Les prothèses biologiques en milieu à risque septique sont d’utilisation croissante. Au vu de leur coût nettement supérieur à celui des prothèses synthétiques, il est important d’analyser leur utilité en terme de service médical rendu et sur le plan médico-économique. L’objectif était d’étudier la pertinence de l’utilisation des bioprothèses lors des cures d’éventration classées Ventral Hernia Working Group (VHWG) II/III. Les données de 119 patients requérant, hors urgence, une cure d’éventration grade VHWG II/III entre 2010 et 2017 ont été analysées. Les résultats des patients traités par bioprothèse (n = 59) ou par prothèse synthétique (n = 60) ont été comparés. Le critère de jugement principal était l’infection du site opératoire (ISO) à 90 jours. Les critères de jugement secondaires étaient le taux de récidive, le coût de la prothèse, la durée de séjour et taux de réhospitalisation. Les 2 groupes étaient comparables après analyse des données démographiques, pré- et peropératoires. Le taux d’ISO était significativement supérieur dans le groupe biologique (20 % vs 7 %; p = 0,010), ainsi que le taux de récidive (56 % vs 28 %; p = 0,003) avec un suivi médian de 40 mois. Le coût de la prothèse était significativement supérieur dans le groupe biologique (3363 vs 249€ ; p < 0,010). Dans cette étude rétrospective, l’utilisation d’une bioprothèse pour les éventrations VHWG II/III était associée à un taux plus élevé d’ISO et de récidive avec un coût 13 fois supérieur à l’utilisation d’une prothèse synthétique. The implantation of biological prostheses in an at-risk environment has seen increasing use. Their markedly higher cost compared to synthetic prostheses makes it important to analyze their usefulness in terms of actual benefit and cost-effectiveness. This study aims to examine the relevance of bioprostheses during surgical repair of Grade II/III ventral hernias as classified by the Ventral Hernia Working Group (VHWG). This study analyzed the data of 119 patients requiring non-emergency repair of VHWG II/III grade hernias between 2010 and 2017. The results of patients who were treated with a bioprosthesis (n = 59) were compared to those receiving a synthetic prosthesis (n = 60). The primary outcome was surgical site infection (SSI) at 90 days. The secondary endpoints were hernia recurrence rate, cost of the prosthesis, duration of hospital stay, and re-hospitalization rate. The two groups were shown to be comparable by analysis of demographic, pre- and intra-operative data. The SSI rate was significantly higher in the bioprosthesis group (20% vs. 7%; P = 0.010), as was the recurrence rate (56% vs. 28%; P = 0.003) with a median follow-up of 40.15 months. The cost of the bioprosthesis was significantly higher than that of the synthetic prosthesis (€ 3363 vs. € 249; P < 0.010). In this retrospective study, the use of a bioprosthesis for repair of VHWG II/III ventral hernias was associated with a higher rate of both SSI and hernia recurrence at a cost 13 times greater than the use of a synthetic prosthesis.

Aim of the study: The implantation of biological prostheses in an at-risk environment has seen increasing use. Their markedly higher cost compared to synthetic prostheses makes it important to analyse their usefulness in terms of actual benefit and cost-effectiveness. This study aims to examine the relevance of bioprostheses during surgical repair of Grade II/III ventral hernias as classified by the Ventral hernia working group (VHWG). Materials and methods: This study analysed the data of 119 patients requiring non-emergency repair of VHWG II/III grade hernias between 2010 and 2017. The results of patients who were treated with a bioprosthesis (n = 59) were compared to those receiving a synthetic prosthesis (n = 60). The primary outcome was surgical site infection (SSI) at 90 days. The secondary endpoints were hernia recurrence rate, cost of the prosthesis, duration of hospital stay and re-hospitalisation rate. Results: The two groups were shown to be comparable by analysis of demographic, pre-and intraoperative data. The SSI rate was significantly higher in the bioprosthesis group (20% vs. 7%; P = 0.010), as was the recurrence rate (56% vs. 28%; P = 0.003) with a median follow-up of 40 months. The cost of the bioprosthesis was significantly higher than that of the synthetic prosthesis ((SIC) 3363 vs. (SIC)249; P < 0.010). Conclusion: In this retrospective study, the use of a bioprosthesis for repair of VHWG II/III ventral hernias was associated with a higher rate of both SSI and hernia recurrence at a cost 13 times greater than the use of a synthetic prosthesis. (c) 2021 Published by Elsevier Masson SAS.

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Iterative ileo-colic resection (IICR) for Crohn's disease is often required for patients. Previous retrospective studies highlighted an increased overall and surgical morbidity. However, large recent data are lacking on this frequent situation. The aim of this study was to compare perioperative characteristics and results between primary ileo-colonic resection (PICR) and IICR for Crohn’s disease in a prospective multi- centric cohort. From 2013 to 2015, 567 patients undergoing ileocolonic resection were prospectively included in 19 centres of the GETAID chirurgical. Perioperative characteristics and postoperative results of both groups (431 PICR, 136 IICR) were compared. Uni- and multi-variate analyses of the risk factors of overall 30-days postoperative morbidity was carried out in the IICR group. IICR patients were less malnourished (27.2% vs. 39.9%, p = 0.007), with more stricturing phenotype (69.1% vs. 54.3% p = 0.003) and were older (11% > 65 years vs. 4.2%, p = 0.03). Preoperative treatment (steroids, anti-TNF) were not different between the two groups (p = 0.514). Laparoscopic approach was less frequently used for IICR (45.6% vs. 84.5%, p < 0.01) with an increased conversion rates (27.4% vs. 14.6%, p < 0.01). Operating time was significantly longer for IICR (155.9 vs. 138.9 min, p = 0.02). IICR patients presented less internal fistula (25% vs. 37.6%, p = 0.007), without differences in stoma rates (17.6% vs. 21.8%). Overall postoperative morbidity was 29.1%, increased in the IICR group (36.8% vs. 26.7%, p = 0.024), with more ileus (11.8% vs. 3.7%, p < 0.001), without difference in anastomotic leakage (AL) rate (8.8% vs. 8.4%) or prolonged length of stay (LOS) (IICR: 9.30 days ± 6.9 vs. PICR: 10.2 days ± 23.0, p = 0.499). Uni-and multi-variate analyses did not identify specific risk factors of overall postoperative morbidity in the IICR group and anti-TNF treatment was not associated with increased morbidity (41.3 vs. 40.2%, p = 0.460). After PRIC the post-operative outcomes were not modified by the number of surgical procedures (second (n = 97) vs. third or more (n = 39): conversion (p = 0.568), overall morbidity (p = 0.513) or intra-abdominal septic complication (p = 0.087). IICR is more technically challenging but half of patients can be operated through a laparoscopic approach. Increased morbidity is linked to post-operative ileus. Anastomotic leakage and intra-abdominal sceptic complications are not different. Iterative ileo-colic resection should not be considered as a factor in favour of stoma creation.

Postoperative recurrence rate following surgery for ileocolonic Crohn’s disease (CD) can be up to 60%. Predictive factors of postoperative recurrence remain controversial and have never been evaluated in a large prospective cohort study, leading difficulties regarding patients’ risk stratification and indication of postoperative prophylactic treatments. From September 2013 to September 2015, data on 592 consecutive patients who underwent surgery for ileocolonic CD at 19 academic French centres were collected prospectively in the RICCO registry held by the GETAID chirurgie group. Among them, 346 patients underwent a postoperative ileocoloscopy within 6–12 months following surgery and were included in the present study. Endoscopic recurrence was defined as a Rutgeerts score ≥ i2. Clinical recurrence was defined as a symptomatic (CD activity index score>150) endoscopic recurrence. 12-month postoperative endoscopic and clinical recurrence rates were 57.6 ± 3.4% and 11.3 ± 2.2%, respectively. A total of 173 patients (50%) had a postoperative prophylactic treatment (excluding probiotics, aminosalicylates, and budesonide), including thiopurines in 69 patients (20%) and anti-TNF therapy in 94 patients (27%). In multivariate Cox regression analysis, the absence of postoperative smoking (OR = 0.57; CI 95% = 0.40–0.83; p = 0.004), postoperative prophylactic treatment (OR = 0.49; CI 95% = 0.34–0.71; p < 0.001), and a B3 disease behaviour according to the Vienna classification (OR = 0.59; CI 95% = 0.41–0.85; p = 0.005) were identified as the only independent predictors of reduced endoscopic recurrence rate. Postoperative prophylactic treatment (OR = 0.42; CI 95% = 0.20–0.85; p = 0.016), and a B3 disease behaviour (OR = 0.29; CI 95% = 0.13–0.68; p = 0.004) were identified as the only independent predictors of reduced clinical recurrence rate. Postoperative anti-TNF therapy was associated with a significant reduction of both 12-month endoscopic (p < 0.001) and clinical (p = 0.018) recurrence rates. Postoperative prophylactic anti-TNF therapy significantly decreases both endoscopic and clinical recurrence rates following surgery for ileocolonic Crohn disease. This study suggest that upfront surgery followed by postoperative anti-TNF therapy is probably the best therapeutic approach for complex Crohn disease (B3 disease behaviour) with low recurrence rate after surgery.

Background: Despite the use of anti-TNF therapy for prevention of postoperative recurrence, more than 20% of Crohn's disease (CD) patients present an endoscopic recurrence 6 months after surgery. The aim of our study was to assess the relationship between serum adalimumab (ADA) concentration 3 months after surgery and endoscopic recurrence at 6 months in CD patients treated with adalimumab for prevention of postoperative recurrence. Methods: This was a prospective, multicenter study between January 2014 and March 2016. All CD patients who underwent an ileocecal resection with ileocolonic anastomosis and were treated with ADA monotherapy (introduced one month after surgery subcutaneously with 160 mg at week 0, 80 mg at week 2 and then 40 mg every week), for prevention of postoperative recurrence were included in the study. Serum ADA concentration was determined 2 months after ADA introduction. Endoscopic recurrence at 6 months was defined as a Rutgeerts endoscopic score ≥ i2. Results: Fifteen CD patients were included (9 male and 6 female), with a median age of 24 years-old [15–47]. Disease phenotype was considered as penetrating in 8 patients (53%), stricturing in 5 patients (34%) and inflammatory in 2 (13%). Eight (53%) patients had an isolated ileal disease and 7 (47%) an ileocolonic location. Eight patients (53%) had at least 2 risk factors for postoperative recurrence according to ECCO guidelines and 14 (93%) were already treated with anti-TNF before surgery. The overall endoscopic recurrence rate was 46.7%. The median serum ADA concentration 3 months after surgery was 7.9 μg/mL (0.04–11.8) and no patient had anti-ADA antibodies. Median serum ADA concentration was significantly higher in CD patients without endoscopic postoperative recurrence compared to CD patients with endoscopic postoperative recurrence (8.2 μg/mL vs 2.5 μg/mL, p=0.121). According to Rutgeerts score, the median serum ADA concentration was 8.2, 5.1 and 0.2 mg/mL in patients with a score ≤ i1, i2 and ≥i3, respectively (p=0.033). Indeed, the serum ADA concentration was inversely correlated to the Rutgeerts score (Pearson coefficient = −0.61, p=0.015). The ROC curve analysis demonstrated a specificity of 71% and a sensitivity of 87% for serum ADA concentration threshold of 4 μg/mL to predict endoscopic recurrence (area under the curve = 0.75±0.14). Thus, 83% of CD patients with a serum ADA concentration <4 μg/mL had an endoscopic recurrence, compared to 22% of CD patients with a serum ADA concentration >4μg/mL (p=0.04). Conclusions: In our study, there was a significant correlation between serum ADA concentration 3 months after surgery and endoscopic postoperative recurrence at 6 months in CD patients treated with ADA to prevent postoperative recurrence.

L'objectif de cette étude prospective était de comparer les résultats à court-terme de la PG robot-assistée (PGRA) versus laparoscopique (PGL). Entre 2011 et 2016, tous les patients opérés d'une PG avec abord mini-invasif été inclus et classés en 2 groupes : PGRA ou PGL. Une PGRA était proposée au patient selon la disponibilité du système Da Vinci®. Trente-huit PG ont été inclues (26 F/12 H) : PGRA (n = 15) et PGL (n = 23). Les durées opératoires ne différaient pas entre les deux groupes (PGRA : 207 min vs PGL : 187 min, p = 0,5). Les taux de conversion, d'échec de conservation splénique et de transfusion per- et postopératoire étaient nuls dans les deux groupes. Une fistule pancréatique a été diagnostiquée pour 40 % et 32 % (p = 0,7). Les DMS étaient similaires dans les 2 groupes (PGRA : 8 jours vs PGL : 9 jours, p = 0,3). Le taux de complications à 90 jours de grade ≥ III étaient de 6,5 % pour les PGRA versus 8 % pour les PGL (p = 1). La PG robot-assistée est une technique sûre, potentiellement équivalente à la PGL mais qui pose un problème de surcoût (une étude médico-économique sera disponible en juillet 2017).

Prosthetic-related infection and erosion occurring after a laparoscopic ventral rectopexy (LVR) are rare complications, and their importance is often underestimated. The aim of this study was to compare the incidence rate and surgical management of these complications in LVR patients with polyester (PE) or polypropylene (PP) prostheses.

Los divertículos del colon izquierdo son los que, con más frecuencia, son responsables de las complicaciones infecciosas, mientras que la diverticulitis complicada del colon derecho es algo excepcional. La sigmoidectomía selectiva está indicada en pacientes que han presentado varios episodios de diverticulitis sigmoidea. Se programa a distancia del último episodio infeccioso para tener las mínimas secuelas inflamatorias perisigmoideas. La colectomía laparoscópica ha sustituido progresivamente a la cirugía convencional y, hoy día, es la técnica de referencia. Las indicaciones de la colectomía izquierda por laparotomía son, actualmente, las contraindicaciones de la laparoscopia. Estas contraindicaciones pueden ser de índole anestésica, quirúrgica (cirugías abdominales previas, seudotumor inflamatorio, exceso de grasa mesentérica). La resección incluye la totalidad del asa sigmoidea y la porción fija del sigmoide o colon ilíaco y concluye con una anastomosis colorrectal. La preservación de los componentes nerviosos mesentéricos e hipogástricos es esencial para no producir secuelas urinarias y sexuales. Por esta razón, hay que poner especial atención durante las ligaduras vasculares, siempre alejadas del origen de la arteria mesentérica inferior y durante la disección de la unión rectosigmoidea. La mortalidad postoperatoria es inferior al 2%, la morbilidad es de alrededor del 30% y la tasa de fístulas postoperatorias es del 3-4%. La tasa de recidiva de diverticulitis tras la colectomía varía entre el 2 y el 10% según los distintos autores.

Biliary injuries after laparoscopic cholecystectomy are rare but serious. Their mortality rate can reach 9%.Aim of the study: Describe the management of biliary injuries after laparoscopic cholecystectomy in our center.Patients: Between January 1995 and June 2005, 27 patients (13 women, 14 men) were treated. The mean age was 53 years old (range, 18-92 years). The biliary injuries were common bile duct sections (n=16, 60%), common bile duct stenoses (n=5, 18.5%), biliary fistulas from the cystic duct (n=4, 15%), and biliary fistulas from an aberrant biliary duct (n=2, 7.5%).Results: Acute cholecystis was present in 40% of cases (n= 11). An intraoperative cholangiography was done in 12 patients (44%). The mortality rate was 0%. Of the common bile duct sections, 43% were diagnosed during the cholecystectomy (n=7) or after the cholecystectomy within a mean of 11.2 days (n=9). Common bile duct injuries were treated in 16 cases with hepatojejunostomy and in five cases with an external biliary drain. Fistulas from the cystic duct were diagnosed within a mean 14.8 days. A fistula from an aberrant biliary duct was diagnosed during the cholecystectomy (n=1) or in the second postoperative day (n=1). Fistulas were treated with a clip on the cystic duct (n=2), an external biliary drain (n=1), a biliary endoprosthesis (n=1), and the biliary aberrant duct suture (n=2).Conclusion: Common bile duct injuries are a serious complication because their treatment is a hepaticojejunostomy in 75% of cases.

UNLABELLED:Biliary injuries after laparoscopic cholecystectomy are rare but serious. Their mortality rate can reach 9%.AIM OF THE STUDY:Describe the management of biliary injuries after laparoscopic cholecystectomy in our center.PATIENTS:Between January 1995 and June 2005, 27 patients (13 women, 14 men) were treated. The mean age was 53 years old (range, 18-92 years). The biliary injuries were common bile duct sections (n=16, 60%), common bile duct stenoses (n=5, 18.5%), biliary fistulas from the cystic duct (n=4, 15%), and biliary fistulas from an aberrant biliary duct (n=2, 7.5%).RESULTS:Acute cholecystis was present in 40% of cases (n=11). An intraoperative cholangiography was done in 12 patients (44%). The mortality rate was 0%. Of the common bile duct sections, 43% were diagnosed during the cholecystectomy (n=7) or after the cholecystectomy within a mean of 11.2 days (n=9). Common bile duct injuries were treated in 16 cases with hepatojejunostomy and in five cases with an external biliary drain. Fistulas from the cystic duct were diagnosed within a mean 14.8 days. A fistula from an aberrant biliary duct was diagnosed during the cholecystectomy (n=1) or in the second postoperative day (n=1). Fistulas were treated with a clip on the cystic duct (n=2), an external biliary drain (n=1), a biliary endoprosthesis (n=1), and the biliary aberrant duct suture (n=2).CONCLUSION:Common bile duct injuries are a serious complication because their treatment is a hepaticojejunostomy in 75% of cases.

Background: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. Methods: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). Results: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1–26). No patient required additional CBD procedures during follow-up. Conclusions: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.