Asymptomatic portal vein aneurysms: To treat, or not to treat?

Background Portal vein aneurysms are rare dilations in the portal venous system, for which the etiology and pathophysiological consequences are poorly understood. Method We reviewed the existing literature as well as present a unique anecdotal case of a patient presenting with a very large portal vein aneurysm that was successfully managed conservatively and non-operatively without anticoagulation, with close follow-up and routine surveillance. Result The rising prevalence of abdominal imaging in clinical practice has increased rates of portal vein aneurysm detection. While asymptomatic aneurysms less than 3 cm can be clinically observed, surgical intervention may be necessary in large asymptomatic aneurysms (>3 cm) with or without thrombus, or small aneurysms with evidence of evolving mural thrombus formation on imaging. Conclusion Portal vein aneurysms present a diagnostic challenge for any surgeon, and the goal for surgical therapy is based on repairing the portal vein aneurysm, and if portal hypertension is present decompressing via surgically constructed shunts.

Adrenocortical Carcinoma: Complete Surgical Resection After 18 Years.

Adrenal cortical carcinoma (ACC) is a rare neoplasm often associated with an aggressive biological behavior. Complete surgical resection is the mainstay of therapy for ACC and offers the best chance for prolonged disease-free survival. We present an unusual case of a long-standing adrenal mass, well documented over a period of at least 18 years, without the development of metastatic disease, and ultimately proven to represent ACC after successful surgical resection. Physicians should be aware that ACC can present with a wide spectrum of biological behavior, from very aggressive to more indolent disease.

Laparoscopic surgery for inflammatory bowel disease.

Laparoscopic surgery has recently been gaining acceptance as an alternative approach for patients with inflammatory bowel disease. There is increasing evidence demonstrating the multiple potential benefits of laparoscopy including faster recovery, reduced costs, and lower morbidity. For patients with acute colitis, a laparoscopic subtotal colectomy and end ileostomy have been shown to be feasible and safe in experienced hands. When indicated, many of these patients may be able to safely undergo a subsequent laparoscopic approach for construction of an ileo-anal pouch. Although still controversial, an elective laparoscopic restorative proctocolectomy with ileo-anal pouch anastomosis has also been shown to be feasible with functional outcomes at least similar to those obtained with an open approach. However, larger randomized series of patients are needed with longer follow-up in order to draw definite conclusions. For Crohn's disease, a laparoscopic approach is ideal for stoma creation. In addition, laparoscopic ileo-colectomy is arguably the preferred approach for patients with terminal ileal disease. Some experienced laparoscopic groups have also applied laparoscopic techniques for more complicated cases with recurrent disease or disease-related complications, such as fistulous disease. Other short-term benefits of a laparoscopic approach may include a decreased incidence of ventral hernias, decreased incidence of small bowel obstruction, and faster recovery. These benefits may also have significant economic impact. In contrast to earlier reports, there is reliable evidence that conversion is not associated with a poorer outcome. A policy of starting most suitable cases laparoscopically may offer patients the potential benefits of a laparoscopic approach without increasing morbidity.

Incontinence after a lateral internal sphincterotomy: are we underestimating it?

PURPOSE: This study was designed to assess the long-term outcomes and quality of life of patients who have undergone a sphincterotomy for chronic anal fissure. METHODS: The medical records of patients who underwent this operation between 1992 and 2001 were reviewed. A questionnaire was mailed to assess their current status, along with the Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index surveys. RESULTS: A total of 298 patients were identified (158 males; 53 percent; mean age, 46.9 years; mean follow-up, 4.3 years). Postal survey response was 62 percent. Recurrence of the fissure occurred in 17 patients (5.6 percent) of whom 9 (52 percent) were females. Significant factors that resulted in recurrence were initial sphincterotomy performed in the office and local anesthesia (P < 0.001). When comparing office records and response to the postal survey, significantly more patients had flatal incontinence than that recorded in their medical records (P < 0.001). Twenty-nine percent of females who had a vaginal delivery recorded problems with incontinence to flatus (P = 0.04). Temporary incontinence was reported in 31 percent of patients and persistent incontinence to gas occurred in 30 percent. Stool incontinence was not a significant finding. The overall quality-of-life scores were in the normal range, whereas the median Fecal Incontinence Severity Index score was 12. CONCLUSIONS: Recurrence after lateral internal sphincterotomy may be higher after local anesthesia or office procedure. Females who have two or more previous vaginal deliveries should be warned about possible flatal incontinence. Long-term flatal incontinence that is not reported to the caregiver may occur in up to one-third of patients and could be permanent.

Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy.

PURPOSE: The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy. METHODS: A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999-June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means +/- standard deviations, and appropriate statistical tests were used. RESULTS: The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat-type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, US. 3,368 dollars vs. US 3,552 dollars; mean, US 4,003 dollars vs. US 4,037 dollars; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates. CONCLUSIONS: Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.

Does conversion of a laparoscopic colectomy adversely affect patient outcome?

PURPOSE: Conversion during laparoscopic colectomy varies in frequency according to the surgeon's experience and case selection. However, there remains concern that conversion is associated with increased morbidity and higher hospital costs. METHODS: From January 1999 to August 2002, 430 laparoscopic colectomies were performed by two surgeons, with 51 (12 percent) cases converted to open surgery. Converted cases were matched for operation and age to 51 open cases performed mostly by other colorectal surgeons from our department. Data collected included gender, American Society of Anesthesiology score, operative indication, resection type, operative stage at conversion, in-hospital complications, direct hospital costs, unexpected readmission within 30 days, and mortality. RESULTS: There were no significant differences between the groups for age (converted, 55 +/- 19; open, 62 +/- 16), male:female ratio (converted, 17:34; open, 23:28), or American Society of Anesthesiology score distribution. Indications for surgery were neoplasia (converted, 16; open, 31); diverticular disease (converted, 21; open, 13); Crohn's disease (converted, 12; open, 5); and other disease (converted, 2; open, 2). Operative times were similar (converted, 150 + 56 minutes; open, 132 +/- 48 minutes). Conversions occurred before defining the major vascular pedicle/ureter (50 percent), in relation to intracorporeal vascular ligation (15 percent), or during bowel transection or presacral dissection (35 percent). Specific indications for conversion were technical (41 percent), followed by adhesions (33 percent), phlegmon or abscess (23 percent), bleeding (6 percent), and failure to identify the ureter (6 percent). Median hospital stay was five days for both groups. In-hospital complications (converted 11.6 percent; open 8 percent), 30-day readmission rate (converted 13 percent vs. open 8 percent), and direct costs were similar between groups. There were no mortalities. CONCLUSION: Conversion of a laparoscopic colectomy does not result in inappropriately prolonged operative times, increased morbidity or length of stay, increased direct costs, or unexpected readmissions compared with similarly complex laparotomies. A policy of commencing most cases suitable for a laparoscopic approach laparoscopically offers patients the benefits of a laparoscopic colectomy without adversely affecting perioperative risks.

Aortic thrombosis after low anterior resection for rectal cancer: report of a case.

Pelvic surgery for malignant disease has been associated with numerous acute postoperative complications. These complications are primarily vascular or neurologic in origin. Several factors associated with the occurrence of these complications include the lithotomy position, the prolonged use of sequential compression devices, the use of certain types of stirrups, the presence of peripheral vascular disease, and the common hypercoagulable state of most cancer patients. We report for the first time a case of aortic thrombosis after elective low anterior resection for rectal cancer and discuss some factors that may have a role in the occurrence of this devastating complication.