Novel technique for retraction of the gastroesophageal junction in laparoscopic antireflux surgery.

Laparoscopic antireflux surgery is a recognized procedure for patients diagnosed with gastroesophageal reflux disease whose symptoms are refractory to medical treatment. We describe a novel and cost-effective technique that aids in mobilization and retraction of the gastroesophageal junction before repair of the diaphragmatic crural defect. After hiatal dissection and creation of a posterior gastric wrap, an index suture (2-0 ethibond) is placed across the wrap. This is used to retract the gastroesophageal junction and expose the crura for repair and "required facilitate fixation of fundus to the crura (fundopexy)." This technique negates the requirement for further instruments thus reducing operative expenditure and offers minimal disruption to the tissue. We have performed over 350 operative procedures using this technique and recommend it as an alternative choice that is cost effective for retraction of the esophagogastric junction in antireflux surgery.

Migrated biliary stent presenting as a sigmoid diverticulitis-case report.

This is a case report of a patient with biliary stent migration resulting in sigmoid diverticulum perforation. We report the case of a patient who presented with symptoms of diverticulitis 18 months following biliary stent insertion for bile leak following laparoscopic cholecystectomy. This rare complication of biliary stent placement should be included in differential diagnosis of any patient that presents with lower quadrant abdominal pain after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.

Complications following restorative proctocolectomy in children.

BACKGROUND: Adverse outcomes following restorative proctocolectomy (RPC) in adults have been attributed to steroid exposure and use of hand-sutured anastomoses. This study analyses complications in children undergoing RPC. METHODS: This study is a retrospective review of all children undergoing RPC in an English regional center over a 10-year period. The main outcome measure was defined as a complication within 30 days of surgery. Logistic regression analysis was used with possible explanatory variables (eg, steroid use, indication for surgery, weight and height z scores, hematologic indices, degree of blood loss, and use of laparoscopic surgery). RESULTS: Sixty (33 female) patients underwent RPC at a median age of 13.5 years. Of these, 16 had an operative complication and 17 had a late complication. Only severe acute colitis with inability to induce remission as an indication for surgery was significant in predicting operative complications (odds ratio, 6.8 [95% confidence interval, 1.2-37]; P = .03). CONCLUSIONS: Severe acute colitis resistant to medical therapy but not steroid use or hand-sutured anastomoses appears to be a risk factor for complication. This differs from the adult experience.

Parking the pouch: pouch salvage after anastomotic leak following restorative proctocolectomy. Report of a case.

Anastomotic leak is a feared complication after restorative proctocolectomy with formation of an ileal pouch. We describe the use of a technique that is appropriate for profound anastomotic failure in the immediate postoperative period, which will aid in controlling sepsis and may allow salvage of the pouch. A 59-year-old man who failed medical treatment underwent restorative proctocolectomy and ileal pouch-anal anastomosis as a single-stage procedure. The patient developed an anastomotic leak that was not controlled by defunctioning stoma formation. Further surgery was undertaken and the pouch was exteriorized as a mucous fistula. A redo pouch-anal anastomosis was performed 12 months after the original procedure. The patient has good functional outcome with complete continence. Anastomotic leak after restorative proctocolectomy and ileal pouch-anal anastomosis often can be managed by conservative or local procedures. Laparotomy may be required rarely, but this subgroup is associated with pouch failure in up to half of the patients. Awareness that the ileal pouch-anal anastomosis can be taken down and the pouch temporarily parked in the abdominal cavity may persuade surgeons to retain a pouch with the knowledge that the acute pelvic sepsis after an anastomotic leak can be safely treated.

Successful voiding after trial without catheter is not synonymous with recovery of bladder function after colorectal surgery.

PURPOSE: The need for monitoring postoperative urine output and the possibility of lower urinary tract dysfunction following colorectal surgery necessitates temporary urinary drainage. Current practice assumes recovery of lower urinary tract function to coincide with successful micturition after removal of urethral catheter. The aim of this study was to analyze the recovery of bladder function following colorectal surgery. METHODS: Patients undergoing colorectal operations underwent preoperative and postoperative uroflowmetry and residual urine estimation. All patients were catheterized suprapubically at surgery. Uroflowmetry and postvoid residual volumes were recorded postoperatively until recovery of bladder function was complete. RESULTS: Thirty consecutive patients underwent suprapubic catheterization, 25 of whom completed the study. Seventeen (68 percent) patients were able to pass urine within 72 hours of surgery. Recovery of lower urinary tract function was delayed in patients undergoing rectal vs. colonic resections (median, 6 vs. 3 days, P = 0.0015). Postvoid residual volumes greater than 200 ml were noted in three (20 percent) patients following rectal resections beyond the tenth postoperative day, with complete emptying achieved by six weeks. CONCLUSIONS: Apparent successful micturition following rectal resections does not always indicate recovery of bladder function. The use of suprapubic catheters, in addition to being safe and effective, allows assessment of residual volumes postoperatively and smoothes the path to full recovery of lower urinary tract function.