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Background The objective of this study was to evaluate the interest of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine in the management of early postoperative pain. Materials and Methods This is a randomized, phase III, comparative superiority, double-blind, international multicentre study. 290 patients (October 2019 February 2022) underwent surgery for inguinal hernia, by Liechtenstein technique, under general anaesthesia, and with placement of a ropivacaine or saline soaked parietal prosthesis. The primary endpoint was the coughing pain assessment (EVA) at H6. The secondary endpoints were the overall pain assessment at H2, H4 and H6 and the evaluation of the painkillers consumption. Results The prosthesis type had no significant effect on the coughing pain at H6, either for the ITT population (3.3 vs 3.2, p=0.12) or for the PP population (3.3 vs 3.7, p=0.15). The ropivaciane soaked prosthesis resulted in a decrease in the overall pain at H2 (2.3 vs 3.2, p Conclusion The placement of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine did not reduce the coughing pain at H6 but allowed a decrease in the overall pain over the first 6 hours after the surgery and could simplify the management of patients.

Background 20–30% of patients operated for inguinal hernia will present early postoperative pain (EPP) which is, after the organizational causes, the first cause of conversion from ambulatory to traditional hospitalization. The objective of this study was to evaluate the interest of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine in the management of EPP. Materials and Methods This is a randomized, phase III, comparative superiority, double-blind, international multicentre study. From October 2019 to February 2022, 290 patients underwent surgery for inguinal hernia with placement of a ropivacaine or saline soaked parietal prosthesis. The primary endpoint was the H6 coughing pain assessment (EVA). Results The intention to treat population (ITTp) was composed of 150 patients in the ropivacaine group and 140 in the placebo group, for the per-protocol population (PPp) it was 125 and 115. The prosthesis type had no significant effect on H6 coughing pain, either for the ITTp (3.3 vs 3.2, p=0.12) or the PPp (3.3 vs 3.7, p=0.15). The ropivaciane soaked prosthesis resulted in a decrease in the overall pain at H2 (2.3 vs 3.2, p Conclusion The placement of a parietal prosthesis (Cyclomesh ™) soaked with ropivacaine did not reduce the H6 coughing pain but allowed a decrease in the overall pain over the first 6 hours after surgery and could simplify the management of patients.

Resume Le flux sanguin arteriel a destinee des organes de l’etage sus-mesocolique de l’abdomen provient du tronc cœliaque (TC) et de l’artere mesenterique superieure (AMS) qui communiquent via l’artere gastroduodenale, les arcades pancreatico-duodenales anterieure et posterieure, les branches de l’artere pancreatique dorsale et, de maniere inconstante, via une arcade supplementaire reliant directement le TC et l’AMS (arcade de Buhler). La stenose du TC peut entrainer ou non un retentissement hemodynamique sur la circulation splanchnique. Lorsqu’elle est hemodynamiquement significative, elle peut etre asymptomatique, ou symptomatique avec des consequences cliniques proteiformes. La prise en charge therapeutique depend alors du mecanisme extrinseque ou intrinseque de cette stenose. Lorsque des actes de radiologie interventionnelle ou de chirurgie sus-mesocolique sont indiques, la stenose du TC peut engendrer des difficultes techniques ou des phenomenes ischemiques graves necessitant une bonne comprehension de cette entite, une planification des gestes et une prise en charge adaptee. La prise en charge d’une stenose du TC est donc multidisciplinaire et implique le radiologue interventionnel, le chirurgien digestif, le chirurgien vasculaire et le medecin vasculaire. Bien que sa prevalence soit relativement faible, comprise entre 5 et 10 %, la stenose du TC, quelle que soit son etiologie, est une entite devant etre connue des chirurgiens, des radiologues et des medecins de par son importance dans la prise en charge des pathologies sus-mesocoliques. Elle necessite d’etre recherchee, et traitee de maniere adaptee a chaque situation afin d’eviter des complications potentiellement graves.

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Resume Introduction Le traitement d’une hernie symptomatique chez le patient cirrhotique avec ascite refractaire est difficile. Le but de cette etude etait d’evaluer la faisabilite et la securite du traitement de l’ascite refractaire par alfapump® dans le meme temps que le traitement chirurgical d’une hernie de la paroi abdominale chez des patients cirrhotiques avec ascite refractaire. Methodes Les donnees de patients (provenant de 6 centres), ayant eu un traitement combine (implantation d’alfapump® et cure de hernie [groupe combine TC, n = 12]), ont ete comparees retrospectivement a celles de patients ayant des ponctions d’ascite iteratives avec cure de hernie (groupe standard, groupe ST, n = 26). Certains patients du groupe ST avaient une cure de hernie en situation elective (sous groupe STel) et d’autres une cure de hernie en urgence (sous groupe STurg). Les criteres de jugement etaient la necessite d’une ponction d’ascite postoperatoire, le taux de complications infectieuses, le taux de mortalite hospitaliere, la duree de sejour, la survie sans ponction d’ascite. Resultats Aucun des patients du groupe TC n'a necessite de drain peritoneal post operatoire pour evacuer l'ascite versus 21 patients (80 %) dans le groupe ST (p Conclusion Le traitement combine de l’ascite par d’alfapump® avec cure de hernie est faisable chez les patients cirrhotiques. Des etudes prospectives et randomisees devraient confirmer ces resultats.

Elective stoma closure (ESC) is a common procedure. The main complication of ESC is anastomotic leakage, which can be revealed by peritonitis or an enterocutaneous fistula (ECF). The objective of the present study was to describe the natural history of AL after ESC.Between January 2015 and March 2020, all patients having undergone AL after loop or double-barreled ESC were included in a retrospective, single-center study. The rate of ECF and peritonitis at presentation, the success rate of a conservative treatment and the factors associated with the success of healing of ECF were evaluated.From January 2015 to March 2020, 619 patients underwent a loop or double-barreled ESC in our department. The AL rate was 6.3% (n=39). The leakage was revealed by an ECF in 72% of cases (n=28). The mean±standard deviation time between the stoma closure and the diagnosis of the AL was 6±4 days. Conservative treatment was successful in 24 (85%) of the 28 patients with ECF, with a mean±SD time to recovery of 6.6±9.4 months. In a univariate analysis, none of the conservative treatments was significantly associated with healing of the ECF.AL is not rare and is mainly revealed by an ECF. Although the fistula heals in most cases, both the surgeon and the patient must be aware that the time to recovery is long.

Resume Objectifs Evaluation de la valeur du PET scanner au 18F-FDG dans la differenciation des formes benignes et malignes des tumeurs intracanalaires papillaire et mucineuse du pancreas. Introduction Les TIPMP malignes ou de haut risque necessitent une resection chirurgicale mais cette chirurgie devrait etre evitee en cas de TIPMP a faible risque de malignite. Le PET scanner au 18F-FDG a ete etudie dans de nombreuses series retrospectives monocentriques. Methode Il s’agit d’une etude multicentrique francaise prospective non comparative. L’objectif principal de cette etude etait d’analyser la specificite du PET scanner au 18F-FDG pour l’identification des formes malignes des TIPMP (carcinome invasif ou in situ). Le diagnostic final etait obtenu sur l’analyse anatomopathologique de la piece d’exerese. Resultat Sur 120 patients analyses, 99 presentaient une confirmation de TIPMP, incluant 24 lesions malignes, 9 carcinomes in situ et 15 cancers invasifs. Le PET scanner au 18F-FDG etait positif dans 44 et 31 cas respectivement dans l’ensemble de la serie et sur la population de TIPMP. Chez les 99 patients presentant une TIPMP les resultats du PET scanner retrouvaient 13 vrais positifs, 18 faux positif, 57 vrais negatifs et 11 faux negatifs. La sensibilite, specificite, valeur predictive negative et valeur predictive positive etait respectivement de 54,2 %, 76 %, 83,8 % et 41,9 %. Nous n’avons pu identifier une valeur de cut-off de SUVmax permettant la distinction entre une lesion benigne maligne. Les imageries conventionnelles comportaient un scanner abdominal, une imagerie par resonance magnetique nucleaire et une echo-endoscopie. Dans le groupe des patients presentant une TIPMP qui avaient recu les trois techniques d’imagerie, la sensibilite, specificite, valeur predictive positive et negative etaient respectivement de 66,7 %, 84,4 %, 84,4 %, et 66,7 %. Conclusion Dans cette etude, le PET scanner au 18F-FDG n’ameliorait pas la distinction entre les formes benignes et malignes des TIPMP par rapport aux examens d’imagerie conventionnelle.

Resume But Evaluer et comparer les resultats des ampullectomies endoscopiques (AE) et chirurgicales (AC) pour des tumeurs intramuqueuses de l’ampoule. Materiel et methode De 2005 a 2018, 66 patients etaient eligibles a une AE ou AC (a priori adenome, us ≤ T1N0). Le critere principal composite etait le taux de traitement complet : resection R0, apres une procedure unique et dont l’indication etait validee par l’anatomopathologie definitive (adenome et adenocarcinome in situ), sans recidive locale. Les criteres de jugement secondaire etaient : la morbidite, la duree moyenne de sejour (DMS), l’histologie avant resection et definitive, le caractere incomplet ou non de la resection, la duree mediane de suivi, le taux de recidive locale, et les complications a distance (stenose biliaire). Resultats Parmi les 41 patients eligibles a une AE, 36 ont beneficie d’une ampullectomie endoscopique, 5 ont ete adresses secondairement aux chirurgiens devant un envahissement endocanalaire non diagnostique initialement. Le taux de traitement complet etait de 48 % (13 traitements complets/27 indications confirmees). La morbidite etait de 10 %, la DMS de 3,3 jours, 25 % (n = 9) n’avaient pas de lesion adenomateuse sur l’histologie definitive, 30 % des resections etaient R1, 0 % etaient R2, la mediane de suivi etait de 20 mois, le taux de recidive locale etait de 22 %, le taux de stenose biliaire etait de 2 %. Parmi les 30 patients eligibles a une AC (25 initialement + 5 secondairement adresses par les endoscopistes), 24 ont beneficie d’une AC, et 5 d’une duodenopancreatectomie cephalique (DPC) d’emblee, 1 patient n’a pas ete reseque (decouverte de metastases). Une analyse extemporanee a ete realisee chez 22 des 24 AC et confirmait des marges saines sur les canaux biliaire et pancreatique. Le taux de traitement complet etait de 71 % (17 traitements complets/24 indications confirmees). La morbidite etait de 35 %, la DMS etait de 10 jours, 7 patients (29 %) presentaient un adenocarcinome invasif, 6 d’entre eux (86 %) ont beneficie d’une DPC secondaire, aucune des resections n’etaient R1 ou R2, la mediane de suivi etait de 21 mois, il n’y avait pas de recidive locale, le taux de stenose biliaire etait de 8 %. Conclusion Les resultats de la prise en charge different entre une AE et une AC, car les lesions prises en charge par l’endoscopiste et le chirurgien ne sont pas les memes, elles sont plus invasives dans le groupe chirurgie. Apres AE, les suites sont plus simples, neanmoins le taux de traitement complet (definitif) est plus faible.

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.

Resume L’adenocarcinome gastrique (AG) est, au niveau mondial, le 5e cancer le plus frequent, la decroissance de son incidence semble se stabiliser en France. Vingt-cinq experts reunis sous l’egide de l’Association francaise de chirurgie ont collabore a la redaction de ce referentiel dedie a la prise en charge chirurgicale de l’AG. Concernant le bilan pre-therapeutique, la realisation d’une echo-endoscopie chez tous les patients candidats a une exerese chirurgicale (afin de preciser le statut ganglionnaire) et d’une cœlioscopie exploratrice en cas d’AG cT3/T4 et/ou N+ a la recherche d’une carcinose peritoneale a ete retenue. Cependant, le TEP-scanner ne devrait pas etre realise systematiquement mais uniquement lorsque les autres modalites diagnostiques sont insuffisantes. La laparotomie reste la voie d’abord de choix pour la realisation d’une gastrectomie totale ou partielle avec curage ganglionnaire D2 pour les lesions > T2N0. Il est recommande de faire un reservoir jejunal sur anse-en-Y pour le retablissement de continuite apres gastrectomie totale afin de limiter le risque de dumping syndrome et de reflux œsophagien. En cas de carcinose peritoneale sur AG avec PCI limite (≤ 7) chez un patient en bon etat general et dont la maladie est controlee par chimiotherapie, il faut probablement realiser une cytoreduction macroscopiquement complete avec chimiotherapie hyperthermique intraperitoneale en centre expert. Une gastrectomie avec curage D2 peut etre envisagee en cas de cirrhose uniquement si Child A. La realisation d’une gastrectomie palliative a visee symptomatique ou une derivation chirurgicale en cas d’obstruction distale de l’estomac chez un patient en bon etat general peuvent etre envisagees.

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).La fístula biliar es una de las complicaciones más comunes después de la hepatectomía. Este estudio evalúa el efecto del drenaje biliar transcístico durante la hepatectomía en la aparición de una fístula biliar postoperatoria. MÉTODOS: Este ensayo prospectivo aleatorizado y multicéntrico (Clinical Trial NCT01469442) con dos grupos de estudio (grupo transcístico versus grupo control) se llevó a cabo de 2009 a 2016 en 9 centros. Los pacientes fueron sometidos a una hepatectomía (≥ 2 segmentos) en hígados no cirróticos. El resultado principal fue la aparición de una fístula biliar después de la cirugía. Los resultados secundarios fueron la morbilidad, la mortalidad postoperatoria, la duración de la estancia hospitalaria, la reintervención, la necesidad de reingreso y las complicaciones causadas por los catéteres. Se realizaron análisis por intención de tratamiento y por protocolo.Un total de 310 pacientes fueron randomizados. Por intención de tratamiento, 158 pacientes fueron aleatorizados al grupo transcístico y 149 al grupo control. Siete pacientes fueron excluidos del análisis por protocolo por desviaciones del protocolo. La tasa de fístula biliar fue del 5,9% en el análisis por intención de tratamiento y del 6,0% en el análisis por protocolo. Esta tasa fue similar para el grupo transcístico y para el grupo control: 5,7% versus 6,0% (P = 1). No hubo diferencias en términos de morbilidad (49,4% versus 46,9%, P = 0,731), mortalidad (2,5% versus 4,7%, P = 0,367) y reintervenciones (4,4% versus 10,1%, P = 1). La mediana de la duración de la estancia hospitalaria fue mayor para el grupo transcístico (11 versus 10 días, P = 0,042). El riesgo de fístula biliar se correlacionó con el grosor y la longitud de la transección hepática. CONCLUSIÓN: Este ensayo aleatorizado no demuestra la superioridad del drenaje transcístico durante la hepatectomía para prevenir la fístula biliar. No se recomienda el uso de drenaje transcístico durante la hepatectomía para prevenir la fístula biliar postoperatoria.

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.

Resume Introduction L’objectif de cette etude etait de determiner si la duree de drainage apres duodenopancretectomie cephalique (DPC) influencait le taux d’infection de site operatoire (ISO) a 30 jours postoperatoire. Methode Nous avons realise une etude multicentrique, randomisee, en intention de traiter avec deux groupes paralleles en vue de montrer la superiorite du drainage court sur le drainage standard sur les ISO entre 2011 et 2015, chez des patients sans fistule pancreatique (FP) a j3 apres DPC ( NCT01368094 ), ayant beneficie d’un scanner systematique a j3. Le critere de jugement principal etait le taux d’ISO a j30. Les criteres de jugement secondaires etaient les complications specifiques post-DPC (FP grade BC), la morbidite postoperatoire et les facteurs de risque d’ISO, le taux de reoperation, la mortalite a j30, la duree de drainage et la duree d’hospitalisation. Resultats Cent quarante et un patients ont ete randomises : 71 dans le groupe drainage court et 70 dans le groupe drainage standard (70,2 % d’adenocarcinomes, 91,5 % d’anastomoses-pancreatico-jejunales, 66,0 % de drainage bilateral, faisabilite 39,9 %). Le drainage court ne diminuait pas significativement le taux d’ISO a j30 (14,1 % vs 24,3 %, p = 0,12). On observait un taux reduit d’ISO profondes dans le groupe drainage court (2,8 % vs 17,1 %, p = 0,03), entrainant une duree d’hospitalisation reduite (17,8 ± 6,8 vs 21,0 ± 6,1, p = 0,01). La duree de drainage etait statistiquement plus courte dans le groupe drainage court (5 ± 5,6 vs 11,8 ± 7,5, p Conclusion Chez des patients selectionnes sans FP a j3 apres DPC, l’ablation precoce du drainage abdominal ne semble pas augmenter ou diminuer le taux d’ISO.

Surgical management of Hinchey III and IV diverticulitis involves Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial).Follow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded.The overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups.This follow-up study with a median follow-up time of 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.

International audience; Introduction: The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump (R) combined with concomitant hernia repair in cirrhotic patients with refractory ascites. Methods: Using data from six European centres, we retrospectively compared patients treated with alfapump (R) system implantation and concomitant hernia repair [the combined treatment group (CT group, n = 12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n = 26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. Results: Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P < 0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P = 0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P = 0.03). Paracentesis-free survival was significantly better (P = 0.0003) in the CT group than in the ST group. Conclusion: Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required. (C) 2020 Published by Elsevier Masson SAS.

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.

Background The relevance of laparoscopic resection of intrahepatic cholangiocarcinoma (ICC) remains debated. The aim of this study was to compare laparoscopic (LLR) and open (OLR) liver resection for ICC, with specific focus on textbook outcome and lymph node dissection (LND). Methods Patients undergoing LLR or OLR for ICC were included from two French, nationwide hepatopancreatobiliary surveys undertaken between 2000 and 2017. Patients with negative margins, and without transfusion, severe complications, prolonged hospital stay, readmission or death were considered to have a textbook outcome. Patients who achieved both a textbook outcome and LND were deemed to have an adjusted textbook outcome. OLR and LLR were compared after propensity score matching. Results In total, 548 patients with ICC (127 LLR, 421 OLR) were included. Textbook-outcome and LND completion rates were 22.1 and 48.2 per cent respectively. LLR was independently associated with a decreased rate of LND (odds ratio 0.37, 95 per cent c.i. 0.20 to 0.69). After matching, 109 patients remained in each group. LLR was associated with a decreased rate of transfusion (7.3 versus 21.1 per cent; P = 0.001) and shorter hospital stay (median 7 versus 14 days; P = 0.001), but lower rate of LND (33.9 versus 73.4 per cent; P = 0.001). Patients who underwent LLR had lower rate of adjusted TO completion than patients who had OLR (6.5 versus 17.4 per cent; P = 0.012). Conclusion The laparoscopic approach did not substantially improve quality of care of patients with resectable ICC.

International audience; Gastric adenocarcinoma (GA) is the 5th most common cancer in the world; in France, however, its incidence has been steadily decreasing. Twenty-five experts brought together under the aegis of the French Association of Surgery collaborated in the drafting of a series of recommendations for surgical management of GA. As concerns preoperative evaluation and work-up, echo-endoscopy aimed at clarifying lymph node status should be performed in all candidates for surgical resection and exploratory laparoscopy in cases of GA cT3/T4 and/or N+ for peritoneal carcinomatosis. On the other hand, PET-scan should not be performed systematically, but only when the other modalities for diagnosis prove insufficient. Laparotomy remains the route of choice to achieve total or partial gastrectomy with D2 lymph node lymphadenectomy for advanced lesions (> T2N0). To limit the risk of dumping syndrome and esophageal reflux and as a way of reestablishing continuity, construction of a jejunal pouch on Roux-en-Y following total gastrectomy is recommended. In cases of peritoneal carcinosis in GA with a low peritoneal cancer index (PCI) (

Background & Aims Herein, we aimed to establish benchmark values – based on a composite indicator of healthcare quality – for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers. Methods Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers. Results Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65–3.69; p = 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34–5.63; p = 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively. Conclusions This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers. Lay summary In a nationwide French survey of laparoscopic liver resection, expert centers were defined according to the completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional. MÉTODOS: Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non-cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección.Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post-hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92-0,41; P = 0,096) y de PHLF (OR 7,13; i.c. del 95% 0,91-323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08-48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14-0,76; P = 0,010) pacientes CL. CONCLUSIÓN: La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.

To assess the value ofMalignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. TheIn this study

Colorectal surgery is complicated by postoperative collections in up to 25% of cases depending on local conditions. The aim of this study was to identify predictive factors of success of percutaneous drainage of collections in order to avoid follow-up imaging. All consecutive patients between January 2009 and December 2016, who had undergone elective or emergency colorectal surgery (colorectal surgery and appendectomy) complicated by a postoperative collection treated by percutaneous drainage with follow-up imaging prior to drain removal, were included in this single-center and retrospective study. The primary objective was to assess predictive factors of success of the first attempt of percutaneous drainage of collections. Secondary objectives were to describe the natural history of percutaneous drainage of postoperative collections after colorectal surgery and the overall success rate of percutaneous drainage. Fifty-three patients underwent percutaneous drainage of a postoperative collection during the study period and were included in this study. Complete resolution of the collection was observed on the first follow-up radiological examination in 36 patients (58%). In multivariate analysis, post-appendectomy collections (OR = 3.19 (1.14–9.27), p = 0.002) and reduction of the leukocyte count (OR = 3.22 (1.28–8.1), p = 0.013) were significantly associated with success of percutaneous drainage. This is the first study to address that follow-up imaging prior to drain removal might not be necessary in patients undergoing drainage of post-appendectomy collections and/or with more than 30% reduction of the leukocyte count at the first follow-up examination.

Background Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. Methods Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis. Results One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. Conclusion DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Resume La creation d’une stomie digestive, qu’il s’agisse d’une stomie laterale ou d’une stomie terminale est un moment essentiel d’une intervention chirurgicale colorectale et est responsable de complications postoperatoires chez 35 % des patients. Les situations a l’origine de complications sont connues des chirurgiens, bien qu’il existe peu de donnees factuelles dans la litterature permettant de les discriminer. Elles sont liees au patient (obesite, cirrhose, hypertension portale), a la pathologie sous-jacente (occlusion colique) ou aux conditions de l’intervention (urgence). L’objectif de cette mise au point est de decrire ces differentes situations et les donnees de la litterature permettant, dans ces situations, de diminuer le risque de stomie non satisfaisante ou meme compliquee.