Colorectal anastomotic leakage corrected by transanal laparoscopy.

AIM: Interest in transanal laparoscopy has increased in the last decade. This approach can allow primary procedures such as polypectomy, total mesorectal excision and the treatment of postoperative complications such as bleeding, leakage and fistula formation. METHOD: Two patients treated by transanal repair for leakage of a colorectal anastomosis after laparoscopic anterior resection of the rectum are reported. The first developed leakage immediately during the surgery and in the second leakage presented at 4 weeks. A new transanal platform according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany), formed by a reusable port and reusable monocurved instruments was developed to permit manipulation of sutures introduced via the anus in a maximally ergonomic manner. Laparoscopic suturing was performed transanally and a protective ileostomy was added as well. RESULTS: The transanal procedures took 60 and 45 min and the patients were discharged after 5 days and 2 days. At 2 months both defects were found to be healed on contrast radiology and endoscopy; therefore the ileostomy was closed. Anal function was satisfactory with a frequency of two and one times per 24 h with no incontinence or evidence of sepsis. CONCLUSION: Intra-operative or late leakage of colorectal anastomosis can be safely treated by transanal laparoscopy. This new transanal platform offers the surgeon the possibility to work in ergonomic positions, without increasing the cost of the procedure thanks to the reusable nature of the material used.

Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion.

BACKGROUND: This report describes the laparoscopic conversion of a Roux-en-Y gastric bypass (RYGBP) to biliopancreatic diversion (BPD). CASE REPORT: In January 1995, a 47-year-old woman with a body mass index (BMI) of 54 kg/m(2) benefited from a silicon ring vertical banded gastroplasty (SRVBG) for morbid obesity. She showed significant weight loss and reached a BMI of 30 kg/m(2). After 7 years, she experienced weight regain (BMI, 34.5 kg/m(2)), so a laparoscopic conversion to RYGBP was proposed. The patient again had a successful weight loss (BMI, 26 kg/m(2)), but 6 years later, she mentioned a weight regain (BMI, 33 kg/m(2)) with invalidating retrosternal pain. The nutritionist's analysis of the patient showed a certain modification of the alimentary character with frequent meals (grazing/polyphagia), and the psychologist's consultation identified an important binge-eating disorder. A laparoscopic conversion of RYGBP to BPD was proposed. The procedure consisted of (1) adhesiolysis and reduction of a hiatal hernia, (2) sectioning of the gastric pouch proximally to the gastrojejunostomy, (3) resection of the fundus of the gastric remnant excluded by the previous SRVBG, (4) restoration of the continuity of the stomach between the gastric pouch and the gastric remnant, (5) resection of the gastric antrum and pylorus, (6) deconstruction of the previous jejunojejunostomy, (7) restoration of the continuity of the small bowel, (8) measurement of the new common and alimentary limbs and construction of the jejunoileostomy, (9) closure of the mesenteric defect, (10) construction of the gastroileostomy, (11) closure of Petersen's space, and (12) repair of the hiatal hernia followed by a leak test. RESULTS: The operative time was 320 min, and the blood loss was 380 ml. The patient had an uneventful recovery and was discharged on postoperative day 5. Her BMI was 30.5 kg/m(2) after 3 months and 26 kg/m(2) after 6 months. The barium swallow showed good transit through the gastrointestinal tract. CONCLUSIONS: The laparoscopic conversion of RYGBP to BPD is technically feasible and effective during the short term for cases of repeated weight regain.

Ivor Lewis esophagectomy with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy.

INTRODUCTION: Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position. CASE REPORT: An adenocarcinoma of the distal esophagus without lymph nodes invasion was diagnosed in a 51-year-old man. General anesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in the supine position, and five abdominal trocars were placed. Celiac lymphadenectomy was performed with section of the left gastric vessels. A wide Kocher maneuver and pyloroplasty were performed. A wide gastric tube was performed and advanced through the hiatus into the right chest. Subsequently the patient was placed in the prone position. Three trocars (two 5-mm and one 11-mm) were placed on the posterior axillary line in the fifth, seventh, and ninth right intercostal space. The intrathoracic esophagus was dissected. Mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was sectioned, and the esophagus was transected by scissors 1-cm cranial to the azygos vein. A completely thoracoscopic manual double-layer anastomosis was performed by using running sutures with PDS 2/0 externally and Maxon 4/0 internally. Finally the patient was replaced in the supine position to retrieve the specimen through a suprapubic incision, and the gastric tube was fixed to the hiatus. RESULTS: Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was estimated at 170 ml. The gastrograffin swallow on postoperative day 4 showed absence of stenosis and leak. The patient was discharged on postoperative day 6. CONCLUSIONS: Thoracoscopy in the prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely handsewn without selective lung desufflation, and using only three trocars.

Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass.

INTRODUCTION: Rapid weight loss after Roux-en-Y gastric bypass (RYGBP) often is associated with gallstones formation, which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the gastric remnant for an endoscopic retrograde cholangiopancreatography (ERCP). CASE REPORT: A 40-year-old woman with a BMI of 48 kg/m(2), was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. In April 2007, she was admitted for upper right side abdominal pain, vomiting episodes, fever, and jaundice; the BMI at the time was 24 kg/m(2). Hepatic ultrasound showed lithiasis of the common bile duct with intra- and extrahepatic bile duct dilation, as well as gallbladder lithiasis. The patient was taken to the operating room for laparoscopic evaluation. A pursestring suture was performed on the greater curvature of the gastric remnant. After the opening of the stomach, an 18-mm trocar was inserted into the lumen and the endoscope was directly passed through the port into the duodenum. An ERCP was performed under fluoroscopic guidance, and as a result of sphincterotomy the stone was retrieved. After removing the endoscope, the gastrotomy was closed by tying the pursestring. Cholecystectomy was performed as well. RESULTS: The procedure lasted 98 min. Liver function tests returned normal on postoperative day 2, and the patient was discharged on postoperative day 4. After 9 months, the patient was well and asymptomatic. CONCLUSIONS: Patients previously submitted to RYGBP and presenting choledocholithiasis can benefit from an ERCP through the gastric remnant.

Minimally invasive esophagectomy for cancer: laparoscopic transhiatal procedure or thoracoscopy in prone position followed by laparoscopy?

BACKGROUND: Minimally invasive esophagectomy is rapidly emerging as a suitable surgical alternative to the open technique. This retrospective comparative study aimed to compare two minimally invasive techniques for esophagectomy: transhiatal laparoscopy with intrathoracic or cervical anastomosis (group A) and right thoracoscopy in prone position followed by laparoscopy and left cervicotomy (group B) performed by the same surgeon (G.B.C.). The operative time, perioperative blood loss, intensive care and total hospital stays, peri- and postoperative morbidity, in-hospital mortality, number of lymph nodes dissected, and survival were the outcome measures. METHODS: Between April 1999 and August 2005, 24 patients (group A) and 15 patients (group B) underwent minimally invasive esophagectomy for cancer in the authors' department. Their median age was 61 years in group A and 61 years in group B. Preoperatively, the endoscopic location of the tumor was in the upper third in 2 cases (1 vs 1), the middle third in 11 cases (7 vs 4), and the lower third in 26 cases (16 vs 10). Two patients in each group received neoadjuvant chemo- and radiotherapy. One patient (group A) and two patients (group B) received only neoadjuvant chemotherapy, and three patients (group A) received only neoadjuvant radiotherapy. RESULTS: The median operative time was 300 min (range, 240-420 min) in group A and 377 min (range, 240-540 min) in group B (nonsignificant difference [NS]). The median perioperative bleeding was 325 ml (range, 100-800 ml) in group A and 700 ml (range, 100-2,400 ml) in group B (NS). The perioperative complications included one splenectomy in each group and one conversion to thoracotomy in group B. The postoperative medical complications totaled three in group A and six in group B. The postoperative surgical complications included one hemoperitoneum, one pneumothorax, five anastomotic leaks, and two recurrent laryngeal nerve paralyses in group A and two tracheal necroses, four anastomotic leaks, one colic fistula, and three recurrent laryngeal nerve paralyses in group B. The median intensive care unit (ICU) stay was 5 days (range, 2-70 days) for group A and 5 days (range, 1-180 days) for group B (NS). The median hospital stay was 12 days (range, 7-98 days) for group A and 14 days (range, 7-480 days) for group B (p = 0.05). The early mortality rate was 0%. All the specimens were free of disease. The median number of mediastinal/periesophageal lymph nodes was 3 (range, 1-10) for group A and 4 (range, 2-13) for group B (NS), and the median number of celiac/perigastric lymph nodes was 11 (range, 2-31) for group A and 10 (range, 3-22) for group B (NS). After a median follow-up period of 42.4 months (range, 2-84 months) for group A and 19.1 months (range, 1.5-34 months) for group B, 12 patients in group A died after a median period of 22 months (range, 2-55 months), and 7 patients in group B died after a median time of 15 months (range, 1.5-23 months). CONCLUSIONS: This retrospective comparative study showed that minimally invasive esophagectomy performed by thoracoscopy in the prone position is comparable with laparoscopic transhiatal esophagectomy in terms of the significant postoperative and survival outcomes.

A delayed Boerhaave's syndrome diagnosis treated by thoracoscopy in prone position.

Boerhaave's syndrome or postemetic rupture of the esophagus, carries a high morbidity and mortality. The authors report a delayed Boerhaave's syndrome diagnosis (3 days), successfully treated by right thoracoscopic debridement in prone position. Thanks to gravity the cardiopulmonary bloc drops back and the access to the esophagus is direct allowing for accurate placement of the chest tubes near the perforation. The procedure is completed by laparoscopic placement of a feeding jejunostomy with the patient supine.