Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis.

OBJECTIVE AND BACKGROUND: Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). However, the literature on the long-term impact of SEMS as "a bridge to surgery" is limited and contradictory. METHODS: From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias. RESULTS: There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group. CONCLUSIONS: Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.

The gentamicin-collagen sponge for surgical site infection prophylaxis in colorectal surgery: a prospective case-matched study of 606 cases.

PURPOSE: Surgical site infection (SSI) is a major concern in colorectal surgery (CRS). It accounts for 60 % of all postoperative complications and has an incidence of between 10 and 30 %. The gentamicin-collagen sponge (GCS) was developed to help avoid SSI. The aim of this study was the evaluation of the efficacy of a GCS in preventing SSI after CRS. METHOD: This study was a retrospective analysis of data collected in a prospective database. Six hundred six CRS patients were enrolled in the study and prospectively assigned to one of two groups. From January 2007 to December 2008, all procedures were performed without the use of GCS (forming the non-GCS group). From January 2009 to July 2011, all procedures included a GCS (forming the GCS group). The primary endpoint was the presence or absence of SSI at postoperative day 30. RESULTS: The incidence of SSI was 29.7 and 20.8 % in the non-GCS and GCS groups, respectively (p = 0.019). By using a stepwise logistic regression, the predictors of SSI were found to be ASA grade (p < 0.001), operating time (log-transformed value, p < 0.001), gender (p = 0.021), and GCS use (p < 0.001). By adjusting on these variables, a mean reduction in postoperative hospitalization of 8.3 days was found in the GCS group. The proportions of Clavien IIIB-V were 16.6 and 8.9 % for the non-GCS and GCS groups, respectively (p = 0.041). CONCLUSIONS: This study provides additional evidence of the efficacy of the GCS in reducing SSI rates and shortening hospitalization after CRS.

The feasibility of short-stay laparoscopic appendectomy for acute appendicitis: a prospective cohort study.

BACKGROUND: Short-stay laparoscopic appendectomy for acute appendicitis (AA) has not yet been validated. This study was designed to prospectively evaluate the hospital length of stay (LOS) after laparoscopic appendectomy for AA and to determine predictive factors for successful short-stay surgery (LOS <24 h). METHODS: Between January and December 2010, all consecutive adults admitted for AA were prospectively treated with LOS <24 h as a patient management goal. The proportion of patients with LOS <24 h was analyzed for the intention-to-treat (ITT) population and for the population eligible for short-stay surgery. Predictive factors for LOS <24 h were analyzed. RESULTS: Of the 123 patients included in this study, 71.5 % (88/123) were eligible for short-stay surgery. The proportion of LOS <24 h cases was 52 % (64/123) in the ITT population and 72.7 % (64/88) in the eligible population. LOS <12 h was achieved in 17.8 % (22/123) in the ITT patients and 25 % (22/88) of the eligible patients. The main cause of unexpected readmission was postoperative pain (n = 10, 8.1 %). Age <23 years and a serum C-reactive protein level <18 mg/l had a positive predictive value of 100 % for LOS <24 h. Of the eligible patients, 27.2 % (24/88) were subject to unplanned overnight admissions and postsurgery readmissions. CONCLUSIONS: LOS <24 h was feasible for 52 % of patients admitted for AA and for 72.7 % of the patients eligible for short-term surgery. Low age and a low preoperative serum CRP level are predictive factors for the feasibility of short-stay laparoscopic appendectomy for AA.

Technique of open laparoscopy for supramesocolic surgery in obese patients.

BACKGROUND: Incidence of obesity and related diseases are increasing in the world. Visceral surgeons are more often confronted with laparoscopic surgery in obese patients. Besides validated surgery procedures, such as cholecystectomy and gastroesophageal reflux surgery, bariatric procedures are increasingly performed. In obese patients, the thickness of adipose panicle makes open laparoscopy hazardous. METHODS: In our department, we use systematically a technique of open laparoscopy in obese patients for supramesocolic surgery, which is safe, reproducible, and permits good closure of the abdominal wall. RESULTS: The surgical technique consists of opening the abdominal wall through the rectus abdominis. Helped by specific retractors called Descottes (Medtronic Laboratory), both fascias are charged by sutures separately. Incision in the fascias is made safely by pooling on sutures. Introduction of port-site is made under view control. At the end of laparoscopy, closure of both fascias is easily done. CONCLUSIONS: We present a technique of open laparoscopy in obese patients, systematically used, for supramesocolic surgery. This technique is safe, reproducible, and permits an efficient closure of the abdominal wall.

Stapled marsupialisation of chronic low rectal anastomotic sinuses.

PURPOSE: This report describes a technique for the treatment of patients with chronic pelvic anastomotic sinuses (AS) after low anastomosis for rectal cancer in which transanal stapled marsupialisation is performed. METHODS: We reviewed the clinical history of a 62-year-old patient who had a symptomatic chronic pelvic AS more than 6 months after stapled low colorectal side-to-end anastomosis with loop ileostomy for a stage II cancer of the mid rectum without preoperative radiochemotherapy. Pelvic abscess was recurrent three times after percutaneous drainage, operative transanal drainage, and treatment with fibrin glue and ileostomy closure. The fourth treatment was a marsupialisation of the AS. The marsupialisation consisted of a section of the common wall between the colon lumen and the AS. It was performed by transanal route under general anaesthesia with a laparoscopic stapler. RESULTS: There was no intraoperative complication. The postoperative course was uneventful, and the patient was discharged without symptoms. At 3 months, the clinical examination was normal. Functional results were good without defecation disorders. CONCLUSIONS: Marsupialisation with a stapler of a chronic AS after low anastomosis for rectal cancer is an effective and efficient technique. On the basis of our experience, we believe that it may be an alternative management of the chronic AS. It allows conservation of the anastomosis.

Healing of stoma orifices: multicenter, prospective, randomized study comparing calcium alginate mesh and polyvidone iodine mesh.

BACKGROUND: The aim of this multicenter, randomized, prospective study was to reveal a difference in terms of a guided healing period in the case of stoma orifices after reestablishing digestive continuity by comparing an alginate mesh with a polyvidone iodine mesh. METHODS: Between April 2004 and September 2005, a total of 73 patients were randomized into two groups: A (alginate mesh) and M (polyvidone iodine mesh). The groups were comparable for demographic data, indications for and the type of stoma, and perioperative data. The main evaluation criterion was percentage healing at the 28th postoperative day (D28); and the secondary criteria were healing time, rate of infectious complications, and number of dressing changes applied. RESULTS: The mean percentage healing at D28 was 91% in group A and 87% in group M (p = 0.49). The mean healing time was 31 days in group A and 32 days in group M (p = 0.80). One parietal abscess (3%) occurred in group A (p = 0.37). The mean number of meshes used was 13 +/- 5 in group A and 18 +/- 8 in group M (p < 0.005). CONCLUSION: The use of an alginate mesh for guided healing of stoma orifices after reestablishing digestive continuity allows effective healing within a normal period of time with a lower number of meshes.

Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy.

BACKGROUND: Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD. STUDY DESIGN: Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day. RESULTS: PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present. CONCLUSIONS: Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.

Management of obstructed left colon carcinoma.

BACKGROUND/AIMS: The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of this retrospective study is to review the results of three surgical procedures used in our department of Visceral Surgery (subtotal colectomy, segmental resection following intraoperative irrigation, and Hartman's procedure) and to determine if there were advantages of one technique over the other. METHODOLOGY: Ninety-three patients with acute left colonic obstruction were treated by subtotal/total colectomy (n=38), segmental resection following intraoperative irrigation (n=39), and Hartman's procedure (n=16). We assessed immediate postoperative results (mortality and morbidity rates, reoperation rate and hospital stay. RESULTS: The overall mortality and morbidity rates were respectively 13% (n=12) and 30.1% (n=28). The mortality rate was 13% (n=5) in the subtotal colectomy group, 7.7% (n=3) in the intraoperative colonic irrigation and 25% (n=4) in the Hartman's procedure group. The morbidity rates were similar after subtotal or segmental resection (7.9% vs. 10.2%), bowel movements were more frequent after subtotal colectomy (range 1-5 day) than segmental colectomy (range: 1-2 per day). CONCLUSIONS: Segmental resection following intraoperative irrigation is the preferred treatment for left sided malignant colonic obstruction. Subtotal colectomy is recommended for patients with ischemic lesions and serosal tears on the cecum, and when there is a synchronous neoplasm in the proximal colon.

[Adenomatous polyposis of the gallbladder and Gardner's syndrome. A rare association]. / Polypose adénomateuse vésiculaire et syndrome de Gardner: une association rare.

We report one case of adenomatous polyposis of the gallbladder in a 57 year-old woman with Gardner's syndrome presenting with cholangitis. On gross examination the gallbladder contained two calculi and numerous flat or polypoid adenomas less than 1 cm in size. On microscopic examination, the adenomas showed low and high grade intraepithelial neoplasia. Only 10 cases of gallbladder adenomas have been reported in the literature in patients presenting with familial adenomatous polyposis (FAP). Cholecystectomy is usually performed for cholecystitis or cholangitis. These adenomatous gallbladder lesions are discovered late, often when the patient is older than 40. Pathogenesis of gallbladder adenomas is still unclear. It is difficult to assess the risk of malignancy: only 6 cases of gallbladder adenocarcinomas have been reported in patients with FAP.

[Surgical management of chronic pancreatitis]. / Prise en charge chirurgicale de la pancréatite chronique.

Surgical indications for chronic pancreatitis can be schematically separated into five main groups: pain, effects of fibrosis on adjacent organs, the consequences of main pancreatic duct rupture above an obstruction, and suspected cancer. Finally surgery is also indicated in patients who cannot undergo endoscopic procedures (no accessible papilla) or who have too recently undergone this procedure. Surgical procedures include derivation (pancreatic, cystic, biliary) or mixed procedures combining derivation/resection or pancreatic resection. Finally splanchnicectomy can be discussed. Whatever the indication, surgical treatment must meet several goals: the approach to surgery must be multidisciplinary, surgery must be associated with low morbidity and mortality, preserve as much endocrine function as possible, improve quality of life, and be evaluated in the long term, as well as prospectively if possible. We clarify some important points about the management of patients with chronic pancreatitis before discussing the various treatments in detail.

Long-term outcome of laparoscopic antireflux surgery in the elderly.

The aim of this retrospective study was to compare results and five-year surgical outcome of laparoscopic antireflux surgery (LARS) in patients younger than 65 years and elderly patients aged 65 years or older. From January 1992 to December 1998, 2684 patients underwent LARS in 31 surgical units; 369 elderly patients (group 1) were compared with 2315 younger patients (group 2). Elderly patients have a higher American Society of Anesthesiologists score (mean, 2.38 versus 1.98). The conversion rate was higher in group 1 (10.2%, n = 38 versus 6.1%, n = 142), as was the morbidity rate (7.6% in group 1 versus 4.5% in group 2). Mean hospital stay was longer for group 1 (7.6 +/- 5.6 days versus 5.9 +/- 2.8 days). Functional evaluation was excellent in both groups (91-93%) at 3 months and 2 and 5 years. LARS in the elderly is a safe and efficient procedure. Good results appear to be sustainable in the long term.

Duodenopancreatectomy for cystic dystrophy in heterotopic pancreas of the duodenal wall.

AIM OF THE STUDY: Cystic dystrophy in heterotopic pancreas (CDHP) is rare. The aim of this study was to evaluate the diagnosis, management, and follow-up of the CDHP. PATIENTS AND METHODS: Between August 1990 and March 2004, 12 patients with CDHP underwent a duodenopancreatectomy. The patients were retrospectively reviewed. RESULTS: There were 11 men and 1 woman with a mean age of 42.4 years (range: 34-54 years). Nine patients (75%) were alcoholic and 8 patients had chronic pancreatitis. The diagnosis of CDHP was performed in 8 patients (66.6%) after the preoperative workup. Seven patient had a medical treatment with octreotid and endoscopic cystic ponction (N=3) or cystic fenestration (N=1). Recurrence of pain was noted after a mean period of 5 months. Three patients had recurrent acute pancreatitis. Duodenopancreatectomy was performed in all cases. The mortality and morbidity rate were respectively 8.3% (N=1) and 25% (N=3). Mean follow-up was 64 months (ranges: 6 - 158 months). One patient was seen 70 months later with epigastric pain and features of acute pancreatitis of the pancreatic stump due to anastomotic stenosis. The other patients were asymptomatic. CONCLUSIONS: Diagnosis of CDHP is difficult. After failure of medical treatment, duodenopancreatectomy can be proposed.

Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding.

AIM: The purpose of this study was to analyze the diagnostic and therapeutic features of hemosuccus pancreaticus. METHODS: We conducted a retrospective study of nine patients (eight men and one woman, mean age 60 yrs) admitted to surgery or gastroenterology units for hemossucus pancreaticus between 1981 and 2003. The following were studied: symptoms, contribution of established morphologic exams (upper digestive endoscopy, computed tomography (CT) and selective digestive angiography) and treatment. RESULTS: Hemosuccus pancreaticus occurred in chronic alcoholic pancreatitis (N=8) and chronic familial pancreatitis (N=1). Seven patients (77.8%) presented overt digestive bleeding (one melena, two hematochezia, two melena with hematochezia, one hematemesis, one hemorrhagic shock). The inaugural sign was anemia in one patient and epigastric pain in another. An upper digestive endoscopy, performed in eight patients (88.9%), revealed fresh red blood in the first or second duodenum in three and hemossucus pancreaticus in three others. Arteriography was performed in eight patients (88.9%) and CT angiography in one. Surgery was performed in 5 patients (55.6%), after embolization in one. Embolization was effective in 3 patients. Therapeutic abstention proved successful in one patient. There were no deaths. CONCLUSIONS: Hemosuccus pancreaticus is a rare cause of digestive bleeding. Upper digestive endoscopy and selective digestive angiography during active bleeding can provide the diagnosis. Endovascular treatment can control an unstable hemodynamic situation before elective surgery to prevent recurrence, which can be more severe than the first event.

Double L-shaped free-style perforator flap for perineal and vaginal reconstruction after cylindrical abdominoperineal resection.

The improvement of patient carcinological status by an abdominoperineal resection by extended posterior perineal approach in a prone position requires the plastic surgeon to consider other reconstructive options. We present an original double L-shaped free-style propeller flap used to reconstruct the vagina and the perineum of a 57-year-old patient after the resection of a T4 tumour of the lower rectum.

Two-year results on morbidity, weight loss and quality of life of sleeve gastrectomy as first procedure, sleeve gastrectomy after failure of gastric banding and gastric banding.

BACKGROUND: Sleeve gastrectomy (SG) is an alternative to gastric bypass and laparoscopic adjustable gastric banding (GB). METHODS: From January 2004 to January 2006, 111 patients with a follow-up longer than 24 months were prospectively followed. Three treatment groups were defined. Sleeve gastrectomy as first procedure (SGFP; n = 50), sleeve gastrectomy after failure of GB (SG after GB; n = 9) and GB (n = 52). We compared morbidity, mortality, length of stay, number of procedures under general anaesthesia, excess weight loss (EWL) and quality of life. RESULTS: Mean initial body mass index (BMI) was 50.4 (SG), 50.8 (SG after GB) and 43.8 (GB; p = 0.000001). Mean operating time was 97.1 min (SGFP), 122.2 min (SG after GB) and 69.8 min (GB; p < 0.0001). The reoperation rate under general anaesthesia was 2% (SGFP), 11% (SG after GB) and 30.76% (GB; p = 0.00001).The fistula rate was 2% (SGFP), 0% (SG after GB) and 0% (GB). BMI at 24 months was 33.8 (SGFP), 35.3 (SG after GB) and 33.2 (GB; NS). EWL at 24 months was 67.4 (SGFP), 60.3 (SG after GB) and 58.6 (GB; NS). In the SGFP group and in the SG after GB group, the mean quality-of-life score was 1.1. In the GB group, the mean score was 0.95 (NS). CONCLUSIONS: Initial BMI was significantly higher in the SG group but was no longer significantly different from the BMI of the GB group at 12 and 24 months. Excess BMI loss was higher after SG than after GB. This reduction of BMI was considered to be a success for GB. Thus, results of SG should be considered as a success. Quality of life was not significantly different between the three groups. These results validated SG as first procedure or after failure of GB.

Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity.

BACKGROUND: Sleeve gastrectomy is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. The authors report their experience of laparoscopic sleeve gastrectomy (LSG), evaluate the efficacy of this procedure on weight loss, and analyze the short-term outcome. METHODS: The data of 135 consecutive patients undergoing LSG between July 2004 and October 2007 were analyzed prospectively. LSG was indicated only for weight reduction with a body mass index (BMI) > 40 or > 35 kg/m(2) associated with severe comorbidity. Study endpoints included mean BMI, comorbidity, operative data, conversion to laparotomy, intraoperative complications, major and minor complication rates, excess weight loss, follow-up, and duration of hospital stay. Possible risk factors for postoperative gastric fistula (PGF) were investigated. RESULTS: This series comprised 113 females and 22 males with a mean age of 40 years (range, 18-65). Mean weight was 132 kg (range, 94-186), and mean preoperative BMI was 48.8 kg/m(2) (range, 37-72). The mean operating time was 103 minutes (range, 30-550). No patients required conversion to laparotomy, and 96% of patients did not require drainage. The nasogastric tube was removed on postoperative day 1. The postoperative course was uneventful in 94.9% of cases, and the median duration of hospital stay was 3.8 days. The median follow-up was 12.7 months. The mean postoperative BMI decreased to 39.8 kg/m(2) at 6 months (P < .001). Average excess body weight loss was 38.6% and 49.4% at 6 months and 1 year, respectively. There was no mortality, and the major complication rate, corresponding to gastric fistula (PGF) in every case, was 5.1% (n = 7). Management of PGF required reoperation, radiologic and endoscopic procedures, and fibrin glue; the median hospital stay was 47 days. BMI > 60 kg/m(2) appears to be a risk factor for PGF. CONCLUSION: LSG is a reproducible and seems to be an effective treatment to achieve significant weight loss after 12 months follow-up. LSG can be used as a standalone operation to obtain weight reduction. Management of PGF remains a major issue.