Matthieu Faron

Upper digestive tract reconstruction for caustic injuries.

OBJECTIVE The aim of the study was to compare the short- and long-term outcomes of colopharyngoplasty and esophagocoloplasty for caustic injuries of the upper digestive tract. BACKGROUND Simultaneous esophageal and pharyngeal reconstruction by colopharyngoplasty allows regaining nutritional autonomy in patients with severe pharyngoesophageal caustic injuries. METHODS Patients who underwent upper digestive tract reconstruction for caustic injuries by colopharyngoplasty (n = 116) and esophagocoloplasty (n = 122) between 1993 and 2012 were included. Survival and functional outcomes were analyzed. Success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Quality of life was assessed using the QLQ-OG25 and SF12v2 questionnaires. RESULTS Overall Kaplan-Meyer survival at 1, 5, and 10 years after colopharyngoplasty and esophagocoloplasty were 92%, 74%, 67% and 92%, 83%, 73%, respectively (P = 0.56). Quality of life and functional results (success: 57% vs 95%, P < 0.0001) were impaired after colopharyngoplasty. On multivariate analysis, older age (odds ratio [OR]: 0.94; confidence interval [CI]: 0.91-0.97 P < 0.0001) and pharyngeal reconstruction (OR: 0.05; CI: 0.02-0.13, P < 0.0001) were associated with failure. The decline in success with age was more pronounced after colopharyngoplasty with only 1 (7%) of 15 patients operated after the age of 55 being self-sufficient for eating and breathing. Laryngeal resection during colopharyngoplasty had no influence on success (54% vs 58%, P = 0.67) CONCLUSIONS:: The need to associate pharyngeal reconstruction during esophageal reconstruction for caustic injuries has a long-term negative impact on functional outcome.

Similar Outcomes After Primary and Secondary Esophagocoloplasty for Caustic Injuries

BACKGROUND The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce. METHODS The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty. RESULTS Operative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001). CONCLUSIONS Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.

How to Avoid Nontherapeutic Laparotomy in Patients With Multiple Organ Failure of Unknown Origin. The Role of CT Scan Revisited

Diagnosis of intra-abdominal diseases in critically ill patients remains a clinical challenge. Physical examination is unreliable whereas exploratory laparotomy may aggravate patients condition and delay further evaluation. Only a few studies have investigated the place of computed tomography (CT) on this hazardous situation. We aimed to evaluate the ability of CT to prevent unnecessary laparotomy during the management of critically ill patients. Charts of all consecutive patients who had undergone an emergency nontherapeutic laparotomy from 1996 to 2013 were retrospectively studied and patients demographic, clinical characteristics, and surgical findings were collected. During this period 59 patients had an unnecessary laparotomy. Fifty-one patients had at least one preoperative imaging and 36 had a CT scan. CT scans were interpreted to be normal (n = 12), with minor anomalies (n = 10), or major anomalies (pneumoperitoneum, portal venous gas/pneumatosis intestinalis, thickened gallbladder wall, and small bowel obstruction signs). Surgical exploration was performed through laparotomy (n = 55) or laparoscopy. Overall mortality was 37% with a median survival after surgery of 7 days. In univariate analysis, hospitalization in ICU before surgical exploration was the only factor related to death. In our series CT scans, objectively interpreted, helped avoid unnecessary surgical exploration in 61% of our patients.

Peritoneal Metastases from Colorectal Cancer: Treatment Principles and Perspectives

Peritoneal metastases are the third most common site of recurrence of colorectal cancer. Diagnosis is difficult and often made at an advanced stage even on imaging. Curative treatment relies on complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), which dramatically improves survival in selected patients. Main prognostic factors are based on the extent of the peritoneal disease and the completeness of surgery. Therefore, identifying patients at high risk of developing peritoneal metastases with the aim of diagnosing and treating patients at an early stage appears crucial. Proactive attitude and prophylactic treatment based on HIPEC are being evaluated on clinical trials.

Le syndrome d’Amyand : une présentation rare de l’appendicite

Introduction La hernie d’Amyand (HA) correspond a un appendice contenu dans un sac herniaire inguinal, souvent droit. L’âge des patients peut varier entre 3 semaines et 92 ans. Son incidence dans la litterature est tres variable (0,2–1,7 %) et la presence d’une appendicite aigue associee est extremement rare (0,07–0,13 %). La mortalite varie de 5 a 30 % en rapport avec une peritonite grave secondaire a une perforation appendiculaire. Objectif Evaluer la prevalence et les caracteristiques cliniques des patients operes d’une HA en urgence ces 20 dernieres annees. Methodes Etude retrospective sur 1 866 patients operes d’une appendicite aigue entre 1994 et 2013. Resultats 5 patients ont ete operes d’une HA soit une prevalence de 0,2 % et 4,2 % parmi les patients âges de > 64 ans. L’âge moyen etait de 82 ans (75–89). La chirurgie a souvent ete retardee avec un delai moyen de 6 jours (3–15) apres le debut des symptomes. Dans cette serie le diagnostic a pu etre fait en preoperatoire par un scanner (4) ou une echographie. 3 patients (60 %) avaient une appendicite compliquee. La duree mediane de sejour etait de 7 jours (5–10 jours). Un patient a presente une complication postoperatoire (abces de paroi). Il n’y a eu aucun deces dans cette serie. Conclusion L’appendicite comme complication d’une hernie d’Amyand est une pathologie exceptionnelle. Dans notre serie les appendicites associees a une HA etaient frequemment compliquees et survenaient a un âge avance.

Fermeture d’iléostomie et ressection hépatique simultanée : résultats d’une étude cas-témoin

Introduction La fermeture d’une ileostomie (FI) protegeant une anastomose colo-rectale basse ou colo-anale peut etre associee a la resection hepatique (RH) necessaire pour traitement secondaire de metastases hepatiques (MH) d’un cancer colo-rectal reseque. L’association d’une anastomose digestive a la RH est susceptible d’en majorer la morbidite, sans que ceci n’ait ete a ce jour bien evalue. Cette etude a analyse l’impact eventuel de la FI simultanee sur la morbidite des RH pour MH. Patients et methodes De 1996 a 2012, 408 patients ont beneficie d’une RH pour MH. Les 24 patients (6 %) ayant eu une RH associee a une FI (groupe RH + FI), effectuee avant l’hepatectomie, ont ete apparies un a un avec 3 patients operes d’une RH seule (groupe RH de 72 patients) sur les 3 criteres suivants : type de RH, realisation d’une chimiotherapie preoperatoire et la realisation de ≥ 6 cycles avant l’hepatectomie. Resultats Les deux groupes etaient comparables pour l’âge, le sexe, le score ASA, les taux de MH multiples, de MH bilaterales. Un seul patient est decede (groupe RH) en postoperatoire (1 %). L’usage du clampage pediculaire et sa duree, les taux de complications hepatiques et de morbidite globale et Clavien 3–5 etaient comparables dans les deux groupes. Aucun patient n’a developpe de fistule anastomotique sur le site de la FI. Conclusion La FI peut etre realisee simultanement a la RH et ne semble pas en majorer sa morbidite.