Primary anastomosis and nonrestorative resection for perforated diverticulitis with peritonitis: meta-analysis of randomized trials.

AIM: The aim of this meta-analysis was to comparatively evaluate the outcomes of primary anastomosis (PRA) and nonrestorative resection (NRR) as emergency surgery and ostomy reversal in patients with perforated diverticulitis and peritonitis. METHODS: PubMed, MEDLINE via Ovid, Embase, CINAHL, Cochrane Library and Web of Science databases were systematically searched. Postoperative morbidity following emergency resection was the primary end-point. Quality assessment of the included studies was performed using the Cochrane Quality Assessment Tool including recruitment bias and crossover with intention-to-treat analysis. The Haenszel-Mantel method with odds ratios (OR, 95% CI) and the inverse variance method with mean difference (MD, 95% CI) as effect measures were utilized for dichotomous and continuous outcomes, respectively. RESULTS: Four randomized controlled trials totaling 382 patients (180 PRA vs 204 NRR) were included. Morbidity rates following emergency resection did not differ (OR = 0.99, 95% CI 0.65, 1.51; P = 0.95; number needed to treat/harm (NNT) 96). Organ/space surgical site infection rates were 3.3% in PRA vs 11.3% in NRR (OR = 0.29, 95% CI 0.12, 0.74; P = 0.009; NNT = 13). Postoperative morbidity rates following ostomy reversal were significantly lower in PRA (OR = 0.31, 95% CI 0.15, 0.64; P = 0.001; NNT = 7). Pooled ostomy non-reversal rates were 16% in PRA vs 35.5% in NRR (OR = 0.37, 95% CI 0.22, 0.62; P = 0.0001; NNT = 6) with high heterogeneity (I2  = 63%; τ2  = 8.17). Meta-regression analysis revealed significant negative correlation between the PRA-to-NRR crossover rate and the ostomy non-reversal rate (P = 0.029). CONCLUSION: This meta-analysis found that PRA was associated with better short- and long-term outcomes at the cost of significantly longer operating time at emergency surgery.

New, simple and reliable volumetric calculation technique in incisional hernias with loss of domain.

INTRODUCTION: The management of hernias with loss of domain is a challenging problem. It has been shown that the volume of the incisional hernia/peritoneal volume ratio < 20% was a predictive factor for tension-free fascia closure, after pre-operative pneumoperitoneum preparation (Goni Moreno technique). In this study, we propose an easy, reliable and fast technique to perform volumetric calculation, by the surgeon alone. MATERIALS AND METHODS: 3D slicer software (free open-source software) was used to calculate with precision the intra-peritoneal and intra-hernia volumes, and to create a 3D reconstruction of both volumes. The measurement technique is described step by step using detailed figures and videos. RESULTS: The method was used to calculate the volumes for five consecutive patients, managed between January 2018 and March 2019. All the five patients had a ratio greater than 20% and, therefore, received a PPP program. The effectiveness of the procedure is objectified by the increase of the intraabdominal volume and the reduction of the incisional hernia/peritoneal volume ratio. The feasibility of a tension-free fascia closure was confirmed for the five patients. CONCLUSION: In addition to a standardized definition of "loss of domain", a standardized volumetric technique, easy to reproduce, needs to be adopted. Our method can be done by any surgeon with basic computer skills and radiological knowledge in an autonomous and a fast manner, thus helping to select the right technique for the right patient.

C-reactive protein assessment to predict early septic complications after laparoscopic bowel resection for endometriosis: a diagnostic study.

OBJECTIVE: To assess the predictive value of C-reactive protein (CRP) level for early septic complications after laparoscopic bowel resection for endometriosis. DESIGN: Retrospective study using data prospectively recorded in the CIRENDO database. SETTING: University tertiary referral centre. POPULATION: Three hundred and three women managed by segmental resection or disc excision for colorectal endometriosis in 40 consecutive months. METHODS: C-reactive protein was routinely measured at postoperative days 4, 5, and 6. Bowel fistula, pelvic abscess, and pelvic infected haematoma were prospectively recorded. MAIN OUTCOME MEASURES: A receiver operating characteristic (ROC) curve was built to assess the best cut off CRP value to predict early septic complications. RESULTS: The incidence of bowel fistula and pelvic abscess/infected hematoma were 2 and 7.9%, respectively. The CRP cut-off value of 100 mg/l at postoperative day 4 predicts early septic pelvic complications (sensitivity, specificity, positive and negative predictive values of, respectively, 76, 83, 30.2, and 90.4%), and the area under the curve was 0.85 (95% CI 0.78-0.92). CONCLUSION: Postoperative CRP monitoring is useful in the prediction of early septic pelvic complications following bowel endometriosis surgery, with possible impact on the management of postoperative outcomes and hospitalisation stay. TWEETABLE ABSTRACT: Levels of CRP ≥100 mg/l at day 4 after bowel resection or excision for endometriosis are associated with early septic pelvic complications.

Multiple nodule removal in multifocal colorectal endometriosis instead of "en bloc" large colorectal resection.

Surgical management of colorectal endometriosis follows the principles of two main philosophies or approaches: radical and conservative. The radical approach has recently been recommended in multifocal colorectal endometriosis, which frequently concerns patients with rectal nodules. However, an alternative conservative management could employ selective retrieval of macroscopic colorectal deep endometriosis nodules by bowel shaving and disc excision, with preservation of the mesorectum. The conservative approach is justified by the evidence that low colorectal resection may lead to postoperative functional digestive symptoms for which management is most challenging. However, there is a lack of data in the literature specifically focusing on patients with multiple excision of deep colorectal endometriosis. No data exist about the minimal length of healthy bowel that should be conserved between two successive transversal bowel sutures, and on consecutive improvement of functional outcomes. Conversely, no evidence exists on presumed reduction of recurrence rate when young patients undergo low large colorectal resection, instead of multiple selective excisions. Further comparative studies would be welcome, among which the ENDORE randomized trial which may play a central role by comparing functional outcomes related to radical and conservative approach in deep endometriosis infiltrating the rectum.

[Complications of superficial venous surgery of the legs: thigh hematomas and abscess]. / Complications de la chirurgie veineuse superficielle des membres inférieurs: les hématomes et abcès de cuisse.

A series of 1,000 patients has been studied. I. HEMATOMAE: They are nearly continuous during internal saphena stripping but depend on various parameters. 1) Anatomical: a) Varicose veins topography. Perforating veins. Perforating veins of the thigh cause haemorrhage but reactions of venous construction are quite important and precocious not to observe subcutaneous bleedings. More or less "soft" stripping creates a reaction of reflex vasoconstriction. Fore saphenous vein of the thigh Hematomae are more and more numerous and important because the fore saphenous vein is a vein whose wall is thinner, more fragile and almost more superficial. b) Type of patient. In an obese patient, hematoma seems to be more spectacular. In the thin patient, it appears faster, if hematic expression is too late. 2) Stripping techniques: It is possible to propose different techniques of stripping, but none of them can lower specifically post-surgical hematomae. 3) Anaesthesiae: a) General anaesthesia. A bilateral surgery under general anaesthesia was helpful to observe in some cases a less important hematoma at the level of the second operated leg. b) Rachi-anaesthesia. Physiological vasoconstriction requires a latent period for this kind of anaethesia which causes a vasomotor paralysis due to a blockade of the sympathetic nerve. c) Local anaesthesia. It is obtained by crural block in association with injection of Xylocaine Adrenalina at the level of perforating veins of the thigh. This technique causes less hematomae. II. ABSCESSES: Only 4 cases out of 1,000 operated legs have been reported. No related pathology have been observed particularly about lymphatic disorders (erysipelas or lymphoedema), no previous infection known which could not have explained such complications. Therapy was simple: incision at mid-thigh and draining by lamina. The patient recovered within two weeks.

[Clinical characteristics of pain in chronic venous insufficiency]. / Caractéristiques cliniques de la douleur dans l'insuffisance veineuse chronique.

Since the report of the 1st International Conference of Phlebology at Chambéry, devoted to venous pain, the subject has scarcely attracted attention apart from the meeting of the Benelux Society of Phlebology devoted to "pain in the legs". Pain due to superficial venous insufficiency has scarcely changed in nature for 30 years and remains one of the major presenting symptoms in phlebology. Acute or chronic, punctate or diffuse, modifications in this functional symptomatology have been accentuated, or have varied in their aspects under the influence of certain fashions or certain habits of modern life, i.e.: sedentary behaviour, underfloor heating, the use of oral contraceptives or of menopausal hormone replacement therapy. However, the distribution of the various aspects of venous pain remains in the same proportions as those described by the authors cited previously. While the etiological diagnosis must essentially eliminate all other causes: arterial, neurological, muscular, articular, it is essential not to neglect deep venous insufficiency of the gemellar veins, often responsible for a wide range of symptomatology and still all too often neglected. The pathogenesis of this pain not only involves the concept of pain receptors but also the appearance of algogenic metabolites at the site of the microcirculatory unit, to which endothelial cells are particularly sensitive during stasis. In fact, pain is the expression of disorders concerning local exchanges, whether thermal, pressure, metabolic or hemorheological. It is the alarm bell of venous insufficiency and merits the attention of the phebologist who must thus undertake active treatment before problems become irreversible.

[Hyperbaric oxygenation therapy and cicatrization]. / Oxygénothérapie hyperbare et cicatrisation.

HOT is a very useful therapeutic addition in chronic wounds presenting a healing problem and for which usual treatment were unsuccessful. In order to be fully effective, HOT must be included in a strategy of care, taking into account, not only the wound itself but the underlying disease. Peripheral delivery of oxygen and induction of tissue hyperoxygenation with HOT may be verified by measurement of the TcPO2 under HOT. The predictive value of these measurements is helpful in the decision for treatment and its management.

Hyperbaric oxygen therapy in chronic vascular wound management.

Many nonhealing tissues are hypoxic, with oxygen tensions frequently ranging from 5 to 15 mmHg. In such an environment, the normal wound healing sequence is disrupted or halted and phagocytic killing activity depressed. So the adjunctive use of hyperbaric oxygen (HBO), based on physiologic data and clinical observations, can provide the substrate necessary to initiate and sustain the healing process. During a twelve-month period, 20 patients with a nonhealing wound were referred to the hyperbaric center: chronic arterial insufficiency ulcers in 9 cases, diabetic wounds (foot lesions) in 11 cases. Adjunctive HBO therapy, initiated twice a day, consisted of pure oxygen, 2.5 ATA, 90 min. The average length of sessions was 46 (15-108). Complete healing was observed in 15 of 20 cases. The wound management can be helped with the transcutaneous oxygen measurements under hyperbaric oxygen. The distal TCPO2 at 2.5 ATA pure oxygen is a reliable test to predict final outcome (healing or no change), when these values were not different in normal air and in normobaric oxygen: (table; see text) In hyperbaric oxygen therapy, when the distal TCPO2 value was inferior to 100 mmHg, all patients showed either no improvement or aggravation, and when the value was higher than 100 mmHg, wound healing was achieved with all patients.

[Hyperbaric oxygen therapy in the treatment of wounds, in plastic and reconstructive surgery]. / L'oxygénothérapie hyperbare dans le traitement des plaies, en chirurgie plastique et reconstructive.

After recalling the mechanism of action of hyperbaric oxygen (HBO) on healing processes, the authors review the principal indications for this technique in plastic and reconstructive surgery, such as crush injuries and acute post-traumatic ischemia of the limbs, skin flaps and skin grafts, when there is a risk of their not taking, and burns. They stress the importance of strict, stratified therapeutic protocols with control of the hyperoxygenation induced by HBO. In the authors' experience, transcutaneous measurements of the partial pressure of oxygen under the hyperbaric atmosphere is a very useful method with a predictive value to determine the indications for treatment with HBO and to monitor its effects.

Microcirculatory unit. Actual news.

The microcirculatory unit is the localization of important exchanges. Any disturbance in the state of equilibrium, though at first functional, quickly becomes organic. This imbalance can appear at the level of the secretion of prostaglandin modification of the capillary permeability, which may be the consequence of Paf Acether secretion. Free Radical release can disrupt the normal functioning of the cell wall. Venotonic drugs act at this level, assisting the return to normal histochemical equilibrium.

[The compartment syndrome]. / Le syndrome des compartiments.

The compartment syndrome is in fact secondary to intracompartmental hypertension which creates ischemia of the muscles, nerves, vessels, and anterior tibial and peroneal arteries in the leg. Described in the 19th century, the clinical picture is better known when progressing either in the acute form or in the chronic form. Diagnosis depends basically on the measurement of intramuscular pressure; treatment, at least initially, apart from subcutaneous aponeurotic decompression, also calls for hyperbaric oxygen therapy. The latter is particularly indicated in those cases bordering on surgical and medical treatment, for preventing deterioration and improving muscular possibilities in the post-surgical period. At the present time, the physiopathology of the condition is still poorly understood. The whiplash syndrome was well described by Martorelli and is due to rupture of the muscular veins of the calf. The clinical picture is often ambiguous and can suggest underlying phlebitis. The triad of symptoms --pain, disability and ecchymosis-- generally enables a diagnosis to be made, with treatment consisting primarily of immobilization. As for Bywaters' syndrome (crush syndrome), it is still very topical. The original description of the clinical picture by Bywaters during the bombardment of London in 1942 has been replaced by the picture resulting from large scale accidents that are part of modern society. The picture is still highly dramatic and if untreated progresses to acute renal insufficiency. Treatment has certainly changed and hyperbaric therapy (administered at two or three atmospheres) is a valid adjuvant to basic treatment and modifies the progress of the phenomenon with entirely satisfactory results.

[The value of studying the ocular conjunctiva in case-finding in prediabetic states]. / Intérêt de l'étude de la conjonctive oculaire dans le dépistage du prédiabète.

Capillaroscopy, the only method available for the study of the microcirculation, without modifying its hydraulics, often provides a wealth of information in certain systemic diseases in which the microcirculatory involvement precedes clinical manifestations and of course, macrovascular complications. The prospective study of a healthy population is particularly demonstrative and the authors proposed scores on which diabetic microangiopathy could be suspected. The latter was confirmed by detailed laboratory investigations on one hand, and by the course of the disease on the other. For this reason, any subject at risk of diabetes should undergo at least one annual capillaroscopic examination of the ocular conjunctiva or if not, of the peri-ungual region. Furthermore, the study of microvessels in subjects with controlled and treated disease showed a regression of the anomalies which depended on proper control of diabetes, and this particularly nontraumatic test procedure which can be repeated and provides a wealth of information, can give a good reflection of proper therapeutic control, especially if it is performed by a trained and experienced investigator.

[The role of support in the prevention of venous thromboses of the lower limbs]. / Rôle de la contention dans la prévention des thromboses veineuses des membres inférieurs.

Support and exercise has long been accepted as a mechanical method of preventing venous stasis. In recent years the role of the venous endothelium in the pathogenesis of thrombosis has been emphasised. The trouble occurs at the level of the microcirculation. Given the delicate balance at that level, it is easy to appreciate how various antagonistic systems (serotonin, quinine, etc.) can be easily distorted. Elastic support helps prevent these endothelial changes.