Benjamin Menahem

Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.

OBJECTIVE To review prospective randomized controlled trials to determine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is associated with lower risks of mortality and pancreatic fistula after pancreaticoduodenectomy (PD). BACKGROUND Previous studies comparing reconstruction by PG and PJ reported conflicting results regarding the relative risks of mortality and pancreatic fistula after these procedures. METHODS MEDLINE, the Cochrane Trials Register, and EMBASE were searched for prospective randomized controlled trials comparing PG and PJ after PD, published up to November 2013. Meta-analysis was performed using Review Manager 5.0. RESULTS Seven trials were selected, including 562 patients who underwent PG and 559 who underwent PJ. The pancreatic fistula rate was significantly lower in the PG group than in the PJ group (63/562, 11.2% vs 84/559, 18.7%; odds ratio = 0.53; 95% confidence interval, 0.38-0.75; P = 0.0003). The overall mortality rate was 3.7% (18/489) in the PG group and 3.9% (19/487) in the PJ group (P = 0.68). The biliary fistula rate was significantly lower in the PG group than in the PJ group (8/400, 2.0% vs 19/392, 4.8%; odds ratio = 0.42; 95% confidence interval, 0.18-0.93; P = 0.03). CONCLUSIONS In PD, reconstruction by PG is associated with lower postoperative pancreatic and biliary fistula rates.

Liver transplantation versus liver resection for hepatocellular carcinoma in intention to treat: An attempt to perform an ideal meta‐analysis

This meta‐analysis compared the effects of liver transplantation (LT) and liver resection (LR) on overall survival (OS) and disease‐free survival (DFS) in patients with hepatocellular carcinoma (HCC) small transplantable HCC or within Milan criteria. Articles comparing LR with LT for HCC, based on Milan criteria or small size, published up to June 2015 were selected, and a meta‐analysis was performed. No randomized controlled trial has been published to date comparing survival outcomes in patients with HCC who underwent LR and LT. Nine studies were identified, including 570 patients who underwent LR and 861 who underwent LT. For HCC within the Milan criteria, the 1‐year OS rates following LR and LT were 84.5% (473/560) and 84.4% (710/841), respectively (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.71‐1.33; P = 0.8), and the 5‐year OS rates were 47.9% (273/570) and 59.3% (509/858), respectively (OR, 0.60; 95% CI, 0.35‐1.02; P = 0.06). One‐year DFS rates were similar (OR, 1.00; 95% CI, 0.39‐2.61; P = 1.00), whereas the 3‐year DFS rate was significantly lower in the LR group (54.4%, 210/386) than in the LT group (74.2%, 317/427; OR, 0.24; 95% CI, 0.07‐0.80; P = 0.02), and the 5‐year DFS rate was significantly lower for LR than LT (OR, 0.18; 95% CI, 0.06‐0.53; P < 0.01). For small HCCs, the 5‐year OS rate was significantly lower for patients who underwent LR than LT (OR, 0.30; 95% CI, 0.19‐0.48; P < 0.001). In conclusion, relative to LR, LT in patients with HCC meeting the Milan criteria had no benefits before 10 years for OS. For DFS, the benefit is obtained after 3 years. Liver Transplantation 23 836–844 2017 AASLD.

Transjugular intrahepatic portosystemic shunt placement increases feasibility of colorectal surgery in cirrhotic patients with severe portal hypertension

BACKGROUND Colorectal resection in cirrhotic patients is associated with high mortality and morbidity related to portal hypertension and liver insufficiency. METHODS This retrospective study evaluated the clinical outcomes of cirrhotic patients who underwent transjugular intrahepatic porto-systemic shunt (TIPS) placement before colorectal resection for cancer. Main outcomes measures were postoperative morbidity and mortality rates. RESULTS TIPS placement was successful in all eight patients and significantly decreased the mean hepatic venous pressure gradient from 15.5 ± 2.9 to 7.5 ± 1.9 mmHg (p = 0.02). Surgical procedures included right colectomy (n = 3), left colectomy (n = 2), and proctectomy with total mesorectal excision (n=3). Post-operatively, two patients (25%) died of multiple organ failure. The overall postoperative morbidity rate was 75%, and major complications were seen in 25%. CONCLUSION Portal decompression via TIPS placement may enable selected cirrhotic patients with severe portal hypertension to undergo colorectal resection for cancer.

Delayed laparoscopic cholecystectomy increases the total hospital stay compared to an early laparoscopic cholecystectomy after acute cholecystitis: an updated meta‐analysis of randomized controlled trials

BACKGROUND The objective of this study was to review the available prospective, randomized, controlled trials to determine whether an early (ELC) or a delayed (DLC) approach to a laparoscopic cholecystectomy is associated with an increase in length of hospitalization after acute cholecystitis. METHODS Medline, the Cochrane Trials Register and EMBASE were searched for prospective, randomized, controlled trials (RCTs) comparing ELC versus DLC, published up to May 2014. A meta-analysis was performed using Review Manager 5.0. RESULTS Nine RCTs were included in a total of 617 who underwent ELC and 603 patients who underwent DLC after acute cholecystitis. The mean hospital stay was 5.4 days in the ELC group and 9.1 days in the DLC group. The meta-analysis showed a mean hospital stay significantly lower in the ELC group [medical doctor (MD) = 3.24, 95% confidence interval (CI) = 1.95-4.54, P < 0.001]. The major biliary duct injury rate in the ELC group was 0.8% (2/247) and 0.9% (2/223) in the DLC group. The meta-analysis showed no significant difference between the ELC and DLC groups [relative risk (RR) =0.96, 95%CI = 0.25-3.73, P = 0.950]. CONCLUSION DLC is associated with a longer total hospital stay but equivalent morbidity as compared to ELC for patients presenting with acute cholecystitis. ELC would appear to be the treatment of choice for patients presenting with ELC.

Effect of bariatric surgery on urinary and fecal incontinence: prospective analysis with 1-year follow-up.

BACKGROUND Few studies have established that obesity promotes all types of urinary incontinence and disorders of the pelvic floor. The role of bariatric surgery in urinary incontinence remains poorly studied. OBJECTIVE To determine the effect of bariatric surgery on urinary incontinence, dysuria, and fecal incontinence before and 1 year after bariatric surgery. SETTING University hospital expert in bariatric surgery METHODS: This was an observational cohort study of 140 patients who underwent bariatric surgery between September 2013 and September 2014. Patients prospectively completed 4 questionnaires, 2 for urinary symptoms and 2 for fecal incontinence. Eighty-three women and 33 men completed 4 questionnaires the day before surgery when arriving in the department and 1 year after surgery. RESULTS Of the 140 patients, 116 completely responded to the 4 questionnaires. The rate of urinary incontinence was 50.9% before surgery and 19% at 1-year follow-up (P<.0001). After bariatric surgery, there was improvement in the rate of stress urinary incontinence: 39.7% before surgery versus 15.5% at 1 year (P<.0001). In addition, there was an improvement in urinary urge incontinence: 36.8% versus 7.9% at 1 year (P<.0001). The dysuria rate was 19.8% before surgery versus 3.4% at 1 year (P<.0001). Bariatric surgery improved the quality of life related to urinary symptoms (P<.0001). One year after surgery, there was no significant difference in terms of prevalence and severity of fecal incontinence. CONCLUSION We confirmed with our study that weight loss after bariatric surgery improves stress urinary incontinence, urge incontinence, dysuria, and quality of life. However, we did not find any positive effect on fecal incontinence.

Emergency surgery for epidural abcess secondary to sacral fistula after laparoscopic proctectomy

A 61-year-old man presented via the emergency department with a few days history of abdominal and colic occlusion symptoms. He presented signs of sepsis, midline lumbar spine tenderness and reduced hip flexion. Computer tomography of the abdomen and pelvis showed a presacral collection contiguous with the posterior part of the colo-rectal anastomosis, and MRI lumbar spine revealed abscess invation into the epidural space. He underwent a laparotomy with washout of the presacral abscess and a colostomy with a prolonged course of intravenous antibiotic therapy. At 3 weeks after initial presentation he had made a full clinical recovery with progressive radiological resolution of the epidural abscess. The objective of the case report is to highlight a unique and clinically significant complication of a rare post-operative complication after rectal surgery and to briefly discuss other intra-abdominal sources of epidural abscess.

The NOTA (Non Operative Treatment for Acute Appendicitis) Study: One Step Beyond or Nearby?

To the Editor: We read with great interest the results of the prospective study on the efficacy and safety of antibiotics for patients presenting with right lower quadrant abdominal pain by Di Saverio et al. This publication addressed the growing tendency of nonoperative management of suspected appendicitis as supported by a recent randomized controlled trial. The authors concluded that if patients’ conditions are correctly addressed to the proper treatment option, starting from correct clinical evaluation, antibiotic therapy for suspected acute appendicitis is safe and effective. However, we respectfully take issue with the authors on several points and the implications of their conclusion.

Reply to Letter: "Pancreatogastrostomy Is Superior to Pancreatojejunostomy for Prevention of Pancreatic Fistula After Pancreaticoduodenectomy".

To the Editor: W ith great interest, we read the article by Menahem and colleagues. The authors conducted an up-to-date metaanalysis of randomized controlled trials comparing pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) for prevention of pancreatic fistula after pancreaticoduodenectomy (PD). They concluded that PG was more efficient than PJ in reducing the incidence of postoperative pancreatic fistula. In view of this, should we draw a conclusion and change the current practice? Yet, this is not always the case. Some important remarks regarding the conclusion have to be made. First, as a meta-analysis of trials comparing 2 surgical procedures, the surgical techniques varied among included trials. Conventional PD, pylorus-preserved PD, and PD with extended resection were performed. Either end-to-end PJ or end-to-side PJ was used. The method of PG was also not standardized among included trials. In addition, the type and thickness of suture material and the method of pancreatic anastomosis were diversified on the basis of the surgeon’s discretion. It is reasonable to speculate that the rates of pancreatic fistulas of each arm may be influenced by the most important confounding factor in the surgical trials, the surgical techniques. Second, the incidence of postoperative pancreatic fistula in the PG group pooled in this meta-analysis is still far from satisfactory (11.2%). On the contrary, new surgical techniques of PJ have been continuously developed to win the battle against postoperative pancreatic fistula, with some of them proven to be very effective. For example, the binding PJ was proven to be an effective and safe technique with encouraging results. Also, isolated Roux loop PJ reduced the incidence of pancreatic fistula and improved the safety of PD by separating PJ from the choledochojejunostomy and gastrojejunostomy. In fact, a recent randomized control trial showed comparable incidences of postoperative