D. Collet

Laparoscopic enucleation of pancreatic neoplasm

BackgroundEnucleation is an alternative procedure for treating benign and borderline neoplasms of the pancreas, which preserves healthy parenchyma and pancreatic function. This study aimed to evaluate the postoperative and long-term results after laparoscopic enucleation.MethodsData collected prospectively from 23 consecutive patients who underwent laparoscopic pancreatic enucleation were analyzed.ResultsLaparoscopic enucleation was achieved successfully for 21 patients (91.3%). One death (4%) occurred. A postoperative pancreatic fistula was observed in three cases (13%), and was clinically significant in one case (4%). Enucleation was performed for endocrine neoplasm in 15 patients (65%) and for cystic neoplasm in eight patients (35%). All the patients had benign tumors at the final histopathologic diagnosis. During a median follow-up period of 53xa0months, no patient experienced tumor recurrence or new-onset exocrine or endocrine insufficiency.ConclusionLaparoscopic enucleation is a safe and effective procedure for the radical treatment of benign and borderline pancreatic tumors. The laparoscopic approach seems to be associated with a decrease in operative time, hospital stay, and pancreatic fistula after enucleation. Laparoscopy should become the standard approach in the future for enucleation of presumed benign lesions.

Les pancréatectomies laparoscopiques: À propos d’une expérience de 22 cas

Resume Objectifs. – Rapporter l’experience de notre service dans les resections laparoscopiques pour tumeurs neuro-endocrines et tumeurs kystiques pancreatiques. Patients et methodes. – Etude retrospective de 22xa0malades (18xa0femmes et 4xa0hommes) operes entre octobre 1999 et fevrier 2003. Resultats. – Vingt-deux malades ont ete programmes pour une resection laparoscopique de leurs lesions pancreatiques. Dix-huit malades ont en definitive une resection laparoscopiquexa0: 10xa0enucleations, 3xa0pancreatectomies caudales, 4xa0pancreatectomies gauches et 1xa0duodenopancreatectomie totale. Les pancreatectomies gauches etaient realisees avec conservation splenique. Quatre (18xa0%) malades ont necessite une conversion (1 enucleation, 2xa0pancreatectomies gauches, 1xa0DPC). La duree moyenne d’intervention a ete de 90xa0min (extremesxa0: 60–120xa0min) pour les enucleations, 90xa0min (60–120xa0min) pour les pancreatectomies caudales, 210xa0min (150–270xa0min) pour les pancreatectomies gauches et de 8xa0heures pour la DPT. La mortalite a ete nulle. La morbidite a ete de 13,6xa0% comprenant 2xa0fistules pancreatiques et un infarctus partiel douloureux de la rate. La duree moyenne d’hospitalisation a ete de 12xa0jours. Conclusion. – Dans les indications choisies, tumeurs kystiques, insulinomes, l’abord laparoscopique ameliore le confort des patients et doit etre recommande.OBJECTIVEnTo evaluate results of laparoscopic pancreatectomy for benign lesions of the pancreas. Peri-operative data, surgical outcomes and techniques are presented.nnnPATIENTS AND METHODSnEighteen women and four men underwent laparoscopic pancreatectomy and were collected retrospectively from 1999 to 2003.nnnRESULTSnLaparoscopic pancreatectomy was attempted in 22 patients and completed successfully in 18: 10 enucleations, three distal pancreatectomies, four left pancreatectomies and one total pancreatectomy for endocrine and cystic tumors. Left and distal pancreatectomies were performed with preservation of the spleen. Four patients were converted (one enucleation, one whipple procedure and two left pancreatectomy). There was no mortality; the post-operative morbidity included two pancreatic leaks and one case of half splenic infarction. The median length of hospital stay was 12 days.nnnCONCLUSIONnPatients appear to benefit from laparoscopic pancreatectomy for pancreatic benign tumors.

Laparoscopic cholecystectomy using intracorporeal lithotripsy

Over a 13-month period (November 1988 to December 1989), we performed our first 104 laparoscopic cholecystectomies using an intracorporeal ultrasonic lithotripsy technique. The procedure in three of these patients was converted to an open operation because of hemorrhage with unexpected findings of cirrhosis in two patients and dense subhepatic adhesions in a third. Endoscopic retrograde cholangiopancreatography was successfully used in three other patients in whom common bile duct stones were identified. We encountered only three postoperative complications out of all the laparoscopic cholecystectomies performed. One complication was a biliary fistula that closed spontaneously 1 week after surgery. The remaining complications were attributable to abscesses, one subhepatic and one pelvic, which were aspirated and drained laparoscopically. There were no deaths. Advantages of the laparoscopic approach included decreased perioperative pain, shortened hospitalization, absence of scar, and more rapid return to prehospitalization activities.

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

UNLABELLEDnThe aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients.nnnPATIENTS AND METHODSnBetween 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life.nnnRESULTSnShort term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05).nnnCONCLUSIONnRe-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.

Wirsungostomy as a salvage procedure after pancreaticoduodenectomy

BACKGROUNDnu2002 Mortality rates associated with postoperative peritonitis or haemorrhage secondary to pancreatic fistula (PF) after pancreaticoduodenectomy (PD) remain high. This study analysed the results of an alternative management strategy for these life-threatening complications.nnnMETHODSnu2002 All patients undergoing PD between January 2004 and April 2011 were identified. Patients who underwent further laparotomy for failure of the pancreatico-digestive anastomosis were identified. Since 2004, this problem has been managed by dismantling the pancreatico-digestive anastomosis and cannulating the pancreatic duct remnant with a thin polyethylene tube (Escat tube), which is then passed through the abdominal wall. Main outcome measures were mortality, morbidity and longterm outcome.nnnRESULTSnu2002 From January 2004 to April 2011, 244 patients underwent a PD. Postoperatively, 21 (8.6%) patients required re-laparotomy to facilitate a wirsungostomy. Two patients were transferred from another hospital with life-threatening PF after PD. Causes of re-laparotomy were haemorrhage (n= 12), peritonitis (n= 4), septic shock (n= 4) and mesenteric ischaemia (n= 1). Of the 21 patients who underwent wirsungostomy, six patients subsequently died of liver failure (n= 3), refractory septic shock (n= 2) or mesenteric ischaemia (n= 1) and nine patients suffered complications. The median length of hospital stay was 42 days (range: 34-60 days). The polyethylene tube at the pancreatic duct was removed at a median of 4 months (range: 2-11 months). Three patients developed diabetes mellitus during follow-up.nnnCONCLUSIONSnu2002 These data suggest that preservation of the pancreatic remnant with wirsungostomy has a role in the management of patients with uncontrolled haemorrhage or peritonitis after PF.

Laparoscopic Adjustable Gastric Banding Results after 2 Years with Two Different Band Types

Background: Laparoscopic gastric banding is the most common operation in Europe for morbid obesity. Many devices from different companies are now available. The aim of this study was to compare the results over a 2-year period of 2 types of band: the Lap-Band ® and the Minimizer® band. Methods: In a non-randomized study, 2 consecutive groups were prospectively analyzed. Group A consisted of 120 patients who received the Lap-Band ® , and group B consisted of 68 patients who received the Minimizer band which contains eyelets. All the bands were placed above the lesser sac by the perigastric approach. Results: 4 early complications were observed in group A (1 phlebitis, 1 pneumopathy and 2 early displacements of the band); and 1 in group B (1 retention of urine). After a follow-up of 2 years, the displacement rate of the band was 10.8% in group A and 0% in group B. One gastric erosion was observed in group B, but not in group A. After 2 years, the average loss of excess weight was 50% in both groups. Conclusion: With the Minimizer band, we did not observe any slipping, and the efficacy with respect to weight loss was equivalent to the Lap-Band®

Intérêt de l'ampullectomie chirurgicale dans la prise en charge des lésions bénignes de l'ampoule de Vater

AIM OF THE STUDYnTo report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater.nnnPATIENTS AND METHODSnFrom 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins.nnnRESULTSnThere was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence.nnnCONCLUSIONnTransduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.

Article originalIntérêt de l'ampullectomie chirurgicale dans la prise en charge des lésions bénignes de l'ampoule de VaterValue of surgical ampullectomy in the management of benign ampullary tumors

AIM OF THE STUDYnTo report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater.nnnPATIENTS AND METHODSnFrom 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins.nnnRESULTSnThere was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence.nnnCONCLUSIONnTransduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.

Primary monophasic synovial sarcoma of the pancreas

We report a case of synovial sarcoma of the pancreas in a 44-year-old male who presented with multiple episodes of retroperitoneal hemorrhage; the diagnosis was confirmed by histology. The patient underwent distal pancreatectomy without complication, and the hospital stay was nine days. No adjuvant treatment was administered. The patient is alive at 1 year.

Laparoscopic Surgery for Gallbladder Stones

The radical treatment of gallstones consists of removal of the calculi and prevention of their recurrence, and cholecystectomy is at present the common solution. Since Langebuchs first operation in 1882, Calot reporting the first French case in 1889, cholecystectomy has reached a high level of technical perfection. With a small access route and complete exploration of the common bile duct, the results are well known: global mortality is less than 0.1%. Frequently, specialised teams report series of patients under 50 years of age with zero mortality. Are there other techniques that permit the removal of calculi and the removal of the gallbladder with results comparable or better than the classic cholecystectomy? We have perfected an operative technique using laparoscopy that destroys the calculi with an ultrasonic lithotriptor followed by drainage or removal of the gallbladder. Our initial results are favourable.