Sébastien Gaujoux

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

Aimu2002 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.

Single-incision laparoscopic colonic surgery

Aimu2002 SILS is an area of growing interest in colorectal surgery. We report our preliminary experience of 13 consecutively selected patients undergoing colonic surgery using SILS.

Effects of a Multimodal Management Strategy for Acute Mesenteric Ischemia on Survival and Intestinal Failure

BACKGROUND & AIMSnAcute mesenteric ischemia (AMI) is an emergency with a high mortality rate; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multimodal management approach, focused on intestinal viability.nnnMETHODSnIn an Intestinal Stroke Center, we developed a multimodal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, nonocclusive AMI, chronic mesenteric ischemia, and other emergencies were excluded. Patients received specific medical management: revascularization of viable small bowel and/or resection of nonviable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients who survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidity. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early or late-stage disease.nnnRESULTSnPatients were followed up for a mean of 497 days (range, 7-2085 d); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P = .03). Among patients with early or late-stage AMI, rates of resection were 18% and 71%, respectively (P = .049). Patients with early stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm; P = .02), and spent less time in intensive care (2.5 vs 49.8; P = .02).nnnCONCLUSIONSnA multidisciplinary and multimodal management approach might increase survival of patients with AMI and prevent intestinal failure.

Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination

OBJECTIVESnPancreaticoduodenectomy (PD) is associated with high morbidity, in part as a result of infectious complications increased by preoperative bile contamination. The aim of the present study was to assess the effect on the incidence of infectious complications of short-term antimicrobial therapy (AMT) in high-risk patients.nnnMETHODSnPatients with a high risk for positive intraoperative bile culture (i.e. those with ampulloma or pancreatic adenocarcinoma with preoperative endoscopic procedures) (high-risk group, n = 99) were compared with low-risk patients (i.e. those with pancreatic adenocarcinoma without preoperative endoscopic procedures) (low-risk group, n = 76). The high-risk group received a 5-day course of perioperative AMT secondarily adapted to the bile antibiogram. The low-risk group received only the usual antimicrobial prophylaxis.nnnRESULTSnPositive bile cultures were significantly more frequent in high-risk patients (81% versus 12%; P < 0.001). The overall rate of infectious complications was lower in the high-risk group (29% versus 46%; P = 0.018). The statistically significant decrease in the rate of infectious complications reflected reduced rates of urinary tract infections, pulmonary infections and septicaemia. Rates of wound infection (3% versus 5%; P = 0.639) and intra-abdominal abscess (7% versus 7%; P = 0.886) were similar in the high- and low-risk groups, as was the need for curative AMT.nnnCONCLUSIONSnThis exploratory study suggests that a postoperative short course of AMT in patients at high risk for biliary contamination reduces the overall rate of infectious complications after PD. The adaptation of perioperative antimicrobial policy to the patients risk for bile contamination seems promising and should be further evaluated.

Colorectal Liver Metastases Growth in the Embolized and Non-Embolized Liver After Portal Vein Embolization: Influence of Initial Response to Induction Chemotherapy

PurposeTo compare tumor progression in both embolized and non-embolized liver lobes after portal vein embolization (PVE) in patients with bilobar colorectal liver metastases (CLM), according to the initial response to induction chemotherapy.MethodsFrom 2002 to 2012, a total of 42 consecutive patients with bilobar CLM initially treated using induction chemotherapy underwent right PVE to achieve adequate future liver remnant volume. Tumoral and liver parenchyma volumes, as well as their volume variations, were measured on computed tomography before and after PVE in both embolized and non-embolized. Patients were classified as fast (≤6xa0cycles of induction chemotherapy) and slow (>6xa0cycles) responders.ResultsOverall, 432 metastases were analyzed in 42 patients. Patients were slow responders in 29 (69xa0%) cases. Tumoral volume increased in 29 (69xa0%) cases in the embolized liver (+48xa0%; pxa0<xa00.0001), and in 28 (66xa0%) cases in the non-embolized liver (+31xa0%; pxa0<xa00.0001). Fast responders had a tumoral volume decrease in both embolized (−4xa0%) and non-embolized (−9xa0%) lobes. On the opposite side, slow responders had tumoral volume increase in both embolized (+79xa0%) and non-embolized (+32xa0%) lobes. On multivariate analysis, a ‘slow’ response to induction chemotherapy was the only factor associated with tumoral progression in both embolized (pxa0=xa00.0012) and non-embolized (pxa0=xa00.001) lobes.ConclusionTumor growth after PVE is observed in both embolized and non-embolized liver lobes in most patients but is significantly associated with slow response to induction chemotherapy.

Lemmel's syndrome as a rare cause of obstructive jaundice.

Obstructive jaundice is a frequent symptom most frequently resulting from choledocolithiasis or pancreatico-biliary and periampullary tumors. If duodenal diverticula are frequently asymptomatic, they can occasionally present with obstructive jaundice in the absence of lithiasis or another obstructing lesion such as a tumor in a presentation called Lemmels syndrome. We herein present a 70-year-old male with obstructive jaundice secondary to a periampullary duodenal diverticulum associated with hepatic abscess. Endoscopic sphincterotomy associated with percutaneous abscess drainage released patient from all symptoms. Lemmels syndrome as a rare cause of obstructive jaundice should be known in order to avoid mismanagement and therapeutic delay.

End-to-end renal vein anastomosis to preserve renal venous drainage following inferior vena cava radical resection due to leiomyosarcoma.

BACKGROUNDnWhen retrohepatic inferior vena cava (IVC) resection is required, for example, for IVC leiomyosarcoma, reconstruction is recommended. This is particularly true when the renal vein confluence is resected to preserve venous outflow, including that of the right kidney.nnnMETHODSnTwo patients with retrohepatic IVC leiomyosarcoma involving renal vein confluences underwent hepatectomy with en bloc IVC resection below the renal vein confluence. IVC reconstruction was not performed, but end-to-end renal vein anastomoses were, including a prosthetic graft in 1 case.nnnRESULTSnThe postoperative course was uneventful with respect to kidney function, anastomosis patency assessed using Doppler ultrasonography and computerized tomography, and transient lower limb edema.nnnDISCUSSIONnEnd-to-end renal vein anastomosis after a retrohepatic IVC resection including the renal vein confluence should be considered as an alternative option for preserving right kidney drainage through the left renal vein when IVC reconstruction is not possible or should be avoided.

Local venous thrombotic risk of an expanding haemostatic agent used during liver resection.

BackgroundFor patients undergoing liver resection that leaves an empty intraparenchymal cavity, traditional topical agents might be inadequate to achieve additional hemostasis. A new hemostatic expanding topical foam (BioFoam®) has been designed to provide a mechanical seal. The objective of this study was to report our preliminary results regarding the safety and the efficacy using this foam.MethodsBetween 2009 and 2011, BioFoam® was used to fill a three-dimensional defect following liver resection in 14 patients. The operative results and postoperative course of these patients were compared to those of 14 matched controls who underwent liver resection but did not receive BioFoam®.ResultsThe two groups were similar in terms of demographics, indications for liver resection, type of surgical procedure, and type and duration of clamping. BioFoam® patients experienced significantly less operative blood loss (275xa0vs. 630xa0ml, pxa0=xa00.032) but similar operative transfusion rates (28.6 vs. 35.7xa0%, pxa0=xa00.686) compared to no-BioFoam® patients. The postoperative mortality was nil and no patient developed postoperative hemorrhage. While the two groups shared similar overall (64.3 vs. 57.1xa0%, pxa0=xa00.599) and major (28.6 vs. 14.3xa0%, pxa0=xa00.357) complications rates, BioFoam® patients experienced significantly higher major vascular thrombosis compared to no-BioFoam® patients (29 vs. 0xa0%, pxa0=xa00.04). In the BioFoam® group, major vascular thrombosis was associated with exposure of the vessel along the transection plane.ConclusionWhile the clinical benefit of BioFoam® in high-risk liver resections leaving a deep parenchymal defect remains to be proven, the associated risk of vascular thrombosis should preclude its use in contact with major veins.