How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review

Anastomosis leakage (AL) after colorectal surgery is an embarrassing problem. It is associated with poor consequence. This review aims to summarize published evidence on prevention of AL after colorectal surgery and provide recommendations according to the Oxford Centre for Evidence-Based Medicine. We conducted bibliographic research on January 15, 2020, of PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. We retained meta-analysis, reviews, and randomized clinical trials. We concluded that mechanical bowel preparation did not reduce AL. It seems that oral antibiotic or oral antibiotic with mechanical bowel preparation could reduce the risk of AL. The surgical approach did not affect the AL rate. The low ligation of the inferior mesenteric artery could reduce the AL rate. The mechanical anastomosis is superior to handsewn anastomosis only in case of right colectomies, with similar results in rectal surgery between the 2 anastomosis techniques. In the case of right colectomies, this anastomosis could be performed intracorporeally or extracorporeally with similar outcomes. The air leak test did not reduce AL. There is no interest of external drainage in colonic surgery but drains reduced the rate of AL and rate of reoperation after low anterior resection. The transanal tube reduced the rate of AL.

[Laparoscopic resection of gastric stromal tumors]

Gastro-intestinal stromal tumors [GIST] are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining

[Surgical treatment of fistula between bladder and intestine secondary to Crohn's disease]

Crohn's disease [CD] is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula [EVF] during the CD. We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term

[Risk factors associated with pancreatic fistula after distal pancreatectomy]

Pancreatic leak [PL] remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy [DP]. 35 patients underwent DP during a 10-year period [2000- 2009]. Informations regarding diagnosis, operative details, and perioperative morbidity and mortality were collected. Nine risk factors were examined. Results: Indications for DP included primary pancreatic disease [n=23; 66%] and non-pancreatic disease [n = 12; 34%]. Postoperative morbidity rate was 43% and none patient died. No patients required a reoperation. Pancreatic fistula was occurred in 11 patients [31%]. On univariate analysis, incidence of pancreatic fistula rate was not significantly associated with these risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, additional procedures, intra operative bleeding and texture of pancreatic parenchyma. We observed significant statistical difference between male and female, 47% of females experienced a pancreatic fistula, while 17% males developed a pancreatic leakage [p =0.05]. The role of the technique of pancreatic stump closure in the development of pancreatic leak remains unclear because of the few number of patients on who we used stapler. The rate of pancreatic fistula after left pancreatectomy is 31%. The female was identified as a risk factor for occurrence of pancreatic fistula after left pancreatectomy. The role implicated in the use of a mechanical claw for the treatment of pancreatic stump requires a larger number of patients to conclude. The body mass index has not been studied in our series

Prognostic factors in gastric carcinoma after R0 resection with DH lymph node dissection. Tunisian experience

Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer. To determine the prognostic factors after R0 resection with DII lymph node dissection. We retrospectively assessed 126 patients who underwent R0 resection with DII lymph node dissection for gastric cancer [excluding the upper third of the stomach] in a single institution between 1991 and 2006 with median follow-up of 38.5 months [6 - 219]. Prognostic factors were assessed by Cox proportional hazard model. There were 45 women and 81 men. The median age was 60 years [21 - 87]. Four patients died [3.2%]. Postoperative hospital morbidity was 16.7%. The pathologic review of the slides revealed that 50% of the tumors were stage T3 [63 cases]. The median number of lymph node removed was 11 [8-40], 50% were involved. Five and 10 years survival rates were respectively 56.9% and 40.2%. In multivariable analysis, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were found to be independent prognosis factors. After R0 resection with DII lymphadenectomy, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were independent predictive factors for survival

[ caroli's disease. Report of 16 cases]

Caroli's disease is a congenital dilatation of the intrahepatic biliary duct. To analyse and discuss diagnostic and therapeutics difficulties through 16 patients with Caroli's disease. Between January 1990 and September 2010, 16 patients underwent surgical procedure for Caroli's disease. Data recorded for each patient included clinical symptoms, biologic findings, previous biliary procedures, and the presenting symptoms. The distribution of the biliary lesions, the surgical procedure and the postoperative outcomes and follow up were detailed. The mean age was 55 years. the mean interval between the first symptoms and diagnosis was 27 months. Five of 16 patients had undergone 12 surgical or dneoscopic procedures prior to liver resection. Before the definitive diagnosis, 9 patients presented 15 episodes of acute cholangitis. The diagnosis was established preoperatively in 13 cases, 5 among them underwent previous biliary surgical procedures. The diagnosis was documented peroperatively in 2 cases and postoperatively in 1 case. The distribution of the biliary lesions was monolobar in 13 and bilobar in 3 patients. 13 patients underwent liver resection, in two cases we performed bilio-jejunostomy and the last one had endoscopic sphyincterotomy. There was no mortality and the overall postoperative morbidity is about 43%. The follow-up shows that 12 patients still alive with a mean follow up for 53 months, from whom only one patient have intrahepepatic lithiasis. The clinical course of Caroli's disease is often complicated by recurrent episodes of angiocholitis and requires iterative surgery. The hepatectomy which prevented septic complications and degenerescence is possible only in a restricted number of patients

Acute peritonitis complicating Crohn's disease: epidemiologic and physiopathological characteristics

An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication. To report the incidence of this complication and to discuss the mechanism of the perforation. We report, retrospectively, 4 cases [3 men and one woman; median age: 30 years] of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases. Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented

[Malignant intraductal papillary mucinous tumours of the pancreas: a three cases report]

Intra ductal papillary mucinous tumors of pancreas are rare and are characterized by a risk of malignant transformation. To clarify their clinical presentation and the performance of different imaging examinations to determine their benign or malignant and achieve their staging. We report three cases of degenerate intra ductal papillary mucinous tumors of pancreas. The combination of CT, the pancreato- MRI and duodenoscopy has led to the diagnosis in all cases. A pancreaticoduodenectomy were performed in two cases. The various imaging techniques allow better detection and analysis of the tumor including the evaluation criteria of degeneration. The treatment of these lesions is still surgery

[Laparoscopic radical prostatectomy: initial experience: about two cases]

Laparoscopic radical prostatectomy was a major breakthrough in the treatment of localized prostate cancer. To report the first two laparoscopic radical prostatectomies performed in Tunisia. The two patients are aged 57 and 66 and were suffering from localized prostate cancer. We first tested the transperitoneal and under-peritoneal paths. We then used an anterogradic surgery technique with preservation of the bladder-neck, extra-facial dissection of neuro-vascular bandles and vesicourethral running anastomosis. The two procedures lasted 435 and 305 minutes. We did not have any conversion nor blood transfusion. Post-operatory situation was simple. The two patients were kept in clinic for 4 days and the trans-urethral catheter was removed 7 days following the surgery. The anatomo-pathologic study finds a negative surgical margins for both patients. 3 months later, both patients are continents. Only one of them showed an erection with phosphodieseterase type 5 inhibitors. The total PSA is indetectable. Laparoscopic radical prostatectomy for localized prostate cancer is a technique that has proven its effectiveness since 10 years at least

[Colo-urachal-cutaneous fistula in an adult]

An infected urachal cyst is an uncommon finding in adults. To report a case of a sigmoid- urachal- cutaneous fistula. A 51 years old adult male presented with fecaloid leaking from rupture of an infected urachal cyst. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments. Colo-urachal-cutaneous fistula is a rare condition; its management is rather complex

[Long-term functional outcome of laparoscopic and reflux surgery]

Medical treatment of gastro esophageal reflux is associated with relapse in 30% of cases. In these patients, the best therapeutic option is surgical treatment, performed laparoscopically. However, there are few data on long-term functional outcome. To determine long-term results of laparoscopic antireflux surgery the mechanisms involved in patients with worse results. We studied patients operated for reflux disease. They had either total or partial laparoscopic fundoplication. These patients were contacted to assess postoperative improvement, satisfaction and asked about the occurrence or not of a persistent postoperative dysphagia. Seventy one patients were included [Nissen in 61% of the cases and Toupet in 39%]. After an average period of 52.4 months,80% of patients were satisfied. 58% were completely improved,while 31% were partially improved after surgery. Persistent reflux symptoms reflux were observed in 8 patients and postoperative dysphagia was reported by 11 patients. Gastroesophageal reflux revealed by chronic cough was the only independent parameter associated with bad functional results in our patients. Laparoscopic anti reflux surgery is associated with a high frequency of satisfaction. However, patients with chronic cough respond less better to surgery. Strict selection of the patients before surgery must be done, to improve the functional results after anti reflux surgery

[Totally implantable venous access ports by cephalic vein cut-down for patients receiving chemotherapy]

The use of an implantable room has become indispensable in the clinical practice for the cancer patients. The increasing use of these devices was associated with a greater incidence of complications. To verify the feasibility of the cephalic vein cut-down technique for placement of venous access devices. A prospective study of 58 port placements was performed at our department of general surgery. The surveillance of devices was collectively insured by the operator and by the oncologists. The indication for implantation was the infusion of intravenous chemotherapy in patients with colorectal cancer in 55.1% cases and breast cancer in 27.5%. The specific complication rate was 7%. The cephalic vein cut-down approach was used successful in 45 [77.5%] patients. When the cephalic vein could not be used, a percutaneous technique was employed using the subclavian vein in 22.4% of the patients. Cephalic vein cut-down technique should be considered a safe and feasible approach for placement of venous access devices

Appendicitis in strangulated femoral hernia: a case report

Herniation of the appendix into a femoral hernia also called De Garengeot hernia-is a rare but well-recognized entity. It is typically discovered incidentally during hernia repair. Acute appendicitis in a strangulated femoral hernia is even more uncommon. Report a new case. We report on a patient admitted for a painful groin mass. She underwent emergency surgery. Exploration identified acute appendicitis in a strangulated femoral hernia sac. Appendectomy associated with Mac Vay's herniorrhaphy were performed. The outcome was uneventful. Surgeons should be aware of the existence of this infrequent and atypical presentation of appendicitis and femoral hernia