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Summary Background Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA). Methods This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA. Results Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P = 0.04). The rates of severe complications (26.9% vs. 26.3%, P = 0.96) and anastomotic leakage (42.3% vs. 31.6%, P = 0.46) were not different between the two groups. Conclusion This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.

The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer.In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019.More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long.

Urethro-rectal fistula (URF) is a rare but serious condition whose treatment is poorly codified. This study aims to evaluate the short and long-term results of multidisciplinary management.We retrospectively collected the records of patients with URF operated on at the University Hospital of Tours between January 1, 2000 and January 1, 2020. Short-term and long-term results according to management are reported.The study included 20 patients. As an initial gesture, 11 patients underwent bladder catheterization and colostomy, seven underwent bladder catheterization alone, one underwent graciloplasty, and one, a York Mason procedure. The success rate of initial conservative management was only 5% (1/20). As a secondary or tertiary intervention, ten patients underwent a York Mason procedure and nine underwent graciloplasty. At the end of the study period, with a median follow-up of 50 months, 19 had been effectively treated for URF, 16 were able to have colostomy closure with restoration of digestive continuity while four had a permanent stoma. One patient had anal incontinence, 14% had major stress urinary incontinence.Multidisciplinary care remains a cornerstone of the treatment of URF because iterative surgeries may be required, with an overall success rate of up to 95% at the end of follow-up.

Summary Context Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied. Goal The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD. Methods A retrospective study was performed in women with CD who gave birth in a French “Level 3” maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score ≥ 9 or a St. Mark's score ≥ 9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses. Results Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR = 8.89, 95% (CI: 1.03–76.57) and crude OR = 4.16, 95% (CI: 1.06–16.27) respectively for AI defined by the Wexner score, and crude OR = 6.8, 95% (CI: 1.30–35.41) and crude OR = 4.3, 95% (CI: 1.23–15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR = 22.86, 95% CI: 1.52–931.28 for a Wexner score ≥ 9 and adjusted OR = 16. 11 (95% CI: 1.43–533.26) for a St Mark score ≥ 9). Conclusion Vaginal birth was associated with the development of severe long-term AI in women with CD.

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset.Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content200μg per gram of feces while EndoPI was defined as fasting glucose126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry.The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI.ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.

Summary Aim of the study Right colonic Diverticulitis (RD) is rare in Europe; few studies have focused on it and its management is not standardised. The aim of this study was to analyse the clinical presentation (complicated, uncomplicated), acute phase management and long-term outcome of RD in western countries. Patients and methods From 2003 to 2017, 93 consecutive patients who presented with RD were retrospectively included at 11 French Hospital Centres. Results The study population consisted of two groups: Uncomplicated Right Diverticulitis (URD) group (63.5%, (n = 59)) and Complicated Right Diverticulitis (CRD) group (36.5%, [n = 34]). 84.7% (n = 50/59) of URD were treated conservatively. 41.2% (n = 14/34) of patients with CRD had emergency surgery (mostly laparotomy) for Hinchey III peritonitis, clinical intolerance or hemodynamic instability. Altogether 5.2% (n = 2/34) patients with CRD had surgery after a cooling off period (initially abscess). The overall rate of severe postoperative complications was low (8%). Recurrence rate was low and comparable in both groups: 6.8% (n = 4/59) for URD and 8.8% (n = 3/34) for CRD, all recurrences occurred in the same locations with an uncomplicated form, 42.9% (n = 3/7) of them had elective laparoscopic surgery and the rest were conservatively treated. Median follow up was 33.2 months. Conclusion Conservative treatment can be proposed safely and efficiently for URD and for selected patients with CRD. Surgery should be reserved for unstable patients or patients with severe forms of complicated diverticulitis in emergency.

Summary Objective Ventral incisional hernia is a common complication of abdominal surgery. The incidence ranges from 2% to 20% and varies greatly from one series to another. The goal of this study was to determine the incidence, risk factors, and preventive measures for ventral incisional hernia. Materials and methods An analysis of the surgical literature was performed using the search engines EMBASE, Cochrane Library, and PubMed with the keywords: abdominal hernia, wound dehiscence, incisional hernia, incidence, trocar site hernia, and hernia prevention. Results The overall incidence of incisional hernia after laparotomy was 9.9%. The incidence was significantly higher for midline incisions compared with transverse incisions (11% vs. 4.7%; P = 0.006). In contrast, the incidence of ventral hernia was only 0.7% after laparoscopy. A compilation of all the studies comparing laparotomy to laparoscopy showed a significantly higher incidence of incisional hernia after laparotomy ( P = 0.001). Independent risk factors for incisional hernia included age and infectious complications. Only two meta-analyses were able to show a significant decrease in risk-related to the use of non absorbable or slowly absorbable suture material. No difference in incisional hernia risk was shown with different suture techniques (11.1% for running suture, 9.8% for interrupted sutures: NS). Conclusion A review of the literature shows that only the choice of incisional approach (transverse incision or laparotomy vs. midline laparotomy) allows a significant decrease in the incidence of ventral incisional hernia.

Summary Introduction Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. Methods A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords “adhesion” and “surgery”. Results Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65–75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93–100% of upper abdominal laparotomies and after 67–93% of lower abdominal laparotomies. Nevertheless, only 15–18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm ® ) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. Conclusions The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.