Theodoros Thomopoulos

Routine chest X-ray is not mandatory after fluoroscopy-guided totally implantable venous access device insertion

BACKGROUND The aim of this study is to determine whether systematic postoperative chest X-ray is required after totally implantable venous access port device (TIVAD) placement under fluoroscopic control. METHODS A retrospective chart review of all consecutive patients with fluoroscopy-guided TIVAD insertion from July 10, 2009 to April 16, 2012 was conducted at the Geneva University Hospitals (n = 927). Patients with an available postoperative chest X-ray were included, regardless of approach (open or percutaneous) and venous access site (subclavian, cephalic, jugular, etc.). Exclusion criteria were incomplete data and preexisting pneumothorax or hemothorax. RESULTS Eight hundred ninety-one patients were included. First-intention venous cutdown was performed in 878 patients (98.5%), with success rates of 79.4% and 88.2% when targeting the left and right cephalic veins, respectively. Percutaneous access was the chosen first-intention procedure for 12 patients (1.3%). Eight-hundred thirty-six (93.8%) insertions were performed only by the open approach and 53 (5.9%) implantations required at least one venous puncture. Two implantations were performed using previous central venous accesses. Immediate complications associated with TIVAD placement and detected on the postoperative chest X-ray consisted of 1 asymptomatic pneumothorax, 1 symptomatic hemothorax, and 2 malpositions of the catheter. One additional pneumothorax was discovered during the first night after TIVAD insertion in a patient who became symptomatic. CONCLUSIONS The very low incidence of immediate complications detected by postprocedural chest X-ray suggests that such a control is not mandatory as a routine method after fluoroscopy-guided TIVAD insertion mainly performed by venous cutdown. X-ray should be performed only in cases of clinical suspicion.

Total Laparoscopic Treatment of an Adult Gastric Duplication Cyst with Intrapancreatic Extension.

Patient: Female, 28 Final Diagnosis: Gastric duplication Symptoms: — Medication: — Clinical Procedure: Resection of the duplication Specialty: Surgery Objective: Rare disease Background: Gastric duplication is a rare malformation mostly diagnosed during childhood. Symptoms in adults are atypical, rare, or may be completely absent. The diagnosis is suggested after a morphological and histological assessment. The treatment is a complete surgical resection. Case Report: We report on a case of a 28-year-old woman referred to our unit for a surgical assessment of a gastric duplication of the antropyloric area associated with paraduodenal and pancreatic extensions, diagnosed by several image tools and histological confirmation. She had undergone a total laparoscopic resection of the duplication without violation of the gastric lumen or any other splanchnic injury. The postoperative course was uneventful and the patient was discharged on postoperative day seven without any complains. Conclusions: The present report illustrates that complete resection of a distal gastric duplication is feasible by a laparoscopic minimal invasive procedure and therefore is considered to be a safe therapeutic modality. Our case is the first distal gastric duplication cyst with pancreatic and paraduodenal extension reported in the literature completely resected by laparoscopic approach.

Roux-En-Y Fistulojejunostomy: a New Therapeutic Option for Complicated Post-Sleeve Gastric Fistulas, Video-Report

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG.MethodsBetween January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG.ResultsIn this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients.ConclusionsRYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Totally laparoscopic treatment of vaginal cuff dehiscence: A case report and systematic literature review.

Highlights • Minimal invasive approaches to hysterectomy, such as total laparoscopic or robotic, can lead to higher incidence of vaginal cuff dehiscence.• Vaginal evisceration is a rare but life-threatening complication if it is misdiagnosed.• Even if several approaches for the management of the vaginal herniation have been describe in the literature, the entirely laparoscopic treatment seems to be safe and effective, demanding nevertheless a high surgical experience.

Management of a ruptured hydatid cyst involving the ribs: Dealing with a challenging case and review of the literature

INTRODUCTION Hydatid liver cysts can rupture into neighboring structures in 15-60% of patients, and most often involves the bile duct, the bronchi, and the peritoneal/pleural cavities. Rarely, chest or abdominal wall involvement occurs that are challenging to manage. This case report and literature review describes the management of patients with chest wall and rib invasion. PRESENTATION OF CASE A 74-year-old woman, of Spanish origin, presented with right upper quadrant abdominal pain and tender localized swelling. On computer tomography (CT) assessment, the rupture of a hydatid cyst into the right anterior chest wall was identified. Partial involvement of the 10th and 11th rib were noted. The diagnosis was confirmed by a serological test. Surgical treatment involved a radical en bloc right hepatic resection together with resection of the involved ribs, diaphragm and subcutaneous tissue. Primary diaphragm and wall closures were performed. The postoperative course was uneventful with three weeks of albendazole treatment. CT follow-up at six months demonstrated the absence of recurrence. DISCUSSION Complete resection is the gold standard treatment of patients with hydatid cysts with the aim to remove all parasitic and pericystic tissues. CONCLUSION The present report illustrates that an aggressive surgical en bloc resection is feasible and should be preferred for the treatment of hydatid cysts with rupture into the chest wall, even when the ribs are involved.

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: A Case Report and Review of the Literature

Patient: Female, 69 Final Diagnosis: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia Symptoms: Occasional and mild shortness of breath • persistent nocturnal cough Medication: — Clinical Procedure: Surgical intervention: right middle lobectomy Specialty: Surgery Objective: Rare disease Background: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary disorder that is characterized by diffuse hyperplasia of bronchiolar and bronchial pulmonary neuroendocrine cells. In this condition, when no other pathological pulmonary condition is detected, DIPNECH is considered to be an idiopathic lung disease. DIPNECH is a rare condition that can be difficult to distinguish from other forms of reactive pulmonary neuroendocrine cell hyperplasia (NECH). We present a case of DIPNECH and describe the approach to diagnosis of this rare condition. Case Report: A 69-year-old woman with a past medical history of successfully treated lobular carcinoma of the breast, presented to our department with a respiratory tract infection. High-resolution computed tomography (HRCT) of the chest showed a suspicious pulmonary nodule, measuring 13 mm, in the right middle pulmonary lobe. Combined positron emission tomography (PET) and computed tomography (CT), showed a solid and metabolically active nodule. A transbronchial biopsy and histopathology confirmed a diagnosis of DIPNECH. Conclusions: It is possible that DIPNECH is an under-diagnosed pulmonary condition because it is rarely associated with symptoms. At this time, there are no evidence-based management guidelines. While the majority of cases have stable clinical course, some cases can progress to cause airway obstruction. This case report highlights this rare, but potentially progressive condition, and the need for evidence-based management guidelines for DIPNECH.

Response to the Comment on: Common Limb Length Does Not Influence Weight Loss After Standard Laparoscopic Roux-en-Y Gastric Bypass

We would like to thank you for the interest and the comments after the publication of our paper. However, we need to clarify some misunderstandings of the author’s remarks. Firstly, we agree that the weight loss is mostly due to the length of the biliopancreatic (BPLL) and the common loop (CLL). However, in our study, we wanted to investigate one and only one variable, which is the CLL. Secondly, the author suggests that we should have used a third group with a longer biliopancreatic loop. We think that the author did not understand very well the objectives of our study. Our aim was to investigate if the CLL could influence weight loss in a standard Roux-en-Y gastric bypass (RYGBP) with 150-cm alimentary limb (AL) and 75 cm (BPL), and not find a relationship with another variable as the BPLL. Thirdly, the author believes that the length of the three loops should be chosen according to the total length of the small bowel. We agree with the author, but actually the ideal length of the gastric bypass limbs is still under debate. In most series, the limb lengths of the RYGBP are 50–75 cm for BPL and 100–150 cm for AL. It is mostly depending on each surgeon’s practice. Especially, in the case of the biliopancreatic diversion or the distal RYGBP, lengthening the BPLL or the ALL or shortening the CLL will increase malabsorption and subsequent weight loss, but especially in the distal bypass, the most effective proportion of limb’s length needs to be clarified. Fourthly, the author points out that we have not taken into account the disease of obesity which is different before and after the ages of 40 and the eating behavior which may explain some failures after RYGBP. Yes, this is a true statement. The ideal scenario would perhaps have been a multivariate analysis to investigate the way how the age and the feeding behavior can influence the weight loss. However, we repeat that this was not the purpose of our study. In addition, there are still many other factors which may influence weight loss such as patient compliance, diet coaching, psychological disorders, and sports. Fifthly, the author suggests that overtime the RYGBP loses its malabsorption mechanism and theoretically retains its restriction mechanismwhich is due both to the size of the gastric pouch and also to the diameter of the gastrojejunal anastomosis. We disagree with his opinion. The RYGBP is a procedure which seems to be more efficient in the long term, compared to pure restrictive procedures. The fact that patients gradually consume bigger amount of food and do not regain their lost weight reveals that malabsoption and mechanisms other than restriction seem to be efficient, such as gastro-endocrine responses (PYYand GLP-1 plasmatic levels) [1]. Afterwards, the author mentions the study of HernándezMartínez who conclude that leaving a 230-cm length of common limb and redistributing the remaining 60% in the alimentary channel and 40 % in the biliopancreatic channel produce sustained EWL.We do not agree with these authors as 230 cm of CLL is too long provoking too much reabsorption of lipids and worse results. Many studies show that when the length of the common channel approaches 100 cm or less, a significant impact on weight loss is observed thanks to malabsorption [2]. The last comment of the author we would like to criticize is about the risk of perforation and the length of the operation because of the measure of the CLL. We agree that there is a risk of perforation, but we were doing that measure just only * Theodoros Thomopoulos teothomopoulos@yahoo.com