What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?

AIM: In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry. METHOD: From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation. RESULTS: A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm3 (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm3 (P = 0.001) was correlated with the risk of impending caecal perforation. CONCLUSION: Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Serum value of procalcitonin as a marker of intestinal damages: type, extension, and prognosis.

BACKGROUND: Ischemic and necrotic damages are complications of digestive diseases and require emergency management. Nevertheless, the decision to surgically manage could be delayed because of no sufficiently preoperative accurate marker of ischemia diagnosis, extension, and prognosis. METHODS: The aim of this study was to assess the predictive value of serum procalcitonin (PCT) levels for diagnosing intestinal necrotic damages, their extension, and their prognosis in patients with ischemic disease including ischemic colitis and mesenteric infarction by a gray zone approach. Between January 2007 to June 2014, 128 patients with ischemic colitis and mesenteric infarction (codes K55.0 and K51.9) were operated, for whom data on PCT were available. We perform a retrospective, multicenter review of their medical records. Patients were divided into subgroups: ischemia (ID group) versus necrosis (ND group); the extension [focal (FD) vs. extended (ED)] and the vital status [deceased (D) vs. alive (A)]. RESULTS: PCT levels were higher in the ND (n = 94; p = 0.009); ED (n = 100; p = 0.02); and D (n = 70; p = 0.0003) groups. With a gray zone approach, the predictive thresholds were (i) for necrosis 2.473 ng/mL, (ii) for extension 3.884 ng/mL, and (iii) for mortality 7.87 ng/mL. CONCLUSION: In our population, PCT could be used as a marker of necrosis; especially in case of extended damages and reflects the patient's prognosis.

Serum procalcitonin correlates with colonoscopy findings and can guide therapeutic decisions in postoperative ischemic colitis.

BACKGROUND: Postoperative ischaemic colitis (POIC) is a life-threatening vascular gastrointestinal condition. Serum procalcitonin (PCT) levels be of value in the detection of necrosis. AIMS: To evaluate the correlation between serum PCT levels and the colonoscopic assessment of the severity of POIC. METHODS: Between January 2007 and November 2014, 150 patients with POIC and PCT data were included in the study. The main outcome measure was the correlation between serum PCT and the colonoscopy-based assessment of the severity of POIC (according to Favier's classification: stage 1/2 without multi-organ failure vs. stage 2/3 with multi-organ failure). RESULTS: Eighty-five percent of the stage 1 cases (n=22) had a serum PCT level ≤2µg/L; 63% (n=19) of the stage 2 cases with multi-organ failure had a PCT level between 4 and 8µg/L, and 70% (n=52) of the stage 3 cases had a PCT level ≥8µg/L. The PCT level was strongly correlated with the Favier stage (Spearman's rho: 0.701; p<0.0001). PCT levels were similar in stage 2 cases with multi-organ failure and in stage 3 cases (16.06µg/L vs. 7.79µg/L, respectively; p=0.35). CONCLUSION AND RELEVANCE: Serum PCT is correlated with stage 2/3 POIC requiring surgery. If PCT ≥5µg/L, surgery should be considered.

Pyopneumothorax and peritonitis due to perforated duodenal ulcer and associated pleuroperitoneal communication.

Pleuroperitoneal communication is an anatomic entity that is typically asymptomatic but sometimes responsible for hydrothorax. This pleural manifestation can be explained by progressive transdiaphragmatic passage of intra-abdominal fluid because of abdominal hyperpressure. The object of this report is to present a hitherto unreported association of concomitant pleural effusion and acute infectious abdominal disease, due to perforated duodenal ulcer. This underscores that pleural effusion associated with acute abdominal pain may reveal the existence of a communication of this type, and requires surgical management.

Effectiveness of intraoperative cholangiography using indocyanine green (versus contrast fluid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy.

INTRODUCTION: During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the "gold standard" for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy. MATERIALS AND METHODS: Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the "analyzability rate" (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis. RESULTS: The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p = 0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure. CONCLUSION: IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.

Partial removal of infected parietal meshes is a safe procedure.

INTRODUCTION: Open tension-free hernioplasty using prosthetic meshes dramatically reduced recurrence rates after hernia or incisional hernia repair and has become the rule. Mesh infections (MI) are the major complication of prosthetic material. The aim of this study was to assess the efficacy of partial removal of mesh (PRM) therapy in the treatment of MI. MATERIALS AND METHODS: From January 2000 to April 2010, from a prospective database, we retrospectively selected patients who underwent surgery for MI. We studied the epidemiological data (sex, age, obesity, diabetes, smoking), the operating time of the initial intervention, the presence of intestinal injuries during the first intervention, the average interval between initial surgical procedure and MI, the location of the hernia, the average size of the hernia, type of mesh used, the position of the mesh, type of surgery performed, the number through interventions required to achieve a cure, the cumulative duration of hospital stay and hernia recurrence rates. RESULTS: Twenty-five patients were supported for a MI in our institution. There were 9 women (36 %) and 16 men (64 %). The median age was 59 years (range 37-78). There were 4 inguinal hernias (16 %), 15 incisional hernias (60 %) and 6 multirecurrent incisional hernias (24 %). It was performed a PRM in 92 % of cases (n = 23), a total excision of the prosthesis in 4 % of cases (n = 1) and no removal of prosthesis in 4 % of cases (n = 1). The average number of reoperations before healing was 1 (range 1-5). The mean cumulative duration of hospitalization until healing was 9.5 days (range 2-43). No visceral resection was performed. CONCLUSION: PRM is feasible in most cases allowing first to spare the capital parietal patients and secondly to avoid major surgery. In case of failure, total removal of the mesh can be discussed.

Management of supra-mesocolic peritonitis using the Levy helicoid drain (Hélisonde®).

INTRODUCTION: Postoperative peritonitis arising in the upper abdomen requiring reoperative surgery has a mortality rate of up to 50%. One therapeutic modality for these patients is the use of the Hélisonde(®) drain, designed by Levy, the Levy Helical Drain (LHD), but it has not seen widespread use. In this paper, we describe our experience in managing supramesocolic peritonitis with this drain at the University Surgical Center at Amiens and we analyze our results. PATIENTS AND METHODS: Between 2005 and 2010, we cared for 190 patients with supramesocolic peritonitis in our unit. Of these, 22 patients with gastric or duodenal fistula underwent transorificial intubation with the LHD. There were 12 men and 10 women with a mean age of 66 years. At surgery, the helical drain was screwed into the fistular orifice, two more flat drains were left adjacent to the fistula, and a jejunal feeding tube was placed. The mean interval between the initial surgery and the drainage procedure was 16.1 ± 14 days. RESULTS: The mean APACHE II score was 20 (10-28). The Mannheim score averaged 28 (19-34). The LHD was completely removed at a mean interval of 35.5 ± 11 days. Six patients (27%) died postoperatively. Postoperative complications included intraperitoneal abscess (n = 3), pneumonia (n=1), and evisceration (n = 2). Two patients required reoperation. The average hospital stay was 70.7 days. Four patients had a persistent chronic fistula. CONCLUSION: The LHD is a useful technical device in the treatment of supramesocolic peritonitis. Its management requires close oversight.

[Conservative treatment of an aortoduodenal fistula after paraaortic lymphadenectomy in hepatobiliary malignancy surgery with aortic endoprosthesis]. / Traitement conservateur d'une fistule aortoduodénale après curage interaorticocave dans le cadre d'une chirurgie hépatobiliaire carcinologique par endoprothèse aortique.

Lower gastrointestinal bleeding from a primary aortoduodenal fistula is unusual and usually fatal. Postoperative aortoduodenal fistula after biliary surgery is a very rare complication. We report hence a 69-year-old female patient who underwent a main bile duct resection with extended paraaortic lymphadenectomy for a cholangiocarcinoma. Acute melena with hemoglobin drop occurred on postoperative day 24. Initial CT-scan showed an aortic pseudoaneurysm with aortoduodenal fistula. An aortic endoprosthesis with endoscopic drainage of periaortic collections allowed successful treatment.