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BACKGROUND: Neoadjuvant immunotherapy emerges as a promising strategy for patients with localized colon cancer (CC) harboring microsatellite instability/mismatch repair deficiency (MSI/dMMR). The aim of this study is to evaluate the concordance between clinical cTN stage assessed by preoperative computed tomography (CT) scan and pTN stage of MSI/dMMR CC. PATIENTS AND METHODS: Consecutive patients diagnosed for localized MSI/dMMR CC and treated with upfront surgery between 2013 and 2022 in two French centers were eligible. Two independent radiologists, blinded to pathological findings, reviewed all preoperative CT scans and assessed cTN stage, with a third radiologist reviewing discordant cases. Radiological predictive diagnostic accuracy for pT4 and pN+ (N+ = N1 or N2) were calculated. RESULTS: One hundred and thirteen patients were included (right CCs = 79%). CT scan diagnostic performances for pT4 were sensitivity (Se) = 33.3%; specificity (Sp) = 94.0%; positive predictive value (PPV) = 66.7%; and negative predictive value (NPV) = 79.6% and for pN+ were Se = 70.3%; Sp = 59.2%; PPV = 45.6%; and NPV = 80.4%. When pT-pN were combined, 37.5% of tumors identified as cT4 and/or cN+ were actually pT1-3 and pN0, and 23.1% of the pT4 and pN+ population was not identified as such radiologically. CONCLUSION: The ability of preoperative CT scan to predict pT and pN stages is limited for localized MSI/dMMR CCs. Reassessing neoadjuvant strategies' benefit-risk balance in this population is needed.
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AIM OF THE STUDY: Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer. METHODS: The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm. RESULTS: One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy. CONCLUSIONS: The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.
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Neoplasias Colorrectales , Cirugía Colorrectal , Procedimientos Quirúrgicos del Sistema Digestivo , Anciano , Neoplasias Colorrectales/cirugía , Cirugía Colorrectal/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Humanos , Morbilidad , Complicaciones Posoperatorias/epidemiología , Estudios ProspectivosAsunto(s)
Colectomía/estadística & datos numéricos , Cirugía Colorrectal/tendencias , Infecciones por Coronavirus/epidemiología , Obstrucción Intestinal/epidemiología , Peritonitis/epidemiología , Neumonía Viral/epidemiología , Betacoronavirus , COVID-19 , Francia/epidemiología , Hospitales/estadística & datos numéricos , Humanos , Pandemias , Aceptación de la Atención de Salud/estadística & datos numéricos , SARS-CoV-2RESUMEN
AIM: To compare the functional results and quality of life after delayed colo-anal anastomosis (DCAA) or immediate colo-anal anastomosis (ICAA) following redo rectal surgery. METHOD: Twenty-six patients with DCAA between 2014 and 2018 were studied retrospectively (group A). Two control groups were used: 26 ICAA after redo surgery (group B) and 52 colo-anal anastomosis (CAA) after anterior resection (group C). Control groups were matched for age, sex, pelvic radiotherapy and time to surgery. Low Anterior Resection Syndrome (LARS) and Gastrointestinal Quality of Life Index (GIQLI) scores were used to assess function and quality of life. RESULTS: The indications for surgery were comparable for groups A and B: anastomotic failure with chronic sepsis (38% vs 50%, P = 0.40), vaginal fistula (42% vs 42%, P = 1) and urinary fistula (20% vs 8%, P = 0.22) as well as the number of previous abdominal operations (1.3 ± 0.9 vs 1.1 ± 0.6, P = 0.19). The median LARS score in the first 2 years was 30 [interquartile range (IQR) 14-41] for group A, 23 (IQR 0-41) for group B and 22 (IQR 11-37) for group C. After 2 years, the median LARS score improved in each group [A, 21 (IQR 11-35); B, 18 (IQR 5-26); C, 13 (IQR 9-20)], but was still high in group A. There was a tendency toward more major LARS in group A than in group B (46% vs 27%; P = 0.149). There was no difference in the mean GIQLI score between groups A and B (120 ± 16 vs 117 ± 19; P = 0.53) at the end of the follow-up period. Time after stoma closure (< 2 years) and previous radiotherapy were risk factors for major LARS in all populations. CONCLUSION: ICAA should be the procedure of choice where possible in redo surgery as it has better functional outcomes.
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Calidad de Vida , Neoplasias del Recto , Canal Anal/cirugía , Anastomosis Quirúrgica/efectos adversos , Colon/cirugía , Femenino , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Recto/cirugía , Estudios Retrospectivos , Síndrome , Resultado del TratamientoRESUMEN
PURPOSE: Perineal hernia (PH) is a tardive complication following abdomino-perineal resection (APR). Many repair methods are described and evidences are lacking. The aim of this study was to report PH management, analyze surgery outcomes and review the available literature. METHODS: We retrospectively included all consecutive PH repair after APR performed between 2001 and 2017. We recorded data on APR surgery, PH symptoms and repair, and follow-up (recurrence and morbidity). Literature review included published articles on PubMed between 1960 and 2017. RESULTS: 24 PH repairs were included. The approach was perineal N = 16, abdominal N = 5 and combined N = 3. A biological mesh was used for 17, a synthetic for 5 and a flap for 2 patients. The median follow-up was 25 months. Overall morbidity was 37.5% (N = 9): 37.5% for the perineal, 20% for the abdominal, and 66.7% for the combined approach. Complications occurred in 35.3% of biological and 20% of synthetic mesh repairs. Recurrence rate was 41.7%, similar for biological (n = 8, 47.1%) and synthetic meshs (n = 2; 40%). No recurrence occurred in the flap group. Depending of the approach, we found 50% for perineal (n = 8) and 40% of the abdominal cohort (N = 2). Among twelve studies, recurrence rates ranged from 0 to 66.7%. Abdominal or laparoscopic approach with synthetic mesh was associated with less recurrences (0 and 12.5% respectively) and complications (37.5% and 9.5%). CONCLUSIONS: Recurrences following PH repair are high irrespective of the repair technique. More studies are necessary to identify PH risk factors and decide the appropriate perineal reconstruction.
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Hernia/etiología , Herniorrafia/estadística & datos numéricos , Perineo/cirugía , Proctectomía/efectos adversos , Abdomen/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma/cirugía , Femenino , Herniorrafia/métodos , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Neoplasias del Recto/cirugía , Recurrencia , Estudios Retrospectivos , Colgajos Quirúrgicos , Mallas Quirúrgicas/estadística & datos numéricosRESUMEN
AIM: Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS: From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS: Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION: Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.
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Adenocarcinoma/cirugía , Mesenterio/cirugía , Complicaciones Posoperatorias/epidemiología , Proctectomía/métodos , Neoplasias del Recto/cirugía , Microcirugía Endoscópica Transanal/métodos , Absceso Abdominal/epidemiología , Adenocarcinoma/patología , Anciano , Fuga Anastomótica/epidemiología , Estudios de Casos y Controles , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Neoplasias del Recto/patología , Reoperación , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Cirugía Endoscópica Transanal/métodosRESUMEN
AIM: The presence of tumour deposits (TDs) in colorectal cancer (CRC) is associated with poor prognosis. The seventh edition of TNM subclassified a new nodal stage, N1c, characterized by the presence of TDs without any concurrent positive lymph node (LN). It is not clear if the N1c category is or is not equal to LN metastasis. We aimed to examine the prevalence, characteristics and prognostic significance of this new subcategory. METHOD: Consecutive patients who underwent surgery for CRC in two centres (2011-2014) were analysed. N1 cM0 patients were matched against non-N1 cM0 (N0, N1a and N1b) patients for 3-year overall survival (OS) and disease-free survival (DFS). RESULTS: We identified 1122 patients with 648 (57.8%) colonic cancers. In 57 patients (5.1%), N1c status was associated with rectal cancers [rectum = 33/57 (57.9%) vs colon = 24/57 (42.1%); P = 0.029], a higher pathological tumour stage [pT3-T4 N1c = 55/843 (6.5% vspT3-T4 non-N1c = 2/279 (0.7%); P < 0.0001] and vascular emboli [n = 35 (61.4%) vs n = 552 (51.8%); P = 0.0305]. Synchronous metastasis was observed in 23 cases (40%). After a mean follow-up of 31 months, 3-year OS for M0 patients, was 89.4%, 89.1%, 86.6% and 81.8% for N0, N1a, N1b and N1c tumours, respectively. DFS was significantly worse for N1c than for N0 (P = 0.0169), with N1c status having a significant effect on DFS in colonic cancers (P = 0.014). The presence of more than one TD was associated with a significantly worse DFS (P = 0.021). CONCLUSION: Our results indicate that N1c CRC patients should be included among high-risk patients for whom it is widely accepted that adjuvant chemotherapy should be considered.
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Quimioradioterapia Adyuvante/métodos , Colectomía/métodos , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Terapia Neoadyuvante/métodos , Adulto , Anciano , Biopsia con Aguja , Estudios de Cohortes , Colectomía/efectos adversos , Colectomía/mortalidad , Neoplasias Colorrectales/terapia , Terapia Combinada , Supervivencia sin Enfermedad , Femenino , Humanos , Inmunohistoquímica , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Invasividad Neoplásica/patología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Estadísticas no Paramétricas , Análisis de Supervivencia , Factores de TiempoRESUMEN
AIM: The abdominal incision for specimen extraction could trigger postoperative pain after laparoscopic colorectal resections (LCRs). Continuous wound infusion (CWI) of ropivacaine may be a valuable option for postoperative analgesia. This study was undertaken to evaluate the potential benefits of ropivacaine CWI on pain relief, metabolic stress reaction, prevention of wound hyperalgesia and residual incisional pain after LCR. A subgroup with intravenous lidocaine infusion (IVL) was added to discriminate between the peripheral and systemic effects of local anaesthetic infusions. METHOD: Patients were randomly allocated to three subgroups: CWI (0.2% ropivacaine 10 ml/h for 48 h); IVL (lidocaine 1.5% at 4 ml/h for 48 h); control group. RESULTS: In all, 95 patients were randomized (86 patients analysed). Postoperative pain intensity did not differ significantly between groups. Within the first 24 h after surgery, morphine requirement was significantly lower in the CWI group compared with the IVL group, but there was no significant difference compared with the control group (P = 0.02 and P = 0.15, respectively). The area of hyperalgesia did not differ significantly between subgroups, nor did the hyperalgesia ratio which was 1.2 cm (0.0-6.7) vs 1.9 cm (0.4-4.0) vs 2.0 cm (0.5-7.0) in the CWI, IVL and control groups respectively (P = 0.35). The number of patients reporting residual incisional pain after 3 months (3/26 vs 4/23 vs 4/23 in the CWI, IVL and control groups respectively) did not differ significantly between the groups, nor did their metabolic stress reactions. CONCLUSION: Ropivacaine CWI at the site of the abdominal incision did not provide any significant benefit either on analgesia or on the prevention of wound hyperalgesia after LCR.
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Anestésicos Locales/administración & dosificación , Colectomía/métodos , Hiperalgesia/prevención & control , Laparoscopía/métodos , Lidocaína/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Ropivacaína/administración & dosificación , Herida Quirúrgica , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Método Doble Ciego , Femenino , Humanos , Infusiones Intralesiones , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Morfina/uso terapéutico , Estrés FisiológicoRESUMEN
BACKGROUND: Patients treated with chemotherapy for microsatellite unstable (MSI) and/or mismatch repair deficient (dMMR) cancer metastatic colorectal cancer (mCRC) exhibit poor prognosis. We aimed to evaluate the relevance of distinguishing sporadic from Lynch syndrome (LS)-like mCRCs. PATIENTS AND METHODS: MSI/dMMR mCRC patients were retrospectively identified in six French hospitals. Tumour samples were screened for MSI, dMMR, RAS/RAF mutations and MLH1 methylation. Sporadic cases were molecularly defined as those displaying MLH1/PMS2 loss of expression with BRAFV600E and/or MLH1 hypermethylation and no MMR germline mutation. RESULTS: Among 129 MSI/dMMR mCRC patients, 81 (63%) were LS-like and 48 (37%) had sporadic tumours; 22% of MLH1/PMS2-negative mCRCs would have been misclassified using an algorithm based on local medical records (age, Amsterdam II criteria, BRAF and MMR statuses when locally tested), compared to a systematical assessment of MMR, BRAF and MLH1 methylation statuses. In univariate analysis, parameters associated with better overall survival were age (P < 0.0001), metastatic resection (P = 0.001) and LS-like mCRC (P = 0.01), but not BRAFV600E. In multivariate analysis, age (hazard ratio (HR) = 3.19, P = 0.01) and metastatic resection (HR = 4.2, P = 0.001) were associated with overall survival, but not LS. LS-like patients were associated with more frequent liver involvement, metastatic resection and better disease-free survival after metastasectomy (HR = 0.28, P = 0.01). Median progression-free survival of first-line chemotherapy was similar between the two groups (4.2 and 4.2 months; P = 0.44). CONCLUSIONS: LS-like and sporadic MSI/dMMR mCRCs display distinct natural histories. MMR, BRAF mutation and MLH1 methylation testing should be mandatory to differentiate LS-like and sporadic MSI/dMMR mCRC, to determine in particular whether immune checkpoint inhibitors efficacy differs in these two populations.
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Biomarcadores de Tumor/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales/genética , Metilación de ADN , Reparación de la Incompatibilidad de ADN , Inestabilidad de Microsatélites , Homólogo 1 de la Proteína MutL/genética , Mutación , Proteínas Proto-Oncogénicas B-raf/genética , Adulto , Anciano , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/terapia , Neoplasias Colorrectales Hereditarias sin Poliposis/mortalidad , Neoplasias Colorrectales Hereditarias sin Poliposis/patología , Neoplasias Colorrectales Hereditarias sin Poliposis/terapia , Diagnóstico Diferencial , Supervivencia sin Enfermedad , Femenino , Francia , Predisposición Genética a la Enfermedad , Herencia , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Técnicas de Diagnóstico Molecular , Análisis Multivariante , Metástasis de la Neoplasia , Linaje , Fenotipo , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Vólvulo Intestinal/diagnóstico , Vólvulo Intestinal/cirugía , Intubación Gastrointestinal/métodos , Mesenterio/cirugía , Cavidad Abdominal/fisiopatología , Cavidad Abdominal/cirugía , Femenino , Humanos , Laparoscopía , Laparotomía/métodos , Masculino , Cuidados Posoperatorios/métodos , Recuperación de la Función , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
AIM: The only studies on the prognosis of T1 tumours are old and investigate colic and rectal cancers. Very few studies use Kikuchi's classification (of dividing submucosa into three strata) to evaluate the depth of the submucosal invasion. This study aimed to assess the pathological risk factors for lymph node metastasis (LNM), and the pathological and oncological results of patients with early rectal cancer (ERC, pT1 tumour). METHOD: Between 2000 and 2014, 91 consecutive patients undergoing surgery [primary total mesorectal excision (TME) or local excision (LE) alone, or LE followed by TME] for ERC were included. RESULTS: Eighteen patients underwent LE, 22 underwent LE followed by TME and 51 underwent primary total TME. After TME (n = 73), 16 (23%) patients had LNM. The LNM rate was 15% for Sm1 tumours, 14% for Sm2 tumours and 30% for Sm3 tumours. In multivariate analysis, lymphovascular invasion (P = 0.027) and high tumour budding (P = 0.037) were the only independent factors predictive of LNM. The depth of submucosal invasion was not associated with an increased risk of LNM. After a mean follow up of 56 ± 46 months, 5-year overall survival, specific survival and disease-free survival were, respectively, 82%, 93% and 75%. No significant difference of survival was found according to the depth of submucosal invasion or to the surgical management. CONCLUSION: Histological features seem to be stronger risk factors for LNM than depth of submucosal invasion. Considering the LNM rate, TME should be discussed after LE in terms of one of these pathological criteria.
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Detección Precoz del Cáncer/estadística & datos numéricos , Mucosa Intestinal/patología , Ganglios Linfáticos/patología , Neoplasias del Recto/diagnóstico , Anciano , Supervivencia sin Enfermedad , Detección Precoz del Cáncer/métodos , Resección Endoscópica de la Mucosa/métodos , Femenino , Estudios de Seguimiento , Humanos , Mucosa Intestinal/cirugía , Ganglios Linfáticos/cirugía , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Invasividad Neoplásica/diagnóstico , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Factores de Riesgo , Cirugía Endoscópica Transanal/métodosRESUMEN
OBJECTIVE: Total small-intestinal volvulus with malrotation (TSIVM) classically presents in the neonatal period; it occurs much less frequently in the adult and is often misdiagnosed. Prognosis is directly related to the degree and duration of intestinal ischemia. Our goal is to describe our experience with TSIVM in the adult, to identify any specific findings and to discuss its management. METHOD: Eleven patients who had undergone surgery for TSIVM at three centers between 1992 and 2012 were included. Surgery was performed as an emergency for five patients and surgery was elective for six. RESULTS: Mean follow-up was 63 months (range: 12-270). Six patients had had previous abdominal surgery. In nine cases, the diagnosis of TSIVM was made preoperatively, mainly by CT scan in eight cases. Seven patients had associated congenital failure of retroperitoneal fixation of the right colon and all of these underwent a Ladd procedure. The mortality rate was zero. Of the five patients who underwent emergency surgery, three required intestinal resections, one of whom developed a short bowel syndrome. The six patients who underwent surgery electively had no surgical complications. CONCLUSION: TSIVM is a very unusual finding in adult patients. The diagnosis can be made by CT scan with IV and oral contrast, but it often comes to light only at the time of surgery, even though the patients have often had recurrent episodes of abdominal symptomatology that dated back to childhood. The Ladd procedure, consisting of division of Ladd's bands, widening of the mesentery, and incidental appendectomy, remains the standard surgical repair. Digestive surgeons who care for adults should be familiar with this procedure, and it should be performed, as often as possible, with the assistance of a pediatric surgeon.
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Anomalías del Sistema Digestivo/cirugía , Vólvulo Intestinal/cirugía , Intestinos/anomalías , Laparoscopía , Adolescente , Adulto , Anciano , Anomalías del Sistema Digestivo/diagnóstico por imagen , Anomalías del Sistema Digestivo/etiología , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Estudios de Seguimiento , Francia , Humanos , Vólvulo Intestinal/diagnóstico por imagen , Vólvulo Intestinal/etiología , Laparoscopía/métodos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
AIM: Correlation between outcome and hospital volume regarding colorectal resection (CRR) has been described, but it suggests that provider variability may have an impact. Our aim was to analyse the influence of institutional characteristics and the impact of volume [high volume (HV) or low volume (LV)] on mortality and morbidity after CRR at a national level. METHOD: Data from 2009-2012, including patient demographics, diagnosis, procedure, mode of admission and discharge and hospital type, were obtained. Each hospital admission was classified as one of four levels of severity. RESULTS: Of 176,444 patients included, 5408 (3.06%) died and 41,240 (23.37%) had a complication. Multivariate analysis showed that factors influencing morbidity were age over 80 years, severity level, pathology other than diverticular disease, male gender, demanding surgery, open surgery and surgery in an HV institution. Factors influencing mortality were the same except for the impact of volume. In HV centres, surgery was significantly more demanding (54.66% vs 47.17%, P < 0.0001), morbidity more frequent (26.59% vs 22.07%, P < 0.0001), but mortality was lower (2.17% vs 3.43%, P < 0.0001). In total, 6038 (3.4%) patients were transferred after surgery. Transfer rate and mortality after transfer were significantly higher in LV institutions (respectively: 4.3% vs 2.5%, P < 0.0001; and 12% vs 10.3%, P < 0.0001). CONCLUSION: High volume centres have higher morbidity, but lower mortality. Six per cent of patients in LV centres required transfer. A national mortality rate after CRR of 3.5% can be expected. Transfer rate and mortality after transfer should be included in the evaluation of institutional mortality. Volume of institution, regardless of type, influences mortality after CRR.
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Colectomía/efectos adversos , Colectomía/mortalidad , Mortalidad Hospitalaria , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Francia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Transferencia de Pacientes/estadística & datos numéricos , Factores de Riesgo , Factores SexualesRESUMEN
AIM: The best form of prophylactic management of a decompressed sigmoid volvulus (SV) is controversial especially in the elderly. We have studied our experience with this condition to assess the short- and long-term results of SV management. METHOD: All patients treated for SV in our department between 2003 and 2013 were retrospectively included. Emergency decompression was attempted in all patients in whom there was no sign of peritonitis. Planned surgical resection was the procedure of choice in young patients. Percutaneous endoscopic colopexy (PEC) was used in high surgical risk patients. RESULTS: There were 65 patients (45 males) of median age 71.5 (24-99) years. Non-surgical reduction was performed in 62 with a success rate of 95% (59/62). Recurrence after initial decompression was 67% at a median follow-up of 5 (1-14) years. A prophylactic surgical resection was performed with primary anastomosis in 33 patients. There were no deaths and the major morbidity rate was 6%. At a mean follow-up of 62 months, only 1 (3%) patient had had a recurrence (at 130 months). PEC was performed in six patients of median age 90 (84-99) years and with a median American Society of Anesthesiologists score of 4. Complications included local site infection (n = 2), pain (n = 1) and abdominal wall bleeding (n = 1). After a median follow-up of 2 (1-4) years, three patients died from medical causes and one recurrence occurred 13 months after removal of the PEC tube. CONCLUSION: Prophylactic treatment after initial decompression of SV results in a low rate of recurrence. Planned sigmoid resection is safe and effective. In frail elderly patients, PEC is satisfactory.
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Colectomía/métodos , Colon Sigmoide/cirugía , Descompresión Quirúrgica/métodos , Vólvulo Intestinal/cirugía , Enfermedad Aguda , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Estudios de Cohortes , Colon Sigmoide/fisiopatología , Colonoscopía/métodos , Tratamiento de Urgencia , Femenino , Estudios de Seguimiento , Humanos , Vólvulo Intestinal/diagnóstico , Vólvulo Intestinal/mortalidad , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Estadísticas no Paramétricas , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.
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Actitud del Personal de Salud , Hernia Ventral/cirugía , Herniorrafia/métodos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Mallas Quirúrgicas , Consenso , Femenino , Francia , Encuestas de Atención de la Salud , Herniorrafia/instrumentación , Humanos , MasculinoRESUMEN
AIM: Total/subtotal colectomy with ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with various reported rates of morbidity, function and quality of life. Our object was to determine these end-points in a series of patients undergoing these operations in our institution. METHOD: All patients who underwent IRA or ISA between 1994 and 2009 were retrospectively reviewed. RESULTS: A total of 320 patients (female 49%) with a median age of 54.2 (16.8-90.6) years underwent 338 IRA or ISA (in 18 patients the anastomosis was done twice) for inflammatory bowel disease (n = 96), polyposis (n = 95) and colorectal cancer (n = 97). Mortality and morbidity rates were 1.2% (n = 4) and 19.5% (n = 66) and 47 surgical complications (13.9%) occurred, including 26 (7.7%) cases of anastomotic leakage, leading to 23 re-operations. After a median follow-up of 49 (0-196) months, 262 patients still had a functioning anastomosis; 45 patients had died and 13 had a proctectomy. Information on function was obtained in 51.4% (133/259) of the cohort after a median follow-up of 77 (10-196) months. The mean (± standard deviation) rates of 24 h and nocturnal defaecation were 3.6 ± 2.4 and 0.5 ± 0.9. A disturbance of faecal or flatus continence occurred in 20% and 21% of patients. There was no case of faecal incontinence to solid stool. The mean SF-36 Physical and Mental Health Summary Scales were 46.3 ± 9.3 and 51.9 ± 9.3. Multivariate analysis showed that IRA and inflammatory bowel disease were both independently associated with poorer long-term function. CONCLUSION: Colectomy with IRA or ISA is safe with low postoperative morbidity and mortality. The employment of IRA and inflammatory bowel disease appear to be independent negative factors on function in multivariate analysis.
Asunto(s)
Colectomía/efectos adversos , Colectomía/métodos , Colon Sigmoide/cirugía , Íleon/cirugía , Complicaciones Posoperatorias/epidemiología , Calidad de Vida , Recto/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Fuga Anastomótica/epidemiología , Neoplasias Colorrectales/cirugía , Incontinencia Fecal/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Enfermedades Inflamatorias del Intestino/cirugía , Poliposis Intestinal/cirugía , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/psicología , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
AIM: The surgical management of obstructed left colorectal cancer (OLCC) is still a matter of debate, and current guidelines recommend Hartmann's procedure (HP). The study evaluated the results of the surgical management with a focus on a strategy of initial colostomy (IC) followed by elective resection. METHOD: All patients operated on for OLCC were reviewed. Clinical, surgical, histological, morbidity and long-term results were noted. RESULTS: From 2000-11, 83 patients (48 men) with a mean age of 70.3 ± 15.1 years underwent surgery for OLCC. Eleven (13.3%) had a subtotal colectomy owing to a laceration of the caecal wall. Eleven had a HP for tumour perforation (n = 6) or as palliation in a severely ill patient (n = 5). The remaining 61 (73.5%) patients had an IC, with the intention of performing an elective resection shortly after recovery. Postoperative complications occurred in six (9.8%) and there were two (3.3%) deaths. Fifty-nine operation survivors had a colonoscopy shortly afterwards which showed a synchronous cancer in two (3.4%). Twelve of the 59 patients had synchronous metastases. The subsequent elective resection including the colostomy site could be performed in 45 (74%) patients during the same admission at a median interval of 11 (7-17) days. The overall median length of hospital stay was 20 days and the 30-day mortality was 3/61 (5%). CONCLUSION: IC followed by surgical resection is a technically simple strategy, allowing initial abdominal exploration with a short period of having a colostomy, and permitting elective surgery with a low morbidity and full oncological lymphadenectomy.
Asunto(s)
Colectomía , Neoplasias del Colon/cirugía , Colostomía , Obstrucción Intestinal/cirugía , Anciano , Anciano de 80 o más Años , Colon Descendente/cirugía , Colon Sigmoide/cirugía , Neoplasias del Colon/complicaciones , Neoplasias del Colon/patología , Femenino , Humanos , Obstrucción Intestinal/etiología , Estimación de Kaplan-Meier , Tiempo de Internación , Neoplasias Hepáticas/secundario , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de TiempoRESUMEN
AIM: Retrorectal tumours (RT) are uncommon, and diagnosis and management remain difficult. The aim of this study was to evaluate the results of the surgical management of RT in our institution. METHOD: Medical notes of all patients operated on for RT were reviewed. Clinical, radiological, surgical, histological data as well as morbidity and long-term results were noted. RESULTS: Forty-seven patients [34 women (72%), mean age 45.8 (range 17-85) years] underwent surgery for RT between 1997 and 2011. The commonest symptoms were pain (n = 31) and suppuration (n = 10). Thirty-nine (83%) patients underwent preoperative magnetic resonance imaging (MRI). Malignant lesions exhibited typical characteristics on MRI including heterogeneity (n = 5, 83%), solid appearance (n = 4, 67%), a low-T1 signal and high-T2 intensity (n = 5, 83%), enhancement after gadolinium injection (n = 5, 83%), irregular margin (n = 4, 67%) and extension above S3 (i = 5, 83%). A Kraske approach was used in 42 (89%) patients with resection of the coccyx in 25 (60%) and an abdominal or combined approach for the remaining five. Four patients developed complications (two haematoma, two abscess), but only one (haematoma) required reoperation. Histological examination showed 38 (80.9%) benign lesions. After a median follow-up of 71 (2-168) months, 5-year disease-free survival was 75% for malignant lesions and 93.1% for benign lesions (P = 0.023). Four (4/42; 9.5%) patients had moderate perineal pain after a Kraske approach, while no anal dysfunction was seen. CONCLUSION: Magnetic resonance imaging was the most helpful investigation for retrorectal tumours. The posterior trans-sacrococcygeal approach is the procedure of choice for complete resection for most, especially for benign and cystic lesions without extension above S2.