Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials.

BACKGROUND: Prophylactic negative-pressure wound therapy (pNPWT) may prevent surgical site infection (SSI) after laparotomy, but existing meta-analyses pooling only high-quality evidence have failed to confirm this effect. Recently, several randomized controlled trials (RCTs) have been published. We performed an updated systematic review and meta-analysis to determine if pNPWT reduces the incidence of SSI after laparotomy. METHODS: MEDLINE, Embase, CENTRAL and Web of Science were searched on the 25.08.2021 for RCTs reporting on the incidence of SSI in patients who underwent laparotomy with and without pNPWT. The systematic review was compliant with the AMSTAR2 recommendation and registered into PROSPERO. Risk ratios (RR) for SSI in patients with pNPWT, and risk difference (RD) between control and pNPWT patients, were obtained using random effects models. Heterogeneity was quantified using the I2 value, and investigated using subgroup analyses, funnel plots and bubble plots. Risk of bias of included RCTs was assessed using the RoB2 tool. RESULTS: Eleven RCTs were included, representing 973 patients who received pNPWT and 970 patients who received standard wound dressing. Pooled RR and RD between patients with and without pNPWT were of, respectively, 0.665 (95% CI 0.49-0.91, I2: 38.7%, p = 0.0098) and -0.07 (95% CI -0.12 to -0.03, I2: 53.6%, p = 0.0018), therefore demonstrating that pNPWT decreases the incidence of SSI after laparotomy. Investigation of source of heterogeneity identified a potential small-study effect. CONCLUSION: The protective effect of pNPWT against SSI after laparotomy is confirmed by high-quality pooled evidence.

[Hemorrhoidal disease in 2022 : how to select the most appropriate treatment ?] / Maladie hémorroïdaire en 2022 : comment choisir le traitement adapté ?

Hemorrhoidal disease is frequent and can lead to major alteration of quality of life. Conservative treatment, instrumental therapies and surgical approach play a complementary role in the management of hemorrhoidal disease. Understanding all techniques is mandatory to guide the patient and offer the best individualized treatment. Guidelines issued by scientific societies can facilitate the therapeutic decision.

La maladie hémorroïdaire est fréquente et ses répercussions sur la qualité de vie peuvent être majeures. Traitement conservateur, procédés non chirurgicaux et interventions chirurgicales jouent un rôle complémentaire dans le traitement d'une maladie hémorroïdaire symptomatique. Pour guider le patient et lui offrir la prise en charge la plus adaptée à sa situation, une connaissance des différents traitements est indispensable. Les recommandations des sociétés savantes, basées sur des avis d'experts, peuvent faciliter la décision thérapeutique.

Impact of Nonalcoholic Steatohepatitis on the Outcome of Patients Undergoing Roux-en-Y Gastric Bypass Surgery: a Propensity Score-Matched Analysis.

PURPOSE: It is currently unknown whether NASH (nonalcoholic steatohepatitis), as compared to simple steatosis, is associated with impaired postoperative weight loss and metabolic outcomes after RYGB surgery. To compare the effectiveness of Roux-en-Y gastric bypass (RYGB) on patients with NASH versus those with simple nonalcoholic fatty liver (NAFL). MATERIALS AND METHODS: We retrospectively retrieved data from 515 patients undergoing RYGB surgery with concomitant liver biopsy. Clinical follow-up and metabolic assessment were performed prior to surgery and 12 months after surgery. We used multivariate analysis of variance (MANOVA) and propensity score matching and we assessed for changes in markers of hepatocellular injury and metabolic outcomes. RESULTS: There were 421 patients with simple NAFL, and 94 with NASH. Baseline alanine and aspartate aminotransferases were significantly higher in patients with NASH (p < 0.01). Twelve months after the RYGB surgery, as determined by both MANOVA and propensity score matching, patients with NASH exhibited a significantly greater reduction in alanine aminotransferase (ß-coefficient - 12 iU/l [- 22 to - 1.83], 95% CI, adjusted p = 0.021) compared to their NAFL counterparts (31 matched patients in each group with no loss to follow-up at 12 months). Excess weight loss was similar in both groups (ß-coefficient 4.54% [- 3.12 to 12.21], 95% CI, adjusted p = 0.244). Change in BMI was comparable in both groups (- 14 (- 16.6 to - 12.5) versus - 14.3 (- 17.3 to - 11.9), p = 0.784). CONCLUSION: After RYGB surgery, patients with NASH experience a greater reduction in markers for hepatocellular injury and similar weight loss compared to patients with simple steatosis.

Role of near-infrared fluorescence in colorectal surgery.

Near-infrared fluorescence (NIRF) is a technique of augmented reality that, when applied in the operating theatre, allows the colorectal surgeon to visualize and assess bowel vascularization, to identify lymph nodes draining a cancer site and to identify ureters. Herein, we review the literature regarding NIRF in colorectal surgery.

The Use of a Stoma Rod/Bridge to Prevent Retraction: A Systematic Review.

PURPOSE: We evaluated evidence related to the use of a rod (bridge) to prevent stoma retraction during loop ostomy construction. METHODS: We completed a systematic review of the literature. We searched MEDLINE, EMBASE, and COCHRANE databases up to December 4, 2019. We posed the following question based on a PICO format. Do adult patients undergoing ostomy surgery experience less stomal retraction when compared to patients managed without placement of a stoma rod? FINDINGS: Our initial search returned 182 articles; after reading studies in full, 5 articles were identified that collectively enrolled 1058 participants. Four studies were randomized controlled trials and one was a prospective cohort study. Meta-analysis could not be performed because of the small number of studies and the heterogeneity of outcomes measurements. The incidence of stoma retraction ranged between 0%-8% in patients managed with a rod and 0.78%-8.2% in patients with no rod. The number of reported adverse events was low. Placement of a stoma rod was associated with more adverse outcomes than in patients managed without a rod. Adverse events included local edema, stoma necrosis, skin necrosis, peristomal moisture-associated skin damage (irritant dermatitis), peristomal abscess, bleeding, and mucocutaneous separation. CONCLUSIONS: Stoma rod does not seem to reduce the risk of stoma retraction and might result in other adverse events. IMPLICATIONS: We recommend avoidance of stoma rod/bridge placement during ostomy surgery.

Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence.

BACKGROUND: Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY: After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.

Surgical management of vascular Ehlers-Danlos syndrome and its challenges: a case report.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a heterogeneous group of rare inherited diseases involving connective tissue. Vascular EDS (vEDS) is associated with abnormal type III collagen, which is an essential component of skin, hollow organs and arterial walls, and causes potentially fatal visceral and arterial complications. The surgical management of these patients is challenging and should be limited to life-saving procedures. CASE DESCRIPTION: We report a case of a 42-year-old male who presented a hemorrhagic shock due to spontaneous rupture of an ascending branch of the left colic artery. The coexisting presence of multiple abdominal vascular abnormalities suggested the diagnosis of vEDS, later confirmed by the discovery of a new missense mutation in the COL3A1 gene with pathogenic significance. The post-operative course was marked by a mechanical ileus caused by an ischemic stenosis of the descending colon. Failure of conservative management and the well-known risk of colonic perforation in these patients led to the decision to perform a diverting ileostomy. CONCLUSION: The management of these patients is difficult, and risk-benefit assessments must be made on a case-by-case basis. Less invasive procedures should be considered whenever possible.

Comment on: Should a colonoscopy be offered routinely to patients with CT proven acute diverticulitis? A retrospective cohort study and meta-analysis of best available evidence.

Latest evidence indicates that patients with acute diverticulitis have higher prevalence of colorectal cancer than reference patients. Therefore, colonoscopy should be offered after an episode of acute diverticulitis.

Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study.

INTRODUCTION: Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. OBJECTIVE: The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. METHODS: A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. RESULTS: Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. CONCLUSION: Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery.

Lateral lymph node dissection for low rectal cancer: Is it necessary?

Rectal cancer constitutes a major public health issue. Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its introduction in the late 1980s. Removal of all lymph nodes located in the mesorectum has indeed improved pathological and oncological outcomes. However, when cancer spreads to the lateral lymph nodes (located along the iliac and obturator arteries) Western and Japanese practices differ. Where the Western guidelines consider this condition as an advanced form of the disease and use neoadjuvant radiochemotherapy liberally, the Japanese guidelines define it as a local disease and proceed to lateral lymph node dissection with or without neoadjuvant treatment. Herein, we review the current literature regarding both therapeutic strategies, with the aim of contributing to potential improvements in treatment and outcome for patients with low and mid rectal cancer.

Does Surgical Approach in Pelvic Floor Repair Impact Sexual Function in Women?

INTRODUCTION: Surgical routes used to correct complex pelvic floor disorders (CPFDs) may have a negative impact on women's sexual function. Currently, there is no evidence concerning the impact of a specific surgical procedure on postoperative sexual function in women. AIM: The aim of this study was to compare an abdominal approach with rectopexy and sacrocolpopexy to a perineal procedure with abdominal rectopexy, regarding female sexual function in cases of CPFDs. METHODS: Women who were operated for CPFDs between January 2003 and June 2010 were retrospectively asked to answer the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, the Miller Score of Incontinence, and a urinary incontinence frequency score. We also questioned them about their sexual function and satisfaction before and after the operation using visual analogic scores. MAIN OUTCOME MEASURE: We compared the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 before and after the surgery in both groups, and we made an intragroup comparison. RESULTS: There were 334 women identified, but only 51 could be included. Globally, we found no statistically significant differences in terms of sexual function before and after surgery between the 25 groups. Intragroup comparison demonstrated that, within the perineal approach group, patients experienced a decrease in their sexual arousal after the procedure. The choice of surgical route for pelvic floor disorders does not seem to have an impact on the results of postoperative sexual function in women. This study adds to the limited literature on sexual outcomes of surgery for CPFD. It is limited principally due to its retrospective design and the small number of patients included. CONCLUSION: Both surgical routes have very similar outcomes on most sexual questions. A perineal approach combined with abdominal rectopexy did, however, demonstrate a slight decrease in sexual arousal of the patients after the intervention. Zawodnik A, Balaphas A, Buchs NC, et al. Does Surgical Approach in Pelvic Floor Repair Impact Sexual Function in Women? Sex Med 2019;7:522-529.

Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges.

Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.

Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure.

PURPOSE: Mucosal advancement flap (MAF) is the best option for complex anal fistula (AF) treatment. Recurrence is not rare and the best surgical option for his handling is a challenge considering the incontinence risk and the healing rate. We aimed to determine the feasibility and outcomes of a second MAF for recurrent complex AF previously treated with mucosal advancement flap. METHODS: We retrospectively identified 32 patients undergoing two or more MAF for recurrent AF in a larger cohort of 121 consecutive cases of MAF operated by the same senior colorectal surgeon. Only complex AF of cryptoglandular origin was enrolled. A long-term follow-up was performed collecting clinical and functional data. RESULTS: Among 121 patients (group A) treated with mucosal advancement flap, 32 (26.4%) (group B) recurred with a complex AF requiring a second mucosal advancement flap procedure. Success rate of group B is 78.1%. Six patients of group B recurred a second time, another MAF was performed with healing in all cases. Complication rate (Clavien Dindo 3b) of group B is 9.4% compared to 8.3% of group A. A slight continence deficit (Miller score 1, 2, and 4) was detected after the first MAF in 3 patients. The Miller score for these patients did not change after the subsequent MAF. CONCLUSIONS: MAF is effective for treatment of complex recurrent AF. A pre-existing MAF procedure does not worsen the healing rate of the second flap. The rate of surgical complications is similar with those reported in the literature for MAFs.

Correction to: Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure.

The name of the second author of this article was incorrectly presented as "Riccardo Scarpa Cosimo" this should have been "Cosimo Riccardo Scarpa".

Risk of colorectal cancer in patients with diverticular disease.

Colorectal cancer constitutes an important burden on the healthcare system. Screening at-risk populations to reduce colorectal cancer-related morbidity and mortality has become part of good clinical practice. However, recommendations regarding subgroups of patients with diverticular disease are subject to controversy. Herein, we review the most recent literature regarding the prevalence of colorectal cancer in patients with diverticular disease, diverticulitis and uncomplicated diverticulitis. The recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer. However, the risk of colorectal cancer is increased in the short-term period after hospitalization related to diverticular disease. According to a recent systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis who underwent colonoscopy. The risk of having colorectal cancer after an episode of acute diverticulitis is 44-fold higher than that of an age- and gender-adjusted reference population. Despite lower among patients with uncomplicated episode, the risk of colorectal cancer remains 40-fold higher in that subpopulation than that in the reference population. To conclude, the recent literature describes an increased risk of colorectal cancer among patients with acute diverticulitis compared to the reference population. Colonoscopy is therefore recommended in patients with diverticulitis to exclude colorectal cancer.

Current Strategies to Prevent Iatrogenic Ureteral Injury During Colorectal Surgery.

Iatrogenic ureteral injuries are a source of major concern among surgeons performing colorectal procedures. Although they are uncommon, these lesions lead to severe morbidity and long-term functional disabilities, as well as an increase in mortality, hospital stay, and cost. The laparoscopic approach has gained popularity in the field of colorectal surgery and is associated with improved global postoperative outcomes. However, it is also considered to increase the risk of ureteral injury when compared to open surgery, especially during left colonic and rectal resections. To overcome these difficulties, surgical techniques have been improved over time through standardization of both open and laparoscopic procedures. However, these techniques are not infallible, and, in difficult cases, instrumental aids such as preoperative ureteral stenting may be used. To substitute the reduced haptic feedback in laparoscopic surgery, lighted stents have been developed. Unfortunately, prophylactic stenting, whether standard or lighted, is also associated with its own morbidity and its benefit-risk ratio remains highly controversial. To enhance the surgeon's visualization capabilities, augmented reality technologies have been developed. Near-infrared fluorescence and hyperspectral imaging are two promising techniques, which have been tested both in the preclinical and clinical settings. Early results show that these technologies could improve our ability to identify and protect the ureters, although technical limitations remain to be solved. Reviewing the current literature, this article aims to evaluate pre- and intraoperative techniques to identify the ureters and potentially to avoid iatrogenic injury. In addition, future trends are explored.

Does near-infrared (NIR) fluorescence angiography modify operative strategy during emergency procedures?

INTRODUCTION: Bowel viability can be difficult to evaluate during emergency surgery. Near-infrared (NIR) fluorescence angiography allows an intraoperative assessment of organ perfusion during elective surgery and might help to evaluate intestinal perfusion during emergency procedures. The aim of this study was to assess if NIR modified operative strategy during emergency surgery. MATERIALS AND METHODS: From July 2014 to December 2015, we prospectively evaluated all consecutive patients, who had NIR assessment during emergency surgery. Primary endpoint was the modification of operative strategy after the assessment with NIR. Secondary endpoints were general post-operative outcomes, including reoperation rate. RESULTS: Fifty-six patients were included in the study. Mean age was 64 ± 17 years. An exploratory laparoscopy was performed in 39% (n = 22) and an open surgery in 61% of cases (n = 34). Conversion rate to open surgery was 41% (n = 9). 32 patients had a bowel resection. In 32% of the cases (n = 18), the result of the NIR test led to a modification of the operative strategy. Among them, 33% (n = 6) had a larger resection or a resection, which was initially not planned. The other 12 patients (67%) had finally no resection, which was initially thought to be performed. Importantly, none of those patients needed a reoperation for ischemia. Mean time for performing NIR test was 167 s (± 121). Overall reoperation rate was 16.1% (n = 9). Two patients had an anastomotic leak. Eight patients (14.3%) died within the first 30 post-operative days; however, none of them presented a bowel ischemia or an anastomotic leak. CONCLUSION: NIR is an easy and short procedure, which can be performed during emergency surgery to assess bowel perfusion. It may help the surgeon to preserve intestinal length or to define the exact limits of resection. Overall, we report a modification of operative strategy in up to one-third of evaluated patients.

[Preservation of sexual function : a challenge for the colorectal surgeon]. / Préservation de la fonction sexuelle : un défi pour le chirurgien colorectal.

Patients with rectal cancer have an increased risk of developing sexual disorders. These dysfunctions are caused by the disease itself (negative psychological impact, nerve compression in the pelvis), as well as by the treatments (radiotherapy, chemotherapy and surgery). Most sexual disorders are due to the surgery and can be attributed to injuries of the retroperitoneal nerves. Sexuality assessment of patients before and after treatment, a precise knowledge of the pelvic anatomy by the surgeon, and an appropriate care by specialists (gynaecologists, urologists and sexologists) are essential to reduce the risk of sexual disorders and to minimize their impact on overall quality of life.

Les patients atteints d'un cancer du rectum présentent un risque accru de développer ou d'aggraver des troubles de la sexualité. Ces dysfonctions sont causées par la maladie (impact psychologique négatif, compression nerveuse dans le petit bassin) d'une part, et par les traitements (radio, chimiothérapie et chirurgie) d'autre part. Parmi ceux-ci, la chirurgie est responsable de la plupart des troubles sexuels, par lésion des plexus neurovégétatifs. Une évaluation de la sexualité des patients avant et après traitement, une connaissance précise de l'anatomie du petit bassin par le chirurgien ainsi qu'une prise en charge adaptée par des spécialistes (gynécologues, urologues, sexologues) constituent les étapes essentielles afin de diminuer le risque de survenue de troubles sexuels et leur impact sur la qualité de vie globale des patients.