Retroperitoneal abscess resulting from perforated retrocecal appendicitis:a case report.

Retroperitoneal abscess secondary to acute appendicitis is a relatively rare, but serious surgical infection. Adequate drainage and coverage with the appropriate antibiotics has led to improved outcome of retroperitoneal abscesses in recent years. We report the case of a 52 years old patient operated in emergency for perforated retrocecal appendicitis. A retroperitoneal abscess was diagnosed 5 days later, by computed tomography. The drainage of the abscess and the antibiotic therapy have ensured the total recovery of the patient. The alternatives of therapy are discussed.

Isolated adenomatous polyposis of the appendix: report of a case.

This case study describes a 61-year-old patient who had previously undergone sigmoid polypectomy. A follow-up colonoscopy revealed a polyp prolapsing into the colonic lumen through the base of the appendix. A laparoscopic-assisted appendectomy was performed, in which the cecum was exteriorized through the trocar hole so that a wide excision of the base could be performed. Fifty-eight polyps were observed in the appendix, but the base was free of polyps. Histologic studies reveal well-differentiated villous adenomatous polyposes. The patient was symptom free four years after surgery.

History of Lap-Band: from dream to reality.

BACKGROUND: Laparoscopy in severely obese patients is a surgical challenge due to the deep operative field, massive visceral fat, hypertrophic and steatotic liver and inadequate instrumentation. However, performing bariatric surgery by laparoscopy permits a minimally invasive procedure in patients who are usually considered high risk because of their morbid obesity. The challenge was to overcome technical difficulties of laparoscopy in the morbidly obese. METHOD: We needed to develop a new surgical protocol for the gastric approach in severely obese patients. The existing silicone band could not be used for laparoscopy, and a new prototype of the silicone band for laparoscopic use was designed. Because of ethical reasons, we began this work on the animal model. In an animal lab program using pigs, we refined the surgical technique of the laparoscopic approach. A new design of the adjustable silicone band for laparoscopic use was developed. RESULTS: After a 1-year animal lab program and approval by the ethics committee, we performed our first human laparoscopic adjustable gastric banding on September 1st, 1993. CONCLUSION: The development of the Lap-Band from concept to animal lab, ending in clinical application, has been an advance in bariatric surgery.

Surgical approach in severe bleeding peptic ulcer.

Hospitalisation and surgery for uncomplicated peptic ulcers have decreased over the past 20 to 30 years, but the total number of operations for bleeding peptic ulcer has increased. Haemorrhage remains the most common complication of peptic ulcer and also the one with the highest mortality rate. Emergency operations to control the bleeding have a mortality rate in the range of 10% to 20%. With the advent of endoscopic haemostasis, the hospital mortality rate is reduced, by reducing rebleeding and emergency operation rate. Emergency operative intervention is clearly indicated for patients with active haemorrhage refractory or inaccessible to endoscopic haemostasis. Combination of successful endoscopic haemostasis and elective early operative intervention favorably influences mortality only if applied to selected patient at high risk of rebleeding and death before sequelae of shock. For those at low risk for recurrent haemorrhage, early operation would be associated with an unacceptable operative risk. Truncal vagotomy and pyloroplasty, with ulcer oversew is the best surgical approach for elective and emergency operation in poor risk patients with duodenal ulcer haemorrhage. Proximal gastric vagotomy and ulcer oversew may be chosen in selected good risk patient. Gastric ulcers are associated with an increased risk of recurrent haemorrhage and malignancy. A more radical procedure (partial gastrectomy) should be favoured since it reduces bleeding recurrence rate without increasing mortality.

Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity. A preliminary report.

A first approach to laparoscopic placement of the adjustable silicone gastric band (ASGB) was begun in our institution in 1992. This work started on an animal model first. In the animal lab, details of laparoscopic dissection around the stomach have been defined. A new prototype of the adjustable silicone band for laparoscopic use has been devised. Four voluntary patients underwent this operation on the 1st, 2nd, and 3rd of September 1993. All the patients were female and the average weight was 116 kg (102-120 kg). The mean body mass index was 43 kg/m2 (36-49 kg/m2). No major operative difficulty was encountered. Immediate postoperative outcome was uneventful.

Hemodynamic changes during laparoscopic cholecystectomy.

Hemodynamics during laparoscopic cholecystectomy under general anesthesia (isoflurane in N2O/O2 (50%)) were investigated in 15 nonobese ASA Class I patients by using invasive hemodynamic monitoring including a flow-directed pulmonary artery catheter. During surgery, intraabdominal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator, and minute ventilation was controlled and adjusted to avoid hypercapnia. Hemodynamics were measured before anesthesia, after the induction of anesthesia, after tilting into 10 degrees head-up position, 5 min, 15 min, and 30 min after peritoneal insufflation, and 30 min after exsufflation. Induction of anesthesia decreased significantly mean arterial pressure and cardiac index (CI). Tilting the patient to the head-up position reduced cardiac preload and caused further reduction of CI. Peritoneal insufflation resulted in a significant increase (+/- 35%) of mean arterial pressure, a significant reduction (+/- 20%) of CI, and a significant increase of systemic (+/- 65%) and pulmonary (+/- 90%) vascular resistances. The combined effect of anesthesia, head-up tilt, and peritoneal insufflation produced a 50% decrease in CI. Administration of increasing concentrations of isoflurane, via its vasodilatory activity, may have partially blunted these hemodynamic changes. These results demonstrate that laparoscopy for cholecystectomy in head-up position results in significant hemodynamic changes in healthy patients, particularly at the induction of pneumoperitoneum.