Different laparoscopic treatment modalities for splenic artery aneurysms: about 3 cases with review of the literature.

INTRODUCTION: The first laparoscopic treatment of splenic artery aneurysm (SAA) was performed in 1993. Since then, many papers have been published mentioning different laparoscopic treatment modalities, including splenectomy, aneurysmectomy, ligation or even occlusion. PATIENTS AND METHODS: An updated literature review of the English medical literature using the following MeSH, 'Lapaorscopic splenic artery aneurysm', 'laparoscopic aneurysectomy', 'Laparoscopic Splenic artery Aneurysm Ligation' and 'Laparoscopic Splenic artery aneurysm excision' was done. Also three cases performed at our institutions are discussed, in terms of techniques, morbidity, mortality and postoperative outcomes. RESULTS: About eight case series and 16 case reports were retrieved from the literature. Different techniques were described by the authors, including splenectomy, aneurysmectomy, splenic aneurysm ligation or even occlusion. Few morbidity cases were reported and none of the authors has mentioned a single mortality case. In our three cases, the postoperative course was uneventful, with good long-term results. CONCLUSIONS: Despite the variations in the adopted operative techniques, the laparoscopic approach seems to be harmless. However, no treatment algorithm or consensus has been published.

Bowel obstruction secondary to an ectopic pancreas in the small bowels: About 2 cases.

INTRODUCTION: Ectopic pancreas is most commonly found in the jejunum and stomach. Most patients remain asymptomatic, and the diagnosis is usually made at autopsy or incidentally. We report here 2 cases of intestinal occlusion, secondary to an ectopic pancreatic tissue. Both cases were managed successfully by laparoscopy and laparotomy with subsequent segmental intestinal resection. CASE PRESENTATIONS: Case 1 - An elderly patient presented to the ER because of intestinal occlusion. Paraclinical investigations were consistent with occlusion, with ileal suffering signs on CT-scan. After laparotomy and segmental intestinal resection were done, histopathalogy showed evidence of ectopic pancreas obstructing the intestinal lumen. Case 2 - A young man presented to the ER with acute onset of epigastric pain. signs of peritoneal irritation. Ct-scan showed evidence of small bowel intussusception. Exploratory laparoscopy was done, and confirmed the diagnosis. The intussusceptum was at the level of the proximal jejunum. The suffering intestinal part was exteriorized and then resected. Histopathology was consistent with an ectopic pancreas. DISCUSSION: Symptomatic ectopic pancreas is extremely rare. Symptoms may include, bleeding, intestinal occlusion and intussusception. Few similar cases have been reported in the literature, and the current ones are to be added. CONCLUSION: As mentioned above, ectopic pancreatic tissue rarely causes symptoms. We presented 2 cases that presented 2 possible complications secondary to this pathology. Both cases were managed successfully.

Primary epiploic appendagitis: from A to Z.

Epiploic appendagitis is a rare and uncommon diagnosis that is frequently unknown to clinicians. Inflammation is usually acute and causes abrupt symptoms, but once the diagnosis is accurately made, most patients respond to pain control and conservative management. We report the case of a young woman presenting with acute primary epiploic appendagitis of the right colon. The inflammatory mass was unusually large and occurred a few months after surgery for gastric bypass. This case will give us the opportunity to discuss the clinical presentation of this disease, as well as the potential associations and risk factors and the means for adequate diagnosis and treatment.

Redefining contraindications to laparoscopic colorectal resection for high-risk patients.

BACKGROUND: Patients with major comorbidities often are denied laparoscopic colorectal resections because they are thought to be at too "high risk." Paradoxically, these patients generally have the most to gain from a minimally invasive surgical approach. This study aimed to examine the feasibility and safety of laparoscopic colorectal resection to determine whether it is contraindicated for "high-risk" patients. METHODS: From August 1996 to February 2004, 368 consecutive patients (95 men) undergoing a laparoscopic colorectal procedure by a single surgeon were prospectively studied with regard to pre-, peri-, and postoperative events. High-risk patients (n = 190) were defined as elderly (age, >80 years; n = 28), morbidly obese (body mass index [BMI], >30 kg/m(2); n = 55), American Society of Anesthesiology (ASA) 3 or 4 (n = 130), and recipients of preoperative radiotherapy (n = 54). Multiple risk factors were found for 67 patients, 7 of whom had three risk factors. The median age of the patients was 66 years (range, 19-92 years). The diagnoses included rectal cancer (n = 48), diverticulitis (n = 43), colon cancer (n = 34), benign polyp (n = 26), and other (n = 39). The following procedures were performed: colon resection (n = 114; left, 63; right, 41; total abdominal colectomy, 10), rectal resection (low anterior resection or pouch) (n = 49), coloanal anastomosis (n = 23), and other (n = 4). Data regarding intent to treat, operative events, morbidity, mortality, and outcomes were analyzed and form the basis of this report. RESULTS: No mortalities occurred. The major morbidity rate was 2%. There were no anastomotic leaks. The cases were laparoscopically performed (94%) or laparoscopically assisted, or were converted to open procedure (3%). The median estimated blood loss was 200 ml, and only 5% required perioperative transfusion. The perioperative course involved the following median periods: 2 days until flatus, 3 days until bowel movement, 1 day until clear liquid diet, 3 days until a regular diet, and 5 days until hospital discharge. CONCLUSION: In experienced hands, laparoscopic colorectal resection can be performed safely for "high-risk" surgical patients. The better than expected outcomes in this patient population reinforce the benefits of minimally invasive surgery for this patient group and argues against using parameters of increased age, morbid obesity, high ASA class, or preoperative radiation alone as contraindications to even complex laparoscopic colorectal procedures.