Lemmel's Syndrome: A Report of Two Cases at the Hospital General Dr. Manuel Gea Gonzalez in Mexico City.

The term ¨Lemmel Syndrome¨ is used to describe obstructive jaundice that is secondary to periampullary duodenal diverticula (PDD) in the absence of choledocholithiasis or neoplasia. PDD is found in 22% of the population. According to our knowledge, only two cases of Lemmel syndrome have been reported in Mexico. We report two cases of Lemmel syndrome in a 94-year-old and a 71-year-old woman who presented with clinical jaundice. One of the cases was treated with endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy, balloon sweep, and the placement of a plastic biliary prosthesis, and the other with laparoscopic biliodigestive bypass and a manual lateral end choledocho-duodenal anastomosis. Our objective is to expand the information on this rare pathology to take it into account as a diagnostic possibility of jaundice and to define appropriate management, which can be endoscopic or surgical.

Three-dimensional vs two-dimensional laparoscopic gastric bypass for manual gastrojejunal anastomosis: A prospective and randomized trial.

OBJECTIVE: The objective of this study was to compare the total procedure time and task-specific execution time in gastric bypass using a three-dimensional (3D) versus two-dimensional (2D) imaging system. MATERIALS AND METHODS: This study was a prospective and randomized clinical trial. Forty obese patients were randomized into two groups: gastric bypass with 3D imaging system or with conventional 2D system. The primary endpoint was operative time during manual gastrojejunal anastomosis. Data collection was carried out on demographics, comorbidities, operative time in three stages, and complications. The same surgeon performed all surgeries. Two patients were excluded because technical issues were encountered for viewing their videos during the trial. RESULTS: A total of 20 patients in the Laparoscopic Gastric Bypass (LGB) 3D group and 18 in the LGB 2D group were analyzed. There were no significant differences in the pre-operative data. The average procedure time was 16.5 min lower in the 3D group versus the 2D group. Execution time for specific tasks was not statistically significant, except for the gastrojejunal anastomosis, which is routinely performed as a manual anastomosis in our surgery group. There was no complication intra- or post-operative. CONCLUSIONS: The use of a 3D imaging system for laparoscopic gastric bypass was associated with a shorter total operative time, especially for the hand-sewn gastrojejunal anastomosis, compared with the 2D imaging system. OBJETIVO: Comparar el tiempo total del procedimiento y de tareas específicas en bypass gástrico laparoscópico (BGL) utilizando sistemas de imagen 3D y 2D.

MÉTODO: Estudio prospectivo, aleatorizado, con 40 pacientes obesos divididos en dos grupos: BGL 2D o 3D. El objetivo principal fue medir el tiempo al realizar la gastroyeyunoanastomosis manual. La recolección de datos incluyó comorbilidad, demografía, tiempo operatorio en tres fases (formación de reservorio, gastroyeyunoanastomosis y yeyunoyeyunoanastomosis) y complicaciones posoperatorias. El mismo cirujano realizó los procedimientos. Se excluyeron dos pacientes por incapacidad para abrir el video. RESULTADOS: Se analizaron 20 pacientes en el grupo 3D y 18 en el grupo 2D. No hubo diferencias significativas en los datos preoperatorios. El tiempo promedio del procedimiento fue menor en el grupo 3D que en el 2D en 16,5 minutos. El tiempo de ejecución para realizar tareas solo fue significativo al realizar la gastroyeyunoanastomosis. No hubo ninguna complicación intraoperatoria ni posoperatoria. CONCLUSIONES: El uso de un sistema de imagen 3D se asoció con un menor tiempo quirúrgico total, en especial para la gastroyeyunoanastomosis manual, en comparación con el sistema de imagen 2D.

A Four-step Technique for Effluent Diversion of Enteroatmospheric Fistulas.

BACKGROUND: Isolation of the enteroatmospheric fistula (EAF) opening and prevention of contamination of the rest of the wound by effluent are important factors in the management of EAF. OBJECTIVE: The aim of this study is to describe an easily reproducible technique for effluent control in patients with EAF. MATERIALS AND METHODS: A retrospective analysis was conducted on all patients who underwent the present technique between 2013 and 2015. The surgical technique included condom-EAF anastomosis, fistula ring creation, negative pressure wound therapy (NPWT), and adaptation of an ostomy bag. RESULTS: A total of 7 patients with a Björck grade 4 abdomen were included. All fistulas were located in the small bowel with a median number of 2 EAFs (range, 2-3) in each patient, and the majority had moderate output volume. The mean number of NPWT changes was 10 (range, 5-18), the mean time of NPWT use was 75.7 days (range, 60-120 days), and the mean length of stay was 108.2 days (range, 103-160 days). The mean time of ostomy formation to restitution of bowel continuity was 14.3 months (range, 8-20 months). Open anterior component separation was employed in all cases for closure of the abdominal wall. No mortality, ventral herniation, or refistulization was registered in the study. The mean follow-up time was 8.5 months (range, 6-12 months). CONCLUSIONS: This is an easily reproducible and safe technique for effluent control in patients with Björk grade 4 abdomen with established EAF.

Laparoscopic cholecystectomy after endoscopic treatment of choledocholithiasis: a retrospective comparative study.

Patients with combined choledocholithiasis and cholecystitis require treatment of both diseases. The aim of our study was to analyze perioperative results of next-day (< 24 h) vs. early (> 24 h) laparoscopic cholecystectomy (LC) after endoscopic clearance of common bile duct stones. We conducted a retrospective study of patients that underwent LC after endoscopic treatment of choledocholithiasis, with combined diagnoses of common bile duct stones (with or without acute cholangitis) and gallbladder stones (with acute or chronic cholecystitis). From January 2014 to May 2017, 87 patients underwent LC after endoscopic sphincterotomy: 40 patients within 24 h (NDLC) and 47 after 24 h (ELC). Regarding pre-ERCP diagnosis, 29 (72.5%) of patients in the NDLC group and 33 (70.2%) of patients in the ELC group had high-risk of choledocholithiasis (p = 0.814), acute cholecystitis (32.5 vs. 25.5%, p = 0.474) and acute cholangitis (17.5 vs. 17%, p = 0.953). The median time from ERCP to LC was 23 h (IQR 22-23) in the NDLC group and 72 h (IQR 48-80) in the ELC group (p < 0.001). No statistically significant differences were found in regard to operative time, estimated blood loss, overall morbidity and rate of conversion to open surgery. Patients in the NDLC group had a shorter total length of stay (2 vs. 4 days, p < 0.001). Laparoscopic cholecystectomy performed within the first 24 h after endoscopic treatment of choledocholithiasis is safe and feasible, without increased postoperative morbidity and associated with reduction of the hospital length of stay.

A New Era of Bile Duct Repair: Robotic-Assisted Versus Laparoscopic Hepaticojejunostomy.

BACKGROUND: Despite scientific evidence of the safety, efficacy, and in some cases superiority of minimally invasive surgery in hepato-pancreato-biliary procedures, there are scarce publications about bile duct repairs. The aim of this study was to compare the outcomes of robotic-assisted surgery versus laparoscopic surgery on bile duct repair in patients with post-cholecystectomy bile duct injury. METHODS: This is a retrospective comparative study of our prospectively collected database of patients with bile duct injury who underwent robotic or laparoscopic hepaticojejunostomy. RESULTS: Seventy-five bile duct repairs (40 by laparoscopic and 35 by robotic-assisted surgery) were treated from 2012 to 2018. Injury types were as follows: E1 (7.5% vs. 14.3%), E2 (22.5% vs. 14.3%), E3 (40% vs. 42.9%), E4 (22.5% vs. 28.6%), and E5 (7.5% vs. 0), for laparoscopic hepaticojejunostomy (LHJ) and robotic-assisted hepaticojejunostomy (RHJ) respectively. The overall morbidity rate was similar (LHJ 27.5% vs. RHJ 22.8%, P = 0.644), during an overall median follow-up of 28 (14-50) months. In the LHJ group, the actuarial primary patency rate was 92.5% during a median follow-up of 49 (43.2-56.8) months. While in the RHJ group, the actuarial primary patency rate was 100%, during a median follow-up of 16 (12-22) months. The overall primary patency rate was 96% (LHJ 92.5% vs. RHJ 100%, log-rank P = 0.617). CONCLUSION: Our results showed that the robotic approach is similar to the laparoscopic regarding safety and efficacy in attaining primary patency for bile duct repair.

Robotic-assisted Roux-en-Y hepaticojejunostomy after bile duct injury.

BACKGROUND: The Da Vinci Robotic Surgical System has positioned itself as a tool that improves the ergonomics of the surgeon, facilitating dissection in confined spaces and enhancing the surgeon's skills. The technical aspects for successful bile duct repair are well-vascularized ducts, tension-free anastomosis, and complete drainage of hepatic segments, and all are achievable with robotic-assisted approach. METHODS: This was a retrospective study of our prospectively collected database of patients with iatrogenic bile duct injury who underwent robotic-assisted Roux-en-Y hepaticojejunostomy. Pre-, intra-, and short-term postoperative data were analyzed. RESULTS: A total of 30 consecutive patients were included. The median age was 46.5 years and 76.7% were female. Neo-confluences with section of hepatic segment IV were performed in 7 patients (those classified as Strasberg E4). In the remaining 23, a Hepp-Couinaud anastomosis was built. There were no intraoperative complications, the median estimated blood loss was 100 mL, and the median operative time was 245 min. No conversion was needed. The median length of stay was 6 days and the median length of follow-up was 8 months. The overall morbidity rate was 23.3%. Two patients presented hepaticojejunostomy leak. No mortality was registered. CONCLUSION: Robotic surgery is feasible and can be safely performed, with acceptable short-term results, in bile duct injury repair providing the advantages of minimally invasive surgery. Further studies with larger number of cases and longer follow-up are needed to establish the role of robotic assisted approaches in the reconstruction of BDI.

Minimally invasive approach (robotic and laparoscopic) to biliary-enteric fistula secondary to cholecystectomy bile duct injury.

Spontaneous biliary-enteric fistula after laparoscopic cholecystectomy bile duct injury is an extremely rare entity. Y-en-Roux hepaticojejunostomy has been demonstrated to be an effective surgical technique to repair iatrogenic bile duct injuries. Seven consecutive patients underwent robotic-assisted (n = 5) and laparoscopic (n = 2) biliary-enteric fistula resection and bile duct repair at our hospital from January 2012 to May 2017. We reported our technique and described post-procedural outcomes. The mean age was 52.4 years, mostly females (n = 5). The mean operative time was 240 min for laparoscopic cases and 322 min for robotic surgery, and the mean estimated blood loss was 300 mL for laparoscopic and 204 mL for robotic cases. In both groups, oral feeding was resumed between day 2 or 3 and hospital length of stay was 4-8 days. Immediate postoperative outcomes were uneventful in all patients. With a median of 9 months of follow-up (3-52 months), no patients developed anastomosis-related complications. We observed in this series an adequate identification and dissection of the fistulous biliary-enteric tract, a safe closure of the fistulous orifice in the gastrointestinal tract and a successful bile duct repair, providing the benefits of minimally invasive surgery.

C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy in Patients with Acute Calculous Cholecystitis: A Multivariate Analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the treatment of choice for mild and moderate acute cholecystitis. The aim of this study was to analyze the utility of C-reactive protein (CRP) as a predictor of difficult laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. MATERIALS AND METHODS: We conducted a prospective study. All patients included were treated with emergency LC. Patients were analyzed as DLC and nondifficult laparoscopic cholecystectomy (NDLC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables were statistically significant in predicting a DLC. Two different models were analyzed. RESULTS: A total of 66 patients were included (37.9% DLC versus 62.1% NDLC). Ideal cutoff point for CRP was calculated as 11 mg/dL, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for predicting DLC being 92% (95% CI 75-97.8), 82.9% (95% CI 68.7-91.5), 76.7%, and 94.4%, respectively. In the first model multivariate analysis, age >45 years, male sex, gallbladder wall thickness ≥5 mm, and pericholecystic fluid collection were significant predictors of DLC, with an area under the curve (AUC) of 0.89. In the second model multivariate analysis, only CRP ≥11 (odds ratio, OR = 17.9, P = .013) was significant predictor of presenting DLC, with an AUC of 0.96. CONCLUSIONS: Preoperative CRP with values ≥11 mg/dL was associated with the highest odds (OR = 17.9) of presenting DLC in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population with acute calculous cholecystitis.

Síndrome abdominal agudo por trombosis venosa mesentérica y portal. Informe de un caso y revisión del tema / Acute abdominal pain due to portal and mesenteric venous thrombosis. Case report and topic review

Resumen Introducción: La isquemia mesenterica se clasifica, según su etiología, en: embolismo arterial, trombosis arterial patologías no oclusivas y trombosis venosa mesenterica (TVM), que es la causa de laparotomía exploradora en 1 de cada 1000 pacientes con síndrome abdominal agudo. Es más común entre la quinta y la sexta décadas de la vida. Caso clínico: Masculino de 31 años de edad, afroamericano, sin antecedentes médicos. Con dolor abdominal generalizado de 72 horas de evolución. Con signos positivos de irritación peritoneal. La tomografia con defecto de llenado en vena mesenterica superior, vena esplénica y vena porta. Se realizó laparotomía de urgencia que requirió resección intestinal por necrosis de yeyuno. Se realizaron estudios hematológicos, oncológicos y autoinmunes sin hallazgos positivos. Discusión: Latrombosis venosa por lo regulares secundaria a síndromes de hipercoagulabilidad o neoplasias. La presentación clínica es inespecífica. En cuanto a los estudios de imagen que se pueden solicitar: ultrasonido, tomografia o resonancia magnética y angiografia percutánea con catéter. Las principales opciones terapéuticas para la isquemia mesenterica aguda son: el tratamiento endovascular, la revascularización quirúrgica, la anticoagulación y laparotomía exploradora en caso de complicaciones viscerales. Conclusión: Aunque es una patología poco frecuente, el médico debe estar familiarizado con su fisiopatologia, diagnóstico y las principales alternativas terapéuticas que hay para ella.

Abstract Background: Four common causes of mesenteric ischemia identified: arterial embolism, arterial thrombosis, non-occlusive pathologies and mesenteric venous thrombosis (MVT). MVT is an uncommon cause of acute abdominal pain and accounts for 1 in 1000 emergency surgical laparotomies for acute abdomen. Case Presentation: A 31 year old male, previously healthy, with 72 hour history of generalized abdominal pain on examination with signs of peritonitis. He underwent a computed tomographic (CT) scan of the abdomen and pelvis, which demonstrated thrombosis of the portal, splenic and superior mesenteric veins. A laparotomy was performed, we found jejunal necrosis and a bowel resection was required. Hematologic, oncologic and autoimmune studies were performed and all of them were negative. Discussion: Venous thrombosis is almost always secondary to other pathologies. The principle ones are: hypercoagulability and occult neoplasia. The clinical presentation is non-specific. To make a diagnosis one can use: a Doppler ultrasound, a CT angiography, a magnetic resonance and a catheter angiography. The available treatments for acute mesenteric ischemia are: endovascular procedures, bypass surgery, anticoagulation and a laparotomy to treat visceral complications. Conclusion: Even if this is an uncommon pathology, physicians need to be aware of pathophysiology, diagnosis and treatment of acute mesenteric ischemia.

Laparoscopic hepaticojejunostomy after bile duct injury.

BACKGROUND: The incidence of bile duct injuries (BDI) after cholecystectomy, which is a life-threatening condition that has several medical and legal implications, currently stands at about 0.6%. The aim of this study is to describe our experience as the first center to use a laparoscopic approach for BDI repair. METHODS: A prospective study between June 2012 and September 2014 was developed. Twenty-nine consecutive patients with BDI secondary to cholecystectomy were included. Demographics, comorbidities, presenting symptoms, details of index surgery, type of lesion, preoperative and postoperative diagnostic work-up, and therapeutic interventions were registered. Videos and details of laparoscopic hepaticojejunostomy (LHJ) were recorded. Injuries were staged using Strasberg classification. A side-to-side anastomosis with Roux-en-Y reconstruction was always used. In patients with E4 and some E3 injuries, a segment 4b or 5 section was done to build a wide anastomosis. In E4 injuries, a neo-confluence was performed. Complications, mortality, and long-term evolution were recorded. RESULTS: Twenty-nine patients with BDI were operated. Women represented 82.7% of the cases. The median age was 42 years (range 21-74). Injuries at or above the confluence occurred in 62%, and primary repair at our institution was performed at 93.1% of the cases. Eight neo-confluences were performed in all E4 injuries (27.5%). The median operative time was 240 min (range 120-585) and bleeding 200 mL (range 50-1100). Oral intake was started in the first 48 h. Bile leak occurred in 5 cases (17.2%). Two patients required re-intervention (6.8%). No mortality was recorded. The maximum follow-up was 36 months (range 2-36). One patient with E4 injury developed a hepaticojejunostomy (HJ) stenosis after 15 months. This was solved with endoscopic dilatation. CONCLUSIONS: The benefits of minimally invasive approaches in BDI seem to be feasible and safe, even when this is a complex and catastrophic scenario.

[Transgastric laparo-endoscopic approach for difficult access lesions. Experimental mode]. / Abordaje laparo-endoscópico transgástrico para lesiones de difícil acceso. Modelo experimental.

BACKGROUND: Gastric neoplasms can be treated by laparoscopy in a safe and efficient way. Some lesions are not accessible to laparoscopic surgery due to their location. A transgastric approach is proposed as an alternative. OBJECTIVE: Show the results with the application of an endoscopic laparotomy in an animal model that maintains functional anatomy, to resect the posterior gastric neoplasms of the stomach wall, close to the cardia and pre-pyloric region. METHODS: The laparo-endoscopic technique for resection of gastric neoplasms located in the posterior wall was developed in twelve pigs at the Hospital General Gea González from May to December 2011. TECHNIQUE: An endoscopy was performed to establish the site of insertion of intragastric trocars. Three gastrotomies were made in the anterior wall; under endoscopic and laparoscopic vision the trocars were inserted. The stomach was insufflated with CO2. The lesion was resected maintaining a 20 mm circumferencial margin. The gastrotomies were sutured. The statistic analysis was made with t Student and exact Fisher tests. RESULTS: One-hundred percent of resections were achieved in an average time of 102.33 minutes (± 4.50). Two complications and no transoperatory deceases occurred. DISCUSSION: The technique we describe allows an appropriate approach to gastric lesions located in the posterior wall, those near to the esophagogastric juntion and the prepiloric region, due to the excellent exposure managed by working inside the stomach with a laparoscopic vision and the two intragastric movile ports. CONCLUSIONS: The laparoscopic transgastric approach is feasible and safe for the resection of gastric neoplasms located in the posterior wall, those close to the esophago-gastric junction, and the pre-pyloric region.

Antecedentes: las neoplasias gástricas pueden tratarse de forma segura y eficaz mediante laparoscopia. Debido a su localización algunas lesiones son inaccesibles mediante cirugía laparoscópica, como alternativa se propone el abordaje transgástrico. Objetivo: exponer los resultados con la aplicación de una técnica laparo-endoscópica en un modelo animal que mantenga funcional la anatomía, para resecar neoplasias gástricas de la pared posterior del estómago, próximas al cardias y a la región pre-pilórica. Material y métodos: el estudio se efectuó entre los meses de mayo a diciembre de 2011en el Hospital General Gea González y consistió en experimentar en 12 cerdos la técnica laparo-endoscópica para resección de neoplasias gástricas de la pared posterior. La inserción de los trócares intragástricos se realizó mediante endoscopia. Se efectuaron tres gastrotomías en la pared anterior y con visión endoscópica los trócares se introdujeron con el auxilio laparoscópico. El estómago se insufló con CO2. La lesión se resecó manteniendo un margen circunferencial de 20 mm, se suturaron las gastrotomías, se utilizaron la prueba de t de Student y la prueba exacta de Fisher para el análisis estadístico. Resultados: todas las resecciones fueron exitosas y se efectuaron en un tiempo promedio de 102.33 minutos (± 4.50), hubo dos complicaciones y ninguna defunción transoperatoria. Conclusiones: el abordaje laparoscópico transgástrico es factible y seguro para resecar neoplasias de la pared posterior del estómago, próximas a la unión esófago-gástrica y área prepilórica.

[Laparoscopic choledochoduodenostomy as an optional treatment choledocholithiasis]. / Coledocoduodenoanastomosis laparoscópica como opción terapéutica en coledocolitiasis compleja.

INTRODUCTION: Choledochoduodenostomy is indicated for unsolved choledocholithiasis and biliary malignant or benign stenosis. This surgical procedure has been feared for its potential complications. This article shows our initial experience with this laparo-endoscopic approach. METHODS: We performed laparoscopic choledochoduodenoastomy in seven elderly patients with recurrent or unsolved choledocholithiasis. Additionally, laparo-endoscopic extraction of gallstones was performed in necessary cases. We gathered and analyzed the demographic data, diagnostic proofs and follow up of the patients. RESULTS: Average age of patients was 71 years, with 57.1% of women in our population. Main omorbidities of our patients included obesity in 71.4%, diabetes mellitus type 2 in 57.4%, and arterial hypertension in 42.85%. Patients had in average 2.7 previous episodes of choledocholithiasis and/or cholangitis and the average diameter of the removed stones was 22.6 mm. Average follow-up was 155 days (range 28 to 420). DISCUSSION: Laparoscopic chooledochoduodenostomy has proved to be safe, effective and be superior to open surgery, as long as an appropriate selection of patients is performed and surgeons with experience on laparoscopic techniques are available. All these factors reduce the long-term complications with which this surgical procedure has been related. CONCLUSIONS: Laparoscopic choledochoduodenostomy is an option for the definitive surgical treatment of "difficult choledocholithiasis" in elderly patients with multiple comorbidities; it also offers the advantages of the minimally invasive approaches.