Mathieu D'Hondt

Gastrogastric Fistula after Gastric Bypass – Is Surgery Always Needed?

Because of regain of weight to BMI 37.1 kg/m2 6 years after a VBG, a 41-year-old female now underwent revision to divided Roux-en-Y gastric bypass, performed laparoscopically. 12 days postoperatively, she started bleeding from the main stomach, and CT scan revealed that the bypassed stomach was distended with clot. She was treated conservatively and stopped bleeding. Upper GI series 2 weeks postoperatively revealed a large gastrogastric fistula between the tiny pouch and the bypassed stomach. We initially planned to close the fistula. However, upper GI series 2 months and 4 months postoperatively showed no sign of gastrogastric fistula, and proton pump inhibitors were stopped. At 1 year after gastric bypass, our patient has had good weight loss.

SILS Sigmoidectomy Versus Multiport Laparoscopic Sigmoidectomy for Diverticulitis

Background and Objectives: In this single-institution study, we aimed to compare the safety, feasibility, and outcomes of single-incision laparoscopic sigmoidectomy (SILSS) with multiport laparoscopic sigmoidectomy (MLS) for recurrent diverticulitis. Methods: Between October 2011 and February 2013, 60 sigmoidectomies were performed by the same surgeon. Forty patients had a MLS and 20 patients had a SILSS. Outcomes were compared. Results: Patient characteristics were similar. There was no difference in morbidity, mortality or readmission rates. The mean operative time was longer in the SILSS group (P = .0012). In a larger proportion of patients from the SILSS group, 2 linear staplers were needed for transection at the rectum (P = .006). The total cost of disposable items was higher in the SILSS group (P < .0001). No additional ports were placed in the SILSS group. Return to bowel function or return to oral intake was faster in the SILSS group (P = .0446 and P = .0137, respectively). Maximum pain scores on postoperative days 1 and 2 were significantly less for the SILSS group (P = .0014 and P = .047, respectively). Hospital stay was borderline statistically shorter in the SILSS group (P = .0053). SILSS was also associated with better cosmesis (P < .0011). Conclusion: SILSS is feasible and safe and is associated with earlier recovery of bowel function, a significant reduction in postoperative pain, and better cosmesis.

Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma

Background and Objectives: Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers. Methods: Retrospective review of a prospectively collected database was performed of all patients with benign lesions or ≤cT1N0 rectal cancer who underwent TEO with curative intent at 3 Belgian centers (2012 through 2014). Results: Eighty-three patients underwent 84 TEOs for 89 rectal lesions (37 adenomas, 43 adenocarcinomas, 1 gastrointestinal stromal tumor, 1 lipoma, 2 neuroendocrine tumors, and 5 scar tissues). Operative time was associated with lesion size (P < .001). Postoperative complications occurred in 13 patients: 7 hemorrhages, 1 urinary tract infection, 1 urinary retention, 2 abscesses, 1 anastomotic stenosis, and 1 entrance into the peritoneal cavity. Median hospital stay was 3 days (range, 1–8). During a median follow-up of 13 months (range, 2–27), there was 1 recurrence. Conclusion: Although longer follow-up is still necessary, TEO appears to be an effective method of excising benign tumors and low-risk T1 carcinomas of the rectum. However, TEO should be considered as part of the diagnostic work-up. Furthermore, the resected specimen of a TEO procedure allows adequate local staging in contrast to an endoscopic piecemeal excision. Nevertheless, definitive histology must be appreciated, and in case of unfavorable histology, radical salvage resection still has to be performed.

Laparoscopic parenchymal preserving liver resections for colorectal liver metastases in the era of highly effective systemic therapy and selective internal radiation therapy can often prevent a hemihepatectomy. (With video)

BACKGROUND Preservation of hepatic parenchyma is important in liver surgery to prevent postoperative liver failure and according to some reports it could offer a prolonged survival and lower recurrence rates compared to major hepatectomies in patients with colorectal liver metastases. However, laparoscopic parenchyma-preserving liver resections can be technically challenging. The aim of this video is to illustrate the concept of laparoscopic parenchymal-preserving liver resections after conversion chemotherapy with targeted therapy. MATERIALS AND METHODS In this video we present three cases in which a laparoscopic parenchymal-preserving liver resection was performed after neo-adjuvant therapy: the first patient had a giant solitary colorectal metastasis in segment V and VIII. Neoadjuvant chemotherapy was given, resulting in a 30% volume reduction of the lesion after which a laparoscopic anterior sectionectomy was successfully performed. The second patient had five colorectal liver metastases. After conversion chemotherapy, four remaining metastases were resected by laparoscopic surgery. The last patient had 7 colorectal liver metastases. After 18 cycles of neo-adjuvant chemotherapy and a good response to selective internal radiation therapy, a laparoscopic liver resection of six metastases and radiofrequency ablation of 1 central lesion were performed. RESULTS The video of these three cases shows that laparoscopic parenchymal-preserving liver surgery is feasible after neo-adjuvant systemic therapy and selective internal radiation therapy. CONCLUSIONS The emergence of more effective systemic chemotherapies with biologicals and SIRT for the treatment of colorectal liver metastases often creates a possibility for parenchymal-preserving liver resections to achieve an R0 resection.

Totally extraperitoneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair device: A prospective case series

BACKGROUND The use of a self-expanding nitinol framed prosthesis (ReboundHRD®) for totally extraperitoneal laparoscopic inguinal hernia repair (TEP-IHR) could solve issues of mesh shrinkage and associated pain. We prospectively evaluated the use of the ReboundHRD® mesh for TEP-IHR. MATERIALS AND METHODS All patients who underwent a TEP-IHR using the ReboundHRD® Large mesh from April 2014 till May 2015, were included. No mesh fixation was performed. Follow-up assessments were performed at the day of surgery, 1, 2, and 7 days, 1, 3, 6, and 12 months. Outcome measures include post-operative pain (visual analogue scale, VAS), operative details, complications, and recurrence rate. RESULTS In total, 69 TEP-IHR procedures were performed in 54 patients (15 bilateral hernias). No perioperative and 5 (9%) postoperative complications occurred, all graded Clavien-Dindo I-II. The median length of stay was 1 day (range 0-3), with 78% of the operations performed in an ambulatory setting. Median VAS score decreased from 3 (range 0-4) on the day of surgery to 1 (range 0-2) on day 7. Patients were completely pain-free at a median time of 5 (range 1-60) days. The majority (80.4%, 37/46) of the active patients went back to work within 2 weeks (maximum 6 weeks). At a median follow-up of 19 months (range 16-26 months), no recurrences occurred. CONCLUSION TEP-IHR using a self-expanding nitinol framed hernia repair device is a safe technique in longterm follow-up. The technique is associated with a low incidence of postoperative pain, a short hospital stay and quick return to normal activities.