Two staged minimally invasive treatment for acute cholecystitis in high risk patients.

BACKGROUND/AIMS: The most optimal treatment for acute cholecystitis in high risk patients and severe acute cholecystitis remains still controversial. We review the outcomes of a two step treatment with percutaneous cholecystostomy and delayed laparoscopic cholecystectomy (DLC). METHODOLOGY: We collected data prospectively from January 2004 to April 2010 from 26 patients that underwent percutaneous transhepatic CT-guided cholecystostomy and DLC. RESULTS: Percutaneous transhepatic CT-guided cholecystostomy was achieved in all cases with no complications. There was just one catheter dislodgement. Most of patients, 92%, improved after drainage. There was one case of mortality. Laparoscopic cholecystectomy was achieved in 88% of patients with no mortality, and a low rate of morbidity (7.6%) and of conversion to open surgery. Pre-operative percutaneous cholangiogram showed additional and useful information in 55.5% of patients. CONCLUSIONS: Two-step minimally invasive treatment combining percutaneous transhepatic CT-guided cholecystostomy and DLC is safe and feasible and report low morbi-mortality rates.

Intragastric Rupture of a Splenic Artery Aneurysm Associated with a Pancreatic Cancer.

Acute upper digestive tract hemorrhage most often arises from gastric and esophageal vessels located in the mucosa or the submucosa. Rupture in the upper gastrointestinal tract is a classical but uncommon complication of arterial (mainly the abdominal aorta) aneurysms. Splenic artery aneurysm usually ruptures in the peritoneum, unless it is associated with a disease eroding the gastrointestinal wall. We present and describe the management of the rare occurrence of an intragastric rupture of a splenic aneurysm associated with a pancreatic cancer.

Minimally invasive management of postoperative esophagojejunal anastomotic leak.

PURPOSE: Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. METHODS: Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. RESULTS: The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. CONCLUSIONS: Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential.