Rectovaginal Fistula: What is the Role of Martius Flap and Gracilis Muscle Interposition in the Therapeutic Strategy?

BACKGROUND: While numerous treatments exist for management of rectovaginal fistula, none has demonstrated its superiority. The role of diverting stoma remains controversial. Few series include Martius flap in the armamentarium. OBJECTIVE: Determine the role of gracilis muscle interposition and Martius flap in the surgical management of rectovaginal fistula. DESIGN: Retrospective cohort study of a pooled prospectively maintained database from 3 centers. SETTINGS/PATIENTS: All consecutive eligible patients with rectovaginal fistula undergoing Martius flap and gracilis muscle interposition were included from 2001 to 2022. MAIN OUTCOMES: Success was defined by absence of stoma and rectovaginal fistula. RESULTS: Sixty-two patients were included with 55 Martius flap and 24 gracilis muscle interposition performed after failures of 164 initial procedures. Total length of stay was longer for gracilis muscle interposition by 2 days (p = 0.01) without a significant difference in severe morbidity (20% vs. 12%, p = 0.53). 27% of Martius flap were performed without stoma, without impact on overall morbidity (p = 0.763). Per-patient immediate success rates were not significantly different between groups (35% vs. 31%, p = 1.0). Success of gracilis muscle interposition after failure of Martius flap was not significantly different from an initial gracilis muscle interposition (p = 1.0). The immediate success rate rose to 49.4% (49% vs. 50%, p = 1.0) after simple perineal procedures. After a median follow-up of 23 months, there was no significant difference detected in success rate between the two procedures (69% vs. 69%, p = 1.0). Smoking was the only negative predictive factor (p = 0.02). LIMITATIONS: By its retrospective nature, this study is limited in its comparison. CONCLUSION: This novel comparison between Martius flap and gracilis muscle interposition suggests that Martius flap presents several advantages, including shorter length of stay, similar morbidity, and success. Proximal diversion via a stoma for Martius flap does not appear mandatory. Gracilis muscle interposition could be reserved as a salvage procedure after Martius flap failure. See Video Abstract.

Ambulatory appendectomy for acute appendicitis: Can we treat all the patients? A prospective study of 451 consecutive ambulatory appendectomies out of nearly 2,000 procedures.

BACKGROUND: Acute appendicitis represents the leading cause of acute gastrointestinal disorders, but only a small series regarding ambulatory appendectomies are available. The aim of this study was to report the results of ambulatory (day-case) appendectomy for acute appendicitis in a large consecutive cohort and to improve selection criteria in order to extend the indications. METHODS: All appendectomy procedures for acute appendicitis (March 2013 to June 2020) were included retrospectively. Criteria to select patients eligible for ambulatory appendectomy were based on our clinico-radiological St-Antoine's score ≥4. RESULTS: In total, 1,730 consecutive patients had an appendectomy for acute appendicitis: 1,279 (74%) in conventional settings and 451 (26%) in ambulatory settings. In the conventional group, 360 (28%) patients had surgery deferred to the next morning, whereas in the ambulatory group, 309 patients (70%) were readmitted the next morning (P < .0001). In the ambulatory group, 376 (83%) patients satisfied the criteria (score ≥4), and 90.9% were discharged on postoperative day 0. Rates of unplanned consultation and readmission were not significantly different (5.1% vs 6.6% P = .243). Multivariate analysis of the entire cohort confirmed absence of radiological perforation as highly predictive of early discharge (odds ratio = 6.073). In our cohort, these patients had an early discharge rate of 86.4% compared to 90.2% in those with a St-Antoine's score ≥4. Considering only radiological evidence of perforation as a selection criterion for ambulatory appendectomy, 581 more patients would be eligible for ambulatory surgery (+60%). CONCLUSION: Ambulatory surgery for acute appendicitis based on St-Antoine's score is safe. We propose to extend the indication for ambulatory management to all patients without radiological evidence of perforation.

Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis.

PURPOSE: The present study assessed the factors associated with the maintenance of a functional anastomosis in a large consecutive series of patients with anastomotic leakage (AL). METHODS: All consecutive patients presenting with AL after colorectal or coloanal anastomosis (2012-2019) were analyzed. The primary end point was a functional anastomosis without a stoma at 1 year. RESULTS: A total of 156 patients were included. AL was initially treated by antibiotics (38%), drainage (43%) or urgent surgery (19%). Initial treatment of AL was not adequate in 24.3%, and reintervention in the form of drainage or surgery was required. A total of 60.9% of patients had a functional anastomosis without a stoma 1 year after surgery. Factors associated with the risk of anastomotic failure at 1 year were diabetes (odds ratio [OR] = 4.24 [95% confidence interval {CI} 1.39-14.24] p = 0.014), neoadjuvant chemoradiotherapy (OR = 3.03 [95% CI 1.14-8.63] p = 0.03) and Grade B (OR = 6.49 [95% CI 2.23-21.74] p = 0.001) or C leak (OR = 35.35 [95% CI 9.36-168.21] p < 0.001). Among patients treated initially by drainage, side-to-end or J-pouch anastomoses were significantly associated with revision of the anastomosis compared to end-to-end (OR = 12.90, p = 0.04). CONCLUSION: After acute AL following coloanal or colorectal anastomosis, 60.9% of patients had a functional anastomosis without a stoma at the 1 year of follow-up. The type of treatment of AL influenced the risk of anastomotic failure.

Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients.

OBJECTIVE: Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis. BACKGROUND: Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach. METHODS: All women (age: 12-45 y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis. RESULTS: A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001). CONCLUSIONS: In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.

Surgery for synchronous and metachronous colorectal cancer: segmental or extensive colectomy?

PURPOSE: To assess the impact of surgical approach on morbidity, mortality, and the oncological outcomes of synchronous (SC) and metachronous (MC) colorectal cancer (CRC). METHODS: All patients undergoing resection for double location CRC (SC or MC) between 2006 and 2020 were included. The exclusion criteria were polyposis or SC located on the same side. RESULTS: Sixty-seven patients (age, 64.8 years; male, 78%) with SC (n = 41; 61%) or MC (n = 26; 39%) were included. SC was treated with segmental colectomy (right and left colectomy/proctectomy; n = 19) or extensive colectomy (subtotal/total colectomy or restorative proctocolectomy with pouch; n = 22). Segmental colectomy was associated with a higher incidence of anastomotic leakage (47.4 vs. 13.6%; p = 0.04) and a higher rate of medical morbidity (47.4 vs. 16.6%; p = 0.04). The mean number of lymph nodes harvested was similar. For MC, the second cancer was treated by iterative colectomy (n = 12) or extensive colectomy (n = 14) and there was no significant difference in postoperative outcomes between the two surgical approaches. The median follow-up period was 42.4 ± 29.1 months. The 5-year overall and disease-free survival of the SC and MC groups did not differ to a statistically significant extent. CONCLUSIONS: Extensive colectomy should be preferred for SC to reduce morbidity and improve the prognosis. In contrast, iterative colectomy can be performed safely for patients with MC.

C-reactive protein values after surgery for inflammatory bowel disease: is it still a good marker for intra-abdominal complication? A retrospective cohort study of 347 procedures : CRP after inflammatory bowel disease surgery.

PURPOSE: C-reactive protein (CRP) is a useful predictive test to early detect abdominal complication after colorectal surgery. Inflammatory bowel disease (IBD) is responsible for chronic inflammation and abnormal basal CRP that could influence the interest of its management after abdominal surgery. The aim of this study is to evaluate CRP as an indicator of postoperative complication in a specific IBD population. METHODS: Retrospective study of patients undergoing ileocolic resection or ileal pouch-anal anastomosis for IBD between 2012 and 2019. RESULTS: Ileocolic resection represents 242 patients and ileal pouch-anal anastomosis 105 patients. CRP was significantly higher at an early (105.2 ± 56.0 vs 128.1 ± 69.8; p = 0.008) and late stage (112.9 ± 72.8 vs 185.3 ± 111.5; p < 0.0001) for patients having an intra-abdominal complication. A BMI > 25 kg/m2 (p = 0.04) and an open surgical approach (p = 0.009) were associated with higher CRP levels in the first postoperative days (POD). In multivariate analysis, preoperative steroid use (p = 0.06), CRP at POD 3 > 100 mg/L (p = 0.003), and a rise between CRP values (p = 0.007) at 48 h were significantly associated with intra-abdominal complication. A CRP at POD 1 < 75 mg/L was associated with a lower rate of intra-abdominal complication (p = 0.01). A score dividing patients into 3 groups according to these values showed significant differences in intra-abdominal complication and anastomotic leakage rates. CONCLUSION: CRP is a useful predictive marker to detect abdominal complication after surgery in IBD population. Measurement of CRP can help to reduce hospitalization stay and orientate towards complementary examinations.

Redo-surgery after failed colorectal or coloanal anastomosis: Morbidity, mortality and factors predictive of success. A retrospective study of 200 patients.

AIM: In cases of anastomotic failure after colorectal (CRA) or coloanal anastomosis (CAA), revision of the anastomosis is an ambitious surgical option that can be proposed in order to maintain bowel continuity. Our aim was to assess postoperative morbidity, risk of failure and risk factor for failure in patients after CRA or CAA. METHODS: All consecutive patients who underwent redo-CRA/CAA in our institution between 2007-2018 were retrospectively included. The success of redo-CRA/CAA was defined by the restoration of bowel continuity 12 months after the surgery. RESULTS: Two hundred patients (114 male: 57%) were analyzed. The indication for redo-CRA/CAA was chronic pelvic infection in 74 patients (37%), recto-vaginal or urinary fistula in 59 patients (30%), anastomotic stenosis in 36 patients (18%) and redo anastomosis after previous anastomosis takedown in 31 patients (15%). Twenty-three percent of the patients developed a severe postoperative complication. Anastomotic leakage was diagnosed in 39 patients (20%). One-year-success of the redo-CRA/CAA was obtained in 80% of patients. In multivariate analysis, only obesity was associated with redo-CRA/CAA failure (p = 0.042). We elaborated a pre-operative predictive score of success using the four variables: male sex, age > 60 years, obesity and history of pelvic radiotherapy. The success of redo-CRA/CAA was 92%, 86%, 80% and 62% for a preoperative predictive score value of 0, 1, 2 and ≥3, respectively (p = 0.010). CONCLUSIONS: In case of failure of primary CRA/CAA, bowel continuity can be saved in 4 out of 5 patients by redo-CRA/CAA despite 23% suffering severe postoperative morbidity.

Tumor downstaging after neoadjuvant chemotherapy determines survival after surgery for gastric adenocarcinoma.

BACKGROUND: Since 2006, surgery combined with perioperative chemotherapy is the standard of care for resectable gastric adenocarcinoma in Europe. Specific effects of neoadjuvant chemotherapy remain unknown. The aim was to evaluate the rate of tumor downstaging and its impact on survival in patients undergoing curative resection after neoadjuvant chemotherapy (NeoCT) for gastric adenocarcinoma. MATERIAL AND METHODS: All patients treated in a curative intent for gastric or esophagogastric junction adenocarcinomas between 1996 and 2016 in our high-volume center were retrospectively included. Tumor downstaging after NeoCT was defined as ypTN inferior to cTN. The accuracy of clinical staging was evaluated in patients treated by upfront surgery before 2006. RESULTS: During the study period, 491 patients were operated for gastric adenocarcinoma, and 449 patients were finally analyzed. Among the 163 (36.3%) patients who received NeoCT, 61 (37.4%) had tumor downstaging. Overall survival and disease-free survival were longer in patients with tumor downstaging compared to patients without it (5-year survival: 84.8% vs 49.7%; P = .002 and 61.7% vs 43.4%; P = .054). In multivariate analysis tumor downstaging was an independent prognosis factor for better overall survival (HR = 5.258; P = .002) and disease-free survival (HR = 2.286; P = .028). Moreover, 45.5% of patients staged cT1-T2N0, in whom upfront surgery was performed, were understaged and ultimately had a more advanced tumor on pathological analysis. CONCLUSION: Response to neoadjuvant chemotherapy constitutes a major prognostic factor for overall and disease-free survival. In the absence of predictive factors for tumor downstaging, the indication for perioperative chemotherapy should remain broad, in particular because of the low accuracy of pretherapeutic staging and therefore the high risk of understaging tumors.

Functional outcomes of patients undergoing successful redo surgery after failed primary colorectal or coloanal anastomosis for rectal cancer.

BACKGROUND: After a failure of a colorectal or coloanal anastomosis, redo anastomotic surgery aims to avoid the risk of permanent stoma but, overall, to provide a satisfactory functional result and quality of life. Very limited data exist regarding the long-term results after a successful redo anastomosis. The present study aimed to report the long-term functional outcomes and quality of life in patients after a successful redo colorectal anastomosis or coloanal anastomosis. METHODS: Between 2007 and 2018, all patients who had a successful restoration of bowel continuity after a failed primary anastomosis performed for a rectal cancer were included. Functional outcomes and quality of life were assessed using the low anterior rectal syndrome score and the Gastrointestinal Quality of Life Index. RESULTS: One hundred and twenty-seven patients were eligible for inclusion in this study, with long-term functional outcomes assessed in 73 patients (57%). After a median follow-up of 69 months, 31 patients presented no or minor low anterior rectal syndrome (42%), whereas 31 patients reported a major low anterior rectal syndrome (42%). A definitive stoma was confectioned in 11 patients (15%), despite the technical success of redo anastomosis due to poor functional results. Only operative interval <36 months was associated with a poor functional outcome (P = .001), whereas all other factors such as pelvic radiotherapy were not (P = .848). An absence of major low anterior rectal syndrome was the only factor associated with improved quality of life (P = .001). CONCLUSION: After successful redo colorectal anastomosis or coloanal anastomosis, good functional outcomes can be achieved in almost half of patients with a well-preserved quality of life but requires a prolonged postoperative period of rehabilitation.

Postoperative diagnostic revision for Crohn disease after subtotal colectomy for inflammatory bowel disease.

PURPOSE: Subtotal colectomy (STC) is performed for severe acute and refractory colitis. The diagnosis can be difficult even after the surgery when colectomy specimen has overlapping features of ulcerative colitis (UC) and Crohn's disease (CD). The aim of this study was to evaluate the rate of postoperative diagnostic revision to CD after surgery and determine predictor factors. METHODS: Retrospective study of 110 patients who underwent STC (2005-2018). RESULTS: Preoperative diagnosis comprised UC = 80 (73%), CD = 11 (10%), and unclassified colitis (IBDU = 19, 17%). Initial diagnosis of IBDU and UC was modified to CD in 6 patients (6%) after STC. The final diagnosis after the follow-up of 10 ± 6 years switched from CD for 8 patients (9%). The multivariate analysis showed that patients with a colitis evolving for less than 10 years and initial diagnosis of IBDU were the two independent factors associated with an increased risk of diagnosis change to CD (p = 0.03; p = 0.016). At the end of the follow-up, 15 patients (14%) had a definitive stoma. CONCLUSIONS: In patients with IBD, attention must be paid to determine the right restorative strategy to patients with an evolution of the disease less than 10 years or with IBDU who are more at risk to have a diagnosis change to CD after STC.

Prognostic value of tumor deposits in rectal cancer: A monocentric series of 505 patients.

BACKGROUND AND OBJECTIVES: It has been suggested that tumor deposits (TDs) may have a worse prognosis in rectal cancer compared with colonic cancer. The aim of this study was to assess TDs prognosis in rectal cancer. METHODS: Patients who underwent total mesorectum excision for rectal adenocarcinoma (2011-2016) were included. A case-matched analysis was performed to assess the accurate impact of TDs for each pN category after exclusion of synchronous metastasis. RESULTS: A total of 505 patients were included. TDs were observed in 99 (19.6%) patients, (pN1c = 37 [7.3%]). TDs were associated with pT3-T4 stage (P = .037), synchronous metastasis (P = .003), lymph node (LN) invasion (P = .041), vascular invasion (P = .001), and perineural invasion (P < .001). TD was associated with a worse 3-year disease-free survival (DFS) among pN0 (51.2% vs 79.8%; P < .001); pN1 patients (35.2% vs 70.1%; P = .004) but not among pN2 patients (37.5% vs 44.7%; P = .499). After matching, pN1c patients had a worse 3-year DFS compared with pN0 patients (58.6% vs 82.4%; P = .035) and a tendency toward a worse DFS among N1 patients (40.1% vs 64.2%; P = .153). DFS was worse when one TD was compared with one invaded LN (40.8% vs 81.3%; P < .001). CONCLUSION: In rectal cancer, TDs have a metastatic risk comparable to a pN2 stage which may lead to changes in adjuvant treatment.

Is ileostomy mandatory for ileal pouch-anal anastomosis? A propensity matched analysis of 388 procedures.

BACKGROUND: Restorative proctocolectomy with ileal-pouch-anal anastomosis is the standard treatment for patients with ulcerative colitis or familial adenomatous polyposis. This procedure has undergone many changes and varies in 1, 2, or 3 stages. A diverting ileostomy can be created with the aim of reducing the consequence of an anastomotic leakage; however, its use is still unknown. METHOD: The value of defunctioning ileostomy was studied in a population of 388 patients undergoing restorative proctocolectomy with ileal-pouch-anal anastomosis between 2005 and 2017. Leakage rate and postoperative morbidity were assessed. Patients were matched on a propensity score using the following criteria: American Society of Anesthesiologists score, body mass index, diagnosis, surgical approach, and year. RESULTS: Two hundred and three ileal-pouch-anal anastomosis for ulcerative colitis and 185 for familial adenomatous polyposis were performed representing 165 1-stage (61.6%), 79 classic 2-stage, 74 modified 2-stage, and 70 3-stage procedures. Regardless of the surgical strategy adopted, there were no significant differences in postoperative morbidity (P = .416), leakage rate (P = .369), and reoperation (P = .237), whether a diverting ileostomy was performed or not. After propensity score matching, there was no significant difference in postoperative morbidity (P = .363), leakage rate (P = .247), or reoperation (P = .243). The rate of persistent ileostomy at 1 year was higher in cases of classic 2-stage or 3-stage procedures (P = .036). CONCLUSION: After propensity score matching, defunctioning ileostomy for ileal-pouch-anal anastomosis does not reduce leakage rate or postoperative morbidity, independent of the surgical strategy. Systematic ileostomy for ileal-pouch-anal anastomosis is probably not justified, and its place should be redefined in a randomized trial.

Can a Local Drainage Salvage a Failed Colorectal or Coloanal Anastomosis? A Prospective Cohort of 54 Patients.

BACKGROUND: Local drainages can be used to manage leakage in select patients without peritonitis. OBJECTIVE: The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anastomosis after anastomotic leakage. DESIGN: A retrospective observational study was performed on a prospectively maintained database. SETTINGS: The study was performed between 2014 and 2017 in a tertiary referral center. PATIENTS: Patients undergoing rectal resections with either a colorectal or coloanal anastomosis with diverting stoma were identified. Anastomotic leakages requiring a radiological or transanal drainage without peritonitis were included. MAIN OUTCOME MEASURES: The primary outcome was the maintenance of the primary anastomosis after local drainage of an anastomotic leakage and stoma reversal. RESULTS: A low anastomosis for rectal cancer with diverting stoma was performed in 326 patients. A total of 77 anastomotic leakages (24%) occurred, of which, 6 (8%) required abdominal surgery, 17 (22%) were treated conservatively (medical management), and 54 (70%) were managed by drainage. Surgical transanal drainage was performed in 21 patients (39%), with radiologic drainage procedures performed in 33 patients (61%). The median interval between surgery and drainage was 13 days (range, 9-21 d). Five patients (9%) required emergency abdominal surgery. Twenty-seven patients (50%) did not require any additional intervention after drainage procedure, whereas 21 patients (39%) underwent redo anastomotic surgery. Forty-three patients (80%) had no stoma at the end of follow-up. Failure to maintain the primary anastomosis after local drainage was associated with increased age (p = 0.04), a pelvic per-operative drainage (p = 0.05), a drainage duration >10 days (p = 0.002), the time between surgery and drainage >15 days (p = 0.03), a side-to-end or J-pouch anastomosis (p = 0.04), and surgical transanal drainage (p = 0.03). LIMITATIONS: The small sample size of the study was the main limitation. CONCLUSIONS: Local drainage procedures maintained primary anastomosis in 50% of cases after an anastomotic leakage. See Video Abstract at http://links.lww.com/DCR/B57. ¿PUEDE UN DRENAJE LOCAL SALVAR UNA ANASTOMOSIS COLORRECTAL O COLOANAL FALLIDA? UNA COHORTE PROSPECTIVO DE 54 PACIENTES: Los drenajes locales se pueden utilizar para controlar las fugas en pacientes seleccionados sin peritonitis.El objetivo de este estudio fue evaluar la eficacia de los procedimientos de drenaje, para mantener una anastomosis primaria baja, después de una fuga anastomótica.Se realizó un estudio observacional retrospectivo en una base de datos mantenida prospectivamente.El estudio se realizó entre 2014-2017, en un centro de referencia terciaria.Se identificaron pacientes sometidos a resecciones rectales con anastomosis colorrectal o coloanal y estoma de derivación. Se incluyeron fugas anastomóticas sin peritonitis, que requirieron drenaje radiológico o transanal.El resultado primario fue el mantenimiento de la anastomosis primaria, después del drenaje local de una fuga anastomótica y la reversión del estoma.Se realizó una anastomosis baja para cáncer rectal con estoma derivativo en 326 pacientes. Se produjeron 77 (24%) fugas anastomóticas, de las cuales 6 (8%) requirieron cirugía abdominal, 17 (22%) fueron tratadas de forma conservadora (tratamiento médico) y 54 (70%) fueron manejadas por drenaje. Se realizó drenaje transanal en 21 pacientes (39%) y procedimientos de drenaje radiológico en 33 pacientes (61%). La mediana del intervalo entre la cirugía y el drenaje fue de 13 días [9-21]. 5 (9%) pacientes requirieron cirugía abdominal de emergencia. Veintisiete (50%) pacientes no requirieron ninguna intervención adicional después del procedimiento de drenaje, mientras que 21 pacientes (39%) se sometieron a una reparación quirúrgica anastomótica. 43 pacientes (80%) no tuvieron estoma al final del seguimiento. El fracaso para mantener la anastomosis primaria después del drenaje local, se asoció con un aumento de la edad (p = 0.04), un drenaje pélvico preoperatorio (p = 0.05), una duración del drenaje >10 días (p = 0.002), el tiempo entre la cirugía y el drenaje >15 días (p = 0.03), anastomosis termino lateral o bolsa en J (p = 0.04) y drenaje quirúrgico transanal (p = 0.03).El pequeño tamaño de la muestra del estudio fue la principal limitación.Después de la fuga anastomótica, los procedimientos del drenaje local conservaron la anastomosis primaria en el 50% de los casos. Vea el Resumen del Video en http://links.lww.com/DCR/B57.

What is the functional result of a delayed coloanal anastomosis in redo rectal surgery?

BACKGROUND: Delayed coloanal anastomosis (DCAA) may be used in patients with complex rectal conditions, such as chronic pelvic sepsis, low recto-vaginal and recto-vesical fistula; however, limited data are available. The aim is to report the morbidity and functional results of DCAA in redo rectal surgery. METHODS: All patients undergoing DCAA between January 2014 and August 2017 were retrospectively included. Success was defined as a functional anastomosis without stoma, evaluated using the Low Anterior Resection Syndrome (LARS) score and the Gastrointestinal Quality of Life Index (GIQLI) functional assessment tools. RESULTS: Of the 72 redo pelvic surgeries, 29 (40.3%) DCAA were performed over a 4-year period. Indications for redo resection were chronic pelvic sepsis (n = 13, 44.8%), recto-vaginal fistula (n = 11, 37.9%) and recto-vesical fistula (n = 5, 17.2%). Mean interval period between the two procedures was 14 ± 3 days (8-21). Global major morbidity (Clavien-Dindo III or IV) was seen in six patients (20.7%). Stoma closure was feasible for 22 (75.9%) patients after a median period of 78 days (interquartile range 61-98). The 6-month success rate was 79.3%. Mean LARS was 28.8 ± 10.2 (3-41) (minor LARS) for 18 patients with no stoma at the end of follow-up. LARS score was significantly better with a follow-up >2 years (23.3 ± 12.2 versus 32.3 ± 7.9), P = 0.074. Mean GIQLI score was 79.2 ± 14.3 (48-98). CONCLUSIONS: Transanal colonic pull through with delayed anastomosis for redo-surgery in complex pelvic situations had low morbidity and avoided a permanent stoma in three out of four patients with an acceptable quality of life.

Can we classify ampullary tumours better? Clinical, pathological and molecular features. Results of an AGEO study.

BACKGROUND: Ampullary adenocarcinoma (AA) originates from either intestinal (INT) or pancreaticobiliary (PB) epithelium. Different prognostic factors of recurrence have been identified in previous studies. METHODS: In 91 AA patients of the AGEO retrospective multicentre cohort, we evaluated the centrally reviewed morphological classification, panel markers of Ang et al. including CK7, CK20, MUC1, MUC2 and CDX2, the 50-gene panel mutational analysis, and the clinicopathological AGEO prognostic score. RESULTS: Forty-three (47%) of the 91 tumours were Ang-INT, 29 (32%) were Ang-PB, 18 (20%) were ambiguous (Ang-AMB) and one could not be classified. Among these 90 tumours, 68.7% of INT tumours were Ang-INT and 78.2% of PB tumours were Ang-PB. MUC5AC expression was detected in 32.5% of the 86 evaluable cases. Among 71 tumours, KRAS, TP53, APC and PIK3CA were the most frequently mutated genes. The KRAS mutation was significantly more frequent in the PB subtype. In multivariate analysis, only AGEO prognostic score and tumour subtype were associated with relapse-free survival. Only AGEO prognostic score was associated with overall survival. CONCLUSIONS: Mutational analysis and MUC5AC expression provide no additional value in the prognostic evaluation of AA patients. Ang et al. classification and the AGEO prognostic score were confirmed as a strong prognosticator for disease recurrence.

C-Reactive Protein Values After Colorectal Resection: Can We Discharge a Patient With a C-Reactive Protein Value >100? A Retrospective Cohort Study.

BACKGROUND: C-reactive protein is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery. Evolution of procedures (laparoscopy, enhanced recovery program, early discharge, complex redo surgery) may influence C-reactive protein values; however, this is poorly studied to date. OBJECTIVE: The aim of this study is to evaluate C-reactive protein as an indicator of postoperative complication and as a predictor for discharge. DESIGN: This is retrospective study of a consecutive monocentric cohort. SETTINGS: All patients undergoing a colorectal resection with anastomosis (2014-2015) were included. MAIN OUTCOMES MEASURES: C-reactive protein, leukocytosis, type of resection, and postoperative course were the primary outcomes measured. RESULTS: A total of 522 patients were included. The majority had either a colorectal (n = 159, 31%) or coloanal anastomosis (n = 150, 29%). Overall morbidity was 29.3%. C-reactive protein was significantly higher among patient having intra-abdominal complications at an early stage (day 1-2) (164.6 vs 136.2; p = 0.0028) and late stage (day 3-4) (209.4 vs 132.1; p < 0.0001). In multivariate analysis, early C-reactive protein was associated with BMI (coefficient, 4.9; 95% CI, 3.2-6.5; p < 0.0001) and open surgical procedures (coefficient, 43.1; 95% CI, 27-59.1; p < 0.0001), while late C-reactive protein value was influenced by BMI (coefficient, 4.8; 95% CI, 2.5-7.0; p = 0.0024) and associated extracolonic procedures (coefficient, 34.2; 95% CI, 2.7-65.6; p = 0.033). Sensitivity, specificity, negative predictive values, and positive predictive values for intra-abdominal complication were 85.9%, 33.6%, 89.3%, and 27.1% for an early C-reactive protein <100 mg/L and 72.7%, 75.4%, 89.4%, and 49.2% for a late C-reactive protein <100 mg/L. Four hundred seven patients with an uneventful postoperative course were discharged at day 8 ± 6.4 with a mean discharge C-reactive protein of 83.5 ± 67.4. Thirty-eight patients (9.3%) were readmitted and had a significantly higher discharge C-reactive protein (138.6 ± 94.1 vs 77.8 ± 61.2, p = 0.0004). Readmission rate was 16.5% for patients with a discharge C-reactive protein >100 mg/L vs 6% with C-reactive protein <100 mg/L (p = 0.0008). For patients included in an enhanced recovery program (discharge at day 4 ± 2.4), the threshold should be higher because discharge is around day 3 or 4. With a C-reactive protein <140, readmission rate was 2% vs 19%, (p = 0.056). LIMITATIONS: This study includes retrospective data. CONCLUSION: C-reactive protein <100 mg/L is associated with a lower risk of intra-abdominal complication and readmission rates. See Video Abstract at http://links.lww.com/DCR/A749.

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients.

BACKGROUND: Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality. METHODS: All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality. RESULTS: A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo-Clavien > 2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA > 2 (OR = 2.75, 95% CI = 1.07-7.62, p = 0.037), multiorgan failure (MOF) (OR = 5.22, 95% CI = 2.11-13.5, p = 0.0037), perioperative transfusion (OR = 2.7, 95% CI = 1.05-7.47, p = 0.04) and upper GI origin (OR = 3.55, 95% CI = 1.32-9.56, p = 0.013). Independent risk factors for morbidity were: MOF (OR = 2.74, 95% CI = 1.26-6.19, p = 0.013), upper GI origin (OR = 3.74, 95% CI = 1.59-9.44, p = 0.0034) and delayed extubation (OR = 0.27, 95% CI = 0.14-0.55, p = 0.0027). CONCLUSION: Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

Hartmann's reversal after colonic perforation or anastomosis leakage, is it the same procedure? A retrospective study of 150 patients.

PURPOSE: The high morbidity rates reported might influence surgeons' decisions of whether to perform Hartmann's reversal (HR). Our aim was to report the results of HR after "primary" Hartmann's procedure (HP) or in redo surgery for failed anastomosis. METHODS: All patients operated between 2007 and 2015 were included. Data and postoperative course were obtained from a review of medical records and databases. RESULTS: One hundred fifty patients (age 60, range (20-91) years, 62% male) were included. Eighty-six patients (57%) were ASA ≥ 2. HP was mostly performed for diverticulitis (29.3%) and anastomotic leakage (24%). HR was possible in 145(97%) patients including six with previous failed attempt. Overall morbidity was 22.7% including 11.7% severe complications (Dindo 3-4). Operative blood loss and Charlson comorbidity index were the only significant risk factor for postoperative pelvic complications (p = 0.03; p = 0.0002, respectively). CONCLUSIONS: In a colorectal tertiary center, HR was feasible in 97% with a low morbidity and a 3.4% anastomotic leakage rate.

Metachronous colorectal cancer risk in Lynch syndrome patients-should the endoscopic surveillance be more intensive?

PURPOSE: Regular follow-up for patients with Lynch syndrome (LS) is vital due to the increased risk of colorectal (50-80%), endometrial (40-60%), and other cancers. However, there is an ongoing debate concerning the best interval between colonoscopies. Currently, no specific endoscopic follow-up has been decided for LS patients who already have an index colorectal cancer (CRC). The aim of this study was to evaluate the risk of metachronous cancers (MC) after primary CRC in a LS population and to determinate if endoscopic surveillance should be more intensive. METHODS: A prospective cohort of patients with a confirmed diagnosis of hereditary CRC since 2009 was included. Patients with LS and a primary CRC were the cohort of choice. RESULTS: One hundred twenty-one patients were included with a median age of 44 years(16-70). At least one MC occurred in 39 patients (32.2%), with a median interval of 67 months (6-300) from index cancer. Fifteen (38.5%) developed two or more MCs during follow-up, with a median number of two (2-6) tumors occurring. Metachronous CRC were diagnosed after a median interval of 24 (6-57) months since last colonoscopy and were more commonly seen in MSH2 mutation carriers (58 vs. 35%, p = 0.001). After a median follow-up of 52.9 (3-72) months, no cancer-related deaths were recorded. CONCLUSION: Patients with LS have an increased risk of MC, especially CRCs. With a median time period of 24 months between colonoscopy and metachronous CRC, the interval between surveillance colonoscopies following primary CRC should not exceed 18 months, especially in patients with MSH2 mutation.

[Mesocolic excision for colonic adenocarcinoma]. / L'exérèse totale du mésocôlon pour adénocarcinome colique.

On the same principle than total mesorectal excision in rectal cancer, the effect of complete mesocolic excision on short and long-term outcomes is actually evaluated for colonic adenocarcinoma. This method, usually performed for left colectomy, offers a surgical specimen of higher quality, with a larger number of lymph nodes harvested. For right colectomy, surgical specifications make it less common complete mesocolic excision and conventional surgery offer comparable outcomes, as regards to postoperative morbidity and mortality rates. No differences are identified between laparoscopic and open surgery. On oncologic outcomes, only two studies report a higher free-disease survival after complete mesocolic excision. Then, there is evidence that complete mesocolic excision offers a higher rate of specimen with extensive lymph node resection, without increased morbidity rate. However, there is limited evidence that it leads to improve long-term oncological outcomes.