Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: Results of a randomized clinical trial.

BACKGROUND: To determine whether the timing of removal of abdominal drainage (AD) after pancreatoduodenectomy (PD) influences the 30-day surgical site infection (30-day SSI) rate. METHODS: A multicenter randomized, intention-to-treat trial with two parallel arms (superiority of early vs. standard AD removal on SSI) was performed between 2011 and 2015 in patients with no pancreatic fistula (PF) on POD3 after PD (NCT01368094). The primary endpoint was the 30-day SSI rate. The secondary endpoints were specific post-PD complications (grade BC PF), postoperative morbidity and risk factor of SSI, reoperation rate, 30-day mortality, length of drainage, length of stay and postoperative infectious complications. RESULTS: One hundred and forty-one patients were randomized: 71 in the early arm, 70 in the standard arm (70.2% of pancreatic adenocarcinomas; 91.5% of pancreatojejunostomies; 66.0% of bilateral drainages; feasibility: 39.9%). Early removal of drains was not associated with a significant decrease of 30-day SSI (14.1% vs. 24.3%, P=0.12). A lower rate of deep SSI was observed in the early arm (2.8% vs. 17.1%, P=0.03), leading to a shorter length of stay (17.8±6.8 vs. 21.0±6.1, P=0.01). Grade BC PF rate (5.6%), severe morbidity (17.7%), reoperation rate (7.8%), 30-day mortality (1.4%) and wound-SSI rate (7.8%) were similar between arms. After multivariate analysis, the timing of AD removal was not associated with an increase of 30-day SSI (OR=0.74 [95% CI 0.35-1.13, P=0.38]). CONCLUSION: In selected patients with no PF on POD3, early removal of abdominal drainage does not seem to increase or decrease surgical site infection's occurrence.

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. METHODS: Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. RESULTS: One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. CONCLUSION: DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Impact of a procalcitonin-based algorithm on the management of adhesion-related small bowel obstruction.

INTRODUCTION: Adhesion-related small bowel obstruction (ASBO) management is difficult if there are no signs of strangulation or peritonitis when intestinal transit has not been restored. The aim of the present study was to determine the impact of combining a procalcitonin (PCT)-based algorithm with clinical signs on the management of uncomplicated ASBO. METHOD: We performed a pilot, retrospective, single-center "before-after" study. During the "before" period (2007 to 2012), patients with uncomplicated ASBO (n=93, the Gastrografin® group) underwent a clinical examination and a Gastrografin® index. During the "after" period (2013 to 2016), patients with uncomplicated ASBO (n=70, the algorithm group) underwent a clinical examination and were assessed with the PCT-based algorithm. The study's primary outcome was the appropriateness of ASBO management. The secondary outcomes were the need for surgery and the time to surgery, the LOS, the morbidity and mortality rates, and the recurrence rate. RESULTS: The proportion of well-managed patients was higher in the algorithm group than in the Gastrografin® group (86% vs. 47%; P<0.001). The time to surgery (48h vs 72h; P=0.02) and the LOS (4 vs. 6days, P=0.02) were significantly lower in the algorithm group. The need for surgery was similar in both groups (31% vs. 37%, P=0.49). The morbidity (P=0.69), mortality (P=0.82) and recurrence rates (P=0.57) were similar in the two groups. CONCLUSION: The use of a PCT-based algorithm is of value in the routine clinical management of ASBO; it reduces the LOS and the time to surgery without increasing the need for surgery.

Serum procalcitonin correlates with colonoscopy findings and can guide therapeutic decisions in postoperative ischemic colitis.

BACKGROUND: Postoperative ischaemic colitis (POIC) is a life-threatening vascular gastrointestinal condition. Serum procalcitonin (PCT) levels be of value in the detection of necrosis. AIMS: To evaluate the correlation between serum PCT levels and the colonoscopic assessment of the severity of POIC. METHODS: Between January 2007 and November 2014, 150 patients with POIC and PCT data were included in the study. The main outcome measure was the correlation between serum PCT and the colonoscopy-based assessment of the severity of POIC (according to Favier's classification: stage 1/2 without multi-organ failure vs. stage 2/3 with multi-organ failure). RESULTS: Eighty-five percent of the stage 1 cases (n=22) had a serum PCT level ≤2µg/L; 63% (n=19) of the stage 2 cases with multi-organ failure had a PCT level between 4 and 8µg/L, and 70% (n=52) of the stage 3 cases had a PCT level ≥8µg/L. The PCT level was strongly correlated with the Favier stage (Spearman's rho: 0.701; p<0.0001). PCT levels were similar in stage 2 cases with multi-organ failure and in stage 3 cases (16.06µg/L vs. 7.79µg/L, respectively; p=0.35). CONCLUSION AND RELEVANCE: Serum PCT is correlated with stage 2/3 POIC requiring surgery. If PCT ≥5µg/L, surgery should be considered.

A critical analysis of factors leading to next-day discharge in ambulatory surgery patients.

INTRODUCTION: Ambulatory surgery (AS) is becoming the rule. However, some patients do not have AS despite correct indications. The purpose of this retrospective study of prospectively collected data was to analyze why these patients do not have AS and evaluate their immediate post-operative course, in order to broaden the indications for AS. MATERIAL AND METHODS: Between January and December 2013, the reasons why patients who had appropriate indications for ambulatory cholecystectomy or hernia repair but later had conventional hospital management were recorded. The primary endpoint was early post-operative morbidity. Secondary endpoints were demographic, surgical, anesthetic, post-operative data as well as analysis of criteria leading to conventional hospital stay. RESULTS: Among 410 patients undergoing surgery for accepted AS indications, 158 (39%) did not have AS; 113 out of these patients (72%) were discharged the day following surgery. Of the 69 patients (43.6%) who did not have AS for medical reasons (50 by the surgeon's decision alone), 60 patients could have undergone AS since their outcome was uneventful in 96% of cases; only three patients (2.5%) had post-operative complications. CONCLUSION: The AS rate could have been increased by 15% through better surgical and anesthetic collaboration.

Management of colon cancer in patients with cirrhosis: A review.

INTRODUCTION: The incidence of cirrhosis is increasing in parallel with that of hepatitis C and non-alcoholic steatohepatitis. Patients with colon cancer and liver cirrhosis constitute an important at-risk group. Many colorectal surgeons and oncologists are not familiar with the management of colon cancer in patients with cirrhosis. Here, we review the literature on the management and prognosis of patients with both colon cancer and cirrhosis. METHODS: The MEDLINE, PubMed and the Cochrane Library electronic databases were systematically searched with appropriate keywords. Only publications in French or English were selected. RESULTS/CONCLUSION: For most studies, the level of evidence is weak. Child A patients should probably be managed in the same way as general population, although they have an elevated risk of morbidity and a five-year survival rate of just 70%. Child B and C patients should be managed more cautiously, although no specific recommendations can be made at present. For colon surgery, laparotomy should be preferred in patients with cirrhosis. The role of adjuvant chemotherapy is unclear, since survival is strongly associated with the improvements in liver function. Oxaliplatin appears to be associated with an elevated post-chemotherapy morbidity rate in patients with portal hypertension.

Serum value of procalcitonin as a marker of intestinal damages: type, extension, and prognosis.

BACKGROUND: Ischemic and necrotic damages are complications of digestive diseases and require emergency management. Nevertheless, the decision to surgically manage could be delayed because of no sufficiently preoperative accurate marker of ischemia diagnosis, extension, and prognosis. METHODS: The aim of this study was to assess the predictive value of serum procalcitonin (PCT) levels for diagnosing intestinal necrotic damages, their extension, and their prognosis in patients with ischemic disease including ischemic colitis and mesenteric infarction by a gray zone approach. Between January 2007 to June 2014, 128 patients with ischemic colitis and mesenteric infarction (codes K55.0 and K51.9) were operated, for whom data on PCT were available. We perform a retrospective, multicenter review of their medical records. Patients were divided into subgroups: ischemia (ID group) versus necrosis (ND group); the extension [focal (FD) vs. extended (ED)] and the vital status [deceased (D) vs. alive (A)]. RESULTS: PCT levels were higher in the ND (n = 94; p = 0.009); ED (n = 100; p = 0.02); and D (n = 70; p = 0.0003) groups. With a gray zone approach, the predictive thresholds were (i) for necrosis 2.473 ng/mL, (ii) for extension 3.884 ng/mL, and (iii) for mortality 7.87 ng/mL. CONCLUSION: In our population, PCT could be used as a marker of necrosis; especially in case of extended damages and reflects the patient's prognosis.

Day case appendectomy in adults: a review.

BACKGROUND: Day-case appendectomy (DCA) for acute appendicitis has been suggested as a valuable alternative to traditional appendectomy but many surgeons are reluctant to apply this technique in adults. The aim of the present review is to discuss the feasibility of DCA in adults. METHODS: Three reviewers independently searched the Pubmed and Embase databases for articles on DCA. They then considered the criteria applicable to the surgery, day-case surgery, time taken for patients to resume normal activities, mean time to resumption of work and patient satisfaction. RESULTS: Between 1993 and 2012, 13 studies (with retrospective (n = 8), prospective (n = 4) or case-control study (n = 1) designs) dealt with DCA. A total of 1152 adults underwent DCA. 312 patients (27.08%) were discharged within 12 h, 614 (53.29%) within 24 h and 242 (21.01%) within 72 h. CONCLUSION: The few data reported in 13 studies, suggest that DCA may be feasible. However prospective studies are needed before DCA can be recommended.

Effectiveness of intraoperative cholangiography using indocyanine green (versus contrast fluid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy.

INTRODUCTION: During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the "gold standard" for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy. MATERIALS AND METHODS: Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the "analyzability rate" (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis. RESULTS: The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p = 0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure. CONCLUSION: IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.

Ambulatory management of gastrointestinal emergencies: what are the current literature data?

INTRODUCTION: Ambulatory management is a modality of care defined in France by a hospitalization of less than 12h without an overnight stay. Currently, few data are available on its role in the management of gastrointestinal emergencies, such as appendectomy for acute appendicitis, cholecystectomy for acute cholecystitis or emergency proctologic surgery. The aim of this systematic review was to study the published data regarding the feasibility of ambulatory management of emergency visceral surgery and to enquire about the possibilities of further development of this form of management. MATERIALS AND METHODS: A literature search was conducted from the PubMed(®) databank taking into account all published data up to July 2013. RESULTS: For acute appendicitis, the success rate of short-stay hospitalization was 72% with unplanned read-mission rates ranging from 0 to 53%, a rate of unscheduled consultations ranging from 0 to 11%, and unplanned inpatient hospitalization rates ranging from 0% to 5%. For acute cholecystitis and proctology, there are few published data. CONCLUSION: Ambulatory management has been sparingly studied in the setting of gastrointestinal surgical emergencies. However, there is probably a place for development of this form of management.

Antibiotic therapy in acute calculous cholecystitis.

Acute calculous cholecystitis may progress in a variety of ways from mild cases treatable with (or even without) oral antibiotics to severe cases complicated by bile peritonitis that require emergency surgical or radiological intervention. A sample of bile should always be sent for microbial cultures to identify aerobic and anaerobic bacterial organisms. Empirically selected broad spectrum antibiotic therapy (with a defined duration, dosage and administration route) should be prescribed according to the severity of the cholecystitis, an associated history of recent antibiotic therapy, and local bacterial susceptibility patterns. As soon as causative organisms have been identified, antibiotic therapy should be adjusted to a narrower spectrum antimicrobial agent based on the specific micro-organism(s) and the results of sensitivity testing.