Stéphane Berdah

Rectal cancer surgery with or without bowel preparation: The French GRECCAR III multicenter single-blinded randomized trial.

Objective:To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP). Background:The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP. Methods:From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay. Results:A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups. Conclusions:This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer. This study is registered with clinicaltrials.gov, number NCT00554892.

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.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding. OBJECTIVE To assess a new, totally endoscopic strategy to manage anastomotic fistulas. DESIGN Prospective study. SETTING Tertiary-care university hospital. PATIENTS This study involved 27 consecutive patients from July 2007 to December 2009. INTERVENTION This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant. MAIN OUTCOME MEASUREMENTS Technical success, mortality and morbidity, migration of the stent. RESULTS Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient. LIMITATIONS Moderate sample size, nonrandomized study. CONCLUSION An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study

BACKGROUND The efficacy of laparoscopy simulators remains controversial. METHODS This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed. RESULTS Before/after scores were significantly improved in the MISTELS (P = .042) and LAP Mentor (P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS (P = .026) and LAP Mentor (P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups. CONCLUSIONS Simulator training provides a more rapid acquisition of competence in surgical technique.

New treatment for ileal pouch-anal or coloanal anastomotic stenosis

Persistent anastomotic stricture following ileal pouch-anal or coloanal anastomoses can be treated by transanal resection using a stapler or a more complex procedure, such as transanal pouch advancement with neoanastomosis. We propose an easier and faster technique, which does not require any particular device. Its long-term functional results are satisfactory in most patients.

Laparoscopy-Assisted Left Ovarian Vein Transposition to Treat One Case of Posterior Nutcracker Syndrome

We report one case of posterior nutcracker syndrome treated by left ovarian vein (LOV) transposition. A 36-year-old woman was suffering from nutcracker syndrome associated with pelvic congestion syndrome. Color duplex scan, computed tomographic scan, and angiography demonstrated a stenosis of a retroaortic left renal vein with proximal dilatation and incompetence of the LOV. The renocaval pullback gradient was 10 mm Hg. The LOV was harvested laparoscopically and transposed into the inferior vena cava. Completion angiography showed a patent reconstruction with no significant gradient. At day 4, an asymptomatic thrombosis was treated by thromboaspiration. Forty months later, the patient remained asymptomatic with a patent transposition. Posterior nutcracker syndrome is a rare condition. When associated with pelvic congestion syndrome due to LOV reflux, it can be treated by LOV transposition.

Hydrolytic Fate of 3/15-Acetyldeoxynivalenol in Humans: Specific Deacetylation by the Small Intestine and Liver Revealed Using in Vitro and ex Vivo Approaches

In addition to deoxynivalenol (DON), acetylated derivatives, i.e., 3-acetyl and 15-acetyldexynivalenol (or 3/15ADON), are present in cereals leading to exposure to these mycotoxins. Animal and human studies suggest that 3/15ADON are converted into DON after their ingestion through hydrolysis of the acetyl moiety, the site(s) of such deacetylation being still uncharacterized. We used in vitro and ex vivo approaches to study the deacetylation of 3/15ADON by enzymes and cells/tissues present on their way from the food matrix to the blood in humans. We found that luminal deacetylation by digestive enzymes and bacteria is limited. Using human cells, tissues and S9 fractions, we were able to demonstrate that small intestine and liver possess strong deacetylation capacity compared to colon and kidneys. Interestingly, in most cases, deacetylation was more efficient for 3ADON than 15ADON. Although we initially thought that carboxylesterases (CES) could be responsible for the deacetylation of 3/15ADON, the use of pure human CES1/2 and of CES inhibitor demonstrated that CES are not involved. Taken together, our original model system allowed us to identify the small intestine and the liver as the main site of deacetylation of ingested 3/15ADON in humans.

Laparoscopic Approach Is feasible in Crohn’s Complex Enterovisceral Fistulas: A Case-Match Review

BACKGROUND: Complex enterovisceral fistulas are internal fistulas joining a “diseased” organ to any intra-abdominal “victim” organ, with the exception of ileoileal fistulas. Few publications have addressed laparoscopic surgery for complex fistulas in Crohn’s disease. OBJECTIVE: The aim of this study was to evaluate the feasibility of such an approach. DESIGN: This study is a retrospective, case-match review. SETTINGS: This study was conducted at a tertiary academic hospital. PATIENTS: All patients who underwent a laparoscopic ileocecal resection for complex enterovisceral fistulas between January 2004 and August 2011 were included. They were matched to a control group undergoing operation for nonfistulizing Crohn’s disease according to age, sex, nutritional state, preoperative use of steroids, and type of resection performed. Matching was performed blind to the peri- and postoperative results of each patient. MAIN OUTCOME MEASURES: The 2 groups were compared in terms of operative time, conversion to open surgery, morbidity and mortality rates, and length of stay. RESULTS: Eleven patients presenting with 13 complex fistulas were included and matched with 22 controls. Group 1 contained 5 ileosigmoid fistulas (38%), 3 ileotransverse fistulas (23%), 3 ileovesical fistulas (23%), 1 colocolic fistula (8%), and 1 ileosalpingeal fistula (8%). There were no significant differences between the groups in terms of operative time (120 (range, 75–270) vs 120 (range, 50–160) minutes, p = 0.65), conversion to open surgery (9% vs 0%, p = 0.33), stoma creation (9% vs 14%, p = 1), global postoperative morbidity (18% vs 32%, p = 0.68), and major complications (Dindo III: 0% vs 9%, p = 0.54; Dindo IV: 0% vs 0%, p = 1), as well as in terms of length of stay (8 (range, 7–32) vs 9 (range, 5–17) days, p = 0.72). No patients died. LIMITATIONS: This is a retrospective review with a small sample size. CONCLUSION: A laparoscopic approach for complex fistulas is feasible in Crohn’s disease, with outcomes similar to those reported for nonfistulizing forms.

Therapeutic anticoagulant does not modify thromboses rate vein after venous reconstruction following pancreaticoduodenectomy.

Recommendations for anticoagulation following major venous reconstruction for pancreatic adenocarcinoma (PA) are not clearly established. The aim of our study was to find out the relation between postoperative anticoagulant treatment and thrombosis rate after portal venous resection. Materials and methods. Between 1986 and 2006, twenty seven portal vein resections were performed associated with pancreaticoduodenectomies (n = 27) (PD).We defined four types of venous resection: type I was performed 1 cm above the confluent of the superior mesenteric vein (SMV) (n = 12); type II lateral resection and venorrhaphy at the level of the confluent SMV (n = 12); type III (n = 1) resulted from a primary end-to-end anastomosis above confluent and PTFE graph was used for reconstruction for type IV (n = 2). Curative anticoagulant treatment was always indicated after type IV (n = 2) resection, and after resection of type II when the length of venous resection was longer than ≥2 cm. Results. Venous thrombosis rate reached: 0%, 41%, and 100% for type I, II, IV resections, respectively. Among them four patients received curative anticoagulant treatment. Conclusion. After a portal vein resection was achieved in the course of a PD, curative postoperative anticoagulation does not prevent efficiently the onset of thrombosis.

Utilisation des simulateurs pour former les internes de chirurgie gynécologique en France : un état des lieux en 2013

OBJECTIVES Simulation is a promising method to enhance surgical education in gynecology. The purpose of this study was to provide baseline information on the current use of simulators across French academic schools. MATERIALS AND METHODS Two questionnaires were created, one specifically for residents and one for professors. Main issues included the type of simulators used and the kind of use made for training purposes. Opinions and agreement about the use of simulators were also asked. RESULTS Twenty-six percent of residents (258/998) and 24% of professors (29/122) answered the questionnaire. Sixty-five percent of residents (167/258) had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents reported access to simulators most commonly during introductory sessions (51%) and days of academic workshops (38%). Residents believed simulators very useful for training. Professors agreed that simulators should become a required part of residency training, but were less enthusiastic regarding simulation becoming a part of certification for practice. CONCLUSION Surgical skills simulators are already experienced by a majority of French gynecologic residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There was a strong agreement that simulation technology should be a component of training.