Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature.

INTRODUCTION: Enhanced recovery programs (ERP) are no longer questionable in the management of patients undergoing surgery. However, there is some doubt as to their feasibility and efficacy in the elderly. Our goal was to systematically review the evidence-based literature concerning the feasibility of ERP in elderly patients undergoing colorectal surgery. MATERIAL AND METHODS: The PubMed and Cochrane Database for systematic reviews as well as the "grey" literature between 2000 and 2015 were sought. Articles were selected if they compared ERP in elderly patients to ERP in young patients (feasibility) or compared ERP to traditional post-operative management in the elderly (efficacy). RESULTS: Sixteen articles were identified according to the inclusion criteria. All showed that an ERP was feasible in the elderly although post-operative morbidity was higher compared to younger patients. Compared to traditional management, ERP was effective since it decreased (as in the young) the overall rate of complications and thus the duration of hospital stay. There were not enough data on the degree of implementation of ERP and the medico-economic aspects to come to any formal conclusions. CONCLUSION: This comprehensive systematic review of the literature showed that ERP was feasible and effective in the elderly undergoing colorectal surgery. Protocols should be adapted to the particular aspects of this population. Future research should target pre-operative evaluation and the place of pre-habilitation in geriatric ERP.

Imaging of non-traumatic abdominal emergencies in adults.

Non-traumatic abdominal pathology is one of the most common reasons for consultation in emergency care services. Abdominal pain is the presenting symptom for many diseases, which often requires urgent care. Clinical history and physical examination are rarely sufficient to establish a definite diagnosis and imaging is usually necessary. The choice of imaging modality is oriented by the clinical context and guided by the institutional capabilities, safety and cost-effectiveness of the available tests. Plain radiographs have little or no place in the evaluation of the acute abdomen. Magnetic resonance imaging (MRI) still has limited availability in many hospitals, thus narrowing the imaging choice to ultrasound (US) and computerized tomography (CT). No scientific evidence exists to allow the imposition of one single strategy. At the present time, the clinician may choose either routine US evaluation complemented by CT in case the US is inconclusive or first-line CT (except for the evaluation of right lower quadrant [RLQ] pain, right upper quadrant [RUQ] pain and in pregnant women where ultrasound is the first-line study).

Emergency gastrointestinal surgery in the elderly.

The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.

Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity.

GOAL: Laparoscopic sleeve gastrectomy (LSG) is performed in certain circumstances after failure of gastric banding. The goal of this study was to evaluate the impact of first-line gastric banding on the morbidity associated with secondary LSG for obesity. PATIENTS AND METHODS: The case records of 102 consecutive patients undergoing LSG were studied retrospectively. The technique of LSG was standardized. Two groups were compared: one with patients having undergone LSG after first-line gastric banding (n = 31) and the second, with patients having undergone first-line LSG (n = 71). Endpoints were overall morbidity and intra/postoperative complications including gastric leaks consecutive to staple line disruption as well as other septic or hemorrhagic complications. Multivariable analysis was performed to detect independent risk factors for morbidity. RESULTS: Overall morbidity was significantly higher in patients having undergone LSG after first-line gastric banding compared with those undergoing first-line LSG (32.2% vs. 7%, P = 0.002). Gastric leaks secondary to staple line disruption also occurred statistically significantly more often in patients with first-line gastric banding (16.1% vs. 2.8%, P = 0.043). Waiting 6 months between gastric band removal and performing LSG did not prevent the increased morbidity compared with first-line LSG. Multivariable analysis revealed that among the factors analyzed (age, gender, comorbidity, body mass index, surgeon, first-line gastric banding), the only independent risk factor for staple line disruption was first-line gastric banding with an odds ratio = 6.6 (95% confidence interval = [1.2-36.3]). CONCLUSION: Undergoing first-line gastric banding increases the risk of complications after secondary LSG. We recommend that patients who undergo LSG after a first-line gastric banding should be warned of the increased risks of morbidity or, alternatively, that LSG be performed preferentially as the initial procedure.

[Is the debate on mechanical bowel preparation, before colorectal surgery, over?]. / Le débat sur la préparation mécanique du côlon avant chirurgie colorectale est-il clos?

The present "point of view" tries to assess the state of the art in 2008 on the role of mechanical bowel preparation before colorectal surgery. The case of bowel preparation has been questioned by several meta-analyses of small randomized trials, suggesting also its detrimental effect in terms of anastomotic leaks. In 2007 two large trials were published and pooling their data suggested an increased risk of deep abscesses when bowel preparation was omitted. A further meta-analysis including all published data on this topic appeared useful. This meta-analysis included almost 5 000 patients and showed bowel preparation involves no benefit in terms of surgical site infections, with more infections after bowel preparation (Odds ratio 1.40 [1.05-1.87]). Sensitivity analysis showed an increased risk of abscesses when bowel preparation was omitted but this risk is not clinically relevant since the number needed to harm was as high as 333 patients. In conclusion this meta-analysis including a huge number of patients does not confirm the detrimental effect of bowel preparation but did not show any benefit of it; these conclusions being valid only for colonic surgery, rectal surgery needing further studies.

[Repair of rectocele using the Stapled TransAnal Rectal Resection (STARR) technique: intermediate results from a multicenter French study]. / Traitement de la rectocèle par résection rectale transanale à la pince mécanique: résultats à moyen terme d'une étude multicentrique en France.

BACKGROUND: Stapled transanal rectal resection is a new alternative for the treatment of outlet obstruction syndrome. The aim of this study was to assess its feasibility and safety in a multicenter context. MATERIALS AND METHOD: The study had a retrospective design and included 102 patients who were operated in 5 centers. All patients complained of symptomatic outlet obstruction. Surgical technique involved a double hemi-circumferential rectal stapling according to the technique described by Longo. Mean follow-up was 17.2 months. RESULTS: The STARR procedure was done in 100 patients (2 patients had a non relaxing sphincter preventing anal dilatation). Immediate postoperative morbidity included bleeding in 4 cases (4%) and rectal stenosis in 3 cases (3%). The main postoperative medium-term complaints were urge to defecate (34%) which was regressive in most patients and de novo incontinence to flatus (9%). Nevertheless, results were considered favorable in 85% of patients. CONCLUSION: This multicenter study, reporting the results of the largest published series, suggests that the STARR technique is feasible and safe in the medium term for the treatment of rectocele. Occurrence of adverse events such as incontinence to flatus should be better evaluated by future studies with longer follow up in order to assess the actual place of STARR in the treatment of rectocele or outlet obstruction.

Band and port-related morbidity after bariatric surgery: an underestimated problem.

OBJECTIVE: To evaluate the magnitude of the morbidity related to the system used for gastric banding Methods Between January 1997 and December 2004, 286 consecutive patients underwent laparoscopic gastric banding (LAGB) in one center. We used 4 models of LapBand 9.75, 10, 11 and Vanguard with pars flacida route. Recalibration of band was performed in our consultation unit without systematic radiologic control. We considered four kinds of complication: port displacement, port rupture, band rupture and others problems. RESULTS: The mean follow up was 3.3+/-2.8 years with a median 2.9 years. Complications occurred within a mean time of 2.2+/-1.9 years. For the models vanguard and size 11, there were no rupture and 15 (27.7%) displacements whereas for size 9.75 and 10 there were 39 ruptures (14.7%) and 15 (5.6%) displacements. Types of complications were related to the bands used i.e. more port displacements for the models vanguard and size 11 and more band and port ruptures for the models size 9.75 and 10. But when we considered the respective follow up according to the type of band these differences were no longer significant. Moreover rupture rate was significantly high but decreased after March 2002 because of changing of junction between port and catheter. Mean excess weight loss (35.2+/-27.7%) was not different in group whether the patients were reoperated or not. CONCLUSION: Band and port related morbidity is an important aspect of bariatric surgery. We have to pay attention to material evolution and to our follow up for calibration. Some new recent technical advancement could improve the management of these patients.

[Evidence-based analysis of prophylactic abdominal drainage]. / Analyse factuelle du drainage abdominal prophylactique.

Abdominal prophylactic drainage in digestive surgery was considered until recently as a dogma. But randomised controlled trials have questioned the routine use of abdominal drain in elective surgery. The aim of this review was to assess the usefulness of abdominal prophylactic drainage according to the concept of evidence-based medicine by analysing published randomised trials and meta-analyses. Levels of evidence vary greatly according to the type of surgery. One can conclude: with a good level of evidence that abdominal drainage has no place following elective cholecystectomy, appendicectomy and colectomy with intraperitoneal anastomosis; that it is perhaps unwarranted (lower level of evidence) following gastroduodenal surgery, pancreatectomy, splenectomy, and rectal surgery; and finally that could be indicated following oesophagectomy and common bile duct surgery (very low level of evidence). Nevertheless, when interpreting these data and evidence-based guidelines we should be consider the limitations of published studies (series coming from very expert teams, selected patients, short series, and elective surgery).

[Major digestive surgery in octogenarians. A prospective study of 54 cases]. / La chirurgie digestive lourde après 80 ans. Etude rétrospective de 54 cas.

OBJECTIVE: The interest in geriatric surgery is on the increase because of the ageing of the population. Our study reviewed the results of a non- specialised unit. Method 54 octogenarians underwent digestive surgery including visceral resection. Cancer predominated the indications (80%). RESULTS: The patients exhibited cardiovascular (87%), endocrine (18.5%) or neuropsychiatric (29.6%) disorders with 75% scoring ASA III or IV. Morbidity was of 81.5% with 20% of specifically surgical complications and a 40.2% rate of cardiovascular complications. Post-surgical mortality was of 7.4% and the survival rate at 2 years was of 44.4%. The treating physicians judged that in 65% of patients the intervention had improved the initial status of the patient and had stabilised the disease in 35% of cases. The percentage of patients living at home declined from 83.3% before the intervention to 64.8% after the intervention. Only 2 out of the 9 patients having undergone stomy of the colon following colectomy continued to improve. CONCLUSION: This study underlines the interest of major surgery in octogenarians, including in units non-specialised in geriatric surgery.

[Surgical hand washing]. / Le lavage chirurgical des mains.

Hand washing is required to prevent nosocomial infection. We reviewed the literature, analyzing controlled randomized trials providing the best level of evidence. The different products and techniques evaluated in these trials are detailed. Compliance with hand washing protocols is also discussed.