Prevention of parastomal hernia by intraperitoneal onlay mesh reinforcement at the time of stoma formation.

PURPOSE: Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of this study is to assess the safety and prophylactic effect of intraperitoneal onlay mesh (IPOM) reinforcement of the abdominal wall at the time of primary stoma formation to prevent PSH occurrence. MATERIALS AND METHODS: This multicentre prospective study concerned 20 patients operated for low rectal carcinoma between 2008 and 2010. Those patients had an elective and potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round composite mesh centred on the stoma site and covering the lateralised colon. There were 8 men and 12 women with a median age of 69 years (range: 44-88) and a body mass index of 27 (range: 21-35). The major outcomes analysed in the study were operative time, complications related to mesh and PSH occurrence. Patients were evaluated 1 month after surgery and then every 6 months with physical examination and computed tomography scan (CT-scan). For PSH, we used the classification of Moreno-Matias. RESULTS: Surgery was performed by laparoscopy in 17 patients and by laparotomy in 3; 12 had an extraperitoneal colostomy, and 8 had a transperitoneal colostomy. The median size of the mesh was 15 cm (range: 12-15). The median operative time was 225 min (range: 175-300), and specific time for mesh placement was 15 min (range: 12-30). One month after surgery, one patient presented with a mild stoma stenosis that was treated successfully by dilatation. With a median follow-up of 24 months (range: 6-42), no other complication potentially related to the use of the mesh was recorded and no mesh had to be removed. On clinical examination, one patient (1/20 = 5 %) had a stoma bulge that appeared a few months after surgery, but was not associated with symptoms. CT-scan evaluation confirmed that all the patients with a normal clinical examination had no PSH and revealed that the patient with the stoma bulge had a stoma loop hernia (type 1a hernia). This patient was followed up for 36 months, no clinical or radiological aggravation of the stoma loop hernia was observed, and he remained totally asymptomatic. CONCLUSIONS: With 95 % of excellent results, IPOM reinforcement at the time of end colostomy formation in selected patients is a very promising procedure. A drawback of this technique is the possibility of developing a stoma loop hernia due to sliding of the exiting colon between the covering mesh and the abdominal wall. However, this risk is low, and no adverse clinical consequence for the patient was noted in our series.

Achalasia: the case for primary laparoscopic treatment.

Laparoscopic Heller myotomy offers the best-known surgical therapy for esophageal achalasia. Nevertheless, this procedure continues to compete with alternative endoscopic treatment and is often considered only as a secondary resort. In this study, the authors performed a review of the results of laparoscopic Heller myotomy and an evaluation of the impact of previous endoscopic treatment regarding perioperative complications and late results. Twenty-seven patients with achalasia confirmed by a manometry examination underwent a primary laparoscopic Heller myotomy (group 1, n = 14) or experienced endoscopic treatment failure (group 2, n = 13). A dysphagia score (0-4) was obtained before and after surgery. Clinical course was reviewed at 2 months and then every 6 months after surgery. In December 1999, patients answered a questionnaire regarding surgery satisfaction, postoperative reflux, and dysphagia for statistical analysis. There were no deaths. Mean hospital stay was 5.6 days. Three perforations occurred in group 2 (25%) versus one in group 1 (6%) (not statistically significant). At a mean 27-month follow-up, the dysphagia score was significantly (P < 0.001) improved in both groups but more significantly in group 1 versus group 2 (not statistically significant). Only one patient in group 2 reported heartburn. All patients in group 1 (100%) were satisfied with surgery as opposed to 10 of 13 patients (75%) in group 2 (P < 0.10). Primary laparoscopic Heller myotomy appears to be the treatment of choice for achalasia. Previous endoscopic treatment increases intraoperative complications and may affect long-term results.

[Assessment of quality of life after antireflux surgery]. / Evaluation de la qualité de vie après chirurgie antireflux.

AIM OF THE STUDY: To assess the quality of life (QoL) of patients operated for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: This prospective study included 82 consecutive patients submitted to antireflux surgery between October 1998 and January 1999. A new questionnaire was used to assess their QoL: the Gastrointestinal Quality of Life Index (GIQLI) that includes 36 items concerning 5 dimensions: symptoms, vitality, emotions, social relations and medical treatment. The series consisted of 44 men and 38 women with a mean age of 47 years (range: 18-78). QoL was assessed before and 6 months after surgery; the follow-up rate was 94% (77/82). The pre- and postoperative GIQLI scores of the study group and the GIQLY score of a control group of 110 healthy patients were compared. RESULTS: Before surgery, the GIQLI score (90 +/- 23) was greatly impaired compared to the score (123 +/- 13) observed in the control group (p < 0.001). After surgery, the GIQLI score (110 +/- 23) increased significantly (p < 0.001), but remained statistically lower than the score of the control group (p < 0.001). The postoperative score recorded in the symptoms dimension was lower than the control group score: 55 +/- 11 versus 66 +/- 6 (p < 0.001), while no significant difference was observed in the other 4 dimensions. Univariate statistical analysis revealed that the postoperative GIQLI score (y) was correlated with the preoperative GIQLI score (x) according to the formula: y = 0.43 x + 71 (p < 0.001) and the sex of the patients, as the postoperative GIQLI score was higher in male patients (115 +/- 19) than in female patients (103 +/- 23) (p < 0.02). CONCLUSION: The QoL of the patients was greatly improved after antireflux surgery, but remained lower than that of a control group of healthy subjects. Better patient selection should improve the results. In our series, male patients or patients with a high preoperative GIQLI score were the best candidates for antireflux surgery.

[Major liver injury. Role of preoperative transcutaneous endoluminal aortic clamping]. / Traumatisme hépatique majeur. Intérêt du clampage aortique endoluminal transcutané pré-opératoire.

Severe contusion of the liver (type V in the Moore and Flint classification) still has a very poor prognosis. Exsanguination may lead to cardiac arrest when the abdomen is opened. Three patients with major liver injury were treated after percutaneous intra-aortic balloon occlusion and complete vascular exclusion of the liver. Two patients survived and one died due to complications resulting from lung trauma. The aorta was occluded with a balloon catheter inserted via the femoral route. The hepatic vascular exclusion was performed surgically after resuscitation had reestablished a satisfactory haemodynamic situation. Liver resection could then be performed under safe conditions. Aortic occlusion is a simple procedure with minimal disadvantages which could improve prognosis of major liver contusion by reducing the rate of intra-operative death.

[Adenocarcinoma on endobrachyesophagus. Results and prognostic factors apropos of 19 cases surgically-treated]. / Adénocarcinomes sur endobrachyoesophage. Résultats et facteurs pronostiques à propos de 19 cas opérés.

The authors report about a retrospective series of 19 operated patients with adenocarcinomas in a columnar lined esophagus. The resection rate was 95%, the postoperative mortality rate was 5.5%. The survival rate following curative exeresis (n = 14) was 32% (+/- 14) at 5 years. All patients with a stage III lesion died after 2 years, while 46% (+/- 19) of those with stage I or II tumors (p less than 0.001) survived at 5 years. In a multivariative analysis, the most important prognostic factor is the histological grade (p less than 0.01), then the extension to the lymph nodes (p less than 0.1). As the adenocarcinoma often reveals the columnar lined esophagus, the improvement of the prognosis certainly depends on the evaluation of the treatment, which combines pre- or postoperative radiation and chemotherapy, in multidepartmental prospective studies.

[Calibrated latero-lateral portacaval anastomosis in the treatment of digestive hemorrhages by portal hypertension in the cirrhotic patient]. / L'anastomose porto-cave latéro-latérale calibrée dans le traitement des hémorragies digestives par hypertension portale du cirrhotique.

The calibrated side to side portocaval shunt was described in 1979 by P. Marion. This type of shunt preserves a hepatopedal blood flow by maintaining portocaval pressure gradient superior to halve of the initial gradient. Twenty nine shunts were performed from 1981 to 1989 in patients with hemorrhagic liver cirrhosis alcoholic in 83 percent of cases). Two patients were in Child Pugh C class (7%), six procedures were performed as an emergency (21%). The operative mortality was nil. The hepatopedal blood flow assessed by direct venous angiography was maintained in 66% of cases at one year and 22% at five years. The actuarial survival rate without recurrent bleeding was 96% at two years, 88% at five years. Severe chronic encephalopathy was noted in three cases (10.3%). One patient was successfully treated by surgical anastomotic tightening with disappearance of the hepatic encephalopathy. The actuarial survival rate without encephalopathy was 82.7% at five years. The side to side calibrated shunt is a technically easy procedure with low mortality, low incidence of thrombosis and clinical results similar to the results of Warren's procedure. For these reasons, we have decided to include this procedure in our local protocol of management of hemorrhagic liver cirrhosis.

[Orthotopic liver transplantation for metastases of bronchial carcinoid tumor]. / Transplantation orthotopique hépatique pour métastases d'une tumeur carcinoïde bronchique.

We report the case of a 42 year old man in whom orthotopic liver transplantation was performed successfully for unresectable hepatic metastases of a bronchial carcinoid tumor. Prior to transplantation, somatostatin therapy, pulmonary lobectomy, and systemic chemotherapy (streptozotocin and fluorouracil) were performed. After 9 months there were no signs of clinical or biological recurrence. Orthotopic liver transplantation might be indicated for unresectable and limited liver metastases of neuroendocrine tumor.