Video. Radiofrequency fulguration of the spleen under laparoscopy to stop iatrogenic hemorrhage.

BACKGROUND: Iatrogenic splenic injury is a potentially serious complication of laparoscopic surgery associated with significant morbidity and mortality. It also has an impact on the prognosis of patients who undergo surgery for digestive cancer. For iatrogenic splenic injury, splenic salvage is the ultimate goal. Various surgical techniques have been developed to achieve hemostasis of the spleen. Radiofrequency fulguration (RF) is reported to be a safe method in an animal trauma model. However, only three articles report RF for the control of splenic hemorrhage in human patients. METHODS: A bicentric, retrospective study was performed. From January 2009 to September 2010, all iatrogenic splenic hemorrhages uncontrolled by conventional hemostasis techniques were treated using RF. The splenic injuries were classified according to the Moore classification and a postoperative, abdominal computed tomography scan was performed for each patient. RF was performed with a straight electrode needle (Integra, Tuttlingen, Germany) introduced percutaneously into the spleen. The electrode was infused with isotonic saline and connected to a 500-kHz generator (Elektrotom 106 HFTT; Berchtold, Tuttlingen, Germany). During the high-frequency coagulation (375 kHz), electrode saline perfusion was automatically regulated from 30 to 110 ml/h according to the variation in tissue impedance, and the power of the generator was kept at 50 W. RESULTS: Three patients (2 men and 1 woman) with a median age of 58 years underwent splenic RF. The splenic injuries (grade 3, Moore classification) occurred during laparoscopic proctectomy in two cases and during laparoscopic gastrectomy in one case. It was possible to achieve complete hemostasis in all the patients during a median time of 10 min. The median blood loss was 100 ml, with no blood transfusion. No splenectomy was necessary, and no postoperative splenic infarction was diagnosed. No conversion was performed. There was no postoperative morbidity or mortality. No recurrent splenic hemorrhage occurred during the follow-up period. The financial cost was 350 per RF. CONCLUSION: Although RF could potentially induce splenic infarction in the event of a large-scale fulguration, it is a safe, quick, and effective spleen-preserving technique for stopping an iatrogenic splenic hemorrhage when conventional hemostasis techniques fail. Furthermore, it is readily available and easy to set up in an emergency situation and can be performed easily by laparoscopy without an additional port.

Role of laparoscopic distal pancreatectomy for solid pseudopapillary tumor.

BACKGROUND: Since the first case report regarding laparoscopic distal pancreatectomy (DP) for solid pseudopapillary tumor (SPT), few additional articles have been published. The objective of this study was to evaluate the feasibility, safety, and long-term outcome of the laparoscopic DP based on a series of adult SPT patients. METHODS: In a single-center study, we screened all adult patients undergoing a laparoscopic DP for SPT. Preoperative, operative, and postoperative data were retrospectively analysed and compared to the results of open DP for SPT published in the medical literature. RESULTS: From April 2000 to June 2010, 5 adult female patients (median age 34 y) underwent a laparoscopic DP for an SPT. No conversion to open surgery was required. The median size of the tumor was 45 mm. The postoperative mortality rate was 0%, and serious complications (Dindo IV) occurred in 2 patients. The postoperative quality of life was not significantly altered by the laparoscopic procedure. At a median follow-up of 60 mo, all patients were alive and without evidence of local recurrence, distant metastasis, diabetes, or exocrine insufficiency. CONCLUSION: Laparoscopy may offer an alternative to open surgery in the treatment of SPT of the distal pancreas in adult female patients. The laparoscopic procedure impacts neither the oncologic outcome nor the quality of life. However, due to the risk of postoperative complications, this procedure should be reserved for specialized centers.

Laparoscopic rectosigmoid resection with transanal colonic pull-through and delayed coloanal anastomosis: a new approach to adult Hirschsprung disease.

BACKGROUND: Hirschsprung disease in adults is a rare and frequently misdiagnosed cause of long-standing, refractory constipation. Surgical procedures initially developed for pediatric patients have been applied to adults with varying degrees of success. OBJECTIVE: Our aim was to describe a new surgical procedure consisting of laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by a delayed coloanal anastomosis for the treatment of Hirschsprung disease in adults and to present our preliminary results with this technique. DESIGN AND SETTING: This was a descriptive observational study of treatment outcome conducted at the colorectal surgical unit of a university teaching hospital in France. PATIENTS: Patients were adults with confirmed Hirschsprung disease treated from October 2006 through February 2009. INTERVENTION: Laparoscopic rectosigmoid resection was performed with a transanal colonic pull-through followed by a delayed coloanal anastomosis. MAIN OUTCOME MEASURES: Clinical and functional data (Cleveland Clinic Florida incontinence scale and Fecal Incontinence Quality of Life scale) were obtained at postoperative visits. RESULTS: Five patients underwent the procedure. One patient died of postoperative cardiovascular complications. No patient had to be reoperated. No anastomotic leakage occurred. One patient developed anastomotic stricture requiring dilatation. No sexual or urinary dysfunction was reported. Postoperative analysis (mean follow-up 16 months) showed good functional outcomes in 3 (75%) of the 4 evaluable patients. LIMITATIONS: This study had only a small number of patients and no controls other comparison with cases reported in the literature. CONCLUSION: Laparoscopic rectosigmoid resection with a transanal colonic pull-through followed by delayed coloanal anastomosis represents a valid alternative in the treatment of Hirschsprung disease in adult patients, because it involves minimally invasive surgery, does not require a preventive diverting stoma, and shows anastomotic security.

Annular pancreas: a rare cause of acute pancreatitis.

CONTEXT: Annular pancreas is an uncommon and rarely reported congenital anomaly which consists of a ring of pancreatic tissue encircling the duodenum. Despite the congenital nature of the disease, clinical manifestations may ensue at any age. CASE REPORT: We herein report the case of a 72-year-old female with acute pancreatitis associated with duodenal obstruction. On radiologic examination, an annular pancreas was diagnosed. In view of her previous medical history and morphologic findings, we concluded that the acute pancreatitis was directly related to the congenital anomaly. Her clinical course was favorable after medical treatment. CONCLUSION: Clinicians should note the possibility of annular pancreas in patients with acute pancreatitis.

Can an intraductal papillary mucinous tumor be a potential indicator of concurrent adenocarcinoma of the pancreas?

CONTEXT: Despite the recent progress of diagnostic and therapeutic modalities, survival rates of pancreatic adenocarcinoma remain poor, mainly due to late diagnosis. CASE REPORT: We report the case of a 56-year-old man who was diagnosed with a symptomatic intraductal papillary mucinous tumor of the pancreas located in the uncus. This tumor was associated with a concurrent stenosis of the isthmic pancreatic duct which resulted in a distal dilation. A Whipple procedure was performed. During the procedure, a concomitant adenocarcinoma was diagnosed 2 cm from the primary intraductal papillary mucinous tumor, causing the isthmic stenosis. A second resection was then performed to the left of the pancreatic isthmus, and adjuvant chemotherapy was performed. The patient is well and without any sign of recurrence 7 months after surgery. CONCLUSION: We discuss the possibility that intraductal papillary mucinous tumors may be a "red flag" enabling earlier diagnosis of a concurrent pancreatic adenocarcinoma arising in another area of the pancreas.

Miniaturized robotic laparoscope-holder for rectopexy: first results of a prospective study.

INTRODUCTION: Thanks to the technical progress in instrumentation, laparoscopic surgery has made considerable advances over the last decade. Various robotic systems have been introduced to assist laparoscopic procedures. A new prototype of miniaturized laparoscope-holder (called the Light Endoscope Robot [LER]) has been developed by the TIMC-IMAG-CNRS Laboratory in Grenoble, France and is now currently marketed by the French company Endocontrol™ (La Tronche, Grenoble). The aim of this pilot study was to assess the LER in clinical practice. SUBJECTS AND METHODS: This was a prospective, single-center study. The LER had already been successfully validated on preclinical laboratory and cadaveric trials. The study was conducted at the Grenoble University Hospital during standardized laparoscopic rectopexies on adult patients. Demographic and operative data and qualitative results were collected prospectively and analyzed retrospectively. All patients provided written informed consent, and the study was approved by the Regional Committee for Medical and Health Research Ethics. RESULTS: Between March 2008 and September 2010, 16 adult patients underwent laparoscopic rectopexy assisted by the LER. All the patients were women with an average age of 63.6 years and an average body mass index of 24 kg/m(2). The procedure was completed in 15 patients. No conversion to open surgery was required. The postoperative mortality rate was 0%, and a complication occurred in 1 patient. The surgeon graded ease of use as 7 ± 2, global comfort as 8 ± 2, and quality of vision as 8 ± 2. CONCLUSIONS: This pilot study demonstrated the feasibility, safety, and comfort for the surgeon of the laparoscopic rectopexy assisted by the miniaturized light endoscope-holder LER.

Laparoscopic Roux-en-Y gastric bypass: comparison between hand-sewn and mechanical gastrojejunostomy.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the ideal operations in the treatment of morbid obesity. There are several variations in the operation, especially during the construction of the gastrojejunostomy (GJA). From June 2006 to September 2008, 104 consecutive obese patients underwent LRYGB. The procedure was standardized, with the exception of the construction of the GJA, which was linear-stapled in 51 patients and hand-sewn in 53 other patients. A retrospective analysis was performed to compare the procedures. The series comprised 81 women and 23 men with a median age of 44 years, and a median BMI of 46.7 kg/m(2). There was no significant difference between the two groups of patients with respect to age, gender, BMI, ASA, and previously failed bariatric surgery. There was no significant difference between the two groups with respect to mortality, conversion, early reoperation, surgical complications, GJA leakage or stricture, and bariatric results. The only significant differences between the two groups were in regards to operating time (190 min for stapled GJA vs. 160 min for hand-sewn GJA, p value 0.029) and operating supply cost (100 Euros less for hand-sewn GJA). In our experience, hand-sewn GJA during LRYGB appears to be as safe as linear-stapled GJA and provides the same bariatric results while remaining slightly less expensive.

Appendicitis: When there is more than meets the eye.

Acute appendicitis is the most frequent emergency in gastrointestinal surgery. Obstruction of the appendiceal lumen appears to be one of the most common physiologic mechanisms for the development of acute appendicitis. Once obstructed, the dilatation of the lumen causes ischemia and necrosis of the wall. The most common organisms involved in appendicitis are Escherichia coli, Peptostreptococcus, Bacillus fragilis and Pseudomonas. Rarely, Actinomyces is involved in this process. In this case report, we report a case of actinomycosis of the appendix vermiformis occurring in a 19-year-old male with no predisposing factors. Along with a review of the literature, we will define the risk factors, clinical characteristics, diagnostic methods, and treatment of actinomycosis.

A fish bone-related hepatic abscess.

We report an unusual case of pyogenic, hepatic abscess caused by fish bone penetration of the duodenum in a 68-year-old woman. The fish bone had migrated into the liver through the duodenal wall. The patient was initially admitted to our emergency room with abdominal pain, fever, and asthenia. A contrastenhanced abdominal coputed tomography (CT) scan showed a hepatic abscess in relation with a straight, foreign body, which had entered through the duodenal wall. Surgery was necessary to remove the foreign body, which was identified as a fish bone. The patient's recovery was uneventful and she was discharged on postoperative day 10. This case is discussed together with the data collected by a medline-based extensive review of the literature.

Right postoperative pleural effusion following laparoscopic appendicectomies: a case series.

Pleural effusion is not a commonly reported complication of appendicectomy. In our experience, we have performed all forms of appendicitis by laparoscopy (n = 217) since August 2006. We report three consecutive cases of right postoperative pleural effusion, all of which occurred during the immediate postoperative course of a laparoscopic appendicectomy. All three patients presented a perforated appendicitis. The right postoperative pleural effusions seem to be linked to the laparoscopic approach, and can be explained by the cumulative effects of peritoneal lavage, pneumoperitoneum and Trendelenburg position. The first two cases were managed medically by intravenous antibiotic therapy. The third patient required a pleural drainage by thoracoscopy. Surgeons should be aware of this complication when operating perforated appendicitis by the laparoscopic method.

Primary malignant fibrous histiocytoma of the pancreas: benefit of the multidisciplinary approach.

Primary malignant fibrous histiocytoma (MFH) is an exceedingly rare tumour of the pancreas with a high recurrence rate and a poor prognosis. Only 11 cases have been reported in the past in the English literature. In this report, the authors present the case of a 45-year-old man who was first operated on for a primary MFH of the pancreas. Eleven months after the surgery, he was diagnosed with a tumoural recurrence presenting as hepatic and pulmonary metastasis. The patient underwent a multidisciplinary treatment of chemotherapy, percutaneous radiofrequency ablation, and a right hepatectomy combined with intraoperative radiofrequency ablation. Under multidisciplinary treatment, the patient fully recovered. He remains disease-free 3 years after his first surgery and 25 months after the recurrence. We report a case of a primary MFH of the pancreas treated by using a multidisciplinary approach resulting in an above average survival rate. Although further cases and longer follow-up periods are necessary to conclude about the role of multidisciplinary treatment in the long-term prognosis of primary MFH of the pancreas, we believe that multidisciplinary treatment could improve the survival rates of other patients.