Intragastric SILS for GIST, a new challenge in oncologic surgery: first experiences.

BACKGROUND: For treatment of Gastrointestinal Stromal Tumour (GIST) located in unreachable areas, such as the esophagogastric junction or pyloric ring, laparoscopic resection cannot be easily applied. We used single-incision laparoscopic surgery (SILS) for intragastric resection of GISTs. PATIENTS AND METHODS: We report on our cases (n=3) of GIST of the stomach treated with the SILS port placed intragastrically through the anterior wall of the stomach. A skin incision of only 2.5 cm was made to perform this intervention. RESULTS: The patients mean age was 68.1 years (range=53-86). The mean operative time was 74.6 (range=67-82) minutes. No intra-operative complications occurred. No conversion was needed. The mean tumor size was 3.8 cm (range=2.7-6.8 cm). All patients healed without any complications. Re-alimentation was started on the third postoperative day. The mean postoperative stay was five days (range: 4-6 days). CONCLUSION: This intragastric SILS procedure for GIST is feasible and safe, and offers a benefiet for further progress in oncologic surgery.

Results of surgical treatment of uncontrollable upper gastrointestinal hemorrhage using endoscopy.

BACKGROUND/AIMS: Acute hemorrhage of the upper gastrointestinal tract occurs at a rate of 50 to 100 per 100,000 annually in the Western adult population. With the increased use of therapeutic endoscopy, the role of surgery is decreasing; surgical intervention is now only used in cases of failure of endoscopic hemostasis. The goal of this study is to determine whether there are predictive factors associated with high-risk post-operative mortality. METHODOLOGY: This retrospective study included 30 patients treated from March 1996 to September 2008 at Brugmann Hospital. These patients presented with upper gastrointestinal non-variceal hemorrhage that was treated first endoscopically then surgically for recurrent hemorrhage. Multiple risk factors (variable and fixed) and parameters were evaluated to determine their influence on mortality. RESULTS: Of 30 patients, 10 (33%) developed recurrent hemorrhage following surgical treatment. A total of 8 (26.6%) deaths occurred of which 4 were related to hemorrhage. Three deaths occurred after the first intervention and 5 occurred after a second intervention. Logistic regression analysis revealed that the total number of blood units transfused and the presence of at least one surgical reintervention both significantly increased mortality rate (p = 0.0426 and p = 0.0068). Other parameters were not significant. However, there is a lack of power due to the small sample size. CONCLUSION: For recurrent massive upper gastrointestinal hemorrhage following endoscopic treatment and necessitating more than 19 blood transfusions, early surgical intervention is recommended and surgical reintervention should be avoided. If reintervention is necessary, radical surgery is recommended. However, the small number of patients treated over a 12-year period limits the results of this study, and these results may represent simple coincidences.

Diffuse abdominal and port site pain caused by the connecting tube in gastric banding.

Laparoscopic adjustable gastric banding is an effective treatment for morbid obesity and has become the most widespread bariatric operation. Complications such as stomach slippage, band erosion or dislocation, pouch dilatation and port complications have been widely reported and discussed. We report two similar cases of women who had had recurrent diffuse abdominal pain and tearing pain at the port site. X-ray examinations showed the small bowel wrapped around the silicone tube, pulling it to the right lower quadrant. Laparoscopic relief and repositioning were performed in both patients.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty.

BACKGROUND: Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB). METHODS: Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting. RESULTS: There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months). CONCLUSIONS: Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

Septic shock in digestive surgery: a retrospective study of 89 patients.

BACKGROUND/AIMS: septic shock is the most severe systemic inflammatory response to infection. Septic shock is associated with organ dysfunction and with major circulatory failure. The aim of this work is to study the impact of septic shock in digestive surgery. This is a retrospective study. METHODOLOGY: Between January 2001 and March 2008, we selected patients hospitalized in the intensive care unit who underwent digestive surgery and who developed septic shock during the same hospitalization were selected: 89 patients were enrolled in this group which included 53 men and 36 women (sex ratio M/W 1.47), and the age average was 71.5 years. They were divided into two subgroups: preoperative septic shock (62/89) and postoperative (27/89). The majority of septic shock occurred in patients who developed an inflammatory disease and an organ perforation. Esophagogastric surgery generates the most postoperative septic shock. RESULTS: The overall mortality was 54%. The most frequent complications were digestive and pulmonary. The germ most frequently encountered is Escherichia coli. The majority of patients received a combination of two or three antibiotics. The empirical antibiotic therapy most frequently administered was a combination of piperacillin/ tazobactam and amikacin. DISCUSSION: The results observed in the present study are, for the most part, in agreement with those found in the literature. However, the question of the most effective antibiotic therapy remains open. CONCLUSION: In digestive surgery, septic shock is pathology with significant mortality (54%). The germ most frequently responsible is Escherichia coli. The most frequently administered empirical antibiotic therapy is a combination of amikacin and piperacillin.

Inclusion of 10% fish oil in mixed medium-chain triacylglycerol-long-chain triacylglycerol emulsions increases plasma triacylglycerol clearance and induces rapid eicosapentaenoic acid (20:5n-3) incorporation into blood cell phospholipids.

BACKGROUND: Lipolysis of a fish oil (FO) emulsion is much slower than that of a soybean [long-chain triacylglycerol (LCT)] emulsion; in contrast, emulsions containing medium-chain triacylglycerol (MCT) are efficiently hydrolyzed by lipoprotein lipase. OBJECTIVES: We questioned whether incorporating 10% FO in a mixed MCT-LCT emulsion would affect plasma triacylglycerol clearance and provide efficient delivery of n-3 polyunsaturated fatty acids to cells and tissues. DESIGN: This prospective crossover study was conducted in 8 normolipidemic subjects with the use of the hypertriglyceridemic clamp model and compared plasma triacylglycerol clearance of a lipid emulsion (5:4:1) made of 50% MCT, 40% LCT, and 10% FO (wt:wt:wt) to a control (5:5) preparation with 50% MCT and 50% LCT. Subjects were daily infused for 5 h, over 4 consecutive days. Fatty acyl pattern was daily measured in plasma phospholipids as well as in leukocyte and platelet phospholipids. RESULTS: Inclusion of 10% FO in mixed emulsion particles enhanced plasma clearance of infused triacylglycerols (18%; P < 0.0001). The faster elimination of the 5:4:1 emulsion appears related to an enhanced uptake of remnant particles rather than to faster intravascular lipolysis. Each infusion of 5:4:1 raised the eicosapentaenoic acid (C20:5n-3) concentration in blood cell phospholipids to reach a 7-fold enrichment in platelets and a >2-fold enrichment in leukocytes after 4 infusions. In contrast, the docosahexaenoic acid (C22:6n-3) concentration remained unchanged in blood cell phospholipids. CONCLUSIONS: Infusion of a mixed emulsion with MCTs, soy LCTs, and FO is associated with efficient plasma triacylglycerol clearance and results in rapid incorporation of C20:5n-3 but not C22:6n-3 in leukocyte and platelet phospholipids.

Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study.

BACKGROUND/AIMS: Appendicitis is one of the most frequent causes of abdominal pain in western countries. It occurs in 6 to 7% of the United States population. Despite laboratory and imagery tests, 15 to 40% appendices removed by laparotomy appear to be normal at histological examination. Thus, others pathologies beside appendicitis may be found in patients with right lower quadrant pain. This had led some to advocate laparoscopy for patients suspected to have acute appendicitis. The aim of this study is to determine the contribution of laparoscopy in patients with right lower quadrant pain and the implications of removing a macroscopic normal appendix. Rates of all pathologies and normal appendices were found at laparoscopy. Morbidity, mortality rates and length of hospital stay linked to laparoscopic appendectomy. DESIGN: Prospective non-randomized study. METHODOLOGY: Between January 1995 and September 2004, 615 patients have been approached by laparoscopy for acute, subacute or chronic abdominal right-lower-quadrant pain in our Department of Digestive and Laparoscopic Surgery. Thirteen patients have not been hold and the study involves 602 patients including 311 men and 291 women with a mean age of 33 years. All removed tools have been analyzed histologically. During the same period, only 5 patients have been approached by laparotomy. RESULTS: Five hundred and thirty patients (88%) had appendicitis, 39 patients (6.5%) had another pathology and no disease was found in 33 patients (5.5%). According to the sex, appendicitis was found in 242 women (83.2%) versus 288 men (92.6%). Thirty-four women (11.7%) versus 5 men (2%) had another pathology. The local morbidity was 4.3%, the general morbidity 1% and the mortality was 0%. The average length of postoperative hospital stay was 4 days (range: 1-27). Oral intake was assumed on average 1.5 days postoperatively (range: 0-13). There were 10 reoperations (1.6%). CONCLUSIONS: Laparoscopy is a reliable technique, safe and reproducible. It is an effective and relatively atraumatic tool to investigate abdominal cavity. This allows an accurate decision-making, which is especially advantageous in young women who have a high rate of non-appendicular pathologies. Laparoscopy also reduces the rate of unnecessary abdominal exploration while realizing a correct diagnosis of others possible pathologies. We therefore advocate laparoscopy in patients with abdominal right-lower-quadrant pain, especially women.

A therapeutic approach to perianal extramammary Paget's disease: topical imiquimod can be useful to prevent or defer surgery.

BACKGROUND: Extramammary Paget's disease (EMPD) is a rare skin disease which can be limited to the epidermis and can sometimes also be associated with underlying carcinomas. At clinical examination, lesions are well-defined eczematous areas and have been described typically in the anogenital region. Surgery is the cornerstone treatment. CASE REPORT: In this report the case of a 66-year-old patient presenting with a long-lasting EMPD of perianal region without deep gastrointestinal neoplasia is described. Because of the extension of the lesion, surgery should have led to abdominoperineal amputation, but the patient rejected this option. Three months of daily application of topical imiquimod was prescribed as an alternative treatment. Biopsy-confirmed complete regression could be observed thereafter, and no recurrence has been noted during a 12-month follow-up. CONCLUSIONS: This successful treatment of a perianal-located EMPD by topical imiquimod warrants further investigations.