Arnaud Alves

Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn's disease: a multivariate analysis in 161 consecutive patients.

PurposeThis study was designed to assess predictive factors of postoperative intra-abdominal septic complication in a homogenous group of patients undergoing ileocecal resection for Crohn’s disease.MethodsFrom 1984 to 2004, 161 consecutive patients with Crohn’s disease (81 males; mean age, 33u2009±u200910xa0years) underwent, as a first operation, an elective ileocecal resection without temporary stoma. Postoperatively, 15 patients (9 percent) developed abdominal septic complications, including abscess and anastomotic leaks. Possible factors for postoperative intra-abdominal septic complication were analyzed by both univariate and multivariate analyses.ResultsThere was no postoperative death. Multivariate analysis found only four independent factors associated with a higher risk of postoperative intra-abdominal septic complication: poor nutritional status (odds ratio, 6.23 (1.75–22.52)), intra-abdominal abscess discovered during surgery (odds ratio, 7.47 (1.5–37.69)), preoperative steroids use more than three months (odds ratio, 5.95 (1.04–34.1)), and recurrent clinical episode of Crohn’s disease (odds ratio (per episode), 1.38 (1.03–1.9)).ConclusionsRecurrent clinical episode of Crohn’s disease, preoperative steroids use, poor nutritional status, and the presence of abscess at the time of surgery significantly increased the risk of septic abdominal complications after first ileocecal resection for Crohn’s disease. Knowledge of these risk factors could permit to propose a temporary stoma in very high-risk patients (i.e., with 3 or more risk factors).

French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease

The aim of this study was to compare in‐hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD).

Factors That Predict Conversion in 69 Consecutive Patients Undergoing Laparoscopic Ileocecal Resection for Crohn’s Disease: A Prospective Study

PURPOSEThis prospective study was designed to identify factors that could predict conversion in patients undergoing first laparoscopic ileocecal resection for Crohn’s disease.METHODSBetween 1998 and 2004, 69 consecutive patients (32 males; mean age, 32 ± 9 years) who had undergone a first laparoscopic ileocecal resection for Crohn’s disease were included in a prospective study. Twenty-one patients (30 percent) were converted into laparotomy. Possible factors for conversion were analyzed by both univariate and multivariate analyses.RESULTSNo patient died. Four patients (9 percent; 2 in each group) required five reoperations because of intraperitoneal hemorrhage (n = 1), anastomotic fistula (n = 3), and small-bowel obstruction (n = 1). Mean hospital stay was significantly increased in converted compared with laparoscopic patients (9 ± 4 vs. 7 ± 3 days; P < 0.05). On univariate analysis, more than three episodes of acute flare of Crohn’s disease (P = 0.02), male gender (P = 0.03), preoperative immunosuppressive drugs (P = 0.04), intra-abdominal abscess or fistula at the time of laparoscopy (P = 0.02), and resection of other intestinal segment (P = 0.02) were factors that predicted conversion. On multivariate analysis, recurrent medical episodes of Crohn’s disease (odds ratio, 2; 95 percent confidence interval, 1–4), and intra-abdominal abscess or fistula at the time of laparoscopy (odds ratio, 15; 95 percent confidence interval, 4–78) were the two independent risk factors for conversion.CONCLUSIONSThis prospective study demonstrated that the severity of the disease increased significantly the conversion rate of the first laparoscopic ileocecal resection. Knowledge of these risk factors for conversion could be helpful in preoperative preparation and counseling of patients.

Laparoscopic colorectal surgery in elderly patients: a matched case-control study in 178 patients.

BACKGROUNDnWe conducted a prospective case-matched study to compare outcomes of laparoscopic colorectal surgery in elderly (>or= 70 years) and younger (< 70 years) patients.nnnSTUDY DESIGNnAmong 506 consecutive patients who underwent 536 colorectal resections supervised by 1 colorectal surgeon (YP), 75 elderly patients (>or= 70 years)were matched with 103 younger patients (< 70 years), according to gender, body mass index, pathology, and surgical procedure. Postoperative mortality and morbidity were defined as in-hospital deaths and complications.nnnRESULTSnOne hundred seventy-eight patients (95 men and 83 women) underwent laparoscopic colorectal resection for colorectal carcinoma (40%) or benign diseases (60%). Laparoscopic surgical procedures included left colectomy (43%), rectal resection (34%), right colectomy (12%), subtotal colectomy (6%), and rectopexy (5%). Cardiopulmonary comorbidities were significantly more frequent in elderly compared with young patients (80% versus 33%, p < 0.001). Mean operating times were similar between elderly and young patients (244+/-89 minutes versus 242+/-80 minutes, NS). Thirty-two patients (18%, 16 in each group) required conversion to laparotomy. There was no mortality. Overall postoperative complications were comparable between groups (32% versus 26%, NS). Sixteen patients (9%, 5 elderly and 11 young) required reoperation. Mean hospital stay was comparable between groups (11+/-8 days versus 10+/-9 days, NS).nnnCONCLUSIONSnThis large case-matched study suggested that laparoscopic colorectal surgery may be proposed in elderly patients, with similar postoperative outcomes as this surgery has in young patients, despite significantly more frequent cardiorespiratory comorbidities.

Rectal cancer surgery without mechanical bowel preparation.

Eight randomized clinical trials and two meta‐analyses recently questioned the value of preoperative mechanical bowel preparation (MBP) in colorectal surgery. However, very few patients having rectal surgery were included in these studies. The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP.

Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy

Temporary faecal diversion is recommended with a low colorectal, coloanal or ileoanal anastomosis (LA). This randomized study evaluated early (EC; 8 days) versus late (LC; 2 months) closure of the temporary stoma.

Operative Results and Quality of Life After Gracilis Muscle Transposition for Recurrent Rectovaginal Fistula

PURPOSE: The aim of this study was to assess the efficacy of gracilis muscle transposition for recurrent rectovaginal fistula. METHODS: Gracilis muscle transposition for recurrent rectovaginal fistula was performed in eight patients. Causes of fistulas included Crohns disease (n = 5), perineal surgery (n = 2), and obstetrical injury (n = 1). All patients underwent a mean of three (range, 1–6) previous repairs. Fecal diversion was performed in all cases. RESULTS: Six of eight patients (75%) healed after gracilis muscle transposition alone. The other two patients required a second gracilis. These two patients failed with another recurrence and one of them underwent laparotomy with successful omental interposition. Thus, after a median follow-up of 28 (range, 4–55) months, the per-gracilis muscle transposition healing rate was 60% (6/10) and the overall healing success rate after gracilis muscle transposition and other procedures was 88% (7/8). For patients with Crohns disease, four of five (80%) presented no recurrent rectovaginal fistula. Seven of eight patients underwent ileostomy closure after gracilis, but two required subsequent stomas, one for a late recurrence. Overall, five of eight patients are stoma-free. Despite healing, postoperative quality of life and sexual activity remained significantly altered. CONCLUSION: Gracilis muscle transposition can be proposed in cases of recurrent rectovaginal fistula. The procedure has a good success rate, especially in Crohns disease patients.

Risk Factors of Unplanned Readmission After Colorectal Surgery: A Prospective, Multicenter Study

PurposeUnplanned readmission after colorectal surgery is a relatively frequent event, knowledge of which often is inaccurate. This study was designed to examine the incidence and causes of readmissions and to determine the criteria that could predict them.MethodsFrom June to September 2002, 1,421 patients were enrolled in a prospective, multicenter study performed by the Association Francaise de Chirurgie. The goal of the study was to determine mortality and morbidity after colorectal surgery for elective or emergency surgical management of diverticular disease or cancer. In the study, readmissions within three months after discharge were assessed.ResultsOf 1,421 patients, 342 patients (27 percent) were readmitted once after a mean period of 53xa0days. Among the readmissions, 248 (19.5 percent) were planned and 94 (7.5 percent) were unplanned (mainly for septic complications). With the multivariate logistic regression analysis, five independent factors were significantly associated with a higher risk of unplanned readmission (in order of importance): surgical field contamination, long duration of operation, need for an associated surgical procedure, hemoglobin level <12xa0g/dl, and absence of air testing after colorectal anastomosis.ConclusionsThe study permitted to individualize several factors significantly associated with a higher risk of unplanned readmission after colorectal surgery.

Total laparoscopic ileal pouch-anal anastomosis : prospective series of 82 patients

BackgroundIleal pouch-anal anastomosis (IPAA) is the recommended procedure for ulcerative colitis and profuse familial adenomatous polyposis. The aims of this study were to report a consecutive series of 82 unselected patients who undergone a total laparoscopic IPAA with a special focus on the postoperative morbidity and 1-year functional results.MethodsBetween 2002 and 2008, 82 consecutive patients undergoing IPAA under a total laparoscopic approach were enrolled. Patient data, surgical procedure, and 1-year functional outcome were analyzed.ResultsAmong the 82 patients, 44 (54%) had a former subtotal colectomy (STC) before IPAA. No patient died postoperatively. Conversion rate was 11%. Overall morbidity was 32%. Symptomatic anastomotic fistulas were observed in nine patients (10%). Reoperation was needed in 5/82 (6%) of the patients. One-year functional results were 4.7xa0±xa01.9 during the day and 1xa0±xa01.2 during the night. Operating time decreased significantly after the first 40 laparoscopic IPAA (pxa0=xa00.0183). No difference was observed in the morbidity and functional results between patients operated for IPAA after a former colectomy or during a restorative proctocolectomy.ConclusionsThis study suggested the feasibility and safety of the total laparoscopic approach IPAA. Total laparoscopic approach could become the best approach for IPAA. Prior colectomy does not modify the result of this demanding surgical procedure.

Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a case-matched study of 180 patients

BACKGROUNDnBecause it has been suggested that obese patients may be at higher risk of morbidity and mortality after surgery, we conducted a prospective case-matched study to compare outcomes of elective laparoscopic colorectal surgery in obese and nonobese patients.nnnMETHODSnSixty-two consecutive nonselected obese patients (body mass index > or =30 kg/m(2)) were matched with 118 nonobese patients. Postsurgical mortality and morbidity were defined as in-hospital death and complications.nnnRESULTSnCardiopulmonary comorbidities were significantly more frequent in obese compared with nonobese patients (44% vs 24%, P < .01). Obesity was significantly associated with increased mean operating time (268 +/- 74 min vs 232 +/- 59 min, P < .001), and conversion rate (32% vs 14%, P < .01). The mortality rate was nil. The overall postsurgical morbidity rate (31% vs 19%, P = not significant) and mean hospital stay (11 +/- 10 days vs 9 +/- 8 days, P = not significant) were similar in obese and nonobese patients.nnnCONCLUSIONSnThe results of this large case-matched study suggest that laparoscopic approach for colorectal surgery is feasible and safe in obese patients.