Jean-Marc Catheline

Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases.

The classic treatment of generalized peritonitis due to perforation of sigmoid diverticula is based on the principle of a two-stage surgery with a temporary derivation of the colonic transit. This procedure is associated with a prohibitively high immediate and delayed morbidity, especially associated with the abdominal wound. The laparoscopic approach to this complication is less aggressive and allows a second-stage elective laparoscopic resection. Eighteen consecutive patients (ten women and eight men; average age, 53.7 years) underwent emergency laparoscopic treatment for generalized peritonitis due to perforated diverticula. Eight of these patients had previously had diverticulitis attacks. By peritoneal cavity exploration and full peritoneal lavage (average, 15 L), the infected sigmoid lesion was stuck with biologic glue. A drain was inserted at the site of the lesion and in some cases also in other abdominal zones. No colostomy was necessary. Antibiotic treatment was started at diagnosis and continued for a minimum of 7 days. There was no mortality. Morbidity was limited to three patients (two cases of lymphangitis and one of pulmonary disease). No patient had a wound abscess or residual deep collections. The mean hospitalization was 8 days. Fourteen patients underwent elective laparoscopic sigmoid resection with a delay of 3.5 months. One conversion to laparotomy was necessary. The laparoscopic treatment of generalized peritonitis due to perforated sigmoid diverticula is an interesting alternative to the traditional treatment. It is associated with a lower morbidity, a shorter postoperative hospital stay, and an improvement in the patients quality of life, because colostomy is avoided. It is also associated with economic savings.

The use of diagnostic laparoscopy supported by laparoscopic ultrasonography in the assessment of pancreatic cancer

AbstractBackground: Pancreatic resection with curative intent is possible in a select minority of patients with carcinomas of the pancreatic head. Diagnostic laparoscopy supported by laparoscopic ultrasonography combines the proven benefits of staging laparoscopy with high-resolution intraoperative ultrasound, thus allowing the surgeon to perform a detailed assessment of the pancreatic cancer. Methods: In a prospective study of 26 patients with obstructive jaundice from a carcinoma of the head of the pancreas, the curative resectability of tumors was assessed by ultrasound (26 cases), computerized tomography (26 cases), endoscopic ultrasound (16 cases), and a combination of diagnostic laparoscopy and laparoscopic ultrasound (26 cases). Results: The findings of ultrasound and computerized tomography were comparable: 50% of patients were excluded from curative resection. Endoscopic ultrasound provided precise information on the primary tumors. The accuracy of the combined diagnostic laparoscopy and laparoscopic ultrasound, when compared with ultrasound, computerized tomography, and endoscopic ultrasound, was better with respect to minute peritoneal or hepatic metastasis: 80.7% (or a further 30.7%) of patients did not qualify for curative resection. Conclusions: Diagnostic laparoscopy supported by laparoscopic ultrasonography enables detection of previously unsuspected metastases; thus, needless laparotomy can be avoided. It should therefore be considered the first step in any potentially curative surgical procedure.

Gastrointestinal surgical emergencies following kidney transplantation

This study reports major gastrointestinal complications in a group of 416 patients following kidney transplantation. Three hundred and ninety-nine patients received a cadaveric kidney while the other 17 received a living related organ. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, and cyclosporin. Perforations occurred in the colon (n=6), small bowel (n=4), duodenum (n=2), stomach (n=1), and esophagus (n=1). There were five cases of acute pancreatitis, four of upper gastrointestinal and two of lower intestinal hemorrhage, two of acute appendicitis, one of acute cholecystitis, one postoperative mesenteric infarction, and two small bowel obstructions. Fifty percent of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or episodes of acute rejection. Ten percent of the complications had an iatrogenic cause. Of the 31 patients affected, 10 (30%) died as a direct result of their gastrointestinal complication. This high mortality appears to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications can be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

Laparoscopic versus open surgery for colorectal carcinoma: a prospective clinical trial involving 157 cases with a mean follow-up of 5 years.

The role of laparoscopic resection in the management of colorectal cancer is still unclear. It has been shown that laparoscopic colectomies can be accomplished with acceptable morbidity. Major concerns are port-site recurrences and neoplastic dissemination. The aims of this study were to compare perioperative results and long-term outcomes in a prospective, nonrandomized study of patients treated by laparoscopic versus open colorectal resection for cancer. In particular, the effects of an initial laparoscopic approach on survival and recurrence were examined. One hundred fifty-seven patients with colorectal carcinoma were included in the prospective trial: 74 underwent laparoscopic resection and 83 underwent conventional open surgery. The two groups were comparable in terms of characteristics, demographic data, stage of disease, and use of adjuvant or palliative chemoradiotherapy. All patients were observed at 1.3- and 6-month intervals. The median duration of follow-up was 60 months (range, 10–125 months). The mean operating time was significantly longer in the laparoscopic group. Six conversions (8.1%) were necessary. The passage of flatus and the restarting of oral intake (P = 0.0001) occurred earlier in the laparoscopic surgery group than in the open conventional surgery group. The mean postoperative stay was significantly shorter in the former group (P = 0.005), as was the length of the scar (P = 0.001). There were no deaths in either group. The overall morbidity was significantly lower (13% versus 33.7%;P = 0.001) in patients treated laparoscopically. No significant differences were observed between the groups in the length of specimens, the size of the tumor, or the number of nodes removed. Late complications were more frequent after open resection (12% versus 5.4%;P = 0.01). Two port-site metastases (2.6%) were seen in stage III and IV locally advanced carcinoma. There was no significant difference in recurrent disease between the groups (24.3% versus 25%) during the 60-month follow-up. Stage-for-stage comparisons showed that disease recurrence rates and crude death rates were comparable.

The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux.

The laparoscopic treatment for gastroesophageal reflux (GR) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period, during which the rate of complications, conversions, and duration of surgery and hospitalization are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in three groups of consecutive patients to determine the effect of the learning period on outcome. One hundred and fifty-six patients (88 men and 68 women) with an average age of 52.3 years (range, 18-78) were included. Surgery was indicated for failure or early relapse after the end of medical treatment or a symptomatic sliding hernia. The preoperative workup (endoscopy, barium meal, or esophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of patients were chronologically defined. The parameters that were examined were the type of preoperative exploration, the type of fundoplication, the operative technique, the conversion rate, the mortality and morbidity rates, the duration of surgery and hospitalization, and the results at short- and medium-term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GR. All patients had an endoscopy, 91% had a barium meal, 77.5% underwent esophageal manometry, and 67% had pH monitoring. One hundred and thirty-six patients had a TF and 20 had a PF. Rossetti type TF became the reference procedure (67% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between groups I and groups II and III (140, 100, 80 minutes, respectively). The rate of conversion, due to a variety of causes, decreased from 9.8% to 3.8%, and then to 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 15% to 3.8%, and then to 0%. There were seven cases of relapse (4.6%), five in group I (10%) and two in group II (4%), with no cases in group III, although the follow-up in group III was shorter. There is an effect of the learning curve on the outcome of treatment for GR, and this must be taken into account in the training of surgeons (training within experienced departments and guidance during their initial interventions) and also in publications to allow a more accurate comparison of this technique with other treatments for GR.

Traitement de la super super obésité morbide par gastrectomie longitudinale

Resume Interet du travail La gastrectomie longitudinale, ou “sleeve gastrectomy”, est une technique restrictive avec reduction de la capacite gastrique de 75%. Nous rapportons notre experience chez 4 patientes super super obeses (indice de masse corporelle “IMC”; > 60 kg/m2. Methodes Quatre patientes avec une super super obesite ont eu une gastrectomie longitudinale. Leur poids preoperatoire moyen etait de 173 kg (extremes de 147 a 190 kg), et l’IMC moyen de 65 kg/m2 (extremes de 61 a 67 kg/m2. Resultats Le suivi postoperatoire moyen a ete de 6 mois (extremes de 2 a 12 mois). La perte de poids moyenne a 6 mois a ete de 40 kg (extremes de 20 a 60 kg). La chute moyenne de l’IMC a 6 mois a ete de 16,3 kg/m2 (extremes de 6 a 23 kg/m2. Nous avons constate une complication postoperatoire chez une seule patiente (abces sous-phrenique traite par drainage). Perspectives La gastrectomie longitudinale est associee a peu de complications perioperatoires, et est rapidement efficace sur la super super obesite morbide. Les resultats a long terme doivent etre evalues. Voir aussi dans ce numero l’editorial de Boyan Christoforov, Patients obeses : quelle place pour la chirurgie bariatrique ? p. 371-2.

Thromboembolism in laparoscopic surgery: risk factors and preventive measures.

The aim of this study was to assess the risk of clinical thromboembolism in laparoscopic digestive surgery. From June 1992 to June 1997, 2,384 consecutive patients were studied. All received perioperative prophylaxis with low-molecular-weight heparin (LMWH), which was continued until full mobility was regained. Eight cases (0.33%) of deep venous thrombosis were noted, but there were no cases of pulmonary embolus. In six cases (five cholecystectomies with reverse Trendelenburg position and one inguinal hernia repair), release of the pneumoperitoneum took longer than 2 hours, and in two cases (one rectopexy and one sigmoid colectomy for diverticulitis), longer than 3 hours. In six of the eight cases, the diagnosis of DVT was made after LMWH had been ceased and the patient had been discharged. All cases were diagnosed before the 10th postoperative day. Pneumoperitoneum is felt to predispose to deep venous thrombosis. Long operations and reverse Trendelenburg position are further potentiating factors. Thromboprophylaxis for laparoscopy should be the same as for conventional surgery, i.e., tailored to individual risk and continued for a minimum of 7 to 10 days. We also recommend using graduated compression stockings, maintaining a relatively low insufflation pressure, keeping use of the reverse Trendelenberg position to a minimum, and intermittently releasing the pneumoperitoneum in longer procedures.

A comparison of laparoscopic ultrasound versus cholangiography in the evaluation of the biliary tree during laparoscopic cholecystectomy.

OBJECTIVE This study assessed the effectiveness of laparoscopic ultrasound in detecting main biliary duct stones. METHODS From November 1994 to August 1998, 600 patients treated by laparoscopic cholecystectomy were included in a prospective study, to compare intraoperative cholangiography and laparoscopic ultrasound. The biliary tree was successively explored by these two methods in the routine detection of common bile duct stones. RESULTS The feasibility of laparoscopic ultrasound was 100%. Cholangiography was performed only in 498 cases (83%). The time taken for laparoscopic ultrasound examination was significantly shorter (10.2 vs 17.9 min, P=0.0001). In this study, common bile duct stones were found in 54 cases (9%). For their detection, results were comparable to laparoscopic ultrasound and intraoperative cholangiography. For laparoscopic ultrasound, sensitivity was 80% and specificity 99%; and for cholangiography 75 and 98% respectively. Both examinations combined had a 100% sensitivity and specificity. Laparoscopic ultrasound failed to recognize the intrapancreatic part of the common bile duct in 78 cases (13%) and did not show anatomical anomalies detected by cholangiography. It did however detect other unsuspected intra-abdominal pathologies. CONCLUSIONS Laparoscopic ultrasound is safe, repeatable, and non-invasive, but a considerable learning curve is necessary to optimize its efficacy. Comparison of relative cost must be undertaken.

Laparoscopic Sleeve Gastrectomy for a Super-Super-Obese Patient with Situs Inversus Totalis

Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m2). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.

Quality of life 2 years after laparoscopic total fundoplication: a prospective study.

This study was a prospective evaluation of the quality of life of 50 patients after laparoscopic total fundoplication surgery for gastroesophageal reflux disease. The quality of life of 50 consecutive patients who underwent laparoscopic total fundoplication was evaluated using the Gastrointestinal Quality of Life Index questionnaire, which included 36 items in five different areas: symptoms, physical well-being, psychologic well-being, social relationships, and effects of medical treatment. Twenty-seven men and 23 women with a mean age of 52.6 ± 16 years (range, 31–68 years) with gastroesophageal reflux disease were treated by laparoscopic total fundoplication (Nissen–Rosetti) and were included in the study. The follow-up was at least 2 years after surgery. The quality of life was evaluated before the surgery and 1 month, 3 months, 6 months, 1 year, and 2 years after surgery with follow-up in 100% of the cases. A control group of 50 healthy volunteers representing an identical population to that of the patients operated on (with respect to age, sex, body mass index, profession, and smoking) anonymously completed the same questionnaire. The preoperative and postoperative Gastrointestinal Quality of Life Index questionnaire scores of patients who had laparoscopic total fundoplication were compared with the Gastrointestinal Quality of Life Index questionnaire scores of the control group. Before surgery, the Gastrointestinal Quality of Life Index questionnaire score (86.7 ± 8.5) was much inferior to that of the control group (123.8 ± 13.6) (P < 0.001). This score significantly improved 3 months after surgery and was comparable (not significant) to that of the healthy control population 3 months, 6 months, 1 year, and 2 years after surgery (119.3 ± 7.8). Improvements were reported mainly with respect to gastrointestinal symptoms and physical well-being. Social relationships were not modified. The quality of life of patients after laparoscopic surgery for gastroesophageal reflux disease improved and was close to the level expected in a healthy individual.