Investigation of Serratia marcescens surgical site infection outbreak associated with peroperative ultrasonography probe.

Early postoperative infections due to Serratia marcescens have been reported by both clinicians and microbiologists in our teaching hospital. Here, we present an interlinked clinical, epidemiological, environmental and genomic investigation of this outbreak due to a T-shaped intraoperative probe contaminated by S. marcescens used during peroperative ultrasonography in laparoscopic liver resection.

Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer?

BACKGROUND: The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer. METHODS: All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively. RESULTS: Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS. CONCLUSIONS: This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.

Does conversion during laparoscopic rectal oncological surgery increases postoperative complications and anastomotic leakage rates? A meta-analysis.

OBJECTIVE: To evaluate, regarding previous published studies, postoperative outcomes between patients undergoing rectal cancer resection performed by totally laparoscopic approach (LAP) compared to those who underwent peroperative conversion (CONV). METHODS: Studies comparing LAP versus CONV for rectal cancer published until December 2017 were selected and submitted to a systematic review and meta-analysis. Articles were searched in Medline and Cochrane Trials Register Database. Meta-analysis was performed with Review Manager 5.0. RESULTS: Twelve prospective and retrospective studies with a total of 4503 patients who underwent fully laparoscopic approach for rectal cancer and a total of 612 patients who underwent conversion were included. Meta-analysis did not show any significant difference on overall mortality between both approaches (OR=0.47, 95%CI=0.18-1.22, P=0.12). However, Meta-analysis showed that anastomotic leakage rate, wound abscess rate and postoperative morbidity rate were significantly decreased with totally laparoscopic approach (OR=0.37, 95%CI =0.24-0.58, P<0.0001; OR=0.29, 95%CI=0.19-0.45, P<0.00001; OR=0.56, 95%CI=0.46-0.67, P<0.00001 respectively). CONCLUSION: This meta-analysis suggests that conversion increases anastomotic leakage, overall morbidity and wound abscess rates without increasing mortality rate for patients who underwent rectal resection for cancer.

Has adherence to treatment guidelines for mid/low rectal cancer affected the management of patients? A monocentric study of 604 consecutive patients.

INTRODUCTION: In 2006 under the supervision of the French health authorities (HAS), recommendations for clinical practice (RCP) in the management of rectal cancers were first published. The primary objective of this study was to assess the impact of these guidelines on multidisciplinary management in terms of therapeutic strategies based on disease staging and quality indicators for surgical excision. Secondarily, we assessed the impact of the RCPs on postoperative and oncological outcomes. METHODS: All consecutive patients having undergone curative surgical excision for middle and low (subperitoneal) rectal cancer from 1995 to 2017 in the university hospital of Caen were included in accordance with the relevant French guidelines. They were divided into two groups: before (Gr1) and after (Gr2) 2006. For each group, a chart review was conducted on demographic variables, preoperative rectal tumor features, disease severity variables and quality of surgery variables. Postoperative and oncological outcomes were likewise assessed and compared between the two groups. RESULTS: Six hundred and four patients were included (Gr1, n=266; Gr2, n=338). Compliance with French guidelines significantly improved (i) use of magnetic resonance imaging (P<0.0001) and CT-scan (P<0.0001)]; (ii) organization of multidisciplinary tumor boards (P<0.0001) leading to suitable neo-adjuvant treatment plan classification (P<0.0001). Consequently, compliance improved widespread total mesorectal excision (P<0.0001), sphincter-sparing surgery (P=0,0005), and completeness of curative resection in the specimen (P<0.0001). Although postoperative 90-day mortality was similar, overall postoperative morbidity significantly increased in Gr2 (P<0.0001). Overall (P=0.0005) and disease-free survival (P=0.0016) of patients in Gr2 were significantly prolonged and correlated with a significant reduction in local and distant recurrences. CONCLUSION: Compliance with the relevant French guidelines improved the quality of multidisciplinary management of patients undergoing curative surgery for subperitoneal rectal cancer. However, further progress is still needed to render accession to the recommendations more comprehensive.

Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery. METHODS: Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis. RESULTS: Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5-12] vs. 6[5-9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140-0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively). CONCLUSIONS: Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.

Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature.

BACKGROUND: Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group). METHODS: The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK). RESULTS: Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups. CONCLUSIONS: This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

Is pathological complete response after a trimodality therapy, a predictive factor of long-term survival in locally-advanced esophageal cancer? Results of a retrospective monocentric study.

OBJECTIVE: To evaluate long-term (5- and 10-year) survival and recurrence rates on the basis of the pathological complete response (pCR) in the specimens of patients with esophageal carcinoma, treated with trimodality therapy. METHODS: Between 1993 and 2014, all consecutives patients with esophageal locally-advanced non-metastatic squamous cell carcinoma (SCC) or adenocarcinoma (ADC) who received trimodality therapy were reviewed. According to histopathological analysis, patients were divided in two groups with pCR and with pathological residual tumor (pRT). The primary endpoint was overall survival (OS). The secondary endpoints included the disease-free survival (DFS), the recurrence rate, and the predictive factors of overall survival and recurrence. RESULTS: One hundred and three patients were included: 49 patients with pCR and 54 patients with pRT. The median OS was significantly longer in pCR group than in pRT group (132±22.3 vs. 25.5±4 months), with both 5- and 10-years OS rates of 75.2% vs. 29.1%, and 51.1% vs. 13.6%, respectively (P<0.001). Also, pRT, major postoperative complications (Dindo-Clavien grade>IIIb) and recurrence were the 3 independent predictive factors for worse OS. CONCLUSIONS: Patients with locally-advanced oesophageal carcinoma, who responded to trimodality therapy with a pCR, could be achieved a 10-year survival rate of 51%.

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis.

BACKGROUND: Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed. METHODS: Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0. RESULTS: Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29). CONCLUSIONS: This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

Management of the colonic volvulus in 2016.

Colonic volvulus is the third leading cause of colonic obstruction worldwide, occurring at two principal locations: the sigmoid colon and cecum. In Western countries, sigmoid volvulus preferentially affects elderly men whereas cecal volvulus affects younger women. Some risk factors, such as chronic constipation, high-fiber diet, frequent use of laxatives, personal past history of laparotomy and anatomic predispositions, are common to both locations. Clinical symptomatology is non-specific, including a combination of abdominal pain, gaseous distention, and bowel obstruction. Abdominopelvic computerized tomography is currently the gold standard examination, allowing positive diagnosis as well as detection of complications. Specific management depends on the location, patient comorbidities and colonic wall viability, but treatment is an emergency in every case. If clinical or radiological signs of gravity are present, emergency surgery is mandatory, but is associated with high morbidity and mortality rates. For sigmoid volvulus without criteria of gravity, the ideal strategy is an endoscopic detorsion procedure followed, within 2 to 5 days, by surgery that includes a sigmoid colectomy with primary anastomosis. Exclusively endoscopic therapy must be reserved for patients who are at excessive risk for surgical intervention. In cecal volvulus, endoscopy has no role and surgery is the rule.

Inflammatory appendix mass in patients with acute appendicitis: CT diagnosis and clinical relevance.

The purpose of our study was to analyze the clinical relevance of computerized tomography (CT) in providing the diagnosis of inflammatory appendix mass (IAM) in patients with acute appendicitis. The CT images of 134 patients were reviewed. Two groups of patients were made according to the presence (group 1; n = 21) or the absence (group 2; n = 113) of IAM. Clinical signs of patients, CT features, complications at surgery, and histological examinations were noted. Inter-observer agreement was assessed by using kappa statistics. Twenty-one patients presenting with CT features of IAM were diagnosed. An excellent inter-observer agreement (κ = 0.94) was assessed for the diagnosis of IAM. No significant statistical difference in the age distribution was observed between patients with IAM (mean age 55) and patients without (mean age 45) (p = 0.2232). No clinical sign showed a statistically significant association with the presence of IAM (p = 0.707) or with complication encountered at surgery (p = 0.180). Delay to CT examination was 5.4 days in patients presenting with CT features of IAM and of 1.7 days for patients presenting without (p = 0.0001). Conversely to acute appendicitis complicated by simple perforation (p = 0.153) or peri-appendicular abscess (p = 0.501), acute appendicitis presenting with IAM showed a statistically significant association with complications encountered at surgery (p = 0.0003) and the need for conversion to open surgery (p = 0.001). Performing CT in complicated acute appendicitis provides the diagnosis of IAM. Distinction of IAM appeared to be of clinical relevance, since immediate surgery in IAM was statistically associated with surgical complications and conversion to open surgery in our study.

Treatment of the liver cross section following hepatectomy.

The incidence of complications after hepatectomy has been considerably reduced over the last 20 years. Better knowledge of liver anatomy and liver regeneration, and methods preventing bleeding during surgery have resulted in morbidity rates below 20% and mortality rates less than 5%. The treatment of the liver cross section remains controversial. Experimental studies have reported convincing biological effects of fibrin sealants or compresses when applied on the liver to decrease hemorrhagic or biliary complications. However, clinical studies are very heterogeneous, providing conflicting results compromising recommendations for routine use.

[Gamna-Gandy bodies in cirrhosis: a meaningless finding?]. / Corpuscules de Gamna-Gandy dans la cirrhose : un signe sans intérêt ?

PURPOSE: To determine the presence of Gamna-Gandy bodies (GGB) on MRI in patients with liver cirrhosis. PATIENTS AND METHODS: A total of 117 consecutive patients with cirrhosis followed-up by MRI were retrospectively reviewed. Two groups were defined: the first group included patients with GGB on MRI (n=15), the other group included patients without GGB (n=102). Both characteristics of groups were reviewed using standard cirrhosis criteria evaluation: sex, age, etiology of cirrhosis, Child-Pugh score, presence of esophageal varices, splenomegaly, ascitis, recanalization of the periumbilical veins, and presence of hepatic encephalopathy. Fisher's exact test and student t-test were used to compare both groups. RESULTS: GGB were more frequently observed in patients with splenomegaly (P=0.035). Hemochromatosis was the only etiology for cirrhosis statistically correlated to the presence of GGB (P=0.006) in our series. No other statistically significant association was noted between GGB and other characteristics of our cirrhotic patients. CONCLUSION: Easily identified on all MRI pulse sequences, GGB do not correlate with the severity of cirrhosis. However, they are strongly correlated with the presence of splenomegaly and may be the result of segmental splenic hypertension. They are frequent in patients with hemochromatosis.

CT in predicting abdominal cocoon in patients on peritoneal dialysis.

AIM: To evaluate the computed tomography (CT) signs of encapsulating peritoneal sclerosis (EPS) in patients on peritoneal dialysis (PD) as predictive factors for the evolution to abdominal cocoon (AC). MATERIALS AND METHODS: Clinical features and CT signs of 90 patients on PD were retrospectively reviewed. According to the clinical features, they were divided into three groups (asymptomatic, moderate, or severe). Clinical results were correlated with previously reported CT signs of EPS, i.e., peritoneal thickening, peritoneal calcifications, loculated fluids, small bowel faeces sign, small bowel obstruction, clustered bowel loops, pseudo sac, signs of bowel ischaemia or necrosis. AC was defined at CT by the association of clustered bowel loops and a pseudo sac. Statistical analysis was performed using the Fisher's exact test and the t-test. RESULTS: Although demonstrated in symptomatic patients (p=0.041), the occurrence of AC was not correlated with the severity of the symptoms (p=0.16). Among the CT signs, the presence of loculated fluids (p=0.011), a small bowel faeces sign (p=0.002); and small bowel obstruction (p=0.0001) were found to be statistically correlated with the appearance of an AC. Moreover, the association of loculated fluids, small bowel faeces sign, small bowel obstruction was extremely sensitive and specific in the development of AC (sensitivity=67%, specifity=100%, positive predictive value=100%, negative predictive value=96%). CONCLUSION: CT should be carried out in every symptomatic patient on PD. Indeed, the association of loculated fluid, small bowel faeces sign, and small bowel obstruction enables the prediction of the development of AC, which is likely to curtail PD and require surgery.

[Value of multidetector-row CT in the management of sigmoid volvulus]. / Apport du scanner multi-détecteurs dans la prise en charge des volvulus du sigmoïde.

PURPOSE: To determine the value of multidetector-row CT (MDCT) in the management of sigmoid volvulus. MATERIALS AND METHODS: Twenty-three MDCT examinations showing sigmoid volvulus were retrospectively evaluated and analyzed based on the type of volvulus (mesentericoaxial versus organoaxial), degree of rotation (180 degrees or 360 degrees ), maximum diameter of the volvulized sigmoid loop and presence or absence of the northern exposure sign, signs of bowel wall ischemia, and ascitis. A statistical analysis was performed to determine the correlation between patients characteristics, CT findings, type of management, and histological findings when available. RESULTS: In our study, organoaxial volvulus occurred in older patients (p=0.047), had a higher risk of recurrence (p=0.015) and more frequently required urgent surgical management than mesentericoaxial volvulus. A higher degree of rotation was associated with a more distended volvulized sigmoid colon (p=0.033) and more frequently required surgery. CONCLUSION: In addition to detection of volvulus and signs of bowel wall ischemic, MDCT can characterize the type of volvulus and degree of rotation, findings that may assist in determining the severity of the process and direct towards optimal management, endoscopic or surgical.

Median arcuate ligament in orthotopic liver transplantation: relevance to arterial reconstruction.

Median arcuate ligament (MAL) syndrome results from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or by fibrous bands of the celiac nervous plexus. In 10% to 50% of cases it is responsible for significant angiographic celiac trunk compression. In orthotopic liver transplantation (OLT), the presence of celiac compression by MAL is considered to be a risk factor for hepatic arterial thrombosis (HAT); it may lead to graft loss. Various surgical procedures have been proposed to overcome the impact of MAL in OLT, but their impact is still ill defined. The aim of our study was to compare standard hepatic artery reconstruction and graft reconstruction (aortohepatic bypass) in terms of HAT among patients with MAL undergoing OLT. We retrospectively reviewed 168 adult recipients of OLT performed from January 1991 to December 1998. Ten cases (5.6%) of celiac compression by MAL were identified after celiomesenteric arteriography. There was no significant difference in terms of HAT incidence when aortohepatic bypass was performed compared to a standard anastomosis; moreover, this was greater in the graft reconstruction group (25% vs 17%; P = .67). In our opinion, the presence of an arcuate ligament should not contraindicate a routine hepatic artery reconstruction.

Avoiding propofol injection pain in children: a prospective, randomized, double-blinded, placebo-controlled study.

BACKGROUND: Pain on injection limits the use of propofol in children. The combination of lidocaine and propofol is widely used to reduce pain. A new solvent [medium-chain triglyceride (mct)/long-chain triglyceride (lct)] has been advocated to be less painful than standard (lct) propofol in adults, but no information is available of its usefulness in pre-school children. We designed a prospective, randomized, double-blinded, placebo-controlled study to assess injection pain with two different propofol emulsions, each given with or without lidocaine in children <7 yr. METHODS: A total of 160 ASA I-III children were randomly assigned to receive lct-propofol or mct/lct-propofol, 5 mg kg(-1), with lidocaine 10 mg ml(-1) or saline. The site and size of venous cannulation and restlessness before injection were recorded in each patient. A pain score graded 0-6 was established based on spontaneous verbal and motor reaction during injection, each graded 0-3. Kruskall-Wallis and Mann-Whitney tests were used for statistical analysis. RESULTS: Median pain scores decreased in all groups compared with lct-propofol-saline (P<0.001) and were least in the lct/mct-propofol-lidocaine group (P<0.001). Painless injection (score, 0-2) occurred in 92.5% of patients in the mct/lct-propofol-lidocaine group compared with 41-77% in the others (P<0.001). CONCLUSIONS: Mct/lct-propofol caused significantly less pain than lct-propofol in preschool children. Mixing of lidocaine with mct/lct-propofol resulted in a further significant decrease, virtually eliminating the pain on injection.

Treatment of anovaginal or rectovaginal fistulas with modified Martius graft.

OBJECTIVE: The treatment of ano- or rectovaginal fistula is still difficult. The use of the Martius flap is well described as an adjunctive technique in their repair. We report our experience of a modified Martius flap in the management of ano- or rectovaginal fistula. METHOD: This is a retrospective study of 14 women presenting with an anovaginal (n = 9) or rectovaginal fistula (n = 5). All were treated by a modified Martius graft. The aetiology included Crohn's disease (n = 7), ulcerative colitis (n = 4), radio-induced (n = 1), obstetric (n = 1) and villous tumour (n = 1). RESULTS: All 14 fistulas healed within the 3 months after surgery. Subsequently, two patients with Crohn's disease required an abdominoperineal resection owing to progressive anal lesions. Two other patients experienced faecal incontinence which improved with functional rehabilitation treatment. CONCLUSION: A modified Martius flap is a valuable option in the treatment of ano- or rectovaginal fistula. In the case of Crohn's disease, however, the prognosis depends primarily on subsequent clinical evolution of the condition.

Evaluation of the risk of contamination of surgical personnel by vaporization of oxaliplatin during the intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC).

AIMS: To evaluate if oxaliplatin is likely to vaporize under HIPEC conditions and to see if it could be a source of pulmonary contamination for surgeons. METHODS: Three oxaliplatin concentrations (230, 460 and 920 mg oxaliplatin/l), 3 heating temperatures (41, 43 and 45 degrees C) and 3 bubbling durations (30, 60 and 90 min) were tested. Drug vaporization was evaluated by using inductively coupled plasma mass spectrometry (ICP-MS) to analyze platinum concentrations in the trap solutions. RESULTS: At all concentrations of oxaliplatin solutions, heating temperatures and bubbling trap periods, the quantities of vaporized platinum were always insignificantly lower than 1 microg/l. CONCLUSIONS: The experimental risk of pulmonary contamination of hospital staff during HIPEC procedure appears to be negligible. However a monitoring study with an analysis of samples of the operating theatre and urine from surgical personnel should be carried out to confirm these conclusions.

[Aberrant pancreas and duodenal diaphragm: an exceptional association]. / Pancréas aberrant et diaphragme duodénal: une association exceptionnelle.

Aberrant pancreas of the duodenal wall (APD) and duodenal diaphragm (DD) are two rare entities, which developed during duodenal embryogenesis. Occurrence, diagnosis and therapeutic approach of these lesions are different. Herein, we report the first case of this exceptional association in a man who had no symptoms. A surgical resection of both lesions was performed and the outcome was uneventful. Embryogenesis, morphological characteristics and treatment are discussed.