Alban Zarzavadjian Le Bian

Pancreaticoduodenectomy in the presence of a common hepatic artery originating from the superior mesenteric artery. Technical implications

Pancreaticoduodenectomy (PD) is considered a technically demanding task. Anatomic variations in duodenopancreatic vascularization [celiac axis and the superior mesenteric artery (SMA)] may carry a risk of potentially life-threatening vascular injury. We retrospectively report a modified PD technique performed in two patients presenting with a Common Hepatic Artery (CHA) originating from SMA. The CHA anatomical pattern was known prior surgical procedure. The main modification consisted in cutting pancreas prior dividing the CHA and the gastroduodenal artery. No intraoperative incident was reported. Perioperative outcomes were unremarkable, no vascular injury or hepatic ischemia was reported. Surgeons planning a PD must analyze in depth imaging (CT-scan with 3D angiography) and try to find these patterns. Furthermore, some rare arterial variations may be met and change typical surgical plan. Knowing prior procedure the arterial pattern and keeping in mind expendable or vital vessels allow to accomplish unusual but effective operations.

Acute pancreatitis associated with a pancreatic hydatid cyst: understanding the mechanism by EUS

The liver and lungs are the most frequent localizations f hydatid disease, whereas pancreatic hydatid cysts are are, accounting for less than 1% of cases.1 Acute pancretitis is associated with hydatid parasitosis in 2% of cases in ndemic areas.2 Like liver cysts,3,4 pancreatic hydatid cysts may cause cute pancreatitis.5-9 Whereas parasite migration into he common bile duct is advocated as the etiological echanism to explain acute pancreatitis caused by liver ydatidosis,3,4 it is unclear why some patients affected y pancreatic cysts develop this complication. Two hyotheses are advocated: main pancreatic duct (MPD) ompression caused by the cyst itself6,10,11 and MPD bstruction by hydatid scolices’ migration from the hyatid cyst.5,9,12 Unfortunately, neither of these hypothees has been confirmed at imaging/surgery. Preoperative diagnosis of a pancreatic hydatid cyst may be ifficult. Symptoms are often aspecific: pain,7,12-14 an epigasric mass,12,15 or weight loss.7 At imaging, hydatid cysts ay be mistaken for cystic pancreatic tumors or intrauctal papillary mucinous neoplasia, especially when ingle.11 The onset of acute pancreatitis may prompt rgent pancreas imaging, although, in these cases, a ydatid cyst may be misdiagnosed as a pseudocyst,6,7 hich is a common complication of acute/recurrent ancreatitis.

Liver resection and metabolic disorders: An undescribed mechanism leading to postoperative mortality

AIM To investigate the mechanism leading to perioperative mortality in patients undergoing major liver resection and presenting with metabolic disorders. METHODS The link between Metabolic Syndrome and non-alcoholic fatty liver disease is currently demonstrated. Various metabolic disorders and the Metabolic Syndrome (the association of ≥ 3 metabolic disorders) have been recently described as a risk factor of perioperative mortality in major liver resection. Patients who passed away during perioperative course of major liver resection and presenting with the association of ≥ 2 metabolic disorders without any other known cause of liver disorders were reviewed. RESULTS From January 2001 to May 2010 in a tertiary centre, ten patients presenting with ≥ 2 metabolic disorders without any other known cause of liver disorders died during perioperative course of major liver resection. The same four-consecutive-steps sequence of events occurred, including jaundice. The analysis of this series suggested a rapidly deteriorating congestive liver resulting in an increased portal hypertension leading to hepatorenal syndrome and lately to multiorgan failure (mimicking septic collapse) as the mechanism leading to exitus. The acute portal hypertension is mainly related to the surgical procedure. The chronic portal hypertension is indeterminate. Patients with ≥ 2 metabolic disorders should be considered as potentially presenting with portal hypertension possibly evolving towards hepatorenal syndrome; thus, they should be considered as having a high perioperative risk and should be carefully evaluated before undergoing major liver resection. CONCLUSION As fibrosis was not present or marginal in liver specimens, the real cause of portal hypertension in patients with multiple metabolic disorders should be investigated with further studies.

Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation.

Diaphragmatic rupture is usually an immediate, left-sided complication of high-velocity thoraco-abdominal trauma. Here we present a rare case of delayed, right-sided diaphragmatic rupture and its laparoscopic mesh repair.

Pancreatic resection in the era of laparoscopy: State of Art. A systematic review

BACKGROUND Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature. DATA SOURCE A systematic review of literature was performed regarding laparoscopic pancreatic resection. RESULTS Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported. CONCLUSIONS Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.

Abdominal emergencies after liver transplantation: presentation and surgical management

With an increasing number of liver transplantation (LT) and an enhanced overall survival, LT recipients are more likely to be admitted in emergency departments of general hospitals. Yet, in LT recipients, common but also benign symptoms may reveal a LT‐related (or not) severe condition. To improve management of LT recipients by emergency physicians and general surgeons and potentially improve long‐term outcomes, a clinical review was performed. Overall, CT scan and blood tests should be systematically performed. Immunosuppressive side effects should be excluded using blood tests. LT‐related complications are more likely to occur during the first three months after LT, including mainly bile leak, arterial aneurysm, and pseudoaneurysm. Patients should be referred in emergency to tertiary centers. Non‐LT‐related complications and common abdominal conditions may also be diagnosed in LT recipients. Except in case of diffuse peritonitis or in hemodynamically unstable patients when surgical procedure should be performed, most conditions should be reassessed regarding the immunosuppressive treatment and the adhesive abdominal cavity.

Anastomotic recurrence of colon cancer: Genetic analysis challenges the widely held theories of cancerous cells' intraluminal implantation and metachronous carcinogenesis.

Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy.

Long-term quality of life in gastroesophageal reflux disease after NISSEN fundoplication: does it depend on preoperative responsiveness to proton pump inhibitors?

Purpose: In patients presenting with uncomplicated gastroesophageal reflux disease, nonresponders to medical treatment are not viewed as good candidates for surgical treatment. Considering preoperative response to medical treatment and quality of life, this study aimed to predict outcome following laparoscopic Nissen fundoplication. Materials and Methods: In an academic center, 35 consecutive patients presenting with a gastroesophageal reflux disease requiring a laparoscopic Nissen fundoplication were prospectively included; 16 patients were nonresponders. Using Gastro-Intestinal Quality-of-Life Index score, quality of life was measured preoperatively and postoperatively at each visit (3, 6, 12, 24, 48, and 72 mo) and was compared between responders and nonresponders. Results: No postoperative complication was recorded. Preoperative score was significantly lower in nonresponders (P<0.02) and digestive symptoms and dietary modifications were more important in nonresponders. The score increased in nonresponders after 48 and 72 months, but this improvement was nonsignificantly lower than in responders (P=0.4). In nonresponders, 6 years after the procedure, all symptoms improved. In responders, dysphagia and gastroesophageal reflux symptoms significantly improved. Conclusions: Laparoscopic Nissen fundoplication seems to improve the quality of life in nonresponders without equaling to responders results, especially because of digestive symptoms. Laparoscopic Nissen fundoplication may be considered as a therapeutic option in selected and informed nonresponder patients.

A Rare Case of Appendicitis-Like Syndrome: Prompt Laparoscopic Diagnosis and Management

BACKGROUND Hyperpyrexia associated with right iliac fossa pain and tenderness in a young patient is a common finding in an Emergency Department, and is frequently caused by acute appendicitis or genitourinary affliction. Especially in the case of young males, it is debated whether the patient should undergo immediate surgery or be referred for imagery, and, when surgery is finally planned, whether an open incision of the iliac fossa or a laparoscopic approach is preferred. OBJECTIVE We describe a case of a patient with a twisted, ischemic ileal hemangioma mimicking an acute appendicitis, which was diagnosed and managed laparoscopically. CASE REPORT A 16-year-old boy was admitted to the Emergency Department with a 2-day history of hyperpyrexia, nausea, right iliac fossa pain, and tenderness. Perioperative computed tomography scan showed a 3-cm image that was interpreted as a periappendicular abscess. At laparoscopy, a twisted ischemic mass adherent to the surrounding ileum was located and removed. The patients outcome was uneventful. Pathology showed a benign hemangioma of the ileal mesentery. To our knowledge, this is the first case treated by laparoscopic resection. CONCLUSIONS Rare conditions, such as peduncolated tumors, can mimic common conditions like acute appencitis. Also, due to the aspecificity of symptoms and difficult interpretation of imagery, diagnosis can be difficult to achieve preoperatively and surgery can be challenging. Laparoscopy can allow a diagnosis to be made and the appropriate treatment to be performed without the need for laparotomy. Rare causes of appendicitis-like syndrome represent an argument in favor of a laparoscopic approach, even in the case of young male patients.

Innovation in Surgery: Qualitative Analysis of the Decision-Making Process and Ethical Concerns

Background. Surgical innovation from surgeon’s standpoint has never been scrutinized as it may lead to understand and improve surgical innovation, potentially to refine the IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) recommendations. Methods. A qualitative analysis was designed. A purposive expert sampling was then performed in organ transplant as it was chosen as the ideal model of surgical innovation. Interviews were designed, and main themes included the following: definition of surgical innovation, the decision-making process of surgical innovation, and ethical dilemmas. A semistructured design was designed to analyze the decision-making process, using the Forces Interaction Model. An in-depth design with open-ended questions was chosen to define surgical innovation and ethical dilemmas. Results. Interviews were performed in 2014. Participants were 7 professors of surgery: 3 in liver transplant, 2 in heart transplant, and 2 in face transplant. Saturation was reached. They demonstrated an intuitive understanding of surgical innovation. Using the Forces Interaction Model, decision leading to contemporary innovation results mainly from collegiality, when the surgeon was previously the main factor. The patient is seemingly lesser in the decision. A perfect innovative surgeon was described (with resiliency, legitimacy, and no technical restriction). Ethical conflicts were related to risk assessment and doubts regarding methodology when most participants (4/7) described ethical dilemma as being irrelevant. Conclusions. Innovation in surgery is teamwork. Therefore, it should be performed in specific specialized centers. Those centers should include Ethics and Laws department in order to integrate these concepts to innovative process. This study enables to improve the IDEAL recommendations and is a major asset in surgery.