Systematic C-reactive protein monitoring reduces hospital stay after laparoscopic ileal pouch-anal anastomosis. A comparative study of 158 consecutive patients with ulcerative colitis.

AIM: C-reactive protein (CRP) is a common biomarker of inflammation which has largely been used to predict the risk of postoperative septic complications after colorectal surgery. However, no data exist concerning its potential benefit after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The aim of this study was to evaluate a CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC. METHODS: Since 2012, 158 patients undergoing a laparoscopic IPAA for UC have been included: 66 patients (CRP group) operated since 2016 had a CRP-driven monitoring discharge on postoperative day 5 (POD 5) and were discharged on POD 6 if CRP < 100 mg/L; these patients were matched (according to age, gender, body mass index, IPAA in two or three steps) to 92 patients operated between 2012 and 2016 without any CRP monitoring (control group). RESULTS: Median length of hospital stay was shorter in the CRP than the control group (7 vs. 9 days; P < 0.001) and discharge on POD 6 occurred more frequently in the CRP group (47% vs. 7%, P < 0.001). No difference was observed between the two groups concerning overall morbidity (P = 0.980), surgical site infection (P = 0.554), Clavien-Dindo ≥ IIIa morbidity (P = 0.523), unplanned rehospitalization (P = 0.734) and 30-day reoperation (P = 0.240). CONCLUSION: CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC is associated with a significant reduction in length of hospital stay, without increasing morbidity, reoperation or rehospitalization rates.

Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer.

AIM: After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter-saving surgery are to perform a side-to-end manual coloanal anastomosis (CAA) (or with J-pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull-through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer. METHOD: From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n = 190) versus DCAA without stoma (n = 33). RESULTS: Overall 3-month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p = 0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant). CONCLUSION: Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).

Postoperative rectovaginal fistula: Can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases.

AIM: Management of rectovaginal fistula (RVF) remains a challenge, especially in cases of postoperative RVF as they are often large and surrounded by inflammatory and fibrotic tissue, making local repair difficult or even impossible. In this situation, colonic pull-through delayed coloanal anastomosis (DCAA) could be an interesting option. The aim of this study was to assess the results of DCAA for RVF observed after rectal surgery. METHODS: All patients who underwent DCAA for RVF were reviewed. Success was defined as a patient without stoma and without any symptoms of recurrent RVF at the end of follow-up. RESULTS: From January 2010 to December 2020, 28 DCAA were performed for RVF after rectal surgery for rectal cancer (n = 21) or endometriosis (n = 7). Ten patients (36%) had at least one previous local procedure before DCAA. DCAA was associated with temporary ileostomy in 22/28 cases (79%). After a mean follow-up of 23 ± 23 (2-82) months, the success rate was 86% (24/28): three patients (11%) required a definitive stoma because of poor functional results (n = 1), chronic pelvic sepsis with anastomotic leakage (n = 1) or stoma reversal refused (n = 1). Another patient (3%) presented with recurrence of RVF, 26 months after DCAA. Although not significant, the success rate was higher in cases of DCAA with diverting stoma (20/22, 91%) than without (4/6, 67%) (p = 0.191). CONCLUSION: In cases of postoperative RVF, DCAA is a safe option which can avoid definitive stoma in the great majority of the patients. Concomitant use of a temporary stoma appears to slightly increase the success rate.

Comparison of reconstruction methods used during liver transplantation in case of a graft with replaced or accessory right hepatic artery: A retrospective study.

Variations in graft arterial anatomy can increase the risk of postoperative hepatic arterial thrombosis (HAT), especially in presence of a replaced or accessory right hepatic artery (RHA). We retrospectively analyzed 223 cases of liver transplantations with the presence of an RHA on the graft. Patient outcomes were compared according to the four different reconstruction methods used: (i) the re-implantation of the RHA into the splenic or gastroduodenal artery (n = 106); (ii) the interposition of the superior mesenteric artery (SMA) (n = 83); (iii) dual anastomosis (n = 24); (iv) use of an aortic patch including the origins of both the SMA and the coeliac trunk (n = 10). A competing risk analysis and Inverse Probability Weighting (IPW) were used. We found that the interposition of the SMA method was associated with a significantly lower incidence of HAT, at 4.8% compared to the re-implantation method at 17.9%, dual anastomosis at 12.5%, and aortic patch at 20%, p = .03. In the competing risk analysis with IPW, the only risk factor for RHA thrombosis was the type of reconstruction. Taking the SMA interposition group as the reference, the sub-hazard ratio (sHR) was 5.05 (CI 95 [1.72; 14.78], p < .01) for the re-implantation group, sHR = 2.37 (CI 95 [0.51; 11.09], p = .27) for the dual anastomosis group and sHR = 2.24 (CI 95 [0.35; 14.33], p = .40) for the aortic patch group. There were no differences for intraoperative transfusion, hospitalization duration (p = .37) or incidence of severe complications (p = .1). The long-term graft (p = .69) and patient (p = .52) survival was not different. In conclusion, the SMA interposition method was associated with a lower incidence of RHA thrombosis.

A Long Graft Artery is a Safe and Reproducible Procedure for Arterial Reconstruction In Liver Transplantation.

BACKGROUND: Although a short and nonredundant anastomosis is most often performed in liver transplantation, there is no strong evidence in the literature about the ideal arterial reconstruction. We describe here the "long-artery" technique that enables a wide side-to-end anastomosis and preserves arterial length. METHODS: We present the results between 2011 and 2019 of the "long-artery" technique performed in our center. Patients with a split liver transplantation or aortohepatic conduits were not included. This technique uses the whole arterial axis of the graft. A side-to-end anastomosis is performed between the common and/or proper hepatic artery of the recipient, and the celiac trunk with an aortic patch of the graft, while the gastroduodenal artery of the recipient is preserved. An omental flap is positioned under the graft artery to prevent kinking. RESULTS: Eight hundred thirty-two transplant patients were included in the analysis. Early hepatic artery thrombosis was diagnosed in 22 (2.6%) patients and occurred within the first 10 days after the procedure. A thrombectomy was performed in 7 patients, which was successful in 4 patients, and 18 patients were retransplanted. Seven patients (0.8%) developed a late hepatic artery thrombosis, including 2 patients who were retransplanted. CONCLUSIONS: The "long-artery" technique is a safe and efficient technique for arterial reconstruction in liver transplantation and does not seem to increase the rate of early hepatic artery thrombosis.

Therapeutic anticoagulation after liver transplantation is not useful among patients with pre-transplant Yerdel-grade I/II portal vein thrombosis: A two-center retrospective study.

BACKGROUND: Portal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT. OBJECTIVES: The aim of our study was to evaluate the role of tAC post-LT in the prevention of PVT recurrence. PATIENTS/METHODS: All adult LTs performed in two high-volume centers between 2003 and 2018 were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC-associated morbidity within 1 year were compared between patients receiving tAC or not. RESULTS: During the study period, of 2612 LTs performed, 235 (9%) patients with PVT were included; 113 patients (48.1%) received post-LT tAC (tAC group) while 122 (51.9%) did not (non-tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 [23%] vs. 5 [4.1%], P < .01) and the initial hospitalization duration was longer (21 vs. 17.5 days, P < .01). Within the first year, PVT recurrence was observed for 9 (3.8%) patients without any difference between the tAC and non-tAC groups (6 [5.1%] vs. 3 [2.5%], P = .39). The only identified risk factor for PVT recurrence was the recipients' age (odds ratio= 0.94, P = .03). Graft (P = .11) and patient (P = .44) survival were similar between the two groups. CONCLUSION: Therapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.

Lateral cavo-caval shunt: an alternative veno-venous bypass in liver surgery.

When inferior vena cava (IVC) resection is mandatory during liver surgery, use of a veno-venous bypass (VVB) is usually required despite its specific related adverse events. We describe a safe and alternative technique which allows both derivation of the portal and the caval blood flow by performing a lateral cavo-caval shunt using a prosthetic graft.

Tacrolimus Concentrations Measured in Excreted Bile in Liver Transplant Recipients: The STABILE Study.

PURPOSE: Tacrolimus (TAC) is the main immunosuppressive drug in liver transplantation. Despite intensive therapeutic drug monitoring (TDM) that relies on whole blood trough concentration (TACblood), patients still present with acute cellular rejection or TAC-related toxic effects with concentrations within the therapeutic range. TAC concentration in peripheral blood mononuclear cells (TACPBMC) is considered as an efficient surrogate marker of TAC efficacy. However, it is still not applicable in daily practice. New TDM methods are therefore needed, especially during the early postoperative period. TAC is metabolized in the liver and eliminated through biliary excretion. We therefore hypothesised that TAC concentration measured in excreted bile (TACbileC) could be a relevant surrogate marker of its efficacy. METHODS: The Therapeutic Drug Monitoring of Tacrolimus Biliary Concentrations for Liver-Transplanted Patients (STABILE) study is a prospective monocentric trial. During the 7 first days after TAC therapy initiation, TACbileC was measured. The correlation between TACbileC and TACPBMC as well as between TACblood and TACPBMC was assessed. The correlations between TACbileC and liver graft function parameter or with occurrence of neurologic toxic effects were also evaluated. FINDINGS: Between May 2016 and April 2017, 41 patients were analyzed. TACbileC was significantly correlated with TACPBMC (r = 0.25, P = 0.007). However, a better correlation was found between TACPBMC and TACblood (r = 0.53, P < 0.001) and was confirmed in multivariate analysis. However, only TACbileC was significantly correlated with liver graft function, such as factor V (r = 0.40, P = 0.009) or bilirubin level (r = 0.21, P = 0.01), and significantly lower in patients presenting with neurologic toxic effects (P < 0.001). Receiver operating characteristic curve analysis found that a TACbileC level lower than 0.20 ng/mL on day 2 after TAC therapy initiation was a good predictive marker of occurrence of neurotoxic effects (AUC = 0.81). IMPLICATIONS: TACbileC is not a better surrogate maker of TAC activity than TACblood. However, TACbileC could help predict the occurrence of TAC toxic effects when a T-tube is inserted. ClinicalTrials.gov identifier: NCT02820259.