Anastomose Iléo-Anale pour Rectocolite Hémorragique (le type d'anastomose influence-t-il les résultats fonctionnels, sexuels, urinaires et la fertilité?)

Données actuelles: L'anastomose iléo-anale (AIA) est le traitement chirurgical de référence de la Rectocolite Hémorragique (RCH). Les conséquences urinaires, sexuelles ainsi que sur la fertilité restent imprécises. But de l'étude: Comparer les résultats post-opératoires et à long terme, incluant les conséquences fonctionnelles, urinaires, sexuelles ainsi que sur la fertilité après AIA manuelle et mécanique avec réservoir en J réalisées chez les patients atteints de RCH. Méthodes: Les données démographiques, préopératoires, péri-opératoires et post-opératoires de 135 AIA consécutives réalisées entre Mai 1996 et Avril 2011 pour RCH au sein d'un centre expert ont été collectées rétrospectivement. Un questionnaire, portant sur les résultats fonctionnels, sexuels, urinaires, de fertilité, de qualité de vie et sur les restrictions après AIA, a été envoyé aux patients. Résultats: La durée moyenne de suivi post-opératoire était de 98,9 +- 60,2 mois. L'âge moyen au moment de l'AIA était de 37,1 +- 12,4 ans. Soixante-deux patients (45,9%) étaient des hommes. La mortalité post-opératoire était nulle. Les patients avec AIA manuelle (n=69; 51,1%) et avec AIA mécanique (n=66; 48,9%) présentaient des caractéristiques similaires. Les patients avec AIA manuelle étaient plus souvent opérés sous cœlioscopie (p=0,006). La technique de l'éversion rectale durant l'AIA était plus souvent réalisée lors de l'AIA mécanique (p<0,0001). Les patients avec AIA mécanique présentaient plus de pochites (p=0,019). Quatre-vingt-huit patients (65,2%) ont répondu au questionnaire. Les patients avec AIA mécanique présentaient un plus grand nombre de selles par 24h (p=0,008), devaient plus souvent restreindre leur alimentation (p=0,003) et présentaient plus de symptômes urinaires (p=0,02) incluant des symptômes d'incontinence urinaire d'effort (p=0,037), d'hyperactivité vésicale (p=0,028) et de dysurie (p=0,026) selon le questionnaire Urinary Symptom Profile . Les autres résultats en termes fonctionnels, de qualité de vie, de restrictions liées à l'AIA et de conséquences de l'AIA sur la sexualité et la fertilité étaient identiques dans les 2 groupes. Conclusion: Les patients opérés d'une AIA manuelle ont des résultats fonctionnels et urinaires meilleurs que les patients opérés d'une AIA mécanique. Les résultats en termes de sexualité et de fertilité sont similaires.Background: Ileal pouch anal anastomosis (IPAA) is the treatment of choice for Ulcerative Colitis (UC). Urinary, sexual and fertility outcomes remain undetermined. Aim/Objective: To compare post-operative and long-term adverse events, functional outcomes, urinary symptoms, sexual and fertility outcomes after hand-sewn IPAA and stapled IPAA performed with J-pouch construction in patients afflicted by UC. Methods: Data were collected from a single institution of 135 consecutive primary IPAA cases performed for initial diagnosis of UC between May 1996 and April 2011. Demographic data, preoperative data, perioperative data and postoperative data were collected retrospectively. A mailed questionnaire was sent to the patients, including functional data, restrictions data due to IPAA, sexual data and fertility data. Results: Mean follow-up was 98.9 +- 60.2 months. Mean age at the time of IPAA was 37.1 +- 12.4 years. Overall 62 patients were male (45.9%). Post-operative mortality rate was zero. Patients with stapled IPAA (n=66, 48.9%) and with hand-sewn IPAA (n=69, 51.1%) had similar characteristics. Patients with hand-sewn IPAA had greater laparoscopic approach (p=0.006). Patients with stapled iPAA had greater anorectal eversion (p<0.0001). Patients with stapled IPAA had greater pouchitis (p=0.019). Eighty-eight patients (65.2%) replied to questionnaire; Patients with stapled IPAA had greater stool frequency per 24h (p=0.008), dietary restriction (p=0.003), stress urinary incontinence symptoms (p=0.037), overactive bladder symptom (p=0.028) and low stream symptoms (p=0.026) from the Urinary Symptom Profile questionnaire. Other functional outcomes, quality of life, restrictions due to IPAA, and results to sexual and fertility questionnaires were similar in the 2 groups of patients who replied. Conclusion: Patients with hand-sewn IPAA had better functional outcomes, including urinary symptoms, and similar sexual and fertility outcomes than those with stapled IPAA.RENNES1-BU Santé (352382103) / SudocSudocFranceF

Ileal-J-Pouch Volvulus After Restorative Proctocolectomy

International audienc

Outcomes of bariatric surgery in patients with inflammatory bowel disease from a French nationwide database

International audienceBackground: The outcomes of bariatric surgery (BS) in patients with chronic inflammatory bowel disease (IBD) remain rarely described. We aimed to evaluate the 90-day morbidity and mortality rates, and the risk of IBD complications 2 years after BS. Method: Patients from the French Programme de Médicalisation des Systèmes d’Information (PMSI) database who underwent a primary BS between 2016 and 2018 were included. We identified patients with a previous diagnosis of IBD. Postoperative 90-day (POD90) morbidity and mortality rates were compared between the two groups. The evolution of IBD was followed 2 years after BS. Results: Between 2016 and 2018, 138 980 patients underwent primary BS, including 587 patients with IBD: 326 (55.5 per cent) with Crohn’s disease (CD) and 261 (44.5 per cent) with ulcerative colitis (UC). The preferred surgical technique was sleeve gastrectomy, especially in the IBD group (81.1 per cent), followed by gastric bypass (14.6 per cent). Patients with IBD had more comorbidities (Charlson Comorbidity Index of 1 or more, hypertension, and diabetes; P &lt; 0.001) than those without IBD. The POD90 mortality rate did not differ between the two groups (0.049 per cent in the IBD group versus 0 per cent in the non-IBD group), but more unscheduled rehospitalizations at POD90 were observed in patients with IBD (6.0 per cent versus 3.7 per cent; P = 0.004). Two years after BS, 86 patients (14.6 per cent) in the IBD group had at least one unplanned readmission for the management of their IBD; 15 patients stayed for 3 or more days. After multivariable analysis, patients with CD had an independent elevated risk of IBD-related unplanned readmissions 2 years after BS versus UC (adjusted odds ratio 1.90, 95 per cent c.i. 1.22 to 2.97; P = 0.005). Conclusion: In a highly selected cohort of patients with well-controlled IBD, BS did not result in added mortality or morbidity. A point of vigilance must be underlined regarding BS in patients with CD

Un cas d’hyperplasie myointimale idiopathique des veines mésentériques du côlon [A case of idiopathic myointimal hyperplasia of mesenteric veins]

National audienceThe idiopathic myointimal hyperplasia of mesenteric veins is a rare pathology, affecting recto-sigmoid and mimicking clinically an inflammatory chronic disease of the bowel. Only about fifteen cases have been reported in the literature. This lesion is characterized by a myointimal thickening of the mesenteric veins, without inflammatory infiltrate of the vascular wall, differentiating it from vasculitis. We present here the case of a 48-year-old man, in whom the diagnosis of ulcerative colitis then digestive vasculitis had first been raised

A systematic literature review on solitary rectal ulcer syndrome is there a therapeutic consensus in 2018?

International audiencePurpose - To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy. Method - A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed. Results - A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary. Conclusions - The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed

Sexuality and fertility outcomes following hand-sewn versus stapled ileal pouch anal anastomosis for ulcerative colitis

International audienceBackground: Ileal pouch anal anastomosis (IPAA) may alter sexuality and fertility in women. The laparoscopic approach seems to reduce infertility rates in women after IPAA. However, the impact of hand-sewn versus stapled IPAA on sexuality and fertility has never been assessed in patients with ulcerative colitis (UC). The objective of this study was to analyse the impact of the IPAA technique on sexuality and fertility in UC. Methods: All UC patients who underwent an IPAA between May 1996 and April 2011 were included. The patients answered mailed questionnaires including sexuality validated questionnaires and fertility questionnaires. The risk factors of sexual dysfunction were explored. Results: A total of 135 patients were included. Eighty-eight patients (65%) answered the questionnaires. Their mean age and follow-up were 37.2 ± 13.4 years and 109.7 ± 57.5 months. The rates of female and male sexual dysfunction were 50% and 29%, respectively. Intestinal transit disorders were identified as risk factors in both men and women, and anastomotic stricture in women sexual dysfunction, in univariate analyses. The IPAA technique did not impact sexual function in women but there was a trend for less erectile dysfunction following hand-sewn IPAA (16.7% vs 44.4%). The fertility rate was 47% in women and 75% in men, with a trend for a better fertility in women after hand-sewn IPAA (p=0.07). Conclusion In this preliminary study, the hand-sewn or stapled IPAA technique did not impact the sexuality or fertility outcomes of UC patients, but there was a trend for better female fertility and male erectile function following hand-sewn IPAA. Intestinal transit disorders contributed to male and female sexual dysfunction after IPAA

The median effective analgesic dose (ED50) of ropivacaine in ultrasound-guided transversus abdominis plane block for analgesia in reversal of ileostomy: A double-blind up-down dose-finding study.

International audienceThe transversus abdominis plane block has become popular since it has been combined with ultrasound-guided techniques. In abdominal surgery, and especially in subumbilical surgery, it improves postoperative analgesia and reduces morphine consumption. Although it has been shown to be an effective technique, there are wide variations in reported doses and volumes of local anaesthetic used. The primary objective was to assess the median effective analgesic dose (ED50 = effective dose in 50% of patients) of ropivacaine in TAP blocks for patients undergoing reversal of ileostomy. A prospective double-blind study. French Teaching Hospital. Twenty-six colorectal patients were included. After standardised general anaesthesia, a unilateral ultrasound-guided TAP block was performed on patients undergoing elective reversal of ileostomy using 20 ml of ropivacaine. Doses were predefined according to the up-and-down method. The first patient received a dose of 1.6 mg kg. The dose adjustment interval was 0.2 ml kg. The potentially toxic dose of 3 mg kg was never exceeded. The primary endpoint was pain (defined as 3 or higher on a numerical pain scale of 0 to 10) at rest 6 h after TAP block. Out of the twenty-six patients who were included in the study, the ED50 of ropivacaine in TAP block for patients undergoing reversal of ileostomy was 2.70 mg kg [95% confidence interval (95% CI) 2.37 to 3.03 mg kg]. The ED50 of ropivacaine in TAP blocks in reversal of ileostomy is close to the toxic threshold. Anaesthesiologists should always be aware of the systemic toxicity risk and use weight-based doses when performing a TAP block

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

International audienceBackground - 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

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

National audienceIntroduction L’appendicectomie est considérée comme facteur protecteur de la rectocolite hémorragique (RCH). Le but de ce travail était de tester l’appendicectomie pour appendicite (APA) et sans appendicite (ASA) sur un modèle murin de RCH (modèle IL10/ Nox1DKO) et de confirmer nos observations chez l’homme Matériels et méthodes Trois groupes de souris mâles (20/groupe) ont été opérés (groupes APA, ASA et contrôle), euthanasiés à un mois, et leurs colons ont été analysés en aveugle. La sévérité de la colite et la présence de dysplasie de haut grade (DHG) et de cancer colorectal (CCR) ont été évaluées. Une cohorte bicentrique de patients RCH opérés consécutivement de colectomie a été étudiée en s’intéressant à l’antécédent d’appendicectomie Résultats Dans le modèle murin, seule l’APA était associée à une amélioration de la colite (p = 0,0005), avec un effet plus important chez les souris jeunes. L’ASA était associée à un taux élevé inattendu de DHG/CCR (65 % versus 0 % dans les autres groupes, p &lt; 0,0001). Parmi les 232 patients RCH de la cohorte, 15 présentaient une appendicectomie, dont 5 avaient un CCR (33 %) et 4 une DHG (27 %) versus 12 (5,5 %) et 18 (8,3 %) chez les non-appendicectomisés, En analyse multivariée, l’appendicectomie était associée à la DHG/CCR dans la RCH (OR = 16.88, 9 5 % CI [3.3-112.7]). Conclusion Le rôle protecteur de l’appendice dans la RCH est lié à l’appendicite mais l’appendicectomie est associée à une néoplasie colique dans la RCH chez l’homme et la souris. Déclaration d’intérêt Les auteurs n’ont pas transmis de conflits d’intérêt

Risk analysis of ischemic-type biliary lesions after liver transplant using octogenarian donors

International audienceWe read with great interest the study of Ghinolfi et al. entitled: “Risk Analysis of Ischemic-Type Biliary Lesions After Liver Transplant using Octogenarian Donor”. The authors reported their series of 123 liver transplantations (LT), performed with the retro-hepatic inferior vena cava (IVC) replacement technique and veno-venous bypass, using octogenarian grafts and found that donor hemodynamic instability, diabetes mellitus and D-MELD were predictive of higher incidence of ischemic-type biliary lesions (ITBL) incidence in multivariate analysis. In our center, we routinely perform LT with retro-hepatic IVC preservation and side-to-side cavo-caval anastomosis. According to surgeon preference, a temporary porto-caval shunt (TPCS) is performed or not. Since 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 LT performed using octogenarian donors. TPCS was performed in 31 cases and absent in 17 cases. We found that octogenarian graft survival was significantly improved when a TPCS was performed (p=0.02) (figure 1-A). We also observed a significant reduction of alkaline phosphatase and gamma-glutamyl transferase level in the early postoperative days (POD), while bilirubin levels were similar