Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study.

BACKGROUND: Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection. METHODS: Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality. RESULTS: Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038). CONCLUSION: Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.

C-reactive protein assessment to predict early septic complications after laparoscopic bowel resection for endometriosis: a diagnostic study.

OBJECTIVE: To assess the predictive value of C-reactive protein (CRP) level for early septic complications after laparoscopic bowel resection for endometriosis. DESIGN: Retrospective study using data prospectively recorded in the CIRENDO database. SETTING: University tertiary referral centre. POPULATION: Three hundred and three women managed by segmental resection or disc excision for colorectal endometriosis in 40 consecutive months. METHODS: C-reactive protein was routinely measured at postoperative days 4, 5, and 6. Bowel fistula, pelvic abscess, and pelvic infected haematoma were prospectively recorded. MAIN OUTCOME MEASURES: A receiver operating characteristic (ROC) curve was built to assess the best cut off CRP value to predict early septic complications. RESULTS: The incidence of bowel fistula and pelvic abscess/infected hematoma were 2 and 7.9%, respectively. The CRP cut-off value of 100 mg/l at postoperative day 4 predicts early septic pelvic complications (sensitivity, specificity, positive and negative predictive values of, respectively, 76, 83, 30.2, and 90.4%), and the area under the curve was 0.85 (95% CI 0.78-0.92). CONCLUSION: Postoperative CRP monitoring is useful in the prediction of early septic pelvic complications following bowel endometriosis surgery, with possible impact on the management of postoperative outcomes and hospitalisation stay. TWEETABLE ABSTRACT: Levels of CRP ≥100 mg/l at day 4 after bowel resection or excision for endometriosis are associated with early septic pelvic complications.

Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients.

INTRODUCTION: Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy. METHODS: This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis. RESULTS: Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality. CONCLUSION: The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Multiple nodule removal in multifocal colorectal endometriosis instead of "en bloc" large colorectal resection.

Surgical management of colorectal endometriosis follows the principles of two main philosophies or approaches: radical and conservative. The radical approach has recently been recommended in multifocal colorectal endometriosis, which frequently concerns patients with rectal nodules. However, an alternative conservative management could employ selective retrieval of macroscopic colorectal deep endometriosis nodules by bowel shaving and disc excision, with preservation of the mesorectum. The conservative approach is justified by the evidence that low colorectal resection may lead to postoperative functional digestive symptoms for which management is most challenging. However, there is a lack of data in the literature specifically focusing on patients with multiple excision of deep colorectal endometriosis. No data exist about the minimal length of healthy bowel that should be conserved between two successive transversal bowel sutures, and on consecutive improvement of functional outcomes. Conversely, no evidence exists on presumed reduction of recurrence rate when young patients undergo low large colorectal resection, instead of multiple selective excisions. Further comparative studies would be welcome, among which the ENDORE randomized trial which may play a central role by comparing functional outcomes related to radical and conservative approach in deep endometriosis infiltrating the rectum.

Therapeutic management of perforated gastro-duodenal ulcer: literature review.

BACKGROUND: Management of perforated gastro-duodenal ulcer (GDU) is not consensual, from no operative treatment to surgery by simple closure, gastrectomy and vagotomy. The purpose of this study is to report results of the literature concerning management of perforated GDU. METHODS: Two authors, identified in the databases Pubmed and Embase studies, related to the therapeutic management of perforated GDU. The data were extracted from articles published between 1940 and 2012. RESULTS: Non-operative treatment is feasible for patients in good general condition and in good local circumstances without evolved peritonitis with a success rate more than 50%. Simple closure is the standard method. Laparoscopy is a safe and feasible method for patient with delay of treatment less than 24 hours and without associated complications with a success (meaning non conversion) of 80% and a mortality less than 1%. Rate of conversion is 7.9%, and increases in case of ulcer size >6 mm, frail ulcer edges, bleeding associated, unusual location and septic shock. Helicobacter pylori eradication is essential. Gastric tube, abdominal irrigation and drainage are still debated. Two-stage treatment for perforated gastric carcinoma, which represents 10 to 16% of gastric perforation, is a good option for frail patients with resectable tumors. CONCLUSION: Management of perforated GDU is still a subject of debate without guidelines but with several possibilities of treatment depending of local circumstances of peritonitis and size of defect >20 mm, general conditions, surgeon patterns and experience.