Ventral Hernia Repair and Obesity: Results from a Nationwide Register Study in France According to the Timeframes of Hernia Repair and Bariatric Surgery.

PURPOSE: Several strategies are suggested for ventral hernia repair (VHR) in bariatric candidates, in terms of timing and technique. The aim was to describe practices in VHR in bariatric patients on a nationwide scale in France. MATERIALS AND METHODS: We used the prospective national hospital discharge summaries database system to conduct a retrospective cohort study. We included patients operated once for sleeve or bypass, between 2007 and 2018, and who had VHR concomitant with bariatric surgery (BS) or within 2 years before or after. RESULTS: Among 11,680 eligible patients, 2039 underwent VHR in the 2 years before BS, 3388 had concomitant BS and VHR, and 6260 patients had VHR within 2 years after BS. Patients who underwent a concomitant surgery presented a higher suture repair rate (86.1% versus 37.1% and 44.0%, P < 0.001). Overall recurrence of VH at 10 years was 23.3% and was higher for patients who underwent VHR first (36.2%) than patients who underwent BS first (24.5%) and the concomitant group (18.6%), P < 0.001. Major complication rate was 11.1%, 7.8%, and 16.9% (P < 0.001) for VHR-first, concomitant, and BS-first groups, respectively. Mesh infection was found in 0.6% (13/2039) of patients in the VHR-first group, in 0.6% (20/3388) in the concomitant group, and in 1.1% (68/6260) in the BS-first group (P < 0.001). CONCLUSION: About one-quarter of bariatric patients undergoing VHR will be reoperated for an anterior hernia. VHR before BS entailed a higher risk of reoperation for recurrence and should be avoided. A concomitant repair entailed the lowest rate of recurrence.

Crohn's disease and postoperative recurrence. The role of anastomotic configurations and the kono-s anastomosis.

BACKGROUND: The observation that in more than 90% of Crohn's disease patients the postoperative recurrences are located in the pre-anastomotic tract leads us to suppose that the anastomosis would play a role in the appearance of recurrences. AIM AND METHODS: To focus the role of different anastomotic configurations in the incidence of recurrences, the Authors have conducted a review of the literature of the last two decades and have revised critically their experience. RESULTS: The rate of recurrences seem to be lower in patients in whom the anastomotic configuration is such as to present a wide lumen; it seems that they are lower after stapled side-to-side anastomosis. The Kono-S anastomosis, recently introduced technique, seems to offer better results. CONCLUSIONS: The role of the various types of anastomosis remains uncertain. Further large-scale controlled trials with long term follow-up are needed. KEY WORDS: Anastomosis, Crohn's disease, Postoperative Recurrences.

Elective surgery for ulcerative colitis, ileo-rectal anastomosis or restorative proctocolectomy An Update.

BACKGROUND: Despite advances in the medical management of Ulcerative Colitis (UC), surgery is required in about a third of patients. AIMS AND METHODS: A review of the literature of the last 20 years was conducted in order to analyze the results of Ileo-Rectal Anastomosis (IRA) and of Ileal Pouch-Anal Anastomosis (IPAA) in the treatment of mild-to-moderate UC. Postoperative complications, functional results and the risk of cancer were analyzed in each of the two groups of patients. RESULTS: In IRA group postoperative morbidity is low, varying from 8 to 28%. The risk of urinary and sexual dysfunction are rare and fertility rates are higher, compared to IPAA. The cumulative probability of success (working IRA) is 84% at 5 years and 51-69% at 10 years. The postoperative morbidity of IPAA is higher; dehiscence and pelvic sepsis were observed respectively in 9.5% and in 5.5%. A sexual dysfunction is present in 3.4%. In 18.8% occurs pouchitis. The risk of failure of the pouch is 6.8% and increased to 8.5% after 5 years. The risk of cancer is higher after IRA than after IPAA, with a cumulative risk at 20 years of 6-14% and 4.2% respectively. DISCUSSION: The choice between IPAA or IRA is based upon patient's preference and clinical criteria (malignancy or sphincter injury). IPAA, intervention of choice, is burdened by a higher rate of complications, such as anastomotic leak with pelvic sepsis and subsequent functional pouch failure, pouchitis, infertility in young women, lesions of the pelvic nerves and portal vein thrombosis. There have been reports of cancer not only in the anal transitional zone, but also in the same pouch, either after mucosectomy that after stapled anastomosis. IRA is less invasive than IPAA and postoperative complications are lower. Does not require dissection of the pelvic and presents no risk of injury of the nerves of the urogenital sphere. The long-term results of the IRA are generally satisfactory and most of the patients stated that after the intervention improve both the health status and quality of life. CONCLUSION: Today IPAA is the gold standard. The IRA is indicated in selected patients where they meet the following requirements: normal sphincter tone, absence of severe perineal disease, rectum does not actively involved by the disease, absence of dysplasia or cancer. It is also indicated in patients who refuse an ileostomy and it can be proposed as a possible interim procedure in young women, because it does not need a pelvic dissection and because the risk of infertility is minimal or absent when compared to IPAA. Because the risk of cancer is higher, patients undergoing IRA must be adequately informed about the risk, as well as recurrent proctitis, also of cancer, and must fully understand the need for surveillance and accept at least annual endoscopy with rectal biopsies; if these conditions are not met, patients should not be candidates for IRA. KEY WORDS: IPAA, IRA, Surgical treatment, Ulcerative Colitis.

Colorectal Cancer in Patients With Inflammatory Bowel Disease: The Need for a Real Surveillance Program.

The association between inflammatory bowel disease (IBD) and colorectal cancer (CRC) has been widely shown. This association is responsible for 10% to 15% of deaths in patients with IBD, even if according to some studies, the risk of developing CRC seems to be decreased. An adequate surveillance of patients identified as at-risk patients, might improve the management of IBD-CRC risk. In this article we review the literature data related to IBD-CRC, analyze potential risk factors such as severity of inflammation, duration, and extent of IBD, age at diagnosis, sex, family history of sporadic CRC, and coexistent primary sclerosing cholangitis, and update epidemiology on the basis of new studies. Confirmed risk factors for IBD-CRC are severity, extent, and duration of colitis, the presence of coexistent primary sclerosing cholangitis, and a family history of CRC. Current evidence-based guidelines recommend surveillance colonoscopy for patients with colitis 8 to 10 years after diagnosis, further surveillance is decided on the basis of patient risk factors. The classic white light endoscopy, with random biopsies, is now considered unsatisfactory. The evolution of technology has led to the development of new techniques that promise to increase the effectiveness of the monitoring programs. Chromoendoscopy has already proved highly effective and several guidelines suggest its use with a target biopsy. Confocal endomicroscopy and autofluorescence imaging are currently being tested and for this reason they have not yet been considered as useful in surveillance programs.

Surgical and medical treatment in patients with acute severe ulcerative colitis.

Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.

The role of sentinel lymph node biopsy in patients with local recurrence or in-transit metastasis of melanoma.

From January 2003 to March 2010, a prospective study was undertaken at the National Cancer Research Institute of Genoa in 15 patients with melanoma who had local recurrence (LR) or a few (≤ 3) in-transit metastases and clinically-negative regional lymph nodes with the aim of defining: i) the feasibility of sentinel node re-staging (r-sN) of the regional nodal basin; ii) the prognostic value of sentinel node status, and iii) the potential benefit in terms of disease-free survival and overall survival in patients with an histologically-positive sentinel node undergoing therapeutic regional lymph node dissection. Preoperative lymphoscintigraphy was performed to identify the r-sN: the radiotracer was intra-dermally injected around the LR or in-transit metastasis. Moreover, 10 min prior to the operative procedure, 0.5 ml intradermal injection of Patent-Blue-V dye was given around each LR or in-transit metastasis site, so that r-sN identification was achieved by both visualization of the nodal blue dye staining and the information supplied by gamma-detection probe. At least one sentinel node was intra-operatively identified in each patient, and a tumor-positive r-sN was required in four out of fifteen patients. The interval between the diagnosis of primary melanoma and the onset of recurrence was longer, although not significantly, in patients with tumor-negative r-sN, a compared to tumor-positive r-sN (49 ± 47 months vs. 25 ± 19 months, p=0.342). There was a trend toward an improved 1-, 3-, and 5-year disease-free survival and overall survival in patients with tumor-negative r-sN a compared to tumor-positive r-sN. Hence, the r-sN proved to be a feasible and accurate staging procedure even in patients with a few localizations of LR or in-transit metastases (≤ 3). r-sN identified those with a more favorable prognosis, supporting an aggressive therapeutic approach in the natural history of their disease; moreover, an unnecessary regional lymph node dissection was safely avoided in 11 out of 15 73.3% patients because they had a tumor-negative r-sN.