Robotic surgery for inguinal and ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis assessed the effectiveness of robotic surgery compared to laparoscopy or open surgery for inguinal (IHR) and ventral (VHR) hernia repair.

METHODS

PubMed and EMBASE were searched up to July 2022. Meta-analyses were performed for postoperative complications, surgical site infections (SSI), seroma/hematoma, hernia recurrence, operating time (OT), intraoperative blood loss, intraoperative bowel injury, conversion to open surgery, length of stay (LOS), mortality, reoperation rate, readmission rate, use of opioids, time to return to work and time to return to normal activities.

RESULTS

Overall, 64 studies were selected and 58 were used for pooled data analyses: 35 studies (227 242 patients) deal with IHR and 32 (158 384 patients) with VHR. Robotic IHR was associated with lower hernia recurrence (OR 0.54; 95%CI 0.29, 0.99; I2: 0%) compared to laparoscopic IHR, and lower use of opioids compared to open IHR (OR 0.46; 95%CI 0.25, 0.84; I2: 55.8%). Robotic VHR was associated with lower bowel injuries (OR 0.59; 95%CI 0.42, 0.85; I2: 0%) and less conversions to open surgery (OR 0.51; 95%CI 0.43, 0.60; I2: 0%) compared to laparoscopy. Compared to open surgery, robotic VHR was associated with lower postoperative complications (OR 0.61; 95%CI 0.39, 0.96; I2: 68%), less SSI (OR 0.47; 95%CI 0.31, 0.72; I2: 0%), less intraoperative blood loss (- 95 mL), shorter LOS (- 3.4 day), and less hospital readmissions (OR 0.66; 95%CI 0.44, 0.99; I2: 24.7%). However, both robotic IHR and VHR were associated with significantly longer OT compared to laparoscopy and open surgery.

CONCLUSION

These results support robotic surgery as a safe, effective, and viable alternative for IHR and VHR as it can brings several intraoperative and postoperative advantages over laparoscopy and open surgery.

Endoscopic Follow-Up Between 3 and 7 Years After Sleeve Gastrectomy Reveals Antral Reactive Gastropathy but no Barrett's Esophagus

BACKGROUND

The main concerns following sleeve gastrectomy (SG) include the risk of gastroesophageal reflux disease (GERD) and its complications, such as Barrett's esophagus (BE). However, there is conflicting data on esophageal conditions, and studies on alterations of gastric mucosa after SG are lacking, despite reported cases of gastric cancer. Our aim was to assess esophageal and gastric lesions after SG.

METHODS

From November 2017, an upper gastrointestinal endoscopy (UGE) was proposed at least 3 years after SG to all patients operated on in our institution. Endoscopic results and gastric histological findings were analyzed. BE was defined as endoscopically suspected esophageal metaplasia with histological intestinal metaplasia.

RESULTS

Between September 2008 and August 2018, 375 patients underwent SG at our institution, of which 162 (43%) underwent at least one UGE 3 years or more after SG (91% women, mean preoperative age: 43.3±10.3 years). Despite a significant increase in the prevalence of symptomatic GERD, hiatal hernia, and esophagitis after SG (p<0.001 vs. preoperatively), no cases of BE were detected. Gastric dysplasia was not found and the prevalence of gastric atrophy tended to decrease after SG. However, 27% of patients with gastric biopsies developed antral reactive gastropathy.

CONCLUSIONS

At a mean follow-up of 54 months after SG, no BE or gastric dysplasia was identified. However, reactive gastric lesions appeared, and their long-term consequences need to be further clarified. Thus, the timing of endoscopic follow-up, starting as early as 3 years after SG should be reevaluated to improve patient adherence with long-term endoscopies.

Obesity increases the surgical complexity and risk of recurrence after midline primary ventral hernia repair: results on 2307 patients from the French Society of hernia surgery (SFCP-CH) registry database

PURPOSE

Obesity is a known risk factor of recurrence after hernia surgery, but available data often concern pooled cases of primary and incisional hernia, with short follow-up. We aimed to analyze the impact of severe obesity (BMI ≥ 35 kg/m2) on the results of midline primary ventral hernia repair (mPVHR), in comparison with non-severely obese patients.

METHODS

Data were extracted from a multicentric registry, in which patients' data are consecutively and anonymously collected. We conducted a retrospective comparative study on patients with severe obesity (sOb) versus non-severely obese patients (non-sOb), who underwent surgery, with a minimal 2-year follow-up after their mPVHR.

RESULTS

Among 2307 patients, 267 sOb and 2040 non-sOb matched inclusion criteria. Compared with non-sOb, sOb group gathered all the worse conditions and risk factors: more ASA3-4 (39.3% vs. 10.2%; p < 0.001), symptomatic hernia (15.7% vs. 6.8%; p < 0.001), defect > 4 cm in diameter (24.3% vs. 8.8%; p < 0.001), emergency surgery (6.1% vs. 2.5%; p = 0.003), and Altemeir class > 1 (9.4% vs. 2.9%; p < 0.001). Laparoscopic IPOM was used more often in sOb patients (40% vs. 32%; p = 0.016), but with smaller Hauters' ratio (46 vs. 73; p < 0.001). Compared with the non-sOb, the rate of day-case surgery was lower (48% vs. 68%; p < 0.001), the surgical site occurrences were significantly more frequent (6.4 %vs. 2.5%; p < 0.001). The main outcome, 2-year recurrence, was 5.9% in the sOb vs. 2.1% (p = 0.008), and 2-year reoperations was 3% vs. 0.3% (p = 0.006). In the adjusted analysis, severe obesity was an independent risk factor for recurrence [OR = 2.82, (95%CI, 1.45; 5.22); p = 0.003].

CONCLUSION

In patients with severe obesity, mPVHR is technically challenging and recurrence rate is three times higher than that of non-severely obese patients.

Surgical management of parastomal hernia following radical cystectomy and ileal conduit: A french multi-institutional experience

BACKGROUND

Parastomal incisional hernia (PH) is a frequent complication following the creation of an ileal conduit (IC), and it can be a significant detriment to quality of life. The aim of this study was to evaluate outcomes of PH repair following IC for urinary diversion.

METHOD

A multicenter retrospective study was conducted of 6 academic hospitals in France. The study's population included patients who underwent surgical treatment for parastomal hernia following IC creation from 2013 to 2021.

RESULTS

Fifty-one patients were included in the study. Median follow up was 15.3 months. Eighteen patients presented with a recurrence (35%), with a median time to recurrence of 11.1 months. The vast majority of PH repair was performed through an open approach (88%). With regard to technique, Keyhole was the most reported technique (46%) followed by Sugarbaker (22%) and suture only (20%). The Keyhole technique was associated with a higher risk of recurrence compared to the Sugarbaker technique (52% vs 10%, p = 0.046). Overall, there was a 7.8% rate of major complications without a statistical difference between PH repair techniques for major complications.

CONCLUSION

Surgical treatment of parastomal hernia following IC was associated with a high risk of recurrence. Novel surgical approaches to PH repair should be considered.

Peri-operative management of obese patients in digestive surgery: Clinical practice guidelines from the French Society of Digestive Surgery

INTRODUCTION

The French Society of Digestive Surgery (Société Française de Chirurgie Digestive [SFCD]) has elaborated clinical practice guidelines for the management of the obese patient undergoing gastro-intestinal surgery.

METHODS

The literature was analyzed according to the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) methodology divided into five chapters: preoperative management, modalities of transportation and installation of the patient in the operating room, specific characteristics related to laparoscopic surgery, specific characteristics related to traditional surgery, and postoperative management. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome).

RESULTS

Synthesis of expert opinions and the application of the GRADE methodology produced 30 recommendations among which three were strong and nine were weak. The GRADE methodology could not be applied for 18 questions, for which only expert opinion was obtained.

CONCLUSION

These clinical practice guidelines can help surgeons optimize the peri-operative management of the obese patient undergoing gastro-intestinal surgery.

Efficacy and safety of endoscopic pyloric balloon dilation in patients with refractory gastroparesis

BACKGROUND AND AIMS

There has been interest in the use of pyloric therapies for the treatment of refractory gastroparesis. However, data on endoscopic pyloric dilation are scarce. We aimed to assess the efficacy and safety of this procedure in refractory gastroparesis.

METHODS

We performed a retrospective analysis of 47 patients referred for refractory gastroparesis, confirmed by gastric emptying scintigraphy, and treated with endoscopic pyloric through-the-scope balloon dilation. The primary endpoint was the effectiveness of the procedure, evaluated with the Gastric Cardinal Symptom Index (GCSI) at 2 and 6 months.

RESULTS

A clinical response, defined by a 1.0 point decrease in the GCSI score, was observed in 25 patients at 2 months (53%) and in 19 patients at 6 months (40%). The mean GCSI score decreased significantly at 2 and 6 months compared to the preoperative score (3.9 ± 0.87 vs 2.3 ± 1.37 and 3.9 ± 0.87 vs 2.9 ± 1.27, respectively; p < 0.0001). No complication was observed. Nine patients had a delayed relapse at 1 year. A second dilation was performed for eight patients and it was effective in five of them (63%). The mean follow-up time of the patients was 27.0 ± 10.4 months. At 2 years, 15 patients still experienced improvement following this treatment (32%). No predictive factor of clinical response was identified.

CONCLUSION

The efficacy of pyloric dilation is 53% at 2 months, with sustained improvement in one third of patients at 2 years. This treatment should be considered as an alternative option to pyloromyotomy.

P-077 SURGICAL TREATMENT OF LARGE INCISIONAL HERNIA WITH BOTULINUM TOXIN A INJECTION: STUDY PROTOCOL FOR A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL

Aim

The best strategy for W3 incisional hernia (IH) repair is not known to date and is associated with high risks of recurrence and morbidity. We aim to demonstrate that preoperative Botulinum Toxin A (BTA) injection in the lateral abdominal wall muscles reduces the rate of postoperative morbimortality after large IH (EHS W3) repair with mesh, compared with placebo injection.

Material & Methods

This study will be a prospective, national multi-center, double-blinded, randomized (1:1) superiority phase III trial with two parallel arms: BTA versus placebo injection. Participants will be selected based on an abdomino-pelvic CT-scan without contrast injection performed in the 6 months preceding the patient's surgery. Main inclusion criteria will comprise midline anterior primary or recurrent IH (subxiphoidal to suprapubic), of width ≥ 10 cm, without loss of domain. Patients included will be randomized (1: 1 ratio), by using a computer-generated randomization scheme, and randomization will by stratified on the center and width of the IH (10–15 cm and &gt; 15 cm). Participants will be randomized on the day of the injection, at least 4 weeks before the surgery.

Results

The primary endpoint will be the occurrence of Clavien-Dindo classification grade II or higher post-operative complication during the 90-day postoperative period. Secondary endpoints will include the rates of primary fascial closure, occurrence of component separation techniques, radiological response to injections, consumption of analgesics and pain, and occurrence of clinical and radiological recurrences.

Conclusions

Protocol version 2.0 is currently being assessed for funding by the French Ministry of Health.

Seventy years of bariatric surgery: A systematic mapping review of randomized controlled trials

While research publications on bariatric surgery (BS) have grown significantly over the past decade, there is no mapping of the existing body of evidence on this field of research. We performed a systematic review followed by a mapping of randomized controlled trials (RCTs) in BS for people with obesity. From January 2020 to December 2020, we performed a systematic review of RCTs evaluating BS, versus another surgical procedure, or versus a medical control group, through a search of Embase and PubMed. There was no restriction on outcomes for study selection. A total of 114 RCTs were included, most (73.7%) of which were based on a comparison with Roux-en-Y gastric bypass (RYGB) and conducted between 2010 and 2020. Only 15% of the trials were multicenter and few (3.5%) were international. The median number of patients enrolled was 61 (interquartile range [IQR]: 47.3-100). Follow-up time was 1 to 2 years in 36% and 22.8% of the trials, respectively. Weight loss was the most studied criterion (87% of RCTs), followed by obesity-related diseases, and medical and surgical complications (73%, 54%, and 47% of RCTs, respectively). Nutritional deficiency frequency, body composition, and mental health were little studied (20%, 18% and 5% of RCTs, respectively). Our literature review revealed that much research in BS is wasted because of replication of RCTs on subjects for which there is already body of evidence, with small populations and follow-up times mostly below 2 years. Yet several research questions remain unaddressed, and there are few long-term trials. Future studies should take into account the experience of the past 70 years of research in this field.

Half of Postoperative Deaths After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Could be Preventable: A French Root Cause Analysis on 5562 Patients

OBJECTIVE

To perform a retrospective root-cause analysis of postoperative death after CRS and HIPEC procedures.

BACKGROUND

The combination of CRS and HIPEC is an effective therapeutic strategy to treat peritoneal surface malignancies, however it is associated with significant postoperative mortality.

METHODS

All patients treated with a combination of CRS and HIPEC between January 2009 and December 2018 in 22 French centers and died in the hospital, were retrospectively analyzed. Perioperative data of the 101 patients were collected by a local senior surgeon with a sole junior surgeon. Three independent experts investigated the typical root cause of death and provided conclusions on whether postoperative death was preventable (PREV group) or not (NON-PREV group). A typical root cause of preventable postoperative death was classified on a cause-and-effect diagram.

RESULTS

Of the 5562 CRS+HIPEC procedures performed, 101 in-hospital deaths (1.8%) were identified, of which a total of 18 patients of 70 years old and above and 20 patients with ASA score of 3. Etiology of peritoneal disease was mainly colorectal. A total of 54 patients (53%) were classified in the PREV group and 47 patients (47%) in the NON-PREV group. The results of the study show that in the PREV group, WHO performance status 1-2 was more frequent and the Median Peritoneal Cancer Index was higher compared with those of the NON-PREV group. The cause of death in the PREV group was classified as: (i) preoperatively for debatable indication (59%), (ii) intraoperatively (30%) and (iii) postoperatively in 17 patients (31%). A multifactorial cause of death was found in 11 patients (20%).

CONCLUSION

More than half of the postoperative deaths after combined CRS and HIPEC may be preventable, mainly by following guidelines regarding preoperative selection of the patients and adequate intraoperative decisions.

Spin occurs in bariatric surgery randomized controlled trials with a statistically nonsignificant primary outcome: A systematic review

OBJECTIVES

To systematically identify the strategy and frequency of spin in reports of bariatric surgery randomized controlled trials (RCTs) with statistically nonsignificant primary endpoint.

STUDY DESIGN AND SETTING

The use of specific reporting strategies to highlight the beneficial effect of an experimental treatment can affect the reader interpretation of trial results, particularly when the primary endpoint is not statistically significant. A literature search was performed to identify RCTs publications assessing the impact of bariatric surgery on obesity-related comorbidities published over the past 10 years (from January 2020 till December 2020) in MEDLINE and EMBASE. RCTs publications with statistically non-significant primary outcomes were included.

RESULTS

Of 46 576 reports screened for title and abstract inclusion, 29 RCT reports met the inclusion criteria for spin analysis. In total, 16 abstracts (55%) and 18 main texts (62%) were classified as having a spin. In abstract results and conclusion sections, the spin was identified in 69% of reports. In main text results, discussion, and conclusion sections, the spin was recognized in 37%, 72%, and 76% of reports respectively. The spin consisted mainly of focusing on within-group improvements and the interpretation of statistically nonsignificant results as showing treatment equivalence.

CONCLUSION

Spin occurred in a high proportion of bariatric surgery RCTs with a statistically nonsignificant primary endpoint.

The male external urethral sphincter is autonomically innervated

INTRODUCTION

The aim of the present study was to describe autonomic urethral sphincter (US) innervation using specific muscular and neuronal antibody markers and 3D reconstruction.

MATERIAL AND METHODS

We performed en-bloc removal of the entire pelvis of three male human fetuses between 18 and 40 weeks. Serial whole mount sections (5 μm intervals) were stained and investigated. The sections were stained with Masson's trichrome and Eosin Hematoxylin, and immunostained with: anti-SMA antibody for smooth muscle; anti-S100 antibody for all nerves; and anti-PMP22 antibody, anti-TH antibody, anti-CGRP antibody, anti-NOS antibody for somatic, adrenergic, sensory and nitrergic nerve fibers, respectively. The slides were digitized for 3D reconstruction to improve topographical understanding. An animated reconstruction of the autonomic innervation of the US was generated.

RESULTS

The external and internal US are innervated by autonomic nerves of the inferior hypogastric plexus (IHP). These nerves are sympathetic (positive anti-TH antibody), sensory (positive anti-CGRP antibody), and nitrergic (positive anti-NOS antibody). Some autonomic fibers run within the neurovascular bundles, posterolaterally. Others run from the IHP to the posteromedial aspect of the prostate apex, above an through the rectourethral muscle. The external US is also innervated by somatic nerves (positive anti-PMP22 antibody) arising from the pudendal nerve, joining the midline but remaining below the rectourethral.

CONCLUSIONS

This study provides anatomical evidence of an autonomic component in the innervation of the external US that travels in the neurovascular bundle. During radical prostatectomy, the rectourethral muscle and the neurovascular bundles are to be preserved, particularly during apical dissection.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

What are the Specifics of Abdominal Wall Surgery in Cirrhotic Patients

The risk of developing an abdominal wall hernia is high in the cirrhotic patient, due to the association of ascites, hypoalbuminemia and amyotrophy in connection with undernutrition frequently associated with cirrhosis. Thus, almost 20% of cirrhotic patients develop an umbilical hernia. Parietal surgery is more at risk in cirrhotic patients and its indications must be discussed on a case-by-case basis. The objective of this work was to review the entire literature on wall 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 December 2019, using French and English as publication languages. The keywords retained were "hernia" [Mesh] and "liver cirrhosis" [Mesh]. In an elective situation, preoperative ascites control is recommended. A parietal prosthesis can be used, even in the case of uninfected ascites, preferably in the retromuscular position. Laparoscopy should be used with caution, due to the bleeding risk. No recommendation can be made on the use of prophylactic intra-abdominal drainage. The literature data do not allow the trans-jugular route portosystemic shunt recommendation, nor the use of a peritoneal-vesical pump to decrease the volume of ascites before parietal surgery in cirrhotic patients.

Daily medical education for confined students during coronavirus disease 2019 pandemic: A simple videoconference solution

The outbreak of coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 infection has recently spread globally and is now a pandemic. As a result, university hospitals have had to take unprecedented measures of containment, including asking nonessential staff to stay at home. Medical students practicing in the surgical departments find themselves idle, as nonurgent surgical activity has been canceled, until further notice. Likewise, universities are closed and medical training for students is likely to suffer if teachers do not implement urgent measures to provide continuing education. Thus, we sought to set up a daily medical education procedure for surgical students confined to their homes. We report a simple and free teaching method intended to compensate for the disappearance of daily lessons performed in the surgery department using the Google Hangouts application. This video conference method can be applied to clinical as well as anatomy lessons.

Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases

AIM

This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA).

METHODS

All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included.

RESULTS

From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients.

CONCLUSION

HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.

Smooth muscle of the male pelvic floor: An anatomic study

Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and innervation of the smooth muscle (SM) of the whole pelvic floor using male fetuses. We removed en-bloc the entire pelvis of three male fetuses. The specimens were serially sectioned before being stained with Masson's trichrome and hematoxylin and eosin, and immunostained for SMs, and somatic, adrenergic, sensory and nitrergic nerve fibers. Slides were digitized for three-dimensional reconstruction. We individualized a middle compartment that contains SM cells. This compartment is in close relation with the levator ani muscle (LAM), rectum, and urethra. We describe a posterior part of the middle compartment posterior to the rectal wall and an anterior part anterior to the rectal wall. The anterior part is split into (1) a centro-levator area of SM cells localized between the right and left LAM, (2) an endo-levator area that upholsters the internal aspect of the LAM, and (3) an infra-levator area below the LAM. All these areas are innervated by autonomic nerves coming from the inferior hypogastric plexus. The core and the infra-levator area receive the cavernous nerve and nerves supplying the urethra. We thus demonstrate that these muscular structures are smooth and under autonomic influence. These findings are relevant for the pelvic surgeon, and especially the urologist, during radical prostatectomy, abdominoperineal resection and intersphincteric resection. Clin. Anat., 2019. © 2019 Wiley Periodicals, Inc.

Thirty-day mortality after emergency surgery for obstructing colon cancer: survey and dedicated score from the French Surgical Association

AIM

The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score.

METHOD

From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value ≤ 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve.

RESULTS

A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age ≥ 75 (P = 0.013), American Society of Anesthesiologists (ASA) score ≥ III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80.

CONCLUSION

Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

Implementation of complex perioperative intervention in older patients with cancer (IMPROVED program)

TPS11630

Background: Nearly 50% of patients are older than 70 years at diagnosis of digestive cancer. Surgical resection is the first line strategy of treatment. Despite improvement in surgical techniques and development of rehabilitation programs, the rate of postoperative complications remains high. Peri-operative involvement of geriatricians may improve care management older cancer patients. Methods: During a 6 months run-up period (emerging project), we structured a multi-professional network (digestive surgeons, anesthetists, geriatricians, digestive oncologists, epidemiologists), we elaborated a innovative peri-operative geriatric intervention (Improved program) in digestive surgery setting based on evidence-based data. We build a dedicated evaluation plan by determinate the best design for assessing geriatric intervention in this complex context and choose the more appropriate endpoints. Results: We will include 554 patients aged 75 or more with resectable digestive cancer in a stepped wedge cluster randomized trial. The intervention is based on 1/ a preoperative geriatric assessment, focusing on frailty parameters and developing a coordinated program of tailored geriatric interventions 2/ a postoperative shared care with an integrated care model where both surgeon and geriatrician share responsibility for the patient management in surgical ward. This geriatric postoperative management will be focus on prevention and correction of complications, early mobilization, optimal nutritional support. The main endpoint Is is Grade II or higher post-surgical complications rate according Clavien-Dindo classification within 30 days after the surgical procedure. Conclusion: We expected to demonstrate a benefit of a peri-operative shared management model to decrease the risk of post-surgical complications In older patients with digestive cancer.

[Colorectal cancer surgery in the elderly]

Colorectal cancer risk factors increase with age, comorbidities, delayed diagnosis, obstruction, emergency and frailty. Surgery is the standard treatment as the survival rate for this pathology is the same as in young patients. It would appear that there is an excess morbidity and mortality of colorectal cancer surgery in the elderly. Early rehabilitation is to be favoured during the postoperative period.

Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation

BACKGROUND

Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score.

METHODS

We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy.

RESULTS

Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%.

CONCLUSIONS

After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.

Detailed muscular structure and neural control anatomy of the levator ani muscle: a study based on female human fetuses

BACKGROUND

Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery is responsible for pelvic floor dysfunction.

OBJECTIVE

We sought to demonstrate the presence of smooth muscular cell areas within the levator ani muscle and describe their localization and innervation.

STUDY DESIGN

Five female human fetuses were studied after approval from the French Biomedicine Agency. Specimens were serially sectioned and stained by Masson trichrome and immunostained for striated and smooth muscle, as well as for somatic, adrenergic, cholinergic, and nitriergic nerve fibers. Slides were digitized for 3-dimensional reconstruction. One fetus was reserved for electron microscopy. We explored the structure and innervation of the levator ani muscle.

RESULTS

Smooth muscular cell beams were connected externally to the anococcygeal raphe and the levator ani muscle and with the longitudinal anal muscle sphincter. The caudalmost part of the pubovaginal muscle was found to bulge between the rectum and the vagina. This bulging was a smooth muscular interface between the levator ani muscle and the longitudinal anal muscle sphincter. The medial (visceral) part of the levator ani muscle contained smooth muscle cells, in relation to the autonomic nerve fibers of the inferior hypogastric plexus. The lateral (parietal) part of the levator ani muscle contained striated muscle cells only and was innervated by the somatic nerve fibers of levator ani and pudendal nerves. The presence of smooth muscle cells within the medial part of the levator ani muscle was confirmed under electron microscopy in 1 fetus.

CONCLUSION

We characterized the muscular structure and neural control of the levator ani muscle. The muscle consists of a medial part containing smooth muscle cells under autonomic nerve influence and a lateral part containing striated muscle cells under somatic nerve control. These findings could result in new postpartum rehabilitation techniques.

Effect of Bariatric Surgery-Induced Weight Loss on Platelet Count and Mean Platelet Volume: a 12-Month Follow-Up Study

BACKGROUND

Abdominal obesity is strongly correlated with cardiovascular risk and associated with platelet hyperactivity. This hyperactivity is associated with an increase in mean platelet volume (MPV). Few data are available about changes in platelet counts and MPV in obese patients after bariatric surgery (BS). The purpose of this study was to describe quantitative and qualitative changes in the platelet lineage after BS.

METHODS

One hundred twenty-eight consecutive patients were included. The mean age was 43 ± 12 years, 77 % of patients were female, and the mean preoperative BMI was 44 ± 6 kg/m². Ninety patients (71 %) had a Roux-en-Y gastric bypass (RYGBP), and 38 (29 %) had a sleeve gastrectomy (SG). Patients were evaluated preoperatively, and postoperative follow-up was performed at 3, 6, and 12 months. The postoperative evaluation included blood samples for full blood count (FBC), including measure of mean platelet volume (MPV).

RESULTS

At the 12-month follow-up, the reduction in preoperative weight was 29 ± 9 %. We showed a significant decrease in platelet count (245 ± 62 vs. 234 ± 54 G/L; p = 0.0015) found in parallel with a non-significant decrease in MPV (9.27 ± 1.1 vs. 9.22 ± 1.05; p = 0.34). With regard to the intervention type, SG caused a more significant decrease in platelet count than RYGBP (p = 0.02). There was no significant difference in MPV variations between the two groups (p = 0.08).

CONCLUSIONS

Our results suggest that BS has a positive impact on platelet metabolism, possibly mediated by weight loss. These data need to be confirmed to understand the multifactorial benefits of BS on cardiovascular risk in obese patients.

Levator ani muscle innervation: Anatomical study in human fetus

AIMS

To characterize the nature and function of the levator ani muscle innervation pathways and to perform a comprehensive three-dimensional reconstruction of female pelvic innervation.

METHODS

A computer-assisted anatomical dissection protocol was applied to seven female human fetuses, after approval from the national biomedicine agency. Specimens were serially sectioned and immunostained for overall (antibody against protein S100), somatic (antibody against peripheral myelin protein 22), adrenergic (antibody against tyrosine hydroxylase), cholinergic (antibody against vesicular acetylcholine transferase), and nitrergic (antibody against the neural isoform of nitric oxide synthase) nerve fibers. Slides were digitized for three-dimensional reconstructions using WinSurf®.

RESULTS

Three main nerve pathways to the levator ani muscle were observed: the levator ani nerve, the pudendal nerve, and the inferior hypogastric plexus. The pudendal nerve was both somatic and autonomic, located below the levator ani muscle (infralevator pathway), supplying innervation to the inferior aspect of the levator ani muscle. The levator ani nerve was solely somatic, located above the levator ani muscle (supralevator pathway), supplying innervation to the superior aspect of the levator ani muscle. The inferior hypogastric plexus nerve fibers were solely autonomic, located in between the levator ani muscle and pelvic organs (endolevator pathway), supplying innervation to the medial portion of the levator ani muscle.

CONCLUSIONS

Our study provides a new representation of levator ani muscle innervation with three nerve pathways, and the levator ani muscle itself as an anatomical landmark.

Total mesorectal excision for cancer: histological and immunohistochemical evidence of nerve removal and risk-factor analysis

AIM

Whether or not nerve-sparing rectal-cancer surgery can effectively prevent removal of the pelvic autonomic nerves has not been substantiated microscopically. We aimed to analyse the quality of nerve preservation in female patients by quantifying residual nerve fibres in total mesorectal excision specimens, to analyse pro-erectile function of the nerve fibres removed and to determine risk factors for pelvic denervation.

METHOD

Serial transverse sections from female patients, 64 ± 18 years of age, were studied after the mesorectal fascia was inked and studied histologically [using anti-S100 and anti-neuronal nitric oxide synthase (nNOS) antibodies]. Nerve fibres located within 1 mm of the inked surface were counted and analysed according to type of surgery, tumour location, pT stage, circumferential resection margin and the necessity for a posterior colpectomy.

RESULTS

Twelve specimens were analysed. Per specimen, the mean number of nerve-fibre sections outside the mesorectum was 5.3 ± 3.6 (range: 1-12). The mean number of fibres per specimen was 6.4 ± 4.1 in patients having a low-rectal tumour and 4.4 ± 2.9 in those with mid or higher rectal tumours (P = 0.42). The mean number of fibres was higher (9.2) for T4 tumours than for T2/T3 tumours (5.0 ± 3.5), but this difference was not statistically sigmificant (P = 0.25). Patients having abdominoperineal excision, a posterior colpectomy or a circumferential resection margin of less than 1 mm had significantly more nerve fibres in the specimen (10.6 ± 1.9 vs 4.4 ± 2.8; P = .041). Fibres localized at the anterolateral rectum corresponded to branches of the neurovascular bundle, expressing rich pro-erectile activity (positive anti-nNOS immunostaining).

CONCLUSION

The neurovascular bundle is a key risk zone for pelvic denervation during total mesorectal excision. Abdominoperineal excision, posterior colpectomy and an invaded circumferential resection margin are associated with perineal denervation.

Concepts of the rectovaginal septum: implications for function and surgery

INTRODUCTION

In the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers' rectoprostatic fascia or rectovesical septum (RVS). Its purpose-and, indeed, its existence-are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men.

METHODS

A review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested.

RESULTS

This manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men.

CONCLUSIONS

The RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.

Remission of type 2 diabetes after omega loop gastric bypass for morbid obesity

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is a validated technique for the treatment of morbid obesity and results in a significant rate of remission of type 2 diabetes (T2D). Omega gastric bypass (OGBP) is an effective and simpler alternative for weight loss, but its effect on T2D is unclear.

METHODS

Between December 2006 and September 2012, 804 laparoscopic OGBPs were carried out in our centre. Among these, 100 (12.4%) patients had T2D at the time of the intervention. Remission of T2D was defined by a glycated haemoglobin (HbA1c) level of <6% without concomitant treatment.

RESULTS

Postoperative follow-up was completed by 81 patients (mean age: 49 ± 11 years; mean weight at surgery: 133 ± 29 kg; mean body mass index (BMI): 47 ± 9 kg/m(2)). Mean preoperative HbA1c was 8 ± 2 g/dL. Before OGBP, seven patients (9%) had received no oral hypoglycaemic treatment, 30 (37%) had received monotherapy, 26 (32%) bitherapy, six (7%) tritherapy and 12 (15%) patients had used insulin. Over a mean follow-up of 26 months (range 1-75), mean weight decreased to 94 ± 23 kg and mean BMI to 35 kg/m(2). Seventy-one (88%) patients had complete remission of T2D and the other 10 (12%) had reduced their treatment. Seven patients (58%) initially treated with insulin no longer required this treatment. Mean time to remission of T2D for patients receiving one or more oral therapies versus insulin was 6.9 versus 17.9 months.

CONCLUSIONS

OMBP is effective treatment for obesity in terms of weight loss and remission of T2D.

Can we predict complete or major response after chemoradiotherapy for rectal cancer by noninvasive methods? Results of a prospective study on 61 patients

Rectal preservation has been proposed as an alternative to radical resection in patients with presumed complete or major response to chemoradiotherapy (CRT). The aim of this prospective study was to evaluate the accuracy of digital rectal examination (DRE) and magnetic resonance imaging (MRI) to predict major or complete rectal cancer response to CRT. Over 2 years, 61 patients underwent radical resection after CRT for rectal cancer. DRE and MRI were carried out before and 6 to 8 weeks after the end of CRT. Data from DRE and MRI post-CRT were compared with pathological examinations. At pathological examination, major/complete responses were recorded for tumors classified ypT1N0 and ypT0N0, respectively. DRE post-CRT showed major/complete response in 26 cases, of which 14 (54%) were confirmed by pathology. The positive (PPV) and negative (NPV) predictive values of DRE to predict major/complete response were 54 and 88 per cent, respectively. MRI post-CRT showed major/complete response in 12 cases, of which nine (75%) were confirmed by pathology. The PPV and NPV of MRI to predict major/complete response were 75 and 82 per cent, respectively. Data from DRE and RMI post-CRT were concordant in 45 patients. The PPV and NPV of concordant DRE and MRI to predict major/complete response were 82 and 91 per cent, respectively. DRE and MRI do not appear to be sufficiently accurate for safe selection of patients appropriate for a rectum-sparing strategy because the risk of leaving an invasive tumor untreated is 18 per cent.

Can We Predict Complete or Major Response after Chemoradiotherapy for Rectal Cancer by Noninvasive Methods? Results of a Prospective Study on 61 Patients

Rectal preservation has been proposed as an alternative to radical resection in patients with presumed complete or major response to chemoradiotherapy (CRT). The aim of this prospective study was to evaluate the accuracy of digital rectal examination (DRE) and magnetic resonance imaging (MRI) to predict major or complete rectal cancer response to CRT. Over 2 years, 61 patients underwent radical resection after CRT for rectal cancer. DRE and MRI were carried out before and 6 to 8 weeks after the end of CRT. Data from DRE and MRI post-CRT were compared with pathological examinations. At pathological examination, major/complete responses were recorded for tumors classified ypT1N0 and ypT0N0, respectively. DRE post-CRT showed major/complete response in 26 cases, of which 14 (54%) were confirmed by pathology. The positive (PPV) and negative (NPV) predictive values of DRE to predict major/complete response were 54 and 88 per cent, respectively. MRI post-CRT showed major/complete response in 12 cases, of which nine (75%) were confirmed by pathology. The PPV and NPV of MRI to predict major/complete response were 75 and 82 per cent, respectively. Data from DRE and RMI post-CRT were concordant in 45 patients. The PPV and NPV of concordant DRE and MRI to predict major/complete response were 82 and 91 per cent, respectively. DRE and MRI do not appear to be sufficiently accurate for safe selection of patients appropriate for a rectum-sparing strategy because the risk of leaving an invasive tumor untreated is 18 per cent.

Ischaemic colitis: indications, extent, and results of standardized emergency surgery

BACKGROUND

Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management.

METHODS

191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively.

RESULTS

Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure.

CONCLUSION

An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.

Restoration of intestinal continuity after colectomy for non-occlusive ischemic colitis

BACKGROUND

Non-occlusive ischemic colitis (IC) is a rare and life-threatening abdominal disease associated with high rates of postoperative mortality. When surgery is performed, in patients with IC, either a Hartmann's procedure (HP) or a total colectomy and ileostomy is required. The possibility of restoration of intestinal continuity in surviving patients is an important issue. The aim of the present study was to report the outcome of surgically managed IC patients and to identify predictive factors for restoration of intestinal continuity and to assess the results of this procedure.

METHODS

Between January 1997 and May 2011, 96 IC patients underwent total colectomy and 68 underwent left colectomy. IC was spontaneous in 62 patients and occurred after prior surgery in 102. Eighty patients died during the postoperative period and nine died during the follow-up from an unrelated disease. Fifteen patients were lost to follow-up. The remaining 60 surviving patients were our study population.

RESULTS

There were 44 men and 16 women with a mean age of 67 years ± 12 SD. Restoration of bowel continuity was performed in 24 patients (40%). There were no predictive factors for restoration of intestinal continuity in terms of sex, age, IC etiology, and the extent of colon resection at primary surgery. The median interval between first surgery and restoration of bowel continuity was 7.9 months (range 0.2-35 months). There were no postoperative deaths and the overall morbidity rate was 45% (11/24). No patients developed anastomotic leak or underwent unplanned reoperation.

CONCLUSIONS

Reversal of HP after IC is feasible in 40% of surviving patients with acceptable mortality and morbidity rates. This restoration of intestinal continuity should therefore be discussed for every surviving IC patient.