Fabian Reche

Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results

AIM To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse. METHODS MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review. RESULTS Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies. CONCLUSION Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study

BackgroundGastrobronchial fistula (GBF) is a complication of esophageal, splenic, or antireflux surgeries and was recently described as a complication of bariatric surgery. Our aim was to study all cases of GBF after laparoscopic sleeve gastrectomy (LSG) managed in five French university bariatric centers in order to establish the incidence and to evaluate the different treatments of this complication.MethodsWe retrospectively studied 13 patients which developed GBF after LSG performed between March 2007 and August 2012. Patients were separated into two groups: patients who had early gastric fistula which has evolved into a GBF (group 1) and patients who had a late gastric fistula, either directly GBF or a late gastric fistula evolved in GBF (group 2).ResultsGroup 1 consisted of five patients and group 2 of eight patients. All patients were undernourished at diagnosis. Management of GBF was a combined thoraco-abdominal surgery with gastrojejunal anastomosis (n = 5) or total gastrectomy (n = 1), multiple endoscopic treatment and thoracic surgery (n = 3), an endobronchial valve (n = 1), total gastrectomy and thoracic drainage (n = 1), and transorificial intubation with thoracic surgery or drainage (n = 2). There was no mortality. All GBF healed.ConclusionsGBF after LSG is a serious complication which is not anecdotal. Most of the early gastric fistulas occuring after LSG become chronic and can evolve into a GBF. Surgical approach is an effective treatment. Endobronchial valve is a novel alternative.

Bariatric surgery improves the employment rate in people with obesity: 2-year analysis

BACKGROUND Beyond medical complications, people with obesity experience dramatic impairment of quality of life, including adverse workplace effects. Obesity results in weight-based discrimination and a high rate of unemployment because of work disability, absenteeism, loss of productivity, and cost. A few studies have been performed to assess the relationship between obesity surgery and the workplace, finding an improvement in weekly working hours and productivity and a decrease in absenteeism, days of sick leave, and state benefit claims. However, the results are still controversial concerning the overall employment rate. OBJECTIVES This study aimed to compare the employment rate before and 2 years after obesity surgery and to evaluate the difference in weight loss between worker and nonworker patients. SETTING Participants were recruited from a tertiary care university hospital in France. METHODS The 2-year outcomes of all patients who underwent obesity surgery between 2010 and 2015 were retrospectively reviewed. The employment status was recorded preoperatively and postoperatively. Retired or permanently disabled patients were excluded from the analysis. RESULTS Preoperatively, 158 of 238 patients were employed compared with 199 of 238 postoperatively (P < .0001). There was no difference in weight loss between the worker and nonworker patients regarding the percentage of excess weight loss and the change in body mass index. CONCLUSION This study supports the finding that bariatric surgery also has a positive impact on the professional sphere, providing the opportunity for unemployed patients to return to work.

Dynamic cystocolpoproctography to confirm the efficacy of laparoscopic rectopexy in the treatment of hedrocele associated with full-thickness rectal prolapse

Hedrocele literally means anal hernia (from the Greek hedros, meaning anus, and kele, meaning hernia). It is an extremely rare form of hernia with only four cases previously reported [1–3]. Like enterocele, hedrocele is a variant of the rare posterior perineal hernias, resulting from a defect in the rectovaginal septum [3]. A peritoneal pouch containing the small bowel protrudes in the anterior wall of the rectum through the anus. Clinical presentation may be with symptoms and signs of a strangulated small bowel in the hedrocele [3]. Diagnosis can be made by dynamic cystocolpoproctography, which has been shown to be superior to MRI in this context [4]. The aim of this short report is to confirm the efficacy of laparoscopic rectopexy in the management of hedrocele after dynamic cystocolpoproctography.

Giant Meckel’s Diverticulum

A 63-year-old patient was diagnosed with asthenia evolving since few months. Past medical history revealed an appendectomy through McBurney’s incision in childhood and laparoscopic cholecystectomy performed 6 years ago. No abdominal anomalies were found at the exploration during this procedure, nor on the CT scan performed at this moment. The patient had no complaints. At physical examination, there was no abdominal pain, no anal bleeding, and no palpable mass and the pelvic exam was normal. Blood test demonstrated an iron-deficiency anemia. The patient was referred to a gastroenterologist who performed EGD and colonoscopy: both were normal. A CT scan was performed (Fig. 1). We decided to perform an explorative laparoscopy. At 30 cm from the ileocecal valve, we discovered a dilated segment of the ileum (Fig. 2). An 18-cm small-bowel resection followed by a side-to-side anastomosis was performed. The outcome was uneventful and the patient was discharged on the first postoperative day. The final pathologic diagnosis was a giant Meckel’s diverticulum (MD) with an inflamed and hemorrhagic ileal mucosa and presence of ulcers, without any aspect of gastric mucosal tissue.

Benefit–risk of intraoperative liver biopsy during bariatric surgery: review and perspectives

Nonalcoholic fatty liver disease (NAFLD) is a metabolic complication of obesity that encompasses a spectrum of conditions, including hepatic steatosis, nonalcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease. Screening for NAFLD is important to limit progression, allow early detection of carcinoma, and follow the need for liver transplantation. Although noninvasive markers exist, hepatic histologic evaluation remains the gold standard for diagnosis. To reduce the risk of complications after liver biopsy but increase the accuracy of NAFLD diagnosis, hepatic tissue can be sampled during bariatric surgery. This practice raises the question whether liver biopsies should be systematically carried out intraoperatively to screen for NAFLD or limited to patients who have positive results for noninvasive markers of NASH. The aim of this systematic review was to determine the prevalence of NASH in patients with obesity undergoing bariatric surgery, the performance of noninvasive markers of NASH and complications of intraoperative liver biopsy. Meta-analysis found an overall NASH prevalence of .25 (95% confidence interval, .12-.39), with a high level of heterogeneity (I2 = 97%) across studies. The review showed that each noninvasive marker alone was unable to discriminate between patients with a normal liver and others. Conversely, intraoperative biopsy was related to some complications. Results from a clinical practices questionnaire in specialized centers for obesity care in France showed a large degree of heterogeneity. A prospective study would be interesting to evaluate an algorithm based on noninvasive markers for clinical decision making to determine the pertinence of liver biopsy during bariatric surgery.

Gastric Band Migration Causing Jejunal Obstruction: a Life-Threatening Complication

The risk of an intragastric band migration remains low in the literature but it could grow up with a longer follow-up of patients. We report a life-threatening complication following a band migration. A 36-year-old, 28-weeks pregnant woman presented to the maternity with abdominal pain, fever, and jaundice 11 years after a gastric banding performed for obesity. C-reactive protein was 246 mg per liter and white-cell count was 4000 per cubic millimeter. On examination, she had tenderness on her right iliac fossa. Abdominal CT scan demonstrated intrajejunal migration of the gastric band that appeared still attached to the subcutaneous upper left abdominal quadrant chamber, pneumoperitoneum, and peritoneal abundant effusion (Figs. 1 and 2). During the CT scan, a spontaneous rupture of the amniotic sac happened. The patient was transferred to the operating room for an emergency surgery. Laparotomy revealed peritonitis due to perforation at the posterior aspect of the stomach, perforation at the duodenojejunal flexure, and two jejunal perforations at respectively 60 and 70 cm from the duodenum because of a migration of the gastric banding (Fig. 3). Partial gastrectomy

Hedrocele Associated With Full-Thickness Rectal Prolapse: A Very Rare Condition Treated by Ambulatory Laparoscopic Anterior Rectopexy

992 DISEASES OF THE COLON & RECTUM VOLUME 60: 9 (2017) Hedrocele is an extremely rare entity that consists of a Douglas pouch anal hernia accompanying an exteriorized rectal prolapse: the peritoneal pouch containing the small bowel protrudes in the anterior wall of the rectum through the anus. We only met 1 case in a series of 175 consecutive patients, whose clinical presentation was a strangulated small bowel in the hedrocele. For us, this severe and specific complication is the reason why surgical treatment is mandatory, once the diagnosis is reached by dynamic cystocolpodefecography. The aim of this video is to present the anatomical abnormalities of this entity and its treatment by laparoscopic anterior rectopexy in a 60-year old woman who presented with a full-thickness rectal prolapse. The cystocolpodefecography demonstrated a deep hedrocele containing several small-bowel loops (Figs. 1 and 2). The patient was proposed for an ambulatory laparoscopic anterior rectopexy. She gave her informed consent for the video and publication. The video clearly demonstrates the deep Douglas pouch that protrudes through the anus, and also shows how the small bowel can slip into the anal hernia. Readers will Hedrocele Associated With Full-Thickness Rectal Prolapse: A Very Rare Condition Treated by Ambulatory Laparoscopic Anterior Rectopexy

Robots for rectopexy: probably hindrance... till now!

We thank Doctors Ian Lindsey and Aisling M. Hogan for their comments concerning our article recently published in Techniques in Coloproctology (1) they published in Annals of Laparoscopic and Endoscopic Surgery under the title “ robots for rectopexy: help or hindrance? ” (2).