Multidisciplinary management of Mirizzi syndrome with cholecystobiliary fistula: the value of minimally invasive endoscopic surgery.

Mirizzi syndrome, a rare complication of gallstones, is defined by obstruction of the main bile duct. This obstruction may worsen and thus result in cholecystobiliary fistula. Surgical management of Mirizzi syndrome is complicated by the presence of inflamed tissue around the hepatic pedicle, making it impossible to distinguish between the main bile duct and the gallbladder. The surgeon's first task is to perform subtotal cholecystotomy (from the fundus of the gallbladder to the neck) without trying to locate the cystic duct. In a second step, the gallstones are extracted and the main bile duct is then repaired. In most cases, a T-tube is used to drain the main bile duct, and abdominal drainage is left in place (in case a bile fistula forms). This study concluded that preoperative drainage of the main bile duct in the treatment of Mirizzi syndrome types II and III is feasible and might help to decrease the postoperative complication rate.

Efficacy of the double-pigtail stent as a conservative treatment for grade B pancreatic fistula after pancreatoduodenectomy with pancreatogastric anastomosis.

BACKGROUND: Despite improvements in surgical techniques and postoperative care, morbidity associated with pancreatoduodenectomy (PD) is still high. Grade B pancreatic fistula (PF) requires a specific combination of radiologically guided external drainage and medical support. This treatment is effective but requires prolonged hospitalization and maintenance of external drainage. The objective of this study was to evaluate the feasibility and efficacy of a double-pigtail stent (DPS) to treat grade B PF after PD with pancreatogastric anastomosis. METHODS: Between January 2008 and October 2011, all patients who presented grade B PF after PD (n = 6) were included in the study. The PF was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula. Endoscopic treatment was standardized with a DPS. The primary efficacy end point was the feasibility and efficacy of DPS placement. Secondary end points included data on the PF, the DPS placement procedure, and long-term outcome. RESULTS: Endoscopic DPS placement was achieved in all patients with no complications. The median time to onset of PF after PD was 14 days. Closure of the external PF was obtained 7 days after the introduction of the DPS. The median time to external drain removal was 7 days after DPS placement, and the median time to oral refeeding was 7 days after DPS placement for all patients. The median time to DPS removal was 60 days. The median length of hospital stay after DPS placement was 10 days. During a median follow-up period of 21 months, there was no recurrence of PF after removal of the DPS. CONCLUSION: Endoscopic treatment of grade B PF after PD appears to be effective and safe and is associated with shorter hospitalization.

Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms.

BACKGROUND: Gastric fistula (GF) is the most serious complication after longitudinal sleeve gastrectomy (LSG), with an incidence ranging from 0 to 5 %. In this context, concomitant upper gastrointestinal bleeding (UGIB) has never been described. Here, we describe our experience of this situation and suggest a procedure for the standardized management of this life-threatening complication. METHODS: We retrospectively analyzed all patients having been treated for post-LSG UGIB in our university medical center between November 2004 and February 2012. Data on GF and UGIB (time to onset, diagnosis and management) were assessed. RESULTS: Forty patients were treated for post-LSG GF in our institution, 18 of whom (45 %) had been referred by tertiary centers. Four patients presented UGIB (10 %): two had undergone primary LSG, one had undergone simultaneous gastric band removal and LSG, and one had undergone repeat LSG. The median time interval between GF and UGIB was 15 days. The four cases of UGIB included three pseudoaneurysms (75 %, with two affecting the left gastric artery and one affecting the upper pole of the splenic artery) and one case of bleeding related to stent-induced gastric ulceration. Computed tomography enabled diagnosis of the pseudoaneurysm in all cases. Two of the four patients (50 %) were treated with selective embolization during arteriography, and two (50 %) were treated surgically with arterial ligation. One of the surgically treated patients died during follow-up. CONCLUSIONS: UGIB after LSG was investigated in the context of a postoperative GF and was found to have been caused by a pseudoaneurysm in 75 % of cases. When looking for a pseudoaneurysm, a primary angiography should be preferred to endoscopy allowing selective arterial embolization in hemodynamically stable patients, whereas surgery should be reserved for treatment failures or hemodynamically instability.

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature.

AIM: Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient's short-term treatment outcome. RESULTS: From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14-88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn's disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3-33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage. CONCLUSION: When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).

Acute cholecystitis: preoperative CT can help the surgeon consider conversion from laparoscopic to open cholecystectomy.

PURPOSE: To establish whether preoperative computed tomographic (CT) findings in patients with acute cholecystitis were associated with conversion from laparoscopic to open cholecystectomy in patients with calculous acute cholecystitis. MATERIALS AND METHODS: The study protocol was approved by the local institutional review board, and written informed consent was provided by all patients at enrollment. From 2008 to 2010, all patients admitted to a university medical center with acute calculous cholecystitis and for whom a preoperative contrast material-enhanced CT study was available were prospectively included. Cholecystectomy was always initiated laparoscopically. To identify risk factors for conversion specifically related to acute cholecystitis, CT studies were analyzed according to predefined criteria by two radiologists who were blinded to the patient's conversion status. Associations between conversion and radiologic findings were assessed by using univariate and multivariate logistic models. RESULTS: A total of 108 patients were analyzed (61 men, 47 women; median age, 58 years; age range, 17-88 years). Conversion occurred in 24 (22%) cases. On preoperative CT images, the absence of gallbladder wall enhancement was associated with the presence of gangrenous acute cholecystitis (sensitivity, 73%). The absence of gallbladder wall enhancement (58% and 40% for conversion and nonconversion, respectively; P = .02) and the presence of a gallstone in the gallbladder infundibulum (78% and 22% for conversion and nonconversion, respectively; P = .04) were associated with acute cholecystitis-related conversion in a multivariate analysis. Interobserver agreement for CT study interpretation was very good (median k value, 0.92; range, 0.76-1.00). CONCLUSION: The absence of gallbladder wall enhancement (associated with the presence of gangrenous acute cholecystitis) and the presence of a gallstone in the gallbladder infundibulum are associated with conversion from laparoscopic to open cholecystectomy.

Atypic large hepatic cyst with persistent elevated CA19.9 serum value: utility of intracystic CA72.4 dosage for a mini-invasive management.

Simple hepatic cysts are very common, but may be difficult to differentiate from a biliary cystadenoma or cystadenocarcinoma. Because the surgical treatment if needed, such as a hepatic fenestration or resection, depends on the diagnosis, the assay of intracystic tumor markers is useful.We report the case of a 67-year-old woman with a large hepatic cyst responsible of pain and inflammation. The combination of imaging findings, serum, and intracystic fluid tumor markers [CA72.4 (carbohydrate hydrogen)] permitted to diagnose a simple hepatic cyst despite an unusual persistent elevated serum CA19.9 level. A laparoscopic cyst fenestration was proposed with an uneventful postoperative course. The pathological findings showed a simple hepatic cyst.In case of hepatic cysts, radiological findings can discriminate between benign and (pre)malignant lesions, but in case of doubtful diagnosis, the serum and intracystic tumor markers can be helpful.The use of serum or intracystic tumor marker allows to choose the correct therapeutic strategy and to use mini-invasive approach when feasible.

Hepatic vascular flow measurements by phase contrast MRI and doppler echography: a comparative and reproducibility study.

PURPOSE: To directly compare and study the variability of parameters related to hepatic blood flow measurements using 3 T phase-contrast magnetic resonance imaging (PC-MRI) and Doppler ultrasound (US). MATERIALS AND METHODS: Nine healthy subjects were studied. Blood velocities and flow rate measurements were performed in the portal vein and the proper hepatic artery. MR studies were performed using a 3 T imager. Gradient-echo fast phase contrast sequences were used with both cardiac and respiratory gating. MR and Doppler flow parameters were extracted and compared. Two methods of calculation were used for Doppler flow rate analysis. RESULTS: Compared to Doppler US, PC-MRI largely underestimated hepatic flow data with lower variability and higher reproducibility. This reproducibility was more pronounced in the portal vein than in the proper hepatic artery associated with poorer velocity correlations. Total hepatic flow values were 1239 +/- 223 mL/min and 1595 +/- 521 mL/min for PC-MRI and Doppler US, respectively. CONCLUSION: Free-breathing PC-MRI can provide reliable noninvasive measurement of hepatic flow parameters compared to Doppler US. The MR technique could help to improve Doppler flow calculations, thereby allowing standardization of protocols, particularly for applications in disease.

Repeat sleeve gastrectomy: optimization of outcomes by modifying the indications and technique.

BACKGROUND: Few series are available concerning repeat sleeve gastrectomy (re-SG), and series have reported contradictory results concerning morbidity rates, with limited data concerning weight loss. OBJECTIVE: Evaluate the short- and medium-term outcomes of re-SG. SETTING: University hospital, France, public practice. METHODS: Between June 2007 and March 2016, all patients undergoing re-SG (n = 46 patients) were included. Re-SG was proposed for patients with insufficient excess weight loss (EWL) (≤50%) or renewed weight gain with excessively high residual gastric volume (>250 mL and/or large gastric pouch). The primary efficacy endpoint was the overall complication rate of re-SG. The secondary efficacy endpoints were operative data, evaluation of weight loss, and correction of co-morbidities, risk factors for gastric leak (GL), by comparing 2 periods (period 1, January 2004-December 2013: blue/green or purple staplers without reinforcement; period 2, after December 2013: black staplers with reinforcement) and comparison of weight loss according to the indication for re-SG. RESULTS: The re-SG group consisted of 46 patients (35 women, mean age: 47.5 yr). The mean body mass index (BMI) before SG was 47.2 kg/m² (35-63.6). The mean time interval between SG and re-SG was 73 months (11-106). The BMI before re-SG was 41.2 kg/m² (29-54.7). Indications for surgery were insufficient weight loss in 25 patients (54.3%) and weight regain in 21 patients (45.7%). A large gastric pouch was visible in 4 patients (8.6%). The mean operating time was 97.6 minutes (45-220). One death (2.1%) and 7 complications (15.2%) were observed. The mean length of hospital stay was 3.6 days (1-30). At last follow-up, mean BMI was 32.1 kg/m2 (20.3-41.3) and mean EWL was 62.3% (18-127.2). When analyzing risk factors for GL, residual gastric volume between 250 and 350 mL was associated with a higher GL rate compared with a volume ≥350 mL, and re-SG performed during period 1 was associated with a higher GL rate than re-SG performed during period 2 (17.4% versus 0%; P = .13). Re-SG performed for weight regain was associated with a significantly higher additional weight loss compared with re-SG performed for insufficient weight loss (mean additional EWL of 45.9%; P = .06). CONCLUSION: Re-SG is feasible, but it requires adaptation of the surgical procedure to decrease complications. Results on weight loss are acceptable, but the best indications for re-SG were a gastric volume>350 mL and in the case of weight regain with the exception of technical failure of the primary SG.

3D C-Arm cone beam CT for targeting the portal vein during TIPS: Initial clinical experience.

PURPOSE: To evaluate the feasibility, safety and usefulness of 3D CBCT with a new injection protocol for targeting the portal vein during TIPS and to determine if it allows decreasing the duration of the procedure. MATERIALS AND METHODS: 3D CBCT was obtained during creation of TIPS in 15 patients (group 2). Portogram quality score was defined using a 5 points scale. The time required to achieve portal puncture was also recorded and results were compared retrospectively in 15 patients who underwent TIPS without 3D CBCT (group 1). RESULTS: The mean time required to puncture the portal vein was shorter when CBCT was used: 15 min versus 24 min (p = 0.156). We recorded 3 failures requiring a second procedure in group 1. There were no complications and no failure in group 2. We recorded 93% of good portography and 80% of good 3D roadmaps. CONCLUSION: 3D CBCT coupled with this new injection protocol provided high rate of good quality portography allowing to bring positional and directional information to improve the needle pass efficiency and to decrease the duration of the procedure.

Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy.

BACKGROUND: Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE: Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING: University hospital, France, public practice. MATERIAL AND METHODS: This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS: A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION: Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.

Eliminating routine upper gastrointestinal contrast studies after sleeve gastrectomy decreases length of stay and hospitalization costs.

BACKGROUND: Recent series have shown the lack of value of routine upper gastrointestinal (UGI) contrast studies on postoperative day 1 or 2 for the detection of gastric leak (GL) after sleeve gastrectomy (SG). Despite this finding, many centers still perform routine early UGI contrast studies after SG. No series has evaluated the impact of eliminating this examination on the overall management of patients undergoing SG. OBJECTIVES: To evaluate the impact of UGI contrast studies on SG management. SETTING: University hospital, France, public practice. METHODS: This study was an ambispective study of a cohort of patients who underwent primary SG between January 2014 and December 2014 (n = 267). Two consecutive groups were compared: patients with routine UGI contrast studies on postoperative day 1 (UGI+group, n = 154) and patients without routine UGI contrast studies (UGI-group, n = 113). The efficacy endpoint of the study was the overall impact of not performing routine UGI contrast studies (length of hospital stay, radiological data, rehospitalization data, and economic assessment). RESULTS: The overall complication rate was 9.3% and no deaths were observed. The GL rate was 1.5%. The mean hospital stay was 1.8 days (2.1 days versus 1.5 days; P = .57). Routine UGI contrast studies did not detect any cases of GL or gastric stenosis. After UGI contrast studies, 56 patients complained of events related to UGI contrast studies (36.4%). A total of 27 computed tomography scans were performed during the first 3 postoperative months (16 in the UGI+group (10.4%) versus 11 in the UGI-group (9.7%); P = .52). Twelve patients were rehospitalized (7 and 5; P = .6). The median length of rehospitalization was 7 days (7 and 5 days; P = .6). Overall cost per patient during SG hospitalization was $5,219 in the UGI+group and $3,678 in the UGI-group (P = .01). CONCLUSION: Eliminating routine UGI contrast studies was associated with decreased length of hospital stay and cost of SG procedures. Larger series are required to show that not performing routine UGI contrast studies has no impact on the postoperative complication rate and the management of these complications.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation.

BACKGROUND: Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES: Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING: University hospital, France, public practice. METHODS: All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS: Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS: Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Feasibility and a Critical Analysis of Exclusion Criteria and Treatment Failure.

BACKGROUND: Day case surgery (DCS) for uncomplicated acute appendicitis (NCAA) is evaluated. The objective of this prospective, single-center, descriptive, nonrandomized, intention-to-treat cohort study was to assess the feasibility of DCS for NCAA with a critical analysis of the reasons for exclusion and treatment failures and a focus on patients discharged to home and admitted for DCS on the following day. STUDY DESIGN: From April 2013 to December 2015, NCAA patients meeting the inclusion criteria were included in the study. The primary end point was the success rate for DCS (length of stay less than 12 hours) in the intention-to-treat population (all NCAA) and in the per-protocol population (no pre- or perioperative exclusion criteria). The secondary end points were morbidity, DCS quality criteria, predictive factors for successful DCS, patient satisfaction, quality of life, and reasons for pre- or perioperative exclusion. A subgroup of patients discharged to home the day before operation was also analyzed. RESULTS: A total of 240 patients were included. The success rate of DCS was 31.5% in the intention-to-treat population and 91.5% in the per-protocol population. The rates of unplanned consultations, hospitalization, and reoperation were 13%, 4%, and 1%, respectively. An analysis of the reasons for DCS exclusion showed that 73% could have been modified. For the 68 patients discharged to home on the day before operation, the DCS success rate was 91%. CONCLUSIONS: Day case surgery is feasible in NCAA. A critical analysis of the reasons for exclusion from DCS showed that it should be possible to dramatically increase the eligible population.

Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure?

BACKGROUND: Causes of failure after laparoscopic sleeve gastrectomy (LSG) are not known but may include a high residual gastric volume (RGV). The aim of this study was to use gastric computed tomography volumetry (GCTV) to investigate the RGV and relate the latter parameter to the outcome of LSG. METHODS: A single-center, prospective study included patients with>24 months of follow-up after LSG. The RGV was measured with a unique GCTV technique. We determined the LSG outcomes according to a variety of criteria and examined potential relationships with the RGV. When the RGV was>250 cc, we offered a repeat LSG (RLSG). RESULTS: Seventy-six patients were included. The mean RGV was 255 cc but differed significantly when comparing "failure" and "success" subgroups, regardless of whether the latter were defined by a percentage of excess weight loss>50 (309 cc versus 225 cc, respectively; P = .0003), a BAROS score>3 (312 cc versus 234 cc; P = .005), the Reinhold criteria (290 cc versus 235 cc; P = .019), or the Biron criteria (308 cc versus 237 cc; P = .008). The RGV threshold (corresponding to the volume above which the probability of failure after LSG is high) was 225 cc. Fifteen RLSGs were performed during the inclusion period. CONCLUSION: A high RGV 34 months after LSG is a risk factor for failure. Knowledge of the RGV can be of value in the management of failure after LSG.

Addition of Molecular Adsorbent Recirculating System (MARS(®)) Albumin Dialysis for the Preoperative Management of Jaundiced Patients with Hilar Cholangiocarcinoma.

The preoperative management of hilar cholangiocarcinoma (HC) with jaundice focuses on decreasing the total serum bilirubin level (SBL) by performing preoperative biliary drainage (PBD). However, it takes about 6-8 weeks for the SBL to fall at a sufficient extent. The objective of this preliminary study was to evaluate the impact of Molecular Adsorbent Recirculating System (MARS(®)) dialysis (in association with PBD) on SBL decrease. From January 2010 to January 2011, we prospectively selected all jaundiced patients admitted to our university hospital for resectable HC and requiring PBD prior to major hepatectomy. The PBD was followed by 3 sessions of MARS dialysis over a period of 72 h. A total of 10 patients with HC were screened and two of them were included (Bismuth-Corlette stage IIIa, gender ratio 1, median age 68 years). The initial SBL in the two patients was 328 and 242 µmol/l, respectively. After three MARS dialysis sessions, the SBL had fallen by 30 and 52%, respectively. After the end of each session, there was a SBL rebound of about 10 µmol/l. The MARS decreased the serum creatinine level, the platelet count and the prothrombin index, but did not modify the serum albumin level. Pruritus disappeared after one and two sessions, respectively. MARS-related morbidity included hypotension (n = 1), tachycardia (n = 1), thrombocytopenia (n = 2) and anaemia (n = 1). When combined with PBD, MARS dialysis appears to accelerate the decrease in SBL and thus may enable earlier surgery. This hypothesis must be validated in a larger study.