Gastrostomy placement : when fluoroscopy helps the endoscopist.

BACKGROUND AND STUDY AIMS: Percutaneous endoscopic gastrostomy is the most common therapeutic procedure performed by the digestive endoscopists in the upper gastrointestinal tract. It aims to feed patients presenting denutrition and/or insufficient oral intake. Percutaneous endoscopic gastrostomy feasibility is about 95-100 % although in some cases it is impossible to achieve it, leading to ask for a surgical placement. Even though the feasibility of the surgical approach is excellent its complications are quite higher than percutaneous endoscopic placement, it requires general anesthesia and sometimes these patients could be non elligible for it due to their comorbidities (malnutrition, cardio-vascular diseases etc.). Another alternative technique is the percutaneous radiological gastrostomy but this procedure is rarely available in our country. PATIENTS AND METHODS: We described four cases in patients with previous failure of PEG, in which we used an hybrid approach between radiological and endoscopic techniques, allowing the placement of gastrostomy tube, without general anesthesia. RESULTS: This was successful in all patients and there was no complication related to the procedure. CONCLUSIONS: This technique offers an additionnal opportunity to avoid general anesthesia and surgical complications in patients with unfavorable conditions.

Uncommon cause of retrosternal pain.

We present the case of a 54-year old male patient who was admitted with severe acute epigastric pain, vomiting, and inability to eat since three days before admission. After having excluded cardiac and pulmonary emergencies, an oesogastroduodenoscopy was planned and showed a gastric volvulus. The patient was treated surgically allowing gastric decompression, gastropexy and Nissen intervention. We discuss the case and describe the classification, the diagnosis, the etiologies and therapeutic options in acute and chronic gastric volvulus.

Management of rectal foreign bodies.

The presence of foreign bodies inserted into the rectum is not an uncommon situation. Precise guidelines for the management and extraction of these foreign bodies are not frequently described in the literature. Anal access, whether endoscopic or surgical, varies depending on the type of foreign bodies, their size and morphology, and their location in the lower digestive tract In this report, we describe a case of three rectal foreign bodies that necessitated a mixed endoscopic and surgical approach, and provide a review of the literature.

Management of latrogenic perforation after gastrointestinal endoscopy.

BACKGROUND/AIMS: Gastrointestinal perforation during endoscopy is a rare but severe complication. Most instances occur during colonoscopy. PATIENTS AND METHODS: We retrospectively evaluated the cases of 23 patients with iatrogenic perforation (13 women, 10 men; mean age = 71 years [range, 49-89]). We identified 6 esogastric perforations, 2 endoscopic retrograde cholangiopancreatography (ERCP)-related perforations, and 15 colonic perforations. Demographics, type and aim of endoscopy, mechanism of perforation, delay of treatment, operative procedure, postoperative hospital stay, and mortality rate were analyzed. RESULTS: Three perforations occurred during diagnostic gastroscopy and 3 during therapeutic gastroscopy. ERCP-related perforations occurred during therapeutic procedures. Nine colonic perforations occurred during interventional colonoscopy. ERCP-related perforations always required laparotomy. For esogastric perforations, surgical treatment usually required laparotomy; only two patients (33%) could be managed by laparoscopy. In contrast, colon perforations could be managed by a laparoscopic approach (suturing and drainage or by laparoscopic resection) in 86.6% of cases. Overall mortality was 13% and occurred exclusively after esogastric perforation. CONCLUSION: Most gastrointestinal perforations occurred during therapeutic colonoscopy; these perforations could be treated by laparoscopy in most cases. Esogastric perforations and perforations after ERCP are rare and must be treated on a case-by-case basis; in most cases, laparotomy is required.

A retrospective study of 74 laparoscopic repairs of abdominal incisional hernias.

INTRODUCTION: A laparoscopic procedure is used more and more frequently to treat incisional hernia with the potential benefits of shorter hospitalisation and a decrease in postoperative pain. The purpose of this retrospective study was to analyse the results of the laparoscopic treatment of incisional hernia at our institution and to identify potential risk factors for recurrence. METHODS: The medical data (pre-operative, peri-operative, and postoperative) of patients who received a laparoscopic repair of their incisional hernia between January 2003 and February 2007 were recorded. The follow-up was based on a retrospective analysis of the information found in the patients' medical records. RESULTS: Seventy-four laparoscopic interventions were performed on 71 patients. Polyester implants with an average size of 412.16 cm2 were used to cover the hernia. The mean operative time was 76.8 +/- 55.6 min (range, 20 to 295 min) and the mean duration of post-operative hospitalisation was 3.75 +/- 2.3 days (range, 2 to 12 days). One breach in the small intestine (1.4%) (sutured with 3/0 silk thread) and 1 conversion to laparotomy (1.4%) for a voluminous incisional hernia occurred during surgery. The post-operative morbidity was 8.2%, the rate of long-term complications was 27%, and 13 recurrences (including 3 with complications) were noted (17.6%) during a mean follow-up of 13 months. There was no postoperative mortality. Recurrences were linked to the use of large meshes corresponding to large incisional hernia diameter (p < 0.05). CONCLUSION: Although the morbidity/mortality rates are acceptable, technical improvements must be found to reduce the recurrence rate, in particular for large incisional hernias.

Restoration of digestive continuity after Hartmann's procedure: ASA score is a predictive factor for risk of postoperative complications.

BACKGROUND/AIMS: Re-establishment of colonic continuity (RDC) following Hartmann's procedure is associated with high morbidity (anastomotic leak 4-16%) and mortality (0-4%) rates. The aim of this retrospective study was to evaluate the morbidity of RDC following Hartmann's procedure, and analyse the various factors that may influence the rate of complications. METHODOLOGY: From 1996 to 2008, 158 patients were treated by Hartmann's colectomy. Hartmann's procedure is generally indicated in cases with infection in the abdominal cavity, combined with a distended or non-prepared intestine, or both. Of the 158 patients, 111 (70.3%) underwent a re-establishment of colonic continuity. The mean patient age was 63.4 years (26-91 years) ; the female/male ratio was 1:64. RESULTS: The mean delay between the Hartmann's procedure and the RDC was 169.7 days (21-1095 days) and the mean duration of the hospital stay was 16.7 days (8-57 days). The mortality rate was 0.9% and incidence of anastomotic stricture was 3.6%. The morbidity was 38.7%. The majority of patients presenting complications had an ASA score > II, and most of the patients without complications were classified as ASA < or = II. CONCLUSIONS: The RDC is an intervention performed safely after a 3 to 5-month delay with acceptable morbidity and negligible mortality. The ASA score is a determining factor for the risk of complications (p < 0.05).

Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs.

BACKGROUND: Information concerning short-term results for laparoscopic extraperitoneal hernia repair is available, but long-term results remain poorly documented. The purpose of this non-randomized prospective study was to evaluate recurrence and chronic pain after hernia repair over a period longer than 10 years. MATERIALS AND METHODS: From 1995 to 2004, all patients aged 30 years or more, manifesting with inguinal hernia, were included in our study. Patients aged 20 to 30 years presenting with bilateral hernia, recurrent hernia, or who were heavy workers were also included. Patients who had pelvic irradiation, strangulated hernia, prostatic cancer resection, or a contra-indication to general anaesthesia were excluded. Of 1096 hernia repairs performed, 248 patients were excluded and underwent open repair and 848 patients (77.4%) were included in our prospective study, which corresponded to 1000 laparoscopic hernia repairs. RESULTS: The sex ratio (male : female) was 5:8, and the average age was 56 years. Seven hundred and fifty-three hernias (75.3%) were first repairs, 247 (24.7%) were recurrent hernias, and 161 were bilateral hernias. There were no mortalities. The conversion rate was 1.1%, and the global postoperative morbidity rate was 10.3%. Average follow-up was 39 months in 92.2% of the patients. Hernia recurrence rate was 1.5%. Chronic pain occurred in 2.9%. During this follow-up, 22 contra-lateral hernias appeared in those patients who initially had unilateral hernia repair (3.2%). All of these contra-lateral hernias could be successfully treated using a laparoscopic total extraperitoneal approach. CONCLUSIONS: The long-term results of this study demonstrate that preperitoneal laparoscopic hernia repair is a safe technique with a very low recurrence rate and low prevalence of chronic pain.

Abdominal surgery during pregnancy: a retrospective study of 23 patients.

OBJECTIVE: The aim of this study was to demonstrate that during pregnancy a large variety of non-gynaecological abdominal pathologies can be safely managed with surgery. METHODS: The medical records of twenty-three patients that were pregnant and underwent open or laparoscopic surgery from 1997 to 2007 were reviewed. RESULTS: Twenty-one of the 23 patients have given birth and all but one of the babies were healthy with normal weights, sizes, and APGAR scores. One patient had spontaneous termination of pregnancy one week after the surgical procedure and one patient is out of follow-up. Preterm partus was induced in three patients due to life-threatening conditions for the mother. Each laparoscopy was performed safely without peri-operative complications. CONCLUSION: Open or laparoscopic abdominal surgery poses little or no additional risk for mother or child.

Surgical resection for colon cancer: laparoscopic assisted vs. open colectomy.

BACKGROUND/AIMS: Laparoscopic surgery has been considered for more than a decade for treatment of colorectal cancer. Although its benefits in term of postoperative comfort and parietal preservation are commonly accepted, its efficiency to achieve proper oncologic resection and to prevent tumor recurrence are still debated. The purpose of this retrospective study is to compare results of a minimally invasive laparoscopic approach to these of open surgery for treatment of colorectal cancer. METHODOLOGY: From January 1st 1999 to September 30th 2004, 239 patients underwent colorectal cancer resections; 28 of these patients underwent surgery in an emergent context and were excluded from this study. Accurate follow-up was available for 165 of the 239 patients (69%). For the study, 165 patients were divided into 3 groups: 39 patients underwent a laparoscopically assisted surgery (L group), 120 patients underwent an open colectomy (O group) and 6 patients initially treated with a laparoscopic approach were converted to open colectomy (L/O group) (conversion rate: 8.8%). RESULTS: Sex ratio, mean age and A.S.A. score, as well as patients' past records were similar in the 3 groups. Histological staging was more often stages 3 and 4 in the O group (62.5%) comparing to the L group (41%) (p < 0.5). Mean operating time was slightly longerwhen a laparoscopically assisted approach was used. Overall early mortality rate of this study was 1.8%. Combined local and general overall morbidity rate was 36%. Overall incidence of anastomotic fistulae was 4% and reintervention rate during the early postoperative period was 8%. Postoperative ileus period was often longer for patients of the O group but without statistical significance. Mean duration of hospital stay was similar in the 3 groups. Data concerning surgical resection did not show any difference between groups. None of the patients experienced a metastatic skin settlement. Overall anastomotic stenosis rate was low (2%). The overall locoregional recurrence rate was 12%, without difference between the 3 groups. Forty-two percent of these recurrences were secondarily treated by curative surgery. Similar survival rates as well as oncological spreading frequencies were found. CONCLUSIONS: Results obtained when comparing minimal invasive laparoscopically assisted surgery to open procedure are similar and efficient.

Laparoscopic management of acute small bowel obstruction: a retrospective study on 156 patients.

BACKGROUND/AIMS: Laparoscopic treatment of small bowel obstruction (SBO) has been proposed in selected patients. This study reports an experience and tries to establish indications for laparoscopy. METHODOLOGY: 156 patients underwent laparoscopic or open approach for SBO. Demographics, clinical, biological, radiological and previous surgery were recorded. Obstruction causes, conversion rates and postoperative complications were retrospectively analyzed. RESULTS: Laparoscopic approach was undertaken for 96 patients (61%) and completed in 62 (65%), whereas 34 (35%) required conversion. 60 patients (39%) underwent a direct open approach. Mortality was 10% and morbidity 38%. Postoperative adhesion was the predominant etiology. Conversion rate and type of approach was directly influenced by cause of obstruction and type of previous surgery, but not by number of previous surgeries. Conversions and open approach increase morbidity, mortality, length of stay and return to transit. CONCLUSIONS: Laparoscopy is an elegant tool for management of selected patients with SBO. A single band of obstruction appearing after minor surgery appears to be a good indication for laparoscopy. Nevertheless, conversion rate and morbidity are still high. On the contrary, laparoscopy seems contraindicated for patients with prior history of major abdominal surgery, neoplasia or multiple laparotomies, and a direct open approach is then advocated. Prospective randomized studies comparing laparoscopy and open approach are required to evaluate their respective efficacy and safety in management of SBO.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: a retrospective study of 100 patients.

BACKGROUND: The objective of this retrospective study is to evaluate the use oflaparoscopic cholecystectomy in the treatment of acute cholecystitis in elderly patients, and to identify risk factors for mortality. METHODOLOGY: In this study we have included patients with acute cholecystitis aged 75 years and older. Patients were diagnosed after anatomical and pathological examination of an operative sample. We retrospectively examined 100 patients who underwent cholecystectomy between June 1991 and February 2007. Seventy-nine patients (79%) underwent laparoscopic cholecystectomy, 12 patients (12%) needed a conversion, and 15 patients (15%) were considered unfit to undergo a laparoscopic approach, due to their hemodynamic condition or for other reasons. RESULTS: American Society of Anesthesiologists Scores (ASA), inflammatory syndrome, length of postoperative stay, number of days in the Intensive Care Unit, local complications, and mortality rate are all significantly higher in the 'laparotomy and conversion'. There was not a significant difference in age or general complications between groups. The mortality risk factors include a high level of CRP, biliary peritonitis, emergency, and the necessity of laparotomy. CONCLUSION: Acute cholecystitis is a severe pathology in the elderly associated with a high rate of morbidity and mortality. Due to the mortality risk factors associated with acute cholecystitis, we recommend elective laparoscopic cholecystectomy for aged patients with symptomatic cholelithiasis, due to its low morbidity and mortality rates.

Management of sigmoid diverticulitis: a retrospective study of 268 patients.

BACKGROUND/AIMS: The therapeutic management of acute diverticulitis has evolved over the last years in favour of an initial conservative approach with laparoscopy rather than a primary anastomosis. We studied the management of sigmoid diverticulitis in the Digestive Surgical Unit to assess it in comparison to actual practice. METHODOLOGY: A retrospective review of patients admitted to our unit from January 1998 to June 2006 for diverticular disease. We divided the patients into 3 groups (Urgent Medical Group (UM), Urgent Surgical Group (US) and Scheduled Surgical Group (SS)), and analysed demographic data, the severity and recurrence of diverticulitis, pathology results, length of stay, morbidity and mortality. RESULTS: The mean age was 60.5+/-14.9 years. The overall mortality was 3% (14.5% for the Acute Surgical Group and 0 % for the Elective Surgical Group); overall morbidity 38.4%; the incidence of neoplasm 4.8% in urgent colectomies and 0.9% in scheduled colectomies. CONCLUSIONS: Based on our study and published reviews, we recommend elective colectomy after 2 recurrent episodes of acute diverticulitis, one episode of complicated acute diverticulitis managed conservatively, or if the patient is younger than 50 years-old. This approach would reduce the number of acute operations, which are associated with high morbidity and mortality.

Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients.

BACKGROUND/AIMS: Among spinal cord injury patients, digestive disorders are frequent, chronic, and progressive. Constipation and fecal incontinence, the most common disorders, can severely affect the quality of life of patients with spinal cord injury (SCI). METHODOLOGY: For this retrospective study, we reviewed the medical records of spinal cord injury patients with an intestinal stoma formation and developed a questionnaire to assess patient quality of life. Between January 1, 1996, and December 31, 2005, 10 SCI patients had a stoma formation for constipation, 10 for wound management, and 3 for other causes. Most of these stomas were performed by laparoscopy, with no postoperative mortality. RESULTS: Postoperative morbidity was 26% at the general level, with a rate of 4% at the local level; morbidity reached 56% at longer follow-up. The average period of bowel dysfunction was 7.2 years. The average time per week spent on bowel management (bowel care and defecation time) was 6 h prior to stoma formation, but decreased to 1.5 h afterwards. Half of the questionnaire respondents reported an improved quality of life. CONCLUSIONS: A left colostomy is an effective and safe alternative for anorectal disorders among SCI patients. For a large percentage of patients, it ensures an improved quality of life.

Evolution during half a century of the results of digestive surgery in geriatric patients. A review of the literature, experience at C.H.U. Brugmann and the medium term outlook.

The undertaking of complex and major surgical procedures on frail elderly patients with multiple disorders has always been and still remains a controversial and enigmatic issue. At the same time, in an increasingly ageing society, the need for such procedures will extend and patients will expect a more favourable outcome. Surgery in old age will, therefore, pose an ongoing challenge. With better anaesthetic management, surgical techniques and comprehensive geriatric assessment, the overall results for all surgery have improved remarkably over the last few decades. Stringent pre-operative assessment and rigorous post-operative care have achieved a significant reduction in mortality and morbidity; surgery has become a lot safer.