Totally laparoscopic treatment of vaginal cuff dehiscence: A case report and systematic literature review.

INTRODUCTION: To highlight the laparoscopic management as a feasible treatment option for vaginal cuff dehiscence with intestinal evisceration after hysterectomy. PRESENTATION OF CASE: We report a rare case of a 49-year-old postmenopausal woman who was admitted to the emergency department with vaginal herniation of approximately 40cm of small bowel 3 months after total laparoscopic hysterectomy, treated laparoscopically exclusively. DISCUSSION: The patient underwent a laparoscopic reduction of the protruded mass, inspection of the entire small bowel and closure of the vaginal dehiscence. She was discharged home in a good health and the postoperative course remains uneventful 6 months later. Our systematic review of the literature found 116 cases of vaginal evisceration, which were described as early as 1864. There is no consensus on the ideal method of surgical repair. To our knowledge, only 2% (3 cases) were treated totally laparoscopically and 10% by a combined approach (laparoscopic and vaginal). Although the current evidence does not suggest that one approach is preferred to the others, the laparoscopic approach seems to be the new trend for the management of this surgical emergency. CONCLUSION: Totally laparoscopic repair in experience hands seems to be a safe approach to cure vaginal evisceration after pelvic surgery.

Tailored therapy for different presentations of chronic pain after stapled hemorrhoidopexy.

BACKGROUND: As stapled hemorrhoidopexy (SH) becomes more widely used, we see more patients with chronic postoperative anal pain after this surgery. Its presentation is variable and difficult to treat. The aim of our study was to investigate the impact of chronic anal pain after SH and whether tailored therapy was likely to achieve a favorable outcome. METHODS: We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions. Depending on the type of pain, unrelated (at rest) or related to defecation, two groups of patients were identified. Moreover, the mean distance of the staple line from the anal verge was calculated in both groups. Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing. A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up. This mean difference of the VAS score between stages was always used as the main outcome measure, depending on the type of presentation, type of pain, and type of treatment. Treatment response was defined as a 50 % decrease of VAS from baseline. RESULTS: There were 22 males and 9 females. The overall median age was 43 years (range 21-62 years). On digital examination and proctoscopy, 15 (48 %) patients had inflammatory changes, 19 (61 %) patients had staple retention, 8 (26 %) patients had anorectal stenosis, and 30 (97 %) patients had scar tissue. All patients had one or more of the following treatments listed from the least to most invasive: topical nifedipine in 12 (39 %) patients, anal dilation in 6 (19 %) patients, anesthetic and steroid infiltration in 18 (58 %) patients, removal of staples in 10 (32 %) patients, and scar excision in 18 (58 %) patients. The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up (1.741 ± SD 1.251; p < 0.743). In patients with pain at rest (n = 20, 65 %), the symptoms improved in 19 (95 %) patients, while the VAS score decreased from 5.552 ± 2.115 SD to 1.457 ± 1.440 SD (95 % CI 3.217-4.964; p < 0.001). In patients with post-evacuation pain (n = 11, 35 %), the symptoms improved in 11 (100 %) patients, while the VAS score decreased from 6.429 ± 1.835 SD to 1.891 ± 1.792 SD (95 % CI 3.784-5.269; p < 0.001). Rating of response based on presentation was 90.0 % (0.9/10) after treatment of staple retention, which led to a significant decrease in the mean VAS score from 6.304 ± 1.845 SD to 1.782 ± 1.731 SD (95 % CI 3.859-5.185; p < 0.001). Anal stenosis was successfully treated in 100.0 % (n = 8/8) of cases with the mean VAS score dropping from 6.500 ± 1.309 SD to 2.125 ± 1.808 SD (95 % CI 2.831-5.919; p < 0.001). Anal inflammation improved in 60.0 % (n = 9/15) of patients and the mean VAS score dropped from 6.006 ± 2.138 SD to 1.542 ± 1.457 SD (95 % CI 3.217-4.964; p < 0.001). The response after scar tissue treatment was 94 % (n = 17/18) of patients with a mean VAS decreasing from 6.117 ± 2.006 SD to 1.712 ± 1.697 SD (95 % CI 3.812-4.974; p < 0.001). Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation. Anal dilation was successful in 75 % of patients, while Anesthetic and steroid infiltration in 23-54 % of patients depending on the clinical presentation. Staple removal was successful in 77 % of patients, and scar excision with mucosal suturing in 94 % of patients. CONCLUSIONS: Our retrospective study suggests that most patients with chronic anal pain after SH may be cured with treatment by applying a stepwise approach from the least to the most invasive treatment.

[The advantage of a specialized HPV clinic within the department of proctology]. / Intérêt d'une consultation HPV spécialisée dans le cadre d'une unité de proctologie.

The "Human Papilloma Virus" (HPV) is the cause of carcinoma of the cervix. With 275000 deaths per year worldwide, this virus is the direct cause of the most common carcinoma in women. If these figures demonstrate that it is a true scourge, then the fact is that routine screening for the precancerous lesion linked to HPV infection has managed to significantly lower the mortality rate in countries where this has been introduced. The frequency of the anal carcinoma has grown in recent years, particularly in HIV+ patients participating in anal sex. Systematic screening and early vaccination should be able to stem this worrying development in the same way that screening for carcinoma of the cervix has in women.

Accuracy of measurement of puborectal contraction by perineal ultrasound in patients with faecal incontinence.

AIM: The study aimed to determine the accuracy of measurement of puborectal contraction, measured by perineal ultrasound during anal voluntary contraction in patients with incontinence. METHOD: Puborectalis sling contraction in 32 consecutive patients investigated for faecal incontinence was determined by two examiners on two occasions (four measurements per patient). The examiners were blinded to each other's results. RESULTS: The mean anterior movement of the puborectalis sling was between 11 and 12 mm for both examiners on both occasions. The global intraclass correlation coefficient for examiners and occasions together was 0.92. The absolute agreement on the movement exceeding or not 8 mm was 87.5% (28 of 32), and the corresponding κ statistic was 0.84. The differences between the two experts were minimal. CONCLUSION: The study confirms the reliability of puborectalis sling contraction measurement and its value as a preoperative predictive tool to assess the prognosis of sphincter repair for postdelivery faecal incontinence.

[Vacuum-assisted abdominal closure: its role in the treatment of complex abdominal and perineal wounds. Experience in 48 patients]. / Le Vacuum Assisted Closure: utilité dans le traitement des plaies abdomino-périnéales complexes. Expérience sur 48 patients.

INTRODUCTION: Vacuum-assisted closure (VAC) is a promising approach for the management of complex abdominal and perineal wounds. This paper summarizes our experience with this therapeutic modality and demonstrates its efficacity in difficult situations. PATIENTS AND METHODS: From January 2003 until December 2005, 48 patients (age 30-89) were treated with VAC therapy for open abdomen, infected laparotomy wounds, or tissue loss due to debridement of Fournier's gangrene. Wound dressings were changed every 2-3 days. RESULTS: Thirty-eight patients (79%) had major co-morbid conditions liable to impact negatively on wound healing. The treatment duration with VAC varied from 20-30 days with an average of eleven dressing changes (minimum 3-maximum 18). Treatment was effective in all patients. Spontaneous closure was achieved in 36 cases (75%); nine patients (19%) required a split-thickness skin graft, and three (6%) underwent delayed secondary closure. CONCLUSION: In our institution, VAC has become the treatment of choice for complex abdominal and perineal wounds. It is a safe, simple, and effective technique to speed wound healing and it has reduced the duration of hospital treatment in difficult clinical situations and in patients whose general condition is often severely compromised.

[When should cholecystectomy be practiced? Not always an easy decision]. / Quand faut-il réaliser une cholécystectomie? Une décision pas toujours simple.

Gallstone disease is a frequent medical problem. Cholelithiasis affects 10% of the population and 30% of patients with gallstones will undergo surgery. The treatment of choice for symptomatic gallstones remains cholecystectomy. A prophylactic cholecystectomy is indicated for asymptomatic patients in the presence of polyps, porcelain gallbladder or during bariatric surgery. The management of the complications of gallstone disease is discussed. At present, common bile duct stones, even if discovered preoperatively, should be managed by a multidisciplinary team including surgeons trained in laparoscopic techniques and gastroenterologists. This review is complemented by the information from a prospective database generated by a program called "DODIG" on 1099 cholecystectomies performed in our institution.

Fatal vascular leak syndrome with extensive hemorrhage, peripheral neuropathy and reactive erythrophagocytosis: an unusual complication of recombinant IL-3 therapy.

A 39-year-old patient with severe aplastic anemia (AA), resistant to therapy, received recombinant human IL-3 (rhIL-3) on a phase I/II trial. During treatment she developed disseminated skin lesions, suggestive of vasculitis, and severe progressive peripheral neuropathy culminating in complete paralysis. She died 25 days after beginning treatment from profuse bleeding. On autopsy, evidence of vascular leaks with widespread bleeding and extensive hemorrhagic involvement of peripheral nerves was found. An additional feature was massive reactive erythrophagocytosis in lymph nodes, spleen and bone marrow. The coincidence between rhIL-3 administration and the dramatic events suggest a causal relation. As a possible pathogenic mechanism, an rhIL-3 induced excessive stimulation of macrophages and production of secondary cytokines such as tumor necrosis factor (TNF) is suggested. TNF is considered as a major factor in the development of both a vascular leak and reactive erythrophagocytosis. This case report can be regarded as an example of the possible unusual pathologic phenomena we may expect to see in the near future with increasing use of growth factors.

[Opening of an emergency center in the University Hospital Center of Vaud]. / Ouverture d'un centre des urgences au C.H.U.V.

Previously decentralised, non-programmed attendances, followed or not by hospitalisation (emergency admissions) at the C.H.U.V. were seen in 7 different sectors. In the context of the opening of a new hospital building for the C.H.U.V., emergencies were concentrated in a new common area known as the "Emergency Centre". The article describes the organisation of this new sector as well as its activity during the first year of its working (7 months). The centre received approximately 1800 patients per month, 51% examined and treated in the department of surgery, 28% by the department of internal medicine, the rest being under the primary responsibility of services of otorhinolaryngology, paediatrics and paediatric surgery and dermatology. Description of the sector includes some maps to demonstrate the architectural concept and its use in case of mass casualties.