Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

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).

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey.

BACKGROUND: The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study. METHODS: This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection. RESULTS: Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010). CONCLUSION: Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

ANTECEDENTES: El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional. MÉTODOS: Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non-cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección. RESULTADOS: Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post-hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92-0,41; P = 0,096) y de PHLF (OR 7,13; i.c. del 95% 0,91-323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08-48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14-0,76; P = 0,010) pacientes CL. CONCLUSIÓN: La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. METHODS: Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. RESULTS: One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. CONCLUSION: DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Ruptured Pancreaticoduodenal Artery Aneurysms Associated with Celiac Stenosis Caused by the Median Arcuate Ligament: A Poorly Known Etiology of Acute Abdominal Pain.

OBJECTIVE/BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysm is a rare but clinically important form of vascular disease. A small proportion of these aneurysms are caused by compression of the artery by the median arcuate ligament (MAL). The objective of the study was to establish whether it is feasible and effective to treat ruptured PDA aneurysms without treating the celiac stenosis caused by the MAL. METHODS: From January 2007 to November 2014, 10 patients were included. Standard embolization or surgical procedures were used to treat the ruptured aneurysms, but the celiac stenosis itself was not treated. The primary end point was the feasibility and efficacy of embolization for the treatment of ruptured PDA aneurysms. The secondary end points included clinical data, imaging findings, the success rate of embolization and the outcome during follow up. RESULTS: All patients presented with acute, non-specific epigastric pain with nausea. An abdominal computed tomography scan revealed peri-pancreatic hematoma in all cases, and PDA aneurysms were visible in six patients. The aneurysms ranged from 2 mm to 10 mm in diameter and were variously located on the anterior PDA (n = 1), the posterior PDA (n = 3), and the branch of the dorsal pancreatic artery (n = 6). Surgery was performed in two cases (with one death). Embolization was successful in the other eight cases. The median length of hospital stay was 10 days (range 8-25 days). Over a median follow up period of 11 months (range 5-48 months), none of the PDA aneurysms recurred. CONCLUSION: Rupture of a PDA aneurysm caused by the MAL should always be considered in the differential diagnosis of acute abdominal pain, because the condition requires specific management. Embolization is safe and has a high success rate. Surgery should only be performed when embolization fails.

Compliance with an empirical antimicrobial protocol improves the outcome of complicated intra-abdominal infections: a prospective observational study.

BACKGROUND: Despite improvements in medical and surgical care, mortality attributed to complicated intra-abdominal infections (cIAI) remains high. Appropriate initial antimicrobial therapy (ABT) is key to successful management. The main causes of non-compliance with empirical protocols have not been clearly described. METHODS: An empirical ABT protocol was designed according to guidelines, validated in the institution and widely disseminated. All patients with cIAI (2009-2011) were then prospectively studied to evaluate compliance with this protocol and its impact on outcome. Patients were classified into two groups according to whether or not they received ABT in compliance with the protocol. RESULTS: 310 patients were included: 223 (71.9%) with community-acquired and 87 (28.1%) with healthcare-associated cIAI [mean age 60(17-97) yr, mean SAPS II score 24(16)]. Empirical ABT complied with the protocol in 52.3% of patients. The appropriateness of empirical ABT to target the bacteria isolated was 80%. Independent factors associated with non-compliance with the protocol were the anaesthetist's age ≥36 yr [OR 2.1; 95%CI (1.3-3.4)] and the presence of risk factors for multidrug-resistant bacteria (MDRB) [OR 5.4; 95%CI (3.0-9.5)]. Non-compliance with the protocol was associated with higher mortality (14.9 vs 5.6%, P=0.011) and morbidity: relaparotomy (P=0.047), haemodynamic failure (P=0.001), postoperative pneumonia (P=0.025), longer duration of mechanical ventilation (P<0.001), longer ICU stay (P<0.001) and longer hospital stay (P=0.002). On multivariate logistic regression analysis, non-compliance with the ABT protocol was independently associated with mortality [OR 2.4; 95% CI (1.1-5.7), P=0.04]. CONCLUSIONS: Non-compliance with empirical ABT guidelines in cIAI is associated with increased morbidity and mortality. Information campaigns should target older anaesthetists and risk factors for MDRB.

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.

Unusual course of the aberrant right hepatic artery running through the pancreatic parenchyma during modified Frey's procedure.

We report a variation of an aberrant right hepatic artery arising from the superior mesenteric artery and crossing into pancreatic head without other hepatic artery substitution. The variant was discovered during radiological examinations in a patient with symptomatic chronic pancreatitis requiring Frey's procedure with reinsertion of the common bile duct into the pancreatic head. An aberrant right hepatic artery arising from the superior mesenteric artery is present in 10 to 20% of case and its course is usually retro-pancreatic. The course of this artery into the pancreatic head is uncommon and can be present up to 10% in case of ARHA. Knowledge of an aberrant right hepatic artery crossing into the pancreatic head is important before pancreatic surgery in order to avoid surgical complications, especially for liver necrosis.

Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum.

BACKGROUND: Management of diverticulum of the lower esophagus or epiphrenic diverticulum can be performed using the abdominal or thoracic approach. In some cases, the thoracic approach is preferred, but few studies have described thoracoscopic resection. The objective of the present study was to investigate the thoracoscopic approach for management of epiphrenic esophageal diverticulum. MATERIAL AND METHODS: From 2008 to 2018, all patients undergoing surgery for epiphrenic esophageal diverticulum by the thoracoscopic approach were included in this single-center, retrospective, observational study. Data on diverticulum, surgery and follow-up were assessed. RESULTS: During the study period, 14 patients underwent surgery. Two patients had two diverticula. The mean location of the superior edge of the diverticulum was 7cm (2-14cm) above the gastro-esophageal junction. The mean size of the diverticulum was 39 millimeters (20-60). Thoracoscopic approach was used in all patients. No conversion to thoracotomy was required. Mean operative time was 168min (120-240). No postoperative mortality occurred. The overall complication rate was 40% (6 complications out of 15 resections), with three major complications including leaks (n=2) and a case of bronchoesophageal fistula (n=1). Median length of hospital stay was 12 days (8-40). At a mean postoperative follow-up of 20.7 months (5-71), 85% of patients had complete disappearance of preoperative symptoms without recurrence of the diverticulum on the barium swallow study test. CONCLUSION: Thoracoscopic approach as management of epiphrenic diverticulum is feasible, with acceptable short-term morbidity. The thoracoscopic approach is also effective in resolving preoperative symptoms.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic.

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

[SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic]. / Recommandations de la SOFFCO-MM en vue de la reprise de l'activité de chirurgie bariatrique et métabolique pendant et après la pandémie Covid-19.

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

Stomal construction: Technical tricks for difficult situations, prevention and treatment of post-operative complications.

The creation of a digestive stoma, whether it is a lateral stoma or a terminal stoma, is an essential gesture in colorectal surgery, but that may result in post-operative complications in 35% of patients. Surgeons are aware of the situations at the origin of complications, although there is little factual data in the literature to discriminate them. They are related to patient-specific factors (obesity, cirrhosis, portal hypertension) or to the underlying pathology (colon obstruction) or the conditions under which the intervention is performed (emergency). The aim of this review is to describe these different situations and the data from the literature that may allow reduction of the risk of an unsatisfactory or even complicated stoma.

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.

Impact of a procalcitonin-based algorithm on the management of adhesion-related small bowel obstruction.

INTRODUCTION: Adhesion-related small bowel obstruction (ASBO) management is difficult if there are no signs of strangulation or peritonitis when intestinal transit has not been restored. The aim of the present study was to determine the impact of combining a procalcitonin (PCT)-based algorithm with clinical signs on the management of uncomplicated ASBO. METHOD: We performed a pilot, retrospective, single-center "before-after" study. During the "before" period (2007 to 2012), patients with uncomplicated ASBO (n=93, the Gastrografin® group) underwent a clinical examination and a Gastrografin® index. During the "after" period (2013 to 2016), patients with uncomplicated ASBO (n=70, the algorithm group) underwent a clinical examination and were assessed with the PCT-based algorithm. The study's primary outcome was the appropriateness of ASBO management. The secondary outcomes were the need for surgery and the time to surgery, the LOS, the morbidity and mortality rates, and the recurrence rate. RESULTS: The proportion of well-managed patients was higher in the algorithm group than in the Gastrografin® group (86% vs. 47%; P<0.001). The time to surgery (48h vs 72h; P=0.02) and the LOS (4 vs. 6days, P=0.02) were significantly lower in the algorithm group. The need for surgery was similar in both groups (31% vs. 37%, P=0.49). The morbidity (P=0.69), mortality (P=0.82) and recurrence rates (P=0.57) were similar in the two groups. CONCLUSION: The use of a PCT-based algorithm is of value in the routine clinical management of ASBO; it reduces the LOS and the time to surgery without increasing the need for surgery.

Conservative endoscopic management for pancreatic trauma.

Traumatic pancreatic injuries are rare: their severity correlates with main pancreatic duct involvement. We report the case of a 5-year-old child who presented with complete disruption of the main pancreatic duct, treated successfully with an endoscopically inserted double pigtail stent.

A critical analysis of factors leading to next-day discharge in ambulatory surgery patients.

INTRODUCTION: Ambulatory surgery (AS) is becoming the rule. However, some patients do not have AS despite correct indications. The purpose of this retrospective study of prospectively collected data was to analyze why these patients do not have AS and evaluate their immediate post-operative course, in order to broaden the indications for AS. MATERIAL AND METHODS: Between January and December 2013, the reasons why patients who had appropriate indications for ambulatory cholecystectomy or hernia repair but later had conventional hospital management were recorded. The primary endpoint was early post-operative morbidity. Secondary endpoints were demographic, surgical, anesthetic, post-operative data as well as analysis of criteria leading to conventional hospital stay. RESULTS: Among 410 patients undergoing surgery for accepted AS indications, 158 (39%) did not have AS; 113 out of these patients (72%) were discharged the day following surgery. Of the 69 patients (43.6%) who did not have AS for medical reasons (50 by the surgeon's decision alone), 60 patients could have undergone AS since their outcome was uneventful in 96% of cases; only three patients (2.5%) had post-operative complications. CONCLUSION: The AS rate could have been increased by 15% through better surgical and anesthetic collaboration.

Percutaneous transgluteal drainage of pelvic abscesses in interventional radiology: A safe alternative to surgery.

AIM: Interventional radiology plays an important role in the management of deep pelvic abscesses. Percutaneous drainage is currently considered as the first-line alternative to surgery. A transgluteal computed tomography (CT)-guided approach allows to access to deep infected collections avoiding many anatomical obstacles (vessels, nerves, bowel, bladder). The objective of this study was to assess the safety and efficacy of a transgluteal approach by reviewing our clinical experience. MATERIALS AND METHOD: We reviewed medical records of patients having undergone percutaneous CT-guided transgluteal drainage for deep pelvic abscesses. We focused on the duration of catheter drainage, the complications related to the procedures and the rate of complete resolution. RESULTS: Between 2005 and 2013, 39patients (27women and 12men; mean age: 52.5) underwent transgluteal approach CT-guided percutaneous drainage of pelvis abscesses in our department. The origins of abscesses were postoperative complications in 34patients (87.2%) and infectious intra-abdominal disease in 5patients (12.8%). The mean duration of drainage was 8.3days (range: 3-33). Laboratory cultures were positive in 35patients (89.7%) and Escherichia coli was present in 71.4% of the positive samples. No major complication was observed. Drainage was successful in 38patients (97.4%). A transpiriformis approach was more significantly associated with intra-procedural pain (P=0.003). CONCLUSION: Percutaneous CT-guided drainage with a transgluteal approach is a safe, well-tolerated and effective alternative to surgery for deep pelvic abscesses. This approach should be considered as the first-line intention for the treatment of deep pelvic abscesses.