tumor site. We aim to evaluate the differences in patient characteristics, tumor characteristics, and outcomes of emergency surgery for obstructive right-sided versus left-sided colonic cancers. METHODS: Between 2000 and 2009, 71 consecutive patients had an emergency colectomy following strict and clear definition of obstruction in a single institution. We retrospectively analyzed pre, per, and postoperative data that were prospectively collected. RESULTS: There were 31 and 40 patients in the right and left group, respectively. Patients aged over 80 were more frequent in the right group (p = 0.03). At operation, ileocecal valve was less often competent in the right group (p = 0.03). The one-stage strategy was more frequent in the right group (p = 0.008). Patients in the right group had a higher rate of nodes invasion (p = 0.04). One- and two-year mortality rate in the right group had a tendency to be higher. CONCLUSIONS: Patients presenting with a right obstructive colonic cancer are older, have a more advanced locoregional disease, and are more often treated in a one-stage strategy than patients with a left obstructive tumor.