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Background: Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery. Methods: This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS. Results: A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R). Conclusion: ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS. [ABSTRACT FROM AUTHOR]

Blooms of Microcystis aeruginosa are prevalent in Lake Qaraoun, Lebanon, which poses a great danger to the environment and to the local population. The threat could be inverted onto an opportunity if an efficient method exists to turn microalgae into valuable fuel products. An experiment was conducted to optimize an efficient pyrolysis conditions to produce bio-fuel from such increasingly prevailing microalgae. Five pyrolysis tests were set, including two different temperatures of 400 and 500 °C, two flow rates of 0.3 and 0.6 ml/min, and three heating rates of 10, 15 and 20 °C /min. On the other hand, in order to further evaluate the quality of pyrolysis oil, three hydrothermal liquefaction (HTL) tests were run, including three temperatures of 200, 250 and 300 °C as well as three residence times of 1, 1.5 and 2 h. According to results, the high temperature and heating rate of 500 °C and 20 °C /min led to the highest quantity (32.5%) and quality, lowest amount of oxygen and highest heating value, of biocrude oil. Moreover, results of GC–MS analysis revealed that pyrolysis oil contained more straight chains and less oxygenated components; therefore, higher quality, than HTL oil. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic right colectomy (LRC) has become a gold standard. However, a major current concern is still whether anastomosis should be performed extracorporeally or entirely laparoscopically. This meta-analysis assesses and compares peri- and postoperative outcomes of intracorporeal anastomosis (IA) versus extracorporeal anastomosis (EA) in LRC. Methods: The research used the PubMed, Embase and Cochrane databases for studies comparing IA with EA during LRC. Our main endpoint was parietal abscess. Secondary endpoints were 30-day morbidity, mortality, time to onset of gas and stools, length of stay, number of lymph nodes removed and postoperative incisional hernia rates. The MINORS criteria were used to evaluate the quality of the studies examined. Results: Twenty-four articles comprising 3699 patients, published between 2004 and 2020, were included in this meta-analysis. After sensitivity analysis, IA was associated with a decrease in parietal abscesses (OR 0.526, IC 0.333–0.832, p = 0.006). Conclusion: This meta-analysis finds that IA allows a decrease in parietal abscesses and time to first gas and stools, surgical repair and length of stay, with similar overall complications. [ABSTRACT FROM AUTHOR]

Background: Defining severe postoperative ileus in terms of consequences could help physicians standardize the management of this condition. The recently described classification based on consequences requires further investigation. The aim of this study was to obtain a snapshot of postoperative ileus in patients undergoing colorectal surgery within enhanced recovery programs and to identify factors associated with non-severe and severe postoperative ileus. Methods: This prospective registry data analysis was conducted in 40 centers in five different countries. A total of 786 patients scheduled for colorectal surgery within enhanced recovery programs were included. The primary endpoint was the incidence rate of postoperative ileus as defined by Vather et al. Results: A total of 121 patients experienced postoperative ileus (15.4%). Non-severe POI occurred in 48 patients (6.1%), and severe postoperative ileus occurred in 73 patients (9.3%). In multivariate analysis, the male gender and intra-abdominal complications were associated with severe postoperative ileus: odd ratio (OR) = 2.03 [95% confidence interval (CI) 1.14–3.59], p = 0.01 and OR = 3.60 [95% CI 1.75–7.40], p < 0.0001, respectively. Conversely, open laparotomy and urinary retention were associated with non-severe POI: OR = 3.03 [95% CI 1.37–6.72], p = 0.006 and OR = 2.70 [95% CI 0.89–8.23], p = 0.08, respectively. Conclusions: Postoperative ileus occurred in 15% of patients after colorectal surgery within enhanced recovery programs. For 60% of patients, this was considered severe. The physiopathology of these two entities could be different, severe POI being linked to intraabdominal complication, while non-severe POI being linked with risk factors for "primary" POI. The physician should pay attention to male patients having POI after colorectal surgery and look for features evocating intraabdominal complications. [ABSTRACT FROM AUTHOR]

Aim: Enhanced recovery programmes (ERPs) were developed to improve the patient's post-operative comfort and reduce post-operative morbidity after several types of major surgery including the incisional hernia repair. The aim of this review was to describe the features of ERPs in the setting for incisional hernia repair.Methods: The literature review was conducted until March 2019, but retrieved very few papers (n = 4) on this topic. All studies were retrospective.Results: Setting and comorbidities of incisional hernia patients are of such importance in many cases that prehabilitation (including tobacco use cessation, management of obesity, diabetes or malnutrition) should play a greater role compared with other specialties. The other peri-operative measures are similar to other specialties but their implementation was very heterogeneous in the published studies.Conclusions: Like in other surgeries, ERPs were feasible and probably efficient to improve the post-operative course of incisional hernia patients. But the level of evidence remains low. [ABSTRACT FROM AUTHOR]

Aim: Enhanced recovery programmes (ERPs) involve early postoperative oral feeding. The aim of this study was to test the hypothesis that intolerance to early feeding was associated with a complicated postoperative course. Method: A retrospective cohort analysis of the prospective multicentre database developed by the Francophone Group for Enhanced Recovery after Surgery (GRACE) was undertaken. Seventy‐one centres in Belgium, France and Switzerland participated in the study. All patients were encouraged to eat within 24 h after surgery. Patients were separated into two groups according to whether early feeding was well tolerated (WT) or poorly tolerated (PT). The primary outcome measure was overall postoperative complications. Secondary outcome measures were unplanned reoperation, early mobilization rate and duration of postoperative hospital stay. Results: Among the cohort of 3034 patients, early feeding was WT in 2614 patients (WT group) and PT in 420 patients (PT group). There were significantly more postoperative complications in the PT group than in the WT group (52.1% vs 17.0%, respectively; P = 0.001), namely more unplanned reoperations, less early mobilization and longer postoperative hospital stay. Multivariate analyses confirmed that PT early feeding was the main and dominant independent factor for postoperative complications [OR 4.47 (95% CI3.49–5.72); P < 0.001], more unplanned reoperations and longer hospital stay. Conclusions: This study demonstrates a close relationship between intolerance to early feeding and a complicated postoperative course. Whenever this simple very early red flag is observed, discharge should not be planned until postoperative complications have been ruled out. [ABSTRACT FROM AUTHOR]

The article discusses studies finding concordant benefits of a combination of mechanical bowel preparation (MBP) and oral antibiotics (OA) in both colonic and rectal surgery. It states that the 2017 joint guidelines of the American Society of Colon and Rectal Surgeons, and the Society of American Gastrointestinal and Endoscopic Surgeons recommended the same. It argues about the lack of randomized controlled trials (RCTs) comparing the combination of MBP and OA in the surgeries.

Background Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. Methods An international working group within the Enhanced Recovery After Surgery ( ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation ( GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. Results The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. Conclusion The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research. [ABSTRACT FROM AUTHOR]

Background: In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and shorter hospital stay can be accomplished without an increase in morbidity or mortality. The purpose of this study was to review systematically the evidence for implementation of an ERAS protocol in pancreatic resections, with particular emphasis on pancreaticoduodenectomies (PDs). Methods: A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 and December 2012. The primary outcome measure was postoperative length of stay. Secondary outcome measures were time to recovery of normal function, overall postoperative complication rates, readmissions, and mortality. Subsequently, a meta-analysis of outcome measures focusing on PD was conducted. This systematic review and meta-analysis was performed according to the PRISMA statement. Results: The literature search produced 248 potentially relevant papers. Of these, eight papers met the predefined inclusion criteria: five case-control studies, two retrospective studies, and one prospective study, describing a total of 1,558 patients. Only three of the studies reported data on discharge criteria and assessed time to recovery and return to normal function. Implementation of an ERAS protocol led in four of five comparative studies to a significant decrease in length of stay (reduction of 2-6 days in different studies). Meta-analysis of four studies focusing on PDs showed that there was a significant difference in complication rates in favor of the ERAS group (absolute risk difference 8.2 %, 95 % confidence interval (CI) 2.0-14.4, p = 0.008). Introduction of an ERAS protocol did not result in an increase in mortality or readmissions. Delayed gastric emptying and incidence of pancreatic fistula did not differ significantly between groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS. Conclusions: This systematic review suggests that using an ERAS protocol in pancreatic resections may help to shorten hospital length of stay without compromising morbidity and mortality. This seemed to apply to distal pancreatectomy, total pancreatectomy, and PD. Meta-analysis was performed for those studies focusing on PD and showed that there were no differences in readmission or mortality. Morbidity rates were significantly lower for patients managed according ERAS principles. [ABSTRACT FROM AUTHOR]

Objective Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS. Method Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence. Results We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed. Conclusion We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices. [ABSTRACT FROM AUTHOR]

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Unplanned readmission after colorectal surgery is a relatively frequent event, knowledge of which often is inaccurate. This study was designed to examine the incidence and causes of readmissions and to determine the criteria that could predict them. From June to September 2002, 1,421 patients were enrolled in a prospective, multicenter study performed by the Association Francaise de Chirurgie. The goal of the study was to determine mortality and morbidity after colorectal surgery for elective or emergency surgical management of diverticular disease or cancer. In the study, readmissions within three months after discharge were assessed. Of 1,421 patients, 342 patients (27 percent) were readmitted once after a mean period of 53 days. Among the readmissions, 248 (19.5 percent) were planned and 94 (7.5 percent) were unplanned (mainly for septic complications). With the multivariate logistic regression analysis, five independent factors were significantly associated with a higher risk of unplanned readmission (in order of importance): surgical field contamination, long duration of operation, need for an associated surgical procedure, hemoglobin level <12 g/dl, and absence of air testing after colorectal anastomosis. The study permitted to individualize several factors significantly associated with a higher risk of unplanned readmission after colorectal surgery. [ABSTRACT FROM AUTHOR]

I Dear Editor, i Enhanced recovery programmes (ERPs) are no longer considered to be revolutionary [1] but are the reference standard of care for colorectal surgery patients. Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: The postoperative outcomes within enhanced recovery after surgery protocol (POWER) Study. [Extracted from the article]

I Dear Editor i , I read with interest the systematic review of the outcomes in robotic I vs i laparoscopic right colectomy for cancer, by Waters I et al i . The authors concluded that the patients undergoing robotic right colectomy had fewer anastomotic complications, better lymph node harvest, and reduced conversion rate and length of stay in "a number of studies". But one can ask, knowing the higher cost of robotic surgery for colectomy and the lack of benefits from the patients' perspective, do we really need a further randomized trial on robotic colectomy?. [Extracted from the article]

The article compares in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery, colectomy, for sigmoid diverticular disease (SDD) in France. The study concludes that a laparoscopic approach to elective treatment of SDD may be related to reduced postoperative morbidity and hospitalization.

Assesses whether such bowel preparation may safely be omitted before elective colorectal surgery. Evaluation of the use of polyethylene glycol (PEG) as bowel preparation; Association of senna with a postoperative septic complication rate similar to that of PEG;

Presents a comparison of heated with cold gas used after abdominal surgical procedures. Absence of pain reduction by gas heating; Inapplicability of study results previously made to gastrointestinal surgery; Findings on the benefit of analgesics when instilled during laparoscopic cholystectomy.

Background: Previous studies have suggested that gas temperature has an influence on postlaparoscopy pain. This trial therefore was conducted to study the effect of gas warming on pain after upper abdominal laparoscopic surgery.Methods: Patients who underwent laparoscopic cholecystectomy, fundoplication, or Heller's myotomy were included and randomly allocated to receive either warm or cold gas. Primary end point was shoulder tip pain, and secondary end points were subcostal, trocar wound, and visceral pains, as well as other postoperative events. Criteria of pain assessment were the visual analog scale, verbal rating scale, and amount of analgesics.Results: A total of 100 patients were suitable for postoperative evaluation. The groups were well matched. Shoulder tip and subcostal pains were significantly more intense after gas warming (p < 0.05). The three assessment criteria showed the same differences. No difference was observed concerning trocar wound and visceral pains and the other secondary end points. Subdiaphragmatic temperature was not significantly different (34.4 degrees with warming vs. 34 degrees without warming).Conclusions: Gas warming does not reduce, and probably increases, postoperative shoulder tip and subcostal pains. [ABSTRACT FROM AUTHOR]

Background: Previous studies have suggested that gas temperature has an influence on postlaparoscopy pain. This trial therefore was conducted to study the effect of gas warming on pain after upper abdominal laparoscopic surgery. Methods: Patients who underwent laparoscopic cholecystectomy, fundoplication, or Heller's myotomy were included and randomly allocated to receive either warm or cold gas. Primary end point was shoulder tip pain, and secondary end points were subcostal, trocar wound, and visceral pains, as well as other postoperative events. Criteria of pain assessment were the visual analog scale, verbal rating scale, and amount of analgesics. Results: A total of 100 patients were suitable for postoperative evaluation. The groups were well matched. Shoulder tip and subcostal pains were significantly more intense after gas warming ( p < 0.05). The three assessment criteria showed the same differences. No difference was observed concerning trocar wound and visceral pains and the other secondary end points. Subdiaphragmatic temperature was not significantly different (34.4° with warming vs. 34° without warming). Conclusions: Gas warming does not reduce, and probably increases, postoperative shoulder tip and subcostal pains. [ABSTRACT FROM AUTHOR]

A randomized, controlled trial is considered to be the “gold standard” to evaluate a new procedure. Thus, this critical review assessed whether the published randomized trials on laparoscopic appendectomy show that it is superior to the open approach.Twelve original articles involving a randomized, controlled trial on laparoscopic appendectomy in adults published between January 1990 and December 1996 were selected. We studied first whether each trial was positive (a procedure is superior to the other) or negative (no difference). We reviewed for each trial the methodology used and the following outcomes: operating time, intraoperative and postoperative complications, time until resumption of diet, postoperative pain, hospital stay, cost, and quality of life analyses. Post-operative morbidity was considered as the major primary outcome.There were six positive and six negative trials. Postoperative complication rates were similar, but the two approaches had specific potential complications, wound infections following open appendectomy, and intra-abdominal abscesses following laparoscopic appendectomy. This review failed to show a superiority of the laparoscopy for the other outcomes, particularly postoperative pain.Differences in positive trials concerned subjective and controversial outcomes, and the flaw in negative trials was their lack of power. Thus, nothing is definitively well established, even after 12 randomized trials. [ABSTRACT FROM AUTHOR]

Despite the huge number of articles published in this field, the superiority of robotic surgery over laparoscopic surgery was not demonstrated in several indications (e.g. colonic, bariatric, gastric surgeries)[2]. Hence, when a surgeon is faced with no strong argument for replacing laparoscopic with robotic surgery, should robotic surgery be presented as a validated option? This process integrates the best scientific data (regarding the superiority, or not of robotic surgery), surgeon expertise and patient preferences to obtain evidence-based decision making[4]. [Extracted from the article]

The timing of elective surgery of colonic diverticulitis in young patients remains controversial. The present meta-analysis aimed to answer the question whether these patients should be operated after the first attack or, more classically, after the second attack. Electronic databases were searched for papers reporting the results of surgery according to the strategies. Major endpoint was the performance of a colostomy (during unplanned surgery or for anastomotic dehiscence complicating elective surgery). Fifteen papers were selected for potential inclusion in the meta-analysis. But, eventually, only three papers gave information about the timing of surgery. Pooling the data of these 3 studies showed that 160 patients underwent elective surgery after the first attack and only 5 patients underwent subsequent emergent surgery at the course of their disease. Hence, no meta-analysis could be performed. Researchers should no longer attempt (like us) to answer this question by any meta-analysis. The failure of the present meta-analysis highlights the limitations of evidence-based surgery in some particular fields. [ABSTRACT FROM AUTHOR]

In the list of participating investigators that appears in Acknowledgements, one of the investigators names appears incorrectly. [ABSTRACT FROM AUTHOR]

A 54-year-old man underwent a therapeutic laparoscopy for giant diaphragmatic rupture complicating a blunt trunk trauma that had occurred 13 months earlier. Laparoscopy revealed a left hemidiaphragm 12-cm defect with an intrathoracic herniation of the omentum, the entire gastric fundus, the splenic flexure of the colon, and the two upper thirds of the spleen. The defect was not suitable for primary suture due to the diaphragmatic edges retraction. We repaired the hernia using a large polypropylene mesh covering the defect with 2-cm overlap. There was no intraoperative surgical or anesthetic complication. Postoperative course was uneventful and 3-month follow-up confirmed the healing of the diaphragmatic hernia. This case is discussed regarding the safety of the procedure, the best minimally invasive approach, and technical aspects of the repair. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Laparoscopic peritoneal lavage for perforated diverticulitis: are we any further forward?" by S Afshar , MA Kurer in the previous issue of year 2016.

A letter to the editor is presented in response to the article "Beyond enhanced recovery" by N. J. Smart and I. R. Damiels in a 2013 issue.

The article discusses the benefits of fast-track surgery on the basis of perioperative care. It states that reduced post-operative length of hospital stay is the major outcome of fast-track surgery. It further states that surgical stress is the cause for post operative organ dysfunction which can be overcome by giving regional anesthesia as it reduces cardiac demands, pain and pulmonary dysfunction. Preoperative assessment of morbidity is useful in determining risk of postoperative morbidity.

A letter to the editor is presented in response to the article "Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: A Systematic Review and Meta-Analysis" by J. T. Dang, N. J. Switzer, J. Wu and colleagues in the 2016 issue.

A letter to the editor in response to the article "Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years" by J. L. Dulucq, P. Wintringer and A. Mahajna, published in a previous issue of the journal is presented.

The authors reflect on the significance of laparoscopic revolution to the management of colorectal diseases. They argue that laparoscopic revolution become the new gold standard for the care of colonic diseases with a high level of evidence because of its mini-invasiveness and better postoperative comfort for surgical patients. Moreover, another improvement in colorectal surgery is the enhanced recovery protocol or the fast surgery approach, which gained worldwide acceptance.

A letter to the editor is presented in response to an article about the long-term results of a multicenter randomized clinical trial of stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy.

A letter to the editor is presented in response to the article "Laparoscopy for Abdominal Emergencies: Evidence-Based Guidelines of the European Association for Endoscopic Surgery," by S. Sauerland and colleagues.

The article focuses on the unsettled issues in the field of laparoscopic surgery. It claims that several studies and randomized clinical trials have already been made, but only few evidence-based laparoscopic guidelines were disseminated for use. British surgeons likewise criticized the guidelines issued by the National Institute for Clinical Excellence in Great Britain and in France. It suggests that clinical research must continue to get sound evidences for the laparoscopic field.

Presents a letter to the editor regarding laparoscopic surgery for colorectal cancer.

Presents an audit of randomized trials of digestive surgery in Europe. Lack of information on randomized trials of digestive surgery; Categorical classification of trials; Stability of trials on conventional surgical procedures.

By now, the feasibility of laparoscopic surgery in obese patients is well established; a conversion rate of 1.4-4.3% has been reported [1, 2]. The main reason for conversion in these cases is the difficulty encountered in exposing the gastroesophageal junction due to a huge fatty liver that covers the entire upper abdomen ("the invisible stomach" [1]). We report here a simple method that allows easy access to the upper stomach in such cases. This technique involves the exposure of the gastroesophageal junction using a laparoscopic suprahepatic route. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Reduction of wound infections in laparoscopic-assisted colorectal resections by plastic wound ring drapes (REDWIL)?-a randomized controlled trial," by J. C. Lauscher, and colleagues in the 2012 issue.

A letter to the editor is presented in response to articles about natural orifice transluminal endoscopic surgery.

A reply from K. Slim to a letter to the editor about his article "Laparoscopic Surgery Today," published in a previous issue of the "British Journal of Surgery," is presented.