RESUMO
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).
Assuntos
Doença Diverticular do Colo , Diverticulite , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos de Coortes , Colo Sigmoide/cirurgia , Diverticulite/cirurgia , Diverticulite/complicações , Doença Diverticular do Colo/cirurgia , Doença Diverticular do Colo/complicações , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , IdosoRESUMO
BACKGROUND: Natural orifice transluminal endoscopy surgery (NOTES) gastrojejunal anastomosis (GJA) with duodenal exclusion (DE) could be used as a less invasive alternative to surgical gastric bypass. The aim of this study was to compare the efficacy and safety of both methods for bariatric purpose. METHODS: This was a prospective, experimental and comparative study on 27 obese living pigs, comparing 4 groups: GJA alone (group 1, G1), GJA + DE (group 2, G2), surgical gastric bypass (group 3, G3), control group (group 4, G4). GJA was endoscopically performed, using NOTES technic and LAMS, while DE was performed surgically for limb length selection. Animals were followed for 3 months. Primary outcome included technical success and weight change, while secondary endpoints included the rate of perioperative mortality and morbidity, histological anastomosis analysis and biological analysis. RESULTS: Technical success was 100% in each intervention group. No death related to endoscopic procedures occurred in the endoscopic groups, while early mortality (< 1 month) was 57,1% in the surgical group, all due to anastomotic dehiscence. At 3 months, compared to baseline, mean weight change was + 3,1% in G1 (p = 0,46); -14,9% in G2 (p = 0,17); +5,6% in G3 (p = 0,38) and + 25% in G4 (p = 0,029). Histopathological analysis of endoscopic GJA showed complete fusion of different layers without leak or abscess. CONCLUSIONS: Endoscopic GJA with DE provides the efficacy of bypass on weight control in an animal model. Next steps consist of the development of devices to perform exclusively endoscopically limb length selection and DE.
Assuntos
Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Suínos , Animais , Estudos Prospectivos , Endoscopia , Obesidade/cirurgia , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). METHODS: This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). RESULTS: Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). CONCLUSION: In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. KEY POINTS: ⢠Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. ⢠An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.
Assuntos
Intestinos/lesões , Mesentério/lesões , Ferimentos não Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Tratamento Conservador/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Intestinos/diagnóstico por imagem , Intestinos/cirurgia , Laparotomia/estatística & dados numéricos , Masculino , Mesentério/diagnóstico por imagem , Pessoa de Meia-Idade , Seleção de Pacientes , Projetos de Pesquisa , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Adulto JovemRESUMO
AIM: To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD: This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS: Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51 (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function. CONCLUSION: The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.
Assuntos
Abdome/cirurgia , Complicações Pós-Operatórias/cirurgia , Proctocolectomia Restauradora/métodos , Reoperação/métodos , Cirurgia Endoscópica Transanal/métodos , Adolescente , Adulto , Idoso , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Estudos de Casos e Controles , Bases de Dados Factuais , Defecação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Proctocolectomia Restauradora/efeitos adversos , Estudos Prospectivos , Reoperação/efeitos adversos , Estudos Retrospectivos , Cirurgia Endoscópica Transanal/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
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 37â ±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 [pâ =â 0.013] and the absence of preoperative enteral support [pâ =â 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, pâ =â 0.283], overall [28% vs 15% respectively, pâ =â 0.077] and severe postoperative morbidity [7% vs 7% respectively, pâ =â 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [pâ =â 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.
Assuntos
Abscesso Abdominal/terapia , Doença de Crohn/cirurgia , Abscesso Abdominal/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Estudos de Coortes , Doença de Crohn/complicações , Drenagem , Procedimentos Cirúrgicos Eletivos , Feminino , França , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Apoio Nutricional , Recidiva , Adulto JovemRESUMO
Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.
Assuntos
Competência Clínica , Simulação por Computador , Currículo , Procedimentos Cirúrgicos do Sistema Digestório/educação , Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Internato e Residência/métodos , França , HumanosRESUMO
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.
Assuntos
Colectomia/normas , Colite Ulcerativa/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Colectomia/métodos , Colectomia/estatística & dados numéricos , Colite Ulcerativa/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: The aim was to determine whether a simulation-based care pathway approach (CPA) curriculum could improve compliance for enhanced recovery programs (ERP), and residents' participation in laparoscopic colorectal surgery (LCS). Indeed, trainee surgeons have limited access to LCS as primary operator, and ERP have improved patients' outcomes in colorectal surgery (CS). METHODS: All residents of our department were trained in a simulation-based CPA: perioperative training consisted in virtual patients built according to guidelines in both ERP and CS, whilst intraoperative training involved a virtual reality simulator curriculum. Twenty consecutive patients undergoing CS were prospectively included before (n=10) and after (n=10) the training. All demographic and perioperative data were prospectively collected, including compliance for ERP. Residents' participation as primary operator in LCS was measured. RESULTS: Five residents (PGY 4-7) were enrolled. None had performed LCS as primary operator. Overall satisfaction and usefulness were both rated 4.5/5, usefulness of pre-, post- and intraoperative training was rated 5/5, 4.5/5 and 4/5, respectively. Residents' participation in LCS significantly improved after the training (0% (0-100) vs. 82.5% (10-100); P=0.006). Pre- and intraoperative data were comparable between groups. Postoperative morbidity was also comparable. Compliance for ERP improved at Day 2 in post-training patients (3 (30%) vs. 8 (80%); P=0.035). Length of stay was not modified. CONCLUSIONS: A simulated CPA curriculum to training in LCS and ERP was correctly implemented. It seemed to improve compliance for ERP, and promoted residents participation as primary operator without adversely altering patients' outcomes.
Assuntos
Competência Clínica , Cirurgia Colorretal/educação , Deambulação Precoce , Treinamento por Simulação/métodos , Estudos de Coortes , Procedimentos Clínicos , Currículo , Educação de Pós-Graduação em Medicina/métodos , Feminino , Humanos , Internato e Residência , Masculino , Estudos Prospectivos , Recuperação de Função Fisiológica , Reino UnidoRESUMO
INTRODUCTION: Enhanced recovery after surgery programs (ERP) often lead to early discharge and return to home. In terms of risk management, extended surveillance is recommended. Surveillance using text messages (TM) has been validated for minor operations in ambulatory surgery. The goal of this study was to evaluate the feasibility of home surveillance by TM after colorectal surgery within an ERP. METHODS: This prospective multicenter study involved the University hospitals of Clermont-Ferrand, Grenoble, Marseille and Lyon Sud between November 2014 and September 2015. All patients underwent colorectal surgery within an ERP. Post-discharge, patients received TM (4 simple questions with regard to pain, bowel movements, temperature and phlebitis) on days 1, 3 and 5. If there was abnormal or lack of response, an automatic alert was sent to the attending physician via Internet and the patient was contacted immediately. RESULTS: One hundred and eleven patients were included. Responses were obtained within a median of 12 (1-422) minutes, and 90% of patients answered all TM. There were 48 alerts: 56% because of pain and 40% due to absence of response to the TM. Alerts led to in-hospital care for 4% of patients including three re-hospitalizations and two unplanned re-operations. The median satisfaction score (85% of patients responded) was 5 on a scale of 1 to 5. CONCLUSION: This study suggests the possibility, as for ambulatory surgery, to use test messaging for post-discharge home surveillance for patients undergoing colorectal surgery within an ERP.
Assuntos
Assistência ao Convalescente/métodos , Colo/cirurgia , Cuidados Pós-Operatórios/métodos , Reto/cirurgia , Telemedicina/métodos , Envio de Mensagens de Texto , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Reoperação/estatística & dados numéricosAssuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos , Doença Diverticular do Colo/terapia , Prescrição Inadequada/prevenção & controle , Doenças do Colo Sigmoide/terapia , Doença Aguda , Doença Diverticular do Colo/diagnóstico , Humanos , Guias de Prática Clínica como Assunto , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery. MATERIAL AND METHODS: This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills. RESULTS AND CONCLUSIONS: There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.
Assuntos
Competência Clínica , Simulação por Computador , Internato e Residência/métodos , Laparoscopia/educação , Currículo , Europa (Continente) , Humanos , Modelos Biológicos , Interface Usuário-ComputadorRESUMO
Intestinal transplantation (IT) can involve small bowel transplantation alone, or be associated with liver or multivisceral transplantation. Although IT is the radical treatment for intestinal failure, home parenteral nutrition (PN) remains the treatment of choice for this disease. Indications for IT are still debated. A recent study showed that early referral for IT is recommended for patients with life-threatening combined liver and intestinal failure or for patients with invasive intra-abdominal desmoid tumors. In the same study, no survival benefit was shown for patients undergoing IT for ultra-short bowel or major complications related to the PN catheter; indications still need to be fully assessed. While short-term outcomes for IT have improved dramatically (one-year survival for small bowel-alone IT is now 80% versus 0-28% in the 1980s), long-term outcomes have not improved much since the introduction of Tacrolimus in the 1990s: five-year survival still does not exceed 60%. Some prospective developments could improve these results: the use of multivisceral grafts, the use of Sirolimus and Thymoglobulins in the immunosuppressive treatment, or the use of new biochemical markers for early diagnosis of graft rejection.