[Convalescence after groin hernia surgery]. / Convalescence après curede hernie inguinale.

Inguinal hernia repair represents one of the most common operations in general surgery worldwide. It is performed either as open surgery using a transinguinal approach or as minimal invasive procedure using a preperitoneal (endoscopic) or transabdominal (laparoscopic) approach, respectively. A mesh is always placed to reinforce the abdominal wall of the groin. Most interventions are nowadays performed in an ambulatory setting, and a short convalescence with early return to daily activities and work is possible. However, postoperative care is not yet widely standardized, and subsequently, off work periods are still often prolonged up to several weeks. This article provides simple recommendations to shorten postoperative convalescence.

La chirurgie pour hernie inguinale est l'intervention la plus pratiquée en chirurgie viscérale. L'intervention s'effectue par voie endoscopique ou ouverte, avec mise en place d'une prothèse. Pratiquée généralement sur un mode ambulatoire, la cure de hernie inguinale permet un retour aux activités quotidiennes et professionnelles précoces avec un taux de complications faible. Toutefois, le suivi postopératoire est peu standardisé. L'objectif de cet article est de proposer des recommandations simples et pratiques à l'attention des médecins de famille.

Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon. METHODS: All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures. RESULTS: The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively. CONCLUSION: Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

[Update in surgical oncology]. / Chirurgie viscérale.

The main novelties in 2019 are about colorectal surgery and oncologic surgery. Acute diverticulitis and mechanical bowel obstruction are frequently diagnosed in primary care medicine. In 2019, EAES (European Association for Endoscopic Surgery) and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) published their recommendations for the management of diverticulitis. Recent data, along with our current practice favor ambulatory treatment without antibiotics for mild diverticulitis. For mechanical bowel obstruction, multicentric studies have demonstrated the increasing role of imaging in predicting the need for surgery and reducing operative delays. The role of minimally invasive techniques in this clinical condition is also emphasized. In addition, the latest published results about neoadjuvant treatment of colon and rectal cancer are reviewed.

Les principales nouveautés 2019 concernent la chirurgie colorectale en général et la chirurgie oncologique. La diverticulite aiguë et l'iléus mécanique sont fréquemment rencontrés en médecine de premier recours. En 2019, les sociétés EAES (European Association for Endoscopic Surgery) et SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) ont édité leurs recommandations pour la prise en charge de la diverticulite. Au CHUV, un algorithme pour la prise en charge de la diverticulite simple est établi en partenariat avec le service des urgences, mettant l'accent sur les traitements ambulatoires et sans antibiotiques pour la plupart des cas. Des études multicentriques ont également permis de démontrer le rôle croissant de l'imagerie dans la prise en charge de l'iléus mécanique, du timing opératoire et des approches mini-invasives. Nous reviendrons aussi sur les principaux résultats publiés en 2019 concernant le traitement néo-adjuvant du cancer colique et rectal.

[Abdominal pain after bariatric surgery†: what to do†?] / Douleurs abdominals après chirurgie bariatrique†: que faire†?

Bariatric and metabolic surgery is the only effective long-term treatment for morbid obesity. The three main practiced surgeries during the last 30 years are the Roux-en-Y gastric bypass (RYGB), the sleeve gastrectomy (SG) and the laparoscopic adjustable gastric banding (AGB). These surgeries can lead to long-term complications of a functional or of a surgical nature. Rapid management in a specialized setting where appropriate investigations can be done is essential. Abdominal pain after bariatric surgery are frequent, multiple and difficult to apprehend. They should not be trivialized because the risks of severe complications without an adequate and quick management are important.

La chirurgie bariatrique est montrée comme étant le seul traitement efficace pour traiter l'obésité morbide sur le long terme. Les trois interventions ayant été les plus pratiquées ces 30 dernières années en Suisse sont le bypass gastrique en Y selon Roux (RYGB), la gastrectomie longitudinale (SG) et la mise en place d'un cerclage gastrique (CG). Ces chirurgies peuvent amener à des complications à long terme de nature fonctionnelle ou chirurgicale. Une prise en charge rapide en milieu spécialisé est primordiale. Les douleurs abdominales après chirurgie bariatrique sont fréquentes, multiples et difficiles à appréhender. Souvent, elles ne sont pas en lien avec la chirurgie primaire mais elles ne doivent pas être banalisées car les risques de complications sévères en l'absence de prise en charge adéquate et rapide sont importants.

Sagittal abdominal diameter is a better predictor than body mass index for duration of laparoscopic left colectomy.

BACKGROUND: Visceral obesity (VO) increases technical difficulty in laparoscopic surgery. The body mass index (BMI) does not always correlate to intra-abdominal fat distribution. Our hypothesis was that simple anthropometric measures that reflect VO, could predict technical difficulty in laparoscopic colorectal surgery, as reflected by the operative time, more accurately than the BMI. METHODS: Charts of all consecutive patients who underwent laparoscopic left colon resection in our institution between 2007 and 2010 were reviewed retrospectively. On a preoperative CT scan, anthropometric measures were taken on an axial plane at the L4-L5 level. Demographic, operative and anthropometric CT measures were correlated with the operative time. Logistic regression analysis was performed to assess the value of anthropometric CT measures or BMI to predict the duration of the colectomy. RESULTS: 121 patients with elective left colon resection for benign (56%) or malignant disease (44%) were included. There were 74 sigmoid resections (61%), 21 left hemicolectomies (17%) and 26 low anterior resections (22%). A longer sagittal abdominal diameter (≥24.8 cm) was significantly associated with longer corrected operative time (248 vs. 228 min, p = 0.043). In multivariate analysis, greater sagittal abdominal diameter, sagittal internal diameter and abdominal perimeter were significantly associated with longer operative time. No significant association was found for the BMI neither in univariate nor in multivariate analysis. CONCLUSIONS: This study suggests that simple linear measures taken on a CT scan, such as sagittal abdominal diameter, sagittal internal diameter and abdominal perimeter, may predict longer operative time in laparoscopic left colonic resections more accurately than BMI.

Antitumor activities of ATP-competitive inhibitors of mTOR in colon cancer cells.

BACKGROUND: The mammalian target of rapamycin (mTOR) is frequently activated in colon cancers due to mutations in the phosphatidylinositol 3-kinase (PI3K) pathway. Targeting mTOR with allosteric inhibitors of mTOR such as rapamycin reduces colon cancer progression in several experimental models. Recently, a new class of mTOR inhibitors that act as ATP-competitive inhibitors of mTOR, has been developed. The effectiveness of these drugs in colon cancer cells has however not been fully characterized. METHODS: LS174T, SW480 and DLD-1 colon cancer cell lines were treated with PP242 an ATP-competitive inhibitor of mTOR, NVP-BEZ235, a dual PI3K/mTOR inhibitor or rapamycin. Tumor cell growth, proliferation and survival were assessed by MTS assay, 5-bromo-2'-deoxyuridine (BrDU) incorporation or by quantification of DNA fragmentation respectively. In vivo, the anticancer activity of mTOR inhibitors was evaluated on nude mice bearing colon cancer xenografts. RESULTS: PP242 and NVP-BEZ235 reduced the growth, proliferation and survival of LS174T and DLD-1 colon cancer cells more efficiently than rapamycin. Similarly, PP242 and NVP-BEZ235 also decreased significantly the proliferation and survival of SW480 cells which were resistant to the effects of rapamycin. In vivo, PP242 and NVP-BEZ235 reduced the growth of xenografts generated from LS174T and SW480 cells. Finally, we also observed that the efficacy of ATP-competitive inhibitors of mTOR was enhanced by U0126, a MEK inhibitor. CONCLUSIONS: Taken together, these results show that ATP-competitive inhibitors of mTOR are effective in blocking colon cancer cell growth in vitro and in vivo and thus represent a therapeutic option in colon cancer either alone or in combination with MEK inhibitors.