Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation.

BACKGROUND: Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES: Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING: University hospital, France, public practice. METHODS: All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS: Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS: Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.

Efficacy of the double-pigtail stent as a conservative treatment for grade B pancreatic fistula after pancreatoduodenectomy with pancreatogastric anastomosis.

BACKGROUND: Despite improvements in surgical techniques and postoperative care, morbidity associated with pancreatoduodenectomy (PD) is still high. Grade B pancreatic fistula (PF) requires a specific combination of radiologically guided external drainage and medical support. This treatment is effective but requires prolonged hospitalization and maintenance of external drainage. The objective of this study was to evaluate the feasibility and efficacy of a double-pigtail stent (DPS) to treat grade B PF after PD with pancreatogastric anastomosis. METHODS: Between January 2008 and October 2011, all patients who presented grade B PF after PD (n = 6) were included in the study. The PF was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula. Endoscopic treatment was standardized with a DPS. The primary efficacy end point was the feasibility and efficacy of DPS placement. Secondary end points included data on the PF, the DPS placement procedure, and long-term outcome. RESULTS: Endoscopic DPS placement was achieved in all patients with no complications. The median time to onset of PF after PD was 14 days. Closure of the external PF was obtained 7 days after the introduction of the DPS. The median time to external drain removal was 7 days after DPS placement, and the median time to oral refeeding was 7 days after DPS placement for all patients. The median time to DPS removal was 60 days. The median length of hospital stay after DPS placement was 10 days. During a median follow-up period of 21 months, there was no recurrence of PF after removal of the DPS. CONCLUSION: Endoscopic treatment of grade B PF after PD appears to be effective and safe and is associated with shorter hospitalization.

Frey procedure for the treatment of chronic pancreatitis associated with common bile duct stricture.

BACKGROUND: The Frey procedure (FP) is the treatment of choice for symptomatic chronic pancreatitis (CP). In cases of biliary stricture, biliary derivation can be performed by choledochoduodenostomy, Roux-en-Y choledochojejunostomy or, more recently, reinsertion of the common bile duct (CBD) into the resection cavity. The objective of the present study was to evaluate the outcomes associated with each of these three types of biliary derivation. METHODS: We retrospectively analyzed demographic, CP-related, surgical and follow-up data for patients having undergone FP for CP with biliary derivation between 2004 and 2012 in our university medical center. The primary efficacy endpoint was the rate of CBD stricture recurrence. The secondary endpoints were surgical parameters, postoperative complications, postoperative follow-up and the presence of risk factors for secondary CBD stricture. RESULTS: Eighty patients underwent surgery for CP during the study period. Of these, 15 patients received biliary derivation with the FP. Eight of the FPs (53.3%) were combined with choledochoduodenostomy, 4 (26.7%) with choledochojejunostomy and 3 (20.0%) with reinsertion of the CBD into the resection cavity. The mean operating time was 390 minutes. Eleven complications (73.3%) were recorded, including one major complication (6.7%) that necessitated radiologically-guided drainage of an abdominal collection. The mean (range) length of stay was 17 days (8-28) and the median (range) follow-up time was 35.2 months (7.2-95.4). Two patients presented stricture after CBD reinsertion into the resection cavity; one was treated with radiologically-guided dilatation and the other underwent revisional Roux-en-Y choledochojejunostomy. Three patients presented alkaline reflux gastritis (37.5%), one (12.5%) cholangitis and one CBD stricture after FP with choledochoduodenostomy. No risk factors for secondary CBD stricture were identified. CONCLUSIONS: As part of a biliary derivation, the FP gave good results. We did not observe any complications specifically related to surgical treatment of the biliary tract. However, CBD reinsertion into the resection cavity appeared to be associated with a higher stricture recurrence rate. In our experience, choledochojejunostomy remains the "gold standard" for the surgical treatment for CBD strictures.

Addition of Molecular Adsorbent Recirculating System (MARS(®)) Albumin Dialysis for the Preoperative Management of Jaundiced Patients with Hilar Cholangiocarcinoma.

The preoperative management of hilar cholangiocarcinoma (HC) with jaundice focuses on decreasing the total serum bilirubin level (SBL) by performing preoperative biliary drainage (PBD). However, it takes about 6-8 weeks for the SBL to fall at a sufficient extent. The objective of this preliminary study was to evaluate the impact of Molecular Adsorbent Recirculating System (MARS(®)) dialysis (in association with PBD) on SBL decrease. From January 2010 to January 2011, we prospectively selected all jaundiced patients admitted to our university hospital for resectable HC and requiring PBD prior to major hepatectomy. The PBD was followed by 3 sessions of MARS dialysis over a period of 72 h. A total of 10 patients with HC were screened and two of them were included (Bismuth-Corlette stage IIIa, gender ratio 1, median age 68 years). The initial SBL in the two patients was 328 and 242 µmol/l, respectively. After three MARS dialysis sessions, the SBL had fallen by 30 and 52%, respectively. After the end of each session, there was a SBL rebound of about 10 µmol/l. The MARS decreased the serum creatinine level, the platelet count and the prothrombin index, but did not modify the serum albumin level. Pruritus disappeared after one and two sessions, respectively. MARS-related morbidity included hypotension (n = 1), tachycardia (n = 1), thrombocytopenia (n = 2) and anaemia (n = 1). When combined with PBD, MARS dialysis appears to accelerate the decrease in SBL and thus may enable earlier surgery. This hypothesis must be validated in a larger study.

Is stenting as "a bridge to surgery" an oncologically safe strategy for the management of acute, left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis.

OBJECTIVE AND BACKGROUND: Self-expanding metallic stent (SEMS) insertion has been suggested as a promising alternative to emergency surgery for left-sided malignant colonic obstruction (LMCO). However, the literature on the long-term impact of SEMS as "a bridge to surgery" is limited and contradictory. METHODS: From January 1998 to June 2011, we retrospectively identified patients operated on for LMCO with curative intent. The primary outcome criterion was overall survival. Short-term secondary endpoints included the technical success rate and overall success rate and long-term secondary endpoints included 5-year overall survival, 5-year cancer-specific mortality, 5-year disease-free survival, the recurrence rate, and mean time to recurrence. Patients treated with SEMS were analyzed on an intention-to-treat basis. Overall survival was analyzed after using a propensity score to correct for selection bias. RESULTS: There were 48 patients in the SEMS group and 39 in the surgery-only group. In the overall population, overall survival (P = 0.001) and 5-year overall survival (P = 0.0003) were significantly lower in the SEMS group than in the surgery-only group, and 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively (P = 0.02)). Five-year disease-free survival, the recurrence rate, and the mean time to recurrence were better in the surgery-only group (not significant). For patients with no metastases or perforations at hospital admission, overall survival (P = 0.003) and 5-year overall survival (30% vs 67%, respectively, P = 0.001) were significantly lower in the SEMS group than in the surgery-only group. CONCLUSIONS: Our study results suggest worse overall survival of patients with LMCO with SEMS insertion compared with immediate surgery.

A comparative study of surgery and endoscopy for the treatment of bile duct stricture in patients with chronic pancreatitis.

BACKGROUND: This study aimed to compare the outcomes of endoscopic treatment (ET) and surgical treatment (ST) for common bile duct (CBD) stricture in patients with chronic pancreatitis (CP). METHODS: From 2004 to 2009, 39 patients (35 men and 4 women; median age, 52 years; range, 38-66 years) were referred for CBD stricture in CP. Of these 39 patients, 33 (85 %) underwent primary ET, and 6 underwent primary ST. Treatment success was defined in both groups as the absence of signs denoting recurrence, with normal serum bilirubin and alkaline phosphatase levels after permanent stent removal in ET group. The follow-up period was longer than 12 months for all the patients. RESULTS: For the patients treated with ET, the mean number of biliary procedures was 3 (range, 1-10) per patient including extractible metallic stents in 35 % and multiple plastic stents in 65 % of the patients. The mean duration of stent intubation was 11 months. The surgical procedure associated with biliary drainage (4 choledochoduodenostomies, 1 choledochojejunostomy, and 1 biliary decompression within the pancreatic head) was a Frey procedure for five patients and a pancreaticojejunostomy for one patient. The overall morbidity rate was higher in the ST group. The total hospital length of stay was similar in the two groups (16 vs 24 days, respectively; p = 0.21). In terms of intention to treat, the success rates for ST and ET did not differ significantly (83 % vs 76 %; p = 0.08). Due to failure, 17 patients required ST after ET. Event-free survival was significantly longer in the ST group (16.9 vs 5.8 months; p = 0.01). The actuarial success rates were 74 % at 6 months, 74 % at 12 months, and 65 % at 24 months in the ST group and respectively 75 %, 69 %, and 12 % in the ET group (p = 0.01). After more than three endoscopic procedures, the success rates were 27 % at 6 months and 18 % at 18 months. CONCLUSION: For bile duct stricture in CP, surgery is associated with better long-term outcomes than endoscopic therapy. After more than three endoscopic procedures, the success rate is low.

Biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma with jaundice.

BACKGROUND AND AIM: The combination of photodynamic therapy and biliary stenting seems to be beneficial in the palliative treatment of unresectable cholangiocarcinoma. We aimed to assess the accuracy of photodynamic therapy in a single centre. METHODS: Fourteen selected patients, with jaundice related to unresectable cholangiocarcinoma, underwent photodynamic therapy and biliary stenting (with or without chemotherapy). Photofrin was injected intravenously (2 mg/kg) 2 days before intraluminal photoactivation. In case of malignant progression, photodynamic therapy was repeated. The outcome parameters were overall survival and quality of life. RESULTS: There were eight men and six women (median age: 67 [42-81]). Unresectability was related to a low Karnofski index (n = 2), peritoneal carcinomatosis (n = 4), vascular involvement (n = 3), invasion of the hepatoduodenal ligament (n = 2) and an under-sized liver remnant (n = 3). Biliary stenting was efficient (> or = 50% total bilirubin) in 78.5% of cases. Eight patients developed cholangitis. The mean number of photodynamic therapy procedures was two (1-4). Six (43%) patients needed > or = 2 procedures. No severe toxicity was noted. Photodynamic therapy improved the Karnofski index in 64% of cases. Six (42.8%) patients received concomitant chemotherapy (gemcitabine). The median survival time was 13.8 [0.7-29.2] months. The 3-, 6- and 12-month survival rates were 85%, 77% and 77%, respectively. CONCLUSION: These results confirm the beneficial effect of biliary drainage, photodynamic therapy and chemotherapy for unresectable cholangiocarcinoma in selected patients with jaundice.

Case report-complex management of a postoperative bronchogastric fistula after laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. Postoperative complications are mainly represented by gastric fistula with an occurrence rate of 0% to 5.1% in the literature. This complication is difficult to manage and requires multiple radiological, endoscopic, and surgical procedures. We report herein the case of a 23-year-old woman who underwent LSG for morbid obesity. This patient was reoperated for peritonitis due to a gastric fistula located on the top of the staple line. Five months later, she complained of a cough with fever and expectoration. A methylene blue test and a computed tomography scan diagnosed a postoperative bronchogastric fistula. After failure of aggressive conservative management, radical surgery was performed with total gastrectomy, reconstruction of the diaphragm using the extended latissimus dorsi flap, and a pulmonary lobectomy. This case report highlights the possible issue of the complex management of gastric fistula after LSG.

Colonic pseudolipomatosis: clinical, endoscopical and pathological features in nine cases.

UNLABELLED: Colonic pseudolipomatosis is a rare and benign condition. It is not well known by gastroenterologists and its pathogenesis is still unclear. METHODS: All cases of colonic pseudolipomatosis seen between February 2002 and June 2004 at the Amiens Universisty Hospital were identified and analyzed. RESULTS: During this period, 2099 colonoscopies were performed and 9 cases of colonic pseudolipomatosis were diagnosed (0.4%). Patients were all males aged from 41 to 67 (median age 52 years). They consulted for rectal bleeding (two patients), diarrhea (two patients) or abdominal pain (two patients). In three patients, colonic pseudolipomatosis was a fortuitous discovery during colonoscopy for polyp surveillance. The lesions presented as whitish and yellowish slightly elevated plaques ranging in size from a few millimeters to 4 cm. They extended over a two to 20 cm-long area, located in the right (two patients), transverse (four patients) or left colon (three patients). Microscopic examination showed empty spaces in the lamina propria measuring from 50 to 600 microm. They were negative for anti-CD31, CD34 and PS100 antibodies at immunohistochemistry and negative for Sudan black in three cases. The ultrastructural study showed in two cases round spaces containing small fibrillary protein-like deposits that might be lymph. CONCLUSION: Colonic pseudolipomatosis is rare. Its pathogenesis is not well-known but could be due to gas invasion or extravasation of lymph into lamina propria, maybe induced by mucosal lesions related to barotrauma or certain colonoscope cleaning solutions.

Management of digestive bleeding related to portal hypertension in cirrhotic patients: A French multicenter cross-sectional practice survey.

AIM: To investigate the conformity of management practices of gastrointestinal hemorrhage in cirrhotic patients with relevant guidelines. METHODS: A questionnaire on the management of digestive bleeding was completed for all consecutive cirrhotic patients admitted to 31 French hospitals. RESULTS: One hundred and twenty-six bleeding events were recorded. It was the first bleeding episode in 79 patients (63%), of whom 40 (51%) had a prior diagnosis of cirrhosis and 25 (32%) had previously undergone an endoscopy. The bleeding episode was a recurrence in 46 patients (37%). The median time between onset and admission was 4 h, but exceeded 12 h in 42% of cases. There was an agreement between centers for early vasoactive drug administration (87% of cases), association with ligation (42%) more often than sclerosis (21%) at initial endoscopy, and antibiotic prophylaxis (64%). By contrast, prescription of beta-blockade alone or in combination (0 to 100%, P = 0.003) for secondary prophylaxis and lactulose (26% to 86%, P = 0.04), differed among centers. CONCLUSION: In French hospitals, management of bleeding related to portal hypertension in cirrhotic patients is generally in keeping with the consensus. Broad variability still remains concerning beta-blockade use for secondary prophylaxis. Screening for esophageal varices, the use of antibiotic prophylaxis and patients information need to be improved.

Endoscopic treatment of chronic pancreatitis.

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.

Groove pancreatitis and pancreatic heterotopia in the minor duodenal papilla.

Groove pancreatitis is a rare form of segmental chronic pancreatitis that involves the anatomic space between the head of the pancreas, the duodenum, and the common bile duct. We report 2 cases of groove pancreatitis with pancreatic heterotopia in the minor papilla. Patients were a 44-year-old woman and a 47-year-old man. Both had a past history of alcohol consumption and presented with abdominal pain, vomiting, and weight loss caused by duodenal stenosis. Abdominal computed tomography revealed thickening of the duodenal wall and enlargement of the pancreatic head in both patients. In 1 patient, ultrasound endoscopy showed a dilated duct in the head of the pancreas. Pancreaticoduodenectomy was performed to rule out pancreatic adenocarcinoma and because of the severity of the symptoms. In both cases, gross and microscopic examinations showed fibrous scar of the groove area. The Santorini duct was dilated and contained protein plugs in both patients, with abscesses in 1 of them. In both cases, there were microscopic foci of heterotopic pancreas with mild fibrosis in the wall of the minor papilla. Groove pancreatitis is often diagnosed in middle-aged alcoholic men presenting with clinical symptoms caused by duodenal stenosis. The pathogenesis of this rare entity could be because of disturbance of the pancreatic secretion through the minor papilla. Pancreatitis in heterotopic pancreas located in the minor papilla and chronic consumption of alcohol seem to be important pathogenic factors.