Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound.

BACKGROUND: The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. METHODS: All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. RESULTS: On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). CONCLUSION: Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Pheochromocytoma surgery without systematic preoperative pharmacological preparation: insights from a referral tertiary center experience.

BACKGROUND: Despite significant advances in imaging and genetics, as well as surgical and anesthetic innovations, morbidity in pheochromocytoma surgery remains significant. The aim of this study was to identify the predictive factors of global and cardiovascular morbidity following unilateral laparoscopic adrenalectomy for pheochromocytoma. METHODS: We conducted a retrospective study from a unicentric cohort. All patients who underwent non-converted laparoscopic unilateral adrenalectomy for pheochromocytoma between 2000 and 2017 were included. Our patients did not systematically benefit from preoperative pharmacological preparation. It is to be noted that they never received alpha-blockers. Preoperative, intraoperative, and postoperative data during follow-ups were collected. Univariate and multivariate analyses by logistic regression were performed. RESULTS: A total of 134 patients were included. Fifty-three percent of patients did not receive preoperative pharmacological preparation (PPP) and 33% neither preoperative antihypertensives nor PPP before surgery. There was no postoperative mortality. The global morbidity was 13.4%, while cardiovascular morbidity was 4.5%. The main factors associated with global morbidity were preoperative diuretics, a medical history of stroke, and the need for pressor amines postoperatively. The main factor associated with cardiovascular morbidity was the need for pressor amines postoperatively. Predictive factors of postoperative need for pressor amines for hypotension were the tumor size, preoperative beta-blockers, and/or diuretics. CONCLUSION: In this large cohort of patients, our data revealed no mortality and low global and cardiovascular morbidity rates, showing that pheochromocytoma surgery without systematic PPP and even without preoperative antihypertensives is feasible and safe for selected patients. Our data also highlight the need for a good preoperative evaluation of the patient and the tumor, in order to optimize treatments and to help the detection of high-risk patients. This also allows us to better prevent and anticipate their possible complications.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse.

INTRODUCTION: Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence. DESIGN: Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center. METHODS: Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery. RESULTS: During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related. CONCLUSIONS: In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Unusual massive venous hemorrhage after pancreatoduodenectomy treated by endovascular approach.

Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective in reducing mortality. Venous PPH is rare, and identifying its source can be challenging. We report a case of late venous PPH in the context of a pancreatic fistula following pancreaticoduodenectomy. During surgical exploration, the area of ​​potential bleeding was inaccessible due to major inflammatory adhesions aggravated by the presence of pancreatic fistula and the delay of relaparotomy. No intra-abdominal bleeding was detected on imaging studies or during abdominal exploration; only a massive bleeding through the drain orifice, which required packing, was observed. Percutaneous transhepatic portography was performed to localize and treat the origin of the bleeding. The hemorrhage was successfully treated by endovascular approach. We found no reports in the literature on the use of interventional radiology with venous stenting to treat venous PPH, except in cases of gastrointestinal variceal hemorrhage due to portal occlusion.

When a Pathological Forearm Fracture Led to Explore the Neck: About a Case.

The majority of patients with parathyroid carcinoma (PC) have significant clinical signs and simultaneous symptoms related to the unregulated hypersecretion of parathyroid hormone (PTH) by the tumor. The aim of this case was to report a patient presenting an isolated bone fracture leading to the diagnosis of PC. A 20-years-old female patient presenting a fracture of both bones of the forearm following a fall from her own height. Imageries showed diffuse bone demineralization. Biology revealed malignant hypercalcemia at 4.1 mmol/L and PTH at 1331 pg/mL. Bone densitometry showed severe osteoporosis with a femoral and lumbar T-score < - 3DS. Imageries showed a right parathyroid mass of 32 mm. An one-piece excision of the pathological gland, right thyroid lobectomy and ipsilateral central lymph node dissection were performed. Postoperatively, the patient presented a hungry bone syndrome with severe hypocalcemia and required substitutive treatment. PTH on day 1 was normal. Pathology analysis found a PC with Ki67 at 3%, lymph node removal was negative. Complete one-piece surgical excision is the only potentially curative treatment for PC. Preoperative suspicion and intraoperative recognition of malignant features is important in order to propose an appropriate compartmental surgery, which can provide the lowest possible recurrence rate.

Laparoscopic management of an ascending colon hernia through the foramen of Winslow.

Herniation through the foramen of Winslow is rare, with a non-specific clinical presentation and his diagnosis may be difficult. A 44-year-old female was admitted with an acute epigastric abdominal pain. A computed tomography showed an internal hernia of the colon in the lesser sac. Laparoscopic reduction of the herniated contents and the fixation of the ascending colon with several non-absorbable sutures were performed. Twenty months after surgery, the patient has not experienced any recurrence. Computed tomography helps practitioners to the preoperative diagnosis of herniation through the foramen of Winslow, to the viability of the herniated contents and presence of occlusion. In case of herniation through the foramen of Winslow favored by a mobile ascending colon with a misapposition of the right Told fascia, the fixation of the colon with a non-absorbable suture was safe and may prevent the risk of recurrent internal hernia and colonic volvulus.