Acute respiratory distress following an otherwise normal, uneventful, screening colonoscopy.

A 62-year-old man with a past history of sleep apnea syndrome, umbilical and left inguinal hernia repairs, was referred to the emergency room for acute respiratory distress. He had underwent a screening colonoscopy 12 hours earlier for a family history of colonic adenoma. This colonoscopy was complete, normal, and uneventful. A plain chest X-ray showed a distended colon extending to the upper third of the right side of the chest (figure 1). Further anamnesis helped the patient to remember a right diaphragmatic hernia, well-documented by CT-scan years ago. He had not previously mentioned this condition, when evaluated for colon screening. The patient was admitted to the surgical intensive care unit. A CT-scan confirmed a right diaphragmatic hernia with terminal ileum and ascending colon content, no sign of mesenteric ischemia, and massive pulmonary collapse. Conservative treatment with nasogastric suction quickly improved the patient's condition. He was discharged at day-6. Diaphragmatic hernia repair was scheduled 10 weeks later. Laparoscopy showed a complete agenesis of the right diaphragmatic dome (figure 2; figure 3), and was therefore converted into laparotomy for complete surgical repair. Postoperative course was unremarkable. Patient was discharged on day-6. Follow-up at 1 month was uneventful. Congenital diaphragmatic hernias are rare and usually diagnosed in the pre- natal period or in neonates with respiratory distress, calling for emergency neonatal repair [1,2]. In underdiagnosed or neglecting adults, the condition can be life-threatening, as seen in our patient [3,4]. Surgical repair is therefore strongly recommended, even in asymptomatic patients [5]. Recurrences are exceptional.

Evolution of minimally invasive liver surgery in France over the last decade.

BACKGROUND: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). METHODS: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. RESULTS: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013). CONCLUSIONS: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

What is the rate of definitive stoma after subtotal colectomy for inflammatory bowel disease? A nationwide study of 1860 patients.

AIM: Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study. METHOD: A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses. RESULTS: A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital. CONCLUSION: We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.

The neuropeptide VIP potentiates intestinal innate type 2 and type 3 immunity in response to feeding.

The nervous system and the immune system both rely on an extensive set of modalities to perceive and act on perturbations in the internal and external environments. During feeding, the intestine is exposed to nutrients that may contain noxious substances and pathogens. Here we show that Vasoactive Intestinal Peptide (VIP), produced by the nervous system in response to feeding, potentiates the production of effector cytokines by intestinal type 2 and type 3 innate lymphoid cells (ILC2s and ILC3s). Exposure to VIP alone leads to modest activation of ILCs, but strongly potentiates ILCs to concomitant or subsequent activation by the inducer cytokines IL-33 or IL-23, via mobilization of cAMP and energy by glycolysis. Consequently, VIP increases resistance to intestinal infection by the helminth Trichuris muris and the enterobacteria Citrobacter rodentium. These findings uncover a functional neuro-immune crosstalk unfolding during feeding that increases the reactivity of innate immunity necessary to face potential threats associated with food intake.