[Indications of laparoscopic general and digestive surgery. Evidence based guidelines of the French society of digestive surgery].
Explore the source record for details and available documents.
Digestive System Diseases↗
Biomedical subjects
R Kianmanesh
Publications and source records attributed to R Kianmanesh.
Doppler assessment after right hepatectomy confirms the need to fix the remnant left liver in the anatomical position.
BACKGROUND: The remnant left liver after right hepatectomy tends to rotate spontaneously into the right subphrenic space. This rotation might induce venous outflow impairment. The aim of this study was to assess immediate venous outflow in the left hepatic vein by intraoperative Doppler ultrasound (US) according to the position of the remnant liver. METHODS: From August 2003 to February 2004, assessment of left hepatic venous outflow was systematically performed in 44 consecutive right hepatic resections by Doppler US in spontaneous and anatomical positions. The anatomical position was defined as the position in which the falciform ligament was in its strict median position. RESULTS: The placement of the left liver from the spontaneous position to the anatomical position resulted in a significant increase in left hepatic venous outflow (20.1 +/- 5.7 versus 8.5 +/- 4.4 cm/s; P < 0.0001). In the spontaneous position, the decrease in left hepatic venous outflow persisted even without division of the left triangular ligament (10.2 +/- 5.4 versus 21.7 +/- 5.3 cm/s in the anatomical position) or removal of the middle hepatic vein (8.4 +/- 3.4 versus 21.3 +/- 5.8 cm/s). CONCLUSION: : Results of this study strongly suggest that after right hepatectomy the remnant left liver should always be fixed in the anatomical position.
Adult↗
Primary endocrine tumours of the liver.
BACKGROUND: In patients with hepatic endocrine tumours, a primary neoplasm is not always found elsewhere despite extensive investigations, raising the possibility that the hepatic lesion is the primary tumour. The aim of this study was to assess the incidence, characteristics and prognosis of patients with primary hepatic endocrine tumours. METHODS: Patients with histologically confirmed hepatic endocrine tumours identified since 1993 were reviewed. All those with no primary tumour identified by computed tomography of the thorax, abdomen and pelvis, upper and lower digestive endoscopy, duodenopancreatic endoscopic ultrasonography or somatostatin receptor scintigraphy (SRS) were included. Clinical and tumour characteristics were assessed retrospectively. RESULTS: Of 393 patients with digestive endocrine tumours, 17 (seven men; median age 55 (range 26-69) years) had hepatic endocrine tumours without evidence of an extrahepatic primary lesion either at diagnosis or during a median follow-up of 43 (range 12-108) months. Ten patients had multiple and seven had single tumours. The tumours were non-functional in 13 patients and well differentiated in 14 patients. SRS was positive in the liver in 11 patients. Curative resection was performed in seven. Overall actuarial survival rates were 100, 69 and 51 per cent at 1, 3 and 5 years respectively. Only poor differentiation was associated with an unfavourable outcome (relative risk 20.8; P < 0.001). CONCLUSION: Primary hepatic endocrine tumours were identified in almost 5 per cent of patients with digestive endocrine tumours. Poor differentiation was the only factor associated with unfavourable outcome.
Adult↗
[Spontaneous splenic rupture: report of three new cases and review of the literature].
This study reports 3 new cases of spontaneous (or atraumatic) splenic rupture of the spleen, including two with massive hemoperitoneum and one with a secondary rupture of splenic infarct, and reviews the literature about this rare disease. These spontaneous ruptures are rare and potentially fatal. They result from infectious diseases (mainly mononucleosis and and paludism) and hematological diseases (mainly malignant hemopathies) in more than 50% of cases. Mortality is close to 20%, and includes some deaths occurring before diagnosis was established and postoperatives deaths, which can result from delayed management and bad general condition of the patients. Splenectomy is usually mandatory. Non-surgical treatment can be indicated only in young and stable patients.
Diagnosis, Differential↗
[Blind loop syndrome].
Malabsorption can raise from several causes, including post surgical conditions. Noticeably, ileo-ileal anastomosis can lead to bacterial stagnation in the caecum, with recirculation of the intestinal content, and intestinal spreading of the colonic flora. We review here nine cases who were operated on in our department in the last 20 years. In five patients the syndrome appeared after an intestinal resection due to a postsurgical intestinal infarction due to adhesions. In four patients it appeared after an ileo-transverse derivation motivated by post-surgical occlusion. We conclude that any type of malabsorption appearing after abdominal surgery, even remotely from the surgical procedure should suggest this uncommon diagnosis. Surgical treatment, i.e. replacement of the intestinal anastomosis with a new termino-terminal anastomosis, is necessary and sufficient.
Adult↗
Can laparoscopy reduce hospital stay in the treatment of Crohn's disease?
PURPOSE: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery. METHODS: Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures). RESULTS: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05). CONCLUSION: There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.
Adult↗
Harmonic scalpel in laparoscopic colorectal surgery.
PURPOSE: With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel in laparoscopic colorectal surgery. METHODS: In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24-80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel. The 10-mm-blade Harmonic Scalpel device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema. RESULTS: There was no mortality. Mean operative time was 276 (range, 200-520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed. CONCLUSION: Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel" are technically easy, feasible, and reliable.
Adenocarcinoma↗
Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization.
Explore the source record for details and available documents.
Hepatectomy↗
[Post-traumatic fracture and migration in the pulmonary artery of the catheter of a totally implantable venous access device. Unusual complication].
The case of a 59 year-old patient, who sustained a post-traumatic fracture of the silastic catheter of his totally implantable venous access device that migrated in the right pulmonary artery, is reported. The venous device was placed six months earlier for the treatment of metastatic spread of a primary unknown adenocarcinoma. The venous device was placed on the left side in consideration of a recent right supraclavicular node biopsy. The catheter was introduced through the left internal jugular vein and its peripheral end was positioned subcutaneously across the clavicle to be connected to the port chamber placed in the infraclavicular region. The accidental fracture of the catheter was attributed to a closed trauma occurred during the transport of a refrigerator on the homolateral shoulder. Treatment involved extraction of the migrated fragment through a percutaneous transfemoral angioradiological procedure. A few days later the chamber was removed and a new totally implantable venous access device was placed on the other side.
Catheterization, Central Venous↗
[Pancreato-biliary maljunctions and congenital cystic dilatation of the bile ducts in adults].
Pancreato-biliary maljunctions (PBM) in adults are defined by the presence of an abnormally long common pancreato-biliary duct (more than 15 mm long) formed outside the duodenal wall and/or by high amylase level in the bile. The high amylase level in the bile is the functional expression of a chronic toxic reflux of pancreatic juices into the biliary tree. The presence of the PBM have two basic consequences: (i) formation of congenital cystic dilatations of the bile duct (CCBD) during embryogenesis and (ii) cancerous degeneration of extrahepatic bile ducts including the gall bladder. CCBD are commonly found in Southeast of Asia and in Japan where more than two-thirds of the worldwide cases are reported. Women are more frequently touched. The main manifestations are pain, cholangitis and acute pancreatitis. Cancerous degeneration mainly due to chronic pancreatico-biliary reflux consecutive to the presence of PBM is the most serious complication of CCBD. Its global incidence is about 16% and increases by age and after cysto-digestive derivations widely performed in the past. In 80% of the cases a cholangiocarcinoma involving the extrahepatic portion of the biliary tree including dilated segments such as the gall bladder and/or cystic wall is found. The treatment of choice of most common types of CCBD with PMD is complete excision of most of the sites where cancer may arise and should interrupt the pancreato-biliary reflux. This treatment significantly reduces the incidence of bile duct cancer to 0.7%. However, despite the absence of mortality, the overall morbidity rates reach from 20% to 40%. In the complete excision, the entire common bile duct from porta hepatis to the intrapancreatic portion of the choledochus and the gall bladder are resected. The bile continuity is assured by a hepatico-jejunal Y anastomosis. When there is no CCBD, the high risk of gall bladder cancer in the presence of a PBM justifies by itself a preventive cholecystectomy even if no biliary stone is present.
Bile Duct Diseases↗
[Hand-sewn intra-abdominal anastomosis performed via video laparoscopy during colorectal surgery].
STUDY OBJECTIVE: Laparoscopic colectomies have been recently shown to be feasible and safe, with the use of stapling devices to fashion the anastomosis. The aim of this study was to evaluate the feasibility and safety of laparoscopic intra-abdominal hand-sewn anastomosis. PATIENTS AND METHODS: Seven patients (four males and three females, mean age 48 years) were included. There were two ileocolic resections for recurrence of Crohn's disease, two right colectomies (one for Crohn's disease and one for carcinoid tumor of the appendix), two left colectomies for diverticulitis and one segmental colectomy for sigmoid volvulus. There were: four side-to-side anastomoses, two side-to-end anastomoses and one end-to-end anastomosis. Anastomoses were fashioned with interrupted single layer sutures in four cases (two ileo-colic and two colorectal anastomoses) and with single layer running sutures in three cases (two ileo-colic and one colo-colic anastomoses). The specimens were retrieved by means of a plastic bag through a 3 to 5 cm long minilaparotomy in five cases and through the rectum in two cases. RESULTS: Mean additional time to perform hand-sewn intra-corporeal anastomosis was 90 +/- 15 min. There was no operative mortality and no intraoperative complications. Postoperative course was uneventful in six patients. Patients were started on an oral fluid diet on day 2 and discharged on day 5, except for one patient with Crohn's disease who had a severe anastomotic bleeding on postoperative day 2 and who required laparotomy for hemostasis through a service colotomy with a single suture. He was discharged on day 8. CONCLUSION: Intra-abdominal hand-sewn anastomoses are feasible and seem reliable. This represents a new step making laparoscopic procedures even closer to conventional techniques. This technique must be evaluated in larger series.
Abdomen↗
[Bronchogenic cyst of the right hemidiaphragm mimicking a hydatic cyst of the liver].
Ectopic subdiaphragmatic development of a bronchogenic cyst is rare. We report the case of a 28-year-old woman with a symptomatic bronchogenic cyst of the right hemidiaphragm simulating a hydatic cyst of the liver on ultrasonography and CT scan. Diagnosis of a diaphragmatic lesion was made during laparotomy, and complete resection was successful. Final diagnosis was done on pathology.
Abdominal Pain↗
[Treatment of gastric cancer].
Gastric cancer (GC) still remains a major cancer problem in the world. Its prognosis is poor with an overall 5-year survival rate less than 20%. Surgical resection is still the only curative treatment of GC. Curative resection depends on tumoral location and extension, particularly lymph node involvement. Proximal GC (fundus, body) are treated by total gastrectomy (TG). For distal GC (antrum, pylorus), the TG is no more the recommended treatment and distal sub-total gastrectomy can safely be performed when carcinologic rules are respected: 5-6 cm free margin for the remnant stomach and at least 2 cm resection of the proximal duodenum. Cardia cancers, upon to their tumoral extension toward the esophagus, can require either TG or proximal esophagogastrectomy by combined thoracic and abdominal approach. As demonstrated in the last controlled studies, D2 extensive lymphadenectomy, in spite of its contribution to a better prognostic staging, does not improve long term survival after curative surgery. TG extended to the spleen or to the pancreas should not be performed in curative surgery because of a high rate of postoperative complications. Limited gastric resections for superficial GC have to be evaluated in Western countries. Palliative exploratory laparotomies should be avoided by better preoperative explorations. Laparoscopic staging in GC could be indicated when palliative resection or bypass are possible. The results of adjuvant chemotherapy is still disappointing and new protocols have to be evaluated. Intraperitoneal chemotherapy with or without hyperthermia represents a serious hope in the treatment of GC, but its significative action on the survival is not well demonstrated, while its morbidity and mortality rate is high.
Antineoplastic Agents↗
A 270 degree laparoscopic posterior fundoplasty in the treatment of gastroesophageal reflux.
BACKGROUND: The aim of this prospective study was to evaluate the results of laparoscopic treatment of gastroesophageal reflux using a posterior fundoplasty. STUDY DESIGN: Fifty-one patients with gastroesophageal reflux or paraesophageal hernia, or both, documented by fibroscopy, acid reflux monitoring, and manometry were evaluated. The operative technique consisted of abdominal esophagus mobilization, approximation of the crura, and construction of a 270 degree posterior gastric valve, 5 to 7 cm in height. A clinical examination was performed after two weeks, four months, one year, and two years, and fibroscopy, acid reflux monitoring, and manometry were done at four months. RESULTS: One patient required a conversion to laparotomy. One opening of the gastric valve was repaired laparoscopically. There was no perioperative death. Morbidity was limited to one case of pulmonary aspiration of gastric juice. All patients but one who were operated on laparoscopically have been clinically evaluated between four and six months after surgery. There was no dysphagia, diarrhea, or gas bloating reported after two months. Four patients without clinical symptoms refused to go through postoperative explorations. Among the 45 remaining patients, one had a reflux recurrence and another only an abnormality on acid reflux monitoring. There was no degradation of the clinical result among the 26 and 12 patients seen at one and two years, respectively. CONCLUSIONS: A 270 degree posterior fundoplasty can be performed laparoscopically without major morbidity. A short follow-up examination confirms the efficacy of the procedure and the absence of specific morbidity. If these results are confirmed, they could be an argument to broaden the indications of the antireflux procedure as compared to prolonged medical treatment.
Adult↗
[Surgical treatment of gastric, enteric, and pancreatic endocrine tumors Part 1. Treatment of primary endocrine tumors].
Endocrine tumors (ET) of the digestive tract (formerly called neuroendocrine tumors) are rare. They are classified into two principal types: gastrointestinal ET's (formerly called carcinoid tumors) which are the most common, and pancreaticoduodenal ET's. Functioning ET's secrete polypeptide hormones which cause characteristic hormonal syndromes. The management of ET is multidisciplinary. Poorly-differentiated ET's have a poor prognosis and are treated by chemotherapy. Surgical excision is the only curative treatment of well-differentiated ET's. The surgical goals are to: 1. prolong survival by resecting the primary tumor and any nodal or hepatic metastases, 2. control the symptoms related to hormonal secretion, 3. prevent or treat local complications. The most common sites of gastrointestinal ET's ( carcinoids) are the appendix and the rectum; these are often small (<1 cm), benign, and discovered fortuitously at the time of appendectomy or colonoscopic removal. Ileal ET's, even if small, are malignant, frequently multiple, and complicated in 30-50% of cases by bowel obstruction, mesenteric invasion, or bleeding. The carcinoid syndrome (consisting of abdominal pain, flushing, diarrhea, hypertension, bronchospasm, and right sided cardiac vegetations) is caused by the hypersecretion of serotonin into the systemic circulation; it occurs in 10% of cases and is usually associated with hepatic metastases. More than half of the cases of pancreatic ET are non-functional. They are usually malignant and of advanced stage at diagnosis presenting as a palpable or obstructing mass or as liver metastases. Insulinoma and gastrinoma (cause of the Zollinger-Ellison syndrome) are the most common functional ET's. 80% are sporadic; in these cases, tumor size, location, and malignant potential determine the type of resection which may vary from a simple enucleation to a formal pancreatectomy. In 10-20% of cases, pancreaticoduodenal ET presents in the setting of multiple endocrine neoplasia (NEM type I), an autosomal-dominant genetic disease with multifocal endocrine involvement of the pituitary, parathyroid, pancreas, and adrenal glands. For insulinoma with NEM-I, enucleation of lesions in the pancreatic head plus a caudal pancreatectomy is the most appropriate procedure. For gastrinoma with NEM-I, the benefit of surgical resection for tumors less than 2-3 cm in size is not clear. The lesions are frequently small, multiple, and widespread and recurrence is frequent after excision. The long-term prognosis is nevertheless fairly good. But the eventual development of liver metastases which are the most common cause of mortality still argues for an aggressive surgical approach in the early stages of the disease.
Adult↗
[Surgical treatment of gastric, enteric pancreatic endocrine tumors. Part 2. treatment of hepatic metastases].
The development of hepatic metastases (HM) marks a turning point in the evolutionand prognosis of well-differentiated endocrine tumors (ET). Management is usually multicisciplinary (chemotherapy, arterial chemo-embolization, percutaneous ablation, somatostatin analogs, biotherapy, and surgery). A thorough pre-operative work-up is neecessary to exclude extrahepatic disease and to detect tiny HM's. Complete resection (RO) is the only curative treatment for well-differentiated ET with HM. The type of resection is specific to each case and may range from wedge resection of a metastasis to complex hepatectomy with simultaneous resection of the primary ET. Cytoreductive surgery may be indicated for palliation when medical therapy fails to control endocrine symptoms. Operative mortality is low (0-6%) and global survival is 60-70% afterafter R) resection of HM of well-differentiated ET's. After resection of HM involving only one hepatic lobe, 5 year survival is better than 90%. When HM are multiple, bilobar and synchronous, the prognosis is very poor--only 10% of such patients can have a complete resection and this often requires a long prologue of ancillary procedures (chemotherapy, chemoembolization, portal vein ligation, percutaneous ablation). Hepatic transplantation (HT) has only a limited rôle in the treatment of HM for ET; mortality is high when HT is associated with large and complex resections, i.e. pancreaticoduodenectomy. Although there is no consensus in the literature, HT should be limited to the most optimal cases (young, good general health, well-differentiated tumor, slow evolution, complete resection of the primary rumor, and unresectable liver metastases). Global survival for HT in patients with ET is 60% at 2 years, 47% at 5 years; tumor-free survival at 5 years is 24%. HT for HM has better survival results for ET's of intestinal origin (carcinoids) than for duodenopancreatic ET's.
Embolization, Therapeutic↗
[Indications for laparoscopy in general and gastrointestinal surgery. Evidence-based recommendations of the French Society of Digestive Surgery].
Explore the source record for details and available documents.
Digestive System Surgical Procedures↗