Bruto Randone

Cholecystocolonic fistula: facts and myths. A review of the 231 published cases

BACKGROUND Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined. METHODS An extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed. RESULTS CCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported. CONCLUSION CCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.

A critical appraisal of laparoscopic pancreatic enucleations: right-sided procedures (Pancreatic Head, Uncus) are not mini-invasive surgery.

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

Laparoscopic Diagnosis and Treatment of Primary Torsion of the Greater Omentum

Clinical presentation of primary torsion of the greater omentum is nonspecific, thus rarely allowing for a preoperative diagnosis. Three patients presented with acute but nonspecific abdominal symptoms. Because ultrasonographic and radiologic findings were unclear, all patients underwent diagnostic laparoscopy. In all cases, laparoscopy enabled us to achieve the diagnosis and to perform a resection of necrotic omentum. The mean duration of the procedure was 56 minutes (range: 42 to 76). The postoperative course was uneventful and the patients were discharged on postoperative day 1 (2) and 3. The value of diagnostic laparoscopy increases when the disease can be treated laparoscopically. The laparoscopic vision allowed us to explore the whole peritoneal cavity, so achieving the diagnosis, and to place the operative trocars at the most convenient sites. The laparoscopic resection of the greater omentum is an easy task even for inexperienced laparoscopic surgeons, allowing patients to benefit from the advantages of a mini-invasive approach.

Laparoscopic minor pancreatic resections (enucleations/atypical resections). A long-term appraisal of a supposed mini-invasive approach.

Introduction A few retrospective, small, often multicentric studies show encouraging results of laparoscopic minor pancreatic surgery, but do not allow for an evaluation of feasibility and effectiveness. Aim Evaluation of the results of laparoscopic minor pancreatic resections (LMPR), including atypical resections and enucleations. Material and methods The outcome of all consecutive patients undergoing LMPR in a tertiary care university hospital specializing in the laparoscopic approach to solid organs (I.M.M., Paris – France) was retrospectively evaluated by the analysis of operating time, blood loss, conversion, morbidity, stay and late outcome. Results Thirty-three patients underwent LMPR (29 enucleations and 4 atypical resections) for various diseases. The conversion rate was 21%, mean operating time 189 min, and mean blood loss 133 ml. Morbidity was 60%; 10 patients (30%) presented a pancreatic fistula. Pancreatic fistula was independent of type of resection, technique of pancreas section, management of enucleated surface and somatostatin administration. Median stay for enucleations was 18 days. Mean follow-up was 61 months. Conclusions Laparoscopic pancreatic enucleation is feasible and safe, with no mortality, no lengthening of operating time and a high success rate. Conversely, it does not imply a reduction in complications or hospital stay at the present state of the art.

Early strangulated recurrence of incisional hernia after laparoscopic repair: an old complication for a new technique.

The introduction of laparoscopy in incisional hernia repair is giving rise to a new class of complications, specific of new techniques and materials. A case of early failure of incisional hernia laparoscopic repair complicated by the strangulation of a jejunal loop four months after surgery is reported. The use of inappropriate material (tacks) to fix the prosthesis to the abdominal wall, a sudden increase of intra-abdominal pressure caused by an episode of haematemesis four hours postoperatively (associated to its consequent endoscopic treatment), and the formation of rectus abdominis muscle hematoma are reported as the main factors determining the slippage of the mesh from the correct position and, ultimately, the early failure of the ventral hernia repair. Furthermore, the aetiology of early failure of laparoscopic incisional hernia repair, reported in literature, is reviewed.

Chilaiditi’s sign or Chilaiditi’s syndrome in the emergency department

A 40-year-old woman presented to our emergency department with an acute 4-hour history of central abdominal pain associated with nausea and vomiting. She had no past medical or surgical history but had undergone a second uncomplicated delivery 15 days previously. Her body mass index was in the normal …

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas

OBJECTIVE To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

Hepatectomies by Laparoscopic Approach: Intra-Glissonian Approach versus Extra-Glissonian and Posterior Approach

Surgery continues to evolve, and the laparoscopic approach for liver resections is now becoming well established. This chapter outlines three surgical approaches via the laparoscopic route. First is the traditional dissection of structures outside the liver and then two separate accounts of the use of the posterior approach to the hilum of the liver, essentially duplicating techniques which are carried out via the open posterior approach as detailed earlier in this book.

Liver – Anatomical Liver Resections

The first footsteps in the field of laparoscopic liver surgery were marked by wedge resections limited to the marginal and anterior regions of the organ. Since then, more technically demanding procedures have been performed with efficacy and safety equaling outcomes in open surgery when performed in highly specialized centers. To propose laparoscopy as a valid and definitive alternative to open access in liver surgery, though, the feasibility of anatomical resections had to be established. This has been now accomplished in centers with a solid expertise in hepato-biliary surgery and laparoscopic techniques. This exciting evolution in minimally invasive liver surgery is the result of technological advances and modifications in laparoscopic equipment coupled with progression in surgical skills. Routine use of preoperative imaging like computed tomography (CT) scans, magnetic resonance imaging (MRI) or intra-operative ultrasound (US) contributed greatly to diagnostic accuracy and planning of the resection. Improved anesthesia and critical care was essential in having good outcomes. This chapter describes our evolution and current technique approach to highly complex liver resections as we practice it at our institution since many years.

Chilaiditi's sign or Chilaiditi's syndrome in the emergency department.

A 40-year-old woman presented to our emergency department with an acute 4-hour history of central abdominal pain associated with nausea and vomiting. She had no past medical or surgical history but had undergone a second uncomplicated delivery 15 days previously. Her body mass index was in the normal range. The patient had marked distension …