Risk of adhesive obstruction after colorectal surgery: the benefits of the minimally invasive approach may extend well beyond the perioperative period.

BACKGROUND: Risk of adhesive small-bowel obstruction (SBO) is high following open colorectal surgery. Laparoscopic surgery may induce fewer adhesions; however, the translation of this advantage to a reduced rate of bowel obstruction has not been well demonstrated. This study evaluates whether SBO is lower after laparoscopic compared with open colorectal surgery. METHODS: Patients who underwent laparoscopic abdominal colorectal surgery, without any previous history of open surgery, from 1998 to 2010 were identified from a prospective laparoscopic database. Details regarding occurrence of symptoms of SBO (colicky abdominal pain; nausea and/or vomiting; constipation; abdominal distension not due to infection or gastroenteritis), admissions to hospital with radiological findings confirming SBO, and surgery for obstruction after the laparoscopic colectomy were obtained by contacting patients and mailed questionnaires. Patients undergoing open colorectal surgery for similar operations during the same period and without a history of previous open surgery also were contacted and compared with the laparoscopic group for risk of obstruction. RESULTS: Information pertaining to SBO was available for 205 patients who underwent an elective laparoscopic procedure and 205 similar open operations. The two groups had similar age, gender, and sufficiently long duration of follow-up. Despite a significantly longer duration of follow-up for the laparoscopic group, admission to hospital for SBO was similar between groups. Patients who underwent laparoscopic surgery also had significantly lower operative intervention for SBO (8% vs. 2%, p = 0.006). CONCLUSIONS: Although the rate of SBO was similar after laparoscopic and open colorectal surgery, the need for operative intervention for SBO was significantly lower after laparoscopic operations. These findings especially in the context of the longer follow-up for laparoscopic patients suggests that the lower incidence of adhesions expected after laparoscopic surgery likely translates into long-term benefits in terms of reduced SBO.

Significance of palliative gastrojejunostomy for unresectable pancreatic head carcinoma.

BACKGROUND/AIMS: When diagnosed, most patients with pancreatic head cancer are defined as having an unresectable tumor, and thus appropriate relief of main symptoms, such as, obstructive jaundice, duodenal obstruction, and pain, is the major concern. However, debate continues concerning the efficacy of gastrojejunostomy at preventing duodenal obstruction. In this study, we evaluated the effects of palliative gastrojejunostomy on the quality of life of patients with unresectable pancreatic head cancer. METHODOLOGY: Between January 2000 and December 2004, of 61 patients with unresectable pancreatic head cancer, 46 underwent palliative surgery; 24 patients underwent biliary bypass with gastrojejunostomy (Group I) and 22 patients underwent biliary bypass only (Group II). Frequencies of nausea and vomiting, serum protein and albumin levels, oral intake, and other metrics were carefully monitored. RESULTS: No significant differences in age, sex, TNM stage, and preoperative symptoms were evident between the two groups. Incidences of nausea and vomiting were similar preoperatively (Group I, 45.8%; Group II, 40.9%, P=0.736), but were significantly different at 3 months postoperatively (Group I, 25.0%; Group II, 68.2%, P=0.003). Preoperative serum protein and albumin levels were similar in the two groups (Group I: 6.6g/dL, 3.5g/dL; Group II: 6.4g/dL, 3.4g/dL, respectively, P-0.223, 0.472), but at 3 months postoperatively, serum protein and albumin levels were significantly different (Group I: 5.9g/dL, 3.1g/dL; Group II: 5.2g/dL, 2.6g/dL, respectively, P=0.010, 0.047). CONCLUSIONS: Our data suggest that palliative gastrojejunostomy in patients with unresectable pancreatic head cancer reduces symptoms related to duodenal obstruction and contributes to quality of life.

Anterior transposition of the third part of the duodenum for the treatment of superior mesenteric artery syndrome.

A 14-year-old adolescent girl with superior mesenteric artery syndrome was referred to us after failure of conservative management. Anterior transposition of the duodenum was performed and appears to be safe for permanently circumventing the duodenal obstruction seen in superior mesenteric artery syndrome, even in a pediatric population.

Abnormalities of intestinal rotation in patients with congenital heart disease and the heterotaxy syndrome.

OBJECTIVE: Abnormalities of intestinal rotation (AIR) are seen in association with congenital heart disease and heterotaxy syndrome. The prevalence of these abnormalities and recommendations for management are unclear. Our objective was to determine the prevalence of screening for AIR by elective imaging among our group and prophylactic vs. emergent surgical intervention for AIR in patients with congenital heart disease and heterotaxy syndrome. METHODS: From October 1988 through October 2000, we identified 74 patients with congenital heart disease and heterotaxy syndrome, 44 (59%) asplenia, 30 (41%) polysplenia. Abdominal imaging was performed in 34 patients (45%). Twenty-four (32%) were found to have AIR. Of 34 patients imaged, 22 (65%) were found to have AIR. Two patients not imaged were found to have AIR: one at autopsy, and the other, incidentally during other abdominal surgery. Because imaging was performed based on individual cardiologist's practice style that did not change over the period of the study and rarely secondary to symptoms, it is likely that the prevalence of AIR in the patients that were not electively imaged would be similar. RESULTS: There was no statistical difference in the presence of AIR between asplenic (34%[15/44]) and polysplenic (30%[9/30]) patients. Of the 22 patients imaged with AIR, 18 underwent Ladd procedure. Five of 12 imaged patients without AIR were found to have other significant gastrointestinal pathologies requiring intervention including gastrostomy tube placement for reflux (3), duodenal web (1), and biliary atresia (1). Of the 40 patients who were not pre-emptively imaged, none suffered acute obstruction solely secondary to AIR. However, in 2 patients intestinal obstruction was suspected and subsequently discovered by imaging and/or laparotomy due to other intestinal anomalies. CONCLUSIONS: AIR is common among patients with heterotaxy syndrome and congenital heart disease. We recommend that patients with congenital heart disease and heterotaxy syndrome have routine elective abdominal imaging of their gastrointestinal tract at birth as part of their evaluation.

Surgical treatment of pancreatic cancer. The United States experience.

About 28,000 new cases of pancreatic cancer are diagnosed yearly in the United States. The diagnosis is now made up to two months more quickly than just a few years ago, but this has had no impact on survival. In most institutions, 20-25% of patients have resectable lesions. The standard operation is still the Whipple pancreaticoduodenectomy, but many surgeons now use the pylorus preserving modification of that procedure. The operative mortality rate has fallen to less than 5%. The five-year survival rate after a resection for attempted cure is about 9%. Palliation requires cholecysto(docho)jejunostomy and gastrojejunostomy, which is often done prophylactically. The operative mortality rate in patients undergoing palliation is less than 10% (recent UCLA experience), and the average survival is seven months.

[Prevention of duodenal hypertension after gastrectomy]. / Profilaktika duodenal'noi gipertenzii pri rezektsii zheludka.

Based on an analysis of outcomes of gastric resections for ulcer disease in 825 patients and experimental investigations the authors consider that the main cause of incompetence of the duodenum stump is stagnation of contents in the duodenum. For the prevention of this complications the Billroth-II resection with transverse (valvular) enteroanastomosis is recommended.

[Observation of the superior mesenteric artery by ultrasonography: for prediction of the superior mesenteric artery syndrome].

Superior mesenteric artery (SMA) syndrome is a major complication after scoliosis surgery. The author reports an ultrasonic observation of the SMA in normal and scoliotic individuals. There are three patterns of the SMA anatomy: Type I in which the SMA runs very close and parallel to the aorta, Type II in which the SMA branches off the aorta at a certain angle and Type III in which the SMA runs parallel to the aorta. Dynamic observation revealed that passage of food displaces the SMA anteriorly and to the left and that turning to the left from a supine position displaces the SMA from just anterior to the left of the aorta in normal individuals and from the right to the left side of the aorta in scoliosis cases. AMA itself has no significance in the occurrence of SMA syndrome because the SMA moves rather freely with the passage of food or position change. When this natural movement of the SMA is disturbed, one should carefully look for the possibility of SMA syndrome.

[Trends in surgery for chronic pancreatitis (author's transl)]. / Tendenzen in der Chirurgie der chronischen Pankreatitis.

Improved preoperative assessment (ERCP, sonography, computer tomography) of pathological changes of the pancreas has impressively changed indications for surgery, timing of the operation and surgical methods used. Intraoperative diagnostics have lost ground due to newer techniques. The aim of surgical treatment is pain relief and the prevention of complications (cholestasis, duodenal stenosis, segmental portal hypertension). Introduction of endoscopic duct visualisation was followed by an increase of resecting techniques based on impressiveness of pathology of ductal changes. Non-invasive methods such as sonography and computer assisted tomography have improved definition of pathological changes and re-encouraged less radical surgery using drainage and anastomosing techniques. Therapeutic consequences of diagnostic progress are demonstrated in 503 cases treated surgically between 1964 and 1981.