[Show abstract][Hide abstract] ABSTRACT: Strong evidence has confirmed the benefit of laparoscopy in colorectal cancer resection but remains a challenging procedure. It is not clear that such promising results in selected patients translate into a favorable risk-benefit balance in real practice. We conducted a multicenter national observational registry to assess operative and oncologic long-term outcomes following laparoscopic colorectal cancer resection.
All patients with laparoscopic colorectal cancer resection between 2001 and 2004 were included. Data were extracted from the prospective Italian national database of 10 high-volume centers (≥40 colorectal cancer laparoscopic resections per year). Surgical technique and follow-up were standardized. Survivals were analyzed by Kaplan-Meier method.
We reported 1832 patients with colon (58.5 %) and rectal cancer (41.5 %). TNM stage was 0-I-II in 1044 patients (57 %) and III-IV in 788 patients (43 %). Surgery included a totally laparoscopic procedure in 1820 patients (99.3 %). Conversion was 10.5 %. Postoperative morbidity and 30-day mortality rates were 17 and 1.2 %, respectively. Clinical anastomotic leakage rate was 8.3 % (n = 152). R0 resection was 95 %. With a median follow-up of 54.2 months, cancer recurrence rate was 13.3 %. At 5 years, cancer-free survival was 86.7 %. Upon multivariate analysis, age (P = 0.001) and TNM stage (P < 0.001) were associated with cancer-free survival. Predictive factors of cancer recurrence were gender (P = 0.029) and TNM stage (P < 0.001).
In high-volume centers and non-selective patients, laparoscopic colorectal resection for cancer achieves good operative results with satisfactory long-term oncologic results. Even in the laparoscopy era, age, gender, and TNM stage remain the most powerful predictor of oncologic outcomes.
No preview · Article · Mar 2015 · World Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Background
Laparoscopic peritoneal lavage has been proposed for generalized peritonitis from perforated diverticulitis to avoid a stoma. Reports of its feasibility and safety are promising. This study aimed to establish determinants of failure to enable improved selection of patients for this approach.Methods
The study included all patients with perforated sigmoid diverticulitis who underwent emergency laparoscopic peritoneal lavage from January 2000 to December 2013. Factors predicting failure of laparoscopic treatment were analysed from data collected retrospectively.ResultsFor patients undergoing emergency sigmoid resection (72 of 361), mortality and morbidity rates were 13 and 35 per cent respectively. In all, 71 patients had laparoscopic lavage, with mortality and morbidity rates of 6 and 28 per cent respectively. Reintervention was necessary in 11 patients (15 per cent) for unresolved sepsis. Age 80 years or more, American Society of Anesthesiologists grade III or above, and immunosuppression were associated with reintervention.Conclusion
Elderly patients and those with immunosuppression or severe systemic co-morbidity are at risk of reintervention after laparoscopic lavage.
No preview · Article · Sep 2014 · British Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: The most serious complication of acute mesenteric vein thrombosis (MVT) is acute intestinal ischemia requiring intestinal resection or causing death. Risk factors for this complication are unknown.
to identify risk factors for severe intestinal ischemia leading to intestinal resection in patients with acute MVT.
We retrospectively analysed consecutive patients seen between 2002 and 2012 with acute MVT in 2 specialized units. Patients with cirrhosis were excluded. We compared patients who required intestinal resection to patients who did not.
Among 57 patients, a local risk factor was identified in 14 (24%) patients, oral contraceptive use in 16 (29%), and at least one or more other systemic pro-thrombotic condition in 25 (44%). Five (9%) patients had diabetes mellitus (DM), 33 (58%) had overweight or obesity, 9 (18%) had hypertriglyceridemia, 10 (19%) had arterial hypertension. Eleven patients (19%) underwent intestinal resection. DM was significantly associated with intestinal resection (p=0.02) while local factors or pro-thrombotic conditions were not. Computed tomography (CT) scans performed at diagnosis found that occlusion of second order radicles of the superior mesenteric vein was more frequently observed in patients who underwent intestinal resection (p=0.009).
n acute MVT, patients with underlying DM have an increased risk of requiring intestinal resection. Neither local factors nor systemic pro-thrombotic conditions are associated to intestinal resection. When CT scan shows the preservation of second order radicles of the superior mesenteric vein, the risk of severe resection is low. This article is protected by copyright. All rights reserved.
No preview · Article · Nov 2013 · Liver international: official journal of the International Association for the Study of the Liver
[Show abstract][Hide abstract] ABSTRACT: A pathologic complete response (pCR) can be observed in up to 25% of patients after preoperative chemoradiotherapy for rectal cancer and is associated with an improved long-term prognosis. However, few data are available regarding the effect of pCR on postoperative morbidity. This study aimed to assess the impact of the pCR on postoperative outcomes after laparoscopic total mesorectal excision (TME).
A prospectively maintained database (2006-2011) was reviewed for all consecutive patients (n = 143) undergoing laparoscopic TME for mid or low rectal cancer after neoadjuvant chemoradiotherapy. Postoperative data were compared for pCR-group and non-pCR-group. A pCR was defined as the absence of gross and microscopic tumor in the specimen, irrespective of the nodal status (ypT0).
Thirty-three patients (23%) had a pCR. Median operating time was greatly shorter in the pCR-group (230 minutes, 180-360), compared with the non-pCR-group (240 minutes, 130-420, P = .02). Lymph node involvement was noted for 12% of the patients in the pCR-group and 33% of the patients in the non-pCR-group (P = .91). Clavien Dindo grade 3 and 4 complications (6% vs 22%, P = .04), infection related morbidity (47% vs 76%, P = .04), and clinical anastomotic leakage rates (9% vs 29%, P = .02) were lesser in the pCR group compared with the non-pCR group. Mean duration of hospital stay was lesser in the pCR-group (9 vs 12 days, P = .01).
This study showed that Clavien Dindo grade 3 and 4 complications, including anastomosis leakage, and infection related complications rates were lesser in patients with pathologic complete response after RCT and laparoscopic TME for rectal cancer.
[Show abstract][Hide abstract] ABSTRACT: Postoperative computed tomography (CT) scan patterns after colorectal resection are difficult to analyze for both clinicians and radiologists. This study aimed to assess the role of single CT scan on postoperative day 5 in predicting postoperative morbidity.
From October 2007 to August 2009, 78 patients undergoing laparoscopic colorectal resection were enrolled in a research study involving a routine contrast-enhanced multi-detector CT scan on postoperative day 5. Two groups were defined: patients with intra-abdominal postoperative morbidity requiring specific management, i.e., surgical or radiological procedure, and/or antibiotic therapy ("complications" group), and patients with uneventful postoperative outcome ("uneventful" group). CT findings were compared between the two groups with Fisher's exact test or chi-square test.
Postoperative abdominal complications occurred in 16 patients (21 %). Of the CT findings on day 5, pneumonia, pulmonary embolism, portal or mesenteric thrombosis, operative area fat infiltration, peritoneal effusion, pneumoperitoneum, intra-abdominal collection, parietal inflammation or collection, and subcutaneous emphysema were observed in both groups without any significant difference. Only small bowel distension [25 % (4/16) in the "complications" group vs. 5 % (3/62) in the "uneventful" group; p = 0.029] and pleural effusion [81 % (13/16) vs. 48 % (30/62); p = 0.024, respectively] were observed significantly more often in the "complications" group.
This study suggested that abdominal complications cannot be predicted by a CT scan on day 5 after laparoscopic colorectal resection. Thus, it cannot be recommended for routine use.
No preview · Article · Jul 2013 · Techniques in Coloproctology
[Show abstract][Hide abstract] ABSTRACT: Background:
Laparoscopic ventral rectopexy for rectal prolapse combines the advantages of a minimally invasive approach with the low recurrence rate observed after abdominal procedures. To date, only a few long-term functional studies and no quality of life assessment are available. The aim of this study was to assess long-term functional outcomes and quality of life after laparoscopic ventral rectopexy.
Between January 2007 and December 2008, patients who underwent laparoscopic ventral rectopexy for full-thickness external rectal prolapse and/or rectocele were prospectively included. Fecal incontinence and constipation were scored (Wexner score and Rome II criteria). Quality of life was assessed using the gastrointestinal quality of life form (GIQLI).
Thirty-three patients were included and 30 (91 %) completed all the questionnaires. There was no morbidity or mortality. The mean length of hospital stay was 5 ± 1 days (range 3-7 days). After a mean follow-up of 42 ± 7 months (range 32-52 months), recurrence of rectocele was observed in two patients (6 %). At the end of follow-up, constipation was improved in 13/18 patients (72 %) and two patients (7 %) presented de novo constipation. The patients' Wexner score improved between preoperative status and end of follow-up (12 ± 7 vs. 4 ± 3, p = 0.002). Compared to the preoperative score, quality of life significantly improved over time: 77 ± 21 preoperatively versus 107 ± 17 at 1 year versus 109 ± 18 at the end of follow-up (p < 0.001).
This prospective study showed that laparoscopic ventral rectopexy was associated with excellent postoperative outcomes and a low long-term recurrence rate. Long-term functional results were excellent in terms of continence, with significant improvement of quality of life and without worsening constipation.
No preview · Article · Jan 2013 · Techniques in Coloproctology
[Show abstract][Hide abstract] ABSTRACT: This study aimed to develop a new model of colorectal liver metastases (LM) in the rat. Both single macroscopic and multiple bilobar microscopic LM were investigated, as this closely resembled the human situation, before right hepatectomy was performed for 'single' right LM. The single macroscopic LM was elicited by direct injection of DHD/K12 colorectal cancer cells under the capsule of the median liver lobe in immunocompetent BDIX rats. The bilobar micrometastases were elicited by intraportal injection of DHD/K12 cells. A preliminary protocol was conducted to assess the dose of cells required to inject in to the portal vein, using 10(6) , 2 × 10(6) and 3 × 10(6) DHD/K12 cells (n = 15 rats). The resultant protocol for the experimental model used intraportal injection of 10(6) DHD/K12 cells and direct injections of 0.5 × 10(6) , 10(6) and 1.5 × 10(6) DHD/K12 cells (n = 15 rats). For both protocols, BDIX rats were sacrificed at day 30 after injection. The preliminary protocol showed that intraportal injection of 10(6) DHD/K12 cells was associated with bilobar micrometastases of 0.8 mm mean diameter at day 30. The main protocol assessed that direct injection of 0.5 × 10(6) under the liver median lobe capsule and intraportal injection of 10(6) DHD/K12 cells were associated at day 30 with a single macroscopic metastasis confined to a liver lobe and bilobar micrometastases, without peritoneal carcinomatosis or lung metastasis. Thus we have developed a new experimental model of bilobar colorectal LM including both macro- and microscopic colorectal LMs, which mimics the human situation and which will be useful in preclinical studies.
No preview · Article · Dec 2012 · International Journal of Experimental Pathology
[Show abstract][Hide abstract] ABSTRACT: La transplantation intestinale peut être isolée, combinée à une transplantation hépatique, ou multiviscérale. Bien qu’elle soit le traitement radical de l’insuffisance intestinale, le traitement de première intention de cette pathologie est la nutrition parentérale et les indications de transplantation restent débattues. Une étude récente a cependant retenu l’insuffisance hépatique associée à l’insuffisance intestinale et la présence d’une tumeur desmoïde comme les deux situations mettant en jeu le pronostic vital et devant faire poser une indication de transplantation. Dans cette même étude, la transplantation pour intestin grêle extrêmement court et pour complications sur cathéter de nutrition parentérale n’apporte pas de bénéfice en termes de survie et reste à évaluer de manière plus complète. Si la greffe intestinale a vu ses résultats à court terme s’améliorer considérablement (la survie des malades à un an est actuellement de 80 % en cas de transplantation d’intestin grêle isolée contre 0 à 28 % dans les années 1980), les résultats à long terme n’ont pas beaucoup évolué depuis les années 1990 et l’introduction du tacrolimus, et la survie à cinq ans des malades ne dépasse actuellement pas 60 %. Certaines pistes pourraient améliorer ces résultats telles que le choix de la greffe multiviscérale, l’ajout du sirolimus ou des thymoglobulines dans le traitement immunosuppresseur d’induction, ou bien l’utilisation de nouveaux marqueurs biologiques pour une détection précoce de rejet du greffon.
No preview · Article · Dec 2012 · Journal de Chirurgie Viscerale
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Segmental reversal of the small bowel (SRSB) is proposed in patients with short-bowel syndrome (SBS) as a rehabilitative therapy, but its effects on absorption have not been studied. OBJECTIVE: We aimed to determine intestinal macronutrient absorption and home parenteral nutrition (HPN) dependence in SBS patients with intestinal failure. DESIGN: We included in a retrospective study all consecutive patients who had an SRSB between 1985 and 2010 and underwent a study of macronutrient absorption. Patients were matched to SBS controls with the same digestive characteristics. Energy and macronutrient absorption were measured. The dependence on HPN was expressed by the number of infusions per week and by the calories infused daily divided by the basal energy expenditure multiplied by 1.5. RESULTS: Seventeen patients who had an SRSB were matched to 17 control patients. Intestinal absorption was higher in the SRSB group for total calories (69.5% compared with 58.0%), fat (48.4% compared with 33.2%), and protein (62.7% compared with 53.4%) (P < 0.05). Median oral autonomy was 100% ± 38.4% in the SRSB group, whereas it was 79% ± 39.6% in the control group (P < 0.05). The number of calories infused was lower in the SRSB group (500 ± 283 compared with 684 ± 541; P < 0.05), as was HPN dependence (33% ± 20% compared with 48% ± 38%; P < 0.05) at the time of the study. CONCLUSION: SRSB allows a gain in macronutrient absorption, which is associated with a lower HPN dependence. To our view, SRSB should be integrated in intestinal rehabilitative adult programs.
No preview · Article · Nov 2012 · American Journal of Clinical Nutrition
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Management of chronic radiation enteritis is often controversial, particularly due to the risk of short bowel syndrome. METHODS: One hundred and seven chronic radiation enteritis patients with short bowel syndrome were studied retrospectively between 1980 and 2009. Survival and home parenteral nutrition dependence rates were evaluated with univariate and multivariate analysis. RESULTS: The survival probabilities were 93%, 67% and 44.5% at 1, 5 and 10 years, respectively. On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR=0.21 [0.11-0.38], p<0.001), an American Society of Anesthesiologists score >3 (HR=0.38 [0.20-0.73], p=0.004) and an age of chronic radiation enteritis diagnosis >60 years (HR=0.45 [0.22-0.89], p=0.02). The actuarial home parenteral nutrition dependence probabilities were 66%, 55% and 43% at 1, 2 and 3 years, respectively. On multivariate analysis, this dependence was significantly decreased when there was a residual small bowel length >100cm (HR=0.35 [0.18-0.68], p=0.002), adaptive hyperphagia (HR=0.39 [0.17-0.87], p=0.02) and the absence of a definitive stoma (HR=0.48 [0.27-0.84], p=0.01). CONCLUSION: The survival of patients with diffuse chronic radiation enteritis after extensive intestinal resection was good and was mainly influenced by underlying comorbidities. Almost two-thirds of patients were able to be weaned off home parenteral nutrition.
No preview · Article · Nov 2012 · Digestive and Liver Disease
[Show abstract][Hide abstract] ABSTRACT: Intestinal transplantation (IT) can involve small bowel transplantation alone, or be associated with liver or multivisceral transplantation. Although IT is the radical treatment for intestinal failure, home parenteral nutrition (PN) remains the treatment of choice for this disease. Indications for IT are still debated. A recent study showed that early referral for IT is recommended for patients with life-threatening combined liver and intestinal failure or for patients with invasive intra-abdominal desmoid tumors. In the same study, no survival benefit was shown for patients undergoing IT for ultra-short bowel or major complications related to the PN catheter; indications still need to be fully assessed. While short-term outcomes for IT have improved dramatically (one-year survival for small bowel-alone IT is now 80% versus 0-28% in the 1980s), long-term outcomes have not improved much since the introduction of Tacrolimus in the 1990s: five-year survival still does not exceed 60%. Some prospective developments could improve these results: the use of multivisceral grafts, the use of Sirolimus and Thymoglobulins in the immunosuppressive treatment, or the use of new biochemical markers for early diagnosis of graft rejection.
No preview · Article · Nov 2012 · Journal of Visceral Surgery
[Show abstract][Hide abstract] ABSTRACT: : This study aimed to assess the results of segmental reversal of the small bowel (SRSB) in patients with short bowel syndrome (SBS) who were "permanently" dependent on parenteral nutrition (PN) and to identify possible prognostic factors for weaning.
: SRSB is a nontransplant surgical option for patients with SBS who require long-term PN. Few studies have reported outcomes in humans.
: All patients who were permanently dependent on PN and underwent a SRSB between 1985 and 2010 for SBS were included. The data were retrospectively retrieved.
: Thirty-eight patients underwent SRSB. The median age was 55.5 years (range, 18-76). The median length of the small bowel remnant was 49 cm (20-140), including a reversed segment of 10 cm (6-15). The median follow-up was 57.7 months (1-304). At the 5-year follow-up, 17 patients had been weaned from PN (45%). In the remaining patients, PN dependency had decreased from 7 ± 1 to 4 ± 1 days per week. The survival rate was 84%. The prognostic factors for weaning were a short time between subtotal enterectomy and SRSB (P = 0.036), a longer than typical stay in the nutrition unit (P = 0.035), and an SRSB longer than 10 cm (P = 0.024).
: SRSB has a role as a conservative alternative to small bowel transplantation in patients with SBS permanently dependent on PN. With a segmental reversal of 10 to 12 cm, almost half of the patients can be expected to be weaned from PN.
No preview · Article · Nov 2012 · Annals of surgery
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND & AIMS: Acute mesenteric ischemia (AMI) is an emergency with high mortality; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multi-modal management approach, focused on intestinal viability. METHODS: We developed a multi-modal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, non-occlusive AMI, chronic mesenteric ischemia and other emergencies were excluded. Patients received specific medical management, revascularization of viable small bowel, and/or resection of non-viable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients that survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidities. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early- or late-stage disease. RESULTS: Patients were followed for a mean of 497 days (range, 7-2085 days); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P=.03). Among patients with early- or late-stage AMI, rates of resection were 18% and 71%, respectively (P=.049). Patients with early-stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm, P=.02), and spent less time in intensive care (49.8 vs 2.5 days, P=.02). CONCLUSION: A multidisciplinary and multimodal management approach might increase survival times of patients with AMI, preventing intestinal failure in acute mesenteric ischemia.
No preview · Article · Oct 2012 · Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association
[Show abstract][Hide abstract] ABSTRACT: Aim:
This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS).
From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay.
A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849).
This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.
No preview · Article · Jun 2012 · Colorectal Disease
[Show abstract][Hide abstract] ABSTRACT: Aim Single-incision laparoscopy for colorectal surgery is of growing importance. The experience of colorectal resection through single-incision laparoscopic surgery was assessed, including the patient outcomes. Method A meta-analysis was performed of studies comparing single-incision laparoscopic with multiport laparoscopy. Endpoints included conversion to laparotomy, operation time, postoperative morbidity, length of skin incision and length of hospital stay. The MEDLINE database was searched and only comparative studies were included in the meta-analysis. Data were retrieved from full-text manuscripts. Meta-analysis was performed according to the Mantel-Haenszel method for random effects. Results From October 2008 to December 2011, 1026 colorectal resections including 921 colonic and 105 rectal procedures using single-incision laparoscopic surgery were reported in 64 studies. Meta-analysis of the 15 comparative studies, including a total of 1075 procedures (494 single-incision and 581 multiport laparoscopies), showed no difference in conversion to open laparotomy [odds ratio (OR) 0.58 (0.24, 1.38); P = 0.22], morbidity [OR 0.84 (0.61, 1.15); P = 0.27] or operation time [weighted mean difference (WMD) -0.27 (-6.50, 5.95); P = 0.93], but a significantly shorter total skin incision [WMD -0.52 (-0.79, -0.25); P < 0.001] and a significantly shorter postoperative length of stay [WMD -0.75 (-1.30, -0.20); P = 0.008] after single-incision laparoscopic surgery compared with a multiport laparoscopic approach. Conclusion Although only 15 nonrandomized comparative studies of varying methodology have been reported, this systematic review and meta-analysis of more than 1000 colorectal procedures suggest that single-incision laparoscopic colorectal surgery is feasible and safe.
No preview · Article · May 2012 · Colorectal Disease
[Show abstract][Hide abstract] ABSTRACT: L’exérèse rectale avec exérèse du mésorectum est le traitement de référence du cancer du rectum. Si l’exérèse locale constitue une alternative séduisante avec des résultats opératoires excellents sans risque de séquelles fonctionnelles digestives, elle fait l’impasse pourtant sur un éventuel envahissement ganglionnaire. Ainsi, il faut impérativement rechercher sur la pièce opératoire les critères histopronostiques défavorables (c’est-à-dire corrélés à un risque élevé de métastase ganglionnaire): infiltration profonde de la sous muqueuse (T1sm3), marges de résection envahies, emboles vasculaires et/ou lymphatiques. Une proctectomie complémentaire doit être proposée en cas de présence d’au moins un ou plusieurs critères défavorables. La microchirurgie endoscopique (TEM) permet l’exérèse locale de tumeurs du moyen et haut rectum, inaccessibles par voie transanale conventionnelle avec une meilleure qualité d’exérèse chirurgicale.