CT scan for early diagnosis of anastomotic leak after colorectal surgery: is rectal contrast useful?

BACKGROUND: Computed tomography (CT) scan with rectal contrast enema (RCE-CT) could increase the detection rate of anastomotic leaks (AL) in the early postoperative period following colorectal surgery, compared to CT scan without RCE. The aim of this study was to assess the benefit of RCE-CT for the early diagnosis of AL following colorectal surgery. METHODS: Patients who had a RCE-CT for suspected AL in the early postoperative period following colorectal surgery with anastomosis between January 2012 and July 2019 at the Dijon University Hospital were retrospectively included. All images were reviewed by two independent observers who were blinded to the original report. The reviewers reported for each patient whether an AL was present or not in each imaging modality (CT scan, then RCE-CT). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were then calculated to determine the diagnostic performance of each modality. RESULTS: One hundred and thirty-nine patients were included. RCE-CT had an increased NPV compared to CT scan (82% vs 77% (p = 0.02) and 84% vs 68% (p < 0.0001) for observers 1 and 2, respectively). RCE-CT had an increased sensitivity compared to CT scan (79% vs 48% (p < 0.0001) for observer 2). RCE-CT had a significant lower false-negative rate for both observers: 18% vs 23% (p = 0.02) and 16% vs 32% (p < 0.0001). CONCLUSIONS: RCE-CT improved the detection rates of AL in the early period following colorectal surgery. RCE-CT should be recommended when a CT scan is negative and AL is still suspected.

Preoperative inflammation is an independent factor of worse prognosis after colorectal cancer surgery.

BACKGROUND: We know that inflammation is related to colorectal cancer prognosis and to the onset of postoperative infections. OBJECTIVE: This study aimed to understand the relationship between preoperative inflammation and the prognosis of colorectal cancer and to elucidate whether the impact of inflammation on cancer prognosis was related to an increased risk of surgical infection or was independent of it. METHODS: Patients who underwent elective colorectal cancer surgery between November 2011 and April 2014 were included in a prospective database (IMACORS). Preoperative c reactive protein was collected for each patient. Patients were followed up according to the French national guidelines. A cut-off of preoperative CRP of 5mg/L was chosen. Clinical characteristics were compared according to CRP using Chi2 and Mann-Whitney tests. The Overall Survival (OS) and Disease-Free-Survival (DFS) were compared by Kaplan-Meier curves. A Cox proportional hazards regression model was applied to perform a multivariate analysis of OS and DFS's predictors. RESULTS: A total of 254 patients were included. The median age was 68 years old. The median follow up was 41.8 months. The overall median preoperative CRP was 5mg/L. Preoperative CRP was significantly associated with N status; CRP being significantly higher among patients with colonic cancer and with patients who didn't receive a neoadjuvant treatment. Multivariate analyse revealed that preoperative CRP is an independent prognostic factor of OS and DFS respectively (HR=2.34 (1.26-4.31), P=0.006 and HR=1.83 (1.15-2.90), P=0.01). CONCLUSION: Preoperative inflammation measured by CRP is independently related with overall and disease-free survival of colorectal cancer.

What results can be expected one year after complex incisional hernia repair with biosynthetic mesh?

BACKGROUND: Incisional hernia is a frequent complication after midline laparotomy. The current standard repair includes the use of a synthetic mesh to prevent recurrence. However, the use of a synthetic mesh in a contaminated field carries a higher risk of mesh infection. In this setting biologic and biosynthetic meshes can be used as they resist to infection, but these are absorbable meshes. This raises the question of the risk of recurrence as the mesh disappears. Phasix® is a biosynthetic mesh getting absorbed in 12-18 months. The aim of this study was to assess the 1-year recurrence rate after abdominal-wall repair with a Phasix® mesh. METHODS: All patients undergoing ventral hernia repair between 2016 and 2018 at the University Hospital of Dijon using a Phasix® mesh were prospectively included in a database. They were all followed-up with a physical exam and a routine CT scan at one year. All postoperative complications were recorded. RESULTS: Twenty-nine patients were included in the study (55.2% women), with a mean BMI of 30,25 kg/m2. Nineteen meshes were sublay and 10 intraperitoneal. Complications at 1 month were mainly mild: Clavien-Dindo I and II (61.1%). No mesh was explanted. There was no chronic infection. The mean length of stay was 11.5 days. The 1-year recurrence rate was 10.3%. CONCLUSION: Patients having undergone complex ventral hernia repair with a Phasix® mesh have a 1-year recurrence rate of 10.3%. No severe surgical site occurrence was detected. A longer follow-up in a larger number of patients could confirm the place of this mesh in abdominal-wall repair.

Inflammatory markers for the early detection of post-operative infection: The same threshold for rectal and colic surgery?

INTRODUCTION: Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal? PATIENTS AND METHOD: This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve. RESULTS: An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P=0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC=0.87) corresponds to CRP on D4 for a threshold of 100mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100mg/L (AUC=0.71): sensitivity 63.6%, NPV 93.9%. CONCLUSION: Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP>100mg/L at D4.

Chyloperitoneum secondary to internal herniation complicating omega-loop gastric bypass.

Chyloperitoneum is a potential complication of omega-loop gastric bypass caused by internal herniation. Chronic compression of the mesentery leads to chylous extravasation that can mimic peritonitis.

Intraperitoneal drains move.

INTRODUCTION: The use of surgical drains is the subject of much debate but they continue to be commonly used. The phenomenon of drain migration from their desired position following surgery has not been studied. The aim of this study was to evaluate the incidence of the displacement of surgical drains among patients undergoing abdominal gastrointestinal surgery. PATIENTS AND METHODS: We performed a review of all patients who underwent an early CT-scan postoperatively after abdominal gastrointestinal surgery prior to drain mobilization, between January 2013 and April 2016 in the Dijon University Hospital Center. Pre-and intra-operative data (number, type and position of drains) and postoperative data (imaging and evolution) were collected retrospectively. RESULTS: This study included 125 patients. Thirty-five (28%) were found to have a displacement of at least one drain from its original position. Forty-one (19.8%) of the 207 studied drains had moved. Postoperative morbidity was not higher in patients with displaced drains (P=0.51). None of all the studied preoperative and operative factors have been found to be a risk factor for drain displacement. CONCLUSION: Surgical drains displacement is frequently encountered in patients undergoing digestive abdominal surgery. In our experience, this phenomenon does not seem to have any clinical implications. When a benefit is expected from the use of surgical drains, intraperitoneal fixation appears to be necessary.

Fcγ receptor expression on splenic macrophages in adult immune thrombocytopenia.

Splenic macrophages play a key role in immune thrombocytopenia (ITP) pathogenesis by clearing opsonized platelets. Fcγ receptors (FcγR) participate in this phenomenon, but their expression on splenic macrophages and their modulation by treatment have scarcely been studied in human ITP. We aimed to compare the phenotype and function of splenic macrophages between six controls and 24 ITP patients and between ITP patients according to the treatments they received prior to splenectomy. CD86, human leucocyte antigen D-related (HLA-DR) and FcγR expression were measured by flow cytometry on splenic macrophages. The major FcγR polymorphisms were determined and splenic macrophage function was assessed by a phagocytosis assay. The expression of the activation markers CD86 and HLA-DR was higher on splenic macrophages during ITP compared to controls. While the expression of FcγR was not different between ITP and controls, the phagocytic function of splenic macrophages was reduced in ITP patients treated with intravenous immunoglobulin (IVIg) within the 2 weeks prior to splenectomy. The FCGR3A (158V/F) polymorphism, known to increase the affinity of FcγRIII to IgG, was over-represented in ITP patients. Thus, these are the first results arguing for the fact that the therapeutic use of IVIg during human chronic ITP does not modulate FcγR expression on splenic macrophages but decreases their phagocytic capabilities.

Should CT scan be performed when CRP is elevated after colorectal surgery? Results from the inflammatory markers after colorectal surgery study.

INTRODUCTION: Serum concentration of C-reactive protein (CRP) that exceeds a pre-defined threshold between the 3rd and 5th postoperative day is a reliable marker of infectious complications after colorectal surgery. However, the optimal strategy to follow when a high CRP is found has not been defined. The aim of this study was to analyze the usefulness of computed tomography (CT) scan in this situation in a prospective cohort of patients following colorectal surgery. METHODS: Between November 2011 and April 2015, patients at two surgical centers who had undergone elective colorectal resection with anastomosis and who had a CRP>12.5mg/dL on the 4th postoperative day (POD) were prospectively included in a database. Data were collected concerning all complications occurring during the 30days following surgery, method of diagnosis, management and clinical course. The decision to perform a CT scan between POD 4 and POD 6 day was guided only by the elevation of CRP in the absence of any other clinical signs; results were analyzed to evaluate the diagnostic value of elevated CRP. Uni- and multivariable analyses were performed to identify risk factors for postoperative infection. RESULTS: The study included a total of 174 patients: 56 (32.1%) had a CT between POD 4 and 6, and this helped detect a postoperative complication in 55.4% of cases. Patients who did not undergo CT had lower CRP values (16.3 vs. 18.5, P=0.02). Among the 118 patients who did not undergo CT, 50.8% eventually developed an infectious complication. The sensitivity of CRP-guided CT was 76.7% with a negative predictive value of 78.8%. CONCLUSION: If an elevated CRP is found on POD 4, an abdominopelvic CT should be performed. A normal result does not formally eliminate the existence of intra-abdominal complication. A study protocol should be set up to evaluate whether systematic revisional surgery or repeat CT scan is the appropriate management if CRP in the next two days reveals persistent inflammation.

Epidemiology, Management, and Survival of Peritoneal Carcinomatosis from Colorectal Cancer: A Population-Based Study.

BACKGROUND: Modern chemotherapy aims to improve long-term survival for selected patients with peritoneal carcinomatosis. Publications suggest promising results, but the spread of these new aggressive treatment strategies in the general population is not well known. OBJECTIVE: The aim of this study was to draw a picture of epidemiology, management, and survival in synchronous and metachronous peritoneal carcinomatosis from colorectal cancer. DESIGN: The cumulative risk of metachronous peritoneal carcinomatosis was estimated in patients resected for cure. Net survival rates were calculated for synchronous and metachronous peritoneal carcinomatosis. SETTINGS: The study was conducted with the use of the Burgundy Digestive Cancer Registry. PATIENTS: Overall, 9174 primary colorectal cancers registered between 1976 and 2011 by the population-based digestive cancer registry were considered. RESULTS: In total, 7% of patients were diagnosed with synchronous peritoneal carcinomatosis. The 5-year cumulative risk of metachronous peritoneal carcinomatosis was 6%, and the stage of the colorectal cancer at diagnosis was the major risk factor. Other independent risk factors were mucinous adenocarcinoma, ulceroinfiltrating tumors, and diagnosis after obstruction or perforation. The proportion of patients resected for cure was 11% and 9% for synchronous and metachronous peritoneal carcinomatosis, and 3-year overall net survival was 8% and 5%. The corresponding rates after resection for cure were 21% and 17%. There was a dramatic increase in the proportion of patients receiving systemic chemotherapy: from 11% before 1997 to 48% in 2011 for synchronous peritoneal carcinomatosis and from 3% to 38% for metachronous peritoneal carcinomatosis. LIMITATIONS: This is a retrospective observational population-based study. CONCLUSION: Peritoneal carcinomatosis complicating colorectal cancer is a major reason for treatment failure. This study identified patients at a high risk of developing peritoneal carcinomatosis who may benefit from specific surveillance. New therapeutic modalities are also needed to improve the prognosis.

Isolated hepatic perfusion: principles and results.

INTRODUCTION: Isolated hepatic perfusion allows the delivery of high dose chemotherapy while decreasing extra-hepatic toxicity, and is used mainly for patients with surgically unresectable liver tumors. PRINCIPLES: Vascular exclusion of the liver is performed after obtaining satisfactory hemodynamic tolerance, occasionally after cavocaval shunt and/or porto-systemic shunt. Perfusion entry can be arterial and/or portal while the exit is portal or caval. The perfusion circuit can be open or closed, using a circulation pump with or without oxygenation. The chemotherapy regimens used are high dose melphalan (with or without TNF-alpha), oxaliplatin, cisplatin and mitomycin, sometimes associated with moderate hyperthermia. The duration of perfusion ranges between 30 and 90 minutes according to the different protocols used. A percutaneous technique with incomplete liver vascular exclusion is also possible. RESULTS: The larger series in the literature show a response rate (partial or complete stabilization) between 60 and 80%, with approximately 5% complete morphologic responses. Morbidity and mortality are 40 and 5%, respectively, including specific morbidity related to the perfusion procedure as well as to chemotherapy. CONCLUSION: Chemotherapy delivered through isolated hepatic perfusion is a new therapeutic alternative, still under development, and can be proposed to patients with surgically unresectable primary or secondary liver tumors within clinical trials. These results seem to be promising, but are still associated with a non-negligible morbidity rate.

Minimally invasive endogastric removal of migrated gastric band after endoscopic failure: how I do it.

Intragastric band migration is a rare and late complication of laparoscopic -adjustable gastric banding and should be recognized by all digestive surgeons. Endoscopic removal is most commonly performed, but surgery is an alternative in cases of endoscopic failure. Many different procedures have been reported. We show here (see Video) a fully laparoscopic endogastric procedure through two 5-mm antral gastrotomies. This technique can also be used to remove benign endogastric tumors. The procedure is safe and provides a large endogastric operative area, with no particular morbidity. Endogastric removal through a fully laparoscopic approach should be considered as the first alternative to endoscopic approach.

Right colectomy: value of the totally laparoscopic approach.

UNLABELLED: The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis. METHODS: The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected. RESULTS: Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up. CONCLUSION: These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.

C-reactive protein and procalcitonin for the early detection of anastomotic leakage after elective colorectal surgery: pilot study in 100 patients.

INTRODUCTION: Anastomotic leakage is the most important complication after colorectal surgery. Its prognosis depends on its early diagnosis. C-reactive protein (CRP) has already shown its usefulness for the early detection of anastomotic leaks. Procalcitonin (PCT) is widely used in intensive care units and is more expensive, but its usefulness in the postoperative period of digestive surgery is not well established. PATIENTS AND METHODS: Between May 2010 and June 2011, 100 patients undergoing elective colorectal surgery were prospectively included in a database. CRP and PCT were measured before surgery and daily until postoperative day 4. All intraabdominal infections were considered as anastomotic leaks, regardless of their clinical impact and their management. The kinetics of PCT and CRP were recorded, as well as their accuracy for the detection of anastomotic fistula. RESULTS: The incidence of fistula was 13% and the overall mortality rate was 2%. Both CRP and PCT were significantly higher in patients with leakage. Areas under the receiver-operating characteristics (ROC) for CRP were higher than those for PCT each day. The best accuracy was obtained for CRP on postoperative day 4 (areas under the ROC curve were 0.869 for CRP and 0.750 for PCT). CONCLUSION: Procalcitonin is neither earlier nor more accurate than CRP for the detection of anastomotic leakage after elective colorectal surgery.

Segment I intrahepatic biliary cystadenocarcinoma impinging on the hepatic vein.

BACKGROUND: Biliary cystadenoma is a rare cystic tumor; prognosis is dependent on the completeness of the surgical resection. CASE REPORT: The case of a 65-year-old woman with a multilocular cystic hepatic tumor is reported. Radiological and laboratory findings suggested the diagnosis of cystadenoma with localized malignant degeneration. RESULTS: A surgical resection of hepatic Segment I was performed, requiring total vascular exclusion (TVE) of the liver and a needle aspiration of a non-degenerated cyst to permit total resection. CONCLUSIONS: TVE and decompression of a cyst presumed to be benign may be warranted to achieve a safe and complete resection of biliary cystadenoma.

Diagnosis of postoperative pancreatic fistula.

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity after pancreatectomy. The International Study Group on Pancreatic Fistula (ISGPF) defines postoperative fistula by an amylase concentration in the abdominal drain of more than three times the serum value on day 3 or more after surgery. However, this definition fails to identify some clinical fistulas. This study examined the association between lipase measured in abdominal drainage fluid and PF. METHODS: Amylase and lipase levels in the abdominal drain were measured 3 days after pancreatic resection. Grade B and C fistulas were classified as clinical fistulas, regardless of whether the measured amylase concentration was considered positive or negative. The PF group included patients with a clinical fistula and/or those with positive amylase according to the ISGPF definition. RESULTS: Sixty-five patients were included. The median level of lipase was higher in patients with positive amylase than in those with negative amylase: 12,176 versus 64 units/l (P < 0·001). The lipase level was 16,500 units/l in patients with a clinical fistula and 224 units/l in those without a clinical fistula (P = 0·001). Patients with a PF had a higher lipase concentration than those without: 7852 versus 64 units/l (P < 0·001). A lipase level higher than 500 units/l yielded a sensitivity of 88 per cent and a specificity of 75 per cent for PF. For clinical fistulas the sensitivity was 93 per cent and specificity 77 per cent when the threshold for lipase was 1000 units/l. CONCLUSION: Lipase concentration in the abdominal drain correlated with PF. A threshold of 1000 units/l yielded a high sensitivity and specificity for the diagnosis of clinical PF.

Radiation-induced pancreatitis: search for the neoplasm!

The management of a patient with a post-radiation pancreatitis is reported. Several biopsies and imaging failed to diagnose the radiation-induced carcinoma revealed during emergency laparotomy. This diagnosis must be kept in mind, and repeated biopsies are necessary.