Stéphane Bourgouin

Duodenal gastrointestinal stromal tumors (GISTs): arguments for conservative surgery.

IntroductionGastrointestinal stromal tumors (GISTs) of the duodenum are rare. We sought to evaluate the postoperative courses and long-term outcomes of conservative surgery (CS) versus pancreaticoduodenectomy (PD) for patients with non-metastatic duodenal GISTs.MethodsSeventeen patients underwent surgery for duodenal GISTs between January 2000 and January 2012; 11 patients underwent CS (CS group), and six patients underwent a PD (PD group).ResultsMortality was similar between the two groups. Patients in the PD group had longer operative times, more tumors located on the pancreatic side of the duodenum, higher rates of post-operative complications including postoperative pancreatic fistulas, and a longer hospital stay, when compared with patients of CS group. All tumors were resected with clear surgical margins (R0 resection). The median disease-free survival times were not different.ConclusionCS was safe and provided similar oncologic outcomes as PD. CS should be the procedure of choice in patients with GIST that does not involve the pancreatic side of the duodenum.

Enterolith ileus due to jejunal diverticulosis

Jejunal diverticulosis is a rare malformation that is often asymptomatic. Complications might be similar to those occurring in large-bowel diverticula but also include a much more particular event: intestinal obstruction due to migration and impaction of enterolith formed inside diverticula. This is a very uncommon entity; diagnosis and management are thus often delayed. Mostly surgical exploration is necessary because obstruction symptoms are unresponsive to medical treatment. The authors report a new case of enterolith ileus in a 74-year-old man, due to jejunal diverticulosis, and its successful surgical management in emergency. Only 39 similar cases have ever been reported in the literature.

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

BACKGROUND Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score). METHODS Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score. RESULTS Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method. CONCLUSIONS The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.

Accidental Section of the Ulnar Nerve in the Wrist During Arthroscopy

Arthroscopy of the wrist is a frequently performed procedure. Its role in diagnosis and treatment is significant. The complications of arthroscopy are well known and are described in the literature. We describe a case of accidental section of the ulnar nerve during repair of the triangular fibrocartilage complex during arthroscopy. The nerve section was caused by the trocar used for drainage in the 6U portal. We propose to establish the injury mechanism and describe a safe procedure for this examination.

Influence of loading speed on the mechanical properties of the colon

Trauma is a leading cause of death for young people in developed countries, becoming a public health issue. After the spleen and liver, the digestive tract is the third most frequently affected organ during blunt abdominal trauma. Gastrointestinal injuries are responsible for significant morbidity and mortality due to the difficulty in diagnosing such intestinal lesions and the resulting delay in treatment. In-depth studies are required to understand the pathophysiological mechanisms that are responsible for these intestinal lesions. Virtual trauma studies using numerical models of the intra-abdominal organs are among the most promising means that are used to study and predict the occurrence of intestinal injuries during abdominal trauma. Mechanical behaviour of the colon has only been studied under quasi-static loads. This study involves the experimental characterization of the mechanical behaviour of the colon using tensile tests to determine the mechanical response under different loads.

Blind pouch syndrome following enteroanastomosis

A 51-year-old man presented to our unit with a 7-day history of abdominal pain that evolved acutely with fever in the last 2 days. His surgical history included an emergency right ileocolectomy that was performed 23 years ago because of an appendicular abscess, with reestablishment of the intestinal continuity by side-to-side isoperistaltic anastomosis. The clinical examination revealed conjunctival pallor, tachycardia, fever and abdominal tenderness. By abdominal computed tomography (CT), we noted a 14-cm intraperitoneal ‘abscess’ limited to its circumference by surgical clips, massive stranding of the surrounding fat and peritoneal effusion without pneumoperitoneum (Fig. 1). An emergency laparotomy was performed, finding a perforated dilated ileal stump. After resection and washing, we reestablished intestinal continuity by handsewn end-toside anastomosis. The patient recovered well and was discharged 5 days after admission. Side-to-side anastomosis is a reliable method of reestablishing intestinal continuity that avoids the difficulties and complications of end-to-end anastomosis. However, side-to-side anastomoses can affect complications if the proximal segment that is distal to the stoma is excessive. In such a case, the segment that projects beyond the stoma dilates, resulting in a gradually enlarging blind pouch that can ulcerate and perforate. The incidence of blind pouch syndrome is extremely low and can occur within 1 month to several years after anastomosis of the small bowels alone, small and large intestine, or colon alone. Although pouches can develop with end-to-side anastomosis, they are much more common with side-to-side procedures, but do not occur after end-to-end anastomosis. These pouches can affect either blind-end segments or solely the distal section of the afferent segment. No report has examined the association between stapled or handsewn anastomoses and the incidence of pouch formation. However, it appears that blind ends are less likely to fill with intestinal contents when they are generated in isoperistaltic fashion. The formation of pouches in side-to-side anastomosis results from (Fig. 2): the creation of an antiperistaltic segment in which peristalsis is directed towards the closed end; the disruption of the circular muscle layer, rendering circular contraction impossible and packing intestinal contents into the closed end. A blind end no longer than 2.5 cm beyond the stoma can dilate under such circumstances into a large blind pouch over years. Bacterial overgrowth in the stagnant bowel contents perturbs intestinal absorption, leading to malnutrition and causes the intestinal wall to become hypertrophic, oedematous and inflamed. Small ulcerations can develop, leading to intestinal intermittent bleeding and perforation in extreme cases. Enteroliths and tumours have also been described in persistent blind pouches. Symptoms are abdominal pain, asthenia because of chronic anaemia and inability to gain weight because of malnutrition and diarrhoea. Acute cases can also present as intestinal perforation, massive gastrointestinal bleeding and intestinal obstructions. The anaemia can either be microcytic, as result of iron deficiency that is caused by intestinal bleeding, or macrocytic, which predominates in cases of intestinal malabsorption. Abdominal CT usually identifies a Fig. 1. Coronal reformatted computed tomography of the abdomen. The image shows a typical aspect of the blind pouch, with an ovoid loop of distended bowel (asterisk) adjacent to staple lines (arrows). The stranding of the mesenteric fat suggests perforation of the pouch.

Preperitoneal pelvic packing

Severe pelvic traumatisms are associated with elevated mortality because of the high risk of exsanguination from multiple sources of bleeding. Treatment should encompass resuscitation, bone stabilization and hemorrhage control by arterio-embolization or surgery. Pre-peritoneal packing has been described in hemodynamically unstable patients who need damage control. The surgical technique of this simple and effective procedure is fully described by the authors with some complementary useful technical advices.

Laparoscopic Management of Gallstone Ileus.

A 93-year-old woman was admitted to our unit with a 3-week history of right hypochondrium pain that had evolved acutely in the last 2 days. Her medical history included major cardiovascular diseases and a hysterectomy performed 40 years earlier. Clinical examination revealed non-specific diffuse abdominal tenderness with abdominal distension, vomiting, and loss of flatus, suggesting an adhesive intestinal obstruction. Routine admission blood tests demonstrated moderate sepsis and acute functional kidney failure, without liver function test abnormalities. Non-injected abdominal computed tomography (CT) was performed, and signs of chronic cholecystitis, pneumobilia with cholecysto-enteric fistula, and small-bowel obstruction due to a 3-cm gallstone impacted in the last jejunal loop were found (Fig. 1). The diagnosis of gallstone ileus was made, and the patient was taken to the operating room to undergo an emergency coelioscopy. The exploration showed small-bowel dilation but failed to reveal the gallbladder because of tight omental adhesions. After distal bowel adhesiolysis, the last jejunal loop was found and the gallstone localized. A 4-cm longitudinal enterotomy at the anti-mesenteric border was carried out and the impacted stone was brought out. The enterotomy was then closed by a continuous suture of absorbable monofilament (Fig. 2). Because of predictable surgical difficulties in this high-risk patient, we chose not to remove the gallbladder to avoid dealing with the cholecysto-enteric fistula repair. The postoperative course was uneventful and the patient was discharged on day 8 post-surgery. Gallstone ileus is a rare complication of calculous gallbladder disease (0.5 to 2 %) and represents 1 to 4 % of mechanical intestinal obstructions. 1 The pathology usually affects elderly patients and is the consequence of an evolved calculous cholecystitis that spontaneously fistulates into the digestive tract. Although the clinical presentation is unspecific, radiological exams can show small-bowel obstruction, ectopic gallstones and pneumobilia, due to the abnormal communication between the biliary tract and the bowels, thereby describing the classical Rigler triad in 15 % of cases. 1 Although a biliary-enteric fistula involves in most cases the gallbladder and the duodenum, in rare cases, the fistula originates directly from the biliary tract, thereby leading to a higher rate of cholangitis. Medical treatment may be attempted but usually fails because the calculous is often stuck at the ileo-caecal junction. In regard to surgical treatment, no consensus is available and four procedures are described as follows: enterotomy with stone extraction and cholecystectomy with fistula repair (one-stage procedure), enterotomy with stone extraction followed by fistula repair during a second intervention (twostage procedure), bowel resection and cholecystectomy with fistula repair or bowel resection alone. 2 Although the onestage procedure offers the most complete treatment, it is also the most complex one, thereby exposing the patient to a higher risk of enteric leakage after cholecysto-enteric fistula repair * Stéphane Bourgouin stephane_bourgouin@hotmail.fr

Traumatisme fermé de l’aorte abdominale chez le polytraumatisé. Comment hiérarchiser la prise en charge à la phase aiguë ?

Blunt trauma of the abdominal aorta is rare. Secondary to high-energy trauma, it is observed mainly in association with complex lesions. Evaluation of injury to the aorta must be a priority due to the risk of life-threatening massive hemorrhage. The clinical presentation can be quite obvious but also variable and often misleading. If in doubt, a systematic injected whole body scan is essential to diagnose aortic lesions. Hemorrhage or ischemia dictates emergency laparotomy. Opening the retroperitoneum increases the risk of infection if there is an associated gastrointestinal tract injury and may contraindicate use of arterial prostheses. Endovascular treatment can be proposed for less symptomatic lesions, including intimal dissection. Stents can be inserted via a femoral approach. In the event of juxtarenal dissection, there is a risk of renal artery thrombosis. Endovascular treatment is currently not recommended. This treatment can be delayed for a few days if necessary. Morbidity is low and long-term results are good.

Fistule ilio-urétérale : complication redoutable d’un faux anévrisme iliaque infecté à Candida. À propos d’un cas

Arterio-ureteral fistula is a rare condition difficult to diagnose. The usual presentation associates acute paroxysmal hematuria with well-identified history and risk factors. We report the case of an 84-year-old man with a life-threatening complication of an ilio-ureteral fistula complicating an anastomotic iliac pseudoaneurysm after prothetic iliofemoral surgery, due to a fungic infection by Candida. After reporting the clinical case and the emergency surgical treatment, we present a review of the literature.