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A stoma exposes patients to several complications which could impair their quality of life (QoL). In the last decade, the market for stoma therapy in France has evolved, with a significant increase in the activities of home health providers, meeting a need for patient follow-up and companionship. International studies have demonstrated the impact of the stoma therapist (ST) follow-up on the improvement of an ostomy patient's QoL. However, the impact of home stoma nurse management has not been analysed. In this context we would like to assess the added value on health-related QoL from the enhanced follow-up of ostomy patients by STs.This is a randomized, controlled, open, national and multicentre trial (12 centres) which includes patients with an ostomy who benefit from either standard follow-up or from an enhanced and personalized follow-up with, in particular, regular consultations with an ST after discharge. The primary end-point is the 3-month QoL score obtained from the Stoma-QoL questionnaire. The secondary end-points are satisfaction of the care, comparison of QoL scores (Stoma-QoL and EuroQuol EQ-5D) and the economic gains by calculating the consumption of resources between the two arms. There will be a modified intention-to-treat analysis with 6-month follow-up in both study arms.The StomaCare trial will be the first randomized controlled study in France to evaluate the impact on QoL of an enhanced follow-up at home of ostomy patients by an ST.

Summary Introduction The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis. Methods An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts. Results Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women. Conclusion These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.

International audience; The impacts of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on cancer care are multiple, entailing a high risk of death from coronavirus disease 2019 (COVID-19) in patients with cancer treated by chemotherapy. SARS-CoV-2 vaccines represent an opportunity to decrease the rate of severe COVID-19 cases in patients with cancer and also to restore normal cancer care. Patients with cancer to be targeted for vaccination are difficult to define owing to the limited contribution of these patients in the phase III trials testing the different vaccines. It seems appropriate to vaccinate not only patients with cancer with ongoing treatment or with a treatment having been completed less than 3 years ago but also household and close contacts. High-risk patients with cancer who are candidates for priority access to vaccination are those treated by chemotherapy. The very high-priority population includes patients with curative treatment and palliative first- or second-line chemotherapy, as well as patients requiring surgery or radiotherapy involving a large volume of lung, lymph node and/or haematopoietic tissue. When possible, vaccination should be carried out before cancer treatment begins. SARS-CoV-2 vaccination can be performed during chemotherapy while avoiding periods of neutropenia and lymphopenia. For organisational reasons, vaccination should be performed in cancer care centres with messenger RNA vaccines (or non-replicating adenoviral vaccines in non-immunocompromised patients). Considering the current state of knowledge, the benefit-risk ratio strongly favours SARS-CoV-2 vaccination of all patients with cancer. To obtain more data concerning the safety and effectiveness of vaccines, it is necessary to implement cohorts of vaccinated patients with cancer.

Aim Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. Method Malnutrition was defined as body mass index 10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. Results Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). Conclusion Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.

Aim The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. Methods This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. Results In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. Conclusion An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.

Background and AimsFew prospective data exist on outcomes of surgery in Crohn’s disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage.MethodsFrom 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups.ResultsAmong 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ± 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159].ConclusionsSurgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

AIM The aim of this comparative study was to report a 10-year experience of an organ preservation strategy by local excision (LE) in selected high-risk patients (aged patients and/or patients with severe comorbidity and/or indication for abdominoperineal excision) versus total mesorectal excision (TME) after neoadjuvant radiochemotherapy (RCT) for patients with locally advanced (T3-T4 and/or N+) low and mid rectal cancer with suspicion of complete tumour response (CTR) or near-CTR. METHOD Thirty-nine patients with rectal cancer who underwent LE after RCT for suspicion of CTR were matched to 71 patients who underwent TME according to body mass index, gender, tumour location and ypTNM stage. Operative, oncological and functional results were compared between groups. RESULTS In the LE group, ypT0, ypTis or ypT1N0R0 were noted in 28/39 (72%). Overall morbidity was observed in 10/39 (26%) in LE vs 46/71 in the TME group (65%) (P = 0.001). Severe morbidity (Clavien-Dindo ≥ 3) was noted in 1/39 patients from the LE group (3%) vs 3/71 (4%) from the TME group (P = 1.000). After a mean follow-up of 63 ± 4 months (range 56-70 months), local recurrence was noted in 2/39 (5%) from the LE group vs 2/71 (3%) from the TME group (P = 0.601). Definitive stoma was noted in 2/39 (6%) from the LE group vs 8/71 (12%) from the TME group (P = 0.489). Major low anterior resection syndrome was noted in 5/23 (22%) from LE group vs 11/33 (33%) from the TME group (P = 0.042). CONCLUSION The accuracy of response prediction after RCT was 72% after LE. In high-risk patients, LE represents a safe alternative to TME with better functional results and the same long-term oncological outcome.

The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS). A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL. A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0–5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04–8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36–23.53]) were associated with AL. Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer.

Resume La saturation intrahospitaliere liee a l’arrivee massive de patients atteints du COVID-19 necessitant une prise en charge urgente conduit a reconsiderer la prise en charge des autres patients. Differer au maximum les hospitalisations et les operations chirurgicales non urgentes est un des objectifs des chirurgiens afin de desengorger autant que possible le systeme de soins. Alors que la majorite des operations programmees sont annulees, la reduction de la chirurgie d’urgence est evidemment compliquee a proposer sans alterer la qualite de la prise en charge et conduire a une perte de chance pour le patient. Cependant, l’appendicite aigue constitue une situation specifique bien particuliere et la frequence de cette pathologie conduit a considerer ce cas particulier. En effet, tandis que le traitement recommande de l’appendicite aigue non compliquee est chirurgical, l’alternative non chirurgicale par antibiotherapie seule a ete largement evaluee dans la litterature au cours de travaux de qualite. Dans la mesure ou la limite principale du traitement medical exclusif de l’appendicite aigue non compliquee est le risque de recidive a distance, cette option therapeutique represente une alternative de choix pour reduire la surcharge intrahospitaliere dans ce contexte de crise sanitaire. L’objectif de ce travail est donc de mettre a disposition des medecins et des chirurgiens un guide pratique issu d’une analyse de la litterature sur le traitement medical de l’appendicite aigue non compliquee de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans des bonnes conditions, notamment lorsque l’acces au bloc operatoire est impossible.

Résumé La saturation intra-hospitalière liée à l’arrivée massive de patients atteints du COVID-19 nécessitant une prise en charge urgente conduit à reconsidérer la prise en charge des autres patients. Différer au maximum les hospitalisations et les opérations chirurgicales non urgentes est un des objectifs des chirurgiens afin de désengorger autant que possible le système de soins.Alors que la majorité des opérations programmées sont annulées, la réduction de la chirurgie d’urgence est évidemment compliquée à proposer sans altérer la qualité de la prise en charge et conduire à une perte de chance pour le patient. Cependant, l’appendicite aiguë constitue une situation spécifique bien particulière et la fréquence de cette pathologie conduit à considérer ce cas particulier. En effet, tandis que le traitement recommandé de l’appendicite aiguë non compliquée est chirurgical, l’alternative non chirurgicale par antibiothérapie seule a été largement évaluée dans la littérature au cours de travaux de qualité. Dans la mesure où la limite principale du traitement médical exclusif de l’appendicite aiguë non compliquée est le risque de récidive à distance, cette option thérapeutique représente une alternative de choix pour réduire la surcharge intra-hospitalière dans ce contexte de crise sanitaire.L’objectif de ce travail est donc de mettre à disposition des médecins et des chirurgiens un guide pratique issu d’une analyse de la littérature sur le traitement médical de l’appendicite aiguë non compliquée de l’adulte afin de pouvoir proposer ce traitement alternatif aux bons patients et dans de bonnes conditions notamment lorsque l’accès au bloc opératoire est impossible.

La pandémie COVID-19 a un impact majeur à toutes les étapes de prise en charge des cancers. Le risque de décès de la COVID-19 chez les patients traités pour un cancer est élevé. La vaccination contre la COVID-19 représente une opportunité majeure pour réduire les risques de formes graves de la maladie et maintenir une filière de soins oncologiques normale. La définition de la population à vacciner est complexe, avec des données scientifiques très limitées et un contexte de pénurie en vaccin. Il apparaît théoriquement important de vacciner les patients atteints de cancers en cours de traitement ou avec un traitement datant de moins de trois ans, ainsi que leur entourage. Les patients actuellement prioritaires dits « à haut risque » sont ceux atteints de cancers en cours de chimiothérapie. Un groupe d’experts a préconisé une population « ultra-prioritaire » différente, incluant les patients sous chimiothérapie à visée curative ou palliative de première ou deuxième ligne, mais aussi ceux traités par chirurgie ou radiothérapie avec un grand volume pulmonaire, ganglionnaires et/ou de tissus hématopoïétiques. La vaccination doit idéalement être réalisée avant le début des soins. Malgré l’absence de données publiées, elle peut aussi s’effectuer pendant une chimiothérapie en évitant les périodes d’aplasie, avec possibilité de vacciner dans les établissements de soins. La mise en place de cohortes avec suivi immunologique et clinique des patients vaccinés atteints de cancer est nécessaire. Dans l’état actuel des connaissances, le rapport bénéfice/risque est très en faveur de la vaccination de tous les patients atteints de cancers.

The aim of this study was to assess recurrence risk factors following ileocolonic resection (ICR) for Crohn disease (CD) in a nationwide cohort study SUMMARY BACKGROUND DATA:: Recurrence rate after ICR for CD can be up to 60%, but its predictive factors have never been evaluated in large prospective cohort studies.From 2013 to 2015, 346 consecutive patients undergoing ICR for CD and a postoperative ileocoloscopy within 6 to 12 months after surgery at 19 academic French centers were included prospectively.Twelve-month postoperative endoscopic (Rutgeerts score ≥i2) and clinical recurrence rates were 57.6% [95% confidence interval (CI), 54.2-61.0] and 11.3% (95% CI, 9-13.6), respectively. A total of 185 patients (54%) had a postoperative CD prophylaxis, comprising thiopurine in 69 (20%), or anti-tumor necrosis factor (TNF) therapy in 93 (27%). In multivariate Cox regression analysis, absence of postoperative smoking {odds ratio [OR] = 0.60 (95% CI, 0.40-0.91); P = 0.016}, postoperative prophylaxis [OR = 0.60 (95% CI, 0.41-0.88); P = 0.009], and penetrating disease behavior [OR = 0.58 (95% CI, 0.39-0.86); P = 0.007] were the only independent predictors of reduced endoscopic recurrence risk. Postoperative prophylaxis [OR 0.31 (95% CI, 0.15-0.66); P = 0.002), and penetrating behavior [OR = 00.36 (95% CI, 0.16-0.81); P = 0.013), were the only independent predictors of reduced clinical recurrence risk. Postoperative anti-TNF therapy was associated with a significant reduction of both 12-month risks of endoscopic (P0.001) and clinical (P = 0.019) recurrences.Absence of postoperative smoking, CD prophylaxis, and penetrating disease behavior could be independent predictors of reduced postoperative recurrence after ICR for CD. Prophylactic anti-TNF therapy reduces both endoscopic and clinical recurrence rates. It suggests that upfront surgery followed by postoperative anti-TNF therapy is probably the best therapeutic approach for complex CD (penetrating disease behavior).

AIM This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA). METHODS All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included. RESULTS From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump

Summary Introduction The French Society of Gastro-Intestinal Surgery (Societe Francaise de Chirurgie Digestive) and the Association of hepato-bilio-pancreatic and transplantation surgery (Association de Chirurgie Hepato-Bilio-Pancreatique et Transplantation) requested that clinical practice recommendations be established with regard to operating room hygiene. Methods The literature was analyzed according to the High Authority of Health (Haute Autorite de sante [HAS]) methodology and after consultation of the Cochrane and Medline databases. Pertinent references were selected, and supplementary references were hand-picked from the reference lists. Only English or French language papers were retained. The recommendations of learned societies and the World Health Organization were also considered. Results Recommendations were proposed with regard to pre-operative patient preparation, skin preparation, draping, wound edge protectors, surgeon hygiene, wound closure, and operating room environment. Conclusion These clinical practice recommendations should guide and improve the daily practice of gastro-intestinal surgeons.

Resume Introduction La Societe Francaise de Chirurgie Digestive et l’Association de Chirurgie Hepato-Bilio-Pancreatique et Transplantation ont souhaite realiser des recommandations pour la pratique clinique concernant l’hygiene au bloc operatoire. Methodes L’analyse de la litterature a ete effectuee selon la methodologie de la Haute Autorite de Sante (HAS), par consultation des bases de donnees Cochrane et Medline. Une selection manuelle a ete effectuee a partir des references ainsi obtenues. Un tri manuel des references listees dans les articles selectionnes a ete fait a la recherche d’articles pertinents supplementaires. La recherche etait limitee aux articles dont la langue de publication etait l’anglais ou le francais. Les recommandations des principales societes savantes et de l’Organisation Mondiale de la Sante ont egalement ete prises en compte. Sur la base de l’analyse de la litterature, le groupe de travail a propose, chaque fois que possible, des recommandations. Resultats Des recommandations ont ete proposees concernant la preparation preoperatoire du patient, la preparation cutanee, le drapage chirurgical, les dispositifs de protection de la paroi abdominale, l’hygiene du chirurgien, la fermeture parietale, et l’environnement au bloc operatoire. Conclusion Ces recommandations pour la pratique clinique pourront permettre de guider et d’ameliorer la pratique quotidienne des chirurgiens digestifs.

The aim of this study was to assess if to prolong follow-up (FU) more than 5 years after surgery for colorectal cancer (CRC) is justified or not. Patients who underwent surgery for a CRC before 2013 and without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery were identified from our database and included. Between 1996 and 2012, 121 patients operated for rectal (RC) (median of FU of 84 months; range 60–211) and 97 with colonic cancer (CC) (median of FU of 78 months; range 60–139), without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery, presented a late tumor recurrence: 13/121 RC (10.7%) versus 2/97 CC (2.1%) (p = 0.014); 8/13 recurrences in RC (61.5%) were observed after neoadjuvant radiochemotherapy, and 9/13 (69.2%) in pN0 tumors. Among the 13 recurrences, 3 had both local and metastatic recurrences (23%), 5 an isolated local recurrence (38.5%) and 5 an isolated metastatic recurrence (38.5%). After surgery for CC, the 2 recurrences were observed in patients with T3N0 tumors. After surgery for a CRC, in patients without tumor recurrence during the first 5 years after surgery, follow-up after 5 years must be continued in rectal cancer patients because of a 10.7% rate of late recurrence. On the opposite, after surgery for colon cancer the 2% rate of late recurrence after 5 years suggested that only patients with pT3–T4 colonic cancer could probably be followed more than 5 years after surgery.

En raison d’un taux important de fistule anastomotique (FA) apres anastomose coloanale ou colorectale, la prise en charge optimale de cette complication est primordiale. L’objectif de cette mise au point etait d’evaluer les moyens de prevention pouvant etre mis en place afin d’eviter les FA et les traitements disponibles. Le premier moyen de prevention des fistules et de leurs complications, a mettre en place lors de la chirurgie, est la realisation d’une stomie de derivation. Celle-ci est indiquee en cas d’anastomose sousdouglassienne. Sa realisation systematique permet de diminuer le taux de stomie definitive et d’eviter une possible reintervention en cas de fistule. Les traitements locaux peuvent etre utiles en cas d’abces pelvien ou de fistule rectovaginale associee. Le drainage radiologique semble avoir une bonne efficacite lors de prise en charge de la FA en phase aigue et offre l’avantage de ne pas agrandir le defect anastomotique, contrairement au drainage transanal. En cas de peritonite, lors de la reintervention en urgence, la conservation anastomotique avec lavage–drainage semble etre une option valable et permet de diminuer le taux de stomie definitive, mais une intervention de Hartmann est parfois necessaire. A distance de l’intervention, lorsque les complications septiques sont controlees, la cicatrisation du trajet de FA est obtenue dans les six mois pour la majorite des patients. Pour les autres patients, nous avons l’habitude de realiser le retablissement de continuite a six mois (meme en cas de trajet fistuleux persistant) si absence de stenose et de large cavite abcedee presacre. Cette strategie permet dans plus de 80 % des cas d’eviter une reintervention par voie abdominale pour realisation d’une nouvelle anastomose, qui reste indiquee en cas d’echec des techniques precedemment decrites.

AIM To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51 (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P

Context The origin of tumor deposit in colorectal cancer is still unknown, and currently there is no single morphological feature to distinguish a metastatic lymph node from a tumor deposit. Histologically, the normal lymph node capsule and trabeculae contain a smooth muscular layer, which when present in extramural deposits would strongly suggest their lymph node origin. Objective We analyze the value of the smooth muscular layer criterion in reclassifying tumor deposit into metastatic lymph node. Design A total of 458 colo-rectal carcinomas surgical specimens treated or not by neoadjuvant (radio)chemotherapy were retrospectively included. Harvested tumor deposits were analyzed by Hematoxylin and Eosin and elastin staining on 10 consecutive serial sections and by α- smooth muscle actin immunostaining. Results A total of 129 tumor deposits were identified. 77 (60%) tumor deposits were reclassified into metastatic lymph node, of which 63 (49%) presented a smooth muscular layer on the initial Hematein Eosin staining and/or after serial tissue sections, confirmed by positive α-smooth muscle actin immunostaining in 43 out of 45 cases (90%). Fourteen (18%) additional tumor deposits were reclassified into metastatic lymph node by the appearance of lymphoid tissue after serial sections. Conclusions The presence of a smooth muscular layer in a presumable tumor deposit is helpful in pointing out its lymph node origin in patients with colo-rectal carcinomas. This criterion could improve the inter-observer agreement of tumor deposit identification, allowing accurate nodal staging and better assessment of patient's prognosis.

Resume Introduction La Societe francaise de chirurgie digestive et la Societe d’imagerie abdominale et digestive ont souhaite proposer des recommandations pour la pratique clinique portant sur la prise en charge de l’appendicite de l’adulte. Methodes L’analyse de la litterature a ete effectuee selon la methodologie de la Haute Autorite de sante (HAS). Une selection manuelle des publications scientifiques a ete effectuee a partir des references obtenues, puis un tri manuel des references listees dans les articles selectionnes a ete fait a la recherche d’articles pertinents supplementaires. La recherche etait limitee aux articles en langue anglaise ou francaise. Les articles se focalisant sur la population pediatrique ont ete exclus. Sur la base de l’analyse de la litterature, le groupe de travail a propose, chaque fois que possible, des recommandations. Ces recommandations ont ete relues et validees par un comite d’experts. Resultats Des recommandations ont ete proposees au sujet de l’appendicite aigue de l’adulte concernant les modalites diagnostiques cliniques, biologiques et radiologiques, la strategie therapeutique devant une forme non compliquee ou compliquee, la technique chirurgicale et les specificites en cas d’appendice macroscopiquement sain, d’ileite terminale et d’appendicite chez le sujet âge et chez la femme enceinte. Conclusion Ces recommandations pour la pratique clinique pourront aider le chirurgien dans l’optimisation de la prise en charge de l’appendicite aigue de l’adulte.

Introduction The COVID-19 pandemic has major impact of healthcare systems, including cancer care pathways. The aim of this work is to discuss in a multidisciplinary approach the therapeutic and/or strategies adaptations for patients treated for a digestive cancer during the European second wave of COVID-19 pandemic. Methods A collaborative work was performed by several French societies to answer how to preserve digestive cancer care with no loss of chance during the second wave of COVID-19. In this context, all recommendations are graded as expert’s agreement according to level evidence found in literature until October 2020 and the experience of the first wave of the COVID-19 pandemic. Results As far as possible, no therapeutic modification should be carried out. If necessary, therapeutic adjustments may be considered if they do not constitute a loss of chance for patients. Considering the level of evidence all therapeutic modifications need to be discussed in multidisciplinary tumor board meeting and with patient consent. By contrast to first wave cancer prevention, cancer screening, supportive care and clinical trials should be continued. Conclusion Recommendations proposed could limit cancer excess mortality due to the COVID-19 pandemic but should be adapted according to the situation in each hospital.

INTRODUCTION To investigate the factors associated with a delayed diagnosis (DD) of acute mesenteric ischemia (AMI). METHODS An observational cohort study from an intestinal failure center. The primary outcome was DD >24 hours. RESULTS Between 2006 and 2015, 74 patients with AMI were included and 39 (53%) had a DD. Plasma lactate

Objective Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. Methods Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. Results During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. Conclusions Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.

Background and AimsThere is no consensus on the best management of the rectum after subtotal colectomy for refractory colitis complicating inflammatory bowel disease [IBD]. The objective was to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy [LSTC] for IBD.MethodsPatients who underwent LSTC with double-end ileo-sigmoidostomy [Gr.A] or end ileostomy with closed rectal stump [Gr.B] for IBD were included from a retrospective database of six European referral centres.ResultsIn total, 314 patients underwent LSTC and were allocated to Gr.A [n = 102] and B [n = 212]. After LSTC, stoma-related complications occurred more frequently in Gr.A [12%] than in Gr.B [4%, p = 0.01]. Completion proctectomy with ileal pouch-anal anastomosis [IPAA] was performed as a three-stage procedure in all patients from Gr.A, and in 88 patients from Gr.B [42%; Gr.B1]. The other 124 patients from Gr.B underwent a modified two-stage procedure [58%; Gr.B2]. The second stage was performed laparoscopically in all patients from Gr.A compared with 73% of Gr.B1 [p ConclusionThis study suggests that both techniques of double-end ileosigmoidostomy and end ileostomy with closed rectal stump are safe and effective for rectal stump management after laparoscopic subtotal colectomy.

There are no specific guidelines for ventral hernia management in Crohn’s disease (CD) patients. We aimed to assess the risk of septic morbidity after mesh repair in CD. This was a retrospective multicentre study comparing CD and non-CD patients undergoing mesh repair for ventral hernia (primary or incisional hernia). Controls were matched 1:1 for the presence of a stoma, history of surgical sepsis, hernia size and Ventral Hernia Working Group (VHWG) score. All demographic, pre-, intra- and postoperative data were retrieved, including long-term data. We included 234 patients, with 114 CD patients. Both groups had comparable VHWG scores (p = 0.12), hernia sizes (p = 0.11), ASA scores ≥ 3 (p = 0.70), body mass index values (p = 0.14), presence of stoma (CD 21.9% vs. controls 15%, p = 0.16), history of sepsis (14% vs. 6.7%, p = 0.23), rates of malnutrition (4.4% vs. 1.7%, p = 0.46), rates of incisional hernia (93% vs. 95%, p = 0.68) and concomitant procedures (18.4% vs. 11.7%, p = 0.12). CD patients carried a higher risk of postoperative septic morbidity (18.4% vs. 5%, p = 0.001), entero-prosthetic fistula (7% vs. 0, p

International audience; Importance Caustic ingestion in adults may result in death or severe digestive sequelae. The scarcity of nationwide epidemiological data leads to difficulties regarding the applicability of their analysis to less specialized centers, which are nevertheless largely involved in the emergency management of adverse outcomes following caustic ingestion.Objective To assess outcomes associated with caustic ingestion in adults across a nationwide prospective database.Design, Settings, and Participants Adult patients aged 16 to 96 admitted to the emergency department for caustic ingestion between January 2010 and December 2019 were identified from the French Medical Information System Database, which includes all patients admitted in an emergency setting in hospitals in France during this period.Exposure Esophageal caustic ingestion.Main Outcomes and Measures The primary end point was in-hospital patient outcomes following caustic ingestion. Multivariate analysis was performed to assess independent predictors of in-hospital morbidity and mortality.Results Among 22 657 226 patients admitted on an emergency outpatient basis, 3544 (0.016%) had ingested caustic agents and were included in this study. The median (IQR) age in this population was 49 (34-63) years, and 1685 patients (48%) were women. Digestive necrosis requiring resection was present during the primary hospital stay in 388 patients with caustic ingestion (11%). Nonsurgical management was undertaken in 3156 (89%). A total of 1198 (34%) experienced complications, and 294 (8%) died. Pulmonary complications were the most frequent adverse event, occurring in 869 patients (24%). On multivariate analysis, predictors of mortality included old age, high comorbidity score, suicidal ingestion, intensive care unit admission during management, emergency surgery for digestive necrosis, and treatment in low-volume centers. On multivariate analysis, predictors of morbidity included old age, higher comorbidity score, intensive care unit admission during management, and emergency surgery for digestive necrosis.Conclusions and Relevance In this study, referral to expert centers was associated with improved early survival after caustic ingestion. If feasible, low-volume hospitals should consider transferring patients to larger centers instead of attempting on-site management.

Objective:To compare outcome of single-port laparoscopy (SPL) and multiport laparoscopy (MPL) laparoscopy for colonic surgery.Summary of Background Data:Benefits of SPL over MPL are yet to be demonstrated in large randomized trials.Methods:In this prospective, double-blinded, superiority trial, pati

Short bowel syndrome (SBS) is a rare disease, resulting from extensive resection of the small intestine. Depending on the severity of malabsorption, it will lead to intestinal failure, defined as the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, resulting in a situation where intravenous supplementation is required. The risk of developing intestinal failure is related to the remaining length of small intestine and the anatomy of the remnant bowel. SBS incidence has been estimated to range from 5 to 10 patients per year per million population. The main consequence of SBS is a marked reduction of intestinal absorption surface and its main complication is undernutrition and hydro-electrolytic abnormalities. Parenteral nutrition (PN), the major treatment of intestinal failure, has long-term complications. In case of PN dependency, treatment with trophic factors can be proposed. Glucagon-like peptide-2 (GLP-2) analogs allow significant reduction of PN dependency and improve quality of life. Rehabilitative surgery should always be proposed, with the primary goal of restoring digestive continuity. Sometimes, an additional surgical procedure, such as an antiperistaltic reversal of a small bowel segment, is performed when restoring digestive continuity in patients with insufficient length of remnant small intestine to enhance the possibility of PN withdrawal. Intestinal transplantation is proposed as a last resort.

Resume Le syndrome du grele court (SGC) est une maladie rare resultant d’une resection etendue de l’intestin grele. Selon la severite de la malabsorption, il va en resulter une insuffisance intestinale, definie comme la reduction de la fonction intestinale en deca du minimum necessaire a l’absorption des macronutriments et/ou de l’eau et des electrolytes, de telle facon qu’une supplementation intraveineuse est necessaire. Le risque de developper une insuffisance intestinale est lie a la longueur d’intestin grele restant et le type de montage chirurgical. La prevalence du SGC est estimee a environ 5 a 10 patients par an par million d’habitants. Le SGC a pour consequence principale une nette diminution de la surface d’absorption intestinale et sa principale complication est le risque de denutrition et de troubles hydro-electrolytiques. La nutrition parenterale (NP) reste le traitement de reference de l’insuffisance intestinale severe, mais elle comporte des effets deleteres a terme. En cas de dependance a la NP, un traitement par facteur trophique peut etre propose, l’analogue du glucagon-like peptide-2 (GLP-2) permettant une reduction significative de la dependance a la NP, et ameliorant la qualite de vie. Une chirurgie de rehabilitation doit systematiquement etre proposee, avec en premier lieu le retablissement de la continuite digestive. Parfois un geste complementaire, tel que la confection d’une anse reverse, est realise au moment du retablissement de continuite chez les malades ne presentant pas une longueur d’intestin grele suffisante pour esperer un sevrage de la NP. La transplantation intestinale est quant a elle proposee en dernier recours.

Purpose To evaluate the inter-reader agreement of the CT features of acute mesenteric ischemia (AMI). Methods Between 2006 and 2014, 109 patients (57 men, 52%, mean age 50 years old [17–83]) admitted to our institution with a diagnosis of AMI were included. CT scans (42% were initially performed in our institution) were reviewed by two abdominal radiologists. Inter-observer agreement of the imaging features of vascular insufficiency and bowel ischemia was assessed by the percentage of agreement and the kappa value. Results The final population included, Inter-observer agreement varied according to the different features (κ = 0.25-0.98). Inter-observer agreement for decreased/absent bowel wall enhancement was moderate (κ = 0.52), but was almost perfect (κ = 0.82) in the 47 patients (43%) with both unenhanced and arterial-phase images without positive oral contrast agent and excellent CT images quality. Conclusion Inter-reader agreement was moderate to substantial for most CT features of AMI. Multiphasic CT scan protocol, including unenhanced, arterial phase and venous phase images, without positive oral contrast agent, and excellent CT images quality improve inter-observer agreement of imaging features of AMI, especially for decreased/absent bowel wall enhancement, and should be performed in patients with suspected AMI.

AIM To compare the learning curve for trans-anal total mesorectal excision (TATME) with laparoscopic TME started by a perineal approach (LTME). METHOD The first 34 consecutive patients who underwent TATME for low rectal cancer were matched with LTME (performed by the same surgeon) for gender, body mass index and chemoradiation. RESULTS Thirty-four patients undergoing TATME (23 men; 58 ± 14 years) were matched with 34 undergoing LTME (23 men; 59 ± 13 years). Intra-operative complications occurred more frequently during TATME (21%) than LTME (6%), but this difference was not significant (P = 0.07). The complications of TATME included rectal (n = 4), bladder (n = 1) and vaginal (n = 1) injury and bleeding (n = 1). Length of stay and postoperative overall and major morbidities were similar between groups. Early symptomatic anastomotic leakage (AL) occurred in 1/34 TATME and 5/34 LTME (15%; P = 0.02) procedures. Asymptomatic AL occurred in four TATME (12%) and four LTME (12%, P = 1). Thus, the overall rate of AL was 5/34 (15%) for TATME vs 9/34 (26%) for LTME (P = 0.4). No significant difference between the two groups was noted with regard to tumour, number of harvested and positive lymph nodes, R1 resection rate or completeness of the mesorectum. Metastatic recurrence was similar between groups (15% vs 18%, P = 0.7), but follow-up was shorter after TATME (13 ± 6 months) than after LTME (25 ± 14 months; P

To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD).The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study.From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method.Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF3 months prior to surgery. In the multivariate analysis, anti-TNF3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time180 min (OR = 2.71; CI 95% = 1.54-4.78, P0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009).Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Background and objectives Without prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients. Methods All consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included. Results Thirteen patients (7 males/6 females, mean age = 47.2 ± 12.1 years) were included. The mean length of remnant small bowel was 47 ± 39 cm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass n = 11 (84%), ilio-hepatic bypass n = 1 (8%) and endarterectomy n = 1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (n = 2), hemorrhagic pericarditis (n = 2), hemorrhagic shock (n = 2) and aortic false aneurysm (n = 1). After a mean follow-up of 27.0 ± 25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed. Conclusion For patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.

But L’abord mini-invasif diminue la morbidite de la chirurgie œsogastrique. Par l’amelioration de la vision et de l’ergonomie, le robot permet de reduire les difficultes techniques rencontrees dans ces procedures, notamment pour la realisation d’anastomoses intracorporelles. L’objectif est de reporter les etapes de mise en place d’un programme de chirurgie robotique œsogastrique. Methodes Apres une formation par simulation et des experts, un programme de chirurgie robotique œsogastrique a ete mis en place, initialement pour des procedures simples, puis pour une chirurgie complexe type Lewis-Santy (LS) et gastrectomie totale (GT). Resultats De novembre 2019 a janvier 2021, 36 procedures ont ete realisees : hernie hiatale/RGO (n = 16) ; diverticule intra-thoracique (n = 2) ; Heller (n = 1), gastrectomie partielle (=4), GT (n = 2), oesophagectomie (LS = 5 ; Mac Keown = 6). Parmi les oesophagectomies, les temps operatoires moyens par approche robotique (AR) thoracique (n = 10) et abdominale (n = 6) etaient de 171,4 min (±37,3) et 157,5 min (±19,4), respectivement. La DMS etait de 8,9 jours en USI/USC et 7,6 jours en hospitalisation conventionnelle. Les pertes sanguines moyennes etaient de 100 ± 16,5 mL. Six anastomoses manuelles ont ete realisees par AR : LS (n = 4) ; gastrectomie (n = 2). Le taux de fistule anastomotique etait de 16 % (n = 1). Dans l’ensemble de la cohorte, une seule procedure par AR a ete convertie. Le taux de complications ≥ 3b etaient de 13,8 %. Conclusion Une progression par etapes de difficultes croissantes et l’assistance d’experts permettent de mettre en place rapidement et de maniere securisee un programme de chirurgie robotique œsogastrique.

Aim To assess the prognostic influence of the circumferential resection margin (CRM) exact value after total mesorectal excision (TME) for mid or low rectal cancer. Methods All patients (n=321), who underwent TME from 2005 and 2013 where identified from a prospective database, including 49 (15%) who presented with a CRM≤1mm. Four groups were defined: Group 1: CRM = 0 mm (n=21); Group 2: 0 1 mm (n=272). Results After a mean follow-up of 42 ± 26 months, locoregional recurrence rates were 8/21 (38%) in Group 1, 3/13 (23%) in Group 2, 0/12 (0%) in Group 3, and 26/272 (10%) in Group 4 (p0.4 mm or ≤ 1 mm and patients with an R0 resection. This article is protected by copyright. All rights reserved.

Objective The aim of this study was to assess whether association of laparoscopic approach and full fast track multimodal (FFT) management can reduce postoperative morbidity after colorectal cancer surgery, as compared to laparoscopic approach with limited fast-track program (LFT). Summary of background data Recent advances in colorectal cancer surgery are introduction of laparoscopy and FFT implementation. Methods Patients eligible for elective laparoscopic colorectal cancer surgery were randomized into 2 groups: FFT or LFT care (with only early oral intake and mobilization starting on Day 1). Primary outcome was postoperative 30-day morbidity, according to Clavien-Dindo classification. Results Two hundred seventy patients were randomized and 263 were analyzed: 130 in FFT group and 133 in LFT group, including 106 colon (FFT: n = 52 and LFT: n = 54) and 157 rectal cancer (FFT: n = 78 and LFT: n = 79). Postoperative 30-day mortality was nil. Overall postoperative 30-day morbidity did not show any difference between the groups (FFT: 35% vs LFT: 29%, P = 0.290), neither regarding the overall population, nor in the colon (FFT: 23% vs LFT: 19%, P = 0.636) or rectal (FFT: 44% vs LFT: 35%, P = 0.330) cancer subgroups. Severe postoperative morbidity was also not different between groups (FFT: 12% vs LFT: 8%, P = 0.266). After multivariate regression analysis, only early intravenous catheter removal (on day 2) [odds ratio: 0.390; 95% confidence interval: (95% CI 0.181-0.842); P = 0.017] and the absence of intraoperative lidocaine intravenous perfusion (odds ratio: 0.182, 95% CI 0.042-0.788; P = 0.019) were identified as independent predictive factors of reduced postoperative morbidity. Conclusion Addition of FFT multimodal management to laparoscopic approach with early oral intake and mobilization does not reduce postoperative morbidity after colorectal cancer surgery.

Prolonged postoperative ileus (PPOI) is a common complication after colorectal resection but data regarding PPOI risk factors after laparoscopic rectal cancer surgery is lacking. This study aimed to identify risk factors for PPOI after laparoscopic sphincter-saving total mesorectal excision (TME) for cancer.All patients who underwent a laparoscopic sphincter-saving TME for cancer from 2005 to 2014 were identified from our prospective database. PPOI was defined as abdominal distension, nausea, and/or vomiting, requiring a nasogastric tube insertion, during the postoperative period.Among 428 consecutive patients, 65 patients (15%) presented with POI. In multivariate analysis, male gender (Odds Ratio (OR) 2.3 [1.1-4.5]; p = 0.026, age70 years (OR: 2.0 [1.1-4.0]; p = 0.037)], conversion to open approach (OR 4.9 [1.5-15.4]; p = 0.007), and intra-abdominal surgical site infection (OR 3.8 [1.9-7.5]; p 0.001) were identified as independent risk factor for PPOI. PPOI risk was 5% in patients without any risk factor but raised to 11, 28, and 54% in patients with 1, 2, or ≥3 risk factors, respectively (p 0.001).PPOI is observed in 15% of the patients after laparoscopic sphincter-saving surgery for rectal cancer. We identified four independent factors for PPOI in multivariate analysis: male, gender, age70, conversion to open approach, and intra-abdominal surgical site infection, leading to the construction of a simple and pragmatic predictive score. This score might help the surgeon to assess patient at risk of PPOI.

Resume Introduction et but de l’etude Le syndrome de grele court (SGC) est la premiere cause d’insuffisance intestinale chronique necessitant une nutrition parenterale a domicile (NPAD) parfois a vie. Pour favoriser l’adaptation intestinale et l’absorption de l’intestin restant des techniques de chirurgie de reconstruction ont ete proposees comme la realisation d’une inversion d’un segment distal de grele d’environ 10 cm pour ralentir le transit du grele et favoriser le temps de contact entre la surface absorptive et les nutriments. Objectif Evaluer les resultats a long terme de l’anse jejunale anti-peristaltique de l’intestin grele (AJAP) chez les patients atteints de SGC. Materiel et methodes Tous les patients ayant eu une AJAP dans le cadre d’un SGC avec un suivi de plus de 3 ans ont ete inclus. Il s’agit d’une etude monocentrique dans un centre associant a la chirurgie une prise en charge multidisciplinaire avec notamment une optimisation nutritionnelle et dietetique adaptee selon le type anatomique de SGC et l’evolution de la maladie. Resultats et analyse statistique Trente-cinq patients ont eu une AJAP pour SGC (longueur moyenne grele restant : 48 ± 24 cm). La longueur moyenne de l’anse inversee etait de 10 ± 2 cm (6–15). Le suivi median etait de 127 mois (36–399) et 28 patients avaient un suivi ≥ 5 ans. Trois ans apres l’AJAP, 14/35 (40 %) ont ete sevres de la nutrition parenterale (NP), 2/35 (6 %) n’ont necessite que des perfusions d’electrolytes (PE) et 19/35 (54 %) ont necessite une poursuite de la NPAD. Cinq ans apres l’AJAP, 7/28 (25 %) restaient sevres de NP, 2/28 (7 %) ne necessitaient que des PE et 19/28 (68 %) etaient en NPAD. Enfin, a la fin du suivi, 7/28 (25 %) restaient sevres de la NP, 3/28 (11 %) n’avaient besoin que de PE et 18/28 (64 %) avaient besoin de NP avec une moyenne de 4,8 ± 1,6 (2–7) jours/semaine. Conclusion L’AJAP permet de reduire la dependance a la NPAD chez la majorite des patients, conduisant a un taux de sevrage de la NP a 3 ans de 40 %. Ce resultat demontre l’importance d’une prise en charge multidisciplinaire integrant la chirurgie dans un programme complet de rehabilitation intestinale. Cependant, cet avantage a tendance a diminuer avec le temps, ce qui conduit a une augmentation des besoins en NP au cours du suivi a long terme.

Introduction et but de l’etude Bien que l’insuffisance intestinale (II) traitee en centre expert de nutrition parenterale (NP) ait un pronostic a long terme favorable, une origine ischemique par infarctus mesenterique (IM) en constitue un facteur pronostique pejoratif independant et est toujours consideree par les medecins comme une situation dramatique. Le but de ce travail etait d’etudier les resultats a long terme de la rehabilitation intestinale des survivants a un IM. Materiel et methodes Etude de cohorte retrospective des patients consecutifs pris en charge en centre expert de NP de 2006 a 2015 apres resection intestinale pour un IM. Les patients admis pour une ischemie mesenterique evolutive ou non chirurgicale n’etaient pas inclus. Les facteurs associes a la dependance a la NP et a la recidive d’ischemie mesenterique etaient evalues par un modele multivarie de regression de Cox. Les resultats sont rapportes en Hazard Ratio (HR) avec leurs intervalles de confiance a 95 % (IC95 %). Resultats et analyse statistique Nous avons inclus 184 patients (âge median de 51 ans) admis dans notre unite apres un delai median de 3 mois apres chirurgie pour un IM. Au diagnostic, l’IM etait le premier accident vasculaire chez 53 % des patients et le taux plasmatique de lactate etait normal dans 51 % des cas. Dans le centre referent initial, le diagnostic d’IM avait ete retarde (delai diagnostique median : 2 jours) et son traitement avait ete insuffisant (taux de revascularisation : 15 %), aboutissant a une resection intestinale et une II chez tous les patients. Apres rehabilitation intestinale multidisciplinaire (nutritionnelle, vasculaire et digestive), la probabilite de survie a 3 ans etait de 86 %, sans recidive d’IM, sans stomie ni NP residuelle dans respectivement 94 %, 70 % et 47 %. En analyse multivariee, les facteurs predictifs de sevrage de la NP etaient : la revascularisation au stade initial de l’IM [HR = 2,4 ; IC95 % = 1,1–5,2 ; p = 0,02], une longueur de grele restant > 50 cm [51–150 cm : HR = 3,8 ; IC95 % = 1,8–8,0 ; > 150 cm : HR = 9,7 ; IC95 % = 3,9-23,8 ; p Conclusion Les patients en II survivants a un IM se sont initialement presente a un stade d’ischemie mesenterique precoce, potentiellement reversible, mais ont ete diagnostiques avec delai et sous-traites. Une rehabilitation intestinale multidisciplinaire en centre expert a cependant permis une survie a long terme sans NP elevee. Une reconnaissance precoce du diagnostic et une revascularisation tant au stade aigu qu’au stade de rehabilitation sont des facteurs pronostics essentiels.

Background According to recent literature, extended colectomy (EC) and segmental colectomy (SC) are equally effective for colonic Crohn’s disease (CCD), with no differences in terms of postoperative morbidity, incidence of long-term recurrence and definitive stoma, but earlier recurrence is observed in patients with SC. Our objective was to evaluate our comparative results between EC and SC. Methods All consecutive patients undergoing surgery for CCD (EC vs. SC) in our Centre were included and compared and we evaluated postoperative morbidity, long-term clinical and surgical recurrence. Results One hundred and twelve patients (mean age at diagnosis of CD, 31 ± 17 years, mean age at surgery 42 ± 17 years) with CCD underwent EC (n = 45) or SC (n = 67); 62 (55%) patients presenting concomitant small bowel disease, 10 (9%) an extra-intestinal manifestation and 16 (14%) were active smokers. Postoperative morbidity was 8/45 (18%) in case of EC vs. 9/67 (13%) in case of SC (NS). In EC group, 8/8 (100%) complicated patients vs. 16/37 (43%) uncomplicated patients were under anti-TNF before surgery (p = 0.04). This significant difference was not showed in SC group. After a median follow-up of 40 ± 34 months (range 1–130), clinical recurrence incidence was 15/45 (33%) in EC vs. 27/67 (40%) in SC patients (NS) and surgical recurrence was 8/45 (18%) in CE vs. 13/67 (19%) in CS patients (NS). Recurrence of the disease occurred after 19 ± 20 months (range, 1–74) in EC vs. 14 ± 26 months (range, 1–130) in CS patients (p = NS). Conclusion Our study confirms that in case of surgery for CCD, EC and SC are equally safe and feasible but recurrence happens earlier after SC than EC. Additionally, the role of anti-TNF is confirmed for postoperative complications.

The formation of tertiary lymphoid organs (TLOs) is orchestrated by the stromal cells of tissues chronically submitted to inflammatory stimuli, in order to uphold specific adaptive immune responses. We have recently shown that the smooth muscle cells of the arterial wall orchestrate the formation of the TLOs associated with atherosclerosis in response to the local release of TNF-α. Observational studies have recently documented the presence of structures resembling TLOs the creeping fat that develops in the mesentery of patients with Crohn's disease (CD), an inflammatory condition combining a complex and as yet not elucidated infectious and autoimmune responses. We have performed a comprehensive analysis of the TLO structures in order to decipher the mechanism leading to their formation in the mesentery of CD patients, and assessed the effect of infectious and/or inflammatory inducers on the potential TLO-organizer functions of adipocytes. Quantitative analysis showed that both T and B memory cells, as well as plasma cells, are enriched in the CD-affected mesentery, as compared with tissue from control subjects. Immunohistochemistry revealed that these cells are concentrated within the creeping fat of CD patients, in the vicinity of transmural lesions; that T and B cells are compartmentalized in clearly distinct areas; that they are supplied by post-capillary high endothelial venules and drained by lymphatic vessels indicating that these nodules are fully mature TLOs. Organ culture showed that mesenteric tissue samples from CD patients contained greater amounts of adipocyte-derived chemokines and the use of the conditioned medium from these cultures in functional assays was able to actively recruit T and B lymphocytes. Finally, the production of chemokines involved in TLO formation by 3T3-L1 adipocytes was directly elicited by a combination of TNF-α and LPS in vitro. We therefore propose a mechanism in which mesenteric adipocyte, through their production of key chemokines in response to inflammatory/bacterial stimuli, may orchestrate the formation of functional TLOs developing in CD-affected mesentery.

Background Fistulizing anoperineal lesions (FAPLs) are common and severe complications of Crohn’s disease (CD), exposing patients to the risk of anal sphincter alteration and permanent stoma. Due to the limited efficacy of current treatments, identifying new local therapies is mandatory. However, testing new treatments is currently limited because no relevant preclinical model of Crohn’s-like FAPL is available. Thus, a reliable and reproducible experimental model of FAPLs is needed to assess new therapeutic strategies. Methods Twenty-one rats received a rectal enema of 2,4,6-trinitrobenzensulfonic acid (TNBS) to induce proctitis. Seven days later, a transsphincteric fistula tract was created with a surgical thread, instilled with TNBS twice a week until its removal at day 7 (group 1), day 14 (group 2), or day 28 (group 3). In each rat, pelvic MRI was performed just before and 7 days after thread removal. Rats were sacrificed 7 days after thread removal for pathological assessment of the fistula tract. Results The optimal preclinical model was obtained in group 3. In this group, 7 days after thread removal, all animals (9 of 9) had a persistent fistula tract visible on MRI with T2-hypersignal (normalized T2 signal intensity: 2.36 ± 0.39 arbitrary units [a.u.] [2.08–2.81]) and elevation of the apparent diffusion coefficient (1.33 ± 0.16 10-3 millimeter squared per seconds [1.18–1.49]). The pathological examination of the fistula tract revealed acute and chronic inflammation, granulations, fibrosis, epithelialization, and proctitis in the adjacent rectum. Conclusions This reproducible preclinical model could be used to assess the effectiveness of innovative treatments in perianal fistulizing CD.