Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. METHODS: Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. RESULTS: Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5-12] vs. 6[5-9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140-0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). CONCLUSIONS: Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.

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.

The effect of metabolic syndrome on postoperative outcomes following laparoscopic colectomy.

BACKGROUND: Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified. METHODS: In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m2, dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien-Dindo III and IV)] and mortality. RESULTS: Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p < 0.001), and presented with more cardiac comorbidities (p < 0.001). MS was associated with increased blood loss (122.5 vs. 79.9 mL p = 0.001) and blood transfusion requirement (5.9 vs. 1.7%, p = 0.021). The anastomotic leak rate was 6.6% (with 2.2% of anastomotic leaks requiring surgical treatment), and the overall reoperation rate was 6.9%. The incidence of severe postoperative complications was 11.5%, and the overall mortality rate 0.6%. No differences were found between the groups in overall postoperative morbidity and mortality. Median length of stay was similar in both groups (7 days). CONCLUSIONS: MS does not jeopardize postoperative outcomes following laparoscopic colectomy.

Morbidity of total thyroidectomy for substernal goiter: A series of 70 patients.

Total thyroidectomy for substernal goiter occasionally requires a sternotomy associated with a cervical incision. We sought to analyze the postoperative complications of thyroidectomy for substernal goiters in our center and more precisely the complications related to the sternotomy. All patients who underwent total thyroidectomy for substernal goiter in our center between 2007 and 2016 were reviewed retrospectively. Patients with combined cervical incision and sternotomy (ST group, n=16) were compared to those with cervical incision alone (CT group, n=54), with regard to postoperative complications. Risk factors for the occurrence of postoperative complications were investigated in this population. A total of 24 patients (34.2%) had one or more postoperative complications. The incidence of transient hypoparathyroidism and recurrent laryngeal nerve injury were higher in the ST group (P=0.001 and P=0.052, respectively). The median duration of hospitalization was longer in the ST group (P<0.001). Eighteen patients (25.8%) had a malignant tumor on final pathology. In univariate analysis, the following risk factors for transient postoperative hypoparathyroidism were identified: sternotomy, preoperative symptomatic character and thyroid height (P=0.001, P=0.009 and P=0.013, respectively). In multivariable analysis, only sternotomy was an independent risk factor for postoperative transient hypoparathyroidism (OR=4.48 [1.1; 18], P=0.035). Sternotomy is associated with added morbidity that is not negligible. This surgical approach should be reserved for substernal goiters that descend into the posterior mediastinum, below the level of the aortic arch, when there is suspicion of carcinoma with loco-regional invasion, or when the thyroid tissue is located mainly intrathoracically (conical shaped thyroid, asymptomatic goiter, ectopic thyroid).

Long-term outcomes of 80-watt KTP and 120-watt HPS GreenLight photoselective vaporization of the prostate.

OBJECTIVE: Photoselective vaporization of the prostate (PVP) is becoming a surgical treatment alternative of transurethral resection of the prostate for male lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). We evaluated the outcome and postoperative complications of PVP performed by 80-W KTP and 120-W HPS GreenLight lasers (AMS®) over a 4-year period. MATERIALS AND METHODS: This is a prospective monocentric study that included all patients who underwent PVP. They had routine follow-up at 1 month, 3 months, 6 months and every year until the fourth postoperative year. Listed data were maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), post-void residual (PVR) volume, prostate-specific antigen (PSA) and prostate volume. We collected the postoperative complications. RESULTS: From September 2005 to May 2008, 77 patients out of a 409 patients cohort underwent surgery and were followed during 4 years. At 4 years mean Qmax increase was 82.5%; mean IPSS, PVR volume, PSA and prostate volume decreases were 79.1, 69.8, 43.8 and 22.9%, respectively. The main side effects observed were storage LUTS. A urinary catheter was replaced after a first withdrawal failure in 10 patients (15.6%) after surgery. CONCLUSIONS: PVP showed a sustainable efficacy and an appealing tolerance profile during a 4-year period in patients with LUTS secondary to BPO.

[Children orbital floor fracture: retrospective study, about 34 cases]. / Fracture du plancher de l'orbite chez l'enfant, étude rétrospective à propos de 34 cas.

INTRODUCTION: Orbital fractures represent 30 % of children facial fractures. Nausea and vomiting are more predictive of entrapment than local trauma stigmatisms. Entrapment and diplopia are more frequent in adults. Delay for surgery is unclear in literature varying from 6 hours to days. The aim of this study is to summarise the aspects of orbital floor fractures in children with regard to clinical and radiological presentation, management, and outcomes. PATIENTS AND METHODS: We conducted a retrospective study including 34 children presenting isolated orbital floor fracture. Clinical, radiological, ophthalmological, surgical data and outcomes were analyzed. RESULTS: Mean age was 9.4 years. In 15% of cases, no local stigmatism of trauma was present. Entrapment fracture was the most frequent, with 81% of fat or muscles entrapment. In all, 27% of the patient had residual diplopia. Residual diplopia developed after trap-door fracture with muscle entrapment and a more than 24 hours delay for surgery. CONCLUSION: Trap-door fracture is frequent in childhood population. Clinical diagnosis can be difficult. However, surgical treatment should be considered before 24 hours to avoid complication as residual diplopia.