Emergency laparoscopic conversion from mini/one anastomosis gastric bypass to modified Roux-en-Y-gastric bypass due to acute bleeding from a recurrent marginal ulcer.

Our aim is to present the laparoscopic technique of an emergency revisional procedure performed to convert a mini/one anastomosis gastric bypass (MGB/OAGB) to a modified Roux-en-Y-gastric-bypass (RYGB) due to recurrent bleeding from a marginal ulcer. A 43 year old woman presented unstable conditions due to acute bleeding from a marginal ulcer after a MGB/OAGB performed 3 years before. After three failed endoscopic haemostasis attempts, she underwent a laparoscopic conversion to a modified RYGB in emergency setting. The patient had an uneventful recovery. She maintained heamodynamical stability after the procedure. She was eventually discharged in the seventh postoperative day after restarting oral feeding on chronic proton pump inhibitors. To our knowledge, there are few descriptions of emergency surgical conversion from a MGB/OAGB to a modified laparoscopic RYGB due to a recurrent marginal ulcer bleeding not responsive to endoscopic treatment. A regular post-operative follow-up is mandatory after bariatric surgery. We advocate performing revisional surgery in an experienced Bariatric Center.

Comparison of two kinds of intraperitoneal chemotherapy following complete cytoreductive surgery of colorectal peritoneal carcinomatosis.

BACKGROUND: Recently, the combination of complete cytoreductive surgery followed immediately by intraperitoneal chemotherapy achieved cure in some patients suffering from peritoneal carcinomatosis (PC). It is now well established that the prognostic impact of the completeness of cytoreduction is high. However, two different modes of intraperitoneal chemotherapy are proposed: early postoperative intraperitoneal chemotherapy (EPIC), which lasts for 5 days and is normothermic, and peroperative intraperitoneal chemohyperthermia (IPCH). To date, the results of these procedures have never been compared. AIM OF THE STUDY: To compare the complications and therapeutic results of EPIC and IPCH after complete cytoreductive surgery of colorectal PC. MATERIALS AND METHODS: Twenty-three consecutive patients with colorectal PC were selected based on the completeness of cytoreductive surgery and sufficient follow-up. They received IPCH with oxaliplatin (460 mg/m(2)) in 2 l/m(2) of dextrose, for 30 min at an intraperitoneal temperature of 43 degrees C, using the coliseum technique. We retrospectively carefully selected another 23 patients, for comparison purposes, suffering from the same disease, with characteristics as similar as possible, but treated earlier with EPIC (mitomycin C 10 mg/m(2) at day 0 and 5-FU 650 mg/m(2) from days 1 to 4), in 1 l/m(2) of ringer lactate. Data concerning these two groups were verified prospectively, but this study was a comparative historical analysis. RESULTS: The two groups were statistically comparable, except for the duration of surgery which was 68 min longer for the IPCH group. Mortality and morbidity were not significantly different, even if two deaths occurred in the EPIC group, and none in the IPCH group. However, the rate of digestive fistulas was higher (P = 0.02) in the EPIC group (26%) than in the IPCH group (0%). Overall survival (OS) was higher in the IPCH group, (54% at 5 years vs. 28% for EPIC), but not significantly (P = 0.22). Peritoneal carcinomatosis recurred much (P = 0.03) more frequently in the EPIC group (57%) than in the IPCH-group (26%). CONCLUSION: This study provides strong arguments indicating that IPCH with oxaliplatin is better tolerated than EPIC with mitomycin C and 5-FU, and is twice as efficient in curing residual peritoneal carcinomatosis measuring less than 1 mm.

Liver abscess after radiofrequency ablation of tumors in patients with a biliary tract procedure.

AIM: The rate of liver abscesses after radiofrequency ablation (RFA) of liver tumors is probably high in patients with a biliary tract drainage procedure connecting the biliary duct system to the upper gastrointestinal tract. And yet, to date this rate, the time of onset of these abscesses, and the prior status of the bile ducts have never been reported in the literature. METHODS: Among 574 patients treated with RFA over 8 years, only 11 patients (with 13 sessions of RFA, 2 patients undergoing two different RFA sessions) presented with an enterobiliary anastomosis or biliary stenting at the time of RFA. This is a retrospective study of patients who were verified prospectively. RESULTS: Among the 9 patients in whom a biliary tract procedure preceded RFA, 4 developed a liver abscess at the site of RFA, which emerged between 13 and 62 days after RFA. It occurred in spite of different types of short-term antibiotic prophylaxis. Pathogenic bacteria were typical of the digestive flora. Abscesses were cured after percutaneous drainage. No abscess occurred among the 4 patients in whom a biliary tract diversion was performed synchronously with RFA. CONCLUSION: When RFA is performed in a patient with a preexisting biliary diversion, the risk of developing a liver abscess is high. Currently, we are unable to recommend any kind of preventive antibiotherapy. A preexisting biliary diversion is not an absolute contraindication for RFA, but the risk of developing a liver abscess is close to 40-50%. When RFA is performed synchronously with a biliary diversion, the risk of a liver abscess seems to disappear.

The trans-metastasis hepatectomy (through metastases previously ablated with radiofrequency): results of a 13-case study of colorectal cancer.

BACKGROUND: Curative trans-metastasis liver resection immediately following radiofrequency (RF) destruction is a new technique that enables the proposition of a curative approach to patients with bilateral, unresectable liver metastases (LM), when the only possible future hepatectomy plane passes through a LM. Firstly, the ill-sited LM, which is located in the only feasible future hepatectomy plane, is ablated using RF; the hepatectomy is then performed through this ablated LM. AIM: The aim of this study is to report the feasibility and efficacy of this new approach, known as post-RF-trans-metastasis-hepatectomy (PRFTMH). MATERIALS AND METHODS: Thirteen patients with colorectal primary cancer were treated with PRFTMPH between January 2000 and May 2004. The mean number of LMs per patient was 10.7. Preoperative hypertrophy of the future remaining liver was achieved by selective portal vein embolization in eight patients. RESULTS: The mortality rate was 7.6% (one death), and morbidity was 24%. No local recurrence was observed at the PRTMPH site after a mean follow-up of 19.4 months (range: 47-10), demonstrating the efficacy of this technique. All patients, except those who died postoperatively, are currently alive; the median survival has not yet been attained after a mean follow-up of 19.4 months. CONCLUSION: TMPRFH is a new and safe technique, combining RF ablation and trans-RF-hepatectomy, which makes it possible to propose a curative approach in certain patients with non-resectable bilateral LMs.

Green urine after intragastric balloon placement for the treatment of morbid obesity.

BACKGROUND: The intragastric balloon is filled with saline and methylene blue dye, to detect balloon deflation early and prevent bowel obstruction, by monitoring the patient's urine for changes in color. METHODS: An intragastric balloon filled with 590 ml of saline plus 10 ml of methylene blue was endoscopically placed under sedation in a 22-year-old man with morbid obesity (BMI 42 kg/m2). 3 days later, the patient's urine changed to dark green, and, suspecting a leaking balloon, endoscopy was repeated under sedation. RESULTS: No signs of balloon deflation were seen, and the urine returned to normal color. The next day, the urine turned green again. 7 days later, the urine discoloration finally disappeared. CONCLUSION: Propofol, a sedative commonly used by anesthesiologists during endoscopic procedures, is known to have several side-effects, and urine discoloration is one of them, albeit rare. This benign side-effect must be known to obesity surgeons to avoid pointless medical expenditure, unnecessary balloon removal and distress for patients and clinicians.