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).

What is the best surgical option after failure of graciloplasty in patients with recurrent rectovaginal fistula? A study of 19 consecutive patients.

BACKGROUND: Management of recurrent rectovaginal fistula (rRVF) remains challenging despite the good results of graciloplasty reported in the literature. However, little is known about how to avoid a permanent stoma if graciloplasty fails. The aim of our study was to report the management of rRVF after failure of graciloplasty. METHODS: A retrospective study was performed on consecutive patients with rRVF after failure of graciloplasty treated at our institution in January 2005-December 2021. RESULTS: There were 19 patients, with a median age at graciloplasty of 39 years (range 25-64 years). Etiologies of RVF were Crohn's disease (CD) (n = 10), postoperative (n = 5), post-obstetrical (n = 3), and unknown (n = 1). After failure of graciloplasty, 45 new procedures were performed, all of them with a covering stoma: trans-anal repairs (n = 31), delayed colo-anal anastomosis (DCAA) (n = 4), biological mesh interposition (n = 3), second graciloplasty (n = 3), stoma only (n = 2) and redo ileal pouch-anal anastomosis (IPAA) (n = 2). One patient was not re-operated on and instead treated medically for CD. After a mean follow-up of 63 ± 49 months, success (i.e., absence of stoma or RVF) was obtained in 11 patients (58%): 4/4 DCAA (100%), 5/31 after local repair (16%), 1 after stoma creation alone (50%) and 1 after redo IPAA (50%). Second graciloplasty and biologic mesh interposition all failed. All 8 patients with failed intervention had CD. CONCLUSIONS: In cases of rRVF after failed graciloplasty, reoperation is possible, although the chance of success is relatively low. The best results were obtained with DCAA. CD is a predictor of poor outcome.

Mesorectal failure after chemoradiotherapy for squamous cell carcinoma of the anus: is sphincter-saving surgery reasonable?

BACKGROUND: Abdominoperineal resection (APR) is today the standard treatment for improving survival in case of mesorectal failure without anal canal recurrence after chemoradiotherapy (CRT) for squamous cell carcinoma of the anus (SCC). The aim of this study was to assess if a sphincter-saving surgery is a safe alternative to classical salvage APR in these patients. METHODS: A retrospective study was conducted on all patients who had total mesorectal excision (TME) with sphincter-saving surgery either with coloanal or low colorectal anastomosis, for mesorectal failure after CRT for SCC between 2012 and 2020 at our institution. The main endpoint of our study was oncological results at the end of follow-up. Postoperative morbidity and mortality were secondary endpoints. RESULTS: There were 10 patients, (8 women, median age 55 years [range 45-61 years]). On TME specimens, R0 resections were noted in five (50%), R1 resection in four (40%) and R2 resection in one (10%). After a median follow-up of 42 months (4-74 months), five patients were alive, and four (40%) were alive at 5-year follow-up. During follow-up, locoregional failure after TME was noted in two patients (20%), distant relapse in three patients (30%) and both locoregional plus distant failure in two patients (20%). Only two patients (20%) had anal recurrence, one in the anal canal, the other in the peri-anastomotic area. Long- term local control was achieved in 2 of the 5 patients (40%) who underwent R0 resection versus only 1/4 patients (25%) with R1 resection. CONCLUSIONS: Our preliminary study suggested that sphincter-saving surgery could be proposed in selected patients with SCC presenting mesorectal failure after CRT, providing a feasible R0 resection.

C-reactive protein monitoring after ileocecal resection and stoma closure reduces length of hospital stay: a prospective case-matched study in 410 patients with Crohn's disease.

BACKGROUND: The aim of this study was to evaluate a C-reactive protein (CRP)-driven monitoring discharge strategy for patients with Crohn's disease (CD) undergoing laparoscopic ileo-cecal resection (ICR) and if needed, temporary stoma closure (SC). METHODS: Four hundred and ten patients who underwent laparoscopic ICR for CD: 153 patients (CRP group) between June 2016 and June 2020 at our department, had a CRP-driven monitoring discharge on postoperative day (POD) 3 and were discharged on POD 4 if CRP < 100 mg/L. These patients were matched (according to age, sex, body mass index, type of CD (and stoma or not) to 257 patients who underwent laparoscopic ICR for CD between January 2009 and May 2016, without CRP monitoring (Control group). For SC, 79 patients with CRP monitoring were matched with 88 control patients. Primary outcome was overall length of hospital stay (LHS). Secondary outcomes were discharge on POD 4 for SC and POD 4 and POD 6 for ICR, 3-month postoperative overall morbidity and severe morbidity rates, surgical site infection, readmission rates, and CRP level in cases of morbidity at 3 months. RESULTS: For ICR without stoma, mean LHS was significantly shorter in the CRP group than in the control group (6.9 ± 2 days vs 8.3 ± 6 days, p = 0.017). Discharge occurred on POD 6 (or before) in 73% of the patients (CRP group) vs 60% (Control group) (p = 0.027). For ICR with stoma, LHS was 8 days for both groups (p = 0.612). For SC, LHS was significantly shorter in the CRP group than in the control group (5.5 ± 3 days vs 7.1 ± 4 days; p = 0.002). Discharge occurred on POD 4 in 62% (CRP group) vs 30% (Control) (p = 0.003). Postoperative 3-month overall and severe morbidity, and rehospitalization rates were similar between groups. CONCLUSIONS: CRP-driven monitoring discharge strategy after laparoscopic ICR for CD is associated with a significant reduction of LHS, without increasing morbidity, reoperation or rehospitalisation rates.

Can end-to-end anastomosis reduce the risks of anastomotic leak compared to side-to-end anastomosis? A comparative study of 518 consecutive patients undergoing laparoscopic total mesorectal excision for low- or mid-rectal cancer.

BACKGROUND: After laparoscopic total mesorectal excision (TME) for low or mid-rectal cancer, we observed several cases of anastomotic leakage (AL) in patients with side-to-end anastomosis (STE). Thus, from December 2018, we routinely performed end-to-end anastomosis (ETE). The aim of this study was to assess if this new strategy changed AL and chronic pelvic sepsis rates in our department. METHODS: A retrospective study was conducted on all the patients who underwent a laparoscopic rectal resection with TME and sphincter-saving surgery for mid- and low-rectal adenocarcinoma from January 2006 to December 2019. A comparative study between STE and routine ETE was performed. The primary outcome was the assessment of postoperative AL rate. The secondary outcomes were: (a) overall morbidity rate; (c) severe morbidity rate defined by a Clavien-Dindo score > 3; (c) chronic leak rate. RESULTS: Five hundred eighteen patients underwent TME: STE was performed in 394 cases (76%) and ETE in 124 but for the first 66 cases only if STE was impossible (i.e., too short colon, obese patients). AL rates for STE were 57/204 (23%) after stapled colorectal anastomosis (CRA) and 34/190 (18%) after manual coloanal anastomosis (CAA). Since December 2018, routine ETE was performed in 58 cases. The AL rate for routine ETE was 3/24 (12%) for CRA, and 2/34 (6%) for CAA: thus, The AL rate dropped from 23% (91/394) after STE to 9% (5/58) after routine ETE (p = 0.0005). After a mean follow-up of 43 months (6-156), incidence of chronic AL was 68/394 (17%) after STE and 15/117 (13%) after ETE (p = 0.32). In the group of ETE with chronic AL, 11 patients (73%) spontaneously healed and stoma reversal was possible, whereas this happened in only 20 patients (29%) after STE (p = 0.0025). CONCLUSIONS: ETE seems to be associated with a significantly lower rate of AL and higher rate of spontaneous healing after chronic AL than STE.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort.

BACKGROUND AND AIMS: Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS: From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS: Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ±â€…20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis.

BACKGROUND: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. METHODS: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. RESULTS: Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. CONCLUSION: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.

ANTECEDENTES: La extensión del tumor más allá del plano del meso-rrecto (ymrT4) ocurre en el 5-10% de los pacientes con cáncer de recto y el 10% de los pacientes desarrollan recidiva local del cáncer de recto (locally recurrent rectal cáncer, LRRC) después de una cirugía primaria. Existe una variación global en la prestación de la asistencia sanitaria para esta pato-logía. MÉTODOS: Se realizó un ensayo de referencia internacional sobre el manejo de ymrT4 y LRRC en Francia y Australia entre 2015 y 2017. La heterogeneidad en el manejo y la toma de decisiones quirúrgicas se analizaron mediante la comparación de las tasas de resección quirúrgica, la lectura a ciegas de la resonancia magnética (RM) pélvica entre países, la evaluación de la calidad de vida y las evaluaciones cualitativas. RESULTADOS: De 154 pacientes (97 en Francia versus 57 en Australia), el 32% tenía ymrT4 y el 68% tenía cáncer de recto con recidiva local. Las tasas de resección quirúrgica fueron del 87,6% versus 77,8% (P = 0,112). La tasa de concordancia en la decisión quirúrgica fue baja (coeficiente kappa = 0,314) con una tasa más baja de exenteración pélvica en Francia, tanto en la práctica clínica (46% versus 85%; P < 0,0001) como en condiciones teóricas (40% versus 88%; P = 0,002). La tasa de resección R0 fue menor en Francia para la LRRC (51% versus 86%, P = 0,007) pero no para el ymrT4 (81% versus 100%, P = 0,139). Las tasas de morbilidad fueron similares. Los pacientes que se sometieron a procedimientos no exenterativos tuvieron una subescala de funcionamiento mental más alta a los 12 meses (P = 0,04) y un nivel de angustia más bajo a los 6 meses (P = 0,04). El análisis cualitativo destacó 5 categorías de factores psicosociales que afectaron a la decisión del tratamiento: paciente, estrategia, especialista, organización y cultura. CONCLUSIÓN: Este ensayo de referencia internacional destaca las diferencias en el tratamiento mundial del cáncer de recto localmente avanzado y de la LRR. La aten-ción estandarizada debería mejorar los resultados para estos pacientes.

Local excision after neoadjuvant chemoradiotherapy versus total mesorectal excision: a case-matched study in 110 selected high-risk patients with rectal cancer.

AIM: The aim of this comparative study was to report a 10-year experience of an organ preservation strategy by local excision (LE) in selected high-risk patients (aged patients and/or patients with severe comorbidity and/or indication for abdominoperineal excision) versus total mesorectal excision (TME) after neoadjuvant radiochemotherapy (RCT) for patients with locally advanced (T3-T4 and/or N+) low and mid rectal cancer with suspicion of complete tumour response (CTR) or near-CTR. METHOD: Thirty-nine patients with rectal cancer who underwent LE after RCT for suspicion of CTR were matched to 71 patients who underwent TME according to body mass index, gender, tumour location and ypTNM stage. Operative, oncological and functional results were compared between groups. RESULTS: In the LE group, ypT0, ypTis or ypT1N0R0 were noted in 28/39 (72%). Overall morbidity was observed in 10/39 (26%) in LE vs 46/71 in the TME group (65%) (P = 0.001). Severe morbidity (Clavien-Dindo ≥ 3) was noted in 1/39 patients from the LE group (3%) vs 3/71 (4%) from the TME group (P = 1.000). After a mean follow-up of 63 ± 4 months (range 56-70 months), local recurrence was noted in 2/39 (5%) from the LE group vs 2/71 (3%) from the TME group (P = 0.601). Definitive stoma was noted in 2/39 (6%) from the LE group vs 8/71 (12%) from the TME group (P = 0.489). Major low anterior resection syndrome was noted in 5/23 (22%) from LE group vs 11/33 (33%) from the TME group (P = 0.042). CONCLUSION: The accuracy of response prediction after RCT was 72% after LE. In high-risk patients, LE represents a safe alternative to TME with better functional results and the same long-term oncological outcome.

Does a transanal drainage tube reduce anastomotic leakage? A matched cohort study in 144 patients undergoing laparoscopic sphincter-saving surgery for rectal cancer.

BACKGROUND: The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS). METHODS: A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL. RESULTS: A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0-5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04-8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36-23.53]) were associated with AL. CONCLUSIONS: Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer.

Segmental Colectomy for Ulcerative Colitis: Is There a Place in Selected Patients Without Active Colitis? An International Multicentric Retrospective Study in 72 Patients.

BACKGROUND AND AIMS: The aim of this study was to report a multicentric experience of segmental colectomy [SC] in ulcerative colitis [UC] patients without active colitis, in order to assess if SC can or cannot represent an alternative to ileal pouch-anal anastomosis [IPAA]. METHODS: All UC patients undergoing SC were included. Postoperative complications according to ClavienDindo's classification, long term results, and risk factors for postoperative colitis and reoperation for colitis on the remnant colon, were assessed. RESULTS: A TOTAL OF: 72 UC patients underwent: sigmoidectomy [n = 28], right colectomy [n = 24], proctectomy [n = 11], or left colectomy [n = 9] for colonic cancer [n = 27], 'diverticulitis' [n = 17], colonic stenosis [n = 5], dysplasia or polyps [n = 8], and miscellaneous [n = 15]. Three patients died postoperatively and 5/69 patients [7%] developed early flare of UC within 3 months after SC. After a median followup of 40 months, 24/69 patients [35%] were reoperated after a median delay after SC of 19 months [range, 2-158 months]: 22/24 [92%] underwent total colectomy and ileorectal anastomosis [n = 9] or total coloproctectomy [TCP] [n = 13] and 2/24 [8%] an additional SC. Reasons for reoperation were: colitis [n = 14; 20%], cancer [n = 3] or dysplasia [n = 3], colonic stenosis [n = 1], and unknown reasons [n = 3]. Endoscopic score of colitis before SC was Mayo 23 in 5/5 [100%] patients with early flare vs 15/42 without early flare [36%; p = 0.0101] and in 9/12 [75%] patients with reoperation for colitis vs 11/35 without reoperation [31%; p = 0.016]. CONCLUSIONS: After segmental colectomy in UC patients, postoperative early colitis is rare [7%]. Segmental colectomy could possibly represent an alternative to IPAA in selected UC patients without active colitis.

Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

BACKGROUND: In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. METHODS: Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. RESULTS: A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. CONCLUSIONS: There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases.

AIM: This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA). METHODS: All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included. RESULTS: From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients. CONCLUSION: HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.

Hospital stay for temporary stoma closure is shortened by C-reactive protein monitoring: a prospective case-matched study.

BACKGROUND: C-reactive protein (CRP) has been suggested as a satisfactory early marker of postoperative complications after colorectal surgery. The aim of this study was to assess the impact of a CRP monitoring-driven discharge strategy, after stoma reversal following laparoscopic sphincter-saving surgery for rectal cancer. METHODS: Eighty-eight patients who had stoma reversal between June 2016 and April 2018 had CRP serum level monitoring on postoperative day (POD) 3 and, if necessary, on POD5. Patients were discharged on POD4 if the CRP level was < 100 mg/L. Patients were matched [according to age, gender, body mass index, neoadjuvant pelvic irradiation, type of anastomosis (stapled or manual), and adjuvant chemotherapy] to 109 identical control patients who had stoma reversal between 2012 and 2016 with the same postoperative care but without CRP monitoring. RESULTS: Postoperative 30-day overall morbidity [CRP group: 12/88 (14%) vs controls: 11/109, (10%), p = 0.441] and severe morbidity rates (i.e. Dindo 3-4) [CRP group: 2/88 (2%) vs controls: 2/109 (2%), p = 0.838] were similar between groups. Mean length of stay was significantly shorter in the CRP group (CRP group: 4.6 ± 1.3 vs controls: 5.8 ± 1.8 days; p < 0.001). Discharge occurred before POD5 in 59/88 (67%) CRP patients vs 15/109 (14%) controls (p < 0.001). The unplanned rehospitalization rate [CRP group: 6/88 (7%) vs controls: 4/109 (4%), p = 0.347] was similar between groups. CONCLUSIONS: In patients having temporary stoma closure after laparoscopic surgery for rectal cancer, postoperative CRP monitoring is associated with a significant shortening of hospital stay without increasing morbidity or rehospitalization rates.

Morbidity and oncological outcomes of rectal cancer impaired by previous prostate malignancy.

BACKGROUND: Specific surgical and oncological outcomes in patients with rectal cancer surgery after a previous diagnosis of prostate cancer have not been well described. The aim of this study was to compare surgical outcomes in patients with rectal cancer with or without a history of prostate cancer. METHODS: Patients who had surgery for rectal cancer with (PC group) or without (no-PC group) previous curative treatment for prostate cancer were enrolled between January 2001 and December 2015. Comparisons between the two groups were performed by multivariable Cox analysis, and after propensity score matching in a 3 : 1 ratio for demographic and tumour characteristics, and surgical and oncological outcomes. RESULTS: A total of 944 patients with rectal cancer were enrolled, of whom 10·8 per cent had a history of prostate cancer. After matching, 83 patients who had received treatment for prostate cancer were compared with 249 who had not. The PC and no-PC groups were similar regarding patient characteristics. Extended total mesorectal excision, conversion to open surgery, transfusion and tumour perforation were more frequent in the PC group than in the no-PC group. Major surgical morbidity (28 versus 17·2 per cent; P = 0·036), anastomotic leakage (25 versus 13·7 per cent; P = 0·019) and permanent stoma (41 versus 12·4 per cent; P < 0·001) occurred more frequently in the PC group. Local recurrence was increased significantly in the PC group (17 versus 8·0 per cent; P = 0·019), and resulted in a significant decrease in disease-free and overall survival. CONCLUSION: Prostate cancer treatment increases short- and long-term surgical morbidity in patients with rectal cancer, and impairs oncological outcomes.

How to manage anal ulcerations and anorectal stenosis in Crohn's disease: algorithm-based decision making : French National Working Group Consensus 2018.

The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for anal ulcerations and anorectal stenosis are suggested. Recommendations have been graded following international recommendations, and when absent professional agreement was established. For each situation, practical algorithms have been drawn.

What is the outcome for patients undergoing more than two ileocolonic resections for recurrent Crohn's disease? A comparative study of 569 consecutive procedures.

AIM: To assess the outcome for patients undergoing repeated ileocolonic resection for recurrent Crohn's disease (CD). METHOD: All patients undergoing ileocolonic resection for terminal ileal CD between 1998 and 2016 in our tertiary care centre were retrospectively reviewed. RESULTS: Between 1998 and 2016, 569 ileocolonic resections were performed for CD: 403 of these were primary resections (1R, 71%), 107 second resections (2R, 19%) and 59 were third (or more) resections (> 2R, 10%). The laparoscopic approach rate was significantly less in the > 2R group (20/59, 34%) compared with the 2R (71/107, 66%; P = 0.002) and 1R (366/403, 91%) groups. However, conversion to an open approach did not show any difference between the three groups [1R group 46/366 (13%) vs 2R group 14/71 (20%) vs > 2R group 3/20 (15%); 1R vs > 2R P = 0.750; 2R vs > 2R P = 0.633]. Postoperative morbidity was significantly increased in the > 2R (28/59, 52%) group compared with the 1R group (115/403, 29%; P < 0.001) but showed no difference compared with the 2R group (43/107, 40%; P = 0.365). There was no difference between the groups in the incidence of severe postoperative morbidity (Clavien-Dindo ≥ 3) [1R group n = 24 (6%); 2R group n = 6 (6%); > 2R group n = 4, 7%; 1R vs > 2R P = 0.865, 2R vs > 2R P = 0.761]. CONCLUSION: Although the overall morbidity rate was higher, repeated surgery for recurrent CD in patients undergoing three or more ileocolonic resections was not associated with an increased risk of severe postoperative morbidity in our series.

Risk Factors for Small Bowel Obstruction After Laparoscopic Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Multivariate Analysis in Four Expert Centres in Europe.

BACKGROUND AND AIMS: Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD]. METHODS: All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO]. RESULTS: From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors. CONCLUSIONS: We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.