Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study.

AIM: The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis. METHOD: This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage. RESULTS: Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted. CONCLUSION: AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Effect of Sublay Preventive Mesh for Terminal Colostomy on Symptoms and Quality of Life in Patients With Parastomal Hernia: A Post-Hoc Analysis of the GRECCAR 7 Cohort.

BACKGROUND: Recent randomized clinical trials and meta-analyses confirm that the use of a prophylactic mesh doesn't significantly reduce the parastomal hernia rate. Data about the benefits of these meshes concerning the symptoms of the parastomal hernia lack in the existing literature. OBJECTIVE: The aim of this study was to perform a post-hoc analysis of the patients presenting parastomal hernia from the GRECCAR 7 randomized clinical trials cohort on whether the presence or absence of the mesh influenced the symptoms, the quality of life and complications of patients with parastomal hernias. DESIGN: We studied the parastomal hernia related symptoms among the two groups of the GRECCAR 7 randomized clinical trial, with or without prophylactic mesh at the time of the index surgery. SETTINGS: Data were retrospectively extracted and analyzed from the GRECCAR 7 database. PATIENTS: Patients diagnosed with a parastomal hernia during the two years of the GRECCAR 7 study. MAIN OUTCOME MEASURES: Several prospectively collected data about the symptoms were studied among this population. We also studied the average interval between parastomal hernia repair surgery and both index surgery and diagnosis of parastomal hernia. RESULTS: Among the 199 patients included in the GRECCAR study, 36 patients (35.6%) were diagnosed with clinical and/or radiological parastomal hernia in the non-mesh group at 2 years follow-up and 33 (33.7%) in the mesh group, without statistically significant difference (p = 0.89). None of the studied symptoms showed any statistically significant difference between the groups. LIMITATIONS: This study relies on a relatively small number of patients, and although data were prospectively collected, we lacked some details about the categorization of the parastomal hernias. CONCLUSIONS: We believe that the use of a prosthetic mesh in a sublay position to prevent parastomal hernia in terminal end colostomy patients should no longer be recommended. See Video Abstract.

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals.

BACKGROUND: The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis. METHOD: The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results. RESULTS: Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks. CONCLUSION: The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Advanced Insights into Human Uterine Innervation: Implications for Endometriosis and Pelvic Pain.

(1) Background: Understanding uterine innervation, an essential aspect of female reproductive biology, has often been overlooked. Nevertheless, the complex architecture of uterine innervation plays a significant role in conditions such as endometriosis. Recently, advances in histological techniques have provided unprecedented details about uterine innervation, highlighting its intricate structure, distribution, and density. The intricate nature of uterine innervation and its influence on pathologies such as endometriosis has garnered increasing attention. (2) Objectives: This review aims to compile, analyze, and summarize the existing research on uterine innervation, and investigate its implications for the pathogenesis of endometriosis and associated pain. (3) Methods: A systematic review was conducted in line with PRISMA guidelines. Using the PubMed database, we searched relevant keywords such as "uterine innervation", "endometriosis", and "pain association". (4) Results: The initial literature search yielded a total of 3300 potential studies. Of these, 45 studies met our inclusion criteria and were included in the final review. The analyzed studies consistently demonstrated that the majority of studies focused on macroscopic dissection of uterine innervation for surgical purposes. Fewer studies focused on micro-innervation for uterine innervation. For endometriosis, few studies focused on neural pain pathways whereas many studies underlined an increase in nerve fiber density within ectopic endometrial tissue. This heightened innervation is suggested as a key contributor to the chronic pain experienced by endometriosis patients. (5) Conclusions: The understanding of uterine innervation, and its alterations in endometriosis, offer promising avenues for research and potential treatment.

Effectiveness of endoscopic ultrasound (EUS)-guided choledochoduodenostomy vs. EUS-guided gallbladder drainage for jaundice in patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography: Retrospective, multicenter study (GALLBLADEUS Study).

OBJECTIVES: The aim of this study was to compare endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) vs. EUS-gallbladder drainage (EUS-GBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) for jaundice resulting from malignant distal biliary obstruction (MDBO). METHODS: This multicenter retrospective study included patients with obstructive jaundice secondary to MDBO who underwent EUS-GBD or EUS-CDS with lumen-apposing metal stents after failed ERCP. The primary end-point was clinical success rate. Secondary end-points were technical success, periprocedural adverse events rate (<24 h), late adverse events rate (>24 h), overall survival, and time to recurrent biliary obstruction. RESULTS: A total of 78 patients were included: 41 underwent EUS-GBD and 37 underwent EUS-CDS. MDBO was mainly the result of pancreatic cancer (n = 63/78, 80.7%). Clinical success rate was similar for both procedures: 87.8% for EUS-GBD and 89.2% for EUS-CDS (P = 0.8). Technical success rate was 100% for EUS-GBD and 94.6% for EUS-CDS (P = 0.132). Periprocedural morbidity (<24 h) rates were similar between both groups: 4/41 (9.8%) for EUS-GBD and 5/37 (13.5%) for EUS-CDS (P = 0.368). There was a significantly higher rate of late morbidity (>24 h) among patients in the EUS-CDS group (8/37 [21.6%]) than in the EUS-GBD group (3/41 [7.3%]) (P = 0.042). The median follow-up duration was 4.7 months. Overall survival and time to recurrent biliary obstruction did not significantly differ between the groups. DISCUSSION: After failed ERCP for MDBO, EUS-GBD and EUS-CDS show comparable clinical success rates and technical success. EUS-GBD appears to be a promising alternative for MDBO, even as a second-line treatment after failed ERCP. Further studies are needed to validate these findings and compare the long-term outcomes of EUS-GBD and EUS-CDS.

Micro-CT and high-field MRI for studying very early post-mortem human fetal anatomy at 8 weeks of gestation.

OBJECTIVE: This study involved very early post-mortem (PM) examination of human fetal anatomy at 8 weeks of gestation (WG) using whole-body multimodal micro-imaging: micro-CT and high-field MRI (HF-MRI). We discuss the potential place of this imaging in early first-trimester virtual autopsy. METHODS: We performed micro-CT after different contrast-bath protocols including diffusible iodine-based contrast-enhanced (dice) and HF-MRI with a 9.4 T machine with qualitative and quantitative evaluation and obtained histological sections. RESULTS: Nine fetuses were included: the crown-rump length was 10-24 mm and corresponded to 7 and 9 WG according to the Robinson formula. The Carnegie stages were 17-21. Dice micro-CT and HF-MRI presented high signal to noise ratio, >5, according to the Rose criterion, and for allowed anatomical phenotyping in these specimens. Imaging did not alter the histology, allowing immunostaining and pathological examination. CONCLUSION: PM non-destructive whole-body multimodal micro-imaging: dice micro-CT and HF-MRI allows for PM human fetal anatomy study as early as 8 WG. It paves the way to virtual autopsy in the very early first trimester. Obtaining a precision phenotype, even regarding miscarriage products, allows a reverse phenotyping to select variants of interest in genome-wide analysis, offering potential genetic counseling for bereaved parents.

How a hospital pharmacist can contribute to a more sustainable operating theater.

Healthcare sectors, particularly operating theaters, are major consumers of resources. Given today's climate-related issues, its seems vital that the different healthcare professionals in operating areas become aware of their roles. This is pronouncedly the case for hospital pharmacists, who fulfill cross-sectional functions in the proper use and management of healthcare products and sterile medical devices. The objective of this review of the literature is to identify the actions a hospital pharmacist can take to impel evolution toward ecologically responsible care in the operating theater. Seven areas in which a pharmacist can assume a leading, supporting or composite role in rendering an operating theater ecologically responsible have been highlighted: purchasing, procurement and storage, harmonization of practices, modification of practices, professional attire, waste elimination and research/teaching. The active participation of all healthcare professionals, including the hospital pharmacist, is essential to the development of a sustainable approach to healthcare.

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study.

OBJECTIVE: To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19. METHODS: From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21). RESULTS: A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity. CONCLUSION: This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

A percutaneous ultrasound-guided iliotibial band release technique reduces surgical time and costs compared to an endoscopic technique.

PURPOSE: External snapping hip is caused by the iliotibial band snapping from the greater trochanter during hip movement. The aim of this study was to compare a technique of ultrasound-guided iliotibial band release versus a similar endoscopic technique. METHODS: An anatomical study was performed on 10 cadavers i.e. 20 hips. The same operator performed ultrasound-guided and endoscopic iliotibial band release on either side of each specimen. An independent operator performed an open control to verify the outcome measures. The primary outcome was iliotibial cutting percentage, defined as the ratio of the transversal cut distance and the width of the iliotibial at the most prominent portion of the great trochanter. Secondary outcomes included nerve injuries. The surgical time was assessed and disposable medical supplies costs were estimated. RESULTS: The average cutting percentage was 95% ± 8 by ultrasound, compared with 91% ± 11 by endoscopy (n.s.). No iatrogenic lesions were found, particularly nerve damage. The average duration of the ultrasound procedure was 12.3 minutes ± 6 compared to 21 minutes ± 10.7 for endoscopy (p=0.04), with a 3-fold decrease between the first and last procedure, regardless of the technique. The ultrasound procedure was 3 times less expensive in terms of disposable medical supplies (120.5€ versus 353.5€). CONCLUSION: This technique of ultrasound-guided iliotibial band release appears to be as effective and safe as a similar endoscopic technique. The surgical time is reasonable for a surgeon trained in ultrasound, with lower disposable supplies costs. A comparative clinical study is further needed to assess the actual benefits of each technique.

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial.

INTRODUCTION: Erector spinae plane block has been proposed to reduce opioid use and improve pain relief with controversial results. This randomized clinical study aimed to assess the efficacy of erector spinae plane block in major spine surgery including multimodal and 'Enhance Recovery After Surgery' programs. METHOD: After institutional review board approval, adult patients undergoing elective lumbar spine surgery with standardized general anesthesia, rehabilitation and multimodal analgesia protocols were randomly allocated to receive bilateral ultrasound-guided block with saline versus ropivacaine (3.75 mg/mL). Before surgery, a bilateral erector spinae plane block was performed at lumbar level (third vertebrae) with 20 mL of solution for each side. The primary outcome was morphine consumption after 24 hours. Secondary outcomes included pain scores and side effects, from postanesthesia care unit to discharge, and questionnaires at 3 months on pain and quality of life (EQ-5D). RESULTS: From November 2019 to July 2021, 50 patients were enrolled with similar characteristics and surgery for each group. After the first 24 hours, there was no statistical difference regarding cumulative intravenous morphine consumption between ropivacaine and saline groups: 7.3 mg (3.7-19) vs 12.5 mg (3.5-26) (p=0.51). Over the five postoperative days, opioid sparing, pain scores and side effects were similar between groups. At 3 months, pain relief, incidence of chronic pain and EQ-5D were similar between groups. DISCUSSION: Erector spinae plane block used in conjunction with 'Enhance Recovery After Surgery' and multimodal analgesia protocols provides limited reduction in opioid consumption and no long-term benefits. TRIAL REGISTRATION NUMBER: EudraCT 2019-001678-26.

Anatomic and functional mapping of human uterine innervation.

OBJECTIVE: To better understand the physiology of pain in pelvic pain pathological conditions, such as endometriosis, in which alterations of uterine innervation have been highlighted, we performed an anatomic and functional mapping of the macro- and microinnervation of the human uterus. Our aim was to provide a 3-dimensional reconstruction model of uterine innervation. DESIGN: This was an experimental study. We dissected the pelvises of 4 human female fetuses into serial sections, and treated them with hematoxylin and eosin staining before immunostaining. SETTING: Academic Research Unit. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Detection of nerves (S100 +) and characterization of the types of nerves. The slices obtained were aligned to construct a 3-dimensional model. RESULTS: A 3-dimensional model of uterine innervation was constructed. The nerve fibers appeared to have a centripetal path from the uterine serosa to the endometrium. Within the myometrium, innervation was dense. Endometrial innervation was sparse but present in the functional layer of the endometrium. Overall innervation was richest in the supravaginal cervix and rarer in the body of the uterus. Innervation was rich particularly laterally to the cervix next to the parametrium and paracervix. Four types of nerve fibers were identified: autonomic sympathetic (TH+), parasympathetic (VIP+), and sensitive (NPY+, CGRP1+ and VIP+). They were found in the 3 portions and the 3 layers of the uterus. CONCLUSIONS: We constructed a 3-dimensional model of the human uterine innervation. This model could provide a solid base for studying uterine innervation in pathologic situations, in order to find new therapeutic approaches.

Comparison of acquisition and iterative reconstruction parameters in abdominal computed tomography-guided procedures: a phantom study.

BACKGROUND: Many computed tomography (CT) navigation systems have been developed to help radiologists improve the accuracy and safety of the procedure. We evaluated the accuracy of one CT computer-assisted guided procedure with different reduction dose protocols. METHODS: A total of 128 punctures were randomly made by two operators on two different anthropomorphic phantoms. The tube voltage was fixed to 100 kVp. Tube currents (mAs) were defined to obtain 4 dose levels: 180 mAs (D1.00), 90 mAs (D0.50), 45 mAs (D0.25) and 15 mAs (D0.10) with respective volume CT dose index (CTDIvol) of 7.02, 3.52, 1.75 and 0.59 mGy. The raw data were reconstructed using level 2 of advanced model-based iterative reconstruction (ADMIRE) (A2) for D1.00, A3 for D0.50, A4 for D0.25 and A5 for D0.10. Two 12-mm targets per phantom were selected. The mean Euclidean distance (EuD) between the tip of the needle and the isocenter of the target was measured for each puncture. The different measures were compared by paired Student's t-tests. RESULTS: The mean EuD was 7.0±3.1 mm for the 128 punctures performed. Regardless of which phantom was considered, no significant difference in accuracy occurred between the 4 dose levels, which were 7.1±3.5 mm for D1.00; 7.1±3.1 mm for D0.50; 7.2±3.0 mm for D0.25 and 6.6±2.6 mm for D0.10. CONCLUSIONS: Abdominal CT-guided procedures, using computer-assisted navigation and iterative reconstruction algorithms, allow precise punctures on anthropomorphic phantoms with a dose reduction of -92% compared to a standard protocol.

Alteration of ribosome function upon 5-fluorouracil treatment favors cancer cell drug-tolerance.

Mechanisms of drug-tolerance remain poorly understood and have been linked to genomic but also to non-genomic processes. 5-fluorouracil (5-FU), the most widely used chemotherapy in oncology is associated with resistance. While prescribed as an inhibitor of DNA replication, 5-FU alters all RNA pathways. Here, we show that 5-FU treatment leads to the production of fluorinated ribosomes exhibiting altered translational activities. 5-FU is incorporated into ribosomal RNAs of mature ribosomes in cancer cell lines, colorectal xenografts, and human tumors. Fluorinated ribosomes appear to be functional, yet, they display a selective translational activity towards mRNAs depending on the nature of their 5'-untranslated region. As a result, we find that sustained translation of IGF-1R mRNA, which encodes one of the most potent cell survival effectors, promotes the survival of 5-FU-treated colorectal cancer cells. Altogether, our results demonstrate that "man-made" fluorinated ribosomes favor the drug-tolerant cellular phenotype by promoting translation of survival genes.

Are colorectal cancer patients at risk for COVID-19 infection during the postoperative period? The Covid-GRECCAR study.

INTRODUCTION: During the COVID-19 pandemic, cancer patients have been regarded as having a high risk of severe events if they are infected with SARS-CoV-2, particularly those under medical or surgical treatment. The aim of this study was to assess the posttreatment risk of infection by SARS-CoV-2 in a population of patients operated on for colorectal cancer 3 months before the COVID-19 outbreak and who after hospitalization returned to an environment where the virus was circulating. MATERIALS AND METHODS: This French, multicenter cohort study included consecutive patients undergoing elective surgery for colorectal cancer between January 1 and March 31, 2020, at 19 GRECCAR hospitals. The outcome was the rate of COVID-19 infection in this group of patients who were followed until June 15, 2020. RESULTS: This study included 448 patients, 262 male (58.5%) and 186 female (41.5%), who underwent surgery for colon cancer (n = 290, 64.7%), rectal cancer (n = 155, 34.6%), or anal cancer (n = 3, 0.7%). The median age was 68 years (19-95). Comorbidities were present in nearly half of the patients, 52% were at least overweight, and the median BMI was 25 (12-42). At the end of the study, 448 were alive. Six patients (1.3%) developed COVID-19 infection; among them, 3 were hospitalized in the conventional ward, and none of them died. CONCLUSION: The results are reassuring, with only a 1.3% infection rate and no deaths related to COVID-19. We believe that we can operate on colorectal cancer patients without additional mortality from COVID-19, applying all measures aimed at reducing the risk of infection.

Ultrasound-Guided Percutaneous Iliotibial Band Release for External Coxa Saltans: A Cadaveric Study.

The surgical treatment of external coxa saltans is not standardized. Many techniques for iliotibial release have been described, both open and arthroscopic. No technique describes ultrasound release. In this cadaveric study, we describe a minimally invasive technique for percutaneous iliotibial release with ultrasound guidance, designed to be performed under local anesthesia. The future objective would be to perform an active intraoperative test of the snapping hip to confirm adequate release, thus reducing the risk of recurrence.

Meta-analysis and Systematic Review of the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia.

OBJECTIVE: The primary endpoint of this meta-analysis was the PSH rate at 1 year of follow-up with or without the use of a mesh. SUMMARY OF BACKGROUND DATA: European guidelines currently recommend the use of a mesh at the time of a stoma formation for the prevention of PSH. These recommendations are based on the RCT and meta-analyses published before 2017. More recently 2 large RCT found no benefit in the mesh group. We investigated whether these latest results could change the conclusion of a meta-analysis. METHODS: We conducted a comprehensive literature search and analyzed RCT investigating the use of a mesh to prevent PSH formation. All studies including end colostomies were included in the qualitative analysis no matter the surgical technique or the type of mesh. All studies with a limited risk of bias and presenting with usable data were used in the quantitative analysis. RESULTS: There is a large heterogeneity among the studies, in terms of position of the mesh, surgical technique, and diagnostic method for the PSH.No statistically significant difference was found on the PSH rate at 1 or 2 years between the mesh and non-mesh groups. CONCLUSIONS: Based on this meta-analysis including the latest RCT on the prevention of PSH, the use of a mesh should not be recommended.