What is the mechanism of prolonged ileus after colectomy for inflammatory bowel disease within the ERAS protocol?

International audienc

Ileus Management International (IMAGINE): protocol for a multicentre, observational study of ileus after colorectal surgery

AIM: The management of postoperative ileus following colorectal surgery remains controversial. It is the commonest complication after elective colorectal resection and is associated with an increased incidence of postoperative adverse events. The prevention and management of postoperative ileus remains unstandardized. This study aims to describe an international profile of gastrointestinal recovery after colorectal surgery and will assess the role of non-steroidal anti-inflammatory drugs, when used as postoperative analgesia, in expediting the return of gastrointestinal function. METHODS: A multicentre, student- and trainee-led, prospective cohort study will be conducted across both Europe and Australasia. Adult patients undergoing elective colorectal resection during 2-week data collection periods between January and April 2018 will be included. A site-specific questionnaire will capture compliance to Enhanced Recovery after Surgery components at participating centres. The primary outcome is time to gastrointestinal recovery, measured using a composite outcome of bowel function and oral tolerance. The impact of non-steroidal anti-inflammatory drugs on gastrointestinal recovery will be evaluated along with safety data with respect to anastomotic leak, acute kidney injury and complications within 30 days of surgery. DISCUSSION: This protocol describes the methodology of an international, observational assessment of gastrointestinal recovery after colorectal surgery. It discusses key challenges and describes how the results will impact on future investigation. The study will be conducted across a large student- and trainee-led collaborative network, with prospective quality assurance and data validation strategies

Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014

The gold standard in treatment of acute cholecystitis is cholecystectomy associated with antibiotics. In certain circumstances, percutaneous cholecystostomy is an interventional alternative. Percutaneous cholecystostomy is usually performed under local anesthesia by the radiologist using ultrasonographic or CT guidance. A drain can be inserted either through a trans-hepatic or a trans-peritoneal approach. Complications occur in nearly 10% of cases including hemorrhage, hemobilia, pneumothorax or bile leaks, depending on whether the approach was trans-hepatic or trans-peritoneal. The main indications for percutaneous cholecystostomy are resistance to medical treatment or severely-ill patients in intensive care. Drains should be maintained 3 to 6 weeks before removal. In patients with good general condition (ASA score I-II), secondary cholecystectomy can be recommended to avoid recurrence

Aberrant Right Hepatic Artery with a Prepancreatic Course Visualized Prior to Pancreaticoduodenectomy

Liver vascularization is known to present with several different variations. Generally, a normal vascular anatomy is reported in up to 50-80 % of cases. For this reason, a precise preoperative mapping of the hepatic vascularization prior to pancreatic surgery is essential to avoid injuries and subsequent complications. We report here a case of a young patient scheduled for Whipple procedure, who presented an arterial pattern type Michels IV, variation reported in 0.6 to 3 % in the literature. Another interesting particularity of this case was the fact that the right hepatic artery had a prepancreatic course. We think that every surgeon performing hepatopancreatic surgery should have heard of this special and rare situatio

Localisations primitives inhabituelles du kyste hydatique

L’Echinococcus granulosus, parasite appartenant à la famille des Cestodes est responsable, à travers sa forme larvaire, d’une maladie : l’hydatidose. Celle-ci se manifeste typiquement au niveau hépatique ou pulmonaire ; cependant une fois sur dix, l’embryon va se loger dans n’importe quel tissu ou organe du corps humain. Les auteurs rapportent quatre cas de localisation inhabituelle de l’hydatidose : rénale, musculaire, pancréatique et thyroïdienne

Central pancreatectomy: comparison of results according to the type of anastomosis

INTRODUCTION: The mild pancreatic tumors are more and more treated by central pancreatectomy (CP) in alternative with the widened pancreatectomies. Indeed, their morbidity is lesser but they are however burdened by a rate of important postoperative fistulas. The purpose of our study is to compare pancreatico-jejunal anastomosis and pancreatico-gastric anastomosis. METHODS: This work was realized in a bicentric retrospective way. Twenty-five CP were included and classified according to two groups according to the pancreatic anastomosis (group 1 for pancreatico-jejunal anastomosis and group 2 for the pancreatico-gastric anastomosis). CP was realized according to a protocol standardized in both centers and the complications were classified according to the classification of Clavien and Dindo and the fistulas according to the classification of Bassi. RESULTS: Both groups were comparable. The duration operating and the blood losses were equivalent in both groups. There was a significant difference (P=0,014) as regards the rate of fistula. The pancreatico-gastric anastomosis complicated more often of a low-grade fistula. However, in both groups, the treatment was mainly medical. Our results were comparable with those found in the literature and confirmed the advantages of the CP with regard to the cephalic duodeno-pancreatectomy (DPC) or to the distal pancreatectomy (DP). However, in the literature, a meta-analysis did not report difference between both types of anastomosis but this one concerned only the DPC. CONCLUSIONS: This work showed a less important incidence of low-grade fistula after pancreatico-jejunal anastomosis in the fall of a PM. This result should be confirmed by a later study on a more important sample of PM

Rectal metastasis of prostate cancer: about a case

Prostate adenocarcinomas present a high risk of metastasis. We report a case of an atypical prostate cancer metastasis. A male patient presented a prostatic adenocarcinoma treated by surgery. A biological recurrence was discovered during the follow-up by an increased rate of Prostate Specific Antigen (PSA) and was treated by hormonotherapy. Several months later, there was a re-increase of the PSA rate. The CT scan showed a radiation proctitis aspect. An intermittent hormonotherapy was decided. Six months later, he presented abdominal pain. Examinations were performed and showed a rectal carcinosarcoma with prostate origins. A surgical management was realised. The outcomes were an early recurrence. A symptomatic treatment was decided. There are not any rectal localisations reported in the literature. Only loco-regional invasions of the rectum are described and no histological modification of metastasis compared to the primitive tumor has been reported. So, we report a metastasis of a prostate adenocarcinoma which transformed into a carcinosarcoma. KEYWORDS: Adenocarcinoma; Carcinosarcoma; Metastasis; Prostate; Rectal neoplasm

Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy

BACKGROUNDS: Central pancreatectomy (CP) is an alternative to pancreaticoduodenectomy and distal pancreatectomy in benign tumours of pancreatic isthmus management. It is known for a high post-operative pancreatic fistula (POPF) rate. The purpose of this study was to compare POPF incidence between pancreatico-jejunostomy (PJ) and pancreatico-gastrostomy (PG). METHODS: Fifty-eight patients (mean age 53.9 ± 1.9 years) who underwent a CP in four French University Hospitals from 1988 to 2011 were analysed. The distal pancreatic remnant was either anastomosed to the stomach (44.8%, n = 25) or to a Roux-en-Y jejunal loop (55.2%, n = 35) with routine external drainage allowing a systematic search for POPF. POPF severity was classified according to the International Study Group on Pancreatic Fistula (ISGPF) and Clavien-Dindo classifications. RESULTS: The groups were similar on sex ratio, mean age, ASA score, pancreas texture, operative time and operative blood loss. Mean follow-up was 36.2 ± 3.9 months. POPF were significantly more frequent after PG (76.9 versus 37.5%, P = 0.003). PG was associated with significantly higher grade of POPF both when graded with ISGPF classification (P = 0.012) and Clavien-Dindo classification (P = 0.044). There was no significant difference in post-operative bleeding (0.918) and delayed gastric emptying (0.877) between the two groups. Hospital length of stay was increased after PG (23.6 ± 3.5 days versus 16.5 ± 1.9 days, P = 0.071). There was no significant difference in incidence of long-term exocrine (3.8 versus 19.2%, P = 0.134) and endocrine (7.7 versus 9.4%, P = 0.575) pancreatic insufficiencies. CONCLUSION: PG was associated with a significantly higher POPF incidence and severity in CP. We recommend performing PJ especially in older patients to improve CP outcomes

Sigmoid stricture associated with diverticular disease should be an indication for elective surgery with lymph node clearance

BACKGROUND: The literature concerning stricture secondary to diverticulitis is poor. Stricture in this setting should be an indication for surgery because (a) of the potential risk of cancer and (b) morbidity is not increased compared to other indications for colectomy. The goal of this report is to study the post-surgical morbidity and the quality of life in patients after sigmoidectomy for sigmoid stricture associated with diverticular disease. METHOD: This is a monocenter retrospective observational study including patients with a preoperative diagnosis of sigmoid stricture associated with diverticular disease undergoing operation between Jan 1, 2007 and Dec 31, 2013. The GastroIntestinal Quality of Life Index was used to assess patient satisfaction. RESULTS: Sixteen patients were included of which nine were female. Median age was 69.5 (46-84) and the median body mass index was 23.55kg/m(2) (17.2-28.4). Elective sigmoidectomy was performed in all 16 patients. Overall, complications occurred in five patients (31.2%) (4 minor complications and 1 major complication according to the Dindo and Clavien Classification); none resulted in death. Pathology identified two adenocarcinomas (12.5%). The mean GastroIntestinal Quality of Life Index was 122 (67-144) and 10/11 patients were satisfied with their surgical intervention. CONCLUSION: Sigmoid stricture prevents endoscopic exploration of the entire colon and thus it may prove difficult to rule out a malignancy. Surgery does not impair the quality of life since morbidity is similar to other indications for sigmoidectomy. For these reasons, we recommend that stricture associated with diverticular disease should be an indication for sigmoidectomy including lymph node clearance