Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

Unplanned readmissions after hernia repair.

INTRODUCTION: Several quality indices have been set up for evaluating the impact of the reduction of the length of stay (LOS), such as the 30-day unplanned readmission (UR30) rate. The main goal of our study was to analyze the UR30 following groin hernia repair (GHR), primary- (PVHR), and incisional ventral hernia repairs (IVHR). METHODS: A French registry-based multicenter study was conducted using prospective data from all consecutive patients registered from 2015 to 2021. RESULTS: The overall incidence of UR30 was 1.32%. This included 160/18,042 (0.87%) for GHR, 41/4012 (1.02%) for PVHR, and 145/3754 (3.86%) for IVHR. The leading cause of UR30 was postoperative complications (POC). The nature of the predominant complications varied among the three categories. The correlation between UR30 and POC (and risk factors for POC) was strong in GHR but was not in IVHR due to a 'protective' longer LOS in this subgroup. As the LOS has decreased over the last years, this has 'mechanically' resulted in an increase in the occurrence of UR30, but not in a rise of POC, neither in volume nor in severity. The reduction of LOS just shifted the problem from inpatient to outpatient settings. CONCLUSION: Since the steady development of day-care surgery, the prevention of the UR not only hinges on the prevention of the POC but newly on a better organization of outpatient care which is currently a huge challenge due to a GPs' and nurses' shortage in France.

FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty.

Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.

Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter?

INTRODUCTION: Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related to the mesh and the surgical technique have rarely been described. METHODS: A registry-based multicenter study using prospectively collected data, including SSIs and their potential risk factors, was conducted in the French Hernia-Club. RESULTS: Between 2012 and 2019, 21,976 consecutive unselected adult patients aged 64.8 ± 15.4 years old (88.9% male) underwent GHR (83.5% unilateral). Fifty four percent were laparoscopic; 97.6% used mesh. The overall incidence of SSI was 0.26%. The incidence of SSI was respectively, 0.24% and 0.19% (p = 0.420) in open vs laparoscopic repairs; 0.19% and 0.25% (p = 0.638) for polyester vs polypropylene mesh; In adjusted multivariate analysis focusing on macroporous meshes (which were the most implanted meshes: 23,148 out of 24,099), there were no differences in terms of SSIs' rates regarding the technique: open versus laparoscopy (p = 0.762) nor the type of mesh used: polypropylene versus polyester (p = 0.557). CONCLUSION: The rate of SSI following GHR was low in this large registry study. Mesh type and surgical technique did not affect SSIs rates. Caution is advised when interpreting these data due to this very low rate of SSI and the potential for a type II error.

Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging.

INTRODUCTION: The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis. METHODS: An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts. RESULTS: Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women. CONCLUSION: These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.

Embolic strokes in a patient with a large floating thrombus in the ascending aorta.

BACKGROUND: A floating thrombus in the ascending aorta is a rare finding that may cause multiple ischemic strokes with catastrophic consequences. The treatment algorithm for such lesions is yet to be defined. CASE REPORT: We report the case of a 50-year-old patient with multiple cerebral ischemic strokes due to a sizeable floating thrombus (25 x 15 x 13 mm) in the ascending aorta. Conservative management utilizing anticoagulants was chosen due to the patient's high estimated perioperative risk. CONCLUSION: An anticoagulation treatment strategy may be feasible, safe, and effective in patients with large mobile thrombus in the aorta who are not eligible for thrombectomy. HIPPOKRATIA 2021, 25 (3):172-174.

Effect of parathyroidectomy on quality of life and non-specific symptoms in normocalcaemic primary hyperparathyroidism.

BACKGROUND: Normocalcaemic primary hyperparathyroidism (NcPHPT) is a new clinical entity being diagnosed increasingly among patients with mild primary hyperparathyroidism (PHPT). The aim of this study was to evaluate quality of life and non-specific symptoms before and after parathyroidectomy in patients with NcPHPT compared with those with hypercalcaemic mild PHPT (Hc-m-PHPT). METHODS: This was a prospective multicentre study of patients with mild PHPT from four university hospitals. Patients were evaluated before operation, and 3, 6 and 12 months after surgery for quality of life using the SF-36-v2® questionnaire, as well as for 25 non-specific symptoms. RESULTS: Before operation, the only statistically significant difference between the NcPHPT and Hc-m-PHPT groups was in the mean(s.d.) blood calcium level (2·54 versus 2·73 mmol; P < 0·001). At 1 year after surgery, the blood calcium level had improved significantly in both groups, with no significant difference between them. Quality of life improved significantly in each group compared with its preoperative score, with regard to the physical component summary (P = 0·040 and P = 0·016 respectively), whereas the mental component summary improved significantly in the Hc-m-PHPT group only (P = 0·043). Only two non-specific symptoms improved significantly in the NcPHPT group compared with nine in the Hc-m-PHPT group. CONCLUSION: Parathyroidectomy mildly improves quality of life and some non-specific symptoms in patients with NcPHPT.

Ambulatory surgery under local anesthesia for parathyroid adenoma: Feasibility and outcome.

The aim of this study was to evaluate the results of ambulatory parathyroid resection performed under local anesthesia (LA). MATERIAL AND METHODS: Outpatients undergoing parathyroid adenoma resection by a focused approach under LA were included. Results were evaluated by intraoperative serum parathormone levels (ioPTH) and the balance of phosphate and calcium postoperatively, at 3 months, 1 year and at the point date. The quality of ambulatory care was evaluated by the number of cancelled interventions, the number of patients hospitalized after surgery or during the first postoperative month. The patient data manager of the institution carried out a medico-economic analysis. RESULTS: From 2005 to 2014, 129 patients met the inclusion criteria [women: 82% (sex ratio 1:5), median age: 72 years]. There was no morbidity for 98% of patients. Twelve patients had no statistically significant drop in ioPTH: two had persistent primary hyperparathyroidism (PHP). LA failed in four patients and PTH was late to normalize in six patients. Six patients had recurrent PHP (4.6%), of which two occurred four years after excision. Outpatient treatment was successful in 95%, without deprogramming or rehospitalization. The cost of the treatment under LA and on an outpatient basis was € 2014.90 (vs. € 2581.47 under general anesthesia and traditional hospitalization) CONCLUSION: Excision of single parathyroid adenomas can be performed under LA in an ambulatory setting without any major risk for the patient. The risk of recurrence after the focused approach requires regular laboratory monitoring for at least five years.

Management of adrenal incidentaloma.

Improvements in medical imaging have resulted in the incidental discovery of many silent and unrecognized adrenal tumors. The term "adrenal incidentaloma" (AI) is applied to any adrenal mass≥1cm in its longest axis that is discovered incidentally during abdominal imaging that was not performed to specifically evaluate adrenal pathology. These incidentalomas may be either secretory or non-secretory, benign or malignant. Distinctive characteristics of these lesions must be determined by the clinician to determine appropriate management. Such distinctions are based on laboratory findings and imaging, principally CT with and without contrast injection. Investigations must be carefully chosen to avoid ordering unnecessary and expensive tests for too many patients while, at the same time, avoiding the risk of failing to diagnose a secreting malignant or tumor. These examinations will determine patient care: surgery or surveillance. When simple surveillance is chosen, specific criteria must be met with regard to diagnostic modalities (clinical, imaging, laboratory testing) and its duration.

Physical activity and sitting time in bariatric surgery patients 1-16 years post-surgery.

Physical activity (PA) is an important adjunct to bariatric surgery in the treatment of severe obesity; however, patient PA levels prior to and in the short-term following surgery are usually low. Scarce data exist describing PA and sedentary behaviours in the long term following surgery. The objectives were to describe PA and sitting time in bariatric patients 1-16 years post-surgery and assess their associations with patient, surgery and weight-loss characteristics. A total of 398 bariatric patients (73% female; mean age 47 ± 11 years, mean 6 ± 4 years since surgery) completed a telephone questionnaire. Patients reported moderate-to-vigorous PA (MVPA: # sessions week(-1) ≥30 min), sitting time (h d(-1)) and change in PA and sitting time vs. pre-surgery (more/same/less). Associations with patient, surgery and weight-loss characteristics were assessed. Only 53% of patients reported ≥1 session week(-1) MVPA, mean sitting time was 7 ± 4 h d(-1), 74% of patients reported more PA and 53% reported less sitting, now vs. pre-surgery. Age, sex, smoking status, pre-surgery body mass index, time-since-surgery and percent excess weight lost were significantly associated with PA and/or sitting outcomes. Patients currently experiencing ≥50% excess weight loss had over three times the odds of reporting ≥1 session week(-1) MVPA (odds ratio [95% confidence interval] 3.28 [1.57, 6.89]) and almost four times greater odds of reporting 'more' PA vs. pre-surgery (3.78 [2.15, 6.62]) compared with their less successful counterparts. Results point to low PA and high sedentariness among bariatric patients in the long-term following surgery, associated with several characteristics. Associations with long-term weight management highlight the need for tailored interventions to promote active living in this patient population.

Complications after total thyroidectomy.

The two most common early complications of thyroid surgery are hypocalcemia (20-30%) and recurrent laryngeal nerve injury (5-11%). Bilateral recurrent nerve paralysis resulting in adduction of the vocal cords is a rare life-threatening complication (occurring in less than 0.1% of cases that requires emergency management. Prevention of complications depends on careful operative technique and is enhanced for some teams by the use of specific techniques such as intraoperative neuromonitoring. Postsurgical hypocalcemia is managed by the administration of calcium plus vitamin D for at least 10 days. Recurrent laryngeal nerve paralysis recovers in most cases, and no invasive therapy should be performed for at least six months, except for emergency presentations; laryngeal surgery techniques may offer significant improvement if phonation or respiratory sequelae persist beyond six months, but the results are inconsistent. There should be a systematic strategy for detection of complications after thyroidectomy involving a multidisciplinary approach.

The role of excess subcutaneous fat in pain and sensory sensitivity in obesity.

BACKGROUND: Previous studies suggest pain sensitivity may be decreased in obesity, but it is unknown whether this is a global or a site-specific phenomenon related to the amount of excess fat. DESIGN: a cross-sectional study comparing obese and non-obese participants on body sites with much and little excess subcutaneous fat in obesity. Hot and cold sensory detection thresholds, pain thresholds, pain tolerance and subjective ratings for a cold (0 °C) and hot (48 °C) stimulus were assessed using a 16 × 16 mm thermode (Medoc, Israel) on the forehead and abdomen. Pressure pain thresholds were measured on the hand. Cold water immersion tolerance duration and subjective ratings were assessed on the hand. Two indices of central pain processing, i.e., temporal summation and heterotopic noxious stimulation, were assessed. RESULTS: A total of 20 obese participants [10M/10F, BMI mean (SD) =41.5 kg/m(2) (9.4 kg/m(2) )] and 20 age- and gender-matched non-obese controls [10M/10F, BMI mean (SD) =23.5 kg/m(2) (2.9 kg/m(2) )] were studied. Compared with non-obese, obese participants had higher thresholds and lower subjective ratings, indexing decreased sensitivity, for painful and non-painful thermal stimuli on the abdomen, an area with much excess subcutaneous fat. Decreases in abdominal sensitivity correlated with measures of adiposity (i.e., waist-to-hip ratio and subcutaneous fat thickness). On areas with little excess subcutaneous fat (forehead and hand), obese and non-obese groups did not differ in measures of thermal or pressure sensitivity, nor for indices of central pain processing. CONCLUSION: Obese participants are less sensitive than non-obese individuals, but only on areas with excess subcutaneous fat.

Soluble L-selectin at levels present in septic patients diminishes leukocyte-endothelial cell interactions in mice in vivo: a mechanism for decreased leukocyte delivery to remote sites in sepsis.

OBJECTIVE: Recent in vivo studies of both septic humans and animals demonstrate that leukocyte delivery is attenuated to sites remote from the primary infection. The mechanisms for this are not entirely clear. L-selectin is integral to rolling, the first step in leukocyte recruitment to an inflammatory site. L-selectin is shed from leukocytes in sepsis, resulting in increased levels of soluble L-selectin in plasma (2.33 microg/mL). This study investigates the effects of soluble L-selectin at levels found in sepsis on leukocyte trafficking in vivo. DESIGN: Prospective, controlled trial. SETTING: Surgical research laboratory in a university hospital. SUBJECTS: Swiss white male mice of 25-35 g. INTERVENTIONS: Mice were randomized to one of three study groups: soluble L-selectin 2.33, soluble L-selectin 8.0, or albumin. Intravital microscopy was performed on postcapillary venules of 20-40 microm in diameter in the cremaster muscle of mice. Leukocyte-endothelial cell interactions (rolling, adherence, and rolling velocity) were measured pre- and post- (1, 15, 30, and 45 mins) intravenous infusion of human recombinant soluble L-selectin (2.33 and 8.0 microg/mL) or human albumin (8.0 microg/mL). MEASUREMENTS AND MAIN RESULTS: The intravenous administration of soluble L-selectin to a systemic concentration of 2.33 microg/mL diminished rolling significantly. Soluble L-selectin at 8.0 microg/mL decreased rolling and increased rolling velocity to a greater degree. Injection of albumin did not alter leukocyte-endothelial cell interactions at any time point. No difference between groups in blood pressure, shear rate, or leukocyte counts was detected. CONCLUSIONS: Soluble L-selectin diminishes leukocyte rolling at levels present in sepsis (2.33 microg/mL). This effect is dose dependent, and could not be explained by differences in blood pressure, shear rate, or leukocyte counts. These findings identify increased soluble L-selectin levels as one of the mechanisms for decreased leukocyte delivery and exudation to remote sites in septic patients.

Clinafloxacin versus piperacillin-tazobactam in treatment of patients with severe skin and soft tissue infections.

Patients (n = 409) with severe skin and soft tissue infections (SSTIs) were randomized to receive clinafloxacin or piperacillin-tazobactam (plus optional vancomycin for methicillin-resistant cocci), administered intravenously, with the option to switch to oral medication. Most patients had cellulitis, wound infections, or diabetic foot infections. Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa were the most common baseline pathogens. Fewer baseline pathogens were resistant to clinafloxacin (1.8%) than to piperacillin-tazobactam (6.2%) (P = 0.001). The clinafloxacin and piperacillin-tazobactam groups did not differ significantly in clinical cure rates (68.8 and 65.2%, respectively) or microbiologic eradication rates (61.5 and 57.2%). Clinafloxacin yielded higher eradication rates for all three of the most common pathogenic species, although no differences were statistically significant. Within the power of this study, the overall frequency of adverse events was similar (P = 0.577) in the two treatment groups. Drug-associated adverse events (P = 0.050) and treatment discontinuations (P = 0.052) were marginally more frequent in the clinafloxacin group, primarily due to phototoxicity in outpatients receiving clinafloxacin. Although most cases of phototoxicity were mild to moderate, four cases were reported as severe. In summary, clinafloxacin monotherapy was equivalent in effectiveness to therapy with piperacillin-tazobactam plus optional vancomycin in the treatment of hospitalized patients with severe SSTIs.