Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals

BACKGROUND

The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.

METHOD

The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.

RESULTS

Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.

CONCLUSION

The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

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 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.

FT-IR and NMR structural markers for thiazole-based γ-peptide foldamers

Nuclear magnetic resonance (NMR) spectroscopy has been established as a potent method for the determination of foldamer structures in solution. However, the NMR techniques could be limited by averaging, so additional experimental techniques are often needed to fully endorse the folding properties of a sequence. We have recently demonstrated that oligo-γ-peptides composed of 4-amino(methyl)-1,3-thiazole-5-carboxylic acids (ATCs) adopt an original helical fold stabilized by hydrogen bonds forming C₉ pseudocycles. The main objective of the present work is to reinvestigate the folding of ATC oligomer 1 in order to identify reliable FT-IR and NMR structural markers that are of value for tracking the degree of organization of ATC-based peptides.

[Usefulness of PCR test for the management of a Mycoplasma pneumoniae outbreak in Bethune Hospital (Pas-de-Calais, France)]

Objet

La biologie moléculaire (PCR) constitue une aide rapide et spécifique pour le diagnostic différentiel des infections respiratoires à mycoplasme, première cause de pneumonies communautaires chez l’enfant de plus de cinq ans.

Méthode

Positivité de la PCR (Chlamylège^®, Argène) (aspiration nasopharyngée, prélèvements respiratoires, écouvillonnage nasophayngé) et/ou du sérodiagnostic (Elisa).

Résultats

Trente-neuf cas diagnostiqués : 31 entre septembre et décembre 2008 (30 enfants et un adulte) et huit depuis juin 2009 (trois adultes et cinq enfants). Les enfants (âge moyen : 3,6 ans) ont été hospitalisés dans 88,6 % des cas pendant 2,9 jours pour atteinte respiratoire haute ou basse, avec surtout échec de traitement aux β-lactamines (65,7 % des cas). Les quatre adultes (âge moyen : 29,5 ans) ont présenté une pneumopathie, avec hospitalisation pour trois d’entre eux dont un en réanimation. Vingt-huit PCR sur 32 se sont avérées positives (87 %) : sans sérologie associée (13), sérologies négatives (huit), IgG et IgM positives (cinq) et IgG seules (deux). Pour sept patients, seule la sérologie a été réalisée : IgM ± IgG. Pour deux enfants, IgM positive isolément, avec une PCR probablement faussement négative (prélèvement paucicellulaire).

Conclusion

La sensibilité de la sérologie dans le diagnostic des infections à mycoplasmes reste limitée : les IgM qui apparaissent généralement une semaine après le début des signes cliniques sont le plus souvent absentes chez l’adulte et élévation tardive des IgG. Le diagnostic précoce des pneumopathies de l’enfant par PCR a permis de caractériser rapidement ce phénomène épidémique et d’adapter les thérapeutiques.

Tests de marche : une avancée dans l'évaluation fonctionnelle cardiorespiratoire

Exercise testing provides information on physical capacity during exercise in addition to spirometric measures of lung function or assessment on treadmills or ergonomic cycle. The "gold standard" assessment of exercise tolerance is measured in the laboratory using treadmills or ergonomic cycle but the necessary equipment is expensive and may not be readily accessible; such tests require people used to work with children. Walking tests are field tests providing a valid and easily accessible method of measuring function-limited exercise tolerance in patients with respiratory or cardiac chronic diseases. These walking tests are non-threatening, inexpensive, easy to perform and to understand for children. Walking tests performed in daily practice are the following: "time-based" tests (2-, 6- or 12-min walking test), 3-min step test (on a step) and the shuttle walking test. It may be a useful measure to assess therapeutic intervention and provide information on the prognosis. They are simple and safe methods to evaluate quality of life in these patients.

[Diagnosis and treatment of congenital bronchopulmonary malformations. A review of 32 cases]

OBJECTIVES

Analysis of our experience and propositions on the diagnosis and treatment of congenital bronchopulmonary malformations (BPM).

POPULATION AND METHODS

Retrospective study of BPM diagnosed between 1997 and 2001. Analysis of clinical spectrum, diagnosis tools, treatment, and clinical outcome.

RESULTS

Thirty-two cases of BPM have been investigated (11 cystic adenomatoid malformations, 7 pulmonary sequestrations, 7 bronchogenic cysts, 4 congenital lobar emphysema, and 3 complex emphysematous malformations). Nineteen patients had a prenatal diagnosis. For 9 others, symptoms occurred before 4 years of age. Evaluation included a CT-scan in all patients (BPM involution in one). Surgical treatment was performed in 30 patients (lobectomy in 18), with a mean age of 7 months for asymptomatic patients. During the follow-up (mean: 3 years), respiratory symptoms were reported in 10 cases, 3 of them were related to the BPM.

DISCUSSION

Improvement in prenatal ultrasound diagnosis modified the management strategy. Considering the risk of pulmonary complications, surgical treatment is required during the first months of life. For congenital lobar emphysema, and some pulmonary sequestrations or small cystic adenomatoid malformations (<3 cm), conservative attitude may be preferred. BPM justify a multidisciplinary management.

Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function

PURPOSE

The purpose of this study was to determine whether preoperative radiotherapy had an influence on the urinary and sexual function of patients having a sphincter-saving, nerve-preserving total mesorectal excision.

METHODS

Urinary and sexual function of male patients undergoing sphincter-saving, nerve-preserving total mesorectal excision for primary resectable rectal carcinoma between January 1998 and December 1999 were evaluated retrospectively. Assessment was by standardized questionnaires.

RESULTS

Fifty male patients met the inclusion criteria. Three patients had died (hepatic metastases), and five were living outside the European community and could not be contacted. Sixteen patients underwent preoperative radiotherapy (Group 1), and 26 patients were not treated preoperatively (Group 2). There was no perioperative mortality. Age, tumor stage, and localization of the tumor were comparable. Median follow-up was 20 months. Urinary function was not significantly different. One patient in Group 1 and 2 patients in Group 2 were impotent before surgery. All remaining patients in Group 2 (n = 24) and 11 of 15 remaining patients in Group 1 were sexually active (P = 0.016). All sexually active patients (n = 24) in Group 2 and 9 of the 11 sexually active patients in Group 1 have normal ejaculation (P = 0.09).

CONCLUSION

Preoperative radiotherapy for primary resectable rectal carcinoma treated by total mesorectal excision with autonomic nerve preservation may impair male sexual function.

[Conformal therapy of locally advanced cholangiocarcinoma of the main bile ducts]

PURPOSE

Retrospective study of 23 patients treated with conformal radiotherapy for a locally advanced bile duct carcinoma.

PATIENTS AND METHODS

Eight cases were irradiated after a radical resection (R0), because they were N+; seven after microscopically incomplete resection (R1); seven were not resected (R2). A dose of 45 of 50 Gy was delivered, followed by a boost up to 60 Gy in R1 and R2 groups. Concomitant chemotherapy was given in 15 cases.

RESULTS

Late toxicity included a stenosis of the duodenum, and one of the biliary anastomosis. Two patients died from cholangitis, the mechanism of which remains unclear. Five patients are in complete remission, six had a local relapse, four developed a peritoneal carcinosis, and six distant metastases. Actuarial survival rate is 75%, 28% and 7% at 1, 3 and 5 years, respectively (median: 16.5 months). Seven patients are still alive with a 4 to 70 months follow-up. Survival is similar in the 3 small subgroups. The poor local control among R0N+ cases might be related to the absence of a boost to the "tumor bed". In R1 patients, relapses were mainly distant metastases, whereas local and peritoneal recurrences predominated in R2.

CONCLUSION

Conformal radiochemotherapy delivering 60 Gy represents a valuable palliative approach in locally advanced biliary carcinoma.

Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum

OBJECTIVE

To evaluate the complications and oncologic and functional results of preoperative radiochemotherapy and sphincter-saving resection for T3 cancers of the lower third of the rectum.

SUMMARY BACKGROUND DATA

Carcinomas of the lower third of the rectum (i.e., located at or below 6 cm from the anal verge) are usually treated by abdominoperineal resection, especially for T3 lesions. Few data are available evaluating concomitant chemotherapy with preoperative radiotherapy for increasing sphincter-saving resection in low rectal cancer.

METHODS

Between 1995 and 1999, 43 patients underwent preoperative radiochemotherapy with conservative surgery for a low rectal tumor located a mean of 4.5 cm from the anal verge (range 2-6); 70% of the lesions were less than 2 cm from the anal sphincter. There were 40 T3 and 3 T4 tumors. Patients received preoperative radiotherapy with a mean dose of 50 Gy (range 40-54) and concomitant chemotherapy with 5-FU in continuous infusion (n = 36) or bolus (n = 7). Sphincter- saving resection was performed 6 weeks after treatment, in 25 patients by using intersphincteric resection. Coloanal anastomoses were associated with a colonic pouch in 86% of the patients, and all patients had a protecting stoma.

RESULTS

There were no deaths related to preoperative radiochemotherapy and surgery. Acute toxicity was mainly due to diarrhea, with 54% of grade 1 to 2. Four anastomotic fistulas and two pelvic hematomas occurred; all patients but one had closure of the stoma. Distal and radial surgical margins were respectively 23 +/- 8 mm (range 10-40) and 8 +/- 4 mm (range 1-20) and were negative in 98% of the patients. Downstaging (pT0-2N0) was observed in 42% of the patients (18/43) and was associated with a greater radial margin (10 vs. 6 mm; P =.02). After a median follow-up of 30 months, the rate of local recurrence was 2% (1/43), and four patients had distal metastases. Overall and disease-free survival rates were both 85% at 3 years. Functional results were good (Kirwan continence I, II) in 79% of the available patients (n = 37). They were slightly altered by intersphincteric resection (57 vs. 75% of perfect continence; NS) but were significantly improved by a colonic pouch (74 vs. 16%; P =.01).

CONCLUSIONS

These results suggest that preoperative radiochemotherapy allowed sphincter-saving resection to be performed with good local control and good functional results in patients with T3 low rectal cancers that would have required abdominoperineal resection in most instances.

[Multiple medullary and extramedullary plasmacytomas in an HIV infected female patient]

INTRODUCTION

Before the HIV infection era, plasmocyte tumor rarely occurred in patients younger than 40 years of age. Less frequent than lymphomas, the incidence of these blood diseases has however substantially increased in HIV-infected patients. In these patients, in addition to onset at earlier age, their clinical presentation is quite different and extramedullary plasmocytomas in unexpected locations are more common.

EXEGESIS

We report the case of a 29-year-old HIV-infected female patient in whom were diagnosed occipital, parotidal, sphenoidal, epidural, and uterine plasmocytomas for which chemotherapy and subsequent radiotherapy were successful. The increase in the incidence of plasmocyte tumors in HIV-infected patients might be facilitated by Epstein Barr Virus (EBV) co-infection, HIV-related chronic antigenic stimulation, and secretion of interleukin 6 by infected lymphocytes.

CONCLUSION

Plasmocyte tumors belong to neoplasia whose incidence is increased in HIV infection. Their currently poor diagnosis should be improved by highly active antiretroviral therapies allowing enhanced chemotherapy with possibility of autograft.

[Primitive leiomyosarcoma of the right atrium presenting with a pulmonary embolism]

Primary Cardiac leiomyosarcoma is a very rare condition. The authors report the case of a 64 year old woman admitted to hospital for suspected pulmonary embolism, confirmed by thoracic angio-CT scan. Despite thrombolytic therapy, a persistent poor haemodynamic condition associated with a superior vena cava syndrome led to a transoesophageal echocardiographic examination which demonstrated an abnormal intra-right atrial mass obstructing the tricuspid valve. At surgery, a leio-myosarcoma was successfully resected under good conditions. During systematic three-monthly clinical and echocardiographic follow-up, transoesophageal echocardiography detected an asymptomatic local recurrence at 15 months, for which surgery was repeated with adjuvant chemotherapy.

Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer

PURPOSE

Standard surgical treatment for low rectal cancer situated below 5 cm from the anal verge or at less than 1 cm from the anal ring is abdominoperineal resection. This is because of the necessity both to achieve a sufficient distal margin and to preserve the whole of the anal sphincter. The aim of this study was to evaluate morbidity, oncologic, and functional results of intersphincteric resection with excision of the internal anal sphincter and low coloanal anastomosis for carcinomas of the anorectal junction.

METHODS

From January 1990 to December 1996, 16 patients were studied prospectively. All patients had an infiltrating adenocarcinoma (5 T2 and 11 T3), located between 2.5 and 4.5 (mean, 3.6) cm from the anal verge. Rectal resection with a minimum distal margin of 2 (mean, 2.4) cm was performed in all cases; six patients underwent partial resection of the internal sphincter, and ten patients had a subtotal resection. A colonic J-pouch was associated with coloanal anastomoses in eight cases. Twelve patients had preoperative radiotherapy, 3 with concomitant chemotherapy; 5 patients had postoperative chemotherapy.

RESULTS

There was no postoperative mortality. Morbidity occurred in four patients, of whom two underwent permanent colostomy after pelvic hemorrhage or anovaginal fistula. After a median follow-up of 44 (range, 11-92) months, no local recurrence was observed, and two patients died of distal metastases. The five-year actuarial survival rate was 75 percent. Continence was normal in one-half of patients and was altered in the other patients who suffered from occasional minor leaks. The median resting pressure was lower after subtotal than after partial resection of the internal sphincter (40 vs. 70 cm H2O; P = 0.02), but functional results were similar in the two groups.

CONCLUSION

These preliminary results suggest that intersphincteric resection can be an alternative to abdominoperineal resection for selected rectal tumors situated at the anorectal junction, without compromising chance of cure. Functional results and continence were not altered by subtotal resection of the internal anal sphincter.

[Adenocarcinoma of the exocrine pancreas: management and therapeutic hopes]

INTRODUCTION

Pancreatic carcinoma is a major public health concern, as it kills more than 6,000 people each year in France.

CURRENT KNOWLEDGE AND KEY POINTS

The main risk factor demonstrated by concordant case-control studies is cigarette smoking. Pancreatic carcinoma is generally diagnosed at an advanced stage. Results of radical surgery are still poor. In most of the reported series, less than 25% of the patients survive at five years.

FUTURE PROSPECTS AND PROJECTS

Postoperative radiochemotherapy slightly increases the hope of cure. In locally advanced tumors, radiochemotherapy, sometimes preoperative, allows some patients to survive more than two years. Though results of palliative chemotherapy remain very poor, some clinical benefit has been observed in randomized trials comparing this treatment with the currently best supportive treatment.

[Mediastinal large B-cell lymphoma. A retrospective anatomic-clinical study of 26 cases]

Mediastinal B-cell lymphomas (with or without sclerosis) have been recently recognized as an entity with particular clinical features. We report 26 patients with a mediastinal large B-cell lymphoma. They represent 5% of the patients with aggressive non-Hodgkin's lymphoma and 2% of all non-Hodgkin's lymphoma seen in our centre between 1962 and 1990. They include 19 females (73%) and 7 males (27%). The sex ratio was 2.7 and the median age was 44 years (range: 17-84 years). Compressive symptoms in relation with a bulky mediastinum were present in 21 cases (80%) and with B symptoms in 5 cases. All these patients received 2 to 4 cycles of chemotherapy with a CHOP-like protocol (epirubicin or doxorubicin, cyclophosphamide, vincristine and prednisone) followed in 24 cases by mediastinum irradiation (40 Gy). Two patients progressed during chemotherapy and did not receive radiotherapy. Nineteen patients had a consolidation chemotherapy according to the same protocol. Twenty-one patients achieved a complete remission after chemotherapy or radiotherapy and 5 failed. Two patients relapsed at 10 months and 9 years. Seventeen patients are alive and in first complete remission with a median follow-up of 102 months (range: 60-260 months). Using the Kaplan-Meier method, the overall survival at 5 and 10 years was respectively 77 and 61% and the relapse-free survival was respectively 68 and 57%. These results confirm the previous findings concerning this distinct entity which is characterized by a predilection for young women, compressive symptoms, a slow response to treatment and a rather good prognosis.

A randomized study of bolus fluorouracil plus folinic acid versus 21-day fluorouracil infusion alone or in association with cyclophosphamide and mitomycin C in advanced colorectal carcinoma

From May 1988 to June 1992, 129 eligible patients suffering from measurable advanced colorectal cancer were enrolled in a randomized study comparing bolus fluorouracil plus leucovorin (FU-FA); continuous fluorouracil infusion (FU-cont); FUcont plus cyclophosphamide and mitomycin C (FUMIC). FU-FA consisted of weekly fluorouracil (FUra) bolus (600 mg/m2) 1 hour after the initiation of a 2-hour infusion of 500 mg/m2 of leucovorin, for 6 weeks every 8 weeks. FUcont patients were planned to receive 400 mg/m2/day FUra infusion, for 21 days every 28 days. In FUMIC patients, FUcont was associated with weekly cyclophosphamide bolus (300 mg/m2) and monthly mitomycin C bolus (10 mg/m2). Quality of life was evaluated using six linear analogue scales, completed by the patient. Accrual in the FUMIC arm was stopped after the 25th patient because of toxicity. The response rates were 22 of 48 (45.8%) with FUcont and 13 of 52 (25%) with FU-FA (P = .048). Progression-free survival (median: 8 v 4.4 months; P = .0026) and overall survival (median: 12.9 v 9.6 months; P = .028) were significantly greater for the FUcont arm compared with the FU-FA arm. Toxicity was observed in 62% of the FUcont patients (grade 3-4: 10%), mainly hand-foot syndrome, diarrhea, mucositis, and mainly gastrointestinal in 69% of the FU-FA patients (grade 3-4: 11.6%). Linear analogue scales exploring quality of life, available for the first 6 months, gave similar scores in FU-FA and FUcont patients. We conclude that this FUcont schedule, achieving high FUra dose-intensity, offers significant advantages, in terms of response and survival, over weekly FUra plus leucovorin.

[Combination of etoposide, cisplatin and ifosfamide (VPH) in the salvage chemotherapy of relapsing or refractory aggressive malignant lymphoma. Study of 51 patients]

Fifty-one patients with non-Hodgkin's lymphoma refractory or relapsing after CHOP-like regimen, underwent a salvage chemotherapy by VPH: etoposide 100 mg/m2/d, D1 to D3, cisplatin 20 mg/m2/d, D1 to D5, ifosfamide 1 g/m2/d D1 to D5, mesna 1.2 g/m2/d D1 to D5, every 4 weeks. Among 46 evaluable patients for efficacy, 21 (45.6%) achieved complete or partial response according to WHO criteria and 25 (54.3%) failed, while five cases (9.8% of all patients) were not evaluable (two initial complete remission before VPH, two early toxic deaths and one confusional syndrome). Thirty-five patients (68.6%) died of lymphoma, three (5.8%) of acute toxicity and 13 (25.5%) are alive: five in complete remission. The toxicity is mainly myelo-suppression, digestive and renal but could be managed as usually. Although the follow-up is short, this regimen appears effective in these circumstances after CHOP failure but it should be used early, before overt chemoresistance. It does not hinder a bone marrow transplantation programme.

[Indications and limitations of anticoagulant treatment in elderly patients]

Anticoagulants constitute the rational treatment of thromboembolic accidents occurring in elderly people, but they are often not prescribed because of the risk of haemorrhage. The chronological age by itself is not a contra-indication, the limitations being the diseases associated with ageing. Anticoagulants may be used as curative treatment in atrial fibrillation with dilated left atrium (greater than 45 mm at echocardiography), in myocardial infarction, embolic strokes and complicated arteritis. They may also be used as preventive and curative treatment in phlebitis and pulmonary embolism. The complications of anticoagulant therapy will be better prevented by using the international normalized ratio and by prescribing doses that are adequate for each indication.