Françoise Guillon

One hundred laparoscopic choledochotomies with primary closure of the common bile duct.

Background: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. Methods: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). Results: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1–26). No patient required additional CBD procedures during follow-up. Conclusions: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.

Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness.

OBJECTIVE This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients. METHOD From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction. RESULTS Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR. CONCLUSIONS The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. BRIEF SUMMARY In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.

Anti-tnf Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort

Objective: To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). Summary Background Data: The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. Methods: From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. Results: Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17–3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32–17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54–4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13–3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04–4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22–4.04, P = 0.009). Conclusions: Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Prise en charge des complications infectieuses ou érosives des prothèses de rectopéxie ventrale par promontofixation laproscopique

But L’objectif de cette etude etait d’analyser la prise en charge diagnostique et therapeutique de l’infection et de l’erosion de prothese de rectopexie et d’en evaluer l’impact sur les resultats fonctionnels. Patients et methodes Il s’agit d’une etude retrospective, descriptive, monocentrique entre 2004 et 2012. Sur 320 procedures, 7 patientes, âge moyen 61 ans, avaient une erosion ou une infection de la prothese de rectopexie. Etaient etudies, la symptomatologie, la prise en charge de cette complication et les resultats sur la symptomatologie fonctionnelle. Resultats Le delai moyen de diagnostic de prothese infectee ou erosive etait de 31 mois (extremes 3 a 62). Les principales manifestations cliniques etaient une ulceration muqueuse (71 %), les ecoulements purulents ou sero-sanglants (57 %) et les douleurs (43 %). 100 % des patientes ont necessite le retrait chirurgical de la prothese, cinq par laparoscopie et deux par voie transanale. Aucune patiente n’a eu de stomie de protection. Les patientes etaient asymptomatiques 3 mois apres le retrait de la prothese. Une patiente a presente une recidive de constipation terminale et l’apparition d’une incontinence anale, une autre une aggravation d’incontinence anale. Conclusion Le traitement des symptomes d’une prothese de RVPL erosive ou infecte est le retrait chirurgical du materiel prothetique par laparoscopie ou voie trans-anale. Une stomie de protection ne doit pas etre realise systematiquement. La recidive de la symptomatologie fonctionnelle n’est pas systematique.