The choice of therapeutic method for the management of primary hyperparathyroidism depends on the severity of the disease and its complications at the time of diagnosis, the specific situation of each patient and his/her natural history, and assessment of the risk/benefit ratio for each method (surgery, local destruction or drugs). This chapter summarizes the indications for the treatment of primary hyperparathyroidism, based on the international literature available as of December 31st, 2023.
Duodenal perforation is a rare occurrence and is associated with high mortality, which rises to 30-50% in cases that involve associated peritonitis. The most frequent etiologies include peptic ulcer, post-operative fistula, endoscopic perforation, and trauma. The challenge in managing this pathology lies in the fact that resection with anastomosis is often unfeasible, and the creation of a stoma is not possible. Management must be tailored on a case-by-case basis that always involves medical measures, often endoscopic interventions, and sometimes surgery. Indeed, the surgical option is feasible in selected patients who are diagnosed early and present without complications. Surgical procedures are classified into two categories: preferably, reconstructive procedures-where resection of the perforation and restoration of digestive continuity is possible, provided that local and hemodynamic conditions are favorable; conversely, a duodenojejunal diversion procedure-in which the perforation is left in situ while enteric secretions are diverted-is the preferred approach when conditions are unfavorable. When local conditions are unfavorable, or there is hemodynamic instability, duodenostomy drainage is the preferred option. This technique involves directing duodenal secretions toward the skin, thereby inducing the formation of a fibrotic fistulous tract with eventual wound healing. The management of duodenal perforation is a lengthy and challenging process.
INTRODUCTION:Anoperineal fistula (APF) treated by fistulectomy provides the best anatomical results but carries a high risk of anal incontinence. Sphincter reconstruction might improve these outcomes, but limited comparative data are available in the literature. The purpose of this study was to compare the outcomes of fistulotomy plus sphincter reconstruction (FSR) and sphincter-sparing techniques for APF repair. METHOD:This two-center retrospective study included patients undergoing FSR or ligation of the intersphincteric fistula tract (LIFT) or rectal advancement flap (control group) techniques. RESULTS:Of the 119 patients included, 95 (79.8%) underwent FSR. There were no statistically significant differences in demographic characteristics between groups. More inter- or trans-sphincteric fistulas were included in the control group, while there were more complex fistulas in the FSR group (P<0.001). The healing rate was 76.2% in the control group compared to 91.6% in the FSR group (P=0.056). No statistically significant difference was found in the overall complication (8.4%) or overall anal incontinence rates (14.7%) (P>0.9). In contrast, the recurrence rate was higher in the control group than in the FSR group (P<0.001). In multivariable analysis, FSR was associated with a lower risk of recurrence compared to the control group (OR=0.16; 95% CI: 0.03-0.77). CONCLUSION:This study suggests that FSR may be superior to the other techniques in terms of cure without increasing morbidity or the risk of anal incontinence.
Primary hyperparathyroidism (PHPT) is associated with numerous established clinical manifestations as well as subclinical impairments, including cardiometabolic complications (cardiovascular mortality, hypertension, prediabetes, diabetes, dyslipidemia, vascular abnormalities). These alterations appear to be linked to elevated parathyroid hormone and/or calcium levels, and could play a direct or indirect role in increasing cardiovascular risk in patients with PHPT. In the absence of robust data and given sometimes heterogeneous results, current French and international guidelines do not recognize cardiometabolic complications as an indication for parathyroidectomy in PHPT. Nevertheless, some data suggest a beneficial effect of surgery on these parameters, notably an improvement in blood pressure, lipid profile, or insulin sensitivity after parathyroidectomy. However, results remain variable depending on the studies, methodologies used, and evaluation criteria retained. This review aims to provide an overview of current knowledge on the impact of parathyroidectomy in PHPT regarding cardiovascular and metabolic risk, and to identify open questions to guide future research.
BACKGROUND:Among the complications associated with Hartmann's procedure, rectal stump blowout appears to be underrecognised. Despite the widespread practice of leaving a catheter in the rectal remnant, there is limited scientific evidence supporting this approach. Other risk factors have been infrequently and inconsistently reported. We analysed our five-year experience to identify predictors of stump blowout following Hartmann's, and to determine whether the use of rectal tubes is of any clinical benefit. METHODS:This retrospective study included all patients who underwent emergency Hartmann's procedure between 2020 and 2025. Primary and secondary outcomes were rectal stump blowout and its latency in days from the surgery. Univariate analysis was conducted to identify variables of interest, which were subsequently entered into a regression model. RESULTS:Among 133 patients included in the study, 9 (6.8%) experienced rectal stump blowout. Black ethnicity (P=0.07; odds ratio 7.4), diagnoses involving colonic perforation (P=0.08; odds ratio 5.6), and placement of pelvic drain (P=0.054; relative risk 0.91) demonstrated nearly significant association with blowout but did not add significantly to the model. Patients with Charlson Comorbidity Index ≥ 7 (P=0.02) and those who underwent multiple bowel resections during Hartmann's procedure (P=0.005) were 9.2-fold and 28.5-fold more likely, respectively, to develop stump leak. The use of rectal tubes did not influence the incidence of blowout (P=0.49). CONCLUSIONS:Highly comorbid patients and those requiring additional bowel resections are at increased risk of post-Hartmann's stump leak. Routine use of protective rectal tubes does not alter the probability to develop a rectal stump blowout.
BACKGROUND:To analyze the outcomes of multiple endocrine neoplasia type 1 (MEN1) patients after distal pancreatectomy (DP) for pancreatic neuroendocrine neoplasm (P-NENs) with a specific attention to postoperative complications and long-term survival. METHODS:MEN1 patients from the French MEN1 cohort who underwent DP for P-NENs between 1990 and 2022 were included in the study. Early and late postoperative complications, secretory control, pancreatic disease-free and overall survival were assessed. RESULTS:Out of 62 patients included, 41 (66%) underwent DP for a non-functioning P-NENs, 14 (23%) for insulinomas, 4 (6%) for a VIPoma and 3 (5%) for a glucagonoma. Median follow-up was 84 months (range: 12-335). No death within the 90 postoperative days was observed. Clavien-Dindo grade III-V postoperative complications occurred in 16% of the patients (n=11). Fourteen patients (23%) developed pancreatic fistulas. Twenty-four patients (39%) developed diabetes mellitus and 8 patients (13%) developed pancreatic exocrine insufficiency. The secretory control rate was 90%. Mean age at death was 56±10.9years. Five-year and ten-year overall survival was 93.0% [CI (85-100)], and 86.7% [CI (76.2-98.5)]. Ten-year liver metastasis-free survival was significantly shorter when DP was performed for non-functioning P-NENs compared to insulinomas 60.4% [CI (47-79)] versus 83.3% [CI (68-87)] (P=0.007). CONCLUSION:Distal pancreatectomy in MEN1 patients is a safe surgical procedure with an acceptable morbidity and a very low postoperative mortality. Further studies are needed to standardize the extent of lymph node removal when distal pancreatectomy is performed in MEN-1 patients.
Incisional hernia is a common late complication of abdominal surgery. Treatment consists in restoring abdominal wall integrity, with prosthetic reinforcement to limit long-term recurrence. In practice, the choice of mesh is complicated by the wide variety of materials, their composition and biological behaviors, while current guidelines are broad and poorly discriminative according to indications. The aim of this review is to summarize the main criteria for selecting parietal meshes and their clinical impact, in order to propose recommendations for rational choice in each situation. Non-absorbable materials are standard in most indications, but are increasingly controversial because of long-term complications associated with a permanent foreign body: notably chronic inflammation, and environmental concerns related to micropollutants. Slowly or partially absorbable materials are a promising alternative, particularly in high-risk contexts, as they optimize tissue integration by modulating the immune response. However, further studies with high levels of evidence are needed to confirm indications. The physical characteristics of meshes, the clinical impact of which is difficult to pinpoint among other operative variables, should be re-assessed by manufacturers, in the light of newly available materials. The choice of parietal mesh is based on a combination of multiple interdependent parameters derived from preclinical and clinical studies. It should be primarily guided by clinical context and the risk of complications.
INTRODUCTION:Postoperative pancreatic fistula (POPF) remains one of the most dreaded complications after pancreatoduodenectomy (PD), especially in patients with soft pancreatic parenchyma and a small main pancreatic duct. In this context, total pancreatectomy (TP) has been proposed to prevent the occurrence of POPF, although its metabolic consequences limit its widespread adoption. OBJECTIVE:To compare the postoperative outcomes of PD and TP in patients at high risk of POPF, assessing morbidity, mortality, and metabolic consequences. METHODS:A systematic literature search was conducted according to the PRISMA recommendations, including comparative studies of PD versus TP in a high-risk population. The criteria analyzed included morbidity, mortality, oncological outcomes and the occurrence of insulin-dependent diabetes mellites. RESULTS:The available data suggest a reduction in overall morbidity and severe complications after TP, but at the cost of a high rate of postoperative diabetes mellites. Islet cell auto-transplantation (IAT) could mitigate these metabolic consequences, and has shown encouraging results on glycemia control and the preservation of residual insulin secretion. CONCLUSION:In patients at high risk of POPF, TP may be a pertinent alternative to PD, especially in complex anatomical or oncological situations. However, the metabolic benefit-risk balance needs to be carefully assessed, and strategies such as TP-IAT may improve functional outcomes. Additional randomized controlled trials are needed, including an accurate assessment of postoperative quality of life.
