Long-term efficacy of fibrin glue injection for perianal fistulas in patients with Crohn's disease.

AIM: The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. METHODS: This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. RESULTS: In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. CONCLUSION: An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.

Diagnostic strategy for trigger identification in severe reactive hemophagocytic lymphohistiocytosis: A diagnostic accuracy study.

Reactive hemophagocytic lymphohistiocytosis (rHLH) management requires early recognition, trigger identification, and adequate treatment in order to reduce mortality. We assessed the diagnostic yield of tissue biopsies to identify trigger in severe rHLH. We included all consecutive patients presenting an rHLH diagnosis (HLH-2004 criteria) admitted to the intensive care unit (ICU) of a tertiary hospital. This retrospective diagnostic accuracy study was conducted according to the Standards for Reporting Diagnostic Accuracy Statement. Among the 134 included patients (median age 47 years [IQR 47-56]), an underlying immunodeficiency was previously known in 61.2%. rHLH trigger was identified in 127 patients (94.8%) (hematological disorder 75%, infection 16%, systemic disease 4%). Diagnostic yield of tissue biopsies was as follows: lymph node 75% (95% confidence interval [CI], 61-85), skin 50% (95% CI, 27-73), bone marrow 44% (95% CI, 34-55), liver 30% (95% CI, 15-49). Splenectomy (yield 77%; 95% CI, 46-95) was reserved to cases of diagnostic deadlock. Procedural severe adverse events included two cases of reversible hemorrhagic shock. Seventy-eight percent of patients received etoposide regarding to the rHLH severity, and 68% could receive trigger-specific treatment in the ICU. A comprehensive diagnostic workup led to an rHLH trigger identification in 95% of patients, allowing prompt initiation of appropriate therapy. Prospective studies to validate a standardized diagnostic approach are warranted.

Penetrating Crohn Disease Is Not Associated With a Higher Risk of Recurrence After Surgery: A Prospective Nationwide Cohort Conducted by the Getaid Chirurgie Group.

OBJECTIVE: The aim of this study was to assess recurrence risk factors following ileocolonic resection (ICR) for Crohn disease (CD) in a nationwide cohort study SUMMARY BACKGROUND DATA:: Recurrence rate after ICR for CD can be up to 60%, but its predictive factors have never been evaluated in large prospective cohort studies. METHODS: From 2013 to 2015, 346 consecutive patients undergoing ICR for CD and a postoperative ileocoloscopy within 6 to 12 months after surgery at 19 academic French centers were included prospectively. RESULTS: Twelve-month postoperative endoscopic (Rutgeerts score ≥i2) and clinical recurrence rates were 57.6% [95% confidence interval (CI), 54.2-61.0] and 11.3% (95% CI, 9-13.6), respectively. A total of 185 patients (54%) had a postoperative CD prophylaxis, comprising thiopurine in 69 (20%), or anti-tumor necrosis factor (TNF) therapy in 93 (27%). In multivariate Cox regression analysis, absence of postoperative smoking {odds ratio [OR] = 0.60 (95% CI, 0.40-0.91); P = 0.016}, postoperative prophylaxis [OR = 0.60 (95% CI, 0.41-0.88); P = 0.009], and penetrating disease behavior [OR = 0.58 (95% CI, 0.39-0.86); P = 0.007] were the only independent predictors of reduced endoscopic recurrence risk. Postoperative prophylaxis [OR 0.31 (95% CI, 0.15-0.66); P = 0.002), and penetrating behavior [OR = 00.36 (95% CI, 0.16-0.81); P = 0.013), were the only independent predictors of reduced clinical recurrence risk. Postoperative anti-TNF therapy was associated with a significant reduction of both 12-month risks of endoscopic (P < 0.001) and clinical (P = 0.019) recurrences. CONCLUSION: Absence of postoperative smoking, CD prophylaxis, and penetrating disease behavior could be independent predictors of reduced postoperative recurrence after ICR for CD. Prophylactic anti-TNF therapy reduces both endoscopic and clinical recurrence rates. It suggests that upfront surgery followed by postoperative anti-TNF therapy is probably the best therapeutic approach for complex CD (penetrating disease behavior).

Postoperative Morbidity After Iterative Ileocolonic Resection for Crohn's Disease: Should we be Worried? A Prospective Multicentric Cohort Study of the GETAID Chirurgie.

BACKGROUND AND AIMS: To compare perioperative characteristics and outcomes between primary ileocolonic resection [PICR] and iterative ileocolic resection [IICR] for Crohn's disease [CD]. METHODS: From 2013 to 2015, 567 patients undergoing ileocolonic resection were prospectively included in 19 centres of the GETAID chirurgie group. Perioperative characteristics and postoperative results of both groups [431 PICR, 136 IICR] were compared. Uni- and multivariate analyses of the risk factors of overall 30-day postoperative morbidity was carried out in the IICR group. RESULTS: IICR patients were less likely to be malnourished [27.2% vs 39.9%, p = 0.007], and had more stricturing forms [69.1% vs 54.3%, p = 0.002] and less perforating disease [19.9% vs 39.2%, p < 0.001]. Laparoscopy was less commonly used in IICR [45.6% vs 84.5%, p < 0.01] and was associated with increased conversion rates [27.4% vs 14.6%, p = 0.012]. Overall postoperative morbidity was 36.8% in the IICR group and 26.7% in the PICR group [p = 0.024]. There was no significant difference between IICR and PICR regarding septic intra-abdominal complications, anastomotic leakage [8.8% vs 8.4%] or temporary stoma requirement. IICR patients were more likely to present with non-infectious complications and ileus [11.8% vs 3.7%, p < 0.001]. Uni- and multivariate analyses did not identify specific risk factors of overall postoperative morbidity in the IICR group. CONCLUSIONS: Surgery for recurrent CD is associated with a slight increase of non-infectious morbidity [postoperative ileus] that mainly reflects the technical difficulties of these procedures. However, IICR remains a safe therapeutic option in patients with recurrent CD because severe morbidity including anastomotic complications is similar to patients undergoing primary resection. PODCAST: This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort.

OBJECTIVE: To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). SUMMARY BACKGROUND DATA: The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. METHODS: From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. RESULTS: Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54-4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009). CONCLUSIONS: Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Gastrointestinal emergencies in critically ill cancer patients.

PURPOSE: To describe gastrointestinal emergencies in cancer patients. METHODS: All cancer patients admitted to the medical ICU of Saint-Louis Hospital for an acute abdominal syndrome during the study period (1997-2011) were included. RESULTS: A total of 164 patients were included. The most common diagnoses were: neutropenic enterocolitis (NE) (n=54, 33%), infectious colitis and peritonitis (n=51, 31%), bowel infiltration by malignancy (n=14, 9%), and mucosal toxicity of chemotherapy (n=12, 7%). Microbiologically documented infections were reported in 82 patients (50%), including 12 fungal infections. Twenty-seven patients (16%) underwent urgent surgery. The hospital mortality rate was 35%. Five factors were independently associated with hospital mortality: the Simplified Acute Physiology Score II (SAPS II) score on day 1 (OR 1.03/SAPS II point, 95% CI 1.01 to 1.05), microbiological documentation (OR 0.27, 95% CI 0.11 to 0.64), neutropenia (OR 0.42, 95% CI 0.19 to 0.95), allogenic hematopoietic stem-cell transplantation (HSCT) (OR 5.13, 95% CI 1.71 to 15.4), and mechanical ventilation (OR 3.42, 95% CI 1.37 to 8.51). CONCLUSIONS: Gastrointestinal emergencies in cancer patients are associated with significant mortality. Mortality correlated both with the severity of organ failure upon ICU admission and the underlying diagnosis. Interestingly, patients admitted to the ICU with neutropenia had better survival.

The Impact of Splenectomy in Myelofibrosis Patients before Allogeneic Hematopoietic Stem Cell Transplantation.

Performing a pretransplantation splenectomy in patients with myelofibrosis (MF) is a matter of debate, as while the procedure improves hematological recovery, it may lead to severe morbidities. We retrospectively analyzed data from 85 consecutive patients who underwent transplantation in our center for MF, including 39 patients who underwent splenectomy before their transplantation. A majority of them had primary MF (78%), were considered high-risk patients (84% dynamic international prognostic scoring system intermediate-2 or higher), and had received transplants from HLA-matched sibling donors (56%) after a reduced-intensity conditioning regimen (82%). One-half of all splenectomized patients presented surgical or postsurgical morbidities, most frequently thrombosis and hemorrhage. After adjustment using Cox models, pretransplantation splenectomy was not associated with nonrelapse mortality or post-transplantation relapse but with an improved overall survival (OS) and event-free survival (EFS). We conclude that some patients with huge splenomegaly may undergo pretransplantation splenectomy without a deleterious impact on post-transplantation outcomes. OS and EFS improvement should in confirmed in controlled study.

Postoperative Complications after Ileocecal Resection in Crohn's Disease: A Prospective Study From the REMIND Group.

OBJECTIVES: We sought to determine the frequency of and risk factors for early (30-day) postoperative complications after ileocecal resection in a well-characterized, prospective cohort of Crohn's disease patients. METHODS: The REMIND group performed a nationwide study in 9 French university medical centers. Clinical-, biological-, surgical-, and treatment-related data on the 3 months before surgery were collected prospectively. Patients operated on between 1 September 2010 and 30 August 2014 were included. RESULTS: A total of 209 patients were included. The indication for ileocecal resection was stricturing disease in 109 (52%) cases, penetrating complications in 88 (42%), and medication-refractory inflammatory disease in 12 (6%). A two-stage procedure was performed in 33 (16%) patients. There were no postoperative deaths. Forty-three (21%) patients (23% of the patients with a one-stage procedure vs. 9% of those with a two-stage procedure, P=0.28) experienced a total of 54 early postoperative complications after a median time interval of 5 days (interquartile range, 4-12): intra-abdominal septic complications (n=38), extra-intestinal infections (n=10), and hemorrhage (n=6). Eighteen complications (33%) were severe (Dindo-Clavien III-IV). Reoperation was necessary in 14 (7%) patients, and secondary stomy was performed in 8 (4.5%). In a multivariate analysis, corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate (odds ratio (95% confidence interval)=2.69 (1.15-6.29); P=0.022). Neither preoperative exposure to anti-tumor necrosis factor (TNF) agents (n=93, 44%) nor trough serum anti-TNF levels were significant risk factors for postoperative complications. CONCLUSIONS: In this large, nationwide, prospective cohort, postoperative complications were observed after 21% of the ileocecal resections. Corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate. In contrast, preoperative anti-TNF therapy (regardless of the serum level or the time interval between last administration and surgery) was not associated with an elevated risk of postoperative complications.

The cervicosternolaparotomy approach for the treatment of graft dysfunction after retrosternal esophageal reconstruction for caustic injuries.

OBJECTIVE: The study purpose was to report the indications, technical aspects, and outcomes of cervicosternolaparotomy during revision surgery after esophageal reconstruction for caustic injuries. METHODS: Patients who underwent cervicosternolaparotomy during revision surgery for graft dysfunction between 1999 and 2015 were included. Cervicosternolaparotomy was performed to mobilize and pull up the primary conduit during surgery for strictures (rescue cervicosternolaparotomy) or to allow retrosternal access for management of other graft-related complications (exposure cervicosternolaparotomy). Statistical tests were performed to identify factors associated with primary conduit preservation during rescue cervicosternolaparotomy. RESULTS: Fifty-five patients were included (28 men; median age, 43 years). Median delay between primary reconstruction and cervicosternolaparotomy was 15 months. Exposure cervicosternolaparotomy was performed in 12 patients (22%) for redundancy (n = 8), spontaneous perforation (n = 2), and caustic reingestion (n = 2). Rescue cervicosternolaparotomy was performed in 43 patients (78%) to treat supra-anastomotic (n = 11), anastomotic (n = 23), and diffuse (n = 9) stenosis. During rescue cervicosternolaparotomy, the primary conduit was preserved in 32 patients; median length gain obtained by transplant release was 8 cm. Failure to preserve the primary conduit was associated with previous surgical repair attempts (P = .003) and lack of initial concomitant pharyngeal reconstruction (P = .039). Two patients died (4%), and 35 patients (64%) experienced operative complications. Operative outcomes were similar after rescue and exposure cervicosternolaparotomy. With a median follow-up of 4.4 years, the functional success rate was 85%. CONCLUSIONS: Cervicosternolaparotomy during revision surgery for graft dysfunction is reliable, is associated with low morbidity and mortality, and has good results.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.

BACKGROUND: Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries. METHODS: In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring. RESULTS: We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision. CONCLUSIONS: Emergency decision-making after caustic injuries can rely on CT alone.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent.

BACKGROUND: The mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown. METHODS: From January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51 %) and the median age was 44 years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59 %), strong acids in 36 patients (25 %), and bleach in 23 patients (16 %). Emergency and long-term outcomes were compared according to the nature of the ingested agent. RESULTS: Four patients died (3 %) and 40 patients (28 %) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13 %, p =0.042) and duodenal (9 vs. 0 %, p = 0.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12 %, p = 0.98). No significant differences were recorded between emergency mortality (9 vs. 1 %, p = 0.15), morbidity (33 vs. 33 %, p = 0.92), the need for esophageal reconstruction (25 vs. 20 %, p = 0.88), and functional success rates (76 vs. 84 %, p = 0.31) after acid and alkali ingestion, respectively. CONCLUSION: Bleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

Esophageal reconstruction by colon interposition after esophagectomy for cancer analysis of current indications, operative outcomes, and long-term survival.

INTRODUCTION: Colon interposition is an alternative solution for esophageal reconstruction if the stomach cannot be used. The study reviews current indications and results of coloplasty for cancer. METHODS: Patients who underwent colon interposition for gastro-esophageal malignancy were included. Primary coloplasty was defined as upfront colon interposition. Salvage coloplasty was defined as colon interposition after primary reconstruction failure. Mortality, morbidity, function, and survival were evaluated. RESULTS: We included 28 patients (24 men, median age 61 years). Ten (36%) patients underwent primary coloplasty due to previous gastrectomy (n = 5), conduit gastric cancer (n = 2), extensive gastroesophageal involvement (n = 2), and gastric cancer recurrence (n = 1). Salvage coloplasty was performed in 18 (64%) patients for postoperative graft necrosis (n = 5) and intractable strictures (n = 3). Operative mortality, morbidity, and graft necrosis rates were 14% (4/28), 86% (24/28), and 14% (4/28), respectively; there were no significant differences between primary and salvage coloplasty. Survival rates at 1-, 3-, and 5 years were 81%, 51%, and 38%, respectively. Survival was decreased after primary coloplasty when compared to salvage coloplasty (P = 0.03). Nine patients experienced tumor recurrence (primary: n = 6, salvage: n = 3) after coloplasty and eight of them died. CONCLUSION: Colon interposition after esophagectomy is a useful but morbid endeavor. Colon interposition as salvage therapy is associated with improved survival compared to its use as primary esophageal replacement, and colon interposition in the latter cohort should be used with caution due to poor cancer-specific survival in this patient population.

Salvage high-dose-rate brachytherapy for esophageal cancer in previously irradiated patients: A retrospective analysis.

PURPOSE: To evaluate outcomes after exclusive salvage high-dose-rate (HDR) intraluminal esophageal brachytherapy given to previously irradiated patients with recurrent esophageal cancer. METHODS AND MATERIALS: We reviewed medical records of 30 patients who were treated by salvage HDR brachytherapy for local esophageal cancer. Brachytherapy delivered four to six fractions of 5-7 Gy at 5 mm from the applicator surface and 20 mm above and below the macroscopic tumor volume. RESULTS: Eighty percentage of patients received treatment as initially planned. Complete response rate, evaluated 1 month after brachytherapy by endoscopy and biopsy, was 53%. Squamous histology and complete endoscopic tumor response at 1 month were significantly associated with better local tumor control. Median local progression-free survival was 9.8 months. Overall survival was 31.5% and 17.5% at 1 and 2 years, respectively. On univariate analysis, preserved performance status and limited weight loss (<10%) before salvage brachytherapy were associated with better overall survival. Severe toxicity (Grade ≥3) occurred in 7 patients (23%). CONCLUSIONS: Although esophageal cancer in previously irradiated patients is associated with poor outcomes, HDR brachytherapy may be a valuable salvage treatment for inoperable patients with locally limited esophageal cancer, particularly in the subset of patients with preserved performance status and limited weight loss (≤10%) before salvage brachytherapy.

Upper digestive tract reconstruction for caustic injuries.

OBJECTIVE: The aim of the study was to compare the short- and long-term outcomes of colopharyngoplasty and esophagocoloplasty for caustic injuries of the upper digestive tract. BACKGROUND: Simultaneous esophageal and pharyngeal reconstruction by colopharyngoplasty allows regaining nutritional autonomy in patients with severe pharyngoesophageal caustic injuries. METHODS: Patients who underwent upper digestive tract reconstruction for caustic injuries by colopharyngoplasty (n = 116) and esophagocoloplasty (n = 122) between 1993 and 2012 were included. Survival and functional outcomes were analyzed. Success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Quality of life was assessed using the QLQ-OG25 and SF12v2 questionnaires. RESULTS: Overall Kaplan-Meyer survival at 1, 5, and 10 years after colopharyngoplasty and esophagocoloplasty were 92%, 74%, 67% and 92%, 83%, 73%, respectively (P = 0.56). Quality of life and functional results (success: 57% vs 95%, P < 0.0001) were impaired after colopharyngoplasty. On multivariate analysis, older age (odds ratio [OR]: 0.94; confidence interval [CI]: 0.91-0.97 P < 0.0001) and pharyngeal reconstruction (OR: 0.05; CI: 0.02-0.13, P < 0.0001) were associated with failure. The decline in success with age was more pronounced after colopharyngoplasty with only 1 (7%) of 15 patients operated after the age of 55 being self-sufficient for eating and breathing. Laryngeal resection during colopharyngoplasty had no influence on success (54% vs 58%, P = 0.67) CONCLUSIONS:: The need to associate pharyngeal reconstruction during esophageal reconstruction for caustic injuries has a long-term negative impact on functional outcome.

Laparoscopic partial splenectomy: a technical tip.

BACKGROUND: Increased awareness of asplenia-related life-threatening complications has led to development of parenchyma sparing splenic resections. The aim of the study was to report a new technique of laparoscopic partial splenectomy, which helps minimize perioperative bleeding risks. METHODS: From November 2004 to October 2012, 12 patients underwent partial laparoscopic resection of the spleen. There were six men (50 %), and median age was 30 years (19-62). Transection of the splenic parenchyma was performed along a line situated 1 cm within the ischemic demarcation, which appeared after ligation of the sectorial vascular pedicles feeding the tumor. Antibiotic prophylaxis and preventive antibacterial immunization were prescribed systematically according to generally accepted guidelines. RESULTS: Mortality was nil, and operative complications occurred in 2 (17 %) patients. Conversion to open partial splenectomy and to laparoscopic total splenectomy was performed in one patient (8.3 %) each. Median operative time was 120 min (range 80-180 min). Median blood loss was 90 ml (range 10-450 ml), and transfusion was not required. Median tumor size was 7 cm (4-12 cm). The median in hospital stay was 5 days (4-7 days). Patients did not comply with long-term (>2 years) immunization and antibioprophylaxis rules. After a median follow-up of 5 years (18 months-9 years), no case of overwhelming post-splenectomy infections occurred. CONCLUSION: Laparoscopic partial splenectomy can be safely performed in patients with splenic tumors. Parenchyma transection 1 cm inside the ischemic demarcation line is a key technical point to minimize blood loss.

Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy.

BACKGROUND: Esophagectomy is the standard of care for high-grade corrosive esophageal necrosis as assessed endoscopically. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to unnecessary esophageal resection, with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of endoscopic high-grade corrosive esophageal necrosis. METHODS: In a before (2000-2007)/after (2007-2012) study of patients with grade 3b endoscopic esophageal necrosis, we compared outcomes after routine emergency esophagectomy versus selection for emergency esophagectomy based on CT evidence of transmural necrosis, defined as at least two of the following: esophageal-wall blurring, periesophageal-fat blurring, and the absence of esophageal-wall enhancement. Survival estimated using the Kaplan-Meier method was the primary outcome. RESULTS: Compared to the routine-esophagectomy group (n = 125), the CT group (n = 72) had better overall survival in the crude analysis (hazard ratio [HR], 0.43; 95 % confidence interval [95 %CI], 0.21-0.85; P = 0.015) and in the analysis matched on gender, age, and ingested agent (HR, 0.36; 95 %CI, 0.16-0.79; P = 0.011). No deaths occurred among patients managed without emergency esophagectomy based on CT findings, and one-third of CT-group patients had their functioning native esophagus at last follow-up. Self-sufficiency for eating and breathing was more common (84 % vs. 65 %; relative risk [RR], 1.27; 95 %CI, 1.04-1.55; P = 0.016) and repeat suicide less common (4 % vs. 15 %; RR, 0.27; 95 %CI, 0.09-0.82; P = 0.019) in the CT group. CONCLUSION: The decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.

Endoscopic and clinical recurrences after laparoscopic or open ileocolic resection in Crohn's disease.

BACKGROUND: After ileocolic resection in Crohn's disease, studies concerning the influence of the laparoscopic or open approach on clinical and endoscopic recurrences are scarce. PATIENTS AND METHODS: In a prospective database, we identified all patients operated on between 2004 and 2012 for primary ileocolic resection in Crohn's disease, with at least 6 months of follow-up. The rates of endoscopic recurrence during the first postoperative year and the clinical recurrence at any time during follow-up were measured and compared after the laparoscopic or open approach. RESULTS: Sixty-two patients (mean±standard deviation age, 33.5±12.7 years; 35 females) were operated on through laparoscopy (n=28) or laparotomy (n=34). Medical treatment, evolution and phenotype of disease, and postoperative course were comparable in both groups. Mean±standard deviation follow-up was 3.5±1.9 years. Ileocolonoscopy was available in 46 (74.2%) patients. Normal endoscopy or minor recurrence (i0 or i1 grade) was significantly more frequent after laparoscopy (14/24 [58.3%]) versus laparotomy (5/22 [22.7%]) (P=.019). Clinical recurrence was comparable at 1 year (P=.116) and at the end of follow-up (P=.799) after laparoscopy (28.6% and 50%, respectively) or laparotomy (11.8% and 55.9%, respectively). CONCLUSIONS: After resection, normal or minor endoscopic lesions (i0 or i1 grade) were more frequent after laparoscopy than after laparotomy. However, clinical recurrence was similar after both techniques.

Tailored treatment according to early post-surgery colonoscopy reduces clinical recurrence in Crohn's disease: a retrospective study.

BACKGROUND: After intestinal resection for Crohn's disease, the severity of endoscopic recurrence in the first year following surgery is predictive of clinical outcome. Aim of the study was to assess the impact on clinical recurrence of tailored therapy based on endoscopic findings in the first year following surgery for Crohn's disease. METHODS: All patients who underwent an intestinal resection for Crohn's disease between 1995 and 2005 at Saint-Louis Hospital were retrospectively included. Time-to-clinical recurrence was compared in two groups: patients who had systematic ileocolonoscopy 6-12 months after intestinal surgery with tailored treatment according to the severity of endoscopic lesions (group C) and patients without systematic endoscopic evaluation (group NC). RESULTS: 132 patients (group C=90, group NC=42) were included. Probabilities of clinical recurrence were significantly lower in group C (21% and 26% at 3 and 5 years, respectively) compared with group NC (31% and 52% at 3 and 5 years respectively, p=0.01). CONCLUSION: Tailored treatment according to endoscopic assessment after ileocolonic resection is significantly associated with reduced clinical recurrence rate.

Long-term follow-up analysis of 100 patients with splenic marginal zone lymphoma treated with splenectomy as first-line treatment.

Splenectomy is considered as one of the first-line treatments for symptomatic patients with splenic marginal zone lymphoma (SMZL). Between 1997 and 2012, 100 hepatitis C virus-negative patients with SMZL were treated by splenectomy as first-line treatment. At 6 months, all patients but three recovered from all cytopenias. The median lymphocyte count at 6 months and 1 year was 11.51 × 10(9)/L and 6.9 × 10(9)/L, respectively. Median progression-free survival (PFS) was 8.25 years. The 5-year and 10-year overall survival (OS) rates were 84% and 67%, respectively. Histological transformation occurred in 11% of patients, and was the only parameter significantly associated with a shorter time to progression (p = 0.0001). Significant prognostic factors for OS were age (p = 0.0356) and histological transformation (p = 0.0312). In this large retrospective cohort, we confirmed that splenectomy as first-line treatment in patients with SMZL corrected cytopenias and lymphocytosis within the first year and was associated with a good PFS.