Results of surgical treatment of uncontrollable upper gastrointestinal hemorrhage using endoscopy.

BACKGROUND/AIMS: Acute hemorrhage of the upper gastrointestinal tract occurs at a rate of 50 to 100 per 100,000 annually in the Western adult population. With the increased use of therapeutic endoscopy, the role of surgery is decreasing; surgical intervention is now only used in cases of failure of endoscopic hemostasis. The goal of this study is to determine whether there are predictive factors associated with high-risk post-operative mortality. METHODOLOGY: This retrospective study included 30 patients treated from March 1996 to September 2008 at Brugmann Hospital. These patients presented with upper gastrointestinal non-variceal hemorrhage that was treated first endoscopically then surgically for recurrent hemorrhage. Multiple risk factors (variable and fixed) and parameters were evaluated to determine their influence on mortality. RESULTS: Of 30 patients, 10 (33%) developed recurrent hemorrhage following surgical treatment. A total of 8 (26.6%) deaths occurred of which 4 were related to hemorrhage. Three deaths occurred after the first intervention and 5 occurred after a second intervention. Logistic regression analysis revealed that the total number of blood units transfused and the presence of at least one surgical reintervention both significantly increased mortality rate (p = 0.0426 and p = 0.0068). Other parameters were not significant. However, there is a lack of power due to the small sample size. CONCLUSION: For recurrent massive upper gastrointestinal hemorrhage following endoscopic treatment and necessitating more than 19 blood transfusions, early surgical intervention is recommended and surgical reintervention should be avoided. If reintervention is necessary, radical surgery is recommended. However, the small number of patients treated over a 12-year period limits the results of this study, and these results may represent simple coincidences.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty.

BACKGROUND: Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB). METHODS: Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting. RESULTS: There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months). CONCLUSIONS: Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

Laparoscopic appendectomies: retrospective study of 2074 cases.

PURPOSE: To determine feasibility and safety of laparoscopic appendectomy (LA). PATIENTS: From January 1991 to June 2006, 2209 consecutive patients underwent appendectomy; for 2074 patients, appendectomy was performed laparoscopically. One thousand and fifty (53%) were women; mean age was 30.8 (11 to 96) years. Mean body mass index was 23.6 (18 to 58 kg/m2). Mean American Society of Anesthesiology score was 1.3 (I to III). RESULTS: Mean operating time was 52 minutes (15 to 200). Conversion to open appendectomy occurred for 84 patients (3.6%) mainly for acute or generalized peritonitis, abscess, or adhesion. Mean hospital stay was 3.75 (1 to 27) days. There was no mortality. Morbidity occurred in 4.5% of the patients: parietal (1.15%), peritoneal complications (1.1%), and others (2.25%). Additional interventions were required for 30 patients (1.5%) primarily for residual abscesses. In this study, 10.9% (n=226) of the specimens were considered normal by the pathologist. In 3.9% (77 cases), laparoscopy did not find any cause for nonspecific abdominal pain. In these cases, appendix was not removed. CONCLUSIONS: LA is technically feasible and safe. Diagnostic laparoscopy is recommended in cases suspicious for acute appendicitis. Laparoscopy permits a complete exploration of the abdominal cavity, helps to localize the appendix, allows for the eliminations of other diagnoses when the appendix is normal, and to facilitate a better peritoneal lavage in case of peritonitis. It is recommended to perform LA routinely in young women and obese. Although advantages of LA still need to be evaluated, in view of the excellent results, we have decided to perform it routinely. We also recommend not removing macroscopically normal appendices discovered during diagnostic laparoscopy for abdominal pain of unexplained origin.

Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study.

BACKGROUND/AIMS: Appendicitis is one of the most frequent causes of abdominal pain in western countries. It occurs in 6 to 7% of the United States population. Despite laboratory and imagery tests, 15 to 40% appendices removed by laparotomy appear to be normal at histological examination. Thus, others pathologies beside appendicitis may be found in patients with right lower quadrant pain. This had led some to advocate laparoscopy for patients suspected to have acute appendicitis. The aim of this study is to determine the contribution of laparoscopy in patients with right lower quadrant pain and the implications of removing a macroscopic normal appendix. Rates of all pathologies and normal appendices were found at laparoscopy. Morbidity, mortality rates and length of hospital stay linked to laparoscopic appendectomy. DESIGN: Prospective non-randomized study. METHODOLOGY: Between January 1995 and September 2004, 615 patients have been approached by laparoscopy for acute, subacute or chronic abdominal right-lower-quadrant pain in our Department of Digestive and Laparoscopic Surgery. Thirteen patients have not been hold and the study involves 602 patients including 311 men and 291 women with a mean age of 33 years. All removed tools have been analyzed histologically. During the same period, only 5 patients have been approached by laparotomy. RESULTS: Five hundred and thirty patients (88%) had appendicitis, 39 patients (6.5%) had another pathology and no disease was found in 33 patients (5.5%). According to the sex, appendicitis was found in 242 women (83.2%) versus 288 men (92.6%). Thirty-four women (11.7%) versus 5 men (2%) had another pathology. The local morbidity was 4.3%, the general morbidity 1% and the mortality was 0%. The average length of postoperative hospital stay was 4 days (range: 1-27). Oral intake was assumed on average 1.5 days postoperatively (range: 0-13). There were 10 reoperations (1.6%). CONCLUSIONS: Laparoscopy is a reliable technique, safe and reproducible. It is an effective and relatively atraumatic tool to investigate abdominal cavity. This allows an accurate decision-making, which is especially advantageous in young women who have a high rate of non-appendicular pathologies. Laparoscopy also reduces the rate of unnecessary abdominal exploration while realizing a correct diagnosis of others possible pathologies. We therefore advocate laparoscopy in patients with abdominal right-lower-quadrant pain, especially women.

A therapeutic approach to perianal extramammary Paget's disease: topical imiquimod can be useful to prevent or defer surgery.

BACKGROUND: Extramammary Paget's disease (EMPD) is a rare skin disease which can be limited to the epidermis and can sometimes also be associated with underlying carcinomas. At clinical examination, lesions are well-defined eczematous areas and have been described typically in the anogenital region. Surgery is the cornerstone treatment. CASE REPORT: In this report the case of a 66-year-old patient presenting with a long-lasting EMPD of perianal region without deep gastrointestinal neoplasia is described. Because of the extension of the lesion, surgery should have led to abdominoperineal amputation, but the patient rejected this option. Three months of daily application of topical imiquimod was prescribed as an alternative treatment. Biopsy-confirmed complete regression could be observed thereafter, and no recurrence has been noted during a 12-month follow-up. CONCLUSIONS: This successful treatment of a perianal-located EMPD by topical imiquimod warrants further investigations.