Splenic abscess and infective endocarditis.

OBJECTIVE: To determine the background, bacteriological, clinical and radiological findings, associated lesions, treatment and outcome of splenic abscesses (SAs) in infective endocarditis (IE). METHODS: Retrospective study (2005-2021) of 474 patients with definite IE. The diagnosis of SA was made in 36 (7.6%) patients (31, 86.1%, males, mean age = 51.3) on abdominal CT. RESULTS: The main implicated organisms were Streptococcus spp (36.1%), Enterococcus faecalis (27.7%), Staphyloccus spp (19.4%). Rare agents were present in 10 patients (27.8%). Pre-existing conditions included a prosthetic valve (19.4%), previous IE (13.9%), intravenous drug use (8.4%), diabetes (25%) alcohol abuse (13.9%), liver disease (5.5%). Vegetations ≥ 15 mm were present in 36.1%. Common presentations were abdominal pain (19.4%) and left-sided pleural effusion (16.5%). SA were more often small (50%; 7 multiple) than large (36.1%; 1 multiple) or microabscesses (13.9%, 3 multiple). Associated complications were extrasplenic abscesses (brain, 11.1%; lung, 5.5%; liver, 2.8%), infectious aneurysms (16.7%: 3 intracranial, 1 splenic, 1 hepatic, 1 popliteal), emboli (brain, 52.8%; spleen, 44.4%, 5 evolving to SA; kidney, 22.2%; aorta, 2.8%), osteoarticular infections (25%). Twenty-eight (77.8%) patients only received antimicrobials, 7 (19.4%) underwent splenectomy, after cardiac surgery in 5. One had percutaneous drainage. The outcome was uneventful (follow-up 3 months-14 years; mean: 17.2 months). CONCLUSION: In SA-IE patients, the prevalence of vegetation size, Enterococcus faecalis, rare germs, diabetes, osteo-arthritic involvement and cancer was higher than in non-SA patients. Some SAs developed from splenic infarcts. IE-patients with evidence of splenic emboli should be evaluated for a possible abcedation. Cardiac surgery before splenectomy was safe.

Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study.

AIM: The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis. METHOD: This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage. RESULTS: Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted. CONCLUSION: AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review.

BACKGROUND: To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE). METHODS: We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020). RESULTS: Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone. CONCLUSIONS: SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study.

OBJECTIVE: To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19. METHODS: From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21). RESULTS: A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity. CONCLUSION: This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

A systematic review of minimal length of lroximal margin in gastric adenocarcinoma resection.

For early distal gastric cancers, a proximal margin (PM) > 2-3 cm might probably be sufficient. For advanced tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length. INTRODUCTION: In gastric cancer surgery, microscopic positive margin is a poor prognostic factor whereas complete resection with tumor-free margins remains a challenging issue. European guidelines recommended a macroscopic margin of 5 or even 8 cm for diffuse-type cancers to achieve R0 resection. However, it is unclear if the length of negative proximal margin (PM) could have a prognostic impact on survival. We aimed to perform a systematic review of the literature analyzing PM length and its prognostic impact in gastric adenocarcinoma. MATERIAL AND METHODS: Pubmed and Embase databases were searched for "gastric cancer" or "gastric adenocarcinoma," combined with "proximal margin," between January 1990 and June 2021. English-written studies that specified PM length were included. Survival data, in relation to PM, were extracted. RESULTS: Twelve retrospective studies, with a total number of 10,067 patients, met inclusion criteria and were analyzed. Mean length of proximal margin on the whole population varied from 2.6 to 5.29 cm. Three studies found minimal PM cut-off to improve overall survival in univariate analysis. Concerning recurrence-free survival analysis, only 2 series showed better results with PM > 2 or > 3 cm, using Kaplan-Meier method. Multivariate analysis demonstrated an independent impact of PM on overall survival in 2 studies. CONCLUSION: For early distal gastric cancers, a PM > 2-3 cm might probably be sufficient. For advanced or proximal tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video).

OBJECTIVES: Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. METHODS: Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. RESULTS: Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465). CONCLUSIONS: The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.

Comparison of sleeve gastrectomy and Roux-en-Y gastric bypass after failure of gastric banding: a two-center study with a propensity score-matched analysis.

BACKGROUND: Few studies on series comparing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) after failure of gastric banding (GB) are available. The objective of this study was to compare the short- and medium-term outcomes of SG and RYGB after GB. MATERIALS AND METHODS: Between January 2006 and December 2017, patients undergoing SG (n = 186) or RYGB (n = 107) for failure of primary GB were included in this two-center study. Propensity-score matching was performed based on preoperative factors with a 2:1 ratio. Primary endpoint was the weight loss at 2 years between the SG and RYGB groups. Secondary endpoints were overall mortality and morbidity, reoperation, correction of comorbidities and the rate of adverse events at 2 years follow-up. RESULTS: In our propensity score matching analysis, operative time was significantly less in the SG group (95 min vs. 179 min; p < 0.001). Post-operative complications were lower in the SG group (9.5% vs. 35.4%; p = 0.003). At 2 years follow-up, the mean EWL was similar as same as comorbidities. There was a significant difference in favor of SG concerning the rate of adverse events at 2 years follow-up (p < 0.001). CONCLUSION: Revision of GB by SG or RYGB is feasible, with a higher rate of early post-operative complications for RYGB. Weight loss at 2 years follow-up is similar; however, RYGB appears to result in a higher rate of adverse events than SG.

Short-term outcomes of single-port versus conventional laparoscopic sleeve gastrectomy: a propensity score matched analysis.

BACKGROUND: Sleeve gastrectomy (SG) has become a frequent bariatric procedure. Single-port sleeve gastrectomy (SPSG) could reduce parietal aggression however its development has been restrained due to fear of a complex procedure leading to increased morbidity and suboptimal sleeve construction. The aim of this study was to compare the short-term outcomes of SPSG versus conventional laparoscopic sleeve gastrectomy (CLSG) with regards to morbidity, weight loss, and co-morbidity resolution. METHODS: Between January 2015 and December 2016, data from all consecutive patients that underwent SPSG and CLSG in two institutions performing exclusively one or the other approach were retrospectively analyzed. Propensity score adjustment was performed on the factors known to influence the choice of approach. RESULTS: During the study period, 1122 patients underwent SG in both institutions (610 SPSG and 512 CLSG). From each group, 314 patients were successfully matched. A 15-min increase in operative time was observed during SPSG (P < 0.001). Postoperative morbidity was similar with a minor increase after SPSG (8.6 vs. 6.7%, P = 0.453). No differences in incisional hernia rates were observed (1.6 (SPSG) vs. 0.3% (CLSG), P = 0.216). Percentage of total weight loss was 31.1% and 28.2% in the CLSG and SPSG 12 months after surgery, respectively (P = 0.321). Co-morbidities resolution 12 months following the procedure was similar. CONCLUSIONS: SPSG can be performed safely with similar intraoperative and postoperative morbidity compared to CLSG. Weight loss and co-morbidities resolution at 1 year are equivalent. A 15-min longer operative time was the only negative side of SPSG.

The Distance between the Pylorus and Left Vagus Nerve during Sleeve Gastrectomy.

The sleeve gastrectomy (SG) can be performed with or without antral preservation (distance from the pylorus <50 mm). The objective of this study was to evaluate the distance between the pylorus and the end of the left vagus nerve in order to determine whether it could be used as a constant anatomical landmark to start gastric transection. This was a prospective, nonrandomized study of 120 patients undergoing SG from January to October 2018. The distance measurement between pylorus and vagus nerve was performed at the beginning of the SG. The primary endpoint was the distance between the beginning of the pylorus and the end of the second branch of the vagus nerve on the upper edge of the antrum. The secondary endpoints was the correlation factors between the preoperative data and the position of the end of the vagus nerve. A total of 120 patients, with a mean body mass index of 42.2 kg/m2 , underwent primary SG. The mean distance between pylorus and the end of the vagus nerve was 50.4 mm (35-64) on the upper part of the antrum. When considering the inferior part of the antrum, the minimum distance was 50 mm. No correlations were found between preoperative data and distance measurements. The vagus nerve can be considered as a constant and reliable anatomical landmark for performing SG with antral preservation. However, no correlation was found between the preoperative data and the location of the end of the vagus nerve. Clin. Anat. 33:562-566, 2020. © 2019 Wiley Periodicals, Inc.

What are the Particularities of Pancreatic Surgery in the Cirrhotic Patient?

The objective of this work was to review the entire literature on pancreatic surgery in order to best define the surgical indications and the specifics of their management. The bibliographic research was done on Pubmed over the period from January 1995 to June 2015, using French and English as the languages of publication. The two main indications discussed here are the management of cancer and chronic pancreatitis. Surgery in the cirrhotic patient exposes the patient to a higher risk of complications than in the non-cirrhotic patient. Child-Pugh and MELD scores should be used to assess risk and guide operative decision. Child-Pugh classes B and a MELD score value greater than 15 are associated with higher morbidity and mortality. However, if suitable selection is made of cirrhotic patients who are candidates for pancreatic surgery, long-term survival seems to be equivalent to the non-cirrhotic group. No risk factors for long-term survival have been reported. In conclusion, cirrhotic patients, candidates for pancreatic surgery must be correctly selected, cirrhosis exposes to a higher risk of postoperative morbidity and mortality.

Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study.

BACKGROUND: Day-case surgery (DCS) has become increasingly popular over recent years, as has laparoscopic liver resection (LLR) for the treatment of benign or malignant liver tumours. The purpose of this prospective study was to demonstrate the feasibility of minor LLR as DCS. METHODS: Prospective, intention-to-treat, non-randomised study of patients undergoing minor LLR between July 2015 and December 2017. Exclusion criteria were resection by laparotomy, major LLR, difficult locations for minor LLR, history of major abdominal surgery, hepatobiliary procedures without liver parenchyma resection, cirrhosis with Child > A and/or portal hypertension, significant medical history and exclusion criteria for DCS. The primary endpoint was the unplanned overnight admission rate. Secondary endpoints were the reason for exclusion, complication data, criteria for DCS evaluation, satisfaction and compliance with the protocol. RESULTS: One hundred sixty-seven patients underwent liver resection during the study period. LLR was performed in 92 patients (55%), as DCS in 23 patients (25%). Reasons for minor LLR were liver metastasis (n = 9), hepatic adenoma (n = 5), hepatocellular carcinoma (n = 4), ciliated hepatic foregut cyst (n = 2) and other benign tumours (n = 3). All day-case minor LLR, except two patients, consisted of single wedge resection, while one patient underwent left lateral sectionectomy. There were four unplanned overnight admissions (17.4%), one unscheduled consultation (4.3%), two hospital readmissions (8.6%) and no major complications/mortality. Compliance with the protocol was 69.5%. Satisfaction rate was 91%. CONCLUSION: In selected patients, day-case minor LLR is feasible with acceptable complication and readmission rates. Day-case minor LLR can therefore be legitimately proposed in selected patients.

Portal vein variants associated with right hepatectomy: An analysis of abdominal CT angiography with 3D reconstruction.

Glissonian approach has been described as a selective vascular clamping procedure during hepatectomy based on external anatomical landmarks. Anatomical variations of the right Glissonian pedicle have been identified with an increased risk of clamping failure during Glissonian approach. The objective of this study was to characterize the anatomical variations of the right Glissonian pedicle at risk of clamping failure during right hepatectomy. This was a retrospective analysis of abdominal multiphasic CT and routine 3D reconstruction (n = 346). Anatomical variations at risk of clamping failure were Types 1 to 3 (Madoff's classification) and an angle of less than 50° between the portal vein and the left portal vein. Primary objective was the risk of right Glissonian pedicle clamping failure. Secondary objectives were the rate of normal anatomy, the rate of variations, and the rate of incomplete or extended clamping. Normal anatomy was found in 245 patients (71%). Anatomical variations were as follows: Type 1: 11%, Type 2: 17%, Type 3: 0.8%, Type 4: 0%. Angle variation less than 50° was observed in 4.5%. The risk of selective clamping failure was 34%. Extension of clamping was observed in 16%, while incomplete clamping was observed in 17.8%. Failure of right Glissonian pedicle clamping was predictable in 34% of cases while 71% of patients presented normal portal vein anatomy. Clin. Anat. 32:328-336, 2019. © 2018 Wiley Periodicals, Inc.

Effectiveness of Fibrin Sealant Application on the Development of Staple Line Complications After Sleeve Gastrectomy: A Prospective Randomized Trial.

OBJECTIVES: Evaluate the effectiveness of the use of fibrin sealant (FS) for preventing the development of staple line complications (SLCs) after sleeve gastrectomy (SG). BACKGROUND: There is no consensus on the best means of preventing SLCs after SG. METHODS: This was a prospective, intention-to-treat, randomized, 2 center study of a group of 586 patients undergoing primary SG (ClinicalTrials.gov identifier: NCT01613664) between March 2014 and June 2017. The 1:1 randomization was stratified by center, age, sex, gender, and body mass index, giving 293 patients in the FS group and 293 in the control group (without FS). The primary endpoint (composite criteria) was the incidence of SLCs in each of the 2 groups. The secondary criteria were the mortality rate, morbidity rate, reoperation rate, length of hospital stay, readmission rate, and risk factors for SLC. RESULTS: There were no intergroup differences in demographic variables. In an intention-to-treat analysis, the incidence of SLCs was similar in the FS and control groups (1.3% vs 2%, respectively; P = 0.52). All secondary endpoints were similar: complication rate (5.4% vs 5.1%, respectively; P = 0.85), mortality rate (0.3% vs 0%, respectively; P = 0.99), GL rate (0.3% vs 1.3%, respectively; P = 0.18), postoperative hemorrhage/hematoma rate (1% vs 0.7%, respectively; P = 0.68), reoperation rate (1% vs 0.3%, respectively; P = 0.32). Length of stay was 1 day in both groups (P = 0.89), and the readmission rate was similar (5.1% vs 3.4%, respectively; P = 0.32). No risk factors for SLCs were found. CONCLUSION: The incidence of postoperative SLCs did not appear to depend on the presence or absence of FS.

Satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared to conventional hospitalization: a prospective non-randomized study.

PURPOSE: Day-case surgery (DCS) has boomed over recent years. However, day-case bariatric surgery remains controversial due to a lack of evaluation. The objective of this study was to compare the experiences and satisfaction with general anesthesia of patients undergoing sleeve gastrectomy (SG) as DCS compared to conventional hospitalization. METHODS: Between January 2015 and June 2016, all patients undergoing primary SG as day-case surgery or with conventional hospitalization were prospectively included in this non-randomized, non-inferiority study comparing the level of satisfaction of patients undergoing SG with conventional hospitalization (CH group, gold standard) versus SG as DCS (DCS group). The primary efficacy endpoint was comparison of the overall satisfaction rate using the EVAN-G questionnaire. The secondary endpoints were evaluation of the 6 dimensions of the EVAN-G questionnaire, discharge from hospital, adhesion with SG management and overall satisfaction with SG. RESULTS: One-hundred and twenty-four patients met the inclusion criteria (62 in both groups). The DCS group was younger with fewer comorbidities (p ≤ 0.01) and had a lower BMI (p ≤ 0.01). Overall, the mean EVAN-G questionnaire score was 66.4 (63.9-68.9) for the DCS group and 68.9 (65.9-71.8) for the CH group (non-inferiority of DCS group). In the DCS group, 19% of patients would have preferred to spend the night in hospital, while 82% of patients in the CH group would have preferred DCS and a total of 75% of patients reported a high level of satisfaction. CONCLUSION: Overall satisfaction of patients undergoing SG as day-case surgery was not inferior to that of patients managed by conventional hospitalization.

Gastropancreatic ligament: Description, incidence, and involvement during laparoscopic sleeve gastrectomy.

During laparoscopic sleeve gastrectomy (LSG), adhesions between the stomach and the pancreas are sometimes found, forming a "gastropancreatic ligament" (GPL). However, the GPL has only been described once in the literature, in 1985. The objective of this study was to determine the incidence of the GPL during LSG, describe this structure and assess its effect on the surgical technique. All patients undergoing primary LSG in our institution (n = 240) and patients referred for gastric fistula (GF) after primary LSG (n = 18) between January 2015 and December 2015 were included. The primary endpoint was the incidence of a GPL during primary LSG. The secondary endpoints were the postoperative complication rate, the postoperative GF rate, and the presence of this ligament during reoperation for GF. Among the 240 patients, a GPL was visible in 49 cases (20.4%) and was described as thin in 34 of these (69.4%). Twelve postoperative complications (5%) were observed, including seven major (2.9%). The GF rate was 2% (n = 5), not requiring reoperation. The gastric stenosis rate was 0.4% (n = 1). The GPL had been previously sectioned in one of the five patients (20%) with postoperative GF. During the study period, 18 patients were referred for GF and 14 were reoperated. A non-sectioned GPL, not described in the operating report, was observed in four patients (28.5%). A GPL was identified in 20.4% of cases. Identification of a GPL could be important in the context of LSG, as section of the ligament allows tension-free stapling to be performed and can therefore possibly reduce the risk of postoperative complications, particularly GF. Clin. Anat. 30:336-341, 2017. © 2017 Wiley Periodicals, Inc.

Laparoscopy-assisted open cystogastrostomy and pancreatic debridement for necrotizing pancreatitis (with video).

INTRODUCTION: Pancreatic pseudocysts and walled-off necrosis are well-known complications, described in 10% of cases of acute pancreatitis. Open cystogastrostomy is usually proposed after failure of minimally invasive drainage or in the presence of septic shock. The objective of this study was to evaluate the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy for treatment of symptomatic pancreatic pseudocyst with pancreatic necrosis. MATERIALS AND METHODS: Between January 2011 and October 2014, all patients with pseudocyst and pancreatic necrosis undergoing open cystogastrostomy were included. Surgical procedure was standardized. The primary efficacy endpoint was the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy as treatment of symptomatic pancreatic pseudocyst. Secondary endpoints included demographic data, preoperative management, operative data, postoperative data and follow-up. RESULTS: Laparoscopy-assisted open cystogastrostomy was performed in 11 patients [six men (54%)], with a median age of 61 years (45-84). Nine patients received preoperative radiological or endoscopic management. First-line open cystogastrostomy was performed in two cases. Median operating time was 190 min (110-240). There was one intraoperative complication related to injury of a branch of the superior mesenteric vein. There were no postoperative deaths and two postoperative complications (18%) including one major complication (postoperative bleeding). The median length of hospital stay after surgery was 16 days (7-35). The median follow-up was 10 months (2-45). One patient experienced recurrence during follow-up. CONCLUSION: Open cystogastrostomy for necrotizing pancreatitis promotes adequate internal drainage with few postoperative complications and a short length of hospital stay. However, this technique must be performed very cautiously due to the risk of vascular injury which can be difficult to repair in the context of severe local inflammation related to pancreatic necrosis.

Use of transanastomotic double-pigtail stents in the management of grade B colorectal leakage: a pilot feasibility study.

INTRODUCTION: Anastomotic leakage (AL) is a major complication of colorectal surgery. The leakage is classified as grade B when the patient's clinical condition requires an active therapeutic intervention but does not require further surgery. The management of grade B AL commonly includes administration of antibiotics and/or the placement of a pelvic drainage performed under radiological guidance or transanal drain. The objective of this study was to evaluate the feasibility and the efficacy of endoscopic transanastomotic drainage using double-pigtail stents (DPSs) in the management of grade B AL in colorectal surgery. PATIENTS AND METHODS: Between September 2011 and December 2014, 650 patients underwent a colorectal procedure in our university hospital; 8.7 % presented with AL, including 42.8 % with grade B. Fourteen patients required endoscopic management and constituted the study population. The study's primary objective was to assess the feasibility and efficacy of DPS placement for the treatment of grade B AL after colorectal surgery. The secondary endpoints were the requirement for radiological drainage, the DPS placement failure rate, the rate of stoma closure and, lastly, feasibility of chemotherapy (if indicated). RESULTS: DPS placement was feasible in 92.8 % of the 14 patients (n = 13). The overall success rate for endoscopic management was 78.5 % (n = 11). The median length of hospitalization after DPS placement was 5 days (3-17). The average duration of drainage through a DPS was 62 days (28-181). Five patients (35.7 %) also underwent drainage with radiological guidance. Of the 10 patients with stoma, closure occurred in 80 %. All patients that required adjuvant chemotherapy were able to receive it. CONCLUSION: The treatment of AL requires multidisciplinary collaboration to save the anastomosis. DPS placement under endoscopic control is associated with AL healing, good clinical tolerance and the ability to undergo chemotherapy and is an alternative to repeat laparotomy when radiological drainage is unfeasible or inefficient.

The short- and long-term outcomes of pancreaticoduodenectomy for cancer in Child A patients are acceptable: a patient-control study from the Surgical French Association report for pancreatic surgery.

BACKGROUND: On the basis of now dated studies, cirrhosis is usually considered to be a contraindication in pancreatoduodenectomy (PD) for adenocarcinoma of the pancreatic head (APH). OBJECTIVE: Examine the outcomes of PD for APH in the presence of cirrhosis. METHODS: Retrospective, multicenter study of cirrhotic patients with APH having undergone PD between January 2004 and March 2012. Cirrhotic patients were matched 1:2 for demographic, surgical and histologic criteria with non-cirrhotic patients. Primary endpoint was morbidity and mortality. Secondary endpoints were surgical parameters, morbidity related to pancreatic surgery and cirrhosis, and follow-up. RESULTS: We included 35 patients with cirrhosis. Twenty-four patients (69%) were Child A and none were Child C. The Child A cirrhotic patients and non-cirrhotic patients respectively had complication rates of 79% vs. 43% (P = 0.002), major complication rates of 33% vs. 21% (P = 0.26), pancreatic fistula rates of 13% vs. 9% (P = 0.57), post-operative mortality of 4% vs. 5% (P = 0.94), 3-year overall survival rates of 44% vs. 50% (P = 0.46). All Child B cirrhotic patients experienced post-operative complications. CONCLUSION: Pancreatoduodenectomy for APH was possible in Child A cirrhotic patients with a mortality and long-term outcomes equivalent to non-cirrhotic patients. Child B cirrhosis remains a clear contraindication to surgery.