Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients.

PURPOSE: Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery. METHODS: We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics. RESULTS: 164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005]. CONCLUSION: The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Mid-term outcomes after biologic mesh use: Does their performance meet our expectations?

INTRODUCTION: The indications for use of biological mesh prostheses are very limited because of their high cost, but include parietal repair in a contaminated setting. Their efficacy has been questioned by several recent studies. We therefore studied the results of all of our patients who received a biological prosthesis, including hernia recurrence and infectious complications. PATIENTS AND METHODS: We retrospectively reviewed the outcomes of 68 patients who underwent biological prosthesis placement from 2009 to 2015 in a single center. RESULTS: The site of implantation was on the anterior abdominal wall in 49 (72%) of cases, in the pelvis in 19 (28%). The median follow-up was 19 months. In the early post-operative period, 22 (32.3%) of patients presented with wall abscess; eight (11.7%) underwent surgical revision and seven (10.2%) underwent interventional radiological drainage. In the medium term, 41/56 (73%) had a late complication; 32 (57%) of the patients developed recurrent herniation and 15 (26.7%) of them were re-operated. In addition, nine (16%) of patients developed a late surgical site infection and eight (14.2%) a chronic residual infection. In multivariate analysis, the risk factors for recurrence were parastomal hernia (P=0.007) and a history of recurrent hernia (P=0.002). CONCLUSION: A majority of patients developed recurrent incisional herniation in the medium term. This puts the use of biological prostheses into question. These results need to be compared to those of semi-absorbable prostheses.

Gastric bleeding risk following spleen preserving distal pancreatectomy with excision of the splenic vessels: a long-term follow-up.

BACKGROUND: Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination. METHODS: From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy. RESULTS: The median follow-up was 76 months (range: 12-334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up. DISCUSSION: Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.

Management of rectal cancer: the 2016 French guidelines.

AIM: Rectal cancer is a malignant disease requiring multidisciplinary management. In view of the increasing number of studies published over the past decade, a comprehensive update is required to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery and the French National Coloproctology Society. METHOD: Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A drafting committee and a large group of expert reviewers contributed to validate the statements. RESULTS: Recommendations include the indications for neoadjuvant therapy, the quality criteria for surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement. CONCLUSION: The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies.

[Urinary complications of pelvic exenterations for rectal cancer with urinary invasion]. / Complications urinaires des exentérations pelviennes pour cancer du rectum avec envahissement urinaire.

OBJECTIVE: Pelvic exenteration for rectal cancer is indicated in locally advanced rectal tumors or pelvic recurrence invading adjacent organs. The oncologic goal being a complete R0 resection. Our aim was to study the urinary complications resulting from pelvic exenterations with urinary reconstruction in order to obtain a complete local control of the disease. METHODS: Between April 2004 and June 2013, 42 patients who underwent pelvic exenteration for primary or recurrent rectal adenocarcinoma with urinary tract reconstruction were included. The urinary reconstruction was performed based on preoperative imaging and intraoperative findings. We studied early (within 30 postoperative days) and late urinary morbidity, as well as postoperative carcinologic control. RESULTS: Forty-two exenterations were performed for primary rectal cancer (n=15) or pelvic recurrence (n=27). R0 complete resection was achieved in 64% of patients. The resection was incomplete (R1) on the urinary tract in 9.5% of patients. The urinary reconstruction methods used were: 31 transileal ureterostomies after total exenteration (bricker procedure), 6 ureteral reimplantations on psoic bladder, 2 ureteroileoplasties, 2 partial cystectomies and one ureteral resection with simple ligation. The median follow-up was 20 months. The perioperative mortality was 2.3% (n=1) and postoperative overall morbidity was 64%. Early and late urinary morbidity was 23.8% and 21.4% respectively. Six patients developed major urinary complications (≥ Clavien IIIb). CONCLUSION: Pelvic exenteration with urinary resection resulted in our experience, in a local disease control of 64% (including a 90.5% for the urinary tract) at the price of an acceptable early specific morbidity and a low mortality that seems to justify an aggressive surgical approach.

What is the established contribution of laparoscopy in the treatment of rectal cancer?

The results of laparoscopic treatment of rectal cancer have been evaluated in several randomized trials. Still, the validity of this approach remains controversial because of concerns regarding its oncological safety. In this review, oncological results of laparoscopic rectal resection were similar to those of laparotomy, with no observed survival difference. Conversion from laparoscopy to laparotomy seemed to be associated with worse oncological results and an increased post-operative morbidity including nervous sequelae. Intra-operative blood loss was significantly reduced with the laparoscopic approach, but post-operative morbidity was not different. Post-operative pain and length of hospital stay were decreased by the laparoscopic approach, and short-term quality of life was improved. There was no demonstration of significant reduction in late morbidity such as incisional hernia and bowel adhesions.

The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception.

AIM: Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients. METHOD: Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded. RESULTS: The mean CCI scores were 13.2 (=/-4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as 'cured' in 26 (65%), 'improved' in 13 (32.5%) and 'unchanged' in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow-up of 38 months. CONCLUSION: Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.

Benefits of perineal colostomy on perineal morbidity after abdominoperineal resection.

PURPOSE: Abdominoperineal resection has a high rate of postoperative morbidity of the perineal wound. This study aimed to determine the effects of perineal colostomy on perineal morbidity after abdominoperineal resection. METHODS: All patients who underwent an abdominoperineal resection for rectal adenocarcinoma between 1993 and 2007 were studied. Two groups were identified and compared who had undergone either an iliac colostomy or a perineal colostomy. RESULTS: The analysis included 110 patients (iliac colostomy group, n = 41; perineal colostomy group, n = 69). There were fewer instances of pelviperineal morbidity (P = .008) and fewer instances of wound dehiscence (P = .02) in the perineal colostomy group, which resulted in a shorter time to healing (35.3 vs 45.1 d, respectively; P = .04). There was no specific postoperative morbidity in any patient and no difference between the 2 groups regarding long-term perineal morbidity. The benefits from perineal colostomy were statistically significant in patients who received radiation therapy in terms of pelviperineal morbidity (P = .01) and healing time (50.8 vs 35.9 days, respectively; P = .02), whereas no difference was found in patients who had not received radiation therapy. CONCLUSION: Perineal colostomy is a safe and functionally acceptable procedure for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. In the present study, there was no additional morbidity related to perineal colostomy, and this procedure was associated with a decrease in perineal morbidity and healing time compared with primary perineal closure, in particular, after radiotherapy treatment.

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma.

BACKGROUND: The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours. METHODS: The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis. RESULTS: Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence. CONCLUSION: Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.

Meta-analysis: evaluation of adjuvant therapy after curative liver resection for hepatocellular carcinoma.

AIM: To evaluate adjuvant modalities after curative resection for hepatocellular carcinoma using a meta-analysis of randomized and non-randomized controlled trials. METHODS: In a first step, a meta-analysis of randomized controlled trials was carried out. Sensitivity analyses after inclusion of non-randomized controlled trials were performed. Four therapeutic modalities were evaluated: pre-operative transarterial chemotherapy, post-operative transarterial chemotherapy, systemic chemotherapy and a combination of systemic and transarterial chemotherapy. RESULTS: Only post-operative transarterial chemotherapy improved survival significantly at 2 years [difference, 22.8%; confidence interval (CI), 8.6-36.9%; P = 0.002] and 3 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005), and decreased the probability of no recurrence at 1 year (difference, 28.8%; CI, 16.7-40.8%; P < 0.001), 2 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005) and 3 years (difference, 28%; CI, 8.2-47.9%; P = 0.006). In a sensitivity analysis after inclusion of non-randomized controlled trials, post-operative transarterial chemotherapy still improved survival at 1 year (difference, 9.6%; CI, 0.8-18.3%; P = 0.03), 2 years (difference, 13.5%; CI, 0.9-26%, P = 0.04) and 3 years (difference, 18%; CI, 7-28.9%; P < 0.001), and decreased the probability of no recurrence at 1 year (difference, 20.3%; CI, 7.7-33%; P = 0.002), 2 years (difference, 35%; CI, 21.4-46.3%; P < 0.001) and 3 years (difference, 34.5%; CI, 18.7-50.3%; P < 0.001). CONCLUSION: Post-operative transarterial chemotherapy improved survival and decreased the cumulative probability of no recurrence. New randomized controlled trials evaluating this modality are required.