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).

Robotic-assisted right colectomy. Official expert recommendations delivered under the aegis of the French Association of Surgery (AFC).

Twenty-seven experts under the aegis of the French Association of Surgery (AFC) offer this reference system with formalized recommendations concerning the performance of right colectomy by robotic approach (RRC). For RRC, experts suggest patient installation in the so-called "classic" or "suprapubic" setup. For patients undergoing right colectomy for a benign pathology or cancer, RRC provides no significant benefit in terms of intra-operative blood loss, intra-operative complications or conversion rate to laparotomy compared to laparoscopy. At the same time, RRC is associated with significantly longer operating times. Data from the literature are insufficient to define whether the robot facilitates the performance of an intra-abdominal anastomosis, but the robotic approach is more frequently associated with an intra-abdominal anastomosis than the laparoscopic approach. Experts also suggest that RRC offers a benefit in terms of post-operative morbidity compared to right colectomy by laparotomy. No benefit is retained in terms of mortality, duration of hospital stay, histological results, overall survival or disease-free survival in RRC performed for cancer. In addition, RRC should not be performed based on the cost/benefit ratio, since RRC is associated with significantly higher costs than laparoscopy and laparotomy. Future research in the field of RRC should consider the evaluation of patient-targeted parameters such as pain or quality of life and the technical advantages of the robot for complex procedural steps, as well as surgical and oncological results.

Computed Tomography Colonography Angiography (CTC-A) prior to colectomy for cancer: A new tool for surgeons.

The pre-operative work-up for non-metastatic colon cancer includes colonoscopy and thoraco-abdomino-pelvic computed tomography (CT) with intravenous (IV) contrast. Colonoscopic determination of the anatomical location of the tumor may be erroneous, particularly with a long redundant colon (dolichocolon), and the search for synchronous colon neoplasms is limited when the endoscope cannot traverse the tumor-bearing segment. While computed tomography colonography angiography (CTC-A) makes it possible to assess distant tumor metastasis, it remains limited for the assessment of loco-regional extension. CTC-A requires specific colonic preparation, controlled colonic insufflation with CO2, and an injection of IV contrast. CTC-A provides a 3-D view of the overall morphology of the colon and precisely localizes the site of the colonic tumor. Merging the images of the colon with those of mesenteric and colonic vessels provides a representation of anatomical vascular variations. This information could help the surgeon to better plan the colectomy. The use of two-dimensional images of CTC-A with sections perpendicular to the major axis of the tumor-bearing colonic segment can provide precise information on the degree of parietal extension and be useful in evaluating the value of neo-adjuvant chemotherapy.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association.

AIM: It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies. METHOD: From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively. RESULTS: In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups. CONCLUSION: The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

BACKGROUND: In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. METHODS: Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. RESULTS: A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. CONCLUSIONS: There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Preoperative nutrition forseverely malnourished patients in digestive surgery: A retrospective study.

INTRODUCTION: Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). METHODOLOGY: A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months. RESULTS: Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26g/L [13-40] in the RP group and 32.5g/L [32-48] in the NRP group (P=0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P=0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P=0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002). CONCLUSION: After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition.

Operating room hygiene: Clinical practice recommendations.

INTRODUCTION: The French Society of Gastro-Intestinal Surgery (SociétéFrançaisedeChirurgieDigestive) and the Association of hepato-bilio-pancreatic and transplantation surgery (AssociationdeChirurgieHépato-Bilio-PancréatiqueetTransplantation) requested that clinical practice recommendations be established with regard to operating room hygiene. METHODS: The literature was analyzed according to the High Authority of Health (HauteAutoritédesanté [HAS]) methodology and after consultation of the Cochrane and Medline databases. Pertinent references were selected, and supplementary references were hand-picked from the reference lists. Only English or French language papers were retained. The recommendations of learned societies and the World Health Organization were also considered. RESULTS: Recommendations were proposed with regard to pre-operative patient preparation, skin preparation, draping, wound edge protectors, surgeon hygiene, wound closure, and operating room environment. CONCLUSION: These clinical practice recommendations should guide and improve the daily practice of gastro-intestinal surgeons.

Surgical management of obstructive left colon cancer at a national level: Results of a multicentre study of the French Surgical Association in 1500 patients.

PURPOSE: Surgical management of obstructive left colon cancer (OLCC) is controversial. The objective is to report on postoperative and oncological outcomes of the different surgical options in patients operated on for OLCC. METHODS: From 2000-2015, 1500 patients were treated for OLCC in centers members of the French Surgical Association. Colonic stent (n=271), supportive care (n=5), palliative derivation (n=4) were excluded. Among 1220 remaining patients, 456 had primary diverting colostomy (PDC), 329 a segmental colectomy (SC), 246 a Hartmann's procedure (HP) and 189 a subtotal colectomy (STC) as first-stage surgery. Perioperative data and oncological outcomes were compared retrospectively. RESULTS: There was no difference between the 4 groups regarding gender, age, BMI and comorbidities. Postoperative mortality and morbidity were 4-27% (PDC), 6-47% (SC), 9-55% (HP), 13-60% (STC), respectively (P=0.005). Among the 431 living patients after PDC, 321 (70%) patients had their primary tumour removed. Cumulative mortality and morbidity favoured PDC (7-39%) and SC (6-40%) compared to HP (1-47%) and STC (13-50%) (P=0.04). At the end of follow-up definitive stoma rates were 39% (HP), 24% (PDC), 10% (SC), and 8% (STC) (P<0.0001). Five-year overall and disease-free survival was: SC (67-55%), PDC (54-48%), HP (54-37%) and STC (48-49%). After multivariate analysis, SC and PDC were associated with better prognosis compared to HP and STC. CONCLUSION: In OLCC, SC and PDC are the two preferred options in patients with good medical conditions. For patients with severe comorbidities PDC should be recommended, reserving HP and STC for patients with colonic ischaemia or perforation complicating malignant obstruction.

Thirty-day mortality after emergency surgery for obstructing colon cancer: survey and dedicated score from the French Surgical Association.

AIM: The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score. METHOD: From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value ≤ 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve. RESULTS: A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age ≥ 75 (P = 0.013), American Society of Anesthesiologists (ASA) score ≥ III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80. CONCLUSION: Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

Long-term outcome and management of right colonic diverticulitis in western countries: Multicentric Retrospective Study.

AIM OF THE STUDY: Right colonic Diverticulitis (RD) is rare in Europe; few studies have focused on it and its management is not standardised. The aim of this study was to analyse the clinical presentation (complicated, uncomplicated), acute phase management and long-term outcome of RD in western countries. PATIENTS AND METHODS: From 2003 to 2017, 93 consecutive patients who presented with RD were retrospectively included at 11 French Hospital Centres. RESULTS: The study population consisted of two groups: Uncomplicated Right Diverticulitis (URD) group (63.5%, (n=59)) and Complicated Right Diverticulitis (CRD) group (36.5%, [n=34]). 84.7% (n=50/59) of URD were treated conservatively. 41.2% (n=14/34) of patients with CRD had emergency surgery (mostly laparotomy) for Hinchey III peritonitis, clinical intolerance or hemodynamic instability. Altogether 5.2% (n=2/34) patients with CRD had surgery after a cooling off period (initially abscess). The overall rate of severe postoperative complications was low (8%). Recurrence rate was low and comparable in both groups: 6.8% (n=4/59) for URD and 8.8% (n=3/34) for CRD, all recurrences occurred in the same locations with an uncomplicated form, 42.9% (n=3/7) of them had elective laparoscopic surgery and the rest were conservatively treated. Median follow up was 33.2 months. CONCLUSION: Conservative treatment can be proposed safely and efficiently for URD and for selected patients with CRD. Surgery should be reserved for unstable patients or patients with severe forms of complicated diverticulitis in emergency.

Oncological impact of anastomotic leakage after laparoscopic mesorectal excision.

BACKGROUND: The effect of anastomotic leakage on oncological outcomes after total mesorectal excision (TME) is controversial. This study aimed to assess the influence of symptomatic and asymptomatic anastomotic leakage on oncological outcomes after laparoscopic TME. METHODS: All patients who underwent restorative laparoscopic TME for rectal adenocarcinoma with curative intent from 2005 to 2014 were identified from an institutional database. Asymptomatic anastomotic leakage was defined by CT performed systematically 4-8 weeks after rectal surgery, with no relevant clinical symptoms or laboratory examination findings during the postoperative course. RESULTS: Of a total of 428 patients, anastomotic leakage was observed in 120 (28·0 per cent) (50 asymptomatic, 70 symptomatic). After a mean follow-up of 40 months, local recurrence was observed in 36 patients (8·4 per cent). Multivariable Cox regression identified three independent risk factors for reduced local recurrence-free survival (LRFS): symptomatic anastomotic leakage (odds ratio (OR) 2·13, 95 per cent c.i. 1·29 to 3·50; P = 0·003), positive resection margin (R1) (OR 2·41, 1·40 to 4·16; P = 0·001) and pT3-4 category (OR 1·77, 1·08 to 2·90; P = 0·022). Patients with no risk factor for reduced LRFS had an estimated 5-year LRFS rate of 87·7(s.d. 3·2) per cent, whereas the rate dropped to 75·3(4·3) per cent with one risk factor, 67(7) per cent with two risk factors, and 14(13) per cent with three risk factors (P < 0·001). Asymptomatic anastomotic leakage was not significantly associated with LRFS in multivariable analysis. CONCLUSION: Symptomatic anastomotic leakage is a risk factor for disease recurrence in patients with rectal adenocarcinoma.

Management of rectal cancer: the 2016 French guidelines.

AIM: Rectal cancer is a malignant disease requiring multidisciplinary management. In view of the increasing number of studies published over the past decade, a comprehensive update is required to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery and the French National Coloproctology Society. METHOD: Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A drafting committee and a large group of expert reviewers contributed to validate the statements. RESULTS: Recommendations include the indications for neoadjuvant therapy, the quality criteria for surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement. CONCLUSION: The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies.

Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients.

BACKGROUND: There are very few studies and no consensus concerning the choice between two- and three-stage ileal pouch-anal anastomosis [IPAA] in inflammatory bowel diseases [IBD]. This study aimed to compare operative results between both surgical procedures. METHODS: Only patients who underwent a laparoscopic IPAA for IBD were included. They were divided into two groups: two-stage [IPAA and stoma closure] [Group A] and three-stage IPAA [subtotal colectomy, IPAA, stoma closure] [Group B]. RESULTS: From 2000 to 2015, 185 patients (107 men, median age of 42 [range, 15-78] years) were divided into Groups A [n = 82] and B [n = 103]. Patients in Group B were younger than in Group A (39 [15-78] vs 43 [16-74] years; p = 0.019), presented more frequently with Crohn's disease [16% vs 5%; p < 0.04], and were more frequently operated in emergency for acute colitis [37% vs 1%; p < 0.0001]. Cumulative operative time and length of stay were significantly longer in Group B (580 [300-900] min, and 19 [13-60] days) than in Group A (290 [145-490] min and 10 [7-47] days; p < 0.0001). Cumulative postoperative morbidity, delay for stoma closure, and function were similar between the two groups. Long-term morbidity was similar between Group A [13%] and Group B [21%; p = 0.18]. CONCLUSIONS: Our study suggested that postoperative morbidity was similar between two- and three-stage laparoscopic IPAA. It suggested that the three-stage procedure is probably safer for high-risk patients [ie in acute colitis].

Is there a place for organ preservation in infiltrating rectal cancer?

Neoadjuvant chemoradiotherapy followed by total mesorectal excision is currently the standard of care for locally advanced rectal cancers. However, this therapeutic approach does not take into account response to neoadjuvant treatment, which can go up to a pathologic complete response in 10-20% of the patients. Moreover, despite its efficacy in terms of local control and survival, radical surgery is associated with a significant risk of postoperative morbidity, anastomotic leakage, permanent stoma, impaired quality of life, bowel and genitourinary dysfunction. Based on these adverse events, new strategies of organ preservation have emerged recently. They include, in case of suspicion of complete tumor response, both "watch and wait" strategy and local excision of the residual scar. They seem attractive options, both for patients and surgeons, in terms of postoperative results. But few high-quality studies are available and fears remain regarding oncologic results and reproducibility of published results. Before these strategies can be recommended, large prospective randomized studies are still needed. The aim of this review is to discuss these two options for organ preservation, based on the current literature, with a special focus on oncologic outcomes.

Elective subtotal colectomy with ileosigmoid anastomosis for colon cancer preserves bowel function and quality of life.

AIM: We report on our experience of elective subtotal colectomy and ileosigmoid anastomosis for colon cancer with focus on postoperative results, function and quality of life. METHOD: Between 1998 and 2011, 106 consecutive patients with colonic malignancy underwent this procedure electively. Function and quality of life (EORTC QLQ-C30) were evaluated retrospectively with questionnaires sent to all patients free of recurrence. RESULTS: There were 62 men and 44 women (mean age 63 years). Postoperative mortality and morbidity rates were 1.9 and 26.4%, respectively. Persistent ileus was the main early complication (16%). After a mean follow-up of 67 ± 36 months, 50 (78.1) out of 64 patients have been evaluated for function and quality of life. The mean number of bowel movements per 24 h was 3 ± 2 and significantly lower when the length of the remaining sigmoid colon was more than 15 cm (P = 0.049). Compared with a European reference population for EORTC QLQ-C30 results, our patients had significantly more diarrhoea (26 vs 3, P = 0.0002) but less pain (10 vs 25, P < 0.0001) and better global quality of life (77 vs 62, P < 0.0001). CONCLUSION: Elective subtotal colectomy for colon cancer is safe and associated with good function and quality of life. Ileosigmoid anastomosis should be discussed when extended colectomy is required, providing the rectosigmoid junction and its vascular supply can be oncologically preserved. For tumours located in the transverse colon or at the splenic flexure, this procedure may be the best surgical option.