Léon Maggiori

Mortality after colorectal cancer surgery: a French survey of more than 84,000 patients.

Objectives:This study aimed to identify risk factors of postoperative 30-day mortality (POM) after colorectal cancer resection. Summary:Meta-analyses have failed to demonstrate any significant benefit of laparoscopy in terms of postoperative mortality. This could be explained by the lack of a large sample size. Methods:All patients who underwent colorectal resection for cancer between 2006 and 2008 in France were included. Data were extracted from the French National Health Service Database. A multivariate analysis evaluating risk factors for POM was performed including the following factors: age, gender, tumor location, associated comorbidities, emergency surgery, synchronous liver metastasis, malnutrition, and surgical approach. Results:During the 3-year period, a total of 84,524 colorectal resections for colorectal cancer were performed: 22,359 through laparoscopy (26%) and 62,165 through laparotomy (74%). From 2006 to 2008, laparoscopic approach rate increased from 23% to 29% (P < 0.001). POM was 5.0%: 2% after laparoscopy and 6% after laparotomy (P < 0.001). In multivariate analysis, 7 independent factors were significantly associated with a higher POM: age 70 years or more [P < 0.001, odds ratio (OR): 3.28; (3.00–3.59)], respiratory comorbidity [P < 0.001, OR: 3.16; (2.91–3.37)], vascular comorbidity [P < 0.001, OR: 2.66; (2.48–2.85)], neurologic comorbidity [P < 0.001, OR: 1.78; (1.51–2.09)], emergency surgery [P < 0.001, OR: 2.68; (2.48–2.90)], synchronous liver metastasis [P < 0.001, OR: 2.63; (2.41–2.86)], and preoperative malnutrition [OR: 1.33; (1.19–1.50)]. Laparoscopic surgery [P < 0.001, OR: 0.59; (0.54–0.65)] was independently associated with a significant decreased POM. Conclusions:This all-inclusive national study showed that POM after colorectal cancer surgery is significantly reduced in case of age less than 70 years, elective surgery, and absence of synchronous liver metastasis, malnutrition, respiratory, neurologic, or vascular comorbidity. Furthermore, it is suggested that a laparoscopic surgery is independently associated with a decreased POM. This result, observed at a national level, must be considered when choosing the best surgical approach for colorectal cancer treatment.

A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: a 2-center study.

Objective: To assess the infertility rate after laparoscopic ileal pouch-anal anastomosis (IPAA). Background: Total proctocolectomy with IPAA is known to be associated with postoperative infertility in open surgery, which may be caused by pelvic adhesions affecting the fallopian tubes. However, fertility after laparoscopic IPAA has never been assessed. Methods: All patients who underwent a total laparoscopic IPAA between 2000 and 2011 and were aged 45 years or less at the time of operation and 18 years or more at the time of data collection were included. The patients answered a fertility questionnaire by telephone. All demographic and perioperative data were prospectively collected. The results were compared with those of controls undergoing laparoscopic appendectomy. Results: Sixty-three patients were included. The mean age at the time of surgery was 31 ± 9 years (range 14–44). IPAA was performed for ulcerative colitis in 73% of the cases and familial adenomatous polyposis in 17%. The mean follow-up after IPAA was 68 ± 33 months (range 6–136). Fifty-six patients answered the questionnaire (89%). Half of them already had a child before IPAA. Fifteen patients attempted pregnancy after IPAA, of which 11 (73%) were able to conceive, resulting in 10 ongoing pregnancies and 1 miscarriage. The global infertility rate was 27%. There was no difference in fertility over time compared with the 14 controls who attempted pregnancy during the same period (90% vs 86% at 36 months, P = 0.397). Conclusions: The infertility rate appears to be lower after laparoscopic IPAA than after open surgery.

Single-incision laparoscopy for colorectal resection: a systematic review and meta-analysis of more than a thousand procedures

Aim  Single‐incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single‐incision laparoscopic surgery was assessed, including the patient outcomes.

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.

Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer.

Aim  Anastomotic leakage (AL) after sphincter‐saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL‐complicating SSR.

Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?

Aim  A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter‐saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life.

Redo surgery for failed colorectal or coloanal anastomosis: A valuable surgical challenge

BACKGROUND Redo surgery (RS) in patients with failed anastomosis is a rare procedure, and data about this surgery are lacking. The aim of this study was to examine the operative results and long-term outcomes of RS. METHODS All patients who underwent RS between 1999 and 2008 were included. Data were analyzed from a prospective colorectal database. Failure of the procedure was defined as the inability to perform the RS or the inability to close the defunctioning stoma. RESULTS Thirty-three patients (22 men) underwent the first surgery at a mean age of 53.4 years. Twenty-four had a colorectal anastomosis (CRA) and nine a coloanal anastomosis (CAA). The reasons for performing RS were stricture (n = 17), prior Hartmann procedure for complication on initial anastomosis (n = 6), chronic fistula (n = 5) or miscellaneous (n = 5). RS was impossible for 2 patients due to extensive adhesions. The mean operating time was 279 min (133-480) and the overall postoperative morbidity rate was 55%. The rate of anastomotic leakage and/or isolated pelvic abscess was 27%. After a mean delay of 3.9 months (0.3-16), 26 patients (79%) had a stoma closure. The mean number of stools per day was 3.2. The failure rates after new handsewn CAA and new stapled CRA were 33% (4/12) and 5% (1/19), respectively (P = .0385). The type of the former anastomosis influenced the success rate of restoring the intestinal continuity: failure rate after prior CAA was 56% and 8% after prior CRA (P = .0031). CONCLUSION Redo surgery for failure of previous CRA or CAA is feasible but requires a demanding surgical procedure with high short-term morbidity.

Segmental reversal of the small bowel can end permanent parenteral nutrition dependency: an experience of 38 adults with short bowel syndrome.

Objective:This study aimed to assess the results of segmental reversal of the small bowel (SRSB) in patients with short bowel syndrome (SBS) who were “permanently” dependent on parenteral nutrition (PN) and to identify possible prognostic factors for weaning. Summary Background Data:SRSB is a nontransplant surgical option for patients with SBS who require long-term PN. Few studies have reported outcomes in humans. Methods:All patients who were permanently dependent on PN and underwent a SRSB between 1985 and 2010 for SBS were included. The data were retrospectively retrieved. Results:Thirty-eight patients underwent SRSB. The median age was 55.5 years (range, 18–76). The median length of the small bowel remnant was 49 cm (20–140), including a reversed segment of 10 cm (6–15). The median follow-up was 57.7 months (1–304). At the 5-year follow-up, 17 patients had been weaned from PN (45%). In the remaining patients, PN dependency had decreased from 7 ± 1 to 4 ± 1 days per week. The survival rate was 84%. The prognostic factors for weaning were a short time between subtotal enterectomy and SRSB (P = 0.036), a longer than typical stay in the nutrition unit (P = 0.035), and an SRSB longer than 10 cm (P = 0.024). Conclusions:SRSB has a role as a conservative alternative to small bowel transplantation in patients with SBS permanently dependent on PN. With a segmental reversal of 10 to 12 cm, almost half of the patients can be expected to be weaned from PN.

Selective portal vein ligation and embolization induce different tumoral responses in the rat liver

BACKGROUND Portal vein ligation (PVL) and portal vein embolization (PVE) are used to enhance liver volume before hepatectomy for colorectal liver metastasis (LM). Impact of such techniques on tumor growth is not well known. This experimental study aimed to assess impact of PVE and PVL on LM growth in a murine model of colorectal LM. METHODS Single macroscopic tumor was induced by injection of 0.5 × 10(6) DHD/K12 cells under the liver capsule of BDIX rats at day 0. Multiple microscopic tumors were obtained by intra-portal injection of 1 × 10(6) cells at day 7. At day 8, rats were divided in 3 groups: PVE group (selective 70% PVE), PVL group (selective 70% PVL); control group (sham laparotomy). Rats were sacrificed at day 37 (11 in PVE, 12 in PVL, and 10 rats in control groups). Liver volume and LM volumes were assessed. RESULTS Nonoccluded liver volume was larger in the PVE and PVL groups vs control group (P < .0001 and P < .0001, respectively) but showed no difference in PVE vs PVL groups (P = .08). LM volume in the occluded liver was smaller in the PVE vs control groups (P = .006) and larger in the PVL vs control groups (P = .001). LM volume in the nonoccluded liver was larger in the PVE and PVL groups vs control group (P = .010 and P = .010, respectively) but showed no difference in PVE vs PVL groups (P= .878). CONCLUSION Both PVL and PVE modify tumor growth, especially in nonoccluded lobe. These results could be of clinical importance in humans where both techniques are widely used.

Surgical management of IBD—from an open to a laparoscopic approach

Surgery is a key feature of IBD management. Up to 70% of patients with Crohns disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohns disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.