A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence.

BACKGROUND: Since 1990, several studies have focused on safety and patient satisfaction in connection with day surgery. However, to date, no meta-analysis has investigated the overall prevalence of surgical site infections (SSI). AIM: To estimate the overall prevalence of SSI following day surgery, regardless of the type of surgery. METHOD: A systematic review and a meta-analysis of the prevalence of SSI following day surgery, regardless of the type of surgery, was conducted, seeking all studies before June 2016. A pooled random effects model using the DerSimonian and Laird approach was used to estimate overall prevalence. A double arcsine transformation was used to stabilize the variance of proportions. After performing a sensitivity analysis to validate the robustness of the method, univariate and multi-variate meta-regressions were used to test the effect of date of publication, country of study, study population, type of specialty, contamination class, time of postoperative patient visit after day surgery, and duration of hospital care. FINDINGS: Ninety articles, both observational and randomized, were analysed. The estimated overall prevalence of SSI among patients who underwent day surgery was 1.36% (95% confidence interval 1.1-1.6), with a Bayesian probability between 1 and 2% of 96.5%. The date of publication was associated with the prevalence of SSI (coefficient -0.001, P = 0.04), and the specialty (digestive vs non-digestive surgery) tended to be associated with the prevalence of SSI (coefficient 0.03, P = 0.064). CONCLUSION: The meta-analysis showed a low prevalence of SSI following day surgery, regardless of the surgical procedure.

Can abdominal surgical emergencies be treated in an ambulatory setting?

INTRODUCTION: The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). METHODS: This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. RESULTS: Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach. CONCLUSIONS: Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported.

GH administration rescues fatty liver regeneration impairment by restoring GH/EGFR pathway deficiency.

GH pathway has been shown to play a major role in liver regeneration through the control of epidermal growth factor receptor (EGFR) activation. This pathway is down-regulated in nonalcoholic fatty liver disease. Because regeneration is known to be impaired in fatty livers, we wondered whether a deregulation of the GH/EGFR pathway could explain this deficiency. Hepatic EGFR expression and triglyceride levels were quantified in liver biopsies of 32 obese patients with different degrees of steatosis. We showed a significant inverse correlation between liver EGFR expression and the level of hepatic steatosis. GH/EGFR down-regulation was also demonstrated in 2 steatosis mouse models, a genetic (ob/ob) and a methionine and choline-deficient diet mouse model, in correlation with liver regeneration defect. ob/ob mice exhibited a more severe liver regeneration defect after partial hepatectomy (PH) than methionine and choline-deficient diet-fed mice, a difference that could be explained by a decrease in signal transducer and activator of transcription 3 phosphorylation 32 hours after PH. Having checked that GH deficiency accounted for the GH signaling pathway down-regulation in the liver of ob/ob mice, we showed that GH administration in these mice led to a partial rescue in hepatocyte proliferation after PH associated with a concomitant restoration of liver EGFR expression and signal transducer and activator of trnascription 3 activation. In conclusion, we propose that the GH/EGFR pathway down-regulation is a general mechanism responsible for liver regeneration deficiency associated with steatosis, which could be partially rescued by GH administration.

Laparoscopic treatment of incisional hernia. State of the art in 2012.

OBJECTIVE: The objective of this review is to evaluate the results of laparoscopic treatment of ventral hernias using intra-peritoneal prosthetic mesh through a review of published surgical series. METHODS: All large series of patients treated for an incisional hernia by laparoscopy and published between 2002 and 2011 were identified. The results of controlled randomized series comparing this technique with open surgical repair were analyzed. RESULTS: Twenty-two series with a total of 7057 patients were analyzed (range 51-1242); the mean Body Mass Index (BMI) was 32 (range: 28.5-46), and the mean size of the hernia defect was 10.6 cm (range: 6-14.9 cm). The mean rate of conversion to open surgical repair was 2.7%. Mean operative duration was 90 ± 33 minutes. Mortality was 0.8%, usually due to an unrecognized intestinal injury (1.6%), which occurred more frequently with second or iterative hernia repairs. Hospital stay averaged 2.5 days. The infection rate was 0.3% and the rate of hernia recurrence was 4.6% (with a mean follow-up of 36 months). No statistically significant differences were found in terms of post-operative complications or hernia recurrence in the randomized studies comparing laparoscopic to open anterior abdominal surgical repair. However, duration of hospital stay was shorter after laparoscopy in some studies. CONCLUSION: Laparoscopic repair of ventral incisional hernia is technically feasible and reliable for large hernia defects, even in obese patients. This approach should be reserved for patients with no history of previous hernia repair in order to avoid the risk of intestinal injury. It appears to allow for a shortened duration of hospitalization.

Laparoscopic repair of intraperitoneal bladder perforation due to indwelling urethral catheter.

Intraperitoneal perforation can occur as a rare but life threatening complication of indwelling urethral catheters. Computed tomography (CT) revealed the bladder perforation by the Foley catheter. The injury could not be managed conservatively due to the presence of systemic infection. We present the case of a successful laparoscopic repair of the bladder due to indwelling urethral catheter.

[Can acute appendicitis be treated by antibiotics and in what conditions?]. / Peut-on traiter une appendicite aiguë par des antibiotiques et dans quelles conditions ?

The current treatment for acute appendicitis is an appendectomy. Several studies have, however, assessed the efficacy of an antibiotic for treating acute appendicitis that is either uncomplicated or complicated by local peritonitis. A meta-analysis in 2007 that collected the results of 44 prospective studies showed that antibiotics were efficacious in 92.8% of cases of appendicitis complicated by local peritonitis, with percutaneous drainage of an abscess when necessary. No predictive factor for failure was identified. The failure of antibiotic treatment did not increase morbidity. Over time and on the whole, the recurrence rate was only 8.9%. The risk of cancer of the appendix (1.5%) nonetheless led to the recommendation of an interval appendectomy for adults. Four randomized controlled trials have compared antibiotic treatment with an appendectomy for the treatment of uncomplicated acute appendicitis. The efficacy of the antibiotic treatment ranged from 86 to 100% and the recurrence rate from 10.4 to 35%. These studies have had various methodological impediments; however, too few patients were included (40 and 80 patients), or only a clinical diagnosis was made before inclusion, or important protocol violations occurred, in particular for almost half the patient in the antibiotic therapy group in the 2009 study. These problems prevent us from relying on these authors' findings. Antibiotics have a role in the initial treatment of acute appendicitis complicated by local peritonitis. In uncomplicated acute appendicitis, the methodological inadequacy of the currently available randomized trials makes it impossible to reach a definitive conclusion about the efficacy of antibiotics.

Elective versus urgent laparoscopic appendectomy for complicated appendicitis.

AIM: Urgent appendectomy in patients with acute appendicitis (AA) complicated by abscess or phlegmon is associated with a high rate of complications. Recent developments in CT scanning have allowed patients with complicated appendicitis to be better identified. We choose to treat these patients with initial antibiotic therapy followed by elective appendectomy. We reported the results of this strategy and compared it with urgent appendectomy. METHODS: A retrospective analysis of patients diagnosed with complicated acute appendicitis (CAA) between 1998 and 2007 treated either by urgent appendectomy or with antibiotic therapy and elective appendectomy was performed. We assessed the efficacy of antibiotic therapy for CAA. We compared the postoperative course between urgent and elective appendectomy. RESULTS: We treated 56 patients with CAA: 40 by urgent appendectomy and 16 by antibiotics. All 16 patients improved with no need for urgent surgery, with 15 undergoing elective appendectomy. Postoperative complications were significantly lower in the elective group. Conversion rate and mean operative time were also lower but not significantly different. However, the duration of total hospital stay, antibiotic therapy and sick leave were higher. CONCLUSIONS: Initial antibiotic therapy followed by elective appendectomy may be proposed in patients diagnosed with CAA.

[Inguinal hernia repair: results of randomized clinical trials and meta-analyses]. / Traitement chirurgical des hernies de l'aine. Résultats des essais randomisés et des méta-analyses.

This evidence-based review of the literature aims to answer two questions regarding inguinal hernia repair: 1. should a prosthetic patch be used routinely? 2. Which approach is better - laparoscopic or open surgery? After a comprehensive search of electronic databases we retained only meta-analyses (n=14) and/or randomised clinical trials (n=4). Review of this literature suggests with a good level of evidence that prosthetic hernia repair is the gold standard; the laparoscopic approach has very few proven benefits and may involve more serious complications when performed outside expert centers. The role of laparoscopy for the repair of bilateral or recurrent hernias needs better evaluation.

[Lymphadenectomy in surgery for cancers of the stomach and esophagus]. / La chirurgie ganglionnaire dans les cancers de l'oesophage et de l'estomac.

Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.

[Not Available]. / La chirurgie ganglionnaire dans les cancers de l'œsophage et de l'estomac.

C. Mariette, G. Piessen, C. Vons Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.

[Not Available]. / La chirurgie ganglionnaire dans les cancers de l'œsophage et de l'estomac.

C. Mariette, G. Piessen, C. Vons Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.

Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients.

BACKGROUND/AIMS: Certain prognostic factors affect the postoperative mortality and long-term survival of patients following hepatic resection for hepatocellular carcinoma (HCC) and may change the surgical strategy. METHODOLOGY: 209 consecutive patients underwent hepatic resection for HCC in our hospital. Seventy-three patients underwent major resection and 136 underwent minor resections. We looked for correlations between clinical, biological, surgical and pathological factors and postoperative mortality, disease-free survival and overall survival. RESULTS: The postoperative mortality rate was 7.7% (it fell to 0% in the last two years). The cumulative overall five-year survival rate was 27% and the overall disease-free survival rate was 7.3%. Multivariate analysis identified: (1) two independent prognostic factors for postoperative mortality: age and tumor size; (2) one risk factor for tumor recurrence: intraoperative blood transfusion, and (3) three independent prognostic factors for overall survival: infiltrative tumor type, surgical margin <10 mm and intraoperative blood transfusion. CONCLUSIONS: In addition to routine staging of the tumor, the preoperative evaluation of HCC patients should include tests to determine whether the tumor is infiltrative or expansive and whether it will be possible to obtain a surgical margin (>10 mm). This procedure should make it possible to propose an appropriate neoadjuvant treatment only to these patients. The prevention of intraoperative bleeding or blood transfusion should improve the disease-free and overall survival rates in HCC patients.