PVA gel as a potential adhesion barrier: a safety study in a large animal model of intestinal surgery.

BACKGROUND: Intra-abdominal adhesions following surgery are a major source of morbidity and mortality including abdominal pain and small bowel obstruction. This study evaluated the safety of PVA gel (polyvinyl alcohol and carboxymethylated cellulose gel) on intestinal anastomoses and its potential effectiveness in preventing adhesions in a clinically relevant large animal model. METHODS: Experiments were performed in a pig model with median laparotomy and intestinal anastomosis following small bowel resection. The primary endpoint was the safety of PVA on small intestinal anastomoses. We also measured the incidence of postoperative adhesions in PVA vs. control groups: group A (eight pigs): stapled anastomosis with PVA gel compared to group B (eight pigs), which had no PVA gel; group C (eight pigs): hand-sewn anastomosis with PVA gel compared to group B (eight pigs), which had no anti-adhesive barrier. Animals were sacrificed 14 days after surgery and analyzed. RESULTS: All anastomoses had a patent lumen without any stenosis. No anastomoses leaked at an intraluminal pressure of 40 cmH2O. Thus, anastomoses healed very well in both groups, regardless of whether PVA was administered. PVA-treated animals, however, had significantly fewer adhesions in the area of stapled anastomoses. The hand-sewn PVA group also had weaker adhesions and trended towards fewer adhesions to adjacent organs. CONCLUSION: These results suggest that PVA gel does not jeopardize the integrity of intestinal anastomoses. However, larger trials are needed to investigate the potential of PVA gel to prevent adhesions in gastrointestinal surgery.

CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) are substantial for patients with swallowing disorders to maintain enteral nutrition or to decompress palliatively intractable small bowel obstruction. Endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination, or obstructed passage. Computed tomography (CT)-fluoroscopic guidance with or without endoscopy can enable placement of CT-PG/CT-PJ or CT-PEG/CT-PEJ if endoscopically guided placement fails. In this retrospective study, we will evaluate the feasibility and safety of this method. METHODS: A total of 101 consecutive patients were referred to our department for feeding support (n = 87) or decompression (n = 14). Reasons were: ENT tumor (n = 51), esophageal cancer (n = 19), mediastinal mass (n = 2), neurological disorder (n = 15). Decompression tubes were placed because of cancer (n = 13) or Crohn's disease (n = 1). The following approaches were chosen: CT fluoroscopy and simultaneous gastroscopy (n = 61), inflation of the stomach via nasogastric tube (n = 29), and direct puncture under CT-fluoroscopic guidance (n = 11). RESULTS: CT fluoroscopy-guided gastrostomy was feasible in 89 of 101 patients. No procedure-related mortality was observed. One tube was misplaced into the colon in a patient with a history of gastrectomy. No complication was seen after removal. Minor complications: dislodgement (n = 17), peristomal leakage (n = 7), wound infection (n = 1), superficial skin infection (n = 6), tube obstruction (n = 2). CONCLUSIONS: CT fluoroscopy-guided PG/PJ or PEG/PEJ is feasible and safe and provides adequate feeding support or decompression. It offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. Long-term complications-mainly tube-related problems-are easily treated.

Complications and outcome after laparoscopic bariatric surgery: LAGB versus LRYGB.

BACKGROUND AND AIMS: Unsatisfactory patient compliance and unfavorable results of weight loss let centers prefer the Roux-en-Y gastric bypass (RYGB) as a combined restrictive and malabsorptive procedure. The aim of this study was to evaluate results of laparoscopic adjustable gastric banding (LAGB) versus laparoscopic RYGB. SETTING: The study was conducted at Centre Hospitalier Emil Mayrisch Clinic for specialized care (n = 618 beds) in Luxembourg (South). MATERIALS AND METHODS: Of 620 procedures, 204 patients had LAGB and 416 LRYGB. Short-term (t(1), 6 months to 2 years), middle-term (t(2), 2 to 5 years), and long-term follow-up (t(3), >5 years) were performed, including weight loss evolution, Bariatric Analysis, and Reporting Outcome System (BAROS). RESULTS: Percent EBWL mean values for LAGB vs. LRYGB were at t(1) 64.3 vs. 79.5, p = 0.01; at t(2) 49.4 vs. 91, p < 0.0001; and at t(3) 52.6 vs. 79.9, p < 0.0001. The BAROS mean values were at t(1) 3.81 vs. 4.00, p = 0.183; at t(2) 3.57 vs. 4.12, p < 0.001; and at t(3) 3.71 vs. 4.04, p = 0.02. Major complication rate (<30 days) was similar (p = 0.601). Long-term (>30 days) complications were more common after LAGB (14.3 versus 3.6%, p < 0.001). Fifty patients (25%) required a second and 36 patients (18%) a third operation (LRYGB). CONCLUSION: The significant difference in %EBWL and BAROS and late adverse events with high re-operation rates in LAGB made the LRYGB more attractive.

Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: mid- and long-term results after 40 patients.

BACKGROUND: Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique. METHODS: From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score. RESULTS: Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction. CONCLUSION: Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.

Stapled transanal rectal resection for symptomatic intussusception: morphological and functional outcome.

INTRODUCTION: Stapled transanal rectal resection (STARR) was developed to correct intussusception causing obstructed defecation. Some patients, however, do not profit from this operation as anticipated. We aimed to study the relationship between functional outcome and rectal morphology after STARR. METHODS: Fifteen consecutive female patients with median age of 64 years [interquartile range (IQR) 58-71 years] were studied before and after STARR. All patients had symptoms of obstructed defecation preoperatively. Pre- and postoperative workup consisted of standardized interview (including Wexner score) with physical examination including procto- and rectoscopy, anorectal manometry, and magnetic resonance (MR) defecography. Median follow up was 18 months (IQR 16-22 months). RESULTS: STARR was technically successful in all 15 patients without intra- or postoperative complications. Median (IQR) Wexner score of fecal incontinence was 0 (0-0) before and 3 (0-4.5) after surgery (p < 0.05). While all patients had repetitive incomplete defecation preoperatively, this symptom was present in seven patients postoperatively (p < 0.01). Third-degree intussusception was diagnosed during MR defecography in all patients preoperatively. After surgery, no patient had third-degree intussusception but one patient had first-degree and one patient had second-degree intussusception (p < 0.05). Size of rectocele was reduced from 2.9 cm (2.0-3.8 cm) to 0.8 cm (0.6-1.9 cm) (p < 0.05). Sphincter pressures were unchanged during anorectal manometry; however, first sensation during balloon distension in the rectum decreased from 50 ml (40-83 ml) before surgery to 30 ml (25-40 ml) after surgery (p < 0.05). CONCLUSION: Stapled transanal rectal resection (STARR) achieved a high rate of morphological correction of intussusception; however, symptoms of obstructed defecation were not improved to the same extent, which warrants exploration in future studies.

Esophageal leiomyomatosis combined with intrathoracic stomach and gastric volvulus.

CASE REPORT: A 42-year-old female presented with long-standing symptoms suggestive of gastroesophageal reflux disease improved after proton pump inhibitor treatment. An upper endoscopy revealed an intrathoracic position of the stomach (type 4 hiatal hernia) with no mucosal abnormality. Barium swallow demonstrated gastric herniation with gastric volvulus without stenosis. A computed tomographic scan confirmed the intrathoracic location of the stomach associated with thickening and edema of the gastric wall due to gastric volvulus, but no evidence of malignancy. The patient was scheduled for laparoscopic gastric repositioning with anterior hemifundoplication. Due to the incidental intraoperative finding of a large distal esophageal tumor (frozen section: esophageal leiomyomatosis), the operation was converted to conventional distal esophagectomy and proximal gastrectomy with reconstruction using a Merendino procedure. Final histology revealed extensive circumferential leiomyomatosis of the distal esophagus with a diameter of 10 cm. Esophageal leiomyomatosis is an extremely rare pathological finding with <100 cases reported in the literature. CONCLUSION: Any surgeon performing laparoscopic fundoplication has to be ready to deal with such unexpected findings, ie, converting the procedure and doing reconstruction with minimal morbidity. The Merendino procedure is a well-established reconstructive surgical option in cases of tumor formation at the gastroesophageal region with fewer postoperative morbidities like reflux symptoms.

Severe complication of laparoscopic mesh hiatoplasty for paraesophageal hernia.

BACKGROUND: Several studies have shown that laparoscopic hernia repair for large paraesophageal hiatal hernia is associated with a high recurrence rate. Therefore, some authors recommend the use of prosthetic meshes. Considering the dynamic area between the esophagus and the diaphragmatic crura with its constant motion, it is astonishing that only a minor number of surgeons describe mesh-associated complications. METHODS: Between January 2000 and August 2008, 26 patients of the Centre Hospitalier Emile Mayrisch (CHEM, Luxembourg) underwent laparoscopic repair for large paraesophageal hiatal hernia (median age, 70 (range, 39-90) years). In nine patients, prosthetic mesh reinforcement was performed (7 composite/2 mono-phase mesh). Crural repair without tension was performed only with sutures. There were no conversions. Follow-up assessment was prospective with the GIQL (Gastro-Intestinal Quality of Life) Index. RESULTS: Responses to the GIQLI questionnaires were obtained from 20 patients (6 died of unrelated causes). Nineteen patients were satisfied with their symptom control 1 year after the operation (GIQLI 127). Sixteen patients had radiological follow-up (median, 24 months). Three patients treated without mesh (3/10) showed a radiological recurrence. All of them (3/10) had symptoms. None of the controlled patients with mesh (0/6) showed a recurrence. One patient developed a severe aortal bleeding 1, 2, and 3 weeks after the laparoscopic mono-phase mesh repair. During conventional operation, the bleeding stopped. Three years later, the follow-up showed a satisfied patient (GIQLI 127). CONCLUSIONS: In view of the described complication, there is still considerable controversy regarding the routine use of mesh. To increase safety, a composite mesh should be preferred.

Polyvinyl alcohol gel prevents adhesion re-formation after adhesiolysis in a rabbit model.

BACKGROUND: Chronic pain, infertility, and bowel obstructions are possible consequences of abdominal adhesions, which can highly affect the patient's quality of life. Patients in whom adhesiolysis has been performed are at high risk for recurrence of adhesions. For that reason, the present study focused on the re-formation of adhesions after adhesiolysis and on the possibility of avoiding it by using the adhesion barrier polyvinyl alcohol (PVA)-gel. MATERIALS AND METHODS: A randomized controlled study was conducted to prove the effectiveness of PVA-gel in reducing postoperative adhesion re-formation after relaparotomy. Moreover, ultrasound was evaluated as a noninvasive technique to determine abdominal adhesion in a rabbit model. All animals underwent an initial laparotomy to cause adhesions and subsequent adhesiolysis in the relaparotomy. PVA-gel was placed onto a side wall defect in 12 animals. Another 12 rabbits served as a control group without PVA-gel being used. Ultrasound before final laparotomy was performed to predict the prevalence of adhesions. Macroscopic evaluation of adhesion formation and planimetry were used to determine the amount of adhesion. RESULTS: PVA-gel was found to reduce significantly the amount of adhesion formation after relaparotomy (P = 0.0001) in comparison with the control group. Here severe adhesion formation was found to develop. The positive-predictive value (100%) for adhesion evaluation using ultrasound is highly satisfying in the rabbit model. CONCLUSIONS: Adhesion re-formation after relaparotomy was found to decrease significantly through the use of PVA-gel. Ultrasound as a noninvasive technique of adhesion detection is a sufficient and reliable method for detecting adhesion formations.

Laparoscopic resection of an intradiaphragmatic bronchogenic cyst.

BACKGROUND: A 43-year-old woman with recurrent hiccup and discomfort in the right upper abdomen was diagnosed by computed tomographic (CT) scan with a cystic tumor in the right liver. Echinococcus serology was negative. METHODS: A laparoscopic procedure was chosen as standard therapy for symptomatic cystic liver tumors. The presumed tumor turned out to be a diaphragmatic cyst 8 cm in diameter at the center of the right hemi-diaphragm. By using the ultrasonic device, the cystic tumor was completely and safely removed from the diaphragm. The defect was closed by using nonabsorbable sutures. A chest drain was inserted for 1 day. RESULTS: The postoperative course was uneventful, and the patient was discharged on day 4. The histopathological examination revealed a bronchogenic cyst. No recurrence was noted by CT-scan after 12 and 24 months. CONCLUSIONS: Due to this rare diagnosis, the intradiaphragmatic location of a bronchogenic cyst is difficult to identify with radiological methods. Complete surgical excision is the treatment of choice. The conventional surgical approach is a posterolateral thoracotomy. In the literature, video-assisted thoracoscopic surgery (VATS) has been described as a safe and effective procedure. In our case, we could demonstrate that the laparoscopic excision of a cyst including partial diaphragmatic resection can be done safely in a diaphragmatic location with all the advantages of minimally invasive surgery.

Cine-MRI detection of intraabdominal adhesions: correlation with intraoperative findings in 89 consecutive cases.

BACKGROUND: This study aimed to evaluate the accuracy of functional cine-MRI in detecting abdominal adhesions. METHODS: For this study, 89 consecutive patients with adhesion-related complaints after previous abdominal surgery underwent preoperative workup including cine-MRI in transverse and sagittal orientations for a dynamic examination of an induced visceral slide. An abdominal map consisting of nine segments was created to document the location and extent of the adhesion. Cine-MRI and intraoperative findings were correlated. RESULTS: A total of 59 laparotomies and 30 laparoscopies were performed. Four cases required open surgery due to severe adhesions. The use of cine-MRI scan for the detection of adhesions showed an overall accuracy of 90%, a sensitivity of 93%, and a positive predictive value of 96%. The stronger the adhesions, the more accurate the scan findings. Of 44 patients with second-degree MRI scan findings, 50% had second-degree intraoperative findings. Of 35 patients with third- and fourth-degree adhesions on MRI scans, 74% had exactly the same intraabdominal findings at surgery. The MRI scan showed adhesions located in the small intestines (75%), large intestines (35%), abdominal cavity (42%), and reproductive organs (32%). Intraoperatively, adhesions were found in the small intestines (70%), large intestines (40%), abdominal cavity (42%), and reproductive organs (28%). CONCLUSIONS: Cine-MRI provides valid preoperative information with respect to extent, location, and strength of intraabdominal adhesions. Cine-MRI is a good alternative for diagnosing abdominal adhesions because objective findings of the scan and intraoperative findings correlate very well with each other.