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Surgical management of Hinchey III and IV diverticulitis involves Hartmann’s procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial). Follow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded. The overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups. This follow-up study with a median follow-up time of > 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.

Background There is a level-1 evidence indicating that postoperative antibiotics are unnecessary following cholecystectomy for grade I or II acute calculous cholecystitis (ACC). We wanted to evaluate the applications of this recommendation in clinical practice four years after the original publication in ABCAL-participating centers. Methods A retrospective analysis of patients operated for grade I or II ACC from January to December 2016 in ABCAL-participating centers was performed. Inclusion criteria were the same as for the ABCAL-study. The primary endpoint was the postoperative antibiotic administration rate. The secondary endpoints were postoperative outcomes. Results Of the 283 patients included, 64% received postoperative antibiotics. Only 19% received antibiotics after POD1. The perioperative outcomes were similar between those that did or did not receive antibiotics after POD1. The median [range] length of stay was significantly shorter in patients who did not receive postoperative antibiotics (4 days [1–20]) compared to the others (6 days [1–50], p > 0.001). Conclusion Despite strong recommendations included in the Tokyo 2018 guidelines, the results of the ABCAL-study are poorly applied even if the absence of postoperative antibiotics has no impact on morbidity. It is important to stress that postoperative antibiotics are not necessary after cholecystectomy for grade I or II ACC.

International audience; BACKGROUND: Enhanced recovery programs (ERPs) are associated with a lower morbidity rate and a shorter length of stay. The present study's objective was to determine whether an ERP is feasible and effective for patients undergoing early cholecystectomy for grade I or II acute calculous cholecystitis. STUDY DESIGN: A 2-step multicenter study was performed. In the first step (the feasibility study), patients were consecutively included in a dedicated, prospective database from March 2019 until January 2020. The primary endpoint was the ERP's feasibility, evaluated in terms of the number and nature of the ERP components applied. During the second step, the ERP's effectiveness in acute calculous cholecystitis was evaluated in a case-control study. The ERP+ group comprised consecutive patients who were prospectively included from March 2019 to November 2020 and compared with a control (ERP-) group of patients extracted from the ABCAL randomized controlled trial treated between May 2010 and August 2012 and who had not participated in a dedicated ERP. RESULTS: During the feasibility study, 101 consecutive patients entered the ERP with 17 of the 20 ERP components applied. During the effectiveness study, 209 patients (ERP+ group) were compared with 414 patients (ERP- group). The median length of stay was significantly shorter in the ERP+ group (3.1 vs 5 days; p < 0.001). There were no intergroup differences in the severe morbidity rate, mortality rate, readmission rate, and reoperation rate. CONCLUSIONS: Implementation of an ERP after early cholecystectomy for acute calculous cholecystitis appeared to be feasible, effective, and safe for patients. The ERP significantly decreased the length of stay and did not increase the morbidity rate. (C) 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

Resume Introduction L’objectif de cette etude etait de determiner si la duree de drainage apres duodenopancretectomie cephalique (DPC) influencait le taux d’infection de site operatoire (ISO) a 30 jours postoperatoire. Methode Nous avons realise une etude multicentrique, randomisee, en intention de traiter avec deux groupes paralleles en vue de montrer la superiorite du drainage court sur le drainage standard sur les ISO entre 2011 et 2015, chez des patients sans fistule pancreatique (FP) a j3 apres DPC ( NCT01368094 ), ayant beneficie d’un scanner systematique a j3. Le critere de jugement principal etait le taux d’ISO a j30. Les criteres de jugement secondaires etaient les complications specifiques post-DPC (FP grade BC), la morbidite postoperatoire et les facteurs de risque d’ISO, le taux de reoperation, la mortalite a j30, la duree de drainage et la duree d’hospitalisation. Resultats Cent quarante et un patients ont ete randomises : 71 dans le groupe drainage court et 70 dans le groupe drainage standard (70,2 % d’adenocarcinomes, 91,5 % d’anastomoses-pancreatico-jejunales, 66,0 % de drainage bilateral, faisabilite 39,9 %). Le drainage court ne diminuait pas significativement le taux d’ISO a j30 (14,1 % vs 24,3 %, p = 0,12). On observait un taux reduit d’ISO profondes dans le groupe drainage court (2,8 % vs 17,1 %, p = 0,03), entrainant une duree d’hospitalisation reduite (17,8 ± 6,8 vs 21,0 ± 6,1, p = 0,01). La duree de drainage etait statistiquement plus courte dans le groupe drainage court (5 ± 5,6 vs 11,8 ± 7,5, p Conclusion Chez des patients selectionnes sans FP a j3 apres DPC, l’ablation precoce du drainage abdominal ne semble pas augmenter ou diminuer le taux d’ISO.

Background About 25% of patients with acute diverticulitis require emergency intervention. Currently, most patients with diverticular peritonitis undergo a Hartmann's procedure. Our objective was to assess whether primary anastomosis (PA) with a diverting stoma results in lower mortality rates than Hartmann's procedure (HP) in patients with diverticular peritonitis. Study Design We conducted a multicenter randomized controlled trial conducted between June 2008 and May 2012: the DIVERTI (Primary vs Secondary Anastomosis for Hinchey Stage III-IV Diverticulitis) trial. Follow-up duration was up to 18 months. A random sample of 102 eligible participants with purulent or fecal diverticular peritonitis from tertiary care referral centers and associated centers in France were equally randomized to either a PA arm or to an HP arm. Data were analyzed on an intention-to-treat basis. The primary end point was mortality rate at 18 months. Secondary outcomes were postoperative complications, operative time, length of hospital stay, rate of definitive stoma, and morbidity. Results All 102 patients enrolled were comparable for age (p = 0.4453), sex (p = 0.2347), Hinchey stage III vs IV (p = 0.2347), and Mannheim Peritonitis Index (p = 0.0606). Overall mortality did not differ significantly between HP (7.7%) and PA (4%) (p = 0.4233). Morbidity for both resection and stoma reversal operations were comparable (39% in the HP arm vs 44% in the PA arm; p = 0.4233). At 18 months, 96% of PA patients and 65% of HP patients had a stoma reversal (p = 0.0001). Conclusions Although mortality was similar in both arms, the rate of stoma reversal was significantly higher in the PA arm. This trial provides additional evidence in favor of PA with diverting ileostomy over HP in patients with diverticular peritonitis. ClinicalTrials.gov Identifier: NCT 00692393.

To assess the effect of pelvic drainage after rectal surgery for cancer.Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed infectiveness of drainage after colectomy, there is still a controversy after rectal surgery.This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months.A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 ± 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P = 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P = 0.83), rate of reoperation (16.6% vs 21.0%; P = 0.22), length of hospital stay (12.2 vs 12.2; P = 0.99) and rate of stoma closure (80.1% vs 77.3%; P = 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio = 1.757; 95% confidence interval 1.078-2.864; P = 0.024).This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.

Postoperative ischaemic colitis (POIC) is a life-threatening vascular gastrointestinal condition. Serum procalcitonin (PCT) levels be of value in the detection of necrosis.To evaluate the correlation between serum PCT levels and the colonoscopic assessment of the severity of POIC.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).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; p0.0001). 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).Serum PCT is correlated with stage 2/3 POIC requiring surgery. If PCT ≥5μg/L, surgery should be considered.

Summary 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.

Background Les programmes de rehabilitation amelioree apres chirurgie (RAAC) sont associes a une morbidite moindre et une duree d’hospitalisation (LOS) plus courte en chirurgie programmee, mais non evalues sur les cholecystectomies precoces pour cholecystite aigue lithiasique (CAL). Materiels et methodes Cette etude est multicentrique (4 centres hospitaliers francais) en deux etapes (faisabilite et efficacite). Pendant la phase faisabilite, les patients etaient inclus dans une base prospective dediee, avec une prise en charge RAAC en ITT, de mars 2019 a janvier 2020. Pendant la phase efficacite, les patients, inclus de mars 2019 a novembre 2020 (RAAC+), ont ete compares a un groupe controle (RAAC−) sans protocole RAAC extrait de l’etude controlee randomisee ABCAL (JAMA 2014). Resultats Dans la phase faisabilite, 101 patients ont beneficie de la RAAC avec une moyenne de 17/20 criteres appliques (range : 12–19). L’information preoperatoire, la mobilite precoce et la realimentation precoce sont les criteres les plus appliques (97 % des patients) contrairement a la compression veineuse intermittente (6 %) et le jeun limite (32 %) moins appliques. Dans la phase efficacite, 209 patients RAAC+ ont ete compares a 414 patients RAAC−. La LOS est significativement plus courte dans le groupe RAAC+ (3,1 jours vs 5, p Conclusion La RAAC dans la cholecystectomie precoce pour CAL est faisable et semble diminuer la LOS sans augmenter la morbidite.

La diagnosi di colecistite acuta si basa su una valutazione clinica, biologica e radiologica. Il suo trattamento dipende dalla valutazione della sua gravita sulla base delle raccomandazioni rilasciate dalla consensus conference tenutasi a Tokyo (“Tokyo guidelines”). Il trattamento chirurgico e indicato nei casi di colecistite lieve o moderata e in caso di fallimento della terapia conservativa e, poi, delle colecistiti acute litiasiche gravi. Il trattamento raccomandato della colecistite acuta litiasica e la colecistectomia, possibilmente per via laparoscopica. Si richiede il rispetto delle norme di sicurezza che si applicano anche in caso di chirurgia laparotomica. La colecistectomia consiste in una dissecazione nei pressi della cistifellea e in una liberazione dei foglietti peritoneali che permettono di allontanarsi dal dotto biliare principale. Un’individuazione degli elementi del peduncolo cistico (arteria e dotto cistico) viene, quindi, eseguita prima di sezionarli. Il drenaggio sistematico del sito chirurgico non e piu la regola, ma rimane indicato durante l’intervento chirurgico difficile ed emorragico o di fronte a un dubbio sulla ferita biliare. L’antibioticoterapia postoperatoria non e piu un dogma, soprattutto in caso di colecistite acuta litiasica lieve o moderata. Alcune situazioni sono indicazioni a una laparotomia immediatamente, mentre altre sono indicazioni a una conversione in laparotomia, in particolare durante gravi lesioni emorragiche e una colecistectomia difficile o se si sospettano delle lesioni dei dotti biliari.

El diagnostico de la colecistitis aguda se basa en una evaluacion clinica, de laboratorio y radiologica. Su tratamiento depende de la evaluacion de su gravedad, basada en las recomendaciones ofrecidas en la conferencia de consenso que tuvo lugar en Tokio («pautas de Tokio»). El tratamiento quirurgico esta indicado en la colecistitis leve o moderada y cuando fracasa el tratamiento conservador en las colecistitis agudas litiasicas graves. El tratamiento recomendado de la colecistitis aguda litiasica es la colecistectomia, si es posible por via laparoscopica. Requiere que se respeten unas reglas de seguridad que tambien son aplicables para la cirugia por laparotomia. La colecistectomia consiste en una diseccion proxima a la vesicula biliar y una liberacion de las hojas peritoneales que permita alejarse de la via biliar principal. A continuacion, se individualizan los elementos del pediculo cistico (arteria y conducto cisticos) antes de seccionar estos ultimos. El drenaje sistematico del lecho quirurgico ya no es la regla, pero esta indicado en caso de cirugia dificil o hemorragica o si hay dudas sobre una posible lesion biliar. La antibioticoterapia postoperatoria tampoco es un dogma en la actualidad, en particular en caso de colecistitis aguda litiasica leve o moderada. Algunas situaciones son indicaciones para una laparotomia de entrada, mientras que otras lo son para una conversion en laparotomia, en particular si se producen lesiones hemorragicas graves, en la colecistectomia dificil o si se sospecha una lesion de las vias biliares.

Resume La vascularisation arterielle colique est principalement assuree par deux branches viscerales de l’aorte abdominale : les arteres mesenteriques superieure et inferieure. En situation physiologique, il existe de nombreuses variations anatomiques dont la connaissance est imperative avant toute chirurgie colique afin d’adapter le geste en preoperatoire ou en peroperatoire. La connaissance de ces variations, et du reseau vasculaire restant, est encore plus importante si le patient a deja eu une colectomie ou s’il presente une pathologie vasculaire thrombotique pouvant aboutir a une veritable suppleance anastomotique entre le reseau iliaque et l’artere mesenterique. Le but de cette mise au point etait de rappeler l’anatomie modale et les principales variations de la vascularisation colique et leurs applications en chirurgie colorectale.

Although there are ever fewer indications for abdominoperineal resection (APR), preservation of the sphincter or rectum during tumor resection is still an important objective [1]. In fact, R0 resection of advanced tumors in the low rectum sometimes requires the anus to be sacrificed (particularly in cases of sphincter or puborectalis invasion) [2]. In this context, APR becomes an oncological and technical challenge.

Leakage of stomal effluent is considered by people living with a stoma to be the key factor that negatively impacts their quality of life (QoL). This non-randomised pilot study evaluated the performance of a new stoma appliance, Flexima® Active O Convex in 40 ostomy patients with a flat, flush or slightly retracted stoma over a 14-day period. Leakage was reported for the wear time of each pouch by the patients. On 79% of occasions, the patient reported no leakage under the skin protector. The appliance was very well tolerated and the condition of the patients' peristomal skin was maintained throughout the study. The performance was rated as ‘good’ or ‘very good’ by most of the patients. The results of this study have shown that the design of this one-piece soft convex appliance can prevent leakage and protect peristomal skin by providing a safe seal around the stoma. It was also reported as being flexible and comfortable to wear.

Aim To report the results of surgery for obstructive right colon cancer (ORCC) and to identify risk factors associated with worse outcomes that may help surgeons to choose the best surgical option. Methods This is a retrospective national cohort study, including all patients operated on for ORCC from 2000 to 2015. Those treated with colonic stent or symptomatic treatment were excluded. We described outcomes after surgery for ORCC and performed multivariate analyses for mortality, morbidity and survival. Results Among 776 patients analyzed, 716 (92%) had their primary tumor removed, with primary anastomosis in 582 (82%). The remaining 194 underwent anastomosis with loop ileostomy (n = 21), resection with double-end stoma (n = 113), defunctioning stoma without resection (n = 48) and ileocolic by-pass (n = 12). Postoperative mortality, morbidity and anastomotic leak rates were 10%, 51% and 14%, respectively. In multivariate analysis, age >70, ASA score ≥3 and hemodynamic instability were predictors of postoperative mortality whereas ASA score ≥3, hemodynamic instability and intra-operative complications were predictors of severe morbidity. No factors were correlated with anastomotic leak. After a median follow-up of 26 months, 8% of patients were alive with a permanent stoma. Five-year overall, disease-free and cancer-specific survival was 42%, 42% and 62%, respectively. In multivariate analysis, peritonitis, synchronous metastases and absence of adjuvant chemotherapy were predictors of decreased overall survival. Conclusions Emergency surgery for ORCC is associated with high mortality and morbidity. Two third of patients with ORCC can be managed with resection and primary anastomosis. For high-risk patients, a staged surgical management may be discussed.

Objectives To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults (≥75) with those of younger adults undergoing early (

Pleuroperitoneal communication is an anatomic entity that is typically asymptomatic but sometimes responsible for hydrothorax. This pleural manifestation can be explained by progressive transdiaphragmatic passage of intra-abdominal fluid because of abdominal hyperpressure. The object of this report is to present a hitherto unreported association of concomitant pleural effusion and acute infectious abdominal disease, due to perforated duodenal ulcer. This underscores that pleural effusion associated with acute abdominal pain may reveal the existence of a communication of this type, and requires surgical management.

Resume La communication pleuroperitoneale est une particularite anatomique parfois responsable d’un hydrothorax, son mode de revelation classique s’expliquant par l’apparition progressive d’une hyperpression intra-abdominale a l’origine d’un passage liquidien transdiaphragmatique. La decouverte de cette communication dans un contexte infectieux aigu, comme une peritonite secondaire a une perforation d’ulcere duodenal, est une situation rare, actuellement jamais decrite. L’association d’un epanchement pleural et d’une douleur abdominale aigue peut donc reveler une communication de ce type necessitant une prise en charge chirurgicale.

Enhanced recovery programs (ERP) improve post-operative outcomes in proportion to how fully they are implemented. Maintaining an optimal level of application of all the ER components is thus essential. Our aim was to assess the sustainability of ER surgical components 2 years after their first implementation.Patients undergoing elective colorectal resections were included in a prospective database. To retrospectively analyze compliance with ERP over a period of 24 months, the following components were considered: colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage.2565 patients with a mean age of 63.6 ± 14.4 years from 63 colorectal centers were included. There were 1853 (72.2%) colectomies and 558 (21.7%) rectal resections. The median duration of hospital stay was 5 days [Interquartiles 4-8]. Overall morbidity was 21.9%, surgical morbidity was 8.1%, including 2.8% anastomotic fistulae. Overall, the ERP component most often applied with was postoperative nasogastric tube omission (93.6%), followed by laparoscopic approach (81.7%), absence of drainage (74.9%), and colonic preparation omission (67.3%). Implementation of surgical components significantly decreased over time: less laparoscopy (from 86.8% to 76.6%, p 0.001), less drain omission (from 88.7% to 72%, p 0.001), less nasogastric tube omission (from 100% to 93.4%, p = 0.002) and less colonic preparation omission (from 73.6% to 65.6%, p = 0.01).This large-scale study found that implementation of surgical components in ERP decreased over time. Further efforts are needed to sustain compliance with ERP and surgical teams should focus on repeated audits.

International audience; AimIn the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry. MethodFrom January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation. ResultsA total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P9cm (P=0.002) and a caecal diameter at the ileocaecal junction >7.5cm (P=0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume >400cm(3) (P=0.001) was correlated with the risk of impending caecal perforation. ConclusionCaecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Background This study evaluated the association between oral gastrografin administration and the need for operative intervention in patients with presumed adhesive small bowel obstruction. Methods Between October 2006 and August 2009, 242 patients with uncomplicated acute adhesive small bowel obstruction were included in a randomized, controlled trial (the Adhesive Small Bowel Obstruction Study, NCT00389116 ) and allocated to a gastrografin arm or a saline solution arm. The primary end point was the need for operative intervention within 48 hours of randomization. The secondary end points were the resection rate, the time interval between the initial computed tomography and operative intervention, the time interval between oral refeeding and discharge, risk factors for the failure of nonoperative management, in-hospital mortality, duration of stay, and recurrence or death after discharge. We performed a systematic review of the literature in order to evaluate the relationship between use of gastrografin as a diagnostic/therapeutic measure, the need for operative intervention, and the duration of stay. Results In the gastrografin and saline solution arms, the rate of operative intervention was 24% and 20%, respectively, the bowel resection rate was 8% and 4%, the time interval between the initial computed tomography and operative intervention, and the time interval between oral refeeding and discharge were similar in the 2 arms. Only age was identified as a potential risk factor for the failure of nonoperative management. The in-hospital mortality was 2.5%, the duration of stay was 3.8 days for patients in the gastrografin arm and 3.5 days for those in the saline solution arm ( P = .19), and the recurrence rate of adhesive small bowel obstruction was 7%. These results and those of 10 published studies suggest that gastrografin did not decrease either the rate of operative intervention (21% in the saline solution arm vs 26% in the gastrografin arm) or the number of days from the initial computed tomography to discharge (3.5 vs 3.5; P = NS for both). Conclusion The results of the present study and those of our systematic review suggest that gastrografin administration is of no benefit in patients with adhesive small bowel obstruction.

4019 Background: The incidence of SRC gastric cancers is markedly increasing in Western countries. SRC cancers may harbor intrinsic resistance to chemotherapy (CTx) leaving many clinicians unsure of the benefits of delaying surgery to pursue a neoadjuvant approach. The primary objective of this study was to assess whether upfront surgery plus adjuvant CTx would provide enough survival benefit for study in a phase III trial when compared to perioperative CTx. Methods: Patients with stage IB-III SRC gastric cancer were randomly assigned to receive upfront surgery plus adjuvant CTx (epirubicin, cisplatin and 5-fluorouracil [ECF regimen], 6 cycles; experimental arm [SurgFirst]) or perioperative CTx (ECF, 3 cycles before and 3 cycles after surgery; control arm [CTxFirst]). Randomization (1:1) was stratified by tumor stage, tumor location, performance status and center. The primary endpoint was overall survival (OS) at 2 years (OS2; target (H1): OS2 > 26%). Results: 83 eligible patients were included in 27 centers from 11/12 to 09/16 (median age, 61 years (range: 32-80 years); male, 59%; ECOG PS 0-1, 99%). Results were (CTxFirst/SurgFirst): full completion of CTx, 87%/77%; surgical resection, 82.5%/90%; major postoperative complications (Clavien Dindo III-IV), 24%/23%; R0 resection rate, 88%/78%; OS2, 60%/53.5%; and median OS, 39/28 months (exploratory hazard ratio, 0.71 [95%CI: 0.40-2.64]). Conclusions: This trial met its primary endpoint (OS2 > 26% in the experimental arm). With OS2 rates > 50%, both CTx modalities deserve further evaluation in Phase III studies in stage IB-III SRC gastric cancer. Clinical trial information: NCT01717924.

Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). However, the literature on the long-term impact of SEMS as "a bridge to surgery" is limited and contradictory.From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias.There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group.Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.

Resume Malgre les nombreuses options de prise en charge des pertes de substance (PDS) perineales apres resection abdominoperineale, allant de la fermeture directe a la reconstruction par lambeau, leurs traitements restent un challenge. Une meilleure comprehension des buts, des inconvenients et des progres dans la prise en charge de ces PDS peut aider le chirurgien a prendre les bonnes decisions therapeutiques, adaptees a chaque patient. Cependant, force est de constater qu’il est difficile de proposer un procede unique, optimal, avec un appui factuel, pour la prise en charge de ces PDS au vu des multiples facteurs pouvant eprouver la cicatrisation. De plus, deux concepts recents, la resection abdominoperineale dite cylindrique et les lambeaux perforants, sont venus recemment modifier notre conception de la reconstruction perineale, ainsi que notre arsenal therapeutique. C’est ce que nous avons voulu detailler dans cette revue.

Although the preoperative management of mild and moderate (Grade I–II) acute calculous cholecystitis (ACC) has been standardized, there is no consensus on the value of abdominal drainage after early cholecystectomy. In a post hoc analysis of a randomized controlled trial (NCT01015417) focused on the value of postoperative antibiotic therapy in patients with ACC, we determined the value of abdominal drainage in patients having undergone laparoscopic cholecystectomy for Grades I–II ACC. All postoperative complications were analyzed after using a propensity score. A post hoc test was used to assess the statistical robustness of our results. Of the 414 enrolled patients, 178 did not have abdominal drainage (forming the no-drainage group) and 236 had drainage (the drainage group). After matching on PS, the deep incisional site infection was 1.1 versus 0.8 %, p = 0.78. This result is similar for the superficial incisional site infections; the distant infections; the overall morbidity, and the readmission rate. Only the hospital length of stay was significantly longer in the drainage group (3.3 vs. 5.1 days, p = 0.003). Neither abdominal drainage nor the absence of postoperative antibiotic therapy was found to be a risk factor for deep incisional site infections. The use of abdominal drainage depends on the surgeon’s personal preferences but is often used in high-risk populations. However, abdominal drainage does not appear to be of any benefit (in terms of postoperative outcomes) and may even compromise recovery in patients having undergone early laparoscopic cholecystectomy for mild or moderate ACC.

International audience; OBJECTIVE:The aim of this study is to evaluate whether a parenchymal-sparing strategy provides similar results in terms of morbidity, mortality, and oncological outcome of non-PSH hepatectomies in a propensity score matched population (PSMP) in case of multiple (>3) bilobar colorectal liver metastases (CLM).BACKGROUND:The surgical treatment of bilobar liver metastasis is challenging due to the necessity to achieve complete resection margins and a sufficient future remnant liver. Two approaches are adaptable as follows: parenchymal-sparing hepatectomies (PSH) and extended hepatectomies (NON-PSH).METHODS:A total of 3036 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched in a 1:1 propensity score analysis in order to compare PSH versus NON-PSH resections.RESULTS:PSH was associated with a lower number of complications (≥1) (25% vs. 34%, p = 0.04) and a lower grade of Dindo-Clavien III and IV (10 vs. 16%, p = 0.03). Liver failure was less present in PSH (2 vs. 7%, p = 0.006), with a shorter ICU stay (0 day vs. 1 day, p = 0.004). No differences were demonstrated in overall and disease-free survival.CONCLUSION:In conclusion, PSH resection for bilobar multiple CLMs represents a valid alternative to NON-PSH resection in selected patients with a reduced morbidity and comparable oncological results.

Two principal branches from the aorta provide the colonic blood supply: the superior and inferior mesenteric arteries. There are numerous anatomical variations, which the surgeon must fully understand before embarking on any colonic surgery. A good knowledge of these variations is particularly important when the patient has already undergone colectomy or presents with occlusive vascular disease. The aim of this review is to summarize the standard anatomy and the main variations of the colonic blood supply as they apply to colorectal surgery in this setting.

Common bile duct neoplastic thrombosis is rare and can cause jaundice in case of gallbladder cancer (GBC). We report the case of a 45-year-old man with GBC located in the fundus associated with a malignant endobiliary thrombus. A surgical procedure has been performed, including segmentectomy 4b+5 with common bile duct resection with Roux-en-Y hepaticojejunostomy. Postoperative courses were uneventful and the patient is alive at 15 months.

Resume L’amputation abdomino-perineale est la technique chirurgicale la plus ancienne dans la prise en charge des cancers du rectum. Ses resultats carcinologiques sont moins bons que ceux de la resection anterieure. En effet, au cours des amputations abdomino-perineales, le taux de perforation rectale est important, et les marges circonferentielles de resection souvent envahies. Recemment la reintroduction du concept d’exerese cylindrique, permettant une exerese au large de la tumeur, a ete proposee et les premiers resultats carcinologiques semblent encourageants. Le but de cette mise au point est d’examiner les resultats carcinologiques des amputations abdomino-perineales, a partir des principales etudes recentes sur la prise en charge des cancers du rectum, et de rapporter les modifications techniques a la disposition du chirurgien colorectal « moderne ».

Over the past few decades, methodological progress and better anatomical knowledge have reduced the morbidity of reconstructive surgery. Muscle-sparing flaps and perforator flaps provide the surgeon with additional options for reconstruction. Based on a review of the local flaps used for perineal reconstruction, this article describes these new solutions and presents a decision tree (based on whether abdominal incision is required or not). If laparotomy is required, abdominal flaps should be preferred. If surgical excision is performed with the patient in the prone position, then gluteal and pudendal donor sites are recommended.

Dans son arsenal législatif, la France propose, pour ses services publics, une offre de gestion originale : la délégation de service public.Elle permet aux autorités organisatrices des services publics d’eau potable et d’assainissement de confier la gestion effective du service public à un opérateur privé pendant une durée suffisamment longue pour que les investissements spécifiques du gestionnaire puissent être amortis, mais limitée dans le temps par une nécessaire réflexion périodique sur le mode de gestion et une remise en concurrence obligée si la délégation est de nouveau choisie.Dorénavant, les dispositions réglementaires sont complètes. Elles permettent à la puissance publique de garder les outils de contrôle de son service public et aux usagers d’être totalement informés des caractéristiques de son service public, des conditions tarifaires et des ses performances.Les clauses de transparence dans les procédures de choix du délégataire, l’existence de comptes rendus périodiques sur l’exécution du contrat, la mise à disposition du public, par le maire de chaque commune, du rapport annuel sur le prix et la qualité du service public, sont autant de garanties vis-à-vis des usagers, et donc des citoyens. La pérennité et l’efficacité du service public sont à ce prix., Amongst its wide-ranging legislation, France offers a new management option for its public services: public service management by private operators.This allows the authorities in charge of the public services for supply of drinking water and sewerage to outsource the actual management of the public service for a period of time that is sufficiently long to enable the operator to amortize its specific investments, but also limited by the periodic management review which is, of course, necessary, and by compulsory re-advertising if the outsourcing is to be renewed.The regulatory provisions have now been finalized. They allow the public authority to retain control over the public service, whilst also ensuring that customers are fully informed of the characteristics of their public service, the pricing conditions and the performance achieved by the service.Transparency clauses in procedures for the selection of the contractor, periodic reports on the performance of the contract, and the annual report on the price and quality of the public service, which is made available to the general public by the Mayor of each municipality, are all guarantees to customers, and therefore to citizens. The durability and the efficiency of the public service depend on such guarantees.

International audience; Background Only few case series have been published about locally advanced carcinoma of the right colon invading the duodenum or pancreas (CRCDP). We report results of a retrospective study about this rare entity focusing on management and prognosis. Methods We reviewed the complete data of patients operated for CRCDP between 1988 and 2005 in four French digestive-surgery departments. Results Fifteen patients were managed [12 men, 3 women, mean age 63 years (43–86)]. These patients underwent attempted curative en bloc resection including right colectomy: 12 were treated by partial duodenectomy (tumours involving only a part of the duodenum); 3 were treated by pancreaticoduodenectomy. All tumours resected had clear resection margins (R0). About 53% of patients had hepatic metastases, duodenocolic fistula, carcinomatosis, abscess or perforation at presentation. Surgery was performed in emergency in 26% of cases. About 20% of patients had serious postoperative complications (heart failure, bile duct necrosis, septic shock), and three other patients had postoperative anastomotic leaks. No patient experienced duodenal fistula after partial duodenectomy. The mean median survival in resected patients was 22 months (0–122). Overall 1 and 3 years survival were 68% (n = 7) and 56% (n = 4). Despite clear resection margins in all patients, 26% of patients developed recurrence (duodenal wall resection n = 3; pancreaticoduodenectomy n = 1). Conclusion Morbidity and mortality after colectomy and en bloc partial duodenectomy or pancreaticoduodenectomy are high but in selected cases could offer prolonged survival. Aggressive surgery including major resection should be performed to obtain clear resection margins even in case of complicated forms.

Resume Les indications chirurgicales de la pancreatite chronique peuvent etre schematiquement separees en cinq grands groupes : la douleur, les consequences de la fibrose sur les organes de voisinage, les consequences de la rupture canalaire en amont d’un obstacle, et la suspicion de cancer. Enfin, les malades chez qui les procedures endoscopiques sont impossibles (papille non accessible) ou trop rapprochees representent un dernier groupe d’indication chirurgicale. Les interventions sont multiples. Il peut s’agir d’interventions de derivation pancreatique, kystique, biliaire ou d’interventions dites mixtes (combinant derivation/resection) ou d’interventions de resection pancreatique. Enfin il peut s’agir d’intervention de denervation. Quelle que soit l’indication, le traitement chirurgical doit repondre a plusieurs objectifs : son indication doit etre discutee de facon multidisciplinaire ; il doit etre associe a une faible morbimortalite, et preserver au mieux la fonction endocrine ; il doit de facon claire ameliorer la qualite de vie, et avoir ete evalue a long terme, au mieux de facon prospective. Nous nous proposons de preciser quelques points importants pour la prise en charge de malades ayant une pancreatite chronique (PC), avant d’aborder les divers traitements de facon detaillee.

Resume Situation Les fistules du moignon rectal apres intervention de Hartmann sont frequentes. Le plus souvent, elles ne necessitent aucun traitement interventionnel mais generent des soins prolonges au cours de l’hospitalisation. But de l’etude Decrire l’utilisation d’une colle biologique dans le traitement des fistules recto-cutanee observees apres intervention de Hartmann. Patients et methodes Dix malades ont ete traite par un encollage du trajet fistuleux apres l’avoir irrigue. La colle a ete reconstituee par adjonction de solvant dans 2 seringues. Le porte-seringue muni d’un piston solidarise a un catheter type Duplocath ® , et le trajet fistuleux a ete catheterise jusqu’au moignon rectal. La colle biologique a ete administree par retrait progressif du catheter de l’extremite rectale jusqu’a l’orifice cutane de la fistule. Resultats Aucune complication n’a ete observee et 7 malades sur 10 ont eu un tarissement complet de la fistule. Conclusion L’encollage simplifie les soins locaux et pourrait permettre de reduire la duree d’hospitalisation.

Purposes : In rectal cancer, the incidence of synchronous liver metastases (SLM) ranges from 14% to 30%. The treatment of SLM combines neo-adjuvant chemo- and/or radiotherapy with of one three surgical resection strategies (rectal resection first, liver resection first or simultaneous resection). The present study evaluated the success rate for each resection strategy. Methods From January 2005 to December 2013, we retrospectively included all patients with distal (middle and low) rectal cancer (MLRC) and SLM and who had been operated on with curative intent. The primary study endpoint was the proportion of complete resections at both tumour sites. The secondary endpoints were postoperative morbidity, the long-term outcome and risk factors for incomplete resection. Results 52 patients were included. There were no significant intergroup differences in the incidence of complete resection (respectively 74%, 66% and 50% in the rectum-first (n = 20), simultaneous (n = 10) and liver-first groups (n = 5); p = 0.3), the overall complication rate or mortality rate after rectal resection (p = 0.5) or liver resection (p = 0.8), overall survival (60, 47 and 38 months, respectively; p = 0.4) or disease-free survival (31, 32 and 7.8 months, respectively; p = 0.1). Emergency surgery was the only risk factor for treatment failure (p = 0.01). Conclusion There were no differences in short and long-term outcomes between the three strategies. No one oncological strategy should be favoured for all cases of MLRC with SLM. The strategy should be choosen, based on the oncological emergency (rectum-first or liver-first), predictive factors for morbidity in rectal surgery and MDT discussion.

Obstructive jaundice is uncommon in patients with hepatocellular carcinoma. It can be due to compression of the common bile duct by the liver tumor or by enlarged lymph node metastases in the porta hepatis. Obstructive jaundice can also be due to direct extension of hepatocellular carcinoma into the bile ducts with or without a detectable primary hepatic tumor. These particular hepatocellular carcinoma have been termed "icteric type hepatoma" by Lin et al. in 1975, who emphasized their poor prognosis. We report a similar case of endobiliary hepatoma without a detectable intraparenchymal hepatic tumor in a seventy year-old man. This case is unusual because of its positive evolution and late recurrence.

Resume Introduction. – L'evaluation des resultats apres chirurgie colorectale est toujours necessaire. Un nouvel index permettant d'apprecier en preoperatoire la mortalite apres resection colorectale pour cancer colorectal ou diverticulite sigmoidienne (index AFC) a ete publie. Patients et methodes. – De novembre 2002 a juillet 2004, une analyse de la mortalite a ete effectuee chez 253 patients ayant eu une resection colique (n = 220, 87 %) ou rectale, avec anastomose (n = 175, 70 %) au CHU d'Amiens, en particulier en fonction du caractere urgent de la resection, de l'existence de troubles neurologiques, de la notion de perte de poids ≥ 10 % et de l'âge (index AFC). Resultats. – L'âge moyen etait de 63 ± 18 ans (17–92) (45 % ≥ 70 ans), 26 % des patients avaient un index ASA ≥ III, 35 % des patients etaient operes en urgence, et 12 % par cœlioscopie. L'etiologie etait neoplasique chez 115 patients (45 %), rattachee a une diverticulite sigmoidienne chez 50 patients (20 %), et 11 ont ete operes pour colite ischemique. La mortalite globale etait de 10 % (n = 26), elle etait de 19 % en urgence et de 5 % apres chirurgie programmee. La morbidite globale etait de 38 %, le taux de fistule de 8 % (n = 14/175), le taux de reprise chirurgicale etait de 14 %. La duree moyenne de sejour etait de 13 ± 8 jours. Une rehospitalisation non programmee etait necessaire chez 10 % des patients. Apres chirurgie pour lesion neoplasique et diverticulite sigmoidienne : -i) la mortalite etait de 9 % ; -ii) parmi les patients ayant zero, un, deux ou trois criteres AFC, la mortalite etait de 0 % (index AFC 0,5 %), 5 % (index AFC 2 %), 15 % (index AFC 9 %) et 33 % (index AFC 16 %) (nombre de patients trop faibles pour quatre criteres). Apres resection pour une autre etiologie que le cancer colorectal et la maladie diverticulaire parmi les patients ayant zero, un, deux ou trois criteres AFC, la mortalite etait de 0, 12, 36, et 25 %. Conclusions. – Ces resultats confirment l'interet de l'index AFC, lors de l'evaluation preoperatoire des patients candidats a une resection colique ou rectale toutes indications confondues.

Control of the left hepatic vein or of the common trunk left hepatic vein-middle hepatic vein during a hepatic resection is presumed difficult. This control is facilitated by the knowledge of the Arantius' ligament anatomy. The combined manoeuvre which associates lowering the top of segment I and section-traction of the Arantius' ligament allows exposure of the inferior aspect of the left or middle hepatic veins and allows safe dissection of these veins.

Resume Introduction. – L'intervention de Hartmann (IDH) est une intervention simplifiee realisable en urgence par tout chirurgien. Cette intervention est cependant actuellement soumise a de nombreuses critiques (morbimortalite importante, taux le plus souvent bas de retablissement de la continuite digestive). Le but de ce travail etait de rapporter l'histoire naturelle de l'IDH et du retablissement de la continuite digestive (RC) pour sigmoidite diverticulaire et analyser les facteurs de risque de mortalite, de morbidite et de non-retablissement de la continuite digestive. Patients et methodes. – Dans trois centres, entre 1992 et 2002, 85 patients ont eu une IDH. L'analyse retrospective portait sur la mortalite, la morbidite (precoce et tardive) de l'IDH et du retablissement secondaire de la continuite digestive. Resultats. – Les patients (âge moyen 68 ans) presentaient une pathologie associee dans 22 % des cas, une immunite alteree dans 17 % des cas et un stade Hinchey 3 ou 4 dans 64 % des cas. Les patients avaient un score ASA superieur ou egal a 3 dans 49 % des cas. Les scores moyens AFC et de Mannheim etaient respectivement de 2 et 21. La mortalite etait de 14 % et la morbidite hospitaliere de 50 %. Les principales complications etaient les complications cardiorespiratoires (18 %), les abces de paroi (14 %) et les complications stomiales (6 %). Precocement, aucun patient n'a presente de fistule du moignon rectal. La duree moyenne de sejour etait de 19 ± 13 jours. La morbidite tardive etait de 29 % et etait dominee par les complications stomiales (12 %) et les occlusions intestinales (7 %). Seules trois (4 %) fistules du moignon rectal sont apparues dont deux infracliniques. Le retablissement de continuite, realise dans 77 % des cas s'est complique d'une seule fistule anastomotique. La mortalite du retablissement de continuite etait de 0 % et la morbidite de 13 %. La duree moyenne d'hospitalisation etait de 10 ± 3 jours. Un âge superieur a 75 ans, un score ASA superieur ou egal a 3 et une maladie sous-jacente etaient retrouves comme facteur de risque de morbimortalite et de non-retablissement de la continuite. Conclusions. – L'intervention de Hartmann reste associee a une mortalite et une morbidite elevees. Le taux de retablissement secondaire de la continuite digestive est eleve dans cette serie. L'intervention de Hartmann reste une operation simplifiee chez des patients fragiles avec des peritonites evoluees. Cette etude permet de preciser l'histoire naturelle de l'intervention de Hartmann. La connaissance de celle-ci est essentielle pour decider quelle est l'intervention (entre intervention de Hartmann et resection–anastomose) la plus adaptee chez un patient ayant une peritonite diverticulaire.

No study on bioclinical criteria predicting a biliary origin for acute pancreatitis has included endosonography as a reference examination. Re-examination of bioclinical parameters deserves consideration in the era where other causes are known (e.g. hereditary, autoimmune).To determine the performance of bioclinical markers in predicting a biliary origin of acute pancreatitis where the diagnosis of biliary lithiasis was established or ruled out using endosonography. Only patients with a first acute episode of pancreatitis were included.213 patients (male: 55%; median age: 56 years) were prospectively included in 14 centres. Causes of acute pancreatitis were: biliary (62%), alcoholic (25%), other (13%). Delay between symptom-onset and admission was48 h in 80%. Endosonography was the sole method establishing the diagnosis of biliary pancreatitis in 15% of patients. At univariate analysis, age, female sex, declared alcohol consumption, elevated aspartate and alanine transaminases on admission, gammaglutamyl transferase, alkaline phosphatase, total bilirubin, lipase, mean corpuscular volume were predictive of a biliary origin. Only age (p0.0001), sex (p0.0008) and alanine transaminase (p0.0004) remained significant at multivariate analysis. At age 50, the respective sensitivity and specificity were 73 and 65%. With an elevated alanine transaminase at 2 times the upper limit of normal range, the respective sensitivity and specificity were 74 and 84%. The probability of a biliary origin of acute pancreatitis could be estimated by the following formula: = 1/1 + exp(4.6967 - 0.0656 x age + 1.1208 x sex - 0.6909 x alanine transaminase).When endosonography is performed to confirm or exclude a biliary origin of acute pancreatitis, age, sex and alanine transaminase at admission are the only factors predictive of a biliary cause.

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.