Elie Chouillard

Laparoscopic Two-Stage Left Colonic Resection for Patients with Peritonitis Caused by Acute Diverticulitis

PurposePurulent or fecal peritonitis is one of the most serious complications of acute diverticulitis. Up to one-fourth of patients hospitalized for acute diverticulitis require an emergent operation for a complication, including abscess, peritonitis, or stenosis. Open Hartmann’s procedure has been the operation of choice for these patients. The advantages of laparoscopy could be combined with those of the primary resection in selected patients with peritonitis complicating acute diverticulitis. However, because of technical difficulties and the theoretic risk of poorly controlled sepsis, laparoscopic Hartmann’s procedure has been seldom reported for such patients.MethodsData were prospectively collected from 2003 to 2005 in a single referral center specialized in abdominal emergencies. Laparoscopic Hartmann’s procedure (Stage 1) was performed in selected patients with peritonitis complicating acute diverticulitis. Secondarily, Hartmann’s reversal (Stage 2) also was performed laparoscopically.ResultsThirty-one patients were studied. The median Mannheim Peritonitis Index score was 21 (±5; range, 12–32). The conversion rate was 19 and 11 percent for Stage 1 and Stage 2, respectively. There was no perioperative uncontrolled sepsis. Overall operative 30-day mortality and morbidity rates were 3 and 23 percent for Stage 1, and 0 and 15 percent for Stage 2, respectively. Stoma reversal was possible in 90 percent of patients.ConclusionsThe results of this small series demonstrated that the indications of laparoscopy in diverticulitis could be extrapolated to selected patients with peritonitis. The technical feasibility and safety of laparoscopic Hartmann’s procedure in selected patients seem acceptable. However, larger-scale, controlled studies are needed to define more accurately the role of laparoscopy in complicated diverticulitis.

Laparoscopic Approach to Colonic Cancer: Critical Appraisal of the Literature

Background/Aims: As laparoscopic colectomy finds its place in the surgical armamentarium, the literature concerning the safety, efficacy, and oncological rational for treatment of colonic cancer is also enriched. A review and critical appraisal of the literature on this subject was the aim of this paper. Methods: A systematic research and a hand search were conducted to gain access to all controlled studies involving laparoscopic colectomy using the Medline, Embase, HealthSTAR, Cumulative Index for Nursing and Allied Health Literature, CancerLit data bases and the Cochrane Central Register of Controlled Trials for the years 1991–2006. Results: Over 40 controlled randomized trials and ten systematic reviews and/or meta-analyses were found. Several of the completed controlled randomized trials have published either short- or long-term results; only partial and short-term results are available in rectal cancer. The principal conclusions are that the laparoscopic approach affords better short-term outcomes including surgical site morbidity, but with increased operative times and direct costs. Among the proven long-term outcomes, cancer recurrence and survival do not seem to be worse. Whether conversion, a source of increased operative time and costs, is responsible for poorer outcomes or whether specific settings associated with poorer outcomes are among the causes of conversion remains to be shown. However, there are still concerns as regards specific laparoscopic-related complications. Conclusion: There seems to no real safety problems in performing laparoscopic colectomy for cancer; improvement in operative times, conversion rates, and complications should make laparoscopy the best cost-effective approach to colectomy.

Giant Pararectal Epidermoid Tumor Mimicking Ovarian Cyst: Combined Laparoscopic and Perineal Surgical Approach

Epidermoid cysts are benign tumors that can develop in any part of the human body. Pelvic cysts adjacent to the rectum develop rarely, and few cases have been described in the literature. We report the case of a 58-year-old woman who underwent laparoscopic and perineal excision of a giant pararectal cyst that was discovered during laparoscopy performed for preoperative provisional diagnosis of an adnexal mass detected on an imaging study. To our knowledge, this is the second case of a pararectal cyst excised using combined laparoscopic and perineal approaches. In the hands of skilled laparoscopic surgeons, we suggest a combined laparoscopic and perineal approach for excision of giant pararectal cystic tumors to avert laparotomy.

Appendiceal Abscess Revealed by Ureteral Stenosis and Hydronephrosis

Acute appendicitis presenting with ureteral stenosis and hydronephrosis is very rare. Here, we report the case of a patient who had complicated acute appendicitis with perforation and abscess resulting in right pyeloureteral dilation.

Sutureless repair of bronchial tears using fibrin sealant-reinforced Vicryl bridge

Tracheal injuries during oesophageal mobilization occur mainly in cases of carcinoma of the middle third. These are usually located on the fragile, less vascularized, membranous posterior wall of the trachea. When recognized during surgery, repair of the rent must be carried out. Management techniques include mainly direct suturing with or without pleural, gastric, pericardial, or muscular flaps. Although fibrin glue has been used to reinforce tracheal repair for more than 20 years, its sutureless combination with Vicryl patches has never been reported to our knowledge. A 38-year-old male patient was admitted for surgical treatment of a squamous cell carcinoma of the thoracic oesophagus. The tumour was classified as T3N1 on preoperative endosonography. Thoracoabdominal computed tomography as well as cervical ultrasonography showed no metastatic disease. The patient was operated under general anaesthesia and had McKeown’s procedure: total oesophagectomy, three-field lymphadenectomy, posterior mediastinal gastroplasty, and cervical oesophagogastric anastomosis. During the dissection of the thoracic oesophagus, and because of the intimate adhesion of the tumour to the posterior aspect of the left main bronchus, a longitudinal 15 · 10mm– tear occurred. Repair was undertaken after complete dissection using a Vicryl bridge reinforced with fibrin sealant. No suture was used. The immediate outcome was uneventful. Oral intake was resumed on day eight. No respiratory complications occurred. Day-14 bronchial fibroscopy was unremarkable. Hemostatic varieties of fibrin have been recognized since the early 1900s. In 1940, Young and Medawar used fibrin solutions as a tissue adhesive for peripheral nerve anastomoses in rabbits.1 Clinical use of fibrin in humans remained anecdotal until the 1970s when German surgeons successfully applied a combination of cryoprecipitate and bovine thrombin in peripheral nerve anastomosis, opening the way to commercialization of fibrin sealant in Europe.2 Fibrin solutions can be applied topically as liquids or as an aerosol. Intraparenchymal injection (liver, spleen, kidney) can be used if massive bleeding precludes surface adhesion. A basic dual-syringe applicator system may be used to achieve field mixing of the two components, cryoprecipitate, source of fibrinogen and factor XIII, and thrombin. Newer forms of fibrin sealant are developed, including the dry fibrin sealant dressings, whose efficacy in controlling extremity haemorrhages has been shown.3 These dressings are composed of highly concentrated pure human fibrinogen, thrombin, and calcium dried on a Vicryl mesh. Therefore, difficulties inherent to liquid formulations are overcome, including blood bank support, premixing, storage at adequate temperatures, and disease transmission.3 Since the early 1980s, fibrin glue has been successfully used to secure tracheal anastomoses in animal experimental models. Ever since, wider use of fibrin in larynx, trachea, and neck surgeries has been reported.4 The use of fibrin sealant in tracheal reconstruction resulted in a stable, leakless trachea, with good systemic and local compatibility. Fibrin was found to promote tracheal wound healing and to reduce significantly the number of sutures required for end-to-end anastomosis. In the 1990s, reduced suture fibrin glue and sutureless fibrin glue, two novel concepts of use of fibrin in tracheal surgery, have been applied. These procedures, performed with a minimum of training, may reduce operative time, leakage, ischaemia, inflammation, and necrosis compared with techniques based on sutures. Suture number for oesophageal, tracheal, and tracheobronchial anastomoses can be reduced with fibrin glue. Other sites of application of these principles include the intestines, blood vessels, the ureters, vas deferens, and the fallopian tubes. The combination of fibrin and Vicryl patch in a sutureless technique of tracheal tear has never been reported. This approach implemented in our patient was successful. By using fibrin glue, one obviates the need for sutures in a hypovascularized tissue, while Vicryl patch replaced the more classical covering flap. In the near future, it is possible that the use of fibrin in tracheal surgery will be even more revolutionary. Recent studies have shown that in vitro–cultured tracheal epithelial cells can be transplanted onto a prefabricated capsule surface in vivo with fibrin glue, which will differentiate into morphological, nearly normal epithelium, showing potential for tracheal reconstruction.5

Reducing pre-operative fasting while preserving operating room scheduling flexibility: feasibility and impact on patient discomfort.

The need to preserve operating room (OR) scheduling flexibility can challenge adherence to the 2‐h pre‐operative fasting period recommendation before elective surgery. Our primary objective was to assess the feasibility of a pre‐operative carbohydrate (CHO) drink delivery strategy preserving OR scheduling flexibility.