Zenker's diverticulum perforation due to transoesophageal echocardiography: Case report of the management of an extremely rare life-threatening iatrogenic complication.

INTRODUCTION: Transoesophageal echocardiography is generally considered to be a safe monitoring and diagnostic tool. Even though the severe morbidity rate is relatively low and mortality rate exceptional, sometimes life-threatening events may occur during this procedure. PRESENTATION OF CASE: We described the case of a 79-year-old woman with an extremely rare case of Zenker's diverticulum perforation following a transoesophageal echocardiography and its successful management with a 6 months follow-up. DISCUSSION: Several specific endoscopic techniques have been described in the literature in case of Zenker's diverticulum and we believe the use of check lists should be implemented. CONCLUSION: We hope that the documentation of this rare iatrogenic complication will remind the operators of this procedure to be aware of a documented Zenker's diverticulum and when necessary, to take the published precautions to prevent a highly severe complication.

Sigmoid Resection with Primary Anastomosis for Uncomplicated Giant Colonic Diverticulum : a Report of two Cases.

Giant colonic diverticulum (GCD) is a rare complication of colonic diverticulosis. A small number of cases has been reported in the literature. Patients with GCD have often few non-specific symptoms. Unfortunately, severe complications exist and may lead to surgical acute abdomen. Therefore, this complication of the diverticular disease must be known and properly treated. There is no gold standard diagnostic test, but an air-fluid or air-filled, rounded, pseudocystic image in relation with the colonic wall in a patient with colonic diverticula should suggest this diagnosis to the clinician. We report two cases of a 70-year-old male patient and a 44-year-old female patient having a giant sigmoid diverticulum. The treatment of choice of an uncomplicated GCD is an elective colonic resection, including the giant -diverticulum, with primary anastomosis ; while in case of complicated GCD (peritonitis, abscess or complex fistula), a two-stage resection should be considered.

Transanal endoscopic microsurgery for rectal tumours using a Single Incision Laparoscopic Port.

BACKGROUND: Transanal endoscopic microsurgery (TEM), first described by Buess enables a less aggressive approach of benign rectal lesions, or even early rectal cancer in a curative intent. MATERIALS AND METHODS: The SILS Port, initially designed for laparoscopic surgery, was successfully used for 20 TEM procedures in 16 patients. Local resection was sufficient in 15 procedures (benign tumours or pT1) out of 20, whereas 5 TEM operations required additional surgery: 3 rectal resections (pT1Nx, pT1sm3Nx and pT2N1) and 1 TEM revision (1 patient refused the rectal resection (pT1Nx). Postoperative complications following Dindo-Clavien were: grade II in 4 patients (pain: 2; fever: 1; bleeding: 1) and grade IIIb in 2 patients (bleeding). No long-term faecal incontinence was noted. CONCLUSION: TEM using the SILS Port is a safe and effective procedure for local resection of benign and certain malignant tumours. Using such a cheaper device, TEM procedure could be available in any operating theatre.

Outcome following laparoscopic and open total mesorectal excision for rectal cancer.

BACKGROUND: There are few reports on the oncological quality of resection and outcome after laparoscopic versus open total mesorectal excision (TME) for rectal cancer in everyday surgical practice. METHODS: Between January 2006 and October 2011, data for patients with mid or low rectal adenocarcinoma who underwent elective TME were recorded in the PROCARE database. A multivariable model and the propensity score as a co-variable in Cox or logistic regression models were used for adjustment of differences in patient mix and non-random assignment of surgical approach. RESULTS: Data for 2660 patients from 82 hospitals were recorded. Implementation of laparoscopic TME was highly variable. The oncological quality of resection was similar in the laparoscopic and the open group: incomplete mesorectal excision in 13·2 and 11·4 per cent respectively, circumferential resection margin positivity in 18·1 per cent, and a median of 11 lymph nodes examined per specimen in both groups. The hazard ratio for survival after laparoscopic versus open TME was 1·05 (95 per cent confidence interval 0·88 to 1·24) after correction for differences in patient mix, and 1·06 (0·89 to 1·25) after correction for the propensity score. The definitive colostomy rate was similar in the two groups: 31·0 per cent after open and 31·4 per cent after laparoscopic TME. Postoperative morbidity was lower and length of stay was shorter after laparoscopic TME compared with open TME. Survival was not negatively affected by converted laparoscopic resection, whereas postoperative morbidity, mortality and length of stay after converted laparoscopy were comparable with those after open TME. CONCLUSION: Oncological outcome is comparable after laparoscopic and open TME in everyday surgical practice.

Pseudomyxoma peritonei: a French multicentric study of 301 patients treated with cytoreductive surgery and intraperitoneal chemotherapy.

OBJECTIVE: To analyze a large series of patients with pseudomyxoma peritonei (PMP) treated with cytoreductive surgery associated with perioperative intraperitoneal chemotherapy (PIC) in 18 French-speaking centers. PATIENTS AND METHODS: From March 1993 to December 2007, 301 patients with diffuse PMP were treated by cytoreductive surgery with PIC. Complete cytoreductive surgery was achieved in 219 patients (73%), and hyperthermic intraperitoneal chemotherapy (HIPEC) was performed in 255 (85%), mainly during the latter period of the study. RESULTS: Postoperative mortality and morbidity were 4.4% and 40%, respectively. The mean follow-up was 88 months. The 5-year overall and disease-free survival rates were 73% and 56%, respectively. The multivariate analysis identified 5 prognostic factors: the extent of peritoneal seeding (p=0.004), the center (p=0.0004), the pathologic grade (p=0.03), gender (p=0.02), and the use of HIPEC (p=0.04). When only the 206 patients with complete cytoreductive surgery were considered, the extent of peritoneal seeding was the only significant prognostic factor (p=0.004). CONCLUSION: This large multicentric retrospective study confirms that cytoreductive surgery combined with PIC (with the use of hyperthermia) should be considered as the gold standard treatment of PMP and should be performed in specialized centers. It underlines the prognostic impact of the extent of peritoneal seeding, especially in patients treated by complete cytoreductive surgery. This prognostic impact appears to be greater than that of the pathologic grade.

Laparoscopic ultrasonography as a good alternative to intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of prospective study.

Intraoperative cholangiography (IOC), used routinely or selectively, is the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasonography (LUS) has emerged as a possible, safe and quick alternative. This study examined the evolving use and the performance of these two methods as primary technique for routine bile duct imaging, so as to detect common bile duct stones (CBDS) and to prevent common bile duct injury (CBDI). A prospective database permitted to evaluate the results of the two methods in 968 consecutive cholecystectomies. Nine hundered and twenty five were performed by laparoscopy, 18 (1.9%) by laparotomy and 25 (2.6) necessitated a conversion. The systematic use of the IOC was gradually replaced by a systematic use of the LUS. The success to delineate and evaluate the CBD, the detection of a CBDS, any type of bile duct complication, especially of CBDI, were registered. All the CBDS suspected by LUS were controlled by IOC. The patients were followed during 1 and 6 months. Six hundred and eighty five IOC and 269 LUS were performed. The procedure was technically unsuccessful in 35 IOC (5.1%) (mainly due to difficulty in catheterising the cystic duct) and in 2 LUS (1%) (due to steatosis). Concerning the detection of CBDS, 31 were detected by IOC (4.5%) and 16 by LUS (6%). Five IOC were considered as false positive, 1 as false negative (sensitivity and specificity of 96,9 and 99,2%) and 1 LUS as false positive (sensitivity and specificity of 100 and 99,6%). Five CBDI were detected in the complete seria: 2 during the dissection before the IOC, 1 thermic injury, 1 late stenosis, 1 lateral stenosis by the cystic clip detected by LUS. However none of these CBDI could have been prevented by IOC. In our experience, in this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and CBDS and was not followed by an increase in CBDI.

[Extensive mesenteric venous thrombosis treatment by regional thrombolysis]. / Traitement des thromboses veineuses mésentériques extensives par thrombolyse régionale.

Two cases of mesenteric venous thrombosis with portal extension are reported. The first patient was treated right away by local intra-arterial thrombolysis, the second one benefited from local venous thrombolysis immediately after intestinal resection. No significant complication was observed.

Hepatocellular carcinoma associated with precocious puberty and oral contraceptives. A case report.

A 36-year-old woman presented with sudden abdominal pain and vomiting. Computed tomography showed a tumour of the right hepatic lobe with possible signs of acute haemorrhage. Her medical history revealed precocious puberty when she was a 5-year-old and the use of oral contraceptives for 18 years. Bisegmentectomy was performed and histological examination revealed hepatocellular carcinoma. The role of male and female sex hormones in the development of hepatic tumours has been well documented but, to our knowledge, association with precocious puberty has not yet been described.

Laparoscopic liver resection of benign liver tumors.

OBJECTIVE: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. BACKGROUND: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. METHODS: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. RESULTS: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. CONCLUSIONS: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Systematic use of total vascular exclusion in 14 elective hepatic resections.

Between March 1992 and May 1995, 14 hepatic resections under total vascular exclusion were performed (10 major resections and 4 minor resections involving central segments). Mean age was 64 years (SD +/- 12). During hepatic resection, 4 patients required blood transfusion. The reason was a too low level of haemoglobin (< 10 gr/100 ml) to undergo Hepatic Vascular Exclusion (HVE) (1 patient), an unacceptable decrease in blood pressure following HVE leading to insertion of venovenous bypass (1 patient), or an extensive bleeding following removal of the clamps (2 patients). The 10 remaining patients did not need peroperative blood transfusion. Two patients were transfused after the 6th postoperative day. Complications usually described during HVE were not encountered except for one pleural effusion needing thoracocentesis.

[Study of the toxicity and results of intraperitoneal hyperthermic chemotherapy in 28 patients with peritoneal carcinomatosis]. / Etude de toxicité et résultats de la chimio-hyperthermie intra-péritonéale chez 28 patients en carcinose péritonéale.

Based on a few previous studies, intra-peritoneal hyperthermic perfusion (IPHP) with Mitomycin C could become a beneficial treatment for peritoneal carcinomatosis. Twenty eight patients with peritoneal carcinomatosis arising from intra-abdominal cancers were treated by IPHP, Mitomycin C, diluted in 3 liters of saline solution warmed to a mean temperature of 45 degrees C, was injected into the abdominal cavity for one hour. Median survival for the whole series (postoperative mortality included) was 260 days. For patients with incomplete resection, median survival was 104 days. For patients with complete resection of carcinomatous nodules larger than 3 mm (19 patients), it was 450 days. In this group, actuarial survival was 56% at 1 year and 42% at 2 years. Only 5 (18%) of the 28 patients developed ascitic effusion during follow-up. These results confirm the efficacity of IPHP on ascitic effusion and on survival rate in patients with nearly complete resection of peritoneal carcinomatosis.

Utilization of gas heater humidifier in the course of coelioscopies.

The increasing utilization of coelioscopic interventions has needed the use of a larger number of trocars, which involves in some cases (especially at the beginning of personal experience) longer operations. In our clinical experience we have met hypothermies that compelled us to modify our way of working. The use of conventional means (like warming cushion, warming of irrigation fluids) could limit the temperature loss only moderately. So we imagined to warm and moisten the gases insufflated into the peritoneal cavity. We give a description of the accessories and the results with some patients.

[Complications of laparoscopic cholecystectomy. Free intraperitoneal calculi]. / Complications de la cholécystectomie par coelioscopie. Devenir des calculs intra-péritonéaux libres.

With the use of laparoscopic cholecystectomy, increasing numbers of gallstones are being left in the peritoneal cavity. To our knowledge, the rarely cause complications. We present two cases with stone spillage after laparoscopic cholecystectomy, with a different outcome.

"Clip-stone" filiation within the biliary tract.

A case of cholangitis due to the migration of a metal clip used for surgical cholecystectomy 4 years earlier, is reported. The diagnostic approach and therapeutic options, either endoscopic or surgical are discussed. The use of resorbable clips during the performance of laparoscopic cholecystectomy should avoid this type of complication.

[Is extracorporeal liver surgery useful for difficult hepatic resections?]. / La chirurgie ex situ du foie est-elle utile au cours des résections hépatiques difficiles?

Five cases of hepatic tumor deemed unresectable by conventional techniques are presented to illustrate the potential benefit offered by complete hepatic vascular exclusion (Pringle maneuver associated with inferior vena cava clamping below and above the liver). The most extensive and difficult liver resections may be achieved, with possible venous reconstruction, if the clamping period is not interrupted. Hepatic vascular exclusion may exceed one hour, up to 85 minutes in this series, with a good liver tolerance, in the absence of preoperative liver dysfunction. The advantages and disadvantages of the ex situ extracorporeal liver resections performed under similar circumstances are discussed. The authors consider that the role of ex situ liver procedures should be very limited.

[Is ex situ surgery of the liver useful for difficult hepatic resections?]. / La chirurgie ex situ du foie est-elle utile au cours des résections hépatiques difficiles?

Five cases of hepatic tumor deemed unresectable by conventional techniques are presented to illustrate the potential benefit offered by complete hepatic vascular exclusion (Pringle maneuver associated with inferior vena cava clamping below and above the liver). The most extensive and difficult liver resections may be achieved, with possible venous reconstruction, if the clamping period is not interrupted. Hepatic vascular exclusion may exceed one hour, up to 85 minutes in this series, with a good liver tolerance, in the absence of preoperative liver dysfunction. The advantages and disadvantages of the ex situ extracorporeal liver resections performed under similar circumstances are discussed. The authors consider that the role of ex situ liver procedures should be very limited.

[Minimal intestinal preparation before colectomy for cancer. Experience of 189 cases]. / Préparation intestinale a minima avant colectomie pour cancer. Expérience de 189 cas.

189 cases of colectomy for cancer have undergone limited bowel preparation by one or two enemas the day before surgery. The anastomosis has been performed manually with a continuous suture of resorbable material. Hospital mortality is 1.6% for the whole series and limited to 0.5% for elective resections despite the old age of the patients included (70.6 +/- 11 years, with 40.7% more than 75 years). Morbidity rate is 13.9% and of 2.6% for local septic complications. No clinical anastomotic dehiscence was demonstrated. From these results, poor local bowel preparation does not appear to be a risk factor of colectomy for cancer.

[Surgical approach to villous tumors of the rectum]. / Abord chirurgical des tumeurs villeuses du rectum.

The authors report the results of the surgical treatment of 39 villous adenomas of the rectum operated on during a 10-year period. Twenty-nine tumours were treated by a local excision, and 10 by a subtotal rectal resection. The choice for the procedure was mainly determined by the level of the lower tumour margin. Thirty-four operations were performed with a curative goal, and the 5 others for debulking. There was no operative mortality, and the morbidity was very low. Four invasive carcinomas were detected in the operative specimens and the four patients were withdrawn from the follow-up. In the "curative group", local recurrence rate was 21% after a mean follow-up period of 46 months. The tumour recurrences were small, and 2/3 among them were easily treated by reoperation (1 case) or further coagulations. With some complementary coagulations, surgery yielded a full control of 100% of the C1, 83% of the C2 and 66% of the C3 lesions. Full tumour clearance was achieved in two patients of the debulking group, with some postoperative coagulations. Our series and the literature confirm the efficiency of the surgical approach, which, moreover, allows the best histological assessment in one single session.