RISQUE DE LA CHIRURGIE COLO-RECTALE ELECTIVE POUR CANCER CHEZ LE CIRRHOTIQUE (DES CHIRURGIE GENERALE)

PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Emphysematous cholecystitis Colecistite enfisematosa

BACKGROUND: Emphysematous cholecystitis is life-threatening condition characterized by gas-forming infection of the gallbladder. It is mostly seems in old male patients with systemic, specially diabetes and vascular diseases. CASE REPORT: - A 30-year-old man without previous diseases was admitted because of right upper quadrant pain and nausea. On admission the patient was febrile (38.7o) with normal bilirubin levels. The white blood count was 26700/µl and reactive protein C was 470. Axial sections of single slice computed tomography imaging (section thickness 5 mm), revealed gallbladder wall enhancement after i.v. contrast, as well as dilatation of the gallbladder with intraluminal air. The patient underwent open cholecystectomy. The culture of the bile showed clostridium perfringes. The postoperative course of the patient was uneventful. CONCLUSION: This is a rare form of cholecystitis that carries a high mortality and usually present insidious clinical signs. CT is the most accurate imaging technique. Antibiotic therapy should begin quickly and include coverage of common pathogens, particularly Clostridia. Surgical intervention should take place as early as possible.<br>INTRODUÇÃO: Colecistite enfisematosa é uma condição de risco de vida caracterizada por infecção da vesícula biliar por agentes produtores de gás. Na sua apresentação mais comum atinge preferencialmente homens idosos portadores de doenças sistêmicas em especial diabetes e vasculopatias. RELATO DO CASO: Paciente do sexo masculino, 30 anos de idade e sem co-morbidades que se apresenta ao pronto-socorro com história de dor abdominal em hipocôndrio direito há cinco dias, febre (38,7o) e náuseas. Os exames laboratoriais mostravam leucocitose (26700/µl) e elevação dos marcadores de inflamação (proteína C reativa, PCR 470). A tomografia computadorizada do abdome revelou realce da parede vesicular após injeção de contraste i.v., bem como dilatação da vesícula com a presença de ar intraluminal. O paciente foi submetido à colecistectomia através de incisão subcostal direita. A cultura da bile foi positiva para Clostridium perfringes. A evolução pós-operatória do paciente foi satisfatória. CONCLUSÃO: Esta é uma rara forma de colecistite com alta mortalidade e usualmente se apresenta com sinais clínicos insidiosos.Tomografia computadorizada é a mais acurada forma de diagnóstico de imagem. Antibioticoterapia de largo espectro deve começar rapidamente incluindo proteção à Clostridia. Procedimento cirúrgico deve ser indicado tão cedo quanto possível

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

International audienceAIM: Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME.METHODS: From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared.RESULTS: Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15).CONCLUSION: Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases

Management of postoperative bladder emptying after proctectomy in men for rectal cancer. A retrospective study of 190 consecutive patients

International audiencePurposeEvaluation of urinary drainage after rectal resection and identification of criteria associated with postoperative urinary dysfunction (UD). UD remains a clinical problem for up to two thirds of patients after rectal resection. Currently, there are no guidelines concerning duration or type of drainage.MethodsOne hundred ninety consecutive rectal resections (abdomino-perineal resection (APR = 47), mechanical coloanal anastomosis (MechCAA = 48), manual coloanal anastomosis (ManCAA = 47), colorectal anastomosis (CRA = 48)) in male patients were included. In patients with a transurethral catheterization (TUC), the drainage was removed at day 5. Patients with a suprapubic catheterization (SPC) underwent drainage removal according to the results of a clamping test at day 5. UD was defined as drainage removal after day 6 and/or acute urinary retention (AUR).ResultsDrainage types were SPC (n = 136, 72 %) and TUC (n = 54, 28 %). SPC was used more frequently after total mesorectal excision (TME) (APR, ManCAA, MechCAA) (83–92 %). Complications rates of SPC and TUC were 20 and 9 %. The clamping test was positive for 61 patients (48 %), and SPC was removed before/on POD6 without any episode of AUR. After TUC removal, two patients (4 %) had AUR. Seventy-two (38 %) patients had UD: 11 (6 %) were discharged with an indwelling catheter, and in 61 (32 %), the catheter was removed after day6. Three independent factors were associated with UD: diabetes (OR = 2.9 (1.2–7.7)), urological history (OR = 2.9 (1.2–7.6)), and TME (OR = 5.2 (2.3–13.5)).ConclusionThe UD rate after surgery for rectal cancer was 38 %. The clamping test is accurate to prevent AUR after SPC removal. The three risk factors may serve to select good candidates for early catheter removal

Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study

Abstract Background Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis. Methods A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol. Results Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively). Conclusion In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design

Does An Ileo-anal Anastomosis Decrease the Rate of Successful Pregnancy Compared to an Ileorectal Anastomosis? A National Study of 1,491 Patients

International audienceObjective: Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileo-rectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis.Summary Background Data: Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach.Methods: All women (age: 12-45 y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis.Results: 1,491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months [39-100]. After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: HR=0.79, 95%CI=0.56-1.11, P=0;17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95%CI=1.20-2.63, P=0.004). IRA and IPAA significantly impacted fertility when compared to the control population (P<0.001).Conclusions: In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared to the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy

Management of Acute Appendicitis in Ambulatory Surgery: Is It Possible? How to Select Patients?

International audienceObjective: Establish a protocol of management of acute appendicitis (AA) in ambulatory surgery (AmbSurg) on the basis of preoperative criteria.Background: Ambulatory laparoscopic appendectomy (LA) for AA has not been yet reported.Methods: All patients who underwent LA between 2010 and 2012 were reviewed. A multivariate analysis was performed to create a predictive score of discharge within the first 24 hours. The score was prospectively used on every AA from January 1, 2013, to December 15, 2013. All patients with 5 or 4 points were proposed for AmbSurg.Results: A total of 468 patients were included retrospectively, 181(38.7%) were discharged within the first 24 hours. In multivariate analysis, predictive factors of early discharge were body mass index less than 28 kg/m2, white cell count less than 15,000/mL, C-reactive protein less than 30 mg/L, no radiological signs of perforation, and appendix diameter of 10 mm or smaller. Rate of discharge at day 1 was 72%, 45%, 39%, 21%, 0%, and 0% according to the score 5 to 0 (P < 0.0001). Prospectively, 184 patients had AA and 103 (56%) had a score of 4 or 5. Thirty-eight underwent ambulatory LA [16 (42%) patients were postponed to the next day and went back home]. All patients were directly discharged from recovery room, except 1 (2.6%) patient, after a mean hospital stay of 8.4 hours ± 6.9 hours. A total of 146 patients underwent LA in conventional surgery and 58% were discharged at day 1. Rate of early discharge was significantly associated with the score ranging from 0% to 92% for a score 0 or 5, validating prospectively the score (P < 0.0001).Conclusions: We establish a simple validated predictive score of early discharge. When applied to AmbSurg, it allowed us to select patients eligible with a success rate of 97%