Morgagni hernia a case report and a review of the literature

Introduction: Herniation through right sternocostal hiatus called Morgagni hernia [MH], constitutes about 3% of all cases of congenital diaphragmatic hernias. It is diagnosed with a lateral chest X-ray and confirmed with a barium enema or computed tomography. The defect can be repaired by a transabdominal, transthoracic approach, or via minimal invasive surgery

Case presentation: An 81-year-old female with a history of cholecystectomy presented to our center with nausea and vomiting for the last two weeks

Surgical technique: The laparoscopic repair of the MH was carried out under general anesthesia, and the patient was positioned in supine position. A segment of transverse colon with omentum, the round and the falciform ligament, the antro-pyloric region along with the first portion of the duodenum were seen herniating into the hernia sac and were easily reduced without significant adhesion to the sac. The defect was closed with non-absorbable 1-0 suture, using transfascial sutures with the knots residing in the subcutaneous plane. A polypropylene mesh of 20 x 15 cm was inserted into the abdominal cavity through 10 mm port, and fixed to the anterior abdominal wall and edge of the diaphragmatic defect with tackers

Discussion : There is no guidelines to date on the optimal surgical approach since open abdominal, open thoracic as well as minimal invasive techniques have all been practiced. In our patient we did not resect hernia sac as we judged that excision was difficult and could have led to damage to the pericardium or mediastinal structures. Closure of the edges of the hernia was done with extracorporeal knots in the subcutaneous plane and we consider the transfascial sutures to be a practical and reliable way to close the defect. Fixation of the mesh was done using tackers. We think that this technique should be the approach of choice for the treatment of MH

[Management of complicated appendicitis at the Hotel-Dieu de France hospital in Beirut]

Objective : To study the effectiveness and evaluate the rate of success of the conservative treatment adopted at the Hôtel-Dieu de France [HDF] university hospital, in the case of complicated appendicitis with an abscess or inflammatory mass and to compare this management with the one described in the literature

Material and Methods: This retrospective observational and descriptive study is based on data from patients treated at the hospital Hôtel- Dieu de France between 2009 and 2013, for complicated appendicitis with an initial non-surgical management. Forty patients were included in this study. Data were collected from medical records of the patients

Results: The average age of patients was 47.93 years and 65% were male. Conservative treatment was effective in 90% of patients with early failure in 7.5% of cases and late failure [relapse after antibiotherapy discontinuation] in 2.5% of cases. Drainage was performed in 32.5 % of patients, and resulted in a significant extension of the average duration of the first hospitalization [10.92 days] compared to patients treated without drainage [5.81 days]. The total duration of antibiotic therapy in our study was 4.5 weeks on average. Twenty-nine patients [72.5%] were operated by laparatomy and 11 [27.5%] laparoscopically, with an average hospital stay shortened from 4.04 to 2.5 days with the laparoscopic technique. As for the pathological examination, 10% of patients presented a mucinous neoplasm. No intra-operative complications were noted. Similarly, none of the patients had postoperative intraabdominal complications

Conclusion : At Hôtel-Dieu de France [HDF] university hospital, the conservative treatment of complicated appendicitis with an abscess or an inflammatory mass, followed by an appendectomy a few weeks later, shows a high success rate [90%]

[Medium-term functional results of surgical lacura of Gastro-Esophageal Reflux]

Introduction: The evaluation of the quality of life [QoL] has now become an established parameter in clinical research, including analysis of the effectiveness of medical or surgical treatment. Therefore, the treatment of gastroesophageal reflux disease [GERD] not only aims to relieve symptoms, prevent complications, minimize undesirable side effects of treatment but also improve the QoL of patients

Material and Methods: Our series includes 51 patients [23 men and 28 women] whose average age was 37 years [range 17-62], treated surgically for GERD at University Hospital Hotel-Dieu de France between 2005 and 2012. Their QoL was evaluated before and after surgery [mean follow-up 4.5 years], retrospectively, using the GIQLI Questionnaire [gastrointestinal quality of life index], which comprises 36 items covering five dimensions: symptoms, physical condition, emotions, social integration and medical treatment

Results: Before the intervention, the GIQLI score was 89 +/- 9; after antireflux surgery, GIQLI score was 113 +/- 9 [p < 0.001]. The unit-variable statistical analysis revealed that the highest GIQLI scores were correlated with the lowest BMI [body mass index]. No statistically significant difference was recorded for the age, sex, and duration of medical treatment before surgery, the surgical indication, surgical technique and the surgical approach. Statistically significant improvement was noted in the following dimensions: symptoms, physical condition, medical treatment and social integration. A non-statistically significant improvement was observed at the level of the emotional dimension. 12% of operated patients resumed a regular medical treatment against reflux, 37% have resumed medical treatment on demand and 51% of patients have never taken medical treatment after the operation. Six patients were reoperated with an overall reoperation rate of 12%

Conclusions: Antireflux surgery significantly improves QoL of patients but does not guarantee the full exemption of medical treatment. In our series, patients with a normal BMI and patients with only the classic complaints of reflux [heartburn, regurgitation, belching] are the best candidates for antireflux surgery. Better patient selection could prove to be a way to improve the results in terms of QoL

Subtotal or total colectomy as surgical treatment of left-sided occlusive colon cancer

The treatment of acutely obstructed carcinoma of the left colon and sigmoid still represents a matter of controversy. The aim of this study was to assess retrospectively the results of its management by emergency subtotal or total colectomy with primary anastomosis. Sixty-seven patients were reviewed. There were 42 males and 25 females. The mean age was 70.5 years [range: 26-87 years]. Mean operative time was 210 minutes. There were five synchronous colon carcinomas [75%] and 23 [343%] synchronous tubulous and tubulovillous adenomas. No death was noted in the series. Ten postoperative complications [15%] occurred in nine patients including one postoperative peritonitis without evidence of anastomotic leak, one alithiasic cholecystitis, one evisceration and two intra-abdominal abscesses. The mean hospital stay was 11.4 days. Fifty-eight patients were assessed at three and twelve months for functional results. No fecal incontinence was encountered. The mean number of bowel movements per 24 hours was 3.2 at three months and 2 at twelve months. All patients were satisfied with their quality of life. Twelve patients [20.7%] occasionally needed anti-diarrheic medications. Urgent subtotal or total colectomy with primary anastomosis is a safe and efficient procedure in the management of acutely obstructed neoplasm of the left colon. It allows to treat in one stage the cancer and the obstruction, bearing no mortality, acceptable morbidity and satisfactory postoperative functional results

Perforation of the rectum and colon during barium enema examination. Report of four cases

Background The barium enema examination [BEE] is an important diagnostic study and considered to be safe without adverse effects. Perforation of the bowel is rare but is the most frequent complication of BEE and can be life-threatening. We report four cases of barium extravasation due to BEE treated at our institution, three rectal perforations and one perforation in the descending colon. The four patients underwent surgery because signs of peritonitis developed. Two of them recovered and two died from multiple organ failure. Perforation of the colon and rectum during BEE constitutes a surgical emergency in most cases. Prompt recognition and management are vital in decreasing morbidity and mortality