Dilemma of sigmoid volvulus management.

INTRODUCTION: Patients with sigmoid volvulus (SV) are at a high risk of recurrence with increased morbidity and mortality. This study aims to review whether patients with SV underwent definitive surgical treatment after initial endoscopic reduction according to the guidelines, and to compare mortality rate between surgical and conservative management. METHODS: Retrospective study conducted at East Kent Hospitals University NHS Foundation Trust, included all patients with SV between 2016 and 2018. The primary outcome was 30-day mortality following the initial management of the acute attack. Secondary outcomes were recurrence rate and overall mortality. The median follow-up period was 3 years. RESULTS: A total of 40 patients were identified with a median age of 82 years; 27 (67%) were males. Of these 40 patients, 6 (15%) had emergency surgery, 26 (65%) received endoscopic decompression only, and 8 (20%) had planned definitive resection; 32 patients (80%) had recurrence and the median interval between any two episodes was 86 days. The mortality rate among patients with ASA grade 3 or 4 in the three groups, elective surgery, emergency surgery and decompression only, was 0%, 25% and 70% respectively, whereas it was 0%, 50% and 33% in those with ASA grade 2. The mortality rate among patients with similar ASA who had a planned surgery was significantly lower compared with those who did not undergo surgery (p=0.003). CONCLUSIONS: In patients with sigmoid volvulus, regardless of ASA grade, performing early definitive surgery following initial endoscopic decompression resulted in a statistically significant lower mortality rate.

Dilemma of sigmoid volvulus management.

INTRODUCTION: Patients with sigmoid volvulus (SV) are at a high risk of recurrence with increased morbidity and mortality. This study aims to review whether patients with SV underwent definitive surgical treatment after initial endoscopic reduction according to the guidelines, and to compare mortality rate between surgical and conservative management. METHODS: Retrospective study conducted at East Kent Hospitals University NHS Foundation Trust, included all patients with SV between 2016 and 2018. The primary outcome was 30-day mortality following the initial management of the acute attack. Secondary outcomes were recurrence rate and overall mortality. The median follow-up period was 3 years. RESULTS: A total of 40 patients were identified with a median age of 82 years; 27 (67%) were males. Of these 40 patients, 6 (15%) had emergency surgery, 26 (65%) received endoscopic decompression only, and 8 (20%) had planned definitive resection; 32 patients (80%) had recurrence and the median interval between any two episodes was 86 days. The mortality rate among patients with ASA grade 3 or 4 in the three groups, elective surgery, emergency surgery and decompression only, was 0%, 25% and 70% respectively, whereas it was 0%, 50% and 33% in those with ASA grade 2. The mortality rate among patients with similar ASA who had a planned surgery was significantly lower compared with those who did not undergo surgery (p=0.003). CONCLUSIONS: In patients with sigmoid volvulus, regardless of ASA grade, performing early definitive surgery following initial endoscopic decompression resulted in a statistically significant lower mortality rate.

The selective use of splenic flexure mobilization is safe in both laparoscopic and open anterior resections.

AIM: Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised. METHOD: Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009. RESULTS: Of 263 resections, SFM data were recorded in 216; 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). Eighty-eight were low anterior resections (LARs) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LARs (61%vs 29%, P<0.001), defunctioning ileostomy rates (75%vs 46%, P=0.001) and operative time (median 255 vs 185 min, P<0.001), with no differences in age, gender, body mass index, American Society of Anesthesiology score, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LARs with and without SFM or between open resections with and without SFM. CONCLUSION: Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers.

Fibrin glue application in the management of refractory chylous ascites in children.

The purpose of this retrospective review of the charts of 6 children who underwent surgical treatment of chylous ascites refractory to conservative measures between 1993 and 2006 was to evaluate the efficiency of fibrin glue application for control of lymph leakage. Five children had postoperative chylous ascites (neuroblastoma, 4; cystic lymphangioma, 1) and 1 had a congenital malformation. Surgical exploration revealed large areas of diffuse lymphatic leakage in all of the patients. Lymphatic fistula was not identified intraoperatively in any patient. Ingestion of lipophilic dye in a concentrated fatty meal was not helpful in locating a lymph fistula. Absorbable mesh was used in association with glue application in the last 3 patients treated. Control of ascites was achieved immediately in 2 patients and within 3 weeks in 2 patients. Repeat surgery was required in the remaining 2 patients. The mean follow-up time was 4.3 years. One patient died of tumor recurrence 12 months after surgical treatment without relapse of the ascites. Two mild late recurrences were observed at 6 and 11 months after surgery and were managed conservatively. The findings of this study show that fibrin glue application on absorbable mesh after dissection of the leakage zones is easy, safe, and effective. We recommend that surgery with glue application be repeated until control of ascites is achieved. We suggest fibrin glue application as a preventive measure against postoperative chylous ascites.

Laparoscopic versus open left lateral hepatic sectionectomy: A comparative study.

BACKGROUND: Laparoscopic liver surgery has been difficult to popularize. High volume liver centres have identified left lateral sectionectomy (LLS) as a procedure with potential for transformation into a primarily laparoscopic procedure where surgeons can safely gain proficiency. METHODS: Forty-four patients underwent either laparoscopic (LLLS) or open (OLLS) left lateral sectionectomy (of segments II/III) for focal lesions at Southampton General Hospital. RESULTS: OLLS and LLLS groups were matched for age, sex and tumour types resected. Median operative time in the LLLS group was 180 (40-340) min and 155 (110-330) min in the OLLS group (p=0.885) with median intra-operative blood loss in the LLLS group 80 (25-800) ml versus a larger 470 (100-3000) ml; p=0.002 for patients receiving OLLS. Post-operative stay was also shorter in the LLLS group (3.5 (1-6) days) compared to the OLLS group (7 (3-12) days; p<0.001). Resection margin was not different in the two groups (11 (1.5-30) mm (LLLS) versus 12 (4-40) mm (OLLS); p=1) and neither was the complication rate (13% for LLLS versus 25% for OLLS; p=0.541). There were no conversions to open in the LLLS group and no deaths in either group at 90 days. Between the first and second 12 LLLS the median operative time fell from 240 (70-340) min to 120 (40-120) min; p=0.005 as well as median post-operative hospital stay from 4.5 (2-6) days to 2 (1-4) days, p=0.001. CONCLUSION: LLLS is a viable alternative to OLLS with potential improvements in intra-operative blood loss and shorter hospital stay without adversely affecting successful resection or complication rates. Larger prospective studies are required to explore this new avenue in laparoscopic liver surgery.

[Laparoscopic mini-gastric bypass: an effective option for the treatment of morbid obesity]. / Le mini-gastric bypass coelioscopique: une option nouvelle pour le traitement de l'obésité morbide.

OBJECTIVE: To evaluate laparoscopic Mini-Gastric Bypass in the treatment of morbid obesity. PATIENTS AND METHODS: Thirty patients with a mean BMI of 41.84.5 Kg/M2 underwent a laparoscopic Mini-Gastric Bypass between March 2005 and February 2006. A laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum 200 cm. distal to the ligament of Treitz Peri-operative and short-term follow-up results up to May 2006 are reported. RESULTS: Conversion to open mini-gastric bypass was necessary in one case (3.3%). Mean operative time was 135 45 minutes. There were no deaths. There were no anastomotic leakages. Two patients developed obstruction at the gastrojejunostomy requiring laparoscopic correction in one case and accounting for an overall morbidity of 6.6%. Mean hospital stay was 3 0.25 days. One patient developed marginal ulcer which resolved with medical treatment; no patients developed symptoms of reflux esophagitis. Mean loss of excess weight was 67.6% at one year and was accompanied by resolution of obesity-associated medical illness in 85% of patients. CONCLUSION: Laparoscopic Mini-Gastric Bypass is a technically simple, safe, and effective procedure in the treatment of morbid obesity and its associated medical illnesses. Moreover, the procedure is easily reversible laparoscopically when post-operative complication occurs.

Do low-type anorectal malformations have a better prognosis than the intermediate and high types? A preliminary report using the Krickenbeck score.

BACKGROUND: Following the development of the Wingspread classification for anorectal malformations, low-type lesions were considered to have a better functional prognosis than intermediate and high lesions. This study rejects this basic presumption following the establishment of the latest standards at Krickenbeck in May 2005. PATIENTS AND METHODS: The surgical approach, whether perineal (group A) or posterior sagittal anorectoplasty (group B), was determined depending on the presence or absence of a perineal fistula. Group C consisted of patients below the age of three years. Sacral anomalies were screened by lumbosacral radiography. Information on postoperative anorectal function (voluntary bowel movements, soiling, and constipation) was gathered by phone call. RESULTS: Eight of the 9 patients in group A, and 2 of the 7 in group B achieved voluntary bowel movements (p < 0.05). No significant differences were found between the two groups with respect to either the occurrence or severity of soiling and constipation. All subjects in group C (n = 4) had fewer than 3 daily stools with total cleanness between episodes but still suffered from constipation. CONCLUSIONS: Basic ideas about anorectal malformations will continue to be modified when the criteria are changed. The use of the Krickenbeck score will help to standardize the results of studies.

Congenital segmental dilatation of the small bowel (CSD).

Congenital segmental dilatation (CSD) is a rare pathology of unknown etiology, usually with early-onset presentation in the neonatal age. We present a case of CSD of the jejunum of a 9-year-old boy with severe malnutrition. Its clinical, radiological and histological features are similar to those described in the literature but the remarkable aspect of this case lies in its late presentation.

Bladder augmentation and/or continent urinary diversion: 10-year experience.

OBJECTIVE: We evaluated the success and the long-term complications associated with augmentation cystoplasty and/or continent urinary diversion in children with urinary incontinence due to neurogenic or malformed bladder. MATERIALS AND METHODS: The records of 23 patients (12 females, 11 males) who underwent such procedures between 1994 and 2004 were reviewed retrospectively. The most common type of augmentation cystoplasty was ileocystoplasty. The most common type of conduit for the urinary continent diversion was appendicovesicostomy. Combined bladder neck closure was not performed systematically. Neocystoureterostomy was done in 14 refluxing ureters. RESULTS: Of the 21 patients who underwent augmentation cystoplasty, only one was incontinent after the procedure and required reconstruction of the bladder neck using the Young-Dees procedure. The most common complications were stomal stenosis and bladder stone formation. CONCLUSION: Augmentation cystoplasty and continent urinary diversion procedures can increase the functional capacity of the small bladder and allow the majority of patients to achieve continence while preserving renal function. Combined bladder neck closure is not necessary to obtain urinary continence; on the contrary, it eliminates a useful pop-off mechanism. Neocystouretrostomy is not required for every refluxing ureter unless it can be performed on the original bladder. Bladder stones and stomal stenosis are the most significant long-term complications in these patients.

Right congenital diaphragmatic hernia a well-known pathology?

In right congenital diaphragmatic hernia (RCDH), several clinical diagnostic pitfalls are possible and should be known to those caring for infants and children with this disorder. The records of the 18 patients at Hotel Dieu de France Hospital with a history of CDH between 1990 and 1999 were collected; those of the ten who had a RCDH were reviewed retrospectively. The mean age at diagnosis was 6 months; the male-to-female ratio was 2:3. The delay between the first symptom and the diagnosis ranged between 0 and 10.5 months (mean 4.5 months). An acute presentation was observed in four cases, consisting of respiratory distress in three; the 4th presented with gastric volvulus and intestinal obstruction. The presenting symptoms were mild in four cases; recurrent respiratory infections in three and failure to thrive in one. The diagnosis was incidental in two cases during the evaluation of respiratory symptoms attributed to an atrial septal defect. The radiologic findings provided by a chest radiograph (CxR) were sufficient to make an accurate diagnosis in eight cases and peritoneography was useful in one. In six cases, the presenting CxR had been misinterpreted as normal or acute lobar pneumonia. Pathologic findings at surgery consisted of lateral and posterior right diaphragmatic defects in nine cases; the defect was lateral and anterior in one. A hernia sac was found in seven cases; malrotation was present in three. Surgical correction was done by an abdominal approach in nine cases and a thoracic approach in one. The diaphragmatic defect was repaired by transverse closure in six cases, diaphragm plication in three and prosthetic closure in one. The postoperative outcome was uneventful in eight cases. Two patients died. Thus, RCDH seems to cause less severe symptoms than left-sided LCDH. It usually manifests beyond the neonatal period as respiratory or gastrointestinal symptoms. The diagnosis should be made easily by a CxR. The presence of a hernia sac correlated with a mild presentation. An abdominal surgical approach is preferred.

Recurrence risk after a first febrile convulsion.

OBJECTIVE: Fever is the most common cause of convulsions, in infancy and childhood. Parents usually are concerned by the risk of recurrence. Our aim is to determine this risk of subsequent convulsions within the first year of the first episode of convulsion. METHODS: This is a prospective study over one year, May 97 to April 98 in which all children with first febrile seizure were enrolled. RESULTS: There were two hundred and thirty six children who had their first febrile convulsion within the study period. Male-to-female ratio was 1.2:1; the mean age at onset was 19 months (standard deviation 14.4). Generalized seizure occurred in 95.6% of the patients with an average duration of 7 minutes (SD 6.4). Ten percent of patients needed anticonvulsant drugs to stop convulsion. Seizure clusters occurred in 13.6 %, and complex febrile seizure was noticed in 21%. Family history was positive for epilepsy in 6.6% and febrile convulsions in 22%. Recurrence within a year from onset occurred in 52 (21%) of the patients. Factors associated with recurrence were: male sex, as male to female ratio was 2.25:1 (P = 0.02) and history of seizure clusters, 23/52, 44% (P = 0.00001). CONCLUSION: Risk factors for recurrence noted were male sex, and complex febrile seizures.

[Augmentation cystoplasty and/or continent urinary diversion. Review of eleven cases]. / Cystoplastie d'augmentation et/ou dérivation urinaire continente. Revue de 11 cas.

Urinary incontinence secondary to neurogenic or malformafive bladders is a major problem influencing social insertion and has been totally transformed by bladder augmentation associated to continent urinary diversion as described by Mitroffanof. We present our experience in eleven cases and try to emphasize on three major points. Combining urinary continent diversion to bladder augmentation guarantees optimal urinary continence. Concomitant bladder neck closure is not necessary to obtain urinary continence; on the contrary, it eliminates a useful pop-off mechanism. Neocystoureterostomy is not requested for every refluxing ureter unless it could be realized on the original bladder.

Transient glucose intolerance associated with the haemolytic-uraemic syndrome.

A 3-year-old girl developed glucose intolerance during treatment with peritoneal dialysis for haemolytic-uraemic syndrome and became insulin dependent for almost a month. Diabetes mellitus in this condition is a rare but potentially serious complication which should be sought by regular blood sugar measurement during the acute stage of the illness.