Colorectal anastomosis after laparoscopic extended left colectomy: techniques and outcome.

AIM: After extended left colectomy, traditional colorectal anastomosis is often not feasible because of insufficient length of the remaining colon to perform a tension-free anastomosis. Total colectomy with ileorectal anastomosis could be an alternative but this can lead to unsatisfactory quality of life. Trans-mesenteric colorectal anastomosis or inverted right colonic transposition (the so-called Deloyers procedure) are two possible solutions for creating a tension-free colorectal anastomosis after extended left colectomy. Few studies have reported their results of these two techniques and mostly via laparotomy. The aim of this study was to describe the trans-mesenteric colorectal anastomosis and the inverted right colonic transposition procedure via a laparoscopic approach and report the outcome in a series of 13 consecutive patients. METHOD: This was retrospective chart review of laparoscopic colorectal surgery with trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure from January 2015 up to 2019. An accompanying video demonstrates these two techniques. RESULTS: Thirteen consecutive patients underwent either a laparoscopic trans-mesenteric colorectal anastomosis (n = 9) or an inverted right colonic transposition procedure (n = 4). One patient had intra-operative presacral bleeding that was stopped successfully without conversion. Two patients had a postoperative intra-abdominal abscess, but no anastomotic complications were recorded. The median number of bowel movements per day after 6 months was 2 (range 2-5). CONCLUSIONS: Trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure is feasible laparoscopically. The now well-established classical advantages of the laparoscopic approach are associated with good functional outcome after these procedures.

A systematic analysis of controlled clinical trials using the NiTi CAR™ compression ring in colorectal anastomoses.

Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I 2 = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses.

Laparoscopic cholecystectomy decreases extra surgical site morbidity compared with open cholecystectomy: A propensity matched analysis.

BACKGROUND: The ideal way to show treatment effectiveness is through randomized controlled trials the 'gold standard' in evidence-based surgery. Indeed, not all surgical studies can be designed as randomized trials, sometimes for ethical and otherwise, for practical reasons. This article aimed to compare laparoscopic cholecystectomy to open cholecystectomy, according to data from an administrative database, managed by a propensity matched analysis. METHODS: Were included all patients with cholelithiasis admitted in Department B between June 1st, 2008 and December 31st, 2009. In this study, the propensity score represented the probability that a patient would be treated by a procedure based on variables that were known or suspected to influence group assignment and was developed using multivariable logistic regression used here to match patients who had laparoscopic cholecystectomy to a control patient who had open cholecystectomy. The main outcome measure was morbidity. This was expressed as the number of patients with 1 or more complications occurring during the hospital stay or within 30 days following discharge. RESULTS: According to intention to treat, 535 patients had a laparoscopic approach (LC group) and 60 patients had a traditional open approach (OC group) regarding associated cardiac disease, previous laparotomy or when choledocholithiasis was suspected, however intra operative cholangiography showed that there was no choledocolithiasis. According to the propensity score, 28 patients in OC were matched with 58 in LC. Comparison between OC and LC before and after propensity matched analysis showed that OC was associated with a higher rate of Extra Surgical Site morbidity (p= 0.010), a longer median duration of intervention, post-operative stay and overall hospital stay (p= 0. 0001). CONCLUSION: LC should be considered as first-line therapy to treat cholelithiasis surgically even if it becomes necessary to convert to OC because of intra operative findings.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review.

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy.

BACKGROUND: Several studies seem to indicate at least a 2-fold increase in bile duct injuries (BDI) since the inception of laparoscopic cholecystectomy. Moreover, injuries seem to be more proximal, seem to be revealed earlier, are expressed by leaks more often than by strictures, are repaired more frequently by nonspecialists (either during the index operation or soon after), and appear to be more often associated with loss of substance and ischemia. The plethora of prior classifications probably attests to the evolving clinical spectrum, the mounting wealth of ever-increasing diagnostic methods, and an acknowledgment of insufficiencies or lack of data in earlier classification reports. Previous attempts at uniformity remain incomplete. The purpose of this study was to devise a nominal classification, combining all existing classification items, taking into account the changing pattern of BDI. METHODS: Extensive bibliographic research, analysis of each category within the individual classifications combined into one uniform classification. RESULTS: Fifteen classifications were retained. All items were integrated into the European Association for Endoscopic Surgery (EAES) classification, using semantic connotations, grouped in three easy-to-remember categories, A (for anatomy), To (for time of), M (for mechanism): (1) the anatomic characteristics of the injury: NMBD for non-main bile duct or MBD for main bile duct (followed by a number 1-6, corresponding to the anatomic level on the MBD), followed by Oc (for occlusion) or D (division), P (partial) or C (complete), LS (loss of substance), VBI (vasculobiliary injury in general), and whenever known, the vessel; (2) time of detection: Ei (early intraoperative), Ep (early postoperative) or L (late); and (3) mechanism of injury: Me (mechanical) or ED (energy-driven). CONCLUSIONS: The EAES composite, all-inclusive, nominal classification ATOM (anatomic, time of detection, mechanism) should allow combination of all information on BDI, irrespective of the original classification used, and thus facilitate epidemiologic and comparative studies; indicate simple, appropriate preventive measures; and better guide therapeutic indications for iatrogenic BDI occurring during cholecystectomy.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS: A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS: A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS: Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Omentoplasty decreases deep organ space surgical site infection compared with external tube drainage after conservative surgery for hepatic cystic echinococcosis: Meta-analysis with a meta-regression.

INTRODUCTION: The rate of deep organ space/surgical site infection after conservative surgery for hepatic cystic echinococcosis (HCE) ranges from 12% to 26% with a post-operative mortality rate between 0% and 7.5%. This systematic review with meta-analysis aimed to investigate whether omentoplasty (OP) following conservative surgery for HCE leads to decreased rates of morbidity and mortality compared to external tube drainage ETD. PATIENTS AND METHODS: We identified 4540 articles through database searching. After verifying the inclusion and exclusion criteria, we retained eight studies for final analysis: two randomized controlled trials (RCT), one prospective comparative study and five retrospective comparative studies. The main outcome measure was organ space/surgical site (OS/SS) morbidity that was limited to "deep organ space/surgical site infection (Deep OS/SSI) with or without re-operation". RESULTS: The eight studies reported results for deep OS/SSI (6/374 (OP) and 60/403 (ETD), respectively). There were statistically significantly less deep OS/SSI with OP (vs. ETD) OR=0.17 95%CI [0.05, 0.62] (P=0.007). A random-effect meta-regression, including the eight studies, showed an interaction in favor of OP. There were also statistically significant less biliary leakage±fistula and overall morbidity in OP compared to ETD. On the other hand, no statistically significant difference was found concerning deep bleeding, mortality and recurrence between these two groups. CONCLUSION: This meta-analysis with a meta-regression showed that there were statistically significant less deep OS/SSI, biliary leakage±fistula and overall morbidity in OP compared to ETD.

Video assisted thoracoscopy or laparoscopy for enucleation of esophageal leiomyoma: A seven-year single center experience of 75 cases.

OBJECTIVE: Leiomyoma is the most common benign tumor of the esophagus. Extra mucosal enucleation is the standard treatment. Herein we evaluated the feasibility and the outcomes of Minimally Invasive Surgery (MIS) using video-assisted thoracoscopic (VATS) or laparoscopic surgery (VALS) for esophageal leiomyoma enucleation. SUBJECTS AND METHODS: Retrospective study of patients who were treated via VATS or VALS for esophageal leiomyoma enucleation in "Hanoi Viet Duc Hospital" from 2010 to 2017 by the same operator. The operative approach, tumor size, complications and outcomes after surgery were recorded. RESULTS: Seventy-five patients were included. Mean age was 41.9 (range 20-68) years. The male/female sex ratio was 2.1:1. Fifty-five patients had clinical symptoms (73.3%). Tumors were identified in the upper third (12%), middle third (51%), and lower third (37%) of the esophagus. Mean tumor size was 3.7 (range 2-11) cm. VALS enucleation was performed in 23 patients who had leiomyoma located near the cardia (gastroesophageal junction or abdominal esophagus). The remaining 52 patients underwent right (n=42) or left VATS (n=10). Five patients (6.7%) sustained esophageal mucosa injury during dissection, repaired by MIS without late morbidity. A mini-incision (2 mini-laparotomies and 1 thoracotomy) was required in three patients (4%) due to large tumor size or mucosal injury. The mean operative time was 105min in VATS and 174min in VALS. No major perioperative surgical or medical complications were reported. The mean duration of hospital stay was 7.2 (range 5-12) days. CONCLUSIONS: MIS enucleation of esophageal leiomyoma is technically safe and associated with a high therapeutic success rate with low medico-surgical morbidity. VATS could be applied for almost all esophageal leiomyoma tumors; however, the VALS approach was preferred for tumors located near the gastroesophageal junction in order to create an anti-reflux valve after enucleation.

Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010.

The fourth Euro-NOTES workshop took place in September 2010 and focused on enabling intensive scientific dialogue and interaction between participants to discuss the state of the practice and development of natural-orifice transluminal endoscopic surgery (NOTES) in Europe. Five working groups were formed, consisting of participants with varying scientific and medical backgrounds. Each group was assigned to an important topic: the correct strategy for dealing with bacterial contamination and related complications, the question of the ideal entry point and secure closure, interdisciplinary collaboration and indications, robotics and platforms, and matters related to training and education. This review summarizes consensus statements of the working groups to give an overview of what has been achieved so far and what might be relevant for research related to NOTES in the near future.

Liver histology alterations during carbon dioxide pneumoperitoneum in a porcine model.

BACKGROUND: This study aimed to investigate the time course changes in liver histology during carbon dioxide (CO(2)) pneumoperitoneum in a large animal model. METHODS: For this study, 14 white pigs were anesthetized. Liver biopsies performed 0, 1, and 2 h after establishment of CO(2) pneumoperitoneum (at 12 mmHg) and after peritoneal desufflation were sent for histologic examination. Heart rate, mean blood pressure, hepatic artery flow, portal vein flow, and aortic flow were recorded in 10-min increments. Three animals served as control subjects. RESULTS: A statistically significant time course increase was observed in portal inflammation, intralobular inflammation, edema, sinusoidal dilation, sinusoidal hyperemia, centrilobular dilation, centrilobular hyperemia, pericentrilobular ischemia, and focal lytic necrosis scores. There were no significant changes in the control group. This eliminated an effect of anesthesia only. The portal vein flow increased as much as 21%, and the hepatic artery flow decreased as much as 31% of baseline, but these differences did not attain statistical significance. Aortic flow remained relatively stable. CONCLUSION: Histomorphologic changes occurred, indicating liver tissue injury during CO(2) pneumoperitoneum at an intraabdominal pressure of 12 mmHg in the porcine model. Portal vein flow increased, and hepatic artery flow decreased, whereas aortic flow remained relatively unaffected in this experiment.

[Right paraduodenal hernia: a rare cause of intestinal obstruction]. / Hernie paraduodénale droite: une cause rare d'occlusion intestinale.

A 17 year old male was admitted emergently with acute small bowel obstruction. An urgent laparotomy revealed a loop of gangreous ileum herniated through a right paraduodenal hernia. The compromised bowel was resected and a primary anastomosis was performed. This case report allows us to discuss the diagnostic and therapeutic features of this rare condition.

Cluster of differentiation antigen 4 (CD4) endocytosis and adaptor complex binding require activation of the CD4 endocytosis signal by serine phosphorylation.

Cluster of differentiation antigen 4 (CD4), the T lymphocyte antigen receptor component and human immunodeficiency virus coreceptor, is down-modulated when cells are activated by antigen or phorbol esters. During down-modulation CD4 dissociates from p56(lck), undergoes endocytosis through clathrin-coated pits, and is then sorted in early endosomes to late endocytic organelles where it is degraded. Previous studies have suggested that phosphorylation and a dileucine sequence are required for down-modulation. Using transfected HeLa cells, in which CD4 endocytosis can be studied in the absence of p56(lck), we show that the dileucine sequence in the cytoplasmic domain is essential for clathrin-mediated CD4 endocytosis. However, this sequence is only functional as an endocytosis signal when neighboring serine residues are phosphorylated. Phosphoserine is required for rapid endocytosis because CD4 molecules in which the cytoplasmic domain serine residues are substituted with glutamic acid residues are not internalized efficiently. Using surface plasmon resonance, we show that CD4 peptides containing the dileucine sequence bind weakly to clathrin adaptor protein complexes 2 and 1. The affinity of this interaction is increased 350- to 700-fold when the peptides also contain phosphoserine residues.

[Internal abdominal hernias]. / Les hernies internes abdominales.

Internal hernias are complete or partial protrusions of one or several viscera or tissues through an intraperitoneal orifice remaining in the abdominal cavity. Whatever the type or anatomical location may be, the seeming banality and lack of specific symptoms contrasts with the seriousness of complications such as strangulation followed by ischemia or intestinal necrosis. Delay in diagnosis can be shortened if these complications are kept in mind at diagnosis and if the imaging studies are illustrative. At the least doubt, surgery will correct the diagnosis and allow adapted treatment.

[Inguinal hernia. What techniques are available for the surgeon? Theoretical and practical advantages and disadvantages]. / Hernie inguinale. De quelles techniques dispose le chirurgien? Avantages et inconvénients théoriques et pratiques.

There are many hernia repair techniques. Among the most popular, the Shouldice Hospital method was the most widely used in the 1980s. Since then, methods employing prosthetic mesh have taken over, mainly because they are tension-free and therefore seem to lead to less recurrence and cause less postoperative pain. There are several ways of placing the prosthesis, which differ according to the approach used and the superficial or deep situation of the prosthesis. The Lichtenstein technique consists of placing and fixing the prosthesis on the posterior wall of the inguinal canal through an inguinal incision: it is currently the most widely used procedure because of its simplicity. The concept of placing the prosthesis in the subperitoneal space was developed by the French school (Rives, Stoppa). Initially the operation was performed through an inguinal (Rives) or midline (Stoppa) incision. These techniques are no longer adapted to the minimally invasive concept of surgery that prevails today and therefore are less used. The laparoscopic approach places the prosthesis through the trocars instead of through a large incision. The transabdominal approach opens the preperitoneal space through the abdominal cavity, breaching the peritoneum. The extraperitoneal approach consists of direct penetration of the preperitoneal space without violating the peritoneum, as in the Stoppa technique. This is undoubtedly the most elegant laparoscopic technique, but more difficult to perform. Other, simpler methods can also reinforce the posterior wall with a preperitoneal prosthesis. The Polysoft prosthesis, placed through an inguinal incision and inguinal ring, is a modern substitute for the Rives technique, but can be performed under local or locoregional anesthesia. Other types of prostheses, consisting of two, both superficial and deep, components are available: the Prolene Hernia System, for instance, is composed of two circular plates, linked together by a central stalk; there are also several types of plugs. As for anesthesia, there are several evidence-based arguments that indicate that local anesthesia is best.

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].