Aviel Roy-Shapira

Laparoscopic management of acute small bowel obstruction

BackgroundAs minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).MethodsFrom December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.ResultsPostoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.ConclusionsLaparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.

The use of laparoscopy in abdominal emergencies

Background: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. Methods: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). Results: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. Conclusions: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

Endoscopic anterior fundoplication with the Medigus Ultrasonic Surgical Endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial.

BackgroundBoth long-term proton pump inhibitor (PPI) use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). This multi-center, prospective study evaluated the clinical experiences of 69 patients who received an alternative treatment: endoscopic anterior fundoplication with a video- and ultrasound-guided transoral surgical stapler.MethodsPatients with well-categorized GERD were enrolled at six international sites. Efficacy data was compared at baseline and at 6xa0months post-procedure. The primary endpoint was a ≥50xa0% improvement in GERD health-related quality of life (HRQL) score. Secondary endpoints were elimination or ≥50xa0% reduction in dose of PPI medication and reduction of total acid exposure on esophageal pH probe monitoring. A safety evaluation was performed at time 0 and weeks 1, 4, 12, and 6xa0months.Results66 patients completed follow-up. Six months after the procedure, the GERD-HRQL score improved by >50xa0% off PPI in 73xa0% (48/66) of patients (95xa0% CI 60–83xa0%). Forty-two patients (64.6xa0%) were no longer using daily PPI medication. Of the 23 patients who continued to take PPI following the procedure, 13 (56.5xa0%) reported a ≥50xa0% reduction in dose. The mean percent of total time with esophageal pH <4.0 decreased from baseline to 6xa0months (Pxa0<xa00.001). Common adverse events were peri-operative chest discomfort and sore throat. Two severe adverse events requiring intervention occurred in the first 24 subjects, no further esophageal injury or leaks were reported in the remaining 48 enrolled subjects.ConclusionsThe initial 6-month data reported in this study demonstrate safety and efficacy of this endoscopic plication device. Early experience with the device necessitated procedure and device changes to improve safety, with improved results in the later portion of the study. Continued assessment of durability and safety are ongoing in a three-year follow-up study of this patient group.

Early Relaparoscopy for Management of Suspected Postoperative Complications

BackgroundDiagnosis of complications after laparoscopic surgery is difficult and sometimes late.MethodsWe compared the outcome of patients who had early (<48xa0h) relaparoscopy for suspected postoperative complication to those where relaparoscopy was delayed (>48xa0h).ResultsDuring the study period, 7726 patients underwent laparoscopic surgery on our service. Of these, 57 (0.7%) patients had relaparoscopy for suspected complication. The primary operations were elective in 48 patients and emergent in nine. Thirty-seven patients had early, 20 had delayed, secondary operations. The most common indication in the early group was excessive pain (46%) followed by peritoneal signs in 35%. In the delayed group, the most common indication was signs of systemic inflammatory response syndrome in 30% and peritoneal signs in 25%. Relaparoscopy was negative in 16 (28%) patients with no difference between groups. The identified complication was treated laparoscopically in 37(65%) patients, and the rest were converted. The patients in the delayed group had a significantly longer hospital stay (pu2009<u20090.003) and had a higher rate of complications (pu2009<u20090.05). They also had a higher mortality rate (10% vs. 2.7%), but the difference was not statistically significant.ConclusionsA policy of early relaparoscopy in patients with suspected complications enables timely management of identified complications with expedient resolution.

Preclinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gastroesophageal reflux disease

BackgroundLaparoscopic fundoplication provides good reflux control, but side-effects due to the surgical procedure are known. Different endoluminal techniques have been introduced, but all with disappointing results.ObjectiveEvaluation of the feasibility and safety of a new device, which enables a totally endoluminal anterior fundoplication for the treatment of gastroesophageal reflux disease (GERD).MaterialThe device is a modified video gastroscope, which incorporates a surgical stapler (using standard 4.8 B-shaped surgical staples) and an ultrasonic sight. The cartridge is mounted on the shaft and the anvil is at the tip. This enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge.MethodSixteen female swine of mixed breed were used in the study; 12 underwent the endoscopic procedure, and 4 were used a controls to monitor weight gain. The 12 study animals were sacrificed at 2, 4, and 8xa0weeks (4 pigs each time) and visually inspected for complications, healing, and fundoplication. The study was sponsored by MediGus Ltd. and monitored for compliance with good laboratory practice (GLP) regulations by an external company (Econ Inc.), which is GLP certified by the German Federal Government. It was conducted at the animal testing facility of the Charité Virchow Clinic in Berlin.ResultsThe procedure went smoothly in all pigs; median procedure time was 12xa0min (range 9–35xa0min). At sacrifice, the stapled area had healed well, all animals had a satisfactory 180° anterolateral fundoplication, and there were no procedure-related complications.Conclusions Creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. Proof of efficacy must await clinical trials, which are underway.

Trans-oral anterior fundoplication: 5-year follow-up of pilot study

AbstractBackgroundnThis is a report of an IRB-approved pilot study of 13 patients who received a trans-oral anterior partial fundoplication for the treatment of GERD using an ultrasound-guided, flexible surgical stapler. All patients had a history of PPI use, objective evidence of GERD, and no significant comorbidity. Under general anesthesia, a flexible stapler was passed trans-orally into the stomach and placed two or three quintuplets of titanium staples approximately 3xa0cm above the gastroesophageal junction. The stapler contains an ultrasonic range finder, video camera, and illuminator.MethodsPrimary follow-up at 6xa0weeks included pH metrics, GERD-HRQL scores, and PPI use. The protocol allowed annual telephone interviews for the following 5xa0years to collect GERD-HRQL scores, PPI use, satisfaction with the procedure, and willingness to have the procedure again.ResultsAt 6xa0weeks, mean total acid exposure was significantly reduced, and 12/13 patients reduced GERD-HRQL scores by ≥50xa0%. Twelve of 13 patients had stopped daily GERD medications, and nine of 13 had stopped all GERD medications. Each year, 11 of the 13 patients could be reached with all 13 patients having at least 4-year follow-up. Throughout the follow-up period, GERD-HRQL scores were normal (<10) in all but one patient. All patients would agree to do the procedure again. The median satisfaction score is 8 (range 6–10) on a scale of 1–10. None reported dysphagia. At 1xa0year, 54xa0% of respondents (6/11) had eliminated PPI use, with another 27xa0% (3/11) taking a reduced dose. Combining respondents at 4 and 5xa0years to account for all patients, 54xa0% (7/13) had eliminated and another 23xa0% (3/13) reduced PPI use ≥50xa0%.ConclusionAt 5xa0years, the procedure remained effective as demonstrated by the improved quality of life and changes in PPI use. The results remained stable after the second year.

Life Threatening Idiopathic Recurrent Angioedema Responding to Cannabis

We present a case of a 27-year-old man with recurrent episodes of angioedema since he was 19, who responded well to treatment with medical grade cannabis. Initially, he responded to steroids and antihistamines, but several attempts to withdraw treatment resulted in recurrence. In the last few months before prescribing cannabis, the frequency and severity of the attacks worsened and included several presyncope events, associated with scrotal and neck swelling. No predisposing factors were identified, and extensive workup was negative. The patient reported that he was periodically using cannabis socially and that during these periods he was free of attacks. Recent data suggest that cannabis derivatives are involved in the control of mast cell activation. Consequently, we decided to try a course of inhaled cannabis as modulators of immune cell functions. The use of inhaled cannabis resulted in a complete response, and he has been free of symptoms for 2 years. An attempt to withhold the inhaled cannabis led to a recurrent attack within a week, and resuming cannabis maintained the remission, suggesting a cause and effect relationship.

Posttraumatic Acute Cholecystitis Caused by Intra-Gallbladder Hemorrhage in a Patient with Anticoagulant Therapy

AbstractBackground: With aging of the population, the incidence of trauma victims who are on anticoagulant or antiplatelet treatment is increasing. These patients are at risk of serious hemorrhage even after relatively minor trauma. They can also show bleeding in unusual locations with unusual consequences.nn Case Study: We report a previously undocumented bleeding complication in an anticoagulated patient, namely a delayed presentation of acute cholecystitis, where cystic duct obstruction was due to bleeding into the gallbladder after blunt abdominal trauma.

Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention

Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5–4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis.

Management of gastrosplenic fistula in the emergency setting - A case report and review of the literature

Introduction A gastrosplenic fistula (GSF) is a very rare complication that arises mainly from a splenic or gastric large cell lymphoma. The proximity of the gastric fundus to the enlarged fragile spleen may facilitate the fistulisation. This complication can lead to massive bleeding, which, though uncommon, may be lethal. We present a patient with massive upper gastrointestinal bleeding secondary to a GSF. Case presentation We present a 48-year-old man with a refractory diffuse large B-cell lymphoma who was admitted to our hospital due to hematemesis. On arrival, he was in hemorrhagic shock, and was taken directly to the intensive care unit. The source of bleeding could not be identified on gastroscopy, the patient remained hemodynamically unstable and a laparotomy was performed. A fistula between a branch of the splenic artery and the stomach was identified. The stomach appeared to be involved in the malignant process. After subtotal gastrectomy and splenectomy, the bleeding was controlled. After stabilization, the patient was admitted to the intensive care unit, and 24 hours later was discharged in stable condition. Discussion We describe a fistula between a branch of the splenic artery and the stomach, which was accompanied by massive bleeding. An emergency laparotomy saved the patients life. Conclusion The purpose of this report is to alert physicians that surgical intervention can be lifesaving in this rare malignant condition. A literature review focusing on the presenting symptoms and the epidemiology of GSF is presented.