Two-Year Results of Sleeve Gastrectomy Combined with Posterior Fundoplication for Obesity Patients with Gastroesophageal Reflux Disease.

INTRODUCTION: Currently, gastroesophageal reflux disease (GERD) is the main side effect after sleeve gastrectomy (SG), causing discomfort and potential long-term risks. Surgical techniques combining fundoplication with SG are being evaluated to limit postoperative GERD. METHODS: This single-center retrospective study evaluated patients who underwent SG with posterior fundoplication in the context of GERD between 2018 and 2021, with postoperative follow-up up to 24 months. The results were compared to a control group (ratio 1 to 4) who had SG without fundoplication. Observed total weight loss (TWL) was compared to predicted TWL using the Sophia multinational study's machine learning-based calculator. RESULTS: The series included 22 patients (mean body mass index 44.4 kg/m2) with GERD conditions: GERD symptoms (n = 15), hiatal hernia (n = 6), esophagitis (n = 7), and Barrett's esophagus (n = 5). Two patients required reoperation, including one for valve perforation. At 2 years, GERD was present in three patients (13.6%), including two who regularly took proton pump inhibitors. Compared to the control group (n=88), the frequency of GERD persisting at 2 years was significantly reduced in the SG with fundoplication group (p=0.05). The TWL at 12 and 24 months was 27.7% and 26.1%, respectively, with no significant difference compared to the weight predicted by the model, nor compared to the control group. CONCLUSION: The combination of posterior fundoplication with SG can be proposed in patients with GERD who have a contraindication to Roux-en-Y gastric bypass. Specific morbidity may exist at the beginning of the experience.

French survey on a cohort of emergency general surgery modifications induced by lockdown of the SARS-CoV-2 pandemic.

PURPOSE: The brutal COVID-19 pandemic has majorly impacted populations and health systems, and surgeons have observed dramatic changes in their daily clinical activities. A survey of French digestive surgeons was conducted to assess these changes. METHODS: An electronic survey was sent to French digestive and general surgeons in the Societe Francaise de Chirurgie Digestive (SFCD) to assess the surgeons' daily activity during the pandemic and investigate changes in patients' management. The care deviations were classified as delay of management, modification of strategy, or modification of organization, and the impact of these changes on patients was evaluated by the surgeon's estimation of loss of chance. RESULTS: A major reduction in surgical elective activity was observed in 50 (75%) of the 67 hospitals that responded. Of these, 48 hospitals (71.6%) reported receiving SARS-CoV-2 patients. A deviation from usual care was observed in 10% of patients admitted for emergency general surgery. Among 140 patients presenting a deviation from usual care, 74 (52.9%) had delayed management, 53 (37.9%) had a modification of strategy, and 64 (45.7%) had a modification of organization. Medical treatment instead of surgical treatment was decided for 37 (26.4%) patients, resulting in a high loss of chance for 6 patients. Delays (p < 0.001) and a switch from surgical to medical treatment (p = 0.002) were independently correlated with overall loss of chance based on multivariate analysis. CONCLUSION: This study highlighted the deviations in general emergency surgery patients and provided implications for the solutions that should be implemented during a new health crisis.

Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271).

BACKGROUND: There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD. METHODS/DESIGN: This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity. DISCUSSION: The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.

An Experimental Study of Intraluminal Hyperpressure Reproducing a Gastric Leak Following a Sleeve Gastrectomy.

INTRODUCTION: A gastric leak (GL) represents the main post-operative complication following a sleeve gastrectomy (SG) and occurs most commonly at the top of the stapling, without any clear explanation. OBJECTIVE: This experimental study evaluates the biomechanical behavior of post-SG gastric specimens using both insufflation and tensile tests. MATERIALS AND METHODS: A total gastrectomy followed by an ex vivo SG was performed in 15 pigs. The "sleeved" stomachs were subjected to intraluminal hyperpressure until failure. Uniaxial circumferential and longitudinal tensile tests were performed using gastric strips obtained from the "resected" stomachs. All the deformations and burst pressures were recorded and analyzed. RESULTS: A GL appeared in the upper third of the stapling in 73% of cases. The mean burst pressure was 26.3 ± 5.3 mmHg and was significantly correlated with the volume of the "sleeved" stomachs (p = 0.02). The overall deformation of the "sleeved" stomachs was comparable in the frontal (38.3%) and profile (40.5%) planes. The greatest displacement was observed at the failure zone (11 mm on average). The biomechanical behavior of the stomach wall differed according to the strip orientation. The circumferential strips presented a higher strain-to-failure rate (97%) and a lower Young's modulus (0.99 MPa) when compared to the longitudinal strips (45% and 2.58 MPa, respectively). CONCLUSION: This preliminary study reproduced a GL in the same location as observed during clinical practice. The volume of the SG influenced the burst pressure. Further experimental studies and numerical simulations should evaluate the impact of shape modifications on an SG.

Preoperative Prediction of Small Bowel Length Using CT Scan and Tridimensional Reconstructions: a New Tool in Bariatric Surgery?

PURPOSE: During Roux-en-Y-gastric Bypass, the limb lengths are preoperatively determined regardless of individual small bowel length (SBL), which presents a great variability. Few studies highlighted anthropometric factors associated with SBL, and none attempted to predict SBL preoperatively. OBJECTIVE: The aim of this study is to evaluate factors correlated to SBL (anthropometric and radiologic) and to establish a preoperative SBL prediction. MATERIAL AND METHODS: In this single-center prospective study, 30 adult patients who underwent laparotomy with a preoperative CT scan were included. Intraoperative SBL measurement was performed with an umbilical tape. Anthropometric parameters were age, gender, height, and BMI. 2D radiological measurements consisted of subcutaneous thickness, abdominal diameters, waist circumference, and mesenteric root length. 3D radiological volumetric reconstructions consisted of whole small bowel and mesentery (WSBM), lean small bowel and mesentery (LSBM), and fat small bowel and mesentery (FSBM). RESULTS: Mean intraoperative measurement of SBL was 531 ± 105 cm. Among the clinical and radiological measurements, the FSBM volume presented the greatest dispersion. Height (p < 0.02) and LSBM volume (p < 0.01) were significantly correlated to the SBL in univariate analysis. LSBM volume was the only measurement significantly associated with SBL in multivariate analysis (p < 0.006). From the multivariate model, a formula was created to predict SBL. The mean percentage difference between predicted and intraoperative SBL measurements for all patients was 13.7%, and 8.4% for obese patients. CONCLUSION: LSBM volume is significantly correlated to the SBL. A preoperative SBL prediction with low percentage error could be performed with LSBM volume.

Effectiveness of pure argon for renal transplant preservation in a preclinical pig model of heterotopic autotransplantation.

BACKGROUND: In kidney transplantation, the conditions of organ preservation following removal influence function recovery. Current static preservation procedures are generally based on immersion in a cold-storage solution used under atmospheric air (approximately 78 kPa N2, 21 kPa O2, 1 kPa Ar). Research on static cold-preservation solutions has stalled, and modifying the gas composition of the storage medium for improving preservation was considered. Organoprotective strategies successfully used noble gases and we addressed here the effects of argon and xenon on graft preservation in an established preclinical pig model of autotransplantation. METHODS: The preservation solution Celsior saturated with pure argon (Argon-Celsior) or xenon (Xenon-Celsior) at atmospheric pressure was tested versus Celsior saturated with atmospheric air (Air-Celsior). The left kidney was removed, and Air-Celsior (n = 8 pigs), Argon-Celsior (n = 8) or Xenon-Celsior (n = 6) was used at 4 °C to flush and store the transplant for 30 h, a duration that induced ischemic injury in our model when Air-Celsior was used. Heterotopic autotransplantation and contralateral nephrectomy were performed. Animals were followed for 21 days. RESULTS: The use of Argon-Celsior vs. Air-Celsior: (1) improved function recovery as monitored via creatinine clearance, the fraction of excreted sodium and tubulopathy duration; (2) enabled diuresis recovery 2-3 days earlier; (3) improved survival (7/8 vs. 3/8 pigs survived at postoperative day-21); (4) decreased tubular necrosis, interstitial fibrosis, apoptosis and inflammation, and preserved tissue structures as observed after the natural death/euthanasia; (5) stimulated plasma antioxidant defences during the days following transplantation as shown by monitoring the "reduced ascorbic acid/thiobarbituric acid reactive substances" ratio and Hsp27 expression; (6) limited the inflammatory response as shown by expression of TNF-alpha, IL1-beta and IL6 as observed after the natural death/euthanasia. Conversely, Xenon-Celsior was detrimental, no animal surviving by day-8 in a context where functional recovery, renal tissue properties and the antioxidant and inflammation responses were significantly altered. Thus, the positive effects of argon were not attributable to the noble gases as a group. CONCLUSIONS: The saturation of Celsior with argon improved early functional recovery, graft quality and survival. Manipulating the gas composition of a preservation medium constitutes therefore a promising approach to improve preservation.

A multicentre, randomised, controlled trial to assess the safety, ease of use, and reliability of hyaluronic acid/carboxymethylcellulose powder adhesion barrier versus no barrier in colorectal laparoscopic surgery.

BACKGROUND: Intra-peritoneal adhesions are frequent following abdominal surgery and are the most common cause of small bowel obstructions. A hyaluronic acid/carboxymethylcellulose (HA/CMC) film adhesion barrier has been shown to reduce adhesion formation in abdominal surgery. An HA/CMC powder formulation was developed for application during laparoscopic procedures. METHODS: This was an exploratory, prospective, randomised, single-blind, parallel-group, Phase IIIb, multicentre study conducted at 15 hospitals in France to assess the safety of HA/CMC powder versus no adhesion barrier following laparoscopic colorectal surgery. Subjects ≥18 years of age who were scheduled for colorectal laparoscopy (Mangram contamination class I‒III) within 8 weeks of selection were eligible, regardless of aetiology. Participants were randomised 1:1 to the HA/CMC powder or no adhesion barrier group using a centralised randomisation list. Patients assigned to HA/CMC powder received a single application of 1 to 10 g on adhesion-prone areas. In the no adhesion barrier group, no adhesion barrier or placebo was applied. The primary safety assessments were the incidence of adverse events, serious adverse events, and surgical site infections (SSIs) for 30 days following surgery. Between-group comparisons were made using Fisher's exact test. RESULTS: Of those randomised to the HA/CMC powder (n = 105) or no adhesion barrier (n = 104) groups, one patient in each group discontinued prior to the study end (one death in each group). Adverse events were more frequent in the HA/CMC powder group versus the no adhesion barrier group (63% vs. 39%; P <0.001), as were serious adverse events (28% vs. 11%; P <0.001). There were no statistically significant differences between the HA/CMC powder group and the no adhesion barrier group in SSIs (21% vs. 14%; P = 0.216) and serious SSIs (12% vs. 9%; P = 0.38), or in the most frequent serious SSIs of pelvic abscess (5% and 2%; significance not tested), anastomotic fistula (3% and 4%), and peritonitis (2% and 3%). CONCLUSIONS: This exploratory study found significantly higher rates of adverse events and serious adverse events in the HA/CMC powder group compared with the no adhesion barrier group in laparoscopic colorectal resection. TRIAL REGISTRATION: ClinicalTrials.gov NCT00813397. Registered 19 December 2008.

Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons' enemies.

BACKGROUND: The aim of this study was to determine the incidence and predisposing factors of biliary complications (BCs) after pancreaticoduodenectomy (PD) and report our experience in managing these BCs. Pancreatic surgery, particularly PD, has benefited from improvements in operative techniques and postoperative care and is currently safer in terms of mortality. However, the morbidity associated with PD remains high, including frequent complications such as delayed gastric emptying and pancreatic fistulas. Rarer but important BCs are those that manifest as bile leaks (BLs) and biliary strictures (BSs). METHODS: Between April 2005 and December 2011, a total of 397 patients underwent PD at two centers. All data were retrospectively studied with respect to age, gender, pancreatic pathology, neoadjuvant treatment, preoperative biliary stenting, intraoperative data, postoperative pancreatic fistula, BL and BS rates, and mortality. The management of BCs was also analyzed. RESULTS: Thirty patients experienced a BC: 13 BLs (3.3 %) and 17 BSs (4.3 %). A thin bile duct (<5 mm), measured during surgery, was the only predisposing factor for developing a BL or a BS. The management of the BLs consisted of surveillance in six patients (46 %), percutaneous drainage of bilioma in four patients (31 %), and reintervention in three patients (23 %). No patient with a BS had surgery as the frontline treatment: the initial management consisted of an endoscopic procedure, a percutaneous procedure, or medical treatment. Four patients (23.5 %) underwent surgical treatment after failure of nonsurgical procedures. CONCLUSIONS: The only identified predictive factor of BC, either a BS or a BL, was a thin bile duct. Although the noninvasive technique was the treatment of choice initially, reintervention was required in almost 25 % of the cases.

Endoscopic treatment of mandibular condylar fractures in live minipigs: benefits of the operative learning curve.

Endoscopic treatment of mandibular condyle fractures is a minimally invasive technique that avoids the complications of open reduction and internal fixation. We have used live minipigs as an animal model for learning and training the technique. Fourteen condylar fractures were created, reduced, and internally plated in 7 minipigs using an endoscopic approach by a surgeon with no previous experience of the technique. The mandibles were reduced and fixed successfully in each animal. Operating time was reduced as the surgeon became more familiar with the technique. Minipigs are useful as a model for the endoscopic approach to the treatment of mandibular condylar fractures. Surgeons have the opportunity to train and gain surgical endoscopic experience before treating patients.

Biomechanical characterisation of fresh and cadaverous human small intestine: applications for abdominal trauma.

Intestinal injuries are responsible for significant morbidity and mortality arising from trauma to the abdomen. The biomechanical characterisation of the small intestine allows for the understanding of the pathophysiological mechanisms responsible for these injuries. Studies reported in the literature focus principally on quasi-static tests, which do not take into account the stresses experienced during high kinetic trauma. In addition, the use of embalmed human tissue can alter the recorded response. The stress-strain curves from 43 tensile tests performed at 1 m/s were analysed. Samples were prepared from four fresh human intestines and from four embalmed cadaveric intestines. The data indicated a two-phase response, with each response consisting of a quasi-linear increase in the stress followed by an inflection in the curve before a peak preceding the loss of stress. The fresh tissue was more deformable than the embalmed tissue, and its first peak stress was lower (P = 0.034). A complementary histological analysis was performed. The results of the analysis enable an investigation of the response of the intestinal wall layers to stress as a two-layer structure and highlight the high sensitivity of the structure's mechanical behaviour to the speed of loading and the method of preservation.

Postoperative efficacy and safety of vessel sealing: an experimental study on carotid arteries of the pig.

BACKGROUND: The aim of this preclinical study was to analyze the burst pressure of large in vivo sealed vessels, not just immediately, but also in the first 7 postoperative days. METHODS: In 26 anesthetized pigs, the right carotid artery was sealed and cut using a novel device that integrates bipolar and ultrasonic energy. The animals were then awakened. They underwent a second surgical procedure after different follow-up periods ranging from 1 to 7 days: the left common carotid artery was sealed and cut in the same way as the contralateral artery. Perioperative and postoperative clinical events, evolution of burst pressure over time, and comparison between immediate and delayed burst pressure were analyzed. RESULTS: All sealings were successful. There were no perioperative or postoperative complications. Median immediate (day 0) burst pressure was 949 mmHg (IQR 781-1181). Burst pressure decreased postoperatively but was never below 500 mmHg in any pig. CONCLUSION: Postoperative variations are observed in the burst pressure of in vivo sealed arteries. Immediate burst pressure alone should not be used for validating vascular sealing devices.

Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study.

BACKGROUND: The efficacy of laparoscopy simulators remains controversial. METHODS: This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed. RESULTS: Before/after scores were significantly improved in the MISTELS (P = .042) and LAP Mentor (P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS (P = .026) and LAP Mentor (P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups. CONCLUSIONS: Simulator training provides a more rapid acquisition of competence in surgical technique.

The Rapunzel syndrome: a hard-to-swallow tale.

INTRODUCTION: Rapunzel syndrome is a rare entity comprising of a large gastroduodenal trichobezoar due to trichotillomania. Its treatment is often surgical. CASE REPORT: A 27-year-old patient was investigated after an upper gastro-intestinal tract obstruction. Computed tomography and endoscopy showed a large gastric trichobezoar with a duodenojejunal tail. Conservative treatments failed to remove the bezoar. We performed a short laparotomy which allowed the removal of the bezoar through a longitudinal gastrotomy. Postoperative course was uneventful.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study.

BACKGROUND: Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding. OBJECTIVE: To assess a new, totally endoscopic strategy to manage anastomotic fistulas. DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENTS: This study involved 27 consecutive patients from July 2007 to December 2009. INTERVENTION: This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant. MAIN OUTCOME MEASUREMENTS: Technical success, mortality and morbidity, migration of the stent. RESULTS: Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient. LIMITATIONS: Moderate sample size, nonrandomized study. CONCLUSION: An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Very low stapling of the anal canal in laparoscopic ileal pouch-anal anastomosis.

Performing a double-stapled ileal pouch-anal anastomosis requires very low stapling of the anal canal. However, this laparoscopic procedure is often difficult to perform. We describe here a transanal method of everting the rectum, which allows easier transection under visual control and a sufficiently low anastomosis. Once the entire colon and rectum have been dissected out at laparoscopy, a plastic tube is introduced per anum and advanced into the mid sigmoid. The rectum is then divided at the level of the rectosigmoid junction by an endostapler, which also attaches the plastic tube to the rectum. The colon specimen is removed by a small incision at the chosen stoma site. Gentle traction on the plastic tube at the perineum everts the rectal tube. The anal canal is then transected at the desired level relative to the dentate line.

Preoperative infliximab treatment and postoperative complications after laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis: a case-matched study.

BACKGROUND: Infliximab offers promising new therapeutic options for treatment of moderate to severe ulcerative colitis. However, several studies suggest that it increases postoperative complication rates for patients who later require a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). This study aimed to assess the postoperative course of patients after laparoscopic IPAA, comparing those who had and those who had not received infliximab before surgery. METHODS: The authors identified patients from their institution's IPAA database, finding 13 patients who had received preoperative infliximab treatment. Using age, gender, and type of procedure (2 or 3 stages) as criteria, they matched these cases with infliximab-naive patients drawn from the same database. The differences in perioperative data between the two groups were analyzed. Complications and their severity were assessed using the Strasberg classification. RESULTS: No significant difference was found between patients treated with and those treated without infliximab for each variable studied, namely, mean operative time (353 vs. 355 min), complication rate (23 vs. 38%), and mean hospital stay (22 vs. 25 days). CONCLUSION: The study findings showed no adverse impact from previous infliximab therapy on the laparoscopic IPAA postoperative course.

Mid-term functional outcome of laparoscopic restorative proctocolectomy: a prospective study of 40 consecutive cases.

INTRODUCTION: This prospective study aimed to analyze the functional outcome after a two-stage laparoscopic total proctocolectomy with ileal pouch-anal anastomosis. MATERIALS AND METHODS: From May 1999 to May 2008, 68 consecutive two-stage laparoscopic total proctocolectomies with ileal pouch-anal anastomosis were performed (ulcerative colitis: n = 61; familial adenomatous polyposis: n = 7). A covering ileostomy was used in all patients. Forty patients whose covering ileostomy had been closed for a minimum of 2 years were included in this series. RESULTS: Conversion to laparotomy was necessary in 4 of 40 patients (10%). Thirteen postoperative complications occurred in 13 of 40 patients (30%). At a median follow-up of 38 months (range, 26-90), the median number of bowel movements was 4 per 24 hours (range, 2-10); 15 patients (38%) had no nighttime bowel movements. None of the patients had fecal incontinence or urgency. Thirty-four of the 40 patients (85%) experienced no soiling. Seven patients (18%) took regular antidiarrheal medication. All patients were able to resume all activities practiced prior to illness onset, and 36 of 40 (90%) were satisfied with their overall quality of life (very good or good). CONCLUSION: Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis provides satisfying mid-term functional outcome.

Results of non-operative therapy for delayed hemorrhage after pancreaticoduodenectomy.

INTRODUCTION: Hemorrhage after pancreaticoduodenectomy is a life-threatening complication, which occurs in 4% to 16% of cases, even in experienced centers. Many diagnostic and therapeutic options exist but no one has yet established management guidelines. This study aimed to determine the role of conservative management in delayed hemorrhage. PATIENTS AND METHODS: From January 2005 to August 2008, 87 patients underwent pancreaticoduodenectomy at our center. We reviewed, retrospectively, the medical charts of all patients who had experienced postoperative hemorrhage. RESULTS AND DISCUSSION: Early hemorrhage occurred in one patient, who underwent successful reoperation. Nine patients presented with delayed hemorrhage (10.3%), including three with sentinel bleeding. Mean onset was 20 days post-surgery. We used the same initial management for each patient: all had an urgent contrast computed tomography scan. In every case, the bleeding site was arterial. Conservative treatment (embolization or covered stent) was successful in every case. We reoperated on two patients for gastrointestinal perforation, at 9 days and 2 months after embolization, respectively. We transferred seven patients to an intensive care unit, with an average stay of 8 days. Mean hospital stay was 43 days (33-60). All patients survived. CONCLUSION: Conservative management, combining endovascular procedures and aggressive resuscitation, is appropriate for most cases of delayed hemorrhage after pancreaticoduodenectomy.

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis.

BACKGROUND: Restorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated. OBJECTIVES: To compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP. SEARCH STRATEGY: We searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA. SELECTION CRITERIA: All trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Eleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported. AUTHORS' CONCLUSIONS: The laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.

Laparoscopy-assisted left ovarian vein transposition to treat one case of posterior nutcracker syndrome.

We report one case of posterior nutcracker syndrome treated by left ovarian vein (LOV) transposition. A 36-year-old woman was suffering from nutcracker syndrome associated with pelvic congestion syndrome. Color duplex scan, computed tomographic scan, and angiography demonstrated a stenosis of a retroaortic left renal vein with proximal dilatation and incompetence of the LOV. The renocaval pullback gradient was 10 mm Hg. The LOV was harvested laparoscopically and transposed into the inferior vena cava. Completion angiography showed a patent reconstruction with no significant gradient. At day 4, an asymptomatic thrombosis was treated by thromboaspiration. Forty months later, the patient remained asymptomatic with a patent transposition. Posterior nutcracker syndrome is a rare condition. When associated with pelvic congestion syndrome due to LOV reflux, it can be treated by LOV transposition.