Brice Robert

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 patients 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.

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.

Complications tardives de la chirurgie pariétale abdominale : à propos de trois cas de migration de prothèse dans un organe creux

Late complications from abdominal wall surgery: report of three casesof mesh migration into hollow viscus Laparoscopic mesh repair of ventral abdominal wall hernias is routinely performed. Mesh detachment and migration within the abdominal cavity is a late complication of this procedure. Symptoms are non-specific and imaging diagnosis is difficult to achieve because this complication is rare and overlooked.

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.

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.

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 surgeons 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.

Suivi radiologique des tumeurs gastro-intestinales stromales (GIST) sous traitement : à propos d’un cas

Une femme âgée de 83 ans, aux antécédents d’appendicectomie à l’âge de 23 ans, d’hystérectomie pour fibrome utérin en 1993 et d’insuffisance aortique était adressée pour bilan d’anémie de découverte récente marquée à 5,9 g/dl associée à un méléna. Il n’existait pas d’altération de l’état général associée, de douleurs abdominales ou de masse palpable. Sur le plan biologique, on notait une cytolyse ainsi qu’une cholestase anictérique associées à un syndrome inflammatoire biologique dans un contexte apyrétique. La fibroscopie oeso-gastro-duodénale et la coloscopie réalisées en première intention ne retrouvaient pas de cause au saignement digestif. Dans ces conditions, un examen tomodensitométrique abdomino-pelvien sans puis après injection de produit de contraste iodé au temps portal était rapidement réalisé et montrait la présence de plusieurs lésions focales intra hépatiques de taille moyenne, hétérogènes, à centre nécrotique et à périphérie hypodense avant injection et non rehaussées après injection de produit de contraste (fig. 1) . On retrouvait également un épaississement pariétal circonférentiel tumoral étendu sur 4 cm de longueur se N

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

Emphysematous pancreatitis. A rare cause of fulminant multiorgan failure.

5,219 in the UGI+group and

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

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.