Guillaume Zufferey

Surgical management of abdominal and retroperitoneal Castleman's disease

BackgroundAbdominal and retroperitoneal Castlemans disease could present either as a localized disease or as a systemic disease. Castlemans disease is a lymphoid hyperplasia related to human Herpes virus type 8, which could have an aggressive behavior, similar to that of malignant lymphoid neoplasm mainly with the systemic type, or a benign one in its localized form.MethodsThe authors report two cases of localized Castlemans disease in the retroperitoneal space and review the current and recent progress in the knowledge of this atypical disease.Cases presentationThe two patients were young healthy women presenting with a hyper vascular peri-renal mass suggestive of malignant tumor. Both have been resected in-toto. One of them had an extensive resection with nephrectomy, while the second had a kidney preserving surgery. Pathological examination revealed localized Castlemans disease and surgical margins were free of disease. Postoperative course was uneventful, and after more than 5-years of follow-up no recurrences have been observed.ConclusionLocalized Castlemans disease should be considered when facing a solid hypervascular abdominal or retroperitoneal mass. A better knowledge of this disorder and its characteristic would help surgeon to avoid unnecessarily extensive resection for this benign disorder when dealing with abdominal or retroperitoneal tumors. Surgical resection is curative for the localized form, when complete, while splenectomy could be indicated for the systemic form.

Le Vacuum Assisted Closure: utilité dans le traitement des plaies abdomino-périnéales complexes. Expérience sur 48 patients

INTRODUCTION Vacuum-assisted closure (VAC) is a promising approach for the management of complex abdominal and perineal wounds. This paper summarizes our experience with this therapeutic modality and demonstrates its efficacity in difficult situations. PATIENTS AND METHODS From January 2003 until December 2005, 48 patients (age 30-89) were treated with VAC therapy for open abdomen, infected laparotomy wounds, or tissue loss due to debridement of Fourniers gangrene. Wound dressings were changed every 2-3 days. RESULTS Thirty-eight patients (79%) had major co-morbid conditions liable to impact negatively on wound healing. The treatment duration with VAC varied from 20-30 days with an average of eleven dressing changes (minimum 3-maximum 18). Treatment was effective in all patients. Spontaneous closure was achieved in 36 cases (75%); nine patients (19%) required a split-thickness skin graft, and three (6%) underwent delayed secondary closure. CONCLUSION In our institution, VAC has become the treatment of choice for complex abdominal and perineal wounds. It is a safe, simple, and effective technique to speed wound healing and it has reduced the duration of hospital treatment in difficult clinical situations and in patients whose general condition is often severely compromised.Resume Introduction la therapie par pression negative ( vacuum-assisted closure ou VAC) constitue une approche prometteuse dans la prise en charge des plaies abdomino-perineales complexes. Ce travail a pour objectif de resumer notre experience de cette modalite therapeutique et de montrer son efficacite dans des situations difficiles. Patients et methodes de janvier 2003 a decembre 2005, 48 patients âges de 30 a 89 ans, ont ete traites par VAC-therapie pour des plaies de laparotomie infectees, des ventres ouverts et deux gangrenes de Fournier. Les pansements etaient changes tous les 2 ou 3 jours. Resultats les patients avaient presente des complications septiques graves apres une chirurgie abdominale ou perineale (colectomie [15], pancreatectomie [15], bypass gastrique [5], resection de l’intestin grele [5], du duodenum [3], cure d’eventration [2], gangrene de Fournier [2] et transplantation hepatique [1]). Trente-huit patients (79 %) presentaient des comorbidites importantes pouvant influencer defavorablement la guerison de la plaie. La duree du traitement par VAC variait entre 20 et 30 jours pour une moyenne de 11 seances (extremes 3 a 18 seances) therapeutiques. La therapie etait efficace chez tous les malades, permettant dans 36 cas (75 %) une fermeture spontanee, ou necessitant chez 9 patients (19 %) une greffe de peau mince, et chez 3 patients (6 %) une fermeture secondaire. Conclusion dans notre institution, le VAC s’est impose comme traitement de choix des plaies abdomino-perineales complexes. Il s’agit d’une approche sure, simple et efficace pour accelerer la cicatrisation, permettant de reduire la duree du traitement hospitalier dans des situations cliniques difficiles, et chez des malades dont l’etat general et souvent compromis.

Sacral nerve modulation in the treatment of fecal incontinence following repair of rectal prolapse.

PURPOSE: Persistent or newly-diagnosed fecal incontinence following surgical repair of rectal prolapse has been reported in up to 30% of all treated patients. This study tried to evaluate the role of sacral nerve modulation as a potential treatment for this problem. PATIENTS AND METHODS: The medical records of 11 patients (all female; median age, 59 years) in 2 coloproctology centers were retrospectively analyzed. All of the patients had been treated for fecal incontinence by sacral nerve modulation, following transabdominal or transanal repair of rectal prolapse. After a median history of 36 (11–72) months following surgery, patients complained about fecal incontinence (median Cleveland Clinic Incontinence Score, 15 (13–20)), and sacral nerve modulation was proposed. The effect of sacral nerve modulation on the Cleveland score, as well as on the quality of life scoring system of The American Society of Colon and Rectal Surgeons, was evaluated. RESULTS: Based on their continence diaries, 9 of 11 patients reported an improvement of their fecal incontinence during the screening period, and proceeded to a permanent implant. After a median follow-up time of 36 (12–72) months, fecal incontinence scores dropped from a median of 15 (13–20) preoperatively to a median of 5 (3–7) in all implanted patients (P < .01). Quality of life analysis for all implanted patients showed significant improvement in all 4 domains (lifestyle, coping behavior, depression, and embarrassment (P < .01)). CONCLUSION: In this series, with a limited number of patients, sacral nerve modulation has shown a positive effect on the treatment of both persistent and newly-reported fecal incontinence after surgical repair of rectal prolapse.

Measure of the voluntary contraction of the puborectal sling as a predictor of successful sphincter repair in the treatment of anal incontinence.

PURPOSE: Overlapping sphincteroplasty is the surgery of choice for incontinent patients with an anterior defect after childbirth. Numerous predictive factors have been proposed, but no preoperative variables have been successfully shown to be reproducible. The purpose of this study was to assess the prognostic value of voluntary contraction of the puborectal sling before sphincter repair for anal incontinence. METHODS: This prospective study evaluated 109 consecutive women who underwent surgery for postobstetric anal incontinence. Voluntary contraction of the puborectal sling was measured by perineal ultrasound before the surgery. Severity of anal incontinence was evaluated preoperatively and postoperatively with the Miller Incontinence Score (total incontinence = 18, complete continence = 0). RESULTS: The proportion of patients with scores ≤3 was 16.7 percent when the preoperative voluntary contraction of the puborectal sling was ≤4 mm, 48.1 percent when it was 4.1 to 8 mm, and 98.7 percent when it was >8 mm (P < 0.001). Using ≤8 mm to define abnormal shortening, the sensitivity of the test was 0.95 (95 percent confidence interval, 0.75-1.00) and specificity was 0.84 (95 percent confidence interval, 0.75-0.91). CONCLUSION: A preoperative voluntary contraction of the puborectal sling >8 mm convincingly discriminates between patients with a good functional outcome and those with an unsatisfactory outcome after sphincter repair for postobstetric anal incontinence.

Accuracy of measurement of puborectal contraction by perineal ultrasound in patients with faecal incontinence

Aim  The study aimed to determine the accuracy of measurement of puborectal contraction, measured by perineal ultrasound during anal voluntary contraction in patients with incontinence.

Mucosal advancement flap for recurrent complex anal fistula: a repeatable procedure

PurposeMucosal advancement flap (MAF) is the best option for complex anal fistula (AF) treatment. Recurrence is not rare and the best surgical option for his handling is a challenge considering the incontinence risk and the healing rate. We aimed to determine the feasibility and outcomes of a second MAF for recurrent complex AF previously treated with mucosal advancement flap.MethodsWe retrospectively identified 32 patients undergoing two or more MAF for recurrent AF in a larger cohort of 121 consecutive cases of MAF operated by the same senior colorectal surgeon. Only complex AF of cryptoglandular origin was enrolled. A long-term follow-up was performed collecting clinical and functional data.ResultsAmong 121 patients (group A) treated with mucosal advancement flap, 32 (26.4%) (group B) recurred with a complex AF requiring a second mucosal advancement flap procedure. Success rate of group B is 78.1%. Six patients of group B recurred a second time, another MAF was performed with healing in all cases. Complication rate (Clavien Dindo 3b) of group B is 9.4% compared to 8.3% of group A. A slight continence deficit (Miller score 1, 2, and 4) was detected after the first MAF in 3 patients. The Miller score for these patients did not change after the subsequent MAF.ConclusionsMAF is effective for treatment of complex recurrent AF. A pre-existing MAF procedure does not worsen the healing rate of the second flap. The rate of surgical complications is similar with those reported in the literature for MAFs.