Management of latrogenic perforation after gastrointestinal endoscopy.

BACKGROUND/AIMS: Gastrointestinal perforation during endoscopy is a rare but severe complication. Most instances occur during colonoscopy. PATIENTS AND METHODS: We retrospectively evaluated the cases of 23 patients with iatrogenic perforation (13 women, 10 men; mean age = 71 years [range, 49-89]). We identified 6 esogastric perforations, 2 endoscopic retrograde cholangiopancreatography (ERCP)-related perforations, and 15 colonic perforations. Demographics, type and aim of endoscopy, mechanism of perforation, delay of treatment, operative procedure, postoperative hospital stay, and mortality rate were analyzed. RESULTS: Three perforations occurred during diagnostic gastroscopy and 3 during therapeutic gastroscopy. ERCP-related perforations occurred during therapeutic procedures. Nine colonic perforations occurred during interventional colonoscopy. ERCP-related perforations always required laparotomy. For esogastric perforations, surgical treatment usually required laparotomy; only two patients (33%) could be managed by laparoscopy. In contrast, colon perforations could be managed by a laparoscopic approach (suturing and drainage or by laparoscopic resection) in 86.6% of cases. Overall mortality was 13% and occurred exclusively after esogastric perforation. CONCLUSION: Most gastrointestinal perforations occurred during therapeutic colonoscopy; these perforations could be treated by laparoscopy in most cases. Esogastric perforations and perforations after ERCP are rare and must be treated on a case-by-case basis; in most cases, laparotomy is required.

A retrospective study of 74 laparoscopic repairs of abdominal incisional hernias.

INTRODUCTION: A laparoscopic procedure is used more and more frequently to treat incisional hernia with the potential benefits of shorter hospitalisation and a decrease in postoperative pain. The purpose of this retrospective study was to analyse the results of the laparoscopic treatment of incisional hernia at our institution and to identify potential risk factors for recurrence. METHODS: The medical data (pre-operative, peri-operative, and postoperative) of patients who received a laparoscopic repair of their incisional hernia between January 2003 and February 2007 were recorded. The follow-up was based on a retrospective analysis of the information found in the patients' medical records. RESULTS: Seventy-four laparoscopic interventions were performed on 71 patients. Polyester implants with an average size of 412.16 cm2 were used to cover the hernia. The mean operative time was 76.8 +/- 55.6 min (range, 20 to 295 min) and the mean duration of post-operative hospitalisation was 3.75 +/- 2.3 days (range, 2 to 12 days). One breach in the small intestine (1.4%) (sutured with 3/0 silk thread) and 1 conversion to laparotomy (1.4%) for a voluminous incisional hernia occurred during surgery. The post-operative morbidity was 8.2%, the rate of long-term complications was 27%, and 13 recurrences (including 3 with complications) were noted (17.6%) during a mean follow-up of 13 months. There was no postoperative mortality. Recurrences were linked to the use of large meshes corresponding to large incisional hernia diameter (p < 0.05). CONCLUSION: Although the morbidity/mortality rates are acceptable, technical improvements must be found to reduce the recurrence rate, in particular for large incisional hernias.

Restoration of digestive continuity after Hartmann's procedure: ASA score is a predictive factor for risk of postoperative complications.

BACKGROUND/AIMS: Re-establishment of colonic continuity (RDC) following Hartmann's procedure is associated with high morbidity (anastomotic leak 4-16%) and mortality (0-4%) rates. The aim of this retrospective study was to evaluate the morbidity of RDC following Hartmann's procedure, and analyse the various factors that may influence the rate of complications. METHODOLOGY: From 1996 to 2008, 158 patients were treated by Hartmann's colectomy. Hartmann's procedure is generally indicated in cases with infection in the abdominal cavity, combined with a distended or non-prepared intestine, or both. Of the 158 patients, 111 (70.3%) underwent a re-establishment of colonic continuity. The mean patient age was 63.4 years (26-91 years) ; the female/male ratio was 1:64. RESULTS: The mean delay between the Hartmann's procedure and the RDC was 169.7 days (21-1095 days) and the mean duration of the hospital stay was 16.7 days (8-57 days). The mortality rate was 0.9% and incidence of anastomotic stricture was 3.6%. The morbidity was 38.7%. The majority of patients presenting complications had an ASA score > II, and most of the patients without complications were classified as ASA < or = II. CONCLUSIONS: The RDC is an intervention performed safely after a 3 to 5-month delay with acceptable morbidity and negligible mortality. The ASA score is a determining factor for the risk of complications (p < 0.05).

Laparoscopic management of acute small bowel obstruction: a retrospective study on 156 patients.

BACKGROUND/AIMS: Laparoscopic treatment of small bowel obstruction (SBO) has been proposed in selected patients. This study reports an experience and tries to establish indications for laparoscopy. METHODOLOGY: 156 patients underwent laparoscopic or open approach for SBO. Demographics, clinical, biological, radiological and previous surgery were recorded. Obstruction causes, conversion rates and postoperative complications were retrospectively analyzed. RESULTS: Laparoscopic approach was undertaken for 96 patients (61%) and completed in 62 (65%), whereas 34 (35%) required conversion. 60 patients (39%) underwent a direct open approach. Mortality was 10% and morbidity 38%. Postoperative adhesion was the predominant etiology. Conversion rate and type of approach was directly influenced by cause of obstruction and type of previous surgery, but not by number of previous surgeries. Conversions and open approach increase morbidity, mortality, length of stay and return to transit. CONCLUSIONS: Laparoscopy is an elegant tool for management of selected patients with SBO. A single band of obstruction appearing after minor surgery appears to be a good indication for laparoscopy. Nevertheless, conversion rate and morbidity are still high. On the contrary, laparoscopy seems contraindicated for patients with prior history of major abdominal surgery, neoplasia or multiple laparotomies, and a direct open approach is then advocated. Prospective randomized studies comparing laparoscopy and open approach are required to evaluate their respective efficacy and safety in management of SBO.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: a retrospective study of 100 patients.

BACKGROUND: The objective of this retrospective study is to evaluate the use oflaparoscopic cholecystectomy in the treatment of acute cholecystitis in elderly patients, and to identify risk factors for mortality. METHODOLOGY: In this study we have included patients with acute cholecystitis aged 75 years and older. Patients were diagnosed after anatomical and pathological examination of an operative sample. We retrospectively examined 100 patients who underwent cholecystectomy between June 1991 and February 2007. Seventy-nine patients (79%) underwent laparoscopic cholecystectomy, 12 patients (12%) needed a conversion, and 15 patients (15%) were considered unfit to undergo a laparoscopic approach, due to their hemodynamic condition or for other reasons. RESULTS: American Society of Anesthesiologists Scores (ASA), inflammatory syndrome, length of postoperative stay, number of days in the Intensive Care Unit, local complications, and mortality rate are all significantly higher in the 'laparotomy and conversion'. There was not a significant difference in age or general complications between groups. The mortality risk factors include a high level of CRP, biliary peritonitis, emergency, and the necessity of laparotomy. CONCLUSION: Acute cholecystitis is a severe pathology in the elderly associated with a high rate of morbidity and mortality. Due to the mortality risk factors associated with acute cholecystitis, we recommend elective laparoscopic cholecystectomy for aged patients with symptomatic cholelithiasis, due to its low morbidity and mortality rates.

Management of sigmoid diverticulitis: a retrospective study of 268 patients.

BACKGROUND/AIMS: The therapeutic management of acute diverticulitis has evolved over the last years in favour of an initial conservative approach with laparoscopy rather than a primary anastomosis. We studied the management of sigmoid diverticulitis in the Digestive Surgical Unit to assess it in comparison to actual practice. METHODOLOGY: A retrospective review of patients admitted to our unit from January 1998 to June 2006 for diverticular disease. We divided the patients into 3 groups (Urgent Medical Group (UM), Urgent Surgical Group (US) and Scheduled Surgical Group (SS)), and analysed demographic data, the severity and recurrence of diverticulitis, pathology results, length of stay, morbidity and mortality. RESULTS: The mean age was 60.5+/-14.9 years. The overall mortality was 3% (14.5% for the Acute Surgical Group and 0 % for the Elective Surgical Group); overall morbidity 38.4%; the incidence of neoplasm 4.8% in urgent colectomies and 0.9% in scheduled colectomies. CONCLUSIONS: Based on our study and published reviews, we recommend elective colectomy after 2 recurrent episodes of acute diverticulitis, one episode of complicated acute diverticulitis managed conservatively, or if the patient is younger than 50 years-old. This approach would reduce the number of acute operations, which are associated with high morbidity and mortality.

Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients.

BACKGROUND/AIMS: Among spinal cord injury patients, digestive disorders are frequent, chronic, and progressive. Constipation and fecal incontinence, the most common disorders, can severely affect the quality of life of patients with spinal cord injury (SCI). METHODOLOGY: For this retrospective study, we reviewed the medical records of spinal cord injury patients with an intestinal stoma formation and developed a questionnaire to assess patient quality of life. Between January 1, 1996, and December 31, 2005, 10 SCI patients had a stoma formation for constipation, 10 for wound management, and 3 for other causes. Most of these stomas were performed by laparoscopy, with no postoperative mortality. RESULTS: Postoperative morbidity was 26% at the general level, with a rate of 4% at the local level; morbidity reached 56% at longer follow-up. The average period of bowel dysfunction was 7.2 years. The average time per week spent on bowel management (bowel care and defecation time) was 6 h prior to stoma formation, but decreased to 1.5 h afterwards. Half of the questionnaire respondents reported an improved quality of life. CONCLUSIONS: A left colostomy is an effective and safe alternative for anorectal disorders among SCI patients. For a large percentage of patients, it ensures an improved quality of life.

Abdominal surgery during pregnancy: a retrospective study of 23 patients.

OBJECTIVE: The aim of this study was to demonstrate that during pregnancy a large variety of non-gynaecological abdominal pathologies can be safely managed with surgery. METHODS: The medical records of twenty-three patients that were pregnant and underwent open or laparoscopic surgery from 1997 to 2007 were reviewed. RESULTS: Twenty-one of the 23 patients have given birth and all but one of the babies were healthy with normal weights, sizes, and APGAR scores. One patient had spontaneous termination of pregnancy one week after the surgical procedure and one patient is out of follow-up. Preterm partus was induced in three patients due to life-threatening conditions for the mother. Each laparoscopy was performed safely without peri-operative complications. CONCLUSION: Open or laparoscopic abdominal surgery poses little or no additional risk for mother or child.

Laparoscopic cholecystectomy; a retrospective 10-year study.

BACKGROUND/AIMS: To evaluate results of laparoscopic cholecystectomies realized in our department and to compare results concerning local and general complications with those reported in the literature. METHODOLOGY: We analyzed retrospectively all the 1255 laparoscopic cholecystectomies realized in our department between January 95 and December 2004. Local and general complications were analyzed. Mean age was 55.6 (21-94) years, sex ratio (F/M) was 3.9. Common bile duct stones were extracted by endoscopic retrograde endoscopy (ERCP) before surgery or by choledochotomy (less than 1% of cases). The operation was performed with 4 trocars, as described by Dubois. RESULTS: Conversion rate was 1.95%. Mean postoperative hospitalization duration was2.7 days. Morbidity was 5.8% with equal repartition between local and general complications. Therevere 2 common bile duct injuries (0.16%). Six patients suffered from residual bile duct stone after cholecystectomy; 5 were treated by ERCP and 1 by choledochotomy. Three patients died (0.24%) after general complications. CONCLUSIONS: Laparoscopic cholecvstectomv is a common operation with potential possible dramatic complications. We think that a radiological study of the biliary tract must be performed before surgery to avoid mistakes during the operation.

Laparoscopic nissen's fundoplication: retrospective study of 168 cases, long-term follow-up.

BACKGROUND/AIMS: Laparoscopic anti-reflux surgery has shown its efficiency since its description by B. Dallemagne in Belgium and T. Geagea in Canada in 1991. As encountered in the laparotomic approach, this technique can be associated with mid- and long-term postoperative side effects. METHODOLOGY: A retrospective study about 168 patients operated for a gastro-esophageal reflux using the Nissen's technique with division of the short gastric vessels through a laparoscopic approach. There were 73 men (43%) and 95 women (57%) with a median age of 44 years (mean: 54 years, range: 17-82). The patients were seen 10 days, one month and three months postoperatively. After one year, they were seen or contacted by phone. The mean follow-up duration was 19.8 months (median: 12 months, range: 0.33-132). RESULTS: The mean operation time was 109 minutes (range: 57-210). There was no death. The postoperative morbidity rate was 5%. 142 patients (84%) had a third month control gastroscopy. 123 patients (86.6%) didn't report any complaint related to their reflux after 3 months. After one year, 166 patients (98.8%) were contacted. A reflux recurrence was reported by 4 patients (2.4%), 157 (94.2%) had no complaints. Our results are similar to those found in the literature published about laparoscopic anti-reflux surgery. In our series, we noted less mechanical complications than in the literature. The choice of the technique and the characteristics of our patients could explain this difference. CONCLUSIONS: The laparoscopic total fundoplication with division of the short gastric vessels is, for most of the authors, the first choice technique in the surgical treatment of the gastro-esophageal reflux.

Laparoscopic revision for failed anti-reflux surgery. Preliminary results.

BACKGROUND/AIMS: Surgical treatment of gastroesophageal reflux disease has become common practice. These operations are known to fail in about 10%, the need for re-intervention approximates 5%. Re-fundoplications are feasible laparoscopically but are technically demanding. METHODOLOGY: For the present paper, we reviewed retrospectively the 10 patients that, in our practice, needed a re-intervention for failure of a prior fundoplication. The causes were: narrowed passage at wrap level (n=4), intra-thoracic wrap migration (n=3), wrap disruption (n=2) and gastric volvulus (n=1). RESULTS: All 10 patients underwent a re-operation consisting of a confection of a new 360 degrees wrap. All interventions were completed laparoscopically and no major complication occurred. The results of these revised fundoplications were satisfying with complete resolution of reflux and/or dysphagia in all patients but one. This latter patient still needed anti-acid medication for an unexplained persistent reflux. CONCLUSIONS: In our experience, laparoscopic correction of failed fundoplications is technically feasible and associated with low rate of complications and high success rate.

Evolution during half a century of the results of digestive surgery in geriatric patients. A review of the literature, experience at C.H.U. Brugmann and the medium term outlook.

The undertaking of complex and major surgical procedures on frail elderly patients with multiple disorders has always been and still remains a controversial and enigmatic issue. At the same time, in an increasingly ageing society, the need for such procedures will extend and patients will expect a more favourable outcome. Surgery in old age will, therefore, pose an ongoing challenge. With better anaesthetic management, surgical techniques and comprehensive geriatric assessment, the overall results for all surgery have improved remarkably over the last few decades. Stringent pre-operative assessment and rigorous post-operative care have achieved a significant reduction in mortality and morbidity; surgery has become a lot safer.

Metabolism of defined structured triglyceride particles compared to mixtures of medium and long chain triglycerides intravenously infused in dogs.

The present study aimed to determine whether including medium-chain fatty acids (MCFA) in specifically designed structured triglycerides (STG) with a MCFA in sn-1 and sn-3 positions and a long-chain (LC) FA in sn-2 position (MLM) would lead to different effects on plasma lipids and FA distribution into plasma and tissue lipids by comparison to a mixture of separate MCT and LCT molecules (MMM/LLL). The fatty acid (FA) composition was comparable in both lipid emulsions. Lipids were infused over 9h daily, in 2 groups of dogs (n = 6 each), for 28 days as a major component (55% of the non-protein energy intake) of total parenteral nutrition (TPN). Blood samples were obtained on specific days, before starting and just before stopping TPN. The concentration of plasma lipids was measured before starting and before stopping TPN on days 1, 2, 3, 4, 5, 8, 10, 12, 16 and 28. Biopsies were obtained from liver, muscle and adipose tissue 15 days before starting, and again on the day following cessation of TPN. In addition, the spleen was removed after the TPN period. FA composition in plasma and tissue lipids was analysed by gas liquid chromatography in different lipid components of plasma and tissues. No differences in either safety or tolerance parameters were detected between both lipid preparations. A lower rise of plasma TG (P < 0.05) was observed during MLM infusion, indicating a faster elimination rate of MLM vs MMM/LLL emulsion. In spite of the differences of TG molecules which would be assumed to affect the site of FA delivery and metabolic fate, FA distribution in phospholipids (PL) of hepatic and extrahepatic tissues did not substantially differ between both emulsions.

Restoration of digestive continuity after Hartmann's procedure.

BACKGROUND/AIMS: Reestablishment of colonic continuity (RDC) following Hartmann's procedure is associated with high morbidity (anastomotic leak 4-16%) and mortality (0-4%) rates. The aim of this retrospective study is to evaluate the morbidity of RDC following Hartmann's procedure, and to analyze the various factors which may be able to influence the rate of complications. METHODOLOGY: From 1996 to 2002, 74 patients were treated by Hartmann's colectomy. Of these 74 patients, 40 patients underwent a reestablishment of colonic continuity (54% of all the Hartmann's procedures). The common factor of indications is the presence of infection in the abdominal cavity, combined with a distended or prepared intestine, or both. The mean age was 60 years (33-90). RESULTS: The mean delay between Hartmann's operation and the RDC was 139 days (range: 25-450 days) and 15.5 days (8-57 days) was the mean duration of the hospital stay. The mortality rate was 0% and incidence of anastomotic stricture was 2.5%. The morbidity was 45%. The majority of patients presenting complications had an ASA score of III (44.4%), and the patients without complications were for the majority classified as ASA I (45.5%) CONCLUSIONS: The RDC is an intervention performed safely after a 3 to 5-month delay with an acceptable morbidity and a negligible mortality. The ASA score is a determining factor for the risk for complications (p<0.05), unlike the age. However, patients younger than 50 years benefit from a protective factor against complications.

Surgical management of recurrent colon haemorrhage of unknown origin.

Although both endoscopy and angiography have profoundly changed the management of lower GI bleeding, the choice, timing and sequence of these procedures as well as the indications for surgery remain a matter of debate. In cases of massive bleeding, early angiography should be performed as the first choice examination. When this fails, exploratory laparotomy, including peroperative colonoscopy after colonic wash-out, should not be discarded as a diagnostic possibility. If no source of bleeding is identified notwithstanding colonoscopic evaluation in excellent conditions, and it can be assumed that the bleeding has ceased, a conservative attitude may reasonably be advocated.

Management of rectal foreign bodies.

The presence of foreign bodies inserted into the rectum is not an uncommon situation. Precise guidelines for the management and extraction of these foreign bodies are not frequently described in the literature. Anal access, whether endoscopic or surgical, varies depending on the type of foreign bodies, their size and morphology, and their location in the lower digestive tract In this report, we describe a case of three rectal foreign bodies that necessitated a mixed endoscopic and surgical approach, and provide a review of the literature.