Pj. Kestens

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases

AbstractBackground: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown. Objective: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases. Methods: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS). Results: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12–44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence. Conclusions: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients.

AbstractBackground: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage.

Laparoscopic treatment of gallbladder duplication - A plea for removal of both gallbladders

AbstractBackground: Gallbladder duplication is a rare congenital condition, which can now be detected preoperatively by imaging studies. Methods: We report a case of duplicated gallbladder with symptomatic unilobar gallstones. Appropriate biliary workup (ultrasound, oral cholecystography, and intravenous cholangiography) allowed a correct preoperative diagnosis. Results: Laparoscopic treatment included selective removal of the diseased accessory gallbladder. However, postoperative acute cholecystitis and symptomatic gallstone occurred in the remaining main gallbladder, and laparoscopic reintervention was required 27 months later. Conclusions: This case illustrates the need for complete removal of both gallbladders during initial surgery. Precise intraoperative recognition of vascular and biliary anatomy—including abnormalities—is highlighted to avoid mistakes during surgery.

Intrathoracic nissen fundoplication: Long-term clinical and ph-monitoring evaluation

From 1976 until April 1989, 31 intrathoracic total fundoplications were performed for reflux esophagitis and irreducible hiatus hernia. In the first 16 patients (group 1) the operation was complicated with acute perforation of the wrap in 4 cases, bronchogastric fistula in 1, and herniation of the wrap higher in the chest in 1. Technical modifications were applied to 15 more recent patients (group 2). These are enlargement of the hiatus, looseness of the wrap and its appropriate anchorage, avoidance of forceps when handling the stomach, care with the vagi, and efficient gastric decompression in the postoperative period. The postoperative course was always uneventful in group 2. Twenty-six patients, who still have their initial wrap, were considered for clinical evaluation: 11 from group 1 (mean follow-up, 81.5 months) and 15 from group 2 (mean follow-up, 32.8 months). All are free from any symptom of reflux; gas-bloat syndrome is infrequent and dysphagia is relieved. Twenty-four-hour pH monitoring, performed in 14 patients (3 from group 1 and 11 from group 2) (mean follow-up, 42 months), was normal in 13; a pathological upright reflux (time pH less than 4, 8.4%) was demonstrated in one symptom-free woman in whom endoscopy was unremarkable. Mechanisms of complications experienced in group 1 are analyzed in the light of the technical evolution of the procedure, and the place of the intrathoracic total fundoplication in the management of short esophagus is defined, considering the other available surgical techniques.

Ct of the Portal-vein After Portacaval-shunt With Arterialization

Objective Our goal was to assess the state of the portal vein in cirrhotic patients treated with a portacaval shunt associated with an arterialization of the portal vein. Materials and Methods We reviewed the follow-up CT of 23 patients treated by portacaval shunt with arterialization of the portal vein. Results Five patients demonstrated an aneurysm of the portal vein. Follow-up studies revealed progression of the aneurysm and development of a mural thrombosis in four patients. The thrombosed portal vein was calcified in three patients. One patient demonstrated a dilatation of the saphenous vein graft in addition to the portal vein aneurysm. Only one of the five patients was symptomatic, presenting with ascites, dilatation of intrahepatic biliary ducts, and jaundice secondary to the compression of hilar structures by the huge portal vein. Conclusion Aneurysm of the portal vein following portacaval shunt associated with arterialization of the portal vein is not a rare complication.

Experience with the EEA Stapler for Colorectal Anastomosis: Early and Late Results

From March 1979 to January 1983, 250 consecutive patients underwent a left colectomy (LC; n = 119) or an anterior resection (ARR; n = 131). The colorectal anastomoses were constructed with the EEA stapler. After ARR, 56 sutures were low (at 7 cm or less from the dentate line) and 75 high. 8% of the sutures would have been probably impossible without the gun. The mortality rate was 2.8%. At autopsy, only 1 death could be related to an intestinal problem. Anastomotic leaks were observed in 6% of the cases, all after ARR (11.4%). The leaks were twice as frequent after low sutures (16%) than after high sutures (8%). Late severe consequences developed in only 2 patients. The reliability of the results was confirmed at long term. The majority of the patients were symptom-free as early as 6 months after the operation, and X-ray controls exhibited a large normal suture in about 70% of the patients. The EEA appears to be a satisfactory means of performing safe low colorectal sutures.