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.

SARS-CoV-2 infection may result in appendicular syndrome: Chest CT scan before appendectomy.

The initial clinical presentation of coronavirus disease 2019 may be appendicular syndrome. An abdominal CT scan ruled out a diagnosis of appendicitis and a chest CT scan yielded a diagnosis of SARS-CoV-2 infection. CT scan is required before considering emergency surgery for acute appendicitis.

[SARS-CoV-2 infection may result in appendicular syndrome: Chest CT scan before appendectomy]. / L'infection par SARS-CoV-2 peut se traduire par un syndrome appendiculaire : tomodensitométrie thoracique avant appendicectomie.

The initial clinical presentation of coronavirus disease 2019 may be appendicular syndrome. An abdominal CT scan ruled out a diagnosis of appendicitis and a chest CT scan yielded a diagnosis of SARS-CoV-2 infection. CT scan is required before considering emergency surgery for acute appendicitis.

Preoperative evaluation of small bowel complications in Crohn's disease: comparison of diffusion-weighted and contrast-enhanced MR imaging.

PURPOSE: To compare the accuracy of MR enterography (MRE) using combined T2-weighted and contrast-enhanced (CE) sequences with that of combined T2- and diffusion-weighted (DW) sequences for the detection of complex enteric Crohn's disease (CD). MATERIALS: Thirty-eight patients who underwent surgery for CD complications and preoperative MRE from 2011 to 2016 were included. MRE examinations were blindly analyzed independently by one junior and one senior abdominal radiologist for the presence of fistula, stenosis and abscesses. During a first reading session, T2-weighted images (WI), steady-state sequences and DW-MRE were reviewed (set 1). During a separate distant session, T2-WI, True-FISP and CE-MRE were reviewed (set 2). Performance of each reader was evaluated by comparison with the standard of reference established using intraoperative and pathological findings. RESULTS: Forty-eight fistulas, 43 stenoses and 11 abscesses were found. For the senior radiologist, sensitivity for the detection of fistula, stenosis and abscess ranged from 80% to 100% for set 1 and 88% to 100% for set 2 and specificity ranged from 56% to 70% for set 1 and 53% to 93% for set 2, with no significant difference between the sets (p = 0.342-0.429). For the junior radiologist, sensitivity ranged from 53% to 63% for set 1 and 64% to 88% for set 2 and specificity ranged from 0% to 25% for set 1 and 17% to 40% for set 2 (p = 0.001 and 0.007, respectively). CONCLUSION: For a senior radiologist, DW-MRE has similar sensitivity as CE-MRE for the detection of CD complications. For a junior radiologist, CE-MRE yields the best results compared with DW-MRE. KEY POINTS: • For experienced readers, DWI has similar diagnostic capability as contrast-enhanced MR imaging for the diagnosis of Crohn's disease complications. • For senior radiologists, gadolinium chelate injection could be waived for the diagnosis of Crohn's disease complications. • The interpretation of DWI for Crohn's disease complications requires some experience.

Gastrointestinal stenting: Current status and imaging features.

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

MDCT of acute colitis in adults: an update in current imaging features.

Acute colitis is often diagnosed on multidetector row computed tomography (MDCT) because patients with this condition present with abdominal pain and a variety of nonspecific symptoms. Acute colitis has multiple causes with varying degrees of severity. Analysis of the extent of colonic involvement, presence of specific MDCT imaging features and associated signs should help radiologist narrow the diagnosis. Integrating the results of clinical examination and biological tests is mandatory, and in case of ambiguous or nonspecific MDCT findings, endoscopy and colon biopsy should always be considered for a definite diagnosis. The purpose of this review is to discuss and illustrate MDCT features that are helpful for characterizing acute colitis in adults and to provide an update in current MDCT features.

Comparison of two surgical techniques for resection of uncomplicated sigmoid volvulus: laparoscopy or open surgical approach?

AIM OF THE STUDY: The optimal treatment for acute sigmoid volvulus has not been defined. Our aim was to compare the results of two techniques for the management of uncomplicated sigmoid volvulus coming from two separate surgical services, which had each chosen a different technique: open surgical versus laparoscopic. PATIENTS AND METHODS: Patients with sigmoid volvulus who underwent a surgical resection with immediate anastomosis, either emergency or scheduled, were included. Risk of morbidity (Dindo-Clavien criteria) and mortality (criteria of the AFC-French Association of Surgery) were evaluated. RESULTS: Thirteen patients in the open surgical group were operated in a 10-year period and 17 patients in the laparoscopy group were operated on in a seven-year period. The mean age (57 years in both groups) and sex ratio (0.7 versus 0.6, respectively), and the length of hospital stay (18 versus 15 days, respectively) were comparable in the two groups. The open surgical procedure was performed urgently in 62% (n=8/13) versus 24% (n=4/17) in the laparoscopic group. The two groups were comparable in terms of risk factors for mortality by AFC score. The anastomotic leak rate was 8% (n=1/13) for the open surgical group versus 18% (n=3/17) for the laparoscopic group, while serious morbidity was 15% (n=2/13) versus 12% (n=2/17). No recurrence of volvulus was observed in the open group (mean follow-up of 26 months) versus 12% (n=2) in the laparoscopy group (mean follow-up of 32 months). CONCLUSION: We did not find any significant difference between the two techniques. But the technical simplicity and the absence of recurrence in the open surgical group emphasize the importance of this technique.

Accuracy of imaging for predicting operative approach in Crohn's disease.

BACKGROUND: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease. METHODS: Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings. RESULTS: Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE. CONCLUSION: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Primary peritonitis due to Streptococcus A: laparoscopic treatment.

Primary peritonitis is defined as peritoneal infection without an evident intraperitoneal septic focus. This is a rare condition and few cases are reported in the literature. We report a case of primary peritonitis in a 23-year-old female that was diagnosed and treated laparoscopically. The challenge for the surgeon is to consider the possibility of this diagnosis, and to avoid conversion to laparotomy in search of a hypothetical septic focus when none is apparent on laparoscopy.

[Why should an abdominal CT scan be performed for suspected appendicitis in the adult patient? Lessons from ten clinical cases]. / Pourquoi faire un scanner en cas de suspicion d'appendicite aiguë de l'adulte?

Ten years after its introduction, the contribution and indications for computed tomography (CT) in the diagnosis of appendicitis remain the subject of controversy among surgeons. Many argue that CT is frequently superfluous and costly, results in excessive radiation exposure, and delays surgical treatment. On our service, we perform 150 to 180 adult appendectomies annually. We feel that CT helps us to avoid unnecessary appendectomy, to clear up diagnostic uncertainty, and, most importantly, to guide the choice of surgical approach. We illustrate our experience through ten clinical cases in which the use of preoperative imaging has resulted in improved care.

[Management of ileal stenosis in patients with Crohn's disease]. / Prise en charge des sténoses iléales de maladie de Crohn.

Stenosis is the most frequent complication during Crohn's disease. The lesion can be inflammatory, or due to a fibrosing or neoplastic process. The medical treatment with anti-inflammatory drugs is usually sufficient as first line treatment; fibrous lesions require endoscopic or surgical procedures while neoplastic lesions require surgery. A multidisciplinary approach (radiologic, medical, surgical and endoscopic) is needed. In a first part, we discuss the definition of stenosis and the modalities of imaging (particularly MRI) and of treatment (particularly with TNFalpha antagonists). Then we expose the strategy for the management of the most frequent clinical situations: occlusion, ileal inflammatory stenosis, stenosis of an ileocolonic anastomosis and chronic fibrous stenosis. The treatment decision takes into account the results of radiological assessment, CRP level and the effects of the previous treatments.

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases.

BACKGROUND: The aim of this case-matched study was to determine the best treatment strategy for patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases. METHODS: Between 1997 and 2002, 27 patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases were treated by chemotherapy without initial primary resection (chemotherapy group). These 27 patients were compared with 32 patients matched for age, sex, performance status, primary tumour location, number of liver metastases, nature of irresectable disease and type of chemotherapy, but who were treated initially by resection of primary tumour (resection group). RESULTS: The 2-year actuarial survival rate was 41 per cent in the chemotherapy group and 44 per cent in the resection group (P = 0.753). In the latter group, the mortality and morbidity rates for primary resection were 0 and 19 per cent (six of 32 patients) respectively. In the chemotherapy group, intestinal obstruction related to the primary tumour occurred in four of 27 patients. The mean overall hospital stay was 11 days in the chemotherapy group and 22 days in the resection group (P = 0.003). CONCLUSION: Systemic chemotherapy without resection of the bowel cancer is the option of choice because, for most patients, it is associated with a shorter hospital stay and avoids surgery without a detrimental effect on survival.