Background: Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. Method: This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. Results: There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3-5, P < 0.001). Conclusion: The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders. Local excision (LE) is a new strategy for organ preservation but its morbidity post chemoradiotherapy is unknown in comparison to total mesorectal excision (TME). This study observed a significantly lower surgical morbidity of LE in comparison to TME, post neoadjuvant chemoradiotherapy for low rectal cancer, at 30 days (20% vs. 36%) and 2 years (4% vs. 33%) respectively. Local excision is a safe option for organ preservation in patients who are good responders to neoadjuvant therapy.

The aetiology of appendicular abscess is predominantly microbial with aerobic and anaerobic bacteria from gut flora. In this study, by using specific laboratory tools, we co-detected Methanobrevibacter oralis and Methanobrevibacter smithii among a mixture of enterobacteria including Escherichia coli, Enterococcus faecium and Enterococcus avium in four unrelated cases of postoperative appendiceal abscesses. These unprecedented observations raise a question on the role of methanogens in peri-appendicular abscesses, supporting antibiotics as an alternative therapeutic option for appendicitis, including antibiotics active against methanogens such as metronidazole or fusidic acid.

Fecal incontinence is a common complaint. In the presence of extensive sphincter deterioration, after anorectal trauma, or failure of non-invasive surgical procedures, a sphincter reconstruction with dynamic graciloplasty can be proposed. The aim of our study was to evaluate the long-term results of dynamic graciloplasty. A retrospective study was conducted on all the patients who underwent dynamic graciloplasty between 1997 and 2019 in one French tertiary referral center for severe fecal incontinence after previous unsuccessful treatments. Only patients with available long-term results (≥ 1 year) were included. Among 40 patients who underwent dynamic graciloplasty, 31 patients [77% women, median age = 57 years (range 17–74 years)] were included with a mean long-term follow-up of 11 ± 6 years. The mean duration of fecal incontinence was 8 ± 7.9 years and the mean Wexner score was 16 ± 3. Fecal incontinence was adult-acquired in 88% of patients. 74% of patients underwent previously unsuccessful surgical procedures. A diverting colostomy was present in 7 patients (23%). Postoperative overall, surgical and major morbidity occurred in 20 (64%), 17 (55%) and 7 (23%) patients, respectively. At the end of follow-up, 18 patients still used their stimulation device (58%), and 4 patients required a permanent colostomy (12.5%). Long-term efficacy of dynamic graciloplasty was reported by 17 patients (55%). The efficacy of dynamic graciloplasty is conserved in 55% of patients after a mean follow-up of 11 years. This procedure needs to be kept in the surgical armamentarium for persistent and severe fecal incontinence after previous surgical interventions or in the presence of large perineal defects, before the ultimate step of permanent stoma.

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Elevated C-reactive protein, should be used to prompt early detection of AL prior to the development of clinical symptoms. Early biochemical diagnosis and intervention of AL mitigates the negative impact of AL on oncological outcomes in patients with rectal cancer.

La rectocèle est définie par une hernie du rectum par protrusion de sa paroi antérieure au travers de la paroi postérieure du vagin. C’est une situation fréquente, dont on estime la prévalence à 30–50 % des femmes de plus de 50 ans. La symptomatologie amenant les femmes à consulter est variable, dominée par des symptômes anorectaux et/ou gynécologiques, tels que la dyschésie, le recours aux manœuvres digitales d’exonération, la pesanteur pelvienne, l’incontinence anale ou la dyspareunie. La rectocèle peut être isolée ou associée à d’autres troubles de la statique pelvienne impliquant les étages pelviens antérieur et moyen. Une exploration paraclinique (imagerie dynamique, manométrie anorectale) est indispensable avant toute prise en charge chirurgicale de cette affection. L’indication d’une prise en charge chirurgicale d’une rectocèle repose sur l’intensité des plaintes et donc l’altération de la qualité de vie, et se discute après échec d’un traitement médical. Différentes voies d’abord sont possibles, sans qu’il n’existe actuellement un réel consensus dans la littérature. Les voies d’abord dépendent du type de rectocèle : si elle est inférieure ou moyenne et/ou isolée, les voies d’abord basses (abord transanal, transpérinéal, ou transvaginal) peuvent être proposées, tandis qu’en présence d’une rectocèle haute et/ou associée à plusieurs troubles de la statique pelvienne, la voie abdominale (rectopexie) est plus adaptée.

Rapporter l'expérience française de la prise en charge chirurgicale des tumeurs rétro-rectales (TRR). Tous les patients opérés d'une TRR dans 17 centres français étaient rétrospectivement inclus (2000–2019). Les voies d'abord (antérieure, postérieure et combinée) étaient comparées. Deux cent trente-six patients (184 femmes, âge moyen 46 ± 17 ans) ont été inclus. Le diagnostic était fortuit pour 94 patients (40 %). Les TRR étaient malignes dans 10 % des cas. La chirurgie était réalisée par voie antérieure (n = 65, 27,5), postérieure (n = 161, 68 %) ou combinée (n = 10, 4 %). Les voies d'abord postérieure et combinée étaient associées à des abcès de paroi (16 % et 20 % vs 1,5 %, p = 0,008), alors que l'iléus survenait uniquement après une voie antérieure (8 %, p = 0,001). Après un suivi médian de 12 [1–221] mois, une récidive locale était observée dans 10 % des cas. Les complications fonctionnelles étaient rares (douleurs chroniques 8 %, dysfonctions urinaires 3 %, sexuelles 2,5 %, incontinence anale 1 %). Le taux de récidive et les complications fonctionnelles étaient similaires selon la voie d'abord. Les TRR constituent un challenge chirurgical car majoritairement bénignes et potentiellement pourvoyeuses de complications per- et postopératoires. Il ne semble pas y avoir de supériorité d'une voie d'abord sur l'autre.

Aim The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score. Method From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value <= 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve. Results A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age >= 75 (P = 0.013), American Society of Anesthesiologists (ASA) score >= III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80. Conclusion Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

Rapporter les résultats de l’intervention bilatérale de Nesovic pour traiter la pubalgie. L’étude incluait tous les malades ayant eu une intervention bilatérale de Nesovic traitant une pubalgie rebelle aux traitements médicamenteux et physiques, dans un centre de référence unique. Entre 2008 et 2018, 35 malades (34 hommes – 29 ± 8 ans [17–51]) ont eu une intervention bilatérale de Nesovic, Seize étaient des athlètes de haut niveau (46 %). La durée moyenne de séjour a été de 4,5 (± 1) jours. Quatre malades (11 %) ont eu une complication postopératoire mineure transitoire. Il n’y a pas eu de réintervention. Trente et un malades ont repris leur activité sportive (89 %). La durée moyenne du suivi a été de 3 ans. Sept malades (20 %) ont eu une récidive douloureuse imposant une réduction de l’activité. Aucun n’a été réopéré. Notre étude suggère que l’intervention bilatérale de Nesovic est efficace, sûre et reproductible pour la majorité des malades. Ils doivent être informés d’un risque d’échec estimé à 20 %, imposant l’interruption définitive d’une activité de haut niveau.

Aim Faecal incontinence is frequent in the elderly. Little is currently known about the efficacy of sacral nerve modulation (SNM) in the elderly. The present study aimed to assess the impact of age on the outcome of SNM and on the surgical revision and explantation rates by comparing the results of a large data set of patients. Method Prospectively collected data from patients who underwent an implant procedure between January 2010 and December 2015 in seven French centres were retrospectively evaluated. In total, 352 patients [321 women; median age (range): 63 (24-86) years] were included. Clinically favourable and unfavourable outcomes, and surgical revision and explantation rates, were compared according to the age of the patients. Results A similar outcome was observed when comparing patients < 70 years and >= 70 years (a favourable outcome in 79.2% and 76.2%, respectively, P = 0.89). The probability of a successful treatment as a function of time was similar for the two age groups (< 70 years and >= 70 years, P = 0.54). The explantation and revision rates were not influenced by age (explantation rate: 17% in patients vs 14% in patients >= 70 years, P = 0.89; and revision rate: 42% in patients vs 40% in patients >= 70 years, P = 0.89). The probability of explantation as a function of time was similar for the two age groups (P = 0.82). The limitations of this study were its retrospective status, the rate of loss at follow-up and different durations of patient follow-up. Conclusions Our results suggest that patients >= 70 years suffering from faecal incontinence benefit from SNM with a similar risk as a younger population.

La chirurgie du cancer du côlon gauche en occlusion (CCGO) est controversée. L'objectif est de rapporter les résultats postopératoires et oncologiques des différentes options chirurgicales pour un CCGO. De 2000 à 2015, 1500 patients ont été opérés d'un CCGO dans les centres membres de l'Association française de chirurgie. Les prothèses endoscopiques (n = 271), les soins de support (n = 5) et les dérivations internes palliatives (n = 4) n'étaient pas inclus. Parmi les 1220 patients, 456 ont eu une colostomie de dérivation (CD), 329 une colectomie segmentaire avec anastomose (CS), 246 une intervention de Hartmann (H) et 189 patients une colectomie subtotale (CST). Les données périopératoires et les résultats oncologiques étaient comparés entre les groupes. Il n'y avait pas de différence entre les 4 groupes pour le sexe, l'âge, l'IMC et les comorbidités. Les taux de mortalité et morbidité postopératoire étaient 4 et 27 % (CD), 6 et 47 % (CS), 9 et 55 % (H), 13 et 60 % (CST), respectivement (p = 0,005). Parmi les 431 patients vivants après CD, 321 (70 %) patients ont eu une résection de la tumeur primitive. Les taux cumulés de mortalité et morbidité postopératoires étaient en faveur de la CD (7 et 39 %) et de la CS (6 et 40 %) par rapport la H (1 et 47 %) et la STC (13 et 50 %) (p = 0,04). À la fin du suivi, les taux de stomie définitive étaient de 39 % (H), 24 % (CD), 10 % (CS), et 8 % (CST) (p < 0,0001). Les taux de survie globale et sans maladie à 5 ans étaient : CS (67 et 55 %), CD (54 et 48 %), H (54 et 37 %) et STC (48 et 49 %). En analyse multivariée, la CS et la CD étaient associées à un meilleur pronostic que le H et que la CST. Dans le CCGO, la CS et la CD sont les 2 meilleures options pour les malades en bon état général. La CD devrait être recommandée chez les patients fragiles. L'intervention de Hartmann et la CST sont à réserver aux patients avec une ischémie colique ou une perforation. Surgical management of obstructive left colon cancer (OLCC) is controversial. The objective is to report on postoperative and oncological outcomes of the different surgical options in patients operated on for OLCC. From 2000–2015, 1500 patients were treated for OLCC in centers members of the French Surgical Association. Colonic stent (n = 271), supportive care (n = 5), palliative derivation (n = 4) were excluded. Among 1220 remaining patients, 456 had primary diverting colostomy (PDC), 329 a segmental colectomy (SC), 246 a Hartmann's procedure (HP) and 189 a subtotal colectomy (STC) as first-stage surgery. Perioperative data and oncological outcomes were compared retrospectively. There was no difference between the 4 groups regarding gender, age, BMI and comorbidities. Postoperative mortality and morbidity were 4–27% (PDC), 6–47% (SC), 9–55% (HP), 13–60% (STC), respectively (P = 0.005). Among the 431 living patients after PDC, 321 (70%) patients had their primary tumour removed. Cumulative mortality and morbidity favoured PDC (7–39%) and SC (6–40%) compared to HP (1–47%) and STC (13–50%) (P = 0.04). At the end of follow-up definitive stoma rates were 39% (HP), 24% (PDC), 10% (SC), and 8% (STC) (P < 0.0001). Five-year overall and disease-free survival was: SC (67–55%), PDC (54–48%), HP (54–37%) and STC (48–49%). After multivariate analysis, SC and PDC were associated with better prognosis compared to HP and STC. In OLCC, SC and PDC are the two preferred options in patients with good medical conditions. For patients with severe comorbidities PDC should be recommended, reserving HP and STC for patients with colonic ischaemia or perforation complicating malignant obstruction.

La prise en charge des conséquences fonctionnelles après exérèse pancréatique est devenue un nouvel enjeu thérapeutique. L’objectif de notre étude est d’évaluer l’ensemble des facteurs de risques d’insuffisance pancréatique exocrine (IPExo) et d’insuffisance pancréatique endocrine (IPEndo) après chirurgie pancréatique et d’établir un modèle prédictif de survenue de ces insuffisances.

La hernie interne transmésentérique est une cause d’occlusion intestinale fréquente chez l’enfant, mais exceptionnelle chez l’adulte. Nous présentons ici le cas d’un jeune adulte sans antécédent ayant consulté en urgence pour syndrome douloureux abdominal avec arrêt du transit.

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset. Patients and methods: Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content < 200 mu g per gram of feces while EndoPI was defined as fasting glucose > 126 mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry. Results: The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after IP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P = 0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P= 1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI. Conclusion: ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP. (C) 2017 Published by Elsevier Masson SAS.

Mesenteric hernia is a frequent cause of intestinal obstruction in childhood but is exceptional in the adult. We describe a case in a young adult without any remarkable history who presented with an acute abdomen and intestinal obstruction.

The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery.

Aim Poor functional results, such as faecal incontinence (FI), low anterior resection syndrome (LARS) or high stool frequency, can occur after colorectal resections, including proctocolectomy with ileal pouch-anal anastomosis (IPAA), rectal resection and left hemicolectomy. Management of such patients is problematic, and some case reports have demonstrated the effectiveness of sacral nerve stimulation (SNS) in these situations. Our aim was to analyse the effectiveness of SNS on poor functional results and on quality of life in patients after treatment with different types of colorectal resection.Method At five university hospitals from 2006 to 2014, patients with poor functional results after rectal resection, IPAA or left hemicolectomy underwent a staged SNS implant procedure. Failure was defined by the absence or insufficient improvement (< 50%) of FI episodes.Results SNS for bowel dysfunction was performed in 16 patients after rectal resection with coloanal anastomosis, left hemicolectomy with colorectal anastomosis or IPAA. Two (13%) cases of primary failure were observed after the percutaneous stimulation test. Median frequency of stool, FI episodes and urgency were significantly improved in 14 patients. Wexner and LARS scores were also significantly improved for 14 patients. When we compared results according to the type of colorectal surgery (IPAA, rectal resection or left hemicolectomy), median frequencies of stool and urgency, Wexner and LARS scores were still significantly improved. Overall success rate was 75% (12/16 patients) in intention-totreat analysis and 86% (12/14 patients with permanent electrode) in per-protocol analysis.Conclusion SNS seems to improve bowel dysfunction following rectal resection, left hemicolectomy or IPAA.

La pancréatite aiguë nécrosante est une pathologie courante associée à une forte morbi-mortalité. Le développement des techniques radiologiques et endoscopiques du traitement de la nécrose pancréatique impose une approche multidisciplinaire qui a considérablement modifié les indications et les modalités de la chirurgie. Du fait d’une morbidité plus importante que les traitements radiologiques ou endoscopiques, les indications de nécrosectomie chirurgicale par laparotomie sont de plus en plus limitées et leur place actuelle est mal définie. La step-up approach a révolutionné le pronostic à court et moyen termes en diminuant les complications postopératoires et en améliorant les résultats fonctionnels. De plus, cette stratégie évite la nécrosectomie chirurgicale dans un tiers des cas. La laparotomie garde néanmoins certaines indications en urgence. L’objectif de cette mise au point était de préciser la place de la chirurgie dans la prise en charge des pancréatites aiguës nécrosantes en l’intégrant dans une prise en charge multidisciplinaire.Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.

PURPOSE:The purpose of this study was to comprehensively evaluate the short-term outcomes after percutaneous embolization of the superior rectal artery (SRA) with metallic coils and particles for the management of hemorrhoids. MATERIALS AND METHODS:Forty patients (15 men, 25 women) with a mean age of 35±5 years (SD) (range: 25-65 years) were prospectively enrolled. All patients had symptomatic hemorrhoids. The distribution of internal hemorrhoids was as follows: grade I (n=6, 16%); grade II (n=28, 69%) and grade III (n=6; 15%). All patients had percutaneous embolization of the SRA with metallic coils and synthetic polyvinyl alcohol particles. Follow-up evaluation included clinical examination, rectoscopy, histopathological analysis of rectal mucosa, duplex Doppler blood flow quantification, electromyography, sphincterometry of the anal sphincter and analysis of patient satisfaction. RESULTS:No immediate complications were observed and no patients had anal pain syndrome after embolization. Hemorrhoids showed a 43% size reduction after embolization (P<0.05). Taking into account the symptom resolutions such as irritation, discomfort, bloody discharge and pain, satisfaction was observed in 5/6 (83%) patients with grade III hemorrhoids and 32/34 patients (94%) with grades I-II hemorrhoids. One month after embolization, anal sphincter contractility normalized and no changes in anal electromyography were observed. Blood flow in the hemorrhoidal plexus dropped from 109±1.2ml/min/100g (SD) before treatment to 60.2±4.4ml/min/100g (SD) (P<0.05) the day after embolization and remained unchanged one month after embolization. CONCLUSION:Our study demonstrates that embolization of SRA with particle and coils does not lead to ischemia in patients with symptomatic hemorrhoids. Short-term results with regard to symptom management for hemorrhoidal disease are very encouraging and should stimulate further prospective and multicenter studies.