[Feasibility and security of laparoscopic (± robotic) total hysterectomy in outpatient surgery: A French multicenter retrospective study]

OBJECTIVE

To assess the feasibility and safety of total hysterectomy by laparoscopic approach (± robot assisted) in ambulatory.

MATERIALS AND METHODS

French three-center retrospective study including 165 patients who had laparoscopic (± robot assisted) total hysterectomy scheduled as outpatients from January 2016 to December 2020. Clinical and perioperative data were collected. Factors associated with outpatient failure and rehospitalization were evaluated.

RESULTS

The outpatient success rate was 92.7%. Factors associated with outpatient failure were incision time>13:00, large volume of blood loss, intraoperative complications with Oslo score≥2, uterine weight≥250g, indication for benign pathology, and robot-assisted approach. Among patients managed as outpatients, 7.2% were rehospitalized at a mean of 10 days from surgery. The factors associated with rehospitalization were the use of an effective antiaggregant or anticoagulant treatment and the use of intraoperative adhesiolysis. Four patients (2.6%) underwent revision surgery.

CONCLUSION

Minimally invasive hysterectomy can be performed as an outpatient procedure even in cases of malignant pathology. Age and body mass index are not associated with an increased risk of failure or re-hospitalization within one month.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

Background

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.

Methods

This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.

Conclusion

This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

[For which patients could we consider de-escalation in the management of ductal carcinomas in situ?]

Ductal carcinomas in situ (DCIS) of the breast account for 85% to 90% of breast cancer in situ. Current recommendations for the management of DCIS in France are based on surgical excision of the lesions, lumpectomy in healthy margins (margins of excision≥2mm) or mastectomy in case of extensive lesions. Radiation therapy is recommended after conservative surgical treatment. However, it seems relevant for some patients to discuss the benefit of a therapeutic de-escalation. Indeed, it has been reported that radiotherapy has no major impact on overall survival and that its interest could be discussed in the low-risk situations of invasive recurrence for which surgery alone could be sufficient, subject to sufficient margins. These questions call for the precise definition of low risk populations and to clarify the importance of taking into account decision support tools and new molecular markers. The place of scores like that of the University of Southern California - Van Nuys, and that of genomic tests such as the Oncotype test© DX DCIS (DCIS score) need to be specified. The expected results of several prospective studies could go in the direction of a significant therapeutic de-escalation for the management of DCIS in the years to come. In the meantime, however, it is advisable to remain cautious and the inclusion of patients in clinical trials should be favored.

Medical expert witness testimony in France and in Europe

Health care professionals are usually at a loss when it comes to medical "complaints", essentially because they lack knowledge with regard to existing litigation procedures. After a short reminder of the different rights of appeal in France, we describe how medical appeals function in other European countries. Next, we give the details of how the evaluation of claims of bodily damage works, a process in which every physician may be called upon to participate several times in a career, either as the defendant, or as a medical counselor, or as an expert. The goal of this update is to understand the different compensation appeal circuits available to patients and help the surgeon demystify and dedramatize the situation while preparing for the medical expert witness testimony. All such testimony reports, via whatever appeal circuit, follow a similar procedure, even if they are not exactly identical.

Expert witness testimony step by step and how to prepare it

The medical expert witness testimony is a key moment in the pathway of patient complaints as well as in the line of defense of the defendant-physician. For the defendant, it is a difficult time, often experienced as humiliating, because his or her competences are questioned, appraised and discussed in public. However, the defendant must perceive and use this encounter as an opportunity to express his/her viewpoint on the medical accident. This article provides the principal juridical rules that govern the medical expert witness testimony that must be known, as well as some practical advice on how the medical expert witness testimony evolves and how to protect oneself from the complaints, In order to enable the defendant to best prepare for this confrontation between the involved parties.

[Comparison of the accuracy of rectal endoscopic sonography and magnetic resonance imaging in the diagnosis of colorectal endometriosis]

OBJECTIVE

To compare the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of colorectal endometriosis.

METHODS

In retrospective study, 407 patients operated on service of gynecology of Tenon hospital for deep endometriosis with suspected colorectal involvement. All patients underwent MRI and then RES.

RESULTS

In the study, 239 patients (59%) had colorectal endometriosis which were diagnosed with the histology. The sensitivity, specificity, positive and negative predictive value (PPV and NPV) of RES and MRI for the diagnosis of colorectal endometriosis were respectively 92%, 87%, 91%, 88% and 85%, 88%, 91%, 80%. The accuracy of RES was not significantly different than MRI (90% versus 86%, P=0.09).

CONCLUSION

RES is a good exam to diagnose colorectal endometriosis. It is able to improve diagnosis performances.

Multicentre study of the impact of morbidity on long-term survival following hepatectomy for intrahepatic cholangiocarcinoma

BACKGROUND

The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear.

METHODS

This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo-Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis.

RESULTS

A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity.

CONCLUSION

Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

Risk factors and consequences of conversion in laparoscopic major liver resection

BACKGROUND

Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).

METHODS

Data for all patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were reviewed retrospectively. Risk factors for conversion were determined using multivariable analysis. After propensity score matching, the outcomes of patients who underwent conversion were compared with those of matched patients undergoing laparoscopic hepatectomy who did not have conversion, operated on at the same centres, and also with matched patients operated on at another tertiary centre during the same period by an open laparotomy approach.

RESULTS

Conversion was needed in 30 (13·5 per cent) of the 223 patients undergoing LMH. The most frequent reasons for conversion were bleeding and failure to progress, in 14 (47 per cent) and nine (30 per cent) patients respectively. On multivariable analysis, risk factors for conversion were patient age above 75 years (hazard ratio (HR) 7·72, 95 per cent c.i. 1·67 to 35·70; P = 0·009), diabetes (HR 4·51, 1·16 to 17·57; P = 0·030), body mass index (BMI) above 28 kg/m(2) (HR 6·41, 1·56 to 26·37; P = 0·010), tumour diameter greater than 10 cm (HR 8·91, 1·57 to 50·79; P = 0·014) and biliary reconstruction (HR 13·99, 1·82 to 238·13; P = 0·048). After propensity score matching, the complication rate in patients who had conversion was higher than in patients who did not (75 versus 47·3 per cent respectively; P = 0·038), but was not significantly different from the rate in patients treated by planned laparotomy (79 versus 67·9 per cent respectively; P = 0·438).

CONCLUSION

Conversion during LMH should be anticipated in patients with raised BMI, large lesions and biliary reconstruction. Conversion does not lead to increased morbidity compared with planned laparotomy.