Mathieu D’Hondt

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen’s space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.

Value of Preoperative Esophagogastroduodenoscopy in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

Abstract Background : Roux-en-Y gastric bypass hinders post-operative endoscopic evaluation of the upper gastrointestinal tract. Our aims were to determine the prevalence of preoperative endoscopic findings in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) and to determine the proportion of patients in which these findings changed surgical management. Methods : We retrospectively evaluated electronic medical records of patients undergoing esophagogastroduodenoscopy (EGD) with routine antral biopsy for Helicobacter pylori (HP) detection, prior to LRYGB between January 2003 and January 2010 at our institution. The prevalence of all endoscopic findings was determined. Results : 652 underwent preoperative endoscopy prior to LRYGB. The mean age was 39.5 ± 11.3 years and mean body mass index was 42.8 ± 5.0 kg/m2. Abnormalities were found in 444 patients (68.1%). Findings at EGD were hiatal hernia 24.3% (n = 159), esophagitis 30.8% (n = 201), Barrett’s esophagus 0.8% (n = 5), gastritis 36.2% (n = 236), gastric or duodenal ulcers 7.5% (n = 49) and 2 cases of gastric cancer. The prevalence of HP infection was 17.6% (n = 115). In 51 patients (7.8%), endoscopic findings led to postponement of surgery: in 49 patients, gastric or duodenal ulcer had to be treated prior to surgery, in 2 patients, gastric cancer led to changement in surgical approach. Conclusions : Routine preoperative EGD detects different abnormalities which need a specific approach prior to bariatric surgery. EGD with routine biopsies for HP detection should be included in the preoperative workup prior to LRYGB. Positive EGD findings led to a change in medical treatment in a quarter (24.3%) of patients. Postponement of surgery due to the EGD findings was less frequent (7.8%).

Conversion for Unfavorable Intraoperative Events Results in Significantly Worst Outcomes During Laparoscopic Liver Resection: Lessons Learned From a Multicenter Review of 2861 Cases

Objective: To investigate the risk factors for conversion during laparoscopic liver resection and its effect on patient outcome in a large cohort of patients. Additional analysis of outcomes in patients who required conversion for unfavorable intraoperative findings and conversion for unfavorable intraoperative events will be performed to establish if the cause of conversion effects outcome. Summary Background Data: Multiple previous studies demonstrate that laparoscopic liver surgery reduces intraoperative blood loss, hospital stay, and morbidity while maintaining comparable oncological and survival outcomes when compared with open liver resections. However, limited information is available regarding the possible sequelae of conversion to open surgery, especially with regards to cause of conversion. Methods: A retrospective analysis of 2861 cases from prospectively maintained databases of 7 tertiary liver centers across Europe was performed. Results: Neo-adjuvant chemotherapy, previous liver resection(s), resections for malignant lesions, postero-superior location, and the extent of the resection are associated with an increased risk of conversion. Patients who require conversion have longer operations with higher blood loss; a longer HDU and total hospital stay, increased frequency and severity of complications and higher 30- and 90-day mortality. Patients who had an elective conversion for an unfavorable intraoperative finding had better outcomes than patients who had an emergency conversion secondary to an unfavorable intraoperative event in terms of HDU and total hospital stay, severity of complication, and 90-day mortality. Conclusions: Our study highlights the risk factors for conversion and suggests that conversion for unfavorable intraoperative events is associated with worse outcomes.

The interval approach: an adaptation of the liver-first approach to treat synchronous liver metastases from rectal cancer

BackgroundThe waiting interval after chemoradiotherapy (CRT) is an interesting therapeutic window to treat patients with synchronous liver metastases (SLM) from rectal cancer.MethodsA retrospective analysis was performed of 18 consecutive patients (M/F 10/8, age (range) 60 (51–75) years) from five institutions who underwent liver resection of SLM during the waiting interval after CRT for rectal adenocarcinoma.ResultsAll patients underwent interval liver surgery for a median (range) of 4 (2–14) liver metastases. Metastases involved a median (range) of 4 (1–7) liver segments. Median (range) time between end of CRT and liver surgery was 22 (6–45) days. Laparoscopic liver surgery was performed in 12 (67%) patients. No severe complications (Clavien-Dindo ≥ 3b) occurred after liver surgery. Median (range) length of hospital stay after liver surgery was 5 (1–10) days. All patients subsequently underwent rectal resection at a median (range) of 10 (8–13) weeks after end of CRT. Median (IQR) time-to-progression after liver surgery was 4.2 (2.8–9.2) months.ConclusionsThe waiting interval after neoadjuvant CRT is a valuable option to treat SLM from rectal cancer. More data are necessary to confirm its oncological efficacy.

The practice of laparoscopic liver surgery in Belgium: a national survey

Abstract Background: Laparoscopic liver surgery (LLS) gained popularity bringing several advantages including decreased morbidity and reduction of length of hospital stay compared to open. Methods: To understand practice and evolution of LLS in Belgium, a 20-questions survey was sent to all members of the Royal Belgian Society for Surgery, the Belgian Section of Hepato-Pancreatic and Biliary Surgery and the Belgian Group for Endoscopic Surgery. Results: Thirty-seven surgical units representing 61 surgeons performing LLS in Belgium responded: 50% from regional hospitals, 28% from university and 22% from peripheral hospitals. Replies from high volume centers (>50 liver-surgery/year) were 19%. More than 25% of liver procedures were performed laparoscopically in 35% of centers. LLS is adopted since more than 15-years in 14.5% of centers with an increasing rate reported in 59%. Low relevance of LLS in the hospital organization (26.5%) and lack of time in surgical schedules (12%) or of specific training (9%) are the main barriers for further diffusion. More than 80% of the responders agreed to participate to a national prospective registry. Conclusion: LLS is mainly performed in experienced HPB units with an increasing interest in peripheral centers. A prospective national registry will be useful by providing real data in terms of indications, morbidity and overall evolution.

Emergency balloon sealing of a ruptured giant anastomotic aneurysm of the groin.

Abstract An 85-year-old patient presented with a giant pseudo-aneurysm in the groin fifteen years after placement of an aortobifemoral graft (AbG). The pseudo-aneurysm was expanding rapidly. To prevent massive haemorrhage an inflatable balloon was inserted into the native distal aorta. The balloon was inserted via the contralateral groin. After inflation, the pseudo-aneurysm was safely excluded by the interposition of a new prosthetic segment between the left prosthetic branch of the ABG and the common femoral artery. This technique, which has been used for more than 50 years in several other indications, is an elegant method to minimise blood loss in the treatment of large pseudo-aneurysms of the groin.

Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study

PurposeSphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time.MethodsThis study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5–45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity.ResultsOut of the 100 patients, 16 had minor LARS (score 21–29) and 51 patients had major LARS (score 30–42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score.ConclusionsPerioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.

Chronic refractory constipation due to neurogenic bowel dysfunction can be successfully treated by sacral neurostimulation

Abstract Introduction: In the last few decades, sacral neurostimulation (SNS) has proven to be an effective treatment option for functional bowel disorders. Experience concerning the role of SNS in the treatment of chronic constipation due to neurogenic bowel dysfunction (NBD) however is limited. Methods: In this report, we present the case of a 44-year old patient, with chronic refractory neurogenic constipation after a spontaneous cerebral hemorrhage, who was treated with SNS. Results: Prior to treatment with SNS, the Constipation Scoring System showed a score of 22/30. Three months after SNS implantation, this score was reduced to 5/30. Patient had successful evacuation of stool every one to two days. Medication could be reduced to 15 drops of picosulphate per day. Patient experienced a significant improvement in quality of life. Conclusions: We believe that SNS could offer a safe, effective and relatively cost-effective treatment for patients with NBD refractory to conservative treatment.

Foreign body granuloma reaction following SIRT mimicking peritoneal metastases: a word of caution

Abstract Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver malignancy with poor survival rates. Surgical resection is the only curative treatment option, yet only a small portion of cases are resectable. In unresectable situations, suggested therapy consists of a systemic chemotherapy regimen with cisplatinum and gemcitabine. Selective internal radiation therapy (SIRT) has been proposed as an alternative treatment option and may lead to downstaging of unresectable iCCA to surgery. We present a case of a female patient diagnosed with an unresectable iCCA treated with SIRT in order to obtain downstaging. Explorative laparoscopy three months later showed multiple peritoneal lesions in the left upper quadrant, mimicking peritoneal metastases. Anatomopathological investigation showed a foreign body granuloma surrounding the SIRT resin particles. These findings have important consequences, as the presence of peritoneal metastases implies a palliative situation. Anatomopathological confirmation of any intra-abdominal lesion mimicking peritoneal metastases should be carried out.