Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: results from the CLIMHET study group.

BACKGROUND: Laparoscopic right hemicolectomy (LRHC) is increasingly performed for the treatment of right colon disease. Nevertheless, standardization of the surgical technique regarding the performance of intracorporeal (IC) or extracorporeal (EC) anastomosis is lacking. The purpose of this study was to compare short-term postoperative outcomes in patients who had laparoscopic right colectomy either with IC or EC. METHODS: This was a retrospective, non-randomized and multicenter study conducted from January 2005 to December 2015 on the CLIMHET study group cohort from five tertiary centers in France. Data were collected for all patients with LRHC to compare patient characteristics, intraoperative data and postoperative outcomes in terms of medical and surgical complications, duration of hospitalization and mortality. A multivariate analysis was performed to compare the results in the two groups. RESULTS: Of the 597 patients undergoing LRHC, 150 had IC and 447 had EC. The incidence of medical complications (cardiac, vascular, and pulmonary complications) was lower in the IC group than in the EC group (13 vs 20%, p = 0.049). This difference remained significant in multivariate analysis after adjusting to field characteristics and patient histories (p = 0.009). Additionally, a shorter hospital stay (7 vs 8 days, p = 0.003) was observed in the IC group as compared to the EC group. This difference remained significant in favor of the IC group in multivariate analysis (p = 0.029). There was no difference between the groups as regards: surgical complications (p = 0.76), time of mobilization (p = 0.93), reintervention rate (p = 1) and 90-day mortality (p = 0.47). CONCLUSIONS: Our results show that IC anastomosis in LRHC is associated with fewer medical complications and shorter hospital stays compared to EC anastomosis.

Perioperative FOLFOX 4 Versus FOLFOX 4 Plus Cetuximab Versus Immediate Surgery for High-Risk Stage II and III Colon Cancers: A Phase II Multicenter Randomized Controlled Trial (PRODIGE 22).

BACKGROUND: Perioperative chemotherapy has proven valuable in several tumors, but not in colon cancer (CC). OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of perioperative chemotherapy in patients with locally advanced nonmetastatic CC. METHODS: This is a French multicenter randomized phase II trial in patients with resectable high-risk T3, T4, and/or N2 CC on baseline computed tomography (CT) scan. Patients were randomized to receive either 6 months of adjuvant FOLFOX after colectomy (control) or perioperative FOLFOX for 4 cycles before surgery and 8 cycles after (FOLFOX peri-op). In RAS wild-type patients, a third arm testing perioperative FOLFOX-cetuximab was added. Tumor Regression Grade (TRG1) of Ryan et al was the primary endpoint. Secondary endpoints were toxicity, perioperative morbidity, and quality of surgery. RESULTS: A total of 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped (lack of efficacy). The remaining 104 patients (control, n = 52; FOLFOX preop n = 52) represented our intention-to-treat population. In the FOLFOX perioperative group, 96% received the scheduled 4 cycles before surgery. R0 resection and complete mesocolic excision rate were 94% and 93%, respectively. Overall mortality and morbidity rates were similar in both groups. Perioperative FOLFOX chemotherapy did not improve major pathological response rate (TRG1 = 8%) but was associated with a significant pathological regression (TRG1-2 = 44% vs 8%, P < 0.001) and a trend to tumor downstaging as compared to the control group. CT scan criteria were associated with a 33% rate of overstaging in control group. CONCLUSIONS: Perioperative FOLFOX for locally advanced resectable CC is feasible with an acceptable tolerability but is not associated with an increased major pathological response rate as expected. However, perioperative FOLFOX induces pathological regression and downstaging. Better preoperative staging tools are needed to decrease the risk of overtreating patients.

Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores.

AIM: Predicting surgical difficulty is a critical factor in the management of locally advanced rectal cancer (LARC). This study evaluates the accuracy and external validity of a recently published morphometric score to predict surgical difficulty and additionally proposes a new score to identify preoperatively LARC patients with a high risk of having a difficult surgery. METHODS: This is a retrospective study based on the European MRI and Rectal Cancer Surgery (EuMaRCS) database, including patients with mid/low LARC who were treated with neoadjuvant chemoradiation therapy and laparoscopic total mesorectal excision (L-TME) with primary anastomosis. For all patients, pretreatment and restaging MRI were available. Surgical difficulty was graded as high and low based upon a composite outcome, including operative (e.g. duration of surgery) and postoperative variables (e.g. hospital stay). Score accuracy was assessed by estimating sensitivity, specificity and area under the receiver operating characteristic curve (AROC). RESULTS: In a total of 136 LARC patients, 17 (12.5%) were graded as high surgical difficulty. The previously published score (calculated on body mass index, intertuberous distance, mesorectal fat area, type of anastomosis) showed low predictive value (sensitivity 11.8%; specificity 92.4%; AROC 0.612). The new EuMaRCS score was developed using the following significant predictors of surgical difficulty: body mass index > 30, interspinous distance < 96.4 mm, ymrT stage ≥ T3b and male sex. It demonstrated high accuracy (AROC 0.802). CONCLUSION: The EuMaRCS score was found to be more sensitive and specific than the previous score in predicting surgical difficulty in LARC patients who are candidates for L-TME. However, this score has yet to be externally validated.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Intraperitoneal treatment of incisional and umbilical hernias using an innovative composite mesh: four-year results of a prospective multicenter clinical trial.

Intraperitoneal positioning of conventional parietal mesh provides efficient reconstruction but causes visceral adhesion formation in 80-100% of the cases. The purpose of this clinical trial was to assess the performance and tolerance of a new generation of polyester mesh protected by a hydrophilic resorbable film. Eighty patients were included in a prospective multicenter clinical trial. Patients were treated for ventral hernia via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main objective was to evaluate the anti-adhesive capability of the mesh in relation to the viscera. In order to assess the absence of visceral adhesion objectively, an ultrasound (US) specific examination was initially validated (pre-operative prediction vs. per-operative findings) and then used during the follow-up. The usual clinical parameters were also collected to follow the patients on a period up to 4 years. Pre-operative US prediction vs. per-operative macroscopic findings: sensitivity 79%, overall accuracy 76%, negative predictive value 85%. After 12 months, 86% of the patients were ultrasonically adhesion free. Early post-operative complications were: seroma/hematoma (16%), subcutaneous infection (4%), cutaneous necrosis (1%) and occlusions (outside the mesh) (2.5%). No mortality was reported. Clinically, after 12-month follow-up, no complication related to post-operative adhesions to the mesh was noted: (occlusion 0%, fistula 0%). Late complications were: mesh sepsis (1%), new defects (4%) and recurrence (2.5%). Finally, 56 patients (75.7%) were clinically evaluated with a mean follow-up of 48+/-6 months. One direct recurrence was noted while six patients experienced new defect outside the mesh. No long-term severe complication such as occlusion or enterocutaneous fistula was observed. Based on a mean clinical follow-up of 4 years, the results of this prospective multicenter clinical trial demonstrate the safety and the efficiency of this composite mesh in the intraperitoneal treatment of incisional and umbilical hernia. In particular there was no early or long-term main complication due to the intraperitoneal location of the mesh.

[Laparoscopic treatment of an adult gastric duplication cyst]. / Traitement laparoscopique d'une duplication gastrique chez l'adulte.

We hereby report the case of a 24 years old woman with an adult gastric duplication cyst, a very rare congenital disease. Diagnosis was established on preoperative imaging tests. Complete resection of the duplication cyst was undertaken laparoscopically. To the best of our knowledge, this is the first report of laparoscopic resection of an adult gastric duplication cyst.

Hepatic vascular exclusion with preservation of the caval flow for liver resections.

OBJECTIVE: To report the technique and results of an alternative method of vascular clamping during liver resections. BACKGROUND: Most liver resections require vascular clamping to avoid excessive blood loss. Portal triad clamping is often sufficient, but it does not suppress backflow bleeding, which can be prevented only by hepatic vascular exclusion. The latter method adds clamping of the inferior vena cava, which results in hypotension, requiring invasive anesthetic management. There is growing evidence that intermittent clamping is better tolerated than continuous clamping, especially in the presence of underlying liver disease. METHODS: Hepatic vascular exclusion with preservation of the caval flow (HVEPC) involved conventional inflow clamping associated with outflow control by clamping the major hepatic veins, thus avoiding caval occlusion. HVEPC was used in 40 patients undergoing major or complex liver resection, including 16 with underlying liver disease. HVEPC was total (clamping of the porta hepatis and all major hepatic veins) in 20 cases and partial (clamping of the porta hepatis and the hepatic veins of the resected territory) in 20. Clamping was continuous in 22 cases and intermittent in 18. Resections included 12 hemihepatectomies, 12 extended hepatectomies, 3 central hepatectomies, and 13 uni- or bisegmentectomies. RESULTS: Hemodynamic tolerance of clamping was excellent in all cases, without the need for therapeutic adjustment. Median red cell transfusion requirements were 0 units, and 28 patients (70%) did not receive any transfusions during the hospital stay. There were no deaths, and the morbidity rate was 17.5%. Median hospital stay was 10 days. CONCLUSION: HVEPC is a safe and effective procedure applicable to liver tumors without invasion to the inferior vena cava. It offers the advantages of conventional hepatic vascular exclusion without its hemodynamic drawbacks, and it can be applied intermittently or partially.

[Selective use of vascular clamps in major hepatectomy]. / Utilisation sélective des clampages vasculaires au cours des hépatectomies majeures.

OBJECTIVE: To report the results of a selective use of vascular occlusions in major hepatectomies according to the size and location of the hepatic lesion. BACKGROUND: Total vascular exclusion (TVE) and portal triad clamping (PTC) ensure efficient hemostatic effect but lead to warm ischemia of the liver. Lobar vascular occlusion (LVO) avoids warm ischemia of the remnant liver but could result in increased blood loss. PATIENTS AND METHODS: Sixty consecutive major hepatectomies were studied. TVE was applied in 22 patients with large lesions (= 10 cm) or lesions with connections to the major hepatic veins or inferior vena cava. PTC (n = 15) and LVO (n = 23) were applied in remaining cases. RESULTS: Clamping method was efficient in 87%, 93% and 100% for LVO, PTC and TVE, respectively. Median blood transfusions were 0.3 and 2 units for LVO, PTC and TVE, respectively. Postoperative aminotransferase peak value was significantly lower after LVO than after PTC or TVE, while those peaks were not statistically different with these latter two methods. Postoperative prothrombin time fall value was identical in the three groups. Mortality was 3.3% (2/60) and was not influenced by the type of clamping, but both deaths and most complications occurred in patients with abnormal underlying liver parenchyma. CONCLUSION: Provided that adequate techniques are used, the need for blood transfusions is more dependent on the characteristics of the resected tumor than on the type of clamping used. Total vascular exclusion does not create more ischemic injury to the liver than portal triad clamping and it should be recommended for the resection of large or strategically located tumors. Other tumors can be resected in more than 80% of the cases with LVO, thus avoiding ischemia to the remnant liver. With the control of hemorrhage, pathology of underlying liver parenchyma has emerged as the main prognostic factor in major liver resections.

Safety of selective vascular clamping for major hepatectomies.

BACKGROUND: Although hepatic vascular clampings are widely used during major hepatic resections, they may not always be necessary. Selective vascular clamping, which only controls the afferent blood flow of the resected liver, could be a valuable alternative, provided that blood loss is not increased because the opposite liver remains perfused. STUDY DESIGN: The aim of the study was to assess the safety of selective vascular clamping in 43 patients who underwent 36 right hepatectomies and 7 left hepatectomies for lesions located peripherally within the liver. Blood transfusions, hepatic tests, morbidity, mortality, and hospital stay were evaluated. RESULTS: Selective vascular clamping was efficient in 34 of the 43 attempts (79%), but bleeding from the contralateral liver required conversion to portal triad damping in 9 patients (21%). Median blood transfusions were 0 units (range 0 to 4 U), and 28 patients (65%) did not require transfusions. Postoperative laboratory tests showed that larger changes occurred at day 1 and tended to return to preoperative values at the end of the first postoperative week. Median time of hospitalization was 10 days (range 7 to 28 days). Postoperative course was uneventful in 35 patients (81%). Nonlethal complications occurred in 7 patients (16.3%). One patient (2%) with massive hepatic steatosis died of liver failure after right hepatectomy. CONCLUSIONS: Selective vascular clamping is a safe alternative to total inflow occlusion for major hepatectomies applicable in 80% of selected patients with peripheral liver tumors.