The Efficacy of Laparoscopic Roux-En-Y Gastric Bypass after Previous Anti-Reflux Surgery: A Single Surgeon Experience.

BACKGROUND: In this study we assessed feasibility, weight loss results and recurrence of Gastro-Oesophageal Reflux Disease (GORD) in patients undergoing laparoscopic Roux-en-Y Gastric Bypass (RYGB) after previous anti-reflux surgery. METHODS: Retrospective analysis of prospectively collected data was performed for patients undergoing laparoscopic RYGB after previous anti-refux surgery between 1/1/2000 and 1/1/2015. Weight loss was assessed using %Excess Weight Loss (%EWL) and every patient was compared with two matched control subjects. Telephone interviews were conducted to assure maximum follow-up data. Quality Of Life (QOL) was assessed using the Gastro-Intestinal Quality of Life Index (GIQLI), Gastro-intestinal Symptom Rating Scale (GSRS) and Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: A total of 18 patients (11 female, 7 male) were identified (17 Nissen and 1 former Belsey-Mark IV fundoplication). Mean time between surgical interventions was 9.4 years. Laparoscopic RYGB was feasible without intra-operative complications. One patient needed relaparoscopy for falsely suspected leakage and another suffered from postoperative pneumonia. Symptomatic GORD after RYGB was reported by 3 patients (16.7%). QOL was rated good with a GIQLI-score of 118 (range 97-140), GSRS score of 33 (range 15-59) and BAROS-score of 4,6 (range 1.2-6.8). EWL 3 years after surgery was comparable with matched control subjects (80.1% vs. 79.2% in controls, P=0.70). CONCLUSIONS: Laparoscopic conversion of anti-reflux surgery to RYGB with breakdown of the fundoplication is feasible and safe. Weight loss results are equal to control subjects and treatment of GORD is good. No significant decrease in QOL was reported.

Ileocolic Intussusception Caused by a Giant Ulcerating Lipoma of Bauhin's Valve: an Unusual Cause of Intestinal Obstruction in the Adult.

We report a case of intestinal obstruction in a 73-year-old woman caused by ileocolic intussusception. The underlying cause was a giant submucosal ulcerating lipoma (6 × 3.3 × 3.8 cm) extending from the superior mucosal lip of Bauhin's valve. Abdominal ultrasonography showed a pathognomonic target-like mass appearing as multiple concentric rings. CT scan confirmed the diagnosis. Because of apparent obstruction, a laparotomy with right hemicolectomy and ileocolic anastomosis was performed. Lipomas most frequently occur in the cecum and ascending colon where they represent the most common submucosal mesenchymal tumor. They typically occur in elderly women with an incidence that varies from 0.15 to 0.56 %. Pain, rectal bleeding, and obstruction are typical symptoms. When faced with an intussusception in children, reduction with air per rectum can be performed. In adults, however, malignant cell spreading and seeding is of big concern. Since approximately 20-50 % of all underlying causes are malignant, explorative surgery is favored in adults.

Acute necrotizing emphysematous pancreatitis with air in the wirsung duct mimicking duodenal perforation: a case report

A 74-year old hemodynamically unstable woman with an acute abdomen presented at the emergency department. Laboratory findings indicated leukocytosis (21000/µl), increased CRP (300mg/l) and lipase (3792kU/l). CT abdomen without contrast showed multiple air pockets in and around the pancreas body, retroperitoneal along the duodenum as well as air in the Wirsung duct. A duodenal perforation was suspected. On explorative laparoscopy however no immediate sign of perforation was seen despite infusion of methylene blue through a nasogastric catheter. Further exploration showed a necrotizing exudative pancreatitis. Because of perioperative hemodynamic instability, further invasive actions were put off. Acute necrotizing emphysematous pancreatitis is a severe pathology with a high mortality (25-70%). Air in the Wirsung duct is rarely described in literature and so far an underlying explanation remains unclear. In this case gas-forming organisms may have entered the pancreas through haematogenous or lymphatic spread, as well as directly through the ampulla or by transmural passage from the transverse colon

No disponible

Performance of the LHCb RICH detector at the LHC.

The LHCb experiment has been taking data at the Large Hadron Collider (LHC) at CERN since the end of 2009. One of its key detector components is the Ring-Imaging Cherenkov (RICH) system. This provides charged particle identification over a wide momentum range, from 2-100 GeV/c. The operation and control, software, and online monitoring of the RICH system are described. The particle identification performance is presented, as measured using data from the LHC. Excellent separation of hadronic particle types (π, K, p) is achieved.

The use of a self-gripping mesh in open inguinal hernia repair. A prospective observational single surgeon study.

BACKGROUND: The Lichtenstein repair is a well standardized surgical technique that can mostly be performed in day-clinic under loco-regional anesthesia. The major concern is the chronic pain reported after mesh suture fixation. We studied the practical and clinical aspects of a Lichtenstein repair using the semi-resorbable self-fixating Parietex ProGrip mesh. METHODS: Consecutive patients with inguinal hernia were operated according to the Lichtenstein technique using Parietex ProGrip. Complications were assessed. Pain and discomfort were evaluated at discharge, and at 1 and 4 weeks and minimum 6 months after the intervention. RESULTS: 320 patients were included in the study. No intra-operative complications or difficulties occurred. Mean operating time was 36 minutes (range 20-65 minutes). 87.5% of the patients (280) were discharged at day of operation, 11.9% (38 patients) had an overnight stay and 0.6% (2 patients) stayed two nights. Mean number of days of analgesic use is 2.1. At the 1 week follow-up visit, minor pain or discomfort was reported by 45 patients (14%) and at 4 weeks 11 patients (3.4%) still had minor discomfort. At 6 months 1 patient suffered from persisting local numbness. Two recurrences were noted, both were re-operated. CONCLUSIONS: This observational study confirms earlier findings with this semi-resorbable self-gripping mesh regarding operation time, complications and recurrence. The open Lichtenstein hernia repair with the semi-resorbable self-gripping Parietex Progrip mesh seems to offer a reliable alternative for the treatment of inguinal hernia with benefits on operating time as well as on postoperative pain.

Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass caused by an intraluminal blood clot.

We report a rare case of acute early postoperative small bowel obstruction after laparoscopic Roux-en-Y gastric bypass due to an intraluminal blood clot at the site of the jejuno-jejunostomy. Patient was treated successfully with enterotomy and removal of the clot. A review of literature showed three similar publications.

Cat and dog bites. What to do? Guidelines for the treatment of cat and dog bites in humans.

INTRODUCTION: Domestic animal bites are quite common, but mostly cause minor lesions, for which no medical help is sought. The objective of this study is to define the complications resulting from cat and dog bites that lead to hospital admission. This analysis led to updated guidelines for the treatment of dog and cat bites in humans. PATIENTS AND METHODS: The emergency department (ED) data of our hospital for the year 2004 were retrospectively analysed, seeking patients that presented with bite wounds from either cat or dog. The patient files were reviewed. RESULTS: 34 patients, bitten by cats or dogs, presented to our ED in 2004. 73.5% of them (n = 25) consulted within 24 hours after the bite. In 11 of these patients (44.0%), primary closure of the wound was performed after thorough rinsing and evaluation of the dead space. All these patients were given prophylactic antibiotics. In none of these did the wounds need to be reopened afterwards. Nine patients (26.5%) did not present to the ED until after the day they were bitten. In all these patients, the bite wounds were located on the hand (n = 6) or forearm (n = 3). They all consulted because of complications. The main symptoms were limited and there was painful mobilisation of fingers and wrist, and swelling and redness in the area of the bite wound. Their wounds were thoroughly explored and in 6 of these nine late-presenting patients, a tendon lesion or a purulent flexor tenosynovitis was diagnosed. These six patients needed admission for further management. The mean admission duration was 6 days (range 4 to 10 days). None of the admitted patients showed any signs of limited mobility or disability during follow-up after discharge. CONCLUSION: While cat and dog bites often cause minor lesions that can be treated by thorough wound care if presented early, the importance of possible late complications should not be overlooked. Patients that present with the symptoms of tissue infection due to a cat or dog bite should be examined adequately and may need admission. Due to aggressive treatment, we had no serious or disabling complications in our population after discharge.

Initial staging of malignant melanoma by positron emission tomography and sentinel node biopsy.

UNLABELLED: By a retrospective study and literature review we aimed to evaluate the accuracy of Sentinel Node Biopsy (SNB) and F-18-fluorodeoxyglucose positron emission tomography (PET) for early detection of lymph node metastases. MATERIAL AND METHODS: Every patient presenting with a malignant melanoma without clinical lymph node involvement and a Breslow index over 1 mm or a recurrence was subjected to a preoperative PET scan and a sentinel node biopsy. Over a period of 10 months, 5 patients were included. They were submitted to conventional staging techniques, PET and SNB. RESULTS: In none of the patients the PET scan showed signs of lymph node involvement or distant metastases. However, two patients, both with a Breslow index of 1.4, had micrometastases in the sentinel node. CONCLUSION: Already in this small group of patients, PET scanning missed two metastases (40%). This is confirmed by several recent publications, stating that the resolution of positron emission tomography is about 5 mm and thus insufficient to detect micrometastases. Several larger series showed a sensitivity of PET to detect lymph node involvement of 15-50%. Therefore we conclude that PET is of limited use in these patients without palpable lymph nodes. Sentinel node biopsy however proves to be a useful tool and should be considered in the initial staging of malignant melanoma without palpable lymph node or distant metastases.

Autoimmune pancreatitis with evolution to cholangitis: a case report.

We report the case of a 47-year-old Caucasian male patient who presented with obstructive jaundice and mild epigastric pain. Autoimmune pancreatitis was diagnosed based on magnetic resonance imaging, biopsy and clinical evolution, and the patient was successfully treated with corticosteroids. However, a few months later ERCP showed an image compatible with sclerosing cholangitis. Again, treatment with corticosteroids was given, after which the bile ducts became normal. A few months later, again there was a relapse and azathioprine was started. After decreasing the dose of immunesuppression, we saw relapses of cholangitis and pancreatitis, with eventually evolution to chronic calcifying pancreatitis. The aim of this report is to describe autoimmune pancreatitis as a cause of obstructive jaundice, and to illustrate that evolution to an immunesuppression-responsive cholangitis, with evolution to chronic calcifying pancreatitis is possible. Also, our patient had a small fluid collection, possibly a pseudocyst, an unusual finding in autoimmune pancreatitis, which disappeared during treatment.

A safe and simple method for routine open access in laparoscopic procedures.

BACKGROUND: Access to the peritoneal cavity in laparoscopic procedures is generally achieved by means of a pneumoperitoneum, following introduction of a Veress needle. Because this procedure must be done blindly, it is not without visceral or vascular hazards. Therefore, we sought an alternative technique that might obviate these complications. METHODS: In a series of 803 patients, a modified Hasson technique was used to obtain a pneumoperitoneum without risking the complications associated with the introduction of a Veress needle. RESULTS: The modified Hasson technique proved to be feasible in all cases. No visceral or vascular complications resulted, but 10 patients had a transient serous discharge. Follow-up ranged between 5 and 52 months. CONCLUSION: The modified Hasson technique should always be used in laparoscopic procedures.

Evaluation of tissue oximetry in perioperative monitoring of colorectal surgery.

Twenty patients undergoing elective colorectal surgery were studied during and after operation by means of tissue oximetry measuring the subcutaneous partial pressure of oxygen (PscO2) and by gastric intramural pH measurement. Mean(s.d.) PscO2 recorded 24 h after surgery was significantly lower than the peroperative value: 14(10) versus 24(14) mmHg, P less than 0.02. The postoperative PscO2 was also significantly lower than that measured in a control group of ten healthy volunteers: 14(10) versus 34(18) mmHg, P less than 0.001. The peroperative PscO2 of the patients who developed a postoperative complication was significantly lower than that of those who had an uneventful postoperative clinical outcome: 16(9) versus 32(14) mmHg, P less than 0.02. The peroperative PscO2 of the patient group with complications was also significantly lower than that of the control group: 16(9) versus 34(18) mmHg, P less than 0.02. The peroperative PscO2 of the group of patients without complications was almost identical to that of the control group. During operation only one patient developed gastric intramural acidosis. Perioperative oxygen debt and the response of subcutaneous tissue oxygen tension to oxygen breathing seemed to correlate better with clinical outcome than gastric wall pH values and the conventional parameters of tissue perfusion.

Assessment of the perfusion in peripheral tissue beds by subcutaneous oximetry and gastric intramucosal pH-metry in elective colorectal surgery.

Gastric intramucosal pH (pHi) and subcutaneous oxygen tension (PscO2) were compared with traditional perfusion parameters in patients undergoing elective colorectal surgery and were related to clinical outcome. Ten patients were studied per- and postoperatively and tissue oximetry studies were also performed in a group of 10 healthy volunteers. The response of PSCO2 to oxygen breathing proved to be the most sensitive predictor of clinical outcome. Of the 10 patients 8 failed to respond to an O2 challenge, while all 10 volunteers in the control group did so. Out of those 8 patients 6 presented with mainly infectious complications while only 3 had an inadequate perioperative urine output and none presented with signs of arterial or of gastric intramural acidosis. The present study suggests a possible relationship between clinical outcome and oxymetric signs of tissue hypoperfusion after O2 challenge in surgical patients, even in the presence of an adequate urine output and a normal gastric wall pH.

The value of short-term peripheral parenteral nutrition after colorectal surgery: a comparative study with conventional postoperative intravenous fluid.

The potential beneficial effect of postoperative peripheral parenteral nutrition (PPN) was assessed in ten patients undergoing colorectal surgery and compared with the conventional use of intravenous fluids in ten controls. Clinical and biological parameters were checked. A significant improvement in the nitrogen-balance, which was not positive during the first postoperative days was observed. All other daily measured parameters (lipid metabolism, electrolytes, glucose levels and plasma pH) remained within normal ranges. In our opinion, short-term postoperative PPN may lessen protein losses and is indicated in those patients who may have a prolonged paralytic ileus without risking complications of central venous access. However, peripheral solutions may cause phlebitis and PPN is by no means an alternative to central TPN.

A prospective comparative clinical study between monofilament absorbable and non-absorbable sutures for abdominal wall closure.

One hundred and sixty-seven patients undergoing laparotomy were randomly allocated to a continuous layered closure technique with absorbable monofilament polyglyconate (PG) (Maxon*) or non-absorbable polyamide (PA) (Ethilon*). Laparotomy wounds were closely observed during the postoperative hospital course and all patients were reviewed at one month, six months and one year. Any wound complications were noted. Two patients in the PA group (3.0%) presented with burst abdomen and one (1.9%) in the PG group (ns). The incidence of incisional hernia was not statistically different between the two groups (4/64, 6.0% in PA group and 4/65, 6.2% in PG group). The postoperative wound infection rate was 21.0% in the Pa group and 15.4% in the PG group (ns). The present study clearly shows a major increase in incidence of wound failure in patients with infected abdominal wounds in both groups (28.6% vs 3.8% in PA group p less than 0.025; 20% vs 5.5% in Pg group p less than 0.05). This clinical trial confirms the important roles of wound infection and respiratory failure in the occurrence of wound failure; the choice of an absorbable or a non-absorbable suture material seems to play a minor role only.

Prognostic value of gastric intramural pH in surgical intensive care patients.

Gastric intramural pH (pHi), which has been shown to reflect the adequacy of oxygenation in peripheral tissue beds, was measured in acutely ill surgical patients in order to evaluate its value as a prognostic factor and its relation to the sepsis score. Fifty-nine surgical patients were studied on ICU admission. The stomach wall pH was calculated from the PCO2 in gastric juice and arterial bicarbonate concentration using the Henderson-Hasselbalch equation. A fall in tissue pH less than 7.32 was taken as an indication of inadequate tissue oxygenation. Patients with sepsis scores greater than 10 were considered septic. Hospital and short-term (within 72 h of admission) mortality rates were determined. A significantly higher short-term mortality rate was observed in patients having a pHi less than 7.32 (37% vs. 0%, p less than .005). Most (90%) of the septic patients had a pHi less than 7.32. The short-term mortality rate was the highest (50%) in the septic group. In this group also, a linear correlation was found between pHi and the sepsis score (r = -.43, p less than .01). Gastric pHi, however, offered no prediction for the long-term outcome.

Problems in the surgical treatment of motility disorders occurring after gastric surgery.

Delayed or accelerated gastric emptying and excessive reflux of upper intestinal contents into the stomach are the main disorders of motility occurring after gastric surgery. Most of these syndromes may be treated by conservative measures. When surgical therapy is needed attention must be paid to the possible specific side effects of remedial treatment. Interposition of a reversed jejunal loop in the treatment of dumping after Billroth I gastrectomy may be responsible for the development of an anastomotic ulcer. Roux-en-Y biliary diversion for the surgical treatment of postoperative reflux alkaline gastritis may result in a Roux-en-Y syndrome characterized by severe, delayed gastric emptying. Whenever possible, the pyloric sphincter should be preserved in gastric surgery as the elimination of the pylorus is the main cause of postoperative motility disorders.

[Hyperselective vagotomy in the surgical treatment of duodenal ulcers]. / De hyperselective vagotomie in de heelkundige behandeling van het ulcus duodeni.

The results of hyperselective vagotomy for duodenal ulcer in 181 patients were evaluated 0.5-8.5 years after operation. The overall recurrence rate was 12.7%. The functional results were excellent in 151 patients (83.4%).