[Perforating flap for covering sacro-coccygeal cysts: About 8 cases]. / Lambeau perforant pour couverture des kystes sacrococcygiens : à propos de 8 cas.

INTRODUCTION: Multiple surgical revisions (exeresis and directed healing) of recurrent pilonidal cysts are sources of unstable scars. Chronic ulcerations often appear with or without authentic recidivism. A local fasciocutaneous perforating flap based on the parasacral arteries would bring healthy tissue and avoid the disadvantages of conventional techniques (musculo-cutaneous or random). MATERIALS AND METHODS: A series of 8 cases of transposition flap covering based on parasacral perforators, in multi-operated patients. The perforators are identified by Doppler probe before the gesture, then the flap is traced obliquely according to the size of the loss of substance. The gesture is short, not morbid and accessible to all by a technique that excludes fine dissection of the pedicle. The duration of hospitalization is 2days. RESULTS: Despite two minor and resolving complications (a hematoma and a disunion of the donor sit) the healing was complete and without recurrence in all patients at 2years, with 100% satisfaction. CONCLUSION: This reliable and reproducible simple flap becomes the reference technique in our department for the sequelae of recurrent sacro-coccygeal cyst.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients.

AIM: Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR). METHOD: Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated. RESULTS: There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction. CONCLUSION: Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

The effect of immune therapy on surgical site infection following Crohn's Disease resection.

BACKGROUND: Patients with Crohn's disease are increasingly receiving antitumour necrosis factor α (anti-TNF-α) therapy. Whether anti-TNF-α therapy increases the risk of postoperative infectious complications in Crohn's disease is a matter of debate. METHODS: This was a retrospective study of three referral centres. The charts of patients who underwent ileocaecal or ileocolonic resection for Crohn's disease between 2000 and 2011 were reviewed. The impact of baseline characteristics and Crohn's disease-related medications on the risk of postoperative intra-abdominal infectious complications was investigated by univariable and multivariable analysis. RESULTS: A total of 217 patients were included in the study. Median age at the time of surgery was 36·8 (range 15-78) years. A postoperative intra-abdominal infection occurred in 24 (11·1 per cent) of 217 patients. No deaths were reported. On univariable analysis, age less than 25 years (P = 0·023), steroid use (P = 0·017), anti-TNF-α therapy (P = 0·043) and anti-TNF-α treatment in combination with steroids (P = 0·004) were associated with an increased risk of postoperative intra-abdominal infectious complications. On multivariable analysis, only anti-TNF-α therapy in combination with steroids significantly increased this risk (odds ratio 8·03, 95 per cent confidence interval 1·93 to 33·43; P = 0·035). CONCLUSION: Combined use of steroids and anti-TNF-α therapy was associated with an increased risk of postoperative intra-abdominal infectious complications.

Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse.

PURPOSE: This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci robotic system. METHODS: During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed. RESULTS: All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75-340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed. CONCLUSIONS: Our experience indicates that using the Da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.

Gastric electrical stimulation for the treatment of diabetic gastroparesis.

Diabetic gastroparesis is a component of autonomic neuropathy, and is the most common manifestation of gastrointestinal neuropathy. Diabetes is responsible for about one quarter of gastroparesis. The upper gastrointestinal symptoms are often non-specific and dominated by nausea, vomiting, early satiety, fullness, bloating. We also have to look for diabetic gastroparesis in case of metabolic instability, such as postprandial hypoglycaemia. The pathophysiology of diabetic gastroparesis is complex, partly due to a vagus nerve damage, but also to changes in secretion of hormones such as motilin and ghrelin. A decrease in the stem cell factor (SCF), growth factor for cells of Cajal (gastric pacemaker), was found in subjects with diabetic gastroparesis. These abnormalities lead to an excessive relaxation in the corpus, a hypomotility of antrum, a desynchronization antrum-duodenum-pylorus, and finally an abnormal duodenal motility. The treatment of diabetic gastroparesis is based on diabetes control, and split meals by reducing the fiber content and fat from the diet. The antiemetic and prokinetic agents should be tested primarily in people with nausea and vomiting. Finally, after failure of conventional measures, the use of gastric neuromodulation is an effective alternative, with well-defined indications. Introduced in the 1970s, this technology works by applying electrical stimulation continues at the gastric antrum, particularly in patients whose gastric symptoms are refractory to other therapies. Its efficacy has been recently reported in different causes of gastroparesis, especially in diabetes. Gastric emptying based on gastric scintigraphy, gastrointestinal symptoms, biological markers of glycaemic control and quality of life are partly improved, but not normalized. Finally, a heavy nutritional care is sometimes necessary in the most severe forms. The enteral route should be preferred (nasojejunal and jejunostomy if possible efficiency). However, in case of failure especially in patients with small bowel neuropathy, the long-term parenteral nutrition is sometimes required.