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Malabsorption is a consequence of gastric bypass (GB). GB increases the risk of kidney stone formation. This study aimed to evaluate the accuracy of a screening questionnaire for assessing the risk of lithiasis in this population. We performed a monocentric retrospective study to evaluate a screening questionnaire administered to patients who underwent gastric bypass surgery between 2014 and 2015. Patients were asked to answer a questionnaire that included 22 questions divided into four parts: medical history, episodes of renal colic before and after bypass surgery, and eating habits. A total of 143 patients were included in the study, and the mean age of the patients was 49.1 ± 10.8 years. The time between gastric bypass surgery and the completion of the questionnaire was 50.75 ± 4.95 months. The prevalence of kidney stones in the study population was 19.6%. We found that with a score of ≥6, the sensitivity and specificity were 92.9% and 76.5%, respectively. Positive and negative predictive values were 49.1% and 97.8%, respectively. The ROC curve showed an Area Under the Curve (AUC) of 0.932 ± 0.029 (p < 0.001). We developed a reliable and short questionnaire to identify patients at a high risk of kidney stones after gastric bypass. When the results of the questionnaire were equal to or greater than six, the patient was at a high risk of kidney stone formation. With a good predictive negative value, it could be used in daily practice to screen patients who have undergone gastric bypass and are at a high risk of renal lithiasis.

Few studies have evaluated the association between non-clinical and clinical determinants in terms of discontinuing follow-up after bariatric surgery. This cohort study aims to assess these associations. Data were collected from a prospectively maintained database of patients who underwent laparoscopic bariatric surgery from January 2012 to December 2019. The Cox model was used to assess the influence of preoperative determinants on follow-up interruptions for more than one year. Multilevel logistic regression was used to evaluate the association between clinical factors and post-operative weight loss with the regularity of follow-up. During the study period, 9607 consultations were performed on 1549 patients. The factors associated with a follow-up interruption from more than 365 days included male gender (HR = 1.323; CI = 1.146–1.527; p = 0.001) and more recent years of intervention (HR = 1.043; CI = 1.012–1.076; p = 0.0068). Revisional bariatric surgery was associated with a lower risk of follow-up interruption (HR = 0.753; CI = 0.619–0.916; p = 0.0045). Independent risk factors of an irregular follow up were higher age (HR = 1.01; CI = 1.002–1.017; p = 0.0086); male gender (OR = 1.272; CI = 1.047–1.545; p = 0.0153); and higher %TWL (Total Weight Loss) (OR = 1.040 CI = 1.033–1.048 p < 0.0001). A higher preoperative BMI (OR = 0.985; CI = 0.972–0.998; p = 0.0263) and revisional surgery (OR = 0.707; CI = 0.543–0.922; p = 0.0106) were protective factors of irregularity. This study suggests that the male gender and most recent dates of surgery are the two independent risk factors for follow-up interruption. Older age, male gender, and higher weight loss were all independent risk factors of an irregular follow-up. Revision bariatric surgery is a protective factor against interruption and irregular follow-up with a higher preoperative BMI. Further studies are needed to obtain long-term results in these patients with discontinued follow-ups.

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated. This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors. We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction (“OS-SEV90 score”) was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high. Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78–5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12–4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26–3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. “the OS-SEV90 score” based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3–4), and high (≥5). According to “the OS-SEV90 score,” SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group. A predictive model of SPC within 90 days “the OS-SEV90 score” has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Background: With a mortality rate of up to 30%, post-pancreatectomy hemorrhage (PPH) remains a serious complication after pancreatoduodenectomy (PD) for cancer. Little is known about the long-term survival of patients after PPH. This retrospective study aimed to evaluate the impact of PPH on long-term survival after PD. Methods: The study included 830 patients (PPH, n = 101; non-PPH, n = 729) from two centers, who underwent PD for oncological indications. PPH was defined as any bleeding event occurring within 90 days after surgery. A flexible parametric survival model was used to determine the evolution of the risk of death over time. Results: At postoperative day 90, PPH significantly increased the mortality rate (PPH vs. non-PPH: 19.8% vs. 3.7%, p < 0.0001) and severe postoperative complication rate (85.1% vs. 14.1%, p < 0.0001), and decreased median survival (18.6 months vs. 30.1 months, p = 0.0001). PPH was associated with an increased mortality risk until the sixth postoperative month. After this 6-month period, PPH had no more influence on mortality. Conclusions: PPH had a negative impact on the short-term overall survival beyond postoperative day 90 and up to six months after PD. However, compared to non-PPH patients, this adverse event had no impact on mortality after a 6-month period.

Background: Regarding weight loss outcomes, the results published after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y (LRYGB) are conflicting. At this time, no clear evidence exists that outcomes from LSG are similar to those for LRYGB. The main objective of this study was to compare the percent of total weight loss (%TWL) between LRYGB and LSG over the first 2 years using a multilevel mixed-effects linear regression. Methods: Data were collected from a prospectively maintained database of patients who underwent primary laparoscopic bariatric surgery from January 2016 to December 2017 at a French accredited bariatric center. The medical records of 435 consecutive patients were analyzed. %TWL was calculated at each follow-up surgical consultation and used as a repeated outcome variable in our models to assess the long-term %TWL. Due to this hierarchical structure of the data (%TWL at each visit = level 1) within patients (level 2), a multilevel linear regression adjusted for age, sex, preoperative BMI and comorbidities was used. Results: Among the medical records of 435 consecutive patients included, 266 patients underwent LRYGB and 169 underwent LSG. The average %TWL at 2 years was 31.7% for the LRYGB group and 25.8% for the LSG group. The final multivariate model showed that, compared with LRYGB, LSG was associated with a decreased %TWL at over 2 years of follow-up (β: −4.01; CI95%: −5.47 à −2.54; p ≤ 0.001). Conclusion: This observational study suggests that compared with LRYGB, LSG was associated with a decreased %TWL at 2 years using a multilevel model. Further studies are required to confirm the results observed with this statistical model.

Background: Bariatric surgery is known to improve stress urinary incontinence (SUI) and overactive bladder disorders (OAB). However, there is little long-term follow-up in the literature. Objective: To determine the long-term effect of bariatric procedures on SUI and OAB and their impact on quality of life, we applied the ICIQ and USP questionnaires. Setting: The research was conducted at a French university hospital with expertise in bariatric surgery. Methods: We performed an updated follow-up at 6 years of a prospective cohort of 83 women who underwent a bariatric procedure between September 2013 and September 2014. The women completed the USP and ICIQ questionnaires before surgery, 1 year and 6 years after the surgery. Results: Of the 83 patients, 67 responded (80.7%) in full. SUI remained improved at 6 years: the USP score decreased from 3 [1; 7] before surgery to 0 [0; 1] (p = 0.0010) at 1 year after surgery and remained at 0 [0; 0] (p = 0.0253) at 6 years. The decrease in the OAB symptom score remained statistically significant: 3 [1; 7] before the surgery vs. 2 [0; 5] at 6 years (p = 0.0150). However, this improvement was significantly less pronounced than at 1 year: 0 [0; 1] (p = 0.002). Conclusions: Bariatric surgery seems to be effective at treating SUI and OAB with a long-lasting effects, still noted at 6 years.

Resume La radiotherapie abdomino-pelvienne peut induire des lesions aigues ou chroniques au sein de la paroi de l’intestin grele, denommee intestin grele radique (IGR). Le traitement de l’IGR en phase aigue est symptomatique, l’evolution etant favorable avec l’arret de l’irradiation. A l’inverse, la toxicite tardive peut survenir jusqu’a 30 ans apres l’arret de la radiotherapie, posant le probleme de son diagnostic positif. Pres d’un patient sur 5 traites par radiotherapie, va presenter des signes cliniques significatifs d’IGR, incluant un syndrome occlusif, un syndrome de malabsorption, une denutrition et/ou des complications. La prise en charge therapeutique doit etre multidisciplinaire, axee principalement sur la correction de la denutrition. Le traitement chirurgical est indique en cas de complications (i.e., abces, perforation, fistule) et/ou de resistance aux traitements medicaux ; la resection intestinale etant preferee a la simple derivation interne. Les risques majeurs en cas de resection iterative sont le syndrome de grele court et le recours a l’assistance nutritionnelle definitive.

The identification of patients at risk of developing a severe form of acute pancreatitis is a major issue. The goal of this study was to identify parameters at admission associated with severe pancreatitis to develop a predictive severity score.We conducted a retrospective study at Caen University Hospital between January 2014 and December 2017, including 504 patients hospitalized for acute pancreatitis, of whom 74 had a severe form. We developed a predictive score named Admission Severe Acute Pancreatitis (ASAP) score based on parameters associated with a severe form in multivariate analysis. We validated our score in an independent validation cohort of 80 patients.Hypothermia, low oxygen saturation or albumin levels, and high creatinine levels were significantly associated with severe pancreatitis. The ASAP score showed notable predictive accuracy (area under receiver operating characteristic, 0.82), which was significantly higher than Sequential Organ Failure Assessment, persistent Systemic Inflammatory Response Syndrome, and Balthazar. Using the -2.1742 threshold, the ASAP score had a sensitivity and specificity of 74% and a negative predictive value of 95%. These predictive performances for ASAP score were confirmed in the validation cohort.The ASAP score demonstrates remarkable predictive accuracy in distinguishing severe forms of acute pancreatitis.

This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients treated with ursodeoxycholic acid (UDCA) following bariatric surgery.Randomized controlled trials (RCTs) comparing UDCA and controls for the prevention of gallstone formation after bariatric surgery published until February 2022 were selected and subjected to a systematic review and meta-analysis. Articles were searched in the MEDLINE, Web of Science and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.Eleven randomized controlled studies were included, with a total of 2363 randomized patients and 2217 patients analysed in the UDCA group versus 1415 randomized patients and 1257 patients analysed in the control group. Considering analysed patients, prophylactic use of UDCA was significantly associated with decreased (i) gallstone formation (OR = 0.25, 95% CI = 0.21-0.31), (ii) symptomatic gallstone disease (GD) (OR = 0.29, 95% CI = 0.20-0.42) and consequently (iii) cholecystectomy rate (OR = 0.33, 95% CI = 0.20-0.55). The results were similar in ITT analysis, in the subgroup of patients undergoing sleeve gastrectomy or considering only randomized versus placebo studies.Prophylactic use of UDCA after bariatric surgery prevents both gallstone formation and symptomatic GD and reduces the need for cholecystectomy.

The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer. All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively. Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS. This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.

Resume Objectif Evaluer, a partir des donnees publiees de la litterature, les resultats postoperatoires entre patients operes d’une proctectomie carcinologique par une approche totalement laparoscopique (LAP) par rapport a ceux qui ont ete operes et ont eu une conversion peroperatoire (CONV). Methodes Les etudes comparant la LAP a la CONV pour le cancer du rectum publiees jusqu’en decembre 2017 ont ete selectionnees, soumis a un examen systematique et a une meta-analyse. Les articles ont ete recherches dans Medline et Cochrane Trials Register Database. La meta-analyse a ete effectuee avec Review Manager 5.0. Resultats Douze etudes prospectives et retrospectives, portant sur un total de 4503 patients operes par une approche entierement laparoscopique pour le cancer du rectum, et un total de 612 patients qui ont eu une conversion ont ete incluses. La meta-analyse n’a revele aucune difference significative sur la mortalite entre les deux approches (OR 0,47 ; IC a 95 % = 0,18–1,22 ; p = 0,12). Cependant, la meta-analyse a montre que le taux de fistule anastomotique, le taux d’abces de paroi et le taux de morbidite postoperatoire ont ete significativement diminues avec l’approche totalement laparoscopique (OR = 0,37 ; IC a 95 % = 0,24–0,58 ; p Conclusion Cette meta-analyse suggere que la conversion augmente le taux de fistules anastomotiques, la morbidite globale et le taux d’abces de paroi sans augmenter le taux de mortalite chez les patients qui ont subi une proctectomie carcinologique.

Resume Pres de 5 % des cancers colo-rectaux (CCR) sont lies a des anomalies genetiques constitutionnelles par mutation du gene APC (adenomatous polyposis coli) ou du gene MUTYH (MutY human homolog) dans la polypose adenomateuse familiale (PAF). Le but de cette mise au point est d’identifier les differentes formes de polyposes adenomateuses coliques, et d’actualiser les indications de chirurgie, de surveillance et de preciser les strategies chirurgicales devant une polypose colique adenomateuse. Sur le plan du genotype et du phenotype, on distingue la forme profuse (classique) et la forme attenuee. La forme profuse est liee a une mutation germinale inactivatrice du gene APC. Elle se caracterise par un nombre de polypes > 1000 et un âge jeune d’apparition (en moyenne 10 ans). La polypose liee au gene MUTYH est secondaire a une mutation bi-allelique (homozygote) du gene MUTYH, identifiee en 2002 et pourvoyeuse d’un tableau de polypose attenuee (MAP). La transmission de la MAP est autosomique recessive. Dans sa forme profuse liee au gene APC, en l’absence de depistage endoscopique et donc de traitement chirurgical, un CCR survient dans pres de 100 % des cas avant l’âge de 40 ans. Le depistage endoscopique colorectal est recommande des l’âge de 10–12 ans. Que ce soit pour la forme profuse ou pour la MAP, une surveillance du tube digestif haut (estomac et duodenum) est recommandee. Dans la forme profuse, le but du traitement chirurgical prophylactique est de prevenir le deces lie au CCR sans alterer la qualite de vie. L’âge de la chirurgie preventive ne fait pas a ce jour l’objet d’un consensus ; en Europe, elle est proposee des l’âge de 20 ans car le risque de CCR augmenterait nettement apres la 3e decennie. Il existe 3 types d’intervention : la colectomie totale avec anastomose ileo-rectale ; la coloproctectomie avec anastomose ileo-anale et la coloproctectomie avec ileostomie definitive. En theorie, la coloproctectomie totale permet d’atteindre l’objectif d’eliminer le risque de CCR. Si elle reste l’intervention de reference dans la forme profuse, la severite de l’atteinte n’est toutefois pas uniforme chez tous les malades et fait discuter une conservation rectale sous certaines conditions. En conclusion, la prise en charge des PAF se complexifie mais est delimitee par des recommandations de prise en charge, en particulier en France.

Nearly 5% of colorectal cancers are related to constitutional genetic abnormalities. In Lynch Syndrome (LS), the abnormality is a mutation of the deoxyribonucleic acid (DNA) repair system. The goal of this update is to update indications and surgical strategies for patients with LS. Different spectra of disease are associated with LS. The narrow spectrum includes cancers with a high relative risk: colorectal cancer (CRC), endometrial cancer, urinary tract cancers and small intestinal cancer. The broader spectrum includes ovarian tumors, glioblastoma, cutaneous tumors (keratoacanthomas and sebaceous tumors), biliary duct tumors, and gastric tumors. The clinical diagnosis of LS was initially based on the Amsterdam I and II Criteria published in the 1990s and subsequently on the revised Bethesda Criteria, which expanded the criteria and identified patients who should be screened for LS. For patients with LS, learned societies recommend early and regular endoscopic screening because of the high incidence of CRC, i.e., every one to two years from the age of 25 and then annually from the age of 40 or starting 10 years before the age of appearance of the youngest case of CRC in the family. Professional recommendations on prophylactic surgery to prevent cancers in patients with genetic predisposition were published in 2009 under the auspices of the French National Cancer Institute and are still current. There is no formal indication for prophylactic colectomy in LS. Numerous advances have been made in the understanding of LS, allowing a better knowledge of the prevalence of CRCs and associated cancers, with better endoscopic monitoring and a decrease in the prevalence and mortality of CRC.

Resume Pres de 5 % des cancers colorectaux sont lies a des anomalies genetiques constitutionnelles. Dans le syndrome de Lynch, il s’agit d’une mutation du systeme de reparation de l’acide desoxyribonucleique. Le but de cette mise au point est d’actualiser les indications et les strategies chirurgicales devant un syndrome de Lynch. Il existe differents spectres associes au syndrome de Lynch. Le spectre etroit comprend les cancers avec un risque relatif eleve : cancer colorectal (CCR), de l’endometre, des voies excretrices urinaires et cancer de l’intestin grele. Le spectre large comprend les tumeurs de l’ovaire, le glioblastome, les tumeurs cutanees (keratoacanthomes et tumeurs sebacees), les tumeurs des voies biliaires, et de l’estomac. Le diagnostic clinique du syndrome de Lynch reposait initialement sur les criteres d’Amsterdam I puis II publies des les annees 1990 puis sur les criteres revises de Bethesda qui ont permis d’elargir les criteres et d’identifier des patients susceptibles d’etre depistes pour le syndrome de Lynch. En cas de syndrome de Lynch, compte tenu de l’incidence elevee du CCR, les societes savantes recommandent un depistage endoscopique precoce et regulier, a savoir tous les uns a deux ans des l’âge de 25 ans puis annuellement a partir de 40 ans ou 10 ans avant l’âge d’apparition du plus jeune cas de CCR dans la famille. En 2009 des recommandations professionnelles sur la chirurgie prophylactique des cancers a predisposition genetique ont ete publiees sous l’egide de l’Institut national du cancer et font encore reference. Il n’y a pas a proprement parler d’indication de chirurgie prophylactique dans le syndrome de Lynch. De nombreux progres ont ete realises dans la comprehension du syndrome de Lynch, permettant une meilleure connaissance de la prevalence des CCR et des cancers associes, un meilleur suivi endoscopique et une diminution de la prevalence et de la mortalite du CCR.

Background & Aims: Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare primary liver cancer (PLC) associated with a poor prognosis. Given the challenges in its identification and its clinical implications, biomarkers are critically needed. We aimed to investigate the diagnostic and prognostic value of the immunohistochemical expression of Nestin, a progenitor cell marker, in a large multicentric series of PLCs.Methods: We collected 461 cHCC-CCA samples from 32 different clinical centers. Control cases included 368 hepatocellular carcinomas (HCCs) and 221 intrahepatic cholangiocarcinomas (iCCAs). Nestin immunohistochemistry was performed on whole tumor sections. Diagnostic and prognostic performances of Nestin expression were determined using receiver-operating characteristic curves and Cox regression modeling.Results: Nestin was able to distinguish cHCC-CCA from HCC with AUCs of 0.85 and 0.86 on surgical and biopsy samples, respectively. Performance was lower for the distinction of cHCC-CCA from iCCA (AUCs of 0.59 and 0.60). Nestin, however, showed a high prognostic value, allowing identification of the subset of cHCC-CCA (“Nestin High”, >30% neoplastic cells with positive staining) associated with the worst clinical outcome (shorter disease-free and overall survival) after surgical resection and liver transplantation, as well as when assessment was performed on biopsies.Conclusion: We show in different clinical settings that Nestin has diagnostic value and that it is a useful biomarker to identify the subset of cHCC-CCA associated with the worst clinical outcome. Nestin immunohistochemistry may be used to refine risk stratification and improve treatment allocation for patients with this highly aggressive malignancy. Lay summary: There are different types of primary liver cancers (i.e. cancers that originate in the liver). Accurately identifying a specific subtype of primary liver cancer (and determining its associated prognosis) is important as it can have a major impact on treatment allocation. Herein, we show that a protein called Nestin could be used to refine risk stratification and improve treatment allocation for patients with combined hepatocellular carcinoma, a rare but highly aggressive subtype of primary liver cancer.

Resume Introduction Au cours de l’annee 2006, ont ete diffusees les recommandations pour la pratique clinique (RPC) sous l’egide de la Haute Autorite de Sante, sur la prise en charge du cancer du rectum. Les objectifs de cette etude etaient d’evaluer les consequences de l’application de ces RPC dans notre pratique multidisciplinaire en termes de choix des therapeutiques base sur le bilan d’extension, et des criteres de qualite de l’exerese chirurgicale. Secondairement, nous avons evalue l’impact de ces RPC sur les resultats operatoires et carcinologiques. Methodes Tous les patients operes consecutivement a visee curative d’un cancer du rectum sous peritoneal de 1995 a 2017 du centre hospitalier universitaire de Caen, ont ete inclus et divises, selon la date de diffusion des RPC en deux groupes : avant (Gr1) et apres 2006 (Gr2). Etaient colligees dans chaque groupe, les caracteristiques preoperatoires du patient et de la tumeur rectale ; les modalites therapeutiques incluant les donnees perioperatoires, les resultats postoperatoires et oncologiques. Resultats Six cent quatre patients ont ete inclus (Gr1 = 266 et Gr2 = 338). L’application des RPC influencait significativement la realisation : (i) d’un bilan d’extension exhaustif [ex., imagerie par resonnance magnetique pelvienne (p Conclusions L’adhesion aux RPC a permis d’ameliorer la qualite de la prise en charge multidisciplinaire des patients operes a visee curative d’un cancer du rectum sous peritoneal. Toutefois, des progres supplementaires sont encore necessaires pour ameliorer l’exhaustivite de l’adhesion aux RPC.

This study was conducted in order to investigate the safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous biliary drainage (PTBD) in patients with a suspicion of malignant biliary stricture. Fifty consecutive patients with obstructive jaundice underwent PTFB during PTBD. Biopsy specimens were obtained using 5.2-F flexible biopsy forceps and these specimens were independently analysed by two pathologists. Consensus was obtained in case of discrepancy. Biopsy was considered as a true positive when tumour cells were retrieved. In the absence of tumour cells, comparison with available surgical findings and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) and/or percutaneous liver biopsy and/or imaging or clinical follow-up was made to distinguish true and false negatives. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were calculated. Influence of tumour location and pre-operative imaging findings was evaluated. Adverse events were reported. Biliary drainage and tissue sampling were achieved in 100% of patients. Sensitivity and specificity were 70 and 100%, respectively, while overall accuracy was 72%. After excluding the first 25 patients, accuracy and sensitivity for tissue sampling reached 80 and 78%, respectively. Sensitivity was better (87%) if stenosis was located at the upper part of the biliary tree, compared to the lower part (55%). In case of cholangiocarcinoma or intraductal invasion suspected on imaging, biopsy was contributive in 84 and 81% of patients, respectively. Four complications occurred consisting of one bile leak, two haemobilia and one pneumoperitoneum. PTFB combined with PTBD is a safe and effective technique for both histopathological diagnosis and biliary decompression of biliary strictures. Implications for patient care: • Percutaneous transbiliary forceps biopsy is technically feasible (100% of tissue sampling in our study) and is a safe technique. • Radiological management combining PTFB plus PTBD may allow diagnosis and treatment of the biliary stricture at the same time. • Sensitivity and accuracy for PTFB reached 78 and 80%, respectively, with a 100% specificity.

Resume Introduction L’exerese trans-anale (ETA) est de plus en plus utilisee pour le traitement des petits cancers du rectum a cause de son faible taux de complications postoperatoires et de sequelles fonctionnelles par rapport a une exerese totale du mesorectum (ETM). Objectif Comparer dans une meta-analyse les resultats chirurgicaux et anatomopathologiques entre les patients ayant eu une ETA suivie d’une proctectomie avec ETM (groupe TAE) pour un petit cancer du rectum ayant necessite une ETM complementaire versus ceux ayant eu une proctectomie avec ETM d’emblee (groupe TME). Methodes Nous avons realise une revue de litterature dans les bases de donnees MedLine, Cochrane Trial Register qui comparaient les resultats a court terme entre les patients operes d’une ETA suivie d’une ETM complementaire contre les ETM primaires. Les etudes publiees jusqu’a decembre 2016 etaient incluses. La meta-analyse etait effectuee grâce au logiciel Review Manager version 5.0 (Cochrane Collaboration, Oxford, Royaume-Uni). Resultats La meta-analyse montrait que l’ETM complementaire apres ETA etait significativement associee a une augmentation du taux de reprise chirurgicale (OR = 4,28 ; 95 % IC, 1,10–16,76 ; p Conclusions Cette meta-analyse suggere que l’ETA altere significativement les resultats chirurgicaux et les resultats anatomopathologiques sur le caractere complet de l’ETM compare a l’ETM d’emblee. L’approche trans-anale premiere durant l’ETM complementaire devrait etre evaluee afin d’en diminuer les difficultes techniques.

Summary Background Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) Objective To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group). Methods The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK). Results Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR = 4.28; 95% CI, 1.10–16.76; P ≤ 0.04) and incomplete mesorectal excision rate (OR = 5.74; 95% CI, 2.24–14.75; P ≤ 0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups. Conclusions This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

Intrahepatic cholangiocarcinoma is a rare disease with a poor prognosis. In patients where surgical resection is possible, outcome is influenced by perioperative morbidity and lymph node status. Laparoscopic liver resection is associated with improved clinical and oncological outcomes in primary and metastatic liver cancer compared with open liver resection, but evidence on intrahepatic cholangiocarcinoma is still insufficient. The primary aim of this study was to compare overall survival for a large series of patients treated for intrahepatic cholangiocarcinoma by open or laparoscopic approach. Secondary objectives were to compare disease-free survival, predictors of death, and recurrence.Patients treated with laparoscopic or open liver resection for intrahepatic cholangiocarcinoma from 2000 to 2018 from 3 large international databases were analyzed retrospectively. Each patient in the laparoscopic resection group (case) was matched with 1 open resection control (1:1 ratio), through a propensity score calculated on clinically relevant preoperative covariates. Overall and disease-free survival were compared between the matched groups. Predictors of mortality and recurrence were analyzed with Cox regression, and the Textbook Outcomes were described.During the study period, 855 patients met the inclusion criteria (open liver resection = 709, 82.9%; laparoscopic liver resection = 146, 17.1%). Two groups of 89 patients each were analyzed after propensity score matching, with no significant difference regarding pre- and postoperative variables. Overall survival at 1, 3, and 5 years was 92%, 75%, and 63% in the laparoscopic liver resection group versus 92%, 58%, and 49% in the open liver resection group (P = .0043). Adjusted Cox regression revealed severe postoperative complications (hazard ratio: 10.5, 95% confidence interval [1.01-109] P = .049) and steatosis (hazard ratio: 13.8, 95% confidence interval [1.23-154] P = .033) as predictors of death, and transfusion (hazard ratio: 19.2, 95% confidence interval [4.04-91.4] P.001) and severe postoperative complications (hazard ratio: 4.07, 95% confidence interval [1.15-14.4] P = .030) as predictors of recurrence.The survival advantage of laparoscopic liver resection over open liver resection for intrahepatic cholangiocarcinoma is equivocal, given historical bias and missing data.

Patients over 60 years old undergoing bariatric surgery is still increasing.First, to assess the impact of age (60 years) on the 90-day morbidity and mortality of both laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG), and second, to determine the effectiveness of surgical weight loss and resolution of obesity-related comorbidities for patients 60 years of age and older over a 2-year period.Bicentric study from University Hospital of Caen and Memorial Hospital of Saint Lô, France.This is a retrospective review of a prospectively maintained database of patients with morbid obesity undergoing laparoscopic bariatric surgery from October 2005 to April 2019. Patients 60 years of age and older were defined as cases (elderly group [EG], n = 137), and patients younger than 60 years of age were defined as controls (young group [YG], n = 1544). The primary endpoint of the study was the prevalence of severe postoperative complications within 90 days of surgery determined by a propensity-score-matching (PSM) analysis.The PSM population included 133 patients in the EG who were matched 1:2 with 266 patients in the YG. There was no mortality in either group. Although not significant (with an absolute difference of 4.5% between the EG and the YG), the odds of severe postoperative complications were 2.5 times higher in the EG than in the YG (7.5% versus 3.0%, P = .053). At 90 days postoperatively, the prevalences of overall morbidity (31.6% versus 22.9%, P = .044), leakage (5.3% versus 1.1%, P = .026), and reoperation (5.3% versus 1.1%, P = .026) were significantly higher in the EG than in the YG.This propensity-matched study suggests that laparoscopic bariatric surgery is probably an effective treatment in obese elderly patients (EPs) in terms of weight loss and resolution of comorbidities. However, the EP should be warned of the increased risk of severe postoperative complications within 90 days, including leakage and reoperation rates, especially after RYGB.

International audience; Background: To investigate the value of European deprivation index (EDI) and hepatocellular carcinoma (HCC) characteristics and their relationships with outcome after liver transplantation (LT).Methods: Patients undergoing LT for HCC were included from a national database (from "Agence de la Biomédecine" between 2006 and 2016. Characteristics of the patients were blindly extracted from the database. Thus, EDI was calculated in 5 quintiles and prognosis factors of survival were determined according to a Cox model.Results: Among the 3865 included patients, 33.9% were in the fifth quintile (quintile 1, N = 562 [14.5%]; quintile 2, N = 647 [16.7%]; quintile 3, N = 654 [16.9%]; quintile 4, N = 688 [17.8%]). Patients in each quintile were comparable regarding HCC history, especially median size of HCC, number of nodules of HCC and alpha-fetoprotein score. In the univariate analysis of the crude survival, having >2 nodules of HCC before LT and time on waiting list were associated with a higher risk of death (P < 0.0001 and P = 0.03, respectively). EDI, size of HCC, model for end-stage liver disease score, Child-Pugh score were not statistically significant in the crude and net survival. In both survival, time on waiting list and number of HCC ≥2 were independent factor of mortality after LT for HCC (P = 0.009 and 0.001, respectively, and P = 0.03 and 0.02, respectively).Conclusions: EDI does not impact overall survival after LT for HCC. Number of HCC and time on waiting list are independent prognostic factors of survival after LT for HCC.

Abdominal pelvic radiation therapy can induce acute or chronic lesions in the small bowel wall, called radiation enteritis. Treatment of acute radiation enteritis is essentially symptomatic; symptoms regress when radiation is discontinued. Conversely, late toxicity can occur up to 30 years after discontinuation of radiation therapy, posing diagnostic problems. Approximately one out of five patients treated by radiation therapy will present clinical signs of radiation enteritis, including obstruction, malabsorption, malnutrition and/or other complications. Management should be multidisciplinary, centered mainly on correction of malnutrition. Surgery is indicated in case of complications (i.e., abscess, perforation, fistula) and/or resistance to medical treatment; intestinal resection should be preferred over internal bypass. The main risk in case of iterative resections is the short bowel syndrome and the need for definitive nutritional assistance.

Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association.The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL 20% at 12 months).Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (β: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery.Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

To evaluate, regarding previous published studies, postoperative outcomes between patients undergoing rectal cancer resection performed by totally laparoscopic approach (LAP) compared to those who underwent peroperative conversion (CONV).Studies comparing LAP versus CONV for rectal cancer published until December 2017 were selected and submitted to a systematic review and meta-analysis. Articles were searched in Medline and Cochrane Trials Register Database. Meta-analysis was performed with Review Manager 5.0.Twelve prospective and retrospective studies with a total of 4503 patients who underwent fully laparoscopic approach for rectal cancer and a total of 612 patients who underwent conversion were included. Meta-analysis did not show any significant difference on overall mortality between both approaches (OR=0.47, 95%CI=0.18-1.22, P=0.12). However, Meta-analysis showed that anastomotic leakage rate, wound abscess rate and postoperative morbidity rate were significantly decreased with totally laparoscopic approach (OR=0.37, 95%CI =0.24-0.58, P0.0001; OR=0.29, 95%CI=0.19-0.45, P0.00001; OR=0.56, 95%CI=0.46-0.67, P0.00001 respectively).This meta-analysis suggests that conversion increases anastomotic leakage, overall morbidity and wound abscess rates without increasing mortality rate for patients who underwent rectal resection for cancer.

To evaluate, mid-term outcomes between elderly patients (EP, i.e., age > 60 years old) and young patients (YP, i.e., age

Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) can be proposed in case of failed laparoscopic adjustable gastric band (LAGB). The main question is whether the revisional procedure is carried out in one or two stages. Postoperative outcomes between the one-step approach and the two-step approach of conversion of failed LAGB to RYGB or SG were, respectively, compared. A systematic review of the literature published until June 2019 was conducted. All studies comparing one-step and two-step approaches after failed LAGB were included. Primary outcomes include both mortality and morbidity at 30 days postoperatively according to Dindo–Clavien classification. Among the studies included, a random effect model was used with Review Manager 5.3 (Cochrane Collaboration, Oxford, UK). A total of 3895 patients had conversion of failed LAGB to RYGB (n = 3214) or SG (n = 681), respectively. The conversion was carried out in one-step (n = 2767) or two-step (n = 1128) approaches. Meta-analysis did not show statistical difference for overall morbidity rate (OR = 1.01, 95%CI = 0.78–1.30, p = 0.96) whether it is for SG (OR = 1.25, 95%CI = 0.73–2.14, p = 0.42) or RYGB (OR = 0.94, 95%CI = 0.71–1.26, p = 0.69) and for major postoperative morbidity (OR = 0.96, 95%CI = 0.59–1.56, p = 0.87) whether it is for SG (OR = 0.66, 95%CI = 0.22–1.97, p = 0.46) or RYGB (OR = 1.05, 95%CI = 0.61–1.81, p = 0.86). Moreover, there was no statistical difference for specific morbidity rate including reoperation, leak, abscess, postoperative bleeding, and late postoperative complications. Given the retrospective nature of the studies, these results should be interpreted with caution. This updated meta-analysis suggests that conversion of failed LAGB to RYGB or SG can be safely performed in one-step or two-step approaches.

Nearly 5% of colorectal cancers are hereditary colorectal cancers, including adenomatous polyposis. The aim of this review was to highlight the current management of adenomatous polyposis. The two main genetic conditions responsible for adenomatous polyposis are familial adenomatous polyposis (FAP) (caused by an autosomal dominant mutation of the APC gene) and MUTYH-associated polyposis (MAP) (caused by bi-allelic recessive mutations of the MUTYH (MutY human homolog) gene). FAP is characterized by the presence of >1000 polyps and a young age at diagnosis (mean age of 10). In the absence of screening, the risk of colorectal cancer at age 40 is 100%. It is recommended to start screening at the age of 10-12 years. For patients with FAP and MAP, it is also recommended to screen the upper gastrointestinal tract (stomach and duodenum). In FAP, prophylactic surgery aims to reduce the risk of death without impairment of patient quality of life. The best age for prophylactic surgery is not well-defined; in Europe, prophylactic surgery is usually performed at age 20 as the risk of cancer increases sharply during the third decade. There are three main surgical procedures employed: total colectomy with an ileorectal anastomosis, restorative coloproctectomy with a J pouch anastomosis and coloproctectomy with a stoma. Restorative coloproctectomy with J pouch anastomosis is the reference procedure; however, disease can vary in severity from one patient to another and this must be taken into account to decide which procedure should be performed. In conclusion, the management of adenomatous polyposis is complex but is well-defined by guidelines, particularly in France.

IntroductionMany bowel problems following low anterior resection (LAR) for rectal cancer considerably impair the quality of life (QoL) of patients. The LAR syndrome (LARS) scale is a self-report questionnaire to identify and assess bowel dysfunction after rectal cancer surgery. It has been translated and validated in several languages but not in French (metropolitan French). The primary objective is to adapt the LARS scale to the French language (called French-LARS score) and to assess its psychometric properties. Secondary objectives are to assess both the prevalence and severity of LARS and to measure their impact on QoL.Methods and analysisA French multicentre observational cohort study has been designed. The validation study will include translation of the LARS scale following the current international recommendations, assessment of its reliability, convergent and discriminant validities, sensitivity, internal consistency, internal validity and confirmatory analyses. One thousand patients will be enrolled for the analyses. The questionnaire will be initially administered to the first 100 patients to verify the adequacy and degree of comprehension of the questions. Then reproducibility will be investigated by a test–retest procedure in the following 400 patients.An analysis will be conducted to determine the correlation between the LARS score and the Quality of Life Questionnaire (QLQ; European Organization for Treatment and Research of Cancer’s QLQ-C30, QLQ-CR29). Risk factors linked to QoL deterioration will be identified and their impact will be measured. This study will meet the need for a validated tool to improve patient care and QoL.Ethics and disseminationThe institutional review board of the University Hospital of Caen and the ethics committee (CPP Nord Ouest I, 25 January 2019) approved the study.Trial registration numberNCT03569488.

Resume La prise en charge multidisciplinaire du cancer du rectum sous-peritoneal a permis de repousser les limites de la conservation sphincterienne, sans pejorer le pronostic carcinologique. Les sequelles fonctionnelles digestives, dont l’ensemble des symptomes est regroupe sous le terme syndrome de resection anterieure du rectum (SRA), sont devenues une preoccupation de plus en plus frequente des patients et des praticiens. De physiopathologie complexe, le SRA associe a des degres divers une poly-exoneration, une incontinence aux gaz et/ou aux selles, une imperiosite, des troubles de la discrimination et de l’evacuation. Le « LARS » score, valide en 2012, est actuellement utilise pour evaluer precisement la severite du SRA et son impact sur la qualite de vie. Si ce SRA s’ameliore au cours des deux premieres annees, il persiste au-dela, chez pres de 60 % des patients et dans sa forme severe chez un patient sur deux. Les facteurs de risque independants de SRA severe les plus frequemment rapportes incluent la radiotherapie neo-adjuvante, l’etendue de la resection (exerese totale du mesorectum, y compris la resection inter-sphincterienne), l’absence de reservoir colique et la survenue d’une fistule anastomotique. En l’absence de complications chirurgicales et/ou de recidive locale, les praticiens disposent d’un arsenal therapeutique permettant d’ameliorer le resultat fonctionnel des patients, incluant des mesures hygieno-dietetiques, des regulateurs du transit, la rehabilitation multimodale (biofeedback, electrostimulation) et enfin la neuro-modulation sacree. Bien que solution ultime, la stomie definitive est a proposer en cas d’echec. Une meilleure connaissance de l’histoire naturelle du SRA, de ces facteurs de risque ainsi que de ses alternatives therapeutiques permettra a l’avenir une meilleure information et prise en charge de nos patients.

Resume Objectif Evaluer la survie a long terme (5 et 10 ans) et le taux de recidive chez les patients en reponse anatomopathologique complete sur la piece d’œsophagectomie apres radiochimiotherapie neoadjuvante. Methode Entre 1993 et 2014, tous les dossiers de patients consecutifs pris en charge par therapie trimodale pour un cancer de l’œsophage localement avance non metastatique (adenocarcinome ou carcinome epidermoide) ont ete revus. En fonction de l’examen anatomopathologique de la piece operatoire, les patients ont ete classees en deux groupes : un groupe en reponse anatomopathologique complete (RPC) et un groupe avec persistance d’un residu tumoral sur la piece (PRT). L’objectif principal etait la survie globale. Les objectifs secondaires etaient la survie sans recidive, le taux de recidive et les facteurs predictifs de survie globale et de recidive. Resultats Cent trois patients ont ete inclus : 49 dans le groupe RPC et 54 dans le groupe PRT. La mediane de survie globale etait significativement plus longue dans le groupe RPC par rapport au groupe PRT (132 ± 22,3 vs 25,5 ± 4 mois) avec respectivement des taux de survie globale a 5 et 10 ans de 75,2 % vs 29,1 %, et 51,1 % vs 13,6 % (p Conclusions Les patients avec un cancer de l’œsophage localement avance en reponse anatomopathologique complete apres therapie trimodale ont un taux de survie globale a 10 ans de 51 %.

International audience; BACKGROUND:Postoperative complications influence overall and disease free survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma is still a matter of debate and controversy.METHODS:The outcome of 942 consecutive patients, from the multicentric study of the French Association of Surgery, between January 2004 and December 2009 was analyzed. Perioperative data, including severe complications (grade III and above), were used in univariate and multivariate analysis to assess their influence on overall and disease free survival. Recurrence and its location were investigated as well.RESULTS:Median overall and disease free survival were 24 and 19 months respectively. Postoperative complications occurred in 444 patients (47%) with 18.3% of severe complications. On multivariate analysis, severe complications, positive lymph node status and R1-R2 resection were independent prognostic factors for both overall and disease free survival. The median overall survival decreased from 25 to 22 months (p = 0.005) and disease free survival from 21 to 16 months (p = 0.02) if severe complications occurred. Severe complications were independent prognostic factor of recurrence (p < 0.001).CONCLUSIONS:Severe complications significantly alter both overall and disease free survival and are an independent factor of recurrence.

Laparoscopic fundoplication in children under 5 kg is still debated. Our objective was to evaluate the safety and efficacy of laparoscopic fundoplication (LF) in children under 5 kg. We reviewed the cases of 96 children treated by laparoscopic fundoplication between 2005 and 2014. Thirty-five patients had a weight of 5 kg or less at the time of LF (Low Weight Group) and 61 patients had a weight between 5.1 and 10 kg (High Weight Group). The pre-operative, peri-operative, post-operative data regarding surgery and anesthesia were compared between groups. Mean weight was 3.9 ± 0.8 kg in the LWG and 7.8 ± 1.5 kg in the HWG. Children in the LWG were more prone to pre-operative respiratory management (40% mechanical ventilation and 42.9% oxygen therapy). The operating times (82 ± 28 min for LWG and 85 ± 31 min for HWG) and respiratory parameters during the procedure (PCO2) were comparable between groups. Post-operative complications were 1 gastric perforation with peritonitis and 1 small bowel obstruction in the LWG, 2 cases of gastric perforation with peritonitis in the HWG. Mean follow-up was 67 ± 44 months. Significant recurrence of GERD requiring a redo fundoplication was noted in 3 patients in the LWG and 1 patient in the HWG. Laparoscopic fundoplication is a safe procedure in infants ≤ 5 kg without increase of post-operative complications, recurrence, or mean operative time.

Complications in bariatric surgery are varied; they are severe at times but infrequent. They may be surgical or non-surgical, and may occur early or late. The goal of this systematic review is to inform and help the attending physician, the emergency physician and the non-bariatric surgeon who may be called upon to manage surgical complications that arise after adjustable gastric band (AGB), sleeve gastrectomy (SG), or gastric bypass (GBP). Data from evidence-based medicine were extracted from the literature by a review of the Medline database and also of the most recent recommendations of the learned societies implicated. The main complications were classified for each intervention, and a distinction was made between early and late complications. Early complications after AGB include prosthetic slippage or perforation; SG can be complicated early by staple line leak or fistula, and BPG by fistula, stenosis and postoperative hemorrhage. Delayed complications of AGB include intragastric migration of the prosthesis, late prosthetic slippage and infection, while SG can be complicated by gastro-esophageal reflux, and BPG by anastomotic ulcer and internal hernia. The analysis of available data allowed us to develop decisional algorithms for the management of each of these complications.

Resume Le diverticule de Meckel est la malformation congenitale du tractus digestif la plus frequente (environ 2 % de la population generale). Le risque de survenue de complication au cours de la vie est evalue a 2 %, sous la forme d’une hemorragie digestive, d’une occlusion ou d’une diverticulite. Le diagnostic est rarement evoque et les examens d’imagerie, notamment en l’absence de complication, sont peu contributifs. C’est souvent la cœlioscopie exploratrice qui permet d’incriminer le diverticule. La probabilite de survenue de complication diminue avec l’âge, et la decouverte du diverticule de Meckel est donc souvent fortuite chez l’adulte. La resection est indiquee en cas de complication mais reste discutee en cas de decouverte fortuite. L’etude des grandes series de la litterature est en faveur de l’absention en l’absence des facteurs de risque de complications : le sexe masculin, l’âge inferieur a 40 ans, un diverticule superieur a 2 cm et la presence d’anomalie muqueuse macroscopique lors de la resection. La resection/anastomose semble preferable a la resection cuneiforme et a l’agrafage tangentiel en raison du risque d’heterotopie muqueuse qui pourrait etre laissee en place.

Meckel's diverticulum (MD) is the most common gastro-intestinal congenital malformation (approximately 2% in the overall population). The lifetime risk of related complications is estimated at 4%. These include gastro-intestinal bleeding, obstruction or diverticular inflammation. Diagnosis is difficult and rarely made, and imaging, especially in the case of complicated disease, is often not helpful; however exploratory laparoscopy is an important diagnostic tool. The probability of onset of complication decreases with age, and the diagnosis of MD in the adult is therefore often incidental. Resection is indicated in case of complications but remains debatable when MD is found incidentally. According to an analysis of large series in the literature, surgery is not indicated in the absence of risk factors for complications: these include male gender, age younger than 40, diverticulum longer than two centimetres and the presence of macroscopically mucosal alteration noted at surgery. Resection followed by anastomosis seems preferable to wedge resection or tangential mechanical stapling because of the risk of leaving behind abnormal heterotopic mucosa.

This meta-analysis compared the effects of liver transplantation (LT) and liver resection (LR) on overall survival (OS) and disease-free survival (DFS) in patients with hepatocellular carcinoma (HCC) small transplantable HCC or within Milan criteria. Articles comparing LR with LT for HCC, based on Milan criteria or small size, published up to June 2015 were selected, and a meta-analysis was performed. No randomized controlled trial has been published to date comparing survival outcomes in patients with HCC who underwent LR and LT. Nine studies were identified, including 570 patients who underwent LR and 861 who underwent LT. For HCC within the Milan criteria, the 1-year OS rates following LR and LT were 84.5% (473/560) and 84.4% (710/841), respectively (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.71-1.33; P = 0.8), and the 5-year OS rates were 47.9% (273/570) and 59.3% (509/858), respectively (OR, 0.60; 95% CI, 0.35-1.02; P = 0.06). One-year DFS rates were similar (OR, 1.00; 95% CI, 0.39-2.61; P = 1.00), whereas the 3-year DFS rate was significantly lower in the LR group (54.4%, 210/386) than in the LT group (74.2%, 317/427; OR, 0.24; 95% CI, 0.07-0.80; P = 0.02), and the 5-year DFS rate was significantly lower for LR than LT (OR, 0.18; 95% CI, 0.06-0.53; P

Resume Malgre la revolution observee dans la prise en charge multidisciplinaire du cancer du rectum, l’evaluation des sequelles genito-urinaires reste une preoccupation importante. L’evaluation precise preoperatoire a l’aide de scores valides permet de depister des troubles urinaires dans pres de 16 a 23 % des cas et des troubles sexuels chez pres de 35 % des hommes et 50 % des femmes. Quelle que soit la voie d’abord, le respect de l’innervation autonome lors de l’exerese extrafasciale du mesorectum est fondamental dans la prevention de ces sequelles. Cette identification peut etre facilitee par la stimulation nerveuse peroperatoire. Malgre ces precautions, des sequelles urinaires peuvent apparaitre de novo que ce soit une incontinence urinaire dans pres de 33 % des cas ou des troubles de la vidange vesicale dans 25 % des cas. Un âge avance, des troubles urinaires preoperatoires, le sexe feminin et la realisation d’une amputation abdomino-perineale sont des facteurs de risque independants de ces sequelles. Des anomalies postoperatoires precoces du bilan urodynamique seraient predictives de sequelles et justifieraient une reeducation precoce. De la meme maniere, des sequelles sexuelles sont observees que ce soit des troubles de l’erection et/ou de l’ejaculation, des dyspareunies et un defaut de lubrification, aboutissant a une absence d’activite sexuelle de novo chez 28 % des hommes et 18 % des femmes. L’âge avance, une radiotherapie neoadjuvante et la realisation d’une amputation abdomino-perineale en sont des facteurs de risque independants. Le sidenafil semble efficace pour traiter les troubles de l’erection. Des sequelles genito-urinaires et ano-rectales apparaissent chez plus d’un malade sur 10, suggerant une possible physiopathologie commune.

Few studies have established that obesity promotes all types of urinary incontinence and disorders of the pelvic floor. The role of bariatric surgery in urinary incontinence remains poorly studied.To determine the effect of bariatric surgery on urinary incontinence, dysuria, and fecal incontinence before and 1 year after bariatric surgery.University hospital expert in bariatric surgery METHODS: This was an observational cohort study of 140 patients who underwent bariatric surgery between September 2013 and September 2014. Patients prospectively completed 4 questionnaires, 2 for urinary symptoms and 2 for fecal incontinence. Eighty-three women and 33 men completed 4 questionnaires the day before surgery when arriving in the department and 1 year after surgery.Of the 140 patients, 116 completely responded to the 4 questionnaires. The rate of urinary incontinence was 50.9% before surgery and 19% at 1-year follow-up (P.0001). After bariatric surgery, there was improvement in the rate of stress urinary incontinence: 39.7% before surgery versus 15.5% at 1 year (P.0001). In addition, there was an improvement in urinary urge incontinence: 36.8% versus 7.9% at 1 year (P.0001). The dysuria rate was 19.8% before surgery versus 3.4% at 1 year (P.0001). Bariatric surgery improved the quality of life related to urinary symptoms (P.0001). One year after surgery, there was no significant difference in terms of prevalence and severity of fecal incontinence.We confirmed with our study that weight loss after bariatric surgery improves stress urinary incontinence, urge incontinence, dysuria, and quality of life. However, we did not find any positive effect on fecal incontinence.

International audience; BACKGROUND:The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes.METHODS:ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates.RESULTS:During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p

In 2006 under the supervision of the French health authorities (HAS), recommendations for clinical practice (RCP) in the management of rectal cancers were first published. The primary objective of this study was to assess the impact of these guidelines on multidisciplinary management in terms of therapeutic strategies based on disease staging and quality indicators for surgical excision. Secondarily, we assessed the impact of the RCPs on postoperative and oncological outcomes.All consecutive patients having undergone curative surgical excision for middle and low (subperitoneal) rectal cancer from 1995 to 2017 in the university hospital of Caen were included in accordance with the relevant French guidelines. They were divided into two groups: before (Gr1) and after (Gr2) 2006. For each group, a chart review was conducted on demographic variables, preoperative rectal tumor features, disease severity variables and quality of surgery variables. Postoperative and oncological outcomes were likewise assessed and compared between the two groups.Six hundred and four patients were included (Gr1, n=266; Gr2, n=338). Compliance with French guidelines significantly improved (i) use of magnetic resonance imaging (P0.0001) and CT-scan (P0.0001)]; (ii) organization of multidisciplinary tumor boards (P0.0001) leading to suitable neo-adjuvant treatment plan classification (P0.0001). Consequently, compliance improved widespread total mesorectal excision (P0.0001), sphincter-sparing surgery (P=0,0005), and completeness of curative resection in the specimen (P0.0001). Although postoperative 90-day mortality was similar, overall postoperative morbidity significantly increased in Gr2 (P0.0001). Overall (P=0.0005) and disease-free survival (P=0.0016) of patients in Gr2 were significantly prolonged and correlated with a significant reduction in local and distant recurrences.Compliance with the relevant French guidelines improved the quality of multidisciplinary management of patients undergoing curative surgery for subperitoneal rectal cancer. However, further progress is still needed to render accession to the recommendations more comprehensive.