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

Skin Perforator Flap Pedicled by Intercostal Muscle for Repair of a Tracheobronchoesophageal Fistula

International audienceA tracheobronchial fistula (TBF) is a rare complication when an operation is performed to treat esophageal carcinoma; no consensus treatment strategy has emerged. We describe a surgical interposition strategy, using a new flap, to repair a TBF that arose when esophageal squamous cell carcinoma was treated with neoadjuvant chemoradiation and minimally invasive esophagectomy (the 3-stage McKeown procedure). We performed a skin perforator flap pedicled by the intercostal muscle. It is a valuable option that may be the optimal first-line treatment, especially in the context of neoadjuvant radiation therapy. Furthermore, this strategy affords new options for intrathoracic reconstruction

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

Impact of age over 75 years on outcomes after pancreaticoduodenectomy.

International audienceBACKGROUND: The risks associated with pancreaticoduodenectomy (PD) in elderly patients continue to be debated. The aim of our study was to assess the incidence of death and postoperative complications following PD and identify the risk factors in patients >75 y. STUDY DESIGN: All patients who underwent PD between January 2000 and September 2009 were analyzed retrospectively. Patients were divided into two groups according to age (Group 1: patients aged 75 y proved to be predictive factors for mortality (OR 11.04, IC95% [2.57; 47.49], P = 0.001). When compared with Group 1, Group 2 was associated with increased postoperative deaths (24.4% versus 3.66%, P < 0.001) and pancreatic fistulas (26.8% versus 13.2%, P = 0.041), in particular, Grade C fistulas (14.6% versus 4.4%, P = 0.023). In multivariate analysis, only PH proved to be an independent predictive factor for mortality (OR 12.9, IC95% [1.07; 155.5], P = 0.04). CONCLUSIONS: PD in elderly patients aged over 75 y appears to be associated with an increased risk of postoperative death and pancreatic fistula. No single preoperative factor made it possible to predict this risk

Intravascular Leiomyomatosis with Intracardiac Extension

International audienceIntravenous leiomyomatosis (IVL) is a rare non-malignant tumor defined as a benign smooth muscle cell neoplasia in the veins. Patients with IVL may present with symptoms of a uterine leiomyoma such as pelvic pain and vaginal bleeding, or cardio-respiratory symptoms, including dyspnoea and legs swelling. We report the case of a 65 years-old otherwise healthy Caucasian woman. Past medical history consisted of hysterectomy and left salpingo-oophorectomy 15 years before for multiples uterine fibromyomas associated with leiomyoma of vascular origin. A thoraco-abdominal CT scan confirmed the presence of a mass, measuring 76x37x44 mm, arising from the inferior vena cava (IVC) at the level of the left renal vein extending all the way into the right atrium and right ventricle. At laparotomy,,a tumoural mass was excised from the left broad ligament up to the left renal vein and from the IVC up to its retro-hepatic tract. Sternotomy was performed and cardiopulmonary bypass (CPB) was established between ascending aorta, upper vena cava and right common femoral vein. After atriotomy, a voluminous and firm mass was excised from the right atrium, down to the level of the IVC. CPB was maintained for 80 minutes. Perioperative transfusion included two plasma and two red blood cells units. No adjuvant treatment was administered. Follow-up with annual CT scans was performed. Patient had no signs of recurrence after 3 year

Frey procedure combined with biliary diversion in chronic pancreatitis

International audienceBackground. The Frey procedure has become the standard operative treatment in chronic painful pancreatitis. Biliary diversion could be combined when associated with common bile duct obstruction. The aim of the present study was to evaluate the impact of the type of biliary diversion combined with the Frey procedure on late morbidity. Methods. The data from consecutive patients undergoing the Frey procedure and having a minimum follow-up of 2 years were extracted from a maintained prospective database. The mean endpoint was the rate of secondary biliary stricture after the Frey procedure combined with biliary diversion (bilioenteric anastomosis or common bile duct reinsertion in the resection cavity). Results. Between 2006 and 2013, 55 consecutive patients underwent the Frey procedure. Twenty-nine patients had common bile duct obstruction (52.7%). The technique of biliary diversion resulted in bilioenteric anastomosis in 19 patients (65.5 %) and common bile duct reinsertion in 10 patients (34.5 %). Preoperative characteristics and early surgical outcomes were comparable. Pain control was similar. There was significantly more secondary biliary stricture after common bile duct reinsertion than after bilioenteric anastomosis (60% vs 11 %, P = .008). Conclusion. Combined bilioenteric anastomosis during the Frey procedure is an efficient technique for treating common bile duct obstruction that complicates chronic painful pancreatitis. Bilioenteric anastomosis was associated with less secondary biliary stricture than common bile duct reinsertion in the pancreatic resection cavity

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