Benoit Navez

Laparoscopy in the acute abdomen.

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Does the site of platelet sequestration predict the response to splenectomy in adult patients with immune thrombocytopenic purpura

Abstract Splenectomy is the only potentially curative treatment for chronic immune thrombocytopenic purpura (ITP) in adults. However, one-third of the patients relapse without predictive factors identified. We evaluate the predictive value of the site of platelet sequestration on the response to splenectomy in patients with ITP. Eighty-two consecutive patients with ITP treated by splenectomy between 1992 and 2013 were retrospectively reviewed. Platelet sequestration site was studied by 111Indium-oxinate-labeled platelets in 93% of patients. Response to splenectomy was defined at last follow-up as: complete response (CR) for platelet count (PC) ≥100 × 109/L, response (R) for PC≥30 × 109/L and <100 × 109/L with absence of bleeding, no response (NR) for PC<30 × 103/L or significant bleeding. Laparoscopic splenectomy was performed in 81 patients (conversion rate of 16%), and open approach in one patient. Median follow-up was 57 months (range, 1–235). Platelet sequestration study was performed in 93% of patients: 50 patients (61%) exhibited splenic sequestration, 9 (11%) hepatic sequestration and 14 patients (17%) mixed sequestration. CR was obtained in 72% of patients, R in 25% and NR in 4% (two with splenic sequestration, one with hepatic sequestration). Preoperative PC, age at diagnosis, hepatic sequestration and male gender were significant for predicting CR in univariate analysis, but only age (HR = 1.025 by one-year increase, 95% CI [1.004–1.047], p = 0.020) and pre-operative PC (HR = 0.112 for > 100 versus <=100, 95% CI [0.025–0.493], p = 0.004) were significant predictors of recurrence-free survival in multivariate analysis. Response to splenectomy was independent of the site of platelet sequestration in patients with ITP. Pre-operative platelet sequestration study in these patients cannot be recommended.

Total Laparoscopic Treatment of an Adult Gastric Duplication Cyst with Intrapancreatic Extension.

Patient: Female, 28 Final Diagnosis: Gastric duplication Symptoms: — Medication: — Clinical Procedure: Resection of the duplication Specialty: Surgery Objective: Rare disease Background: Gastric duplication is a rare malformation mostly diagnosed during childhood. Symptoms in adults are atypical, rare, or may be completely absent. The diagnosis is suggested after a morphological and histological assessment. The treatment is a complete surgical resection. Case Report: We report on a case of a 28-year-old woman referred to our unit for a surgical assessment of a gastric duplication of the antropyloric area associated with paraduodenal and pancreatic extensions, diagnosed by several image tools and histological confirmation. She had undergone a total laparoscopic resection of the duplication without violation of the gastric lumen or any other splanchnic injury. The postoperative course was uneventful and the patient was discharged on postoperative day seven without any complains. Conclusions: The present report illustrates that complete resection of a distal gastric duplication is feasible by a laparoscopic minimal invasive procedure and therefore is considered to be a safe therapeutic modality. Our case is the first distal gastric duplication cyst with pancreatic and paraduodenal extension reported in the literature completely resected by laparoscopic approach.

Roux-En-Y Fistulojejunostomy: a New Therapeutic Option for Complicated Post-Sleeve Gastric Fistulas, Video-Report

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG.MethodsBetween January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG.ResultsIn this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients.ConclusionsRYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Management of a jejunal obstruction caused by the migration of a laparoscopic adjustable gastric banding. A case report

Highlights • During the nineties, laparoscopic adjustable gastric banding (LAGB) was considered the safest and most reversible procedure in bariatric surgery.• Long-term follow-up of gastric banding implantation shows an overall complication rate of 34%, with a rate of intragastric migration (IGM) of 0.3–11% according to series.• Jejunal obstruction caused by a band migration can only be treated properly by surgery.• Considering also better weight loss and comorbidities improvement with gastric bypass and sleeve gastrectomy than with gastric banding, this type of late complication invite to question the use of LAGB in current bariatric practice

Response to the Comment on: Common Limb Length Does Not Influence Weight Loss After Standard Laparoscopic Roux-en-Y Gastric Bypass

We would like to thank you for the interest and the comments after the publication of our paper. However, we need to clarify some misunderstandings of the author’s remarks. Firstly, we agree that the weight loss is mostly due to the length of the biliopancreatic (BPLL) and the common loop (CLL). However, in our study, we wanted to investigate one and only one variable, which is the CLL. Secondly, the author suggests that we should have used a third group with a longer biliopancreatic loop. We think that the author did not understand very well the objectives of our study. Our aim was to investigate if the CLL could influence weight loss in a standard Roux-en-Y gastric bypass (RYGBP) with 150-cm alimentary limb (AL) and 75 cm (BPL), and not find a relationship with another variable as the BPLL. Thirdly, the author believes that the length of the three loops should be chosen according to the total length of the small bowel. We agree with the author, but actually the ideal length of the gastric bypass limbs is still under debate. In most series, the limb lengths of the RYGBP are 50–75 cm for BPL and 100–150 cm for AL. It is mostly depending on each surgeon’s practice. Especially, in the case of the biliopancreatic diversion or the distal RYGBP, lengthening the BPLL or the ALL or shortening the CLL will increase malabsorption and subsequent weight loss, but especially in the distal bypass, the most effective proportion of limb’s length needs to be clarified. Fourthly, the author points out that we have not taken into account the disease of obesity which is different before and after the ages of 40 and the eating behavior which may explain some failures after RYGBP. Yes, this is a true statement. The ideal scenario would perhaps have been a multivariate analysis to investigate the way how the age and the feeding behavior can influence the weight loss. However, we repeat that this was not the purpose of our study. In addition, there are still many other factors which may influence weight loss such as patient compliance, diet coaching, psychological disorders, and sports. Fifthly, the author suggests that overtime the RYGBP loses its malabsorption mechanism and theoretically retains its restriction mechanismwhich is due both to the size of the gastric pouch and also to the diameter of the gastrojejunal anastomosis. We disagree with his opinion. The RYGBP is a procedure which seems to be more efficient in the long term, compared to pure restrictive procedures. The fact that patients gradually consume bigger amount of food and do not regain their lost weight reveals that malabsoption and mechanisms other than restriction seem to be efficient, such as gastro-endocrine responses (PYYand GLP-1 plasmatic levels) [1]. Afterwards, the author mentions the study of HernándezMartínez who conclude that leaving a 230-cm length of common limb and redistributing the remaining 60% in the alimentary channel and 40 % in the biliopancreatic channel produce sustained EWL.We do not agree with these authors as 230 cm of CLL is too long provoking too much reabsorption of lipids and worse results. Many studies show that when the length of the common channel approaches 100 cm or less, a significant impact on weight loss is observed thanks to malabsorption [2]. The last comment of the author we would like to criticize is about the risk of perforation and the length of the operation because of the measure of the CLL. We agree that there is a risk of perforation, but we were doing that measure just only * Theodoros Thomopoulos teothomopoulos@yahoo.com