Véronique Desfourneaux

Sacral nerve stimulation in faecal incontinence: position statement based on a collective experience

Objective  Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS.

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients.

Aim  Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15–30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI.

Anorectal Physiology in Solitary Ulcer Syndrome: A Case-Matched Series

PURPOSESolitary ulcer syndrome is a rare condition characterized by inflammation and chronic ulcer of the rectal wall in patients suffering from outlet constipation. Despite similar surgical options (rectopexy, anterior resection), solitary ulcer syndrome may differ from overt rectal prolapse with regard to symptoms and pathogenesis. The present work analyzed differences between these conditions in a case-control physiology study.METHODSFrom 1997 to 2002, 931 consecutive subjects were investigated in a single physiology unit for anorectal functional disorders. Standardized questionnaires, anorectal physiology, and evacuation proctography were included in a prospective database. Diagnosis of solitary ulcer syndrome was based on both symptoms and anatomic features in 25 subjects with no overt rectal prolapse (21 females and 4 males; mean age, 37.2 ± 15.7 years) and no past history of anorectal surgery. They were compared with age-matched and gender-matched subjects: 25 with outlet constipation (also matched on degree of internal procidentia), 25 with overt rectal prolapse without any mucosal change, and 14 with overt rectal prolapse and mucosal changes.RESULTSSubjects with solitary ulcer syndrome reported symptomatic levels (digitations, pain, incontinence) similar to those of patients with outlet constipation, but they had significantly more constipation and less incontinence than patients with overt rectal prolapse. Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, and 1, respectively ; P < 0.01) and a paradoxical puborectalis contraction (15 vs. 9, 1, and 1, respectively; P < 0.05). With respect to evacuating proctography, complete rectal emptying was achieved less frequently in this group (5 vs. 12, 23, and 10, respectively; P < 0.05). Compared with patients with overt rectal prolapse, mean resting and squeezing anal pressures were significantly higher in both groups of subjects with solitary ulcer syndrome and with outlet constipation. Prevalence and levels of anatomic disorders (perineal descent, rectocele) did not differ among the four groups except for rectal prolapse grade and prevalence of enterocele (higher in overt rectal prolapse group). Interestingly, and despite matched controls for degree of intussusception, individuals with solitary ulcer syndrome had circular internal procidentia more often compared with those suffering from outlet constipation without mucosal lesions (15 vs. 8, P < 0.05).CONCLUSIONThis case-controlled study quantifies functional anal disorders in patients suffering from solitary ulcer syndrome. Despite no proven etiologic factor, sphincter-obstructed defecation and circular internal procidentia both may play an important part in the pathogenesis and an exclusive surgical approach may not be appropriate in this context.

Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence

BACKGROUND Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse. OBJECTIVE We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse. DESIGN A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010). MAIN OUTCOME MEASURES Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score. RESULTS Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017). LIMITATIONS Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias. CONCLUSION Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

Incontinence in full‐thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

Aim  The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse.

Use of temporary porto‐caval shunt during liver transplantation with inferior vena cava conservation: An effective method to enhance use of octogenarian graft?

We read with great interest the study of Ghinolfi et al. and wanted to congratulate them for their work. The authors reported their series of 123 liver transplantations (LTs), which were performed with the retrohepatic inferior vena cava (IVC) replacement technique and venovenous bypass, using octogenarian grafts, and they found that donor hemodynamic instability, diabetes mellitus, and donor age–Model for End-Stage Liver Disease (D-MELD) were predictive of higher incidence of ischemic-type biliary lesion incidence in the multivariate analysis. In our center, we routinely perform LTs with retrohepatic IVC preservation and side-to-side cavocaval anastomosis. According to surgeon preference, a temporary portocaval shunt (TPCS) is performed or not. From January 2007 to December 2014, 816 transplantations were performed in our institution, and using the same selection criteria as Ghinolfi et al., we identified 48 LTs performed using octogenarian donors. TPCS was performed in 31 patients and absent in 17 patients. We found that octogenarian graft survival was significantly improved when a TPCS was performed (P 5 0.02; Fig. 1A).We also observed a significant reduction of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) levels in the early postoperative days (PODs), whereas bilirubin levels were similar (Fig. 1B-D). The IVC preservation technique is currently preferred to the IVC replacement technique. In this situation, we found that use of TPCS improves octogenarian graft outcome and biliary biological parameters in the early PODs. Interest of TPCS has been previously shown, and some authors also reported improvement of longterm graft survival. However, these results were not specifically focused on octogenarian grafts. The beneficial effects of TPCS might be explained by the improvement of the recipient’s intraoperative hemodynamic status, a decrease of postreperfusion syndrome incidence, or prevention of splanchnic congestion. In conclusion, we agree with Ghinolfi et al. regarding the safety of octogenarian grafts, and we think that TPCS should be recommended when vena cava preservation is performed, in order to improve outcomes and biliary function in this situation.

Anti-tnf Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort

Objective: To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD). Summary Background Data: The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study. Methods: From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method. Results: Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF <3 months prior to surgery. In the multivariate analysis, anti-TNF <3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17–3.39, P = 0.011), with preoperative hemoglobin <10 g/dL (OR = 4.77; CI 95% = 1.32–17.35, P = 0.017), operative time >180 min (OR = 2.71; CI 95% = 1.54–4.78, P < 0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13–3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF <3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04–4.35, P <0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22–4.04, P = 0.009). Conclusions: Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Benefits of temporary portocaval shunt during orthotopic liver transplantation with vena cava preservation: A propensity score analysis

During orthotopic liver transplantation (OLT), clamping of the portal vein induces splanchnic venous congestion and accumulation of noxious compounds. These adverse effects could increase ischemia/reperfusion injury and subsequently the risk of graft dysfunction, especially for grafts harvested from extended criteria donors (ECDs). Temporary portocaval shunt (TPCS) could prevent these complications. Between 2002 and 2013, all OLTs performed in our center were retrospectively analyzed and a propensity score matching analysis was used to compare the effect of TPCS in 686 patients (343 in each group). Patients in the TPCS group required fewer intraoperative transfusions (median number of packed red blood cells—5 versus 6; P = 0.02; median number of fresh frozen plasma—5 versus 6; P = 0.02); had improvement of postoperative biological parameters (prothrombin time, Factor V, international normalized ratio, alkaline phosphatase, and gamma‐glutamyltransferase levels); and showed significant reduction of biliary complications (4.7% versus 10.2%; P = 0.006). Survival analysis revealed that TPCS improved 3‐month graft survival (94.2% versus 88.6%; P = 0.01) as well as longterm survival of elderly (ie, age > 70 years) donor grafts (P = 0.02). In conclusion, the use of TPCS should be recommended especially when considering an ECD graft. Liver Transplantation 23 174–183 2017 AASLD

Lateral cavo-caval shunt: an alternative veno-venous bypass in liver surgery

When inferior vena cava (IVC) resection is mandatory during liver surgery, use of a veno-venous bypass (VVB) is usually required despite its specific related adverse events. We describe a safe and alternative technique which allows both derivation of the portal and the caval blood flow by performing a lateral cavo-caval shunt using a prosthetic graft.

L’appendicectomie est un facteur de risque de dysplasie de haut grade et de cancer colorectal dans la rectocolite hémorragique

Introduction L’appendicectomie est consideree comme facteur protecteur de la rectocolite hemorragique (RCH). Le but de ce travail etait de tester l’appendicectomie pour appendicite (APA) et sans appendicite (ASA) sur un modele murin de RCH (modele IL10/ Nox1DKO) et de confirmer nos observations chez l’homme Materiels et methodes Trois groupes de souris mâles (20/groupe) ont ete operes (groupes APA, ASA et controle), euthanasies a un mois, et leurs colons ont ete analyses en aveugle. La severite de la colite et la presence de dysplasie de haut grade (DHG) et de cancer colorectal (CCR) ont ete evaluees. Une cohorte bicentrique de patients RCH operes consecutivement de colectomie a ete etudiee en s’interessant a l’antecedent d’appendicectomie Resultats Dans le modele murin, seule l’APA etait associee a une amelioration de la colite (p = 0,0005), avec un effet plus important chez les souris jeunes. L’ASA etait associee a un taux eleve inattendu de DHG/CCR (65 % versus 0 % dans les autres groupes, p versus 12 (5,5 %) et 18 (8,3 %) chez les non-appendicectomises, En analyse multivariee, l’appendicectomie etait associee a la DHG/CCR dans la RCH (OR = 16.88, 9 5 % CI [3.3-112.7]). Conclusion Le role protecteur de l’appendice dans la RCH est lie a l’appendicite mais l’appendicectomie est associee a une neoplasie colique dans la RCH chez l’homme et la souris. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.