Patrice Valleur

Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients.

The aim of this study was to determine by univariate and multivariate analyses the factors associated with clinically significant anastomotic leakage (AL) after large bowel resection. From 1990 to 1997 a series of 707 patients underwent colonic or rectal resection (without a stoma). Patients were divided into two groups: those with clinical anastomotic leakage (group 1) and those without it (group 2). AL occurred in 43 of 707 patients (6%). The overall mortality was 2.2% and was significantly higher in patients with AL than in those without: 5 of 43 (12%) versus 11 of 664 (1.6%), p <0.001. Univariate analysis showed 15 variables associated with the risk of AL: previous abdominal or pelvic irradiation (p = 0.02), American Society of Anesthesiologists (ASA) score > 2 (p = 0.04), leukocytosis (p = 0.02), renal failure (p = 0.03), steroid treatment (p = 0.01), duration of operation (p = 0.001), intraoperative septic conditions (p = 0.006), total colectomy (p = 0.009), transverse colectomy (p = 0.02), difficulties encountered during anastomosis (p = 0.001), ileorectal anastomosis (p = 0.02), colocolic anastomosis (p = 0.01), abdominal drainage (p = 0.05), and blood transfusion intraoperatively (p = 0.006) and postoperatively (p = 0.001). Multivariate analysis showed that only preoperative leukocytosis (p = 0.04), intraoperative septic conditions (p = 0.001), difficulties encountered during anastomosis (p = 0.007), colocolic anastomosis (p = 0.004), and postoperative blood transfusion (p = 0.0007) were independent factors associated with AL. The risk of AL increased from a range of 12% to 30% if one risk factor was present, to 38% with two factors, to 50% with three factors. After colorectal resection and intraperitoneal anastomosis, a temporary protective stoma is proposed in selected patients with high risk factors for AL, as observed in our study.

Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial

BACKGROUND Researchers have suggested that antibiotics could cure acute appendicitis. We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis. METHODS In this open-label, non-inferiority, randomised trial, adult patients (aged 18-68 years) with uncomplicated acute appendicitis, as assessed by CT scan, were enrolled at six university hospitals in France. A computer-generated randomisation sequence was used to allocate patients randomly in a 1:1 ratio to receive amoxicillin plus clavulanic acid (3 g per day) for 8-15 days or emergency appendicectomy. The primary endpoint was occurrence of postintervention peritonitis within 30 days of treatment initiation. Non-inferiority was shown if the upper limit of the two-sided 95% CI for the difference in rates was lower than 10 percentage points. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT00135603. FINDINGS Of 243 patients randomised, 123 were allocated to the antibiotic group and 120 to the appendicectomy group. Four were excluded from analysis because of early dropout before receiving the intervention, leaving 239 (antibiotic group, 120; appendicectomy group, 119) patients for intention-to-treat analysis. 30-day postintervention peritonitis was significantly more frequent in the antibiotic group (8%, n=9) than in the appendicectomy group (2%, n=2; treatment difference 5·8; 95% CI 0·3-12·1). In the appendicectomy group, despite CT-scan assessment, 21 (18%) of 119 patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis. In the antibiotic group, 14 (12% [7·1-18·6]) of 120 underwent an appendicectomy during the first 30 days and 30 (29% [21·4-38·9]) of 102 underwent appendicectomy between 1 month and 1 year, 26 of whom had acute appendicitis (recurrence rate 26%; 18·0-34·7). INTERPRETATION Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis. Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment. FUNDING French Ministry of Health, Programme Hospitalier de Recherche Clinique 2002.

Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity.

Complications that might lead to surgery in severe attacks of ulcerative colitis have been found to be correlated with the depth of colonic ulcerations as measured by pathological examination of colectomy specimens. In order to evaluate the value of colonoscopy for the assessment of colonic ulcerations, we have reviewed the clinical, biological, colonoscopic, and anatomical findings in 85 consecutive patients with attacks of ulcerative colitis involving at least the rectosigmoid and part of the descending colon, seen in our center between 1981 and 1989. All had colonoscopy performed by a senior endoscopist at entry. Extensive deep colonic ulcerations were diagnosed in 46 of them, and moderate endoscopic colitis in 39. No complication related to colonoscopy occurred except for one colonic dilatation. Forty-three of the 46 patients with severe endoscopic colitis were operated upon: 38 of them failed to improve with high-dose corticosteroids and five had a toxic megacolon. Extensive ulcerations reaching at least the circular muscle layer were found at pathological examination of colectomy specimen in 42 of the 43 patients. Conversely, 30 of 39 patients with moderate endoscopic colitis went into clinical remission with medical treatment, and only nine patients needed further surgery because of medical treatment failure. Six of these nine patients underwent another colonoscopy prior to colectomy, and all six showed features of severe endoscopic colitis. Deep ulcerations reaching the circular muscle layer were found at pathological examination in five of these six patients and in one additional patient whose colonoscopy had been performed 21 days before colectomy. We conclude that, in expert hands, colonoscopy is safe and accurately selects patients with high risk of surgical complications who need early surgery in case of failure of medical treatment.

Impact of obesity on surgical outcomes after colorectal resection.

BACKGROUND As the impact of obesity on surgical outcomes after colorectal resection is not well known, this study was designed to compare the results of colorectal resection in obese and nonobese patients. METHODS From 1990 to 1997, 584 consecutive patients underwent elective colorectal resection in our department. Of these, 158 (27%) were obese (body mass index >27). Obese and nonobese patients were well matched for demographic data and surgical procedures. RESULTS After right or left colectomy, no difference was noted between obese and nonobese patients for overall mortality, morbidity, or leakage rates. However, after left colectomy, postoperative intra-abdominal collections requiring treatment were significantly more frequent in obese than in nonobese patients (10% versus 2%; P <0.05). After proctectomy, the mortality rate was 5% (3 of 61) among obese patients and 0.5% (1 of 185) among nonobese patients (P <0.02). The anastomotic leakage rate was 16% (5 of 58) for obese patients and 6% (11 of 169) for nonobese patients (P <0. 05), and the corresponding proportions of transfused patients were 43% and 19%, respectively (P <0.02). After proctectomy, multivariate analysis showed that for obese patients, diabetes mellitus (P <0.05) and American Society of Anesthesiologists (ASA) status >2 (P <0.05) were significant risk factors for anastomotic leakage; age >60 years (P <0.01) and ASA status >2 (P <0.05) were significant risk factors for perioperative blood transfusions. CONCLUSIONS Our study suggested that, for obese patients, (1) right colectomy can be performed in the same manner as for nonobese patients; (2) after left colectomy, abdominal drainage may be indicated, and (3) after proctectomy, a defunctioning stoma should be recommended when diabetes mellitus or ASA status >2 is present, and an autologous blood transfusion could be discussed for patients >60 years old or with ASA status >2.

Ileal pouch/anal anastomosis for Crohn's disease.

BACKGROUND Patients with Crohns disease (CD) are not commonly considered as candidates for ileal pouch/anal anastomosis (IPAA). This approach has been avoided because of the poor results observed, retrospectively, in patients with an initial diagnosis of ulcerative colitis who were found to have CD on examination of the resected specimen. However, in 1985, we decided to investigate an alternative to coloproctectomy with definitive end-ileostomy by a prospective study of IPAA for selected patients with CD. METHODS Between 1985 and 1992, 31 patients with CD, but with no evidence of anoperineal or small-bowel disease, were recruited to our study. They comprised 15 men and 16 women whose mean age was 36 years (SD 14; range 16-72). All CD patients underwent IPAA. The short-term and long-term functional results of this procedure were compared with those of 71 ulcerative colitis patients who also underwent IPAA during the same period in our unit. Mean follow-up was 59 (SD 25) months. FINDINGS No significant differences were observed between patients with CD and ulcerative colitis in the postoperative complication rate. Of the 31 CD patients, six (19%) experienced specific complications 9 months to 6 years after surgery: three had pouch-perineal fistulas, which required pouch excision in two cases; one had a pouch-vaginal fistula that was treated by gracilis muscle interposition; and one had an extrasphincteric abscess, which was treated surgically. Two patients (6%), one of whom was treated for an extrasphincteric abscess, experienced CD recurrence on the reservoir, and were treated successfully with azathioprine. At 5-year follow-up, there were no significant differences between patients with CD and ulcerative colitis in stool frequency (5.0 [2.0] vs 4.7 [1.4] per day; p=0.68), continence, gas/stool discrimination, leak or need for protective pads, and sexual activity. INTERPRETATION Our results show that in selected cases of CD without anoperineal or small-bowel manifestations, IPPA can be recommended as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential.

Management of anastomotic leakage after nondiverted large bowel resection

BACKGROUND The purpose of this study was to determine the natural history of anastomotic leakage after elective colorectal resection and supraperitoneal anastomosis without temporary stoma. STUDY DESIGN Medical records from 1990 to 1997 were studied; 655 consecutive patients underwent colonic or rectal resection (without stoma). Patients were divided into two groups: those with clinical anastomotic leakage confirmed by laparotomy (group 1) and those without anastomotic leakage (group 2). Postoperative clinical and biologic findings were compared between the two groups. RESULTS Anastomotic leakage occurred in 39 of 655 patients (6%). Clinically suspected anastomotic leakage was only confirmed by contrast radiography in 13 of 24 patients (54%), and by CT in 8 of 9 patients (89%). Significantly more patients in group 1 than group 2 had the following: fever (> 38 degrees C) on day 2 (p < 0.001); absence of bowel action on day 4 (p < 0.001); diarrhea before day 7 (p < 0.001); collection of more than 400 mL of fluid through abdominal drains from day 0 to day 3 (p < 0.01); renal failure on day 3 (p < 0.02); and leukocytosis after day 7 (p < 0.02). Among the 39 patients in group 1, 28 (71%) had at least one of these clinical or biologic manifestations before day 5, but the mean delay for reoperation was only 8 days. The combination of signs observed before day 5 was associated with an increased risk of anastomotic leakage, from 18% with two signs to 67% with three signs. Overall mortality rate was 2% (13 of 655) and was significantly higher in group 1 than group 2: 5 of 39 (13%) versus 8 of 616 (1%, p < 0.001). In patients with anastomotic leakage, death occurred in 5 of 23 patients (22%) reoperated on after day 5, versus 0 of 11 patients (0%) reoperated on before day 5 (NS). Univariate analysis showed that three clinical characteristics were associated with a significantly high risk of mortality after reoperation for anastomotic leakage: age greater than 65 years (p < 0.01), American Anesthesiologist Association score greater than 3 (p < 0.05), and blood transfusions during the first operation (p < 0.02). CONCLUSIONS In our study, some postoperative clinical and biologic signs were associated with a higher risk of anastomotic leakage. The knowledge of these findings might help in the early diagnosis and management of patients with anastomotic leakage after large bowel resection.

Long-term results of ileal pouch-anal anastomosis for colorectal Crohn's disease

INTRODUCTION: The aim of this study is to report ten-year results of ileal pouch-anal anastomosis in selected patients with colorectal Crohns disease for whom coloproctectomy and definitive end ileostomy was the only alternative. METHODS: 41 patients (22 females/19 males) with a mean age of 36 ± 13 (range, 16–72) years underwent ileal pouch-anal anastomosis for colorectal Crohns disease between 1985 to 1998. None had past or present history of anal manifestations or evidence of small-bowel involvement. Diagnosis of Crohns disease was established preoperatively in 26 patients, on the resected specimen after ileal pouch-anal anastomosis, or after occurrence of Crohns disease-related complication in 15 patients. RESULTS: Follow-up was 113 ± 37 months, (18–174) 20 patients having been followed for more than 10 years. There was no postoperative death. Eleven (27 percent) patients experienced Crohns disease-related complications, 47 ± 34 months (8–101) after ileal pouch-anal anastomosis: 2 had persistent anal ulcerations with pouchitis and granulomas on pouch biopsy and were treated medically; 2 experienced extrasphincteric abscesses and 7 presented pouch-perineal fistulas which were treated surgically. Among them, 3 patients with persistent perineal fistula despite surgery required definitive end-ileostomy. Of the 20 patients followed for more than 10 years, 7 (35 percent) experienced Crohns disease-related complications which required pouch excision in 2 (10 percent). CONCLUSIONS: Ten years after ileal pouch-anal anastomosis for colorectal Crohns disease, rates of Crohns disease-related complications and pouch excision were 35 and 10 percent, respectively. These good long-term results justify for us to propose ileal pouch-anal anastomosis in selected patients with colorectal Crohns disease (i.e., no past or present history of anal manifestations and no evidence of small-bowel involvement) for whom the only alternative is definitive end ileostomy.

The diagnostic value of fine-needle aspiration biopsy under ultrasonography in nonfunctional thyroid nodules: A prospective study comparing cytologic and histologic findings

Fine-needle aspiration biopsy (FNAB) of thyroid nodules has been proposed as a preoperative screening method to reduce the number of patients with benign nodules referred for surgery. Only a few previously published studies have compared cytologic results with a systematic surgical control; furthermore, the role of ultrasound guidance for FNAB in obtaining representative material has been poorly evaluated. The authors tried to assess the diagnostic value of FNAB performed under ultrasonography in a series of patients with a cold nodule and a systematic surgical control. This prospective study included 132 consecutive patients, 19 men and 113 women, aged from 18 to 82 years. The rate of carcinomas was 13.8%. A very high rate of adequate material was obtained (96.2%). Sensitivity, specificity, and global accuracy were 95%, 87.7%, and 89%, respectively. These results, which are equivalent to those previously published but associated with a low level of insufficient material, emphasize the diagnostic value of thyroid FNAB.

Segmental Reversal of the Small Bowel as an Alternative to Intestinal Transplantation in Patients With-short Bowel Syndrome

OBJECTIVE This article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome. SUMMARY BACKGROUND DATA Segmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition. METHODS Eight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy. RESULTS There were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 years and in 3 of 3 patients at 4 years. CONCLUSION Segmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of parenteral nutrition-related complications, because weaning for parenteral nutrition (four patients) or reduction of the frequency of infusions (four patients) was observed in the current study.

Identifying patients with T3-T4 node-negative colon cancer at high risk of recurrence

PURPOSE: Adjuvant chemotherapy is effective for node-positive colon cancer patients. In node-negative patients, it could be justified in high-risk patients. The purpose of this study was to determine clinical and pathological findings associated with tumor recurrence in T3-T4 node-negative colon cancer patients. METHODS: From 1974 to 1993, 108 patients undergoing colectomy for T3-4N0M0 colon cancer, without adjuvant chemotherapy, followed until death or for a minimum of five years, were divided into two groups: patients without recurrence (n=74) and those dead from colon cancer or alive with recurrence (n=34). Thirty-three clinical and pathological findings were studied. RESULTS: In univariate analysis, the following were significantly associated with a high risk of tumor recurrence: male patients (P=0.006), bowel obstruction (P<0.001), weight loss >5 Kg (P=0.03), circumferential tumor (P=0.02), macroscopic or microscopic pericolic organ invasion (T4 stage;P<0.001), perineural invasion (P=0.02), vascular invasion (P=0.045), poor tumor differentiation (P=0.005), mesocolic invasion>1cm (P=0.009), less than 14 uninvolved nodes on the specimen (P=0.03), and visceral peritoneal invasion (T4;P<0.001). In multivariate analysis, the following were independent prognostic factors of recurrence: male patients (P=0.005), bowel obstruction (P=0.002), pericolic organ invasion (i.e., T4 tumor;P=0.02), and less than 14 uninvolved nodes on a specimen (P=0.01). On the other hand, preoperative carcinoembryonic antigen serum level, size and tumor location, blood transfusion, and mucin production were not associated with higher risk of tumor recurrence. CONCLUSION: Our study identifies a subgroup of patients with node-negative colon cancer at high risk of recurrence, who could be included in priority trials of adjuvant chemotherapy.