Preliminary experience with umbilical stoma in transumbilical single-port colorectal surgery.

BACKGROUND: The umbilicus, an embryological natural orifice, is increasingly used as the only access route during single-incision laparoscopic surgery (SILS) for colorectal disease. As a part of some of these procedures, a temporary, diverting ostomy could be exteriorized through the umbilicus itself. Theoretical advantages include better preservation of the abdominal wall and potentially superior cosmetic results. The aim of the present study was to evaluate our preliminary experience in SILS colorectal resection with umbilical stoma (u-stoma). METHODS: We retrospectively reviewed all colorectal patients operated using SILS for benign or malignant disease at Paris Poissy Medical Center. Patients were selected for consideration of u-stoma with our stoma therapists. RESULTS: Between January 2010 and December 2016, 234 patients underwent colorectal SILS procedures. In 74 patients (31.6%), an ileostomy (n = 41) or a colostomy (n = 33) was fashioned. Of these, 20 (27% of all ostomies) were umbilical stomas. The 20 u-stoma patients, 10 men and 10 women, received either a loop ileostomy (n = 14) or an end (n = 4) or loop (n = 2) colostomy. The mean age was 52 years (range 29-81 years). There was no mortality. Operative stoma-related morbidity occurred in only 5% of patients (n = 1: ileal torsion volvulus). Median follow-up after stoma formation was 30 months (range 12-59 months). Adjustment to the stoma and quality of life were satisfactory as estimated by both the patient and the stoma therapist. All stomas were reversed. At a median follow-up of 27.5 months (range 7-55 months) after stoma reversal, two patients had reoperation for incisional hernia. CONCLUSION: This preliminary experience showed that u-stoma is a feasible and safe alternative to more conventional ostomy after SILS.

Serum proteomic profiling of obese patients: correlation with liver pathology and evolution after bariatric surgery.

OBJECTIVE: Chronic liver diseases, including cirrhosis, may develop in obese patients. Steatosis and non-alcoholic steatohepatitis (NASH) are risk factors for progression to fibrosis. To date, diagnosis of steatosis and NASH relies on liver biopsy. The aim of the study was to identify serum markers of steatosis and NASH in obese patients using SELDI-TOF ProteinChip. PATIENTS: Eighty obese non-alcoholic patient candidates for bariatric surgery and devoid of hepatitis B and C infection were selected. Serum samples were collected before surgery and at 6 months after surgery for 33 of these patients. Wedge liver biopsy was performed at the time of bariatric surgery. Twenty-four serum samples from healthy blood donors served as controls. The protein profiles of each serum were assessed using SELDI-TOF ProteinChip technology and were compared according to liver histological lesions. RESULTS: Twenty-four obese patients (30%) had non-significant liver lesions, 32 (40%) had significant steatosis and 24 (30%) had NASH. Comparison of serum protein profiles according to liver lesions identified three peaks (CM10-7558.4, CM10-7924.2 and Q10-7926.9) the intensity of which significantly increased according to the severity of the liver lesions (steatosis and NASH) and returned to normal after bariatric surgery. None was correlated with either liver function tests or metabolic parameters. Identification using immunoSELDI assay characterised these peaks as the double charged ions of alpha- and beta-haemoglobin subunits. CONCLUSION: The differential proteomic method demonstrated changes in serum protein profiles in obese patients according to severity of liver lesions. Free haemoglobin subunits may serve as a serum biomarker of the severity of liver damages.

[Laparoscopic mini-gastric bypass: an effective option for the treatment of morbid obesity]. / Le mini-gastric bypass coelioscopique: une option nouvelle pour le traitement de l'obésité morbide.

OBJECTIVE: To evaluate laparoscopic Mini-Gastric Bypass in the treatment of morbid obesity. PATIENTS AND METHODS: Thirty patients with a mean BMI of 41.84.5 Kg/M2 underwent a laparoscopic Mini-Gastric Bypass between March 2005 and February 2006. A laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum 200 cm. distal to the ligament of Treitz Peri-operative and short-term follow-up results up to May 2006 are reported. RESULTS: Conversion to open mini-gastric bypass was necessary in one case (3.3%). Mean operative time was 135 45 minutes. There were no deaths. There were no anastomotic leakages. Two patients developed obstruction at the gastrojejunostomy requiring laparoscopic correction in one case and accounting for an overall morbidity of 6.6%. Mean hospital stay was 3 0.25 days. One patient developed marginal ulcer which resolved with medical treatment; no patients developed symptoms of reflux esophagitis. Mean loss of excess weight was 67.6% at one year and was accompanied by resolution of obesity-associated medical illness in 85% of patients. CONCLUSION: Laparoscopic Mini-Gastric Bypass is a technically simple, safe, and effective procedure in the treatment of morbid obesity and its associated medical illnesses. Moreover, the procedure is easily reversible laparoscopically when post-operative complication occurs.

Effect of vital capacity manoeuvres on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.

BACKGROUND: Arterial oxygenation may be compromised in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effect of a vital capacity manoeuvre (VCM), followed by ventilation with positive end-expiratory pressure (PEEP), on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery. METHODS: Fifty-two morbidly obese patients (body mass index >40 kg m-2) undergoing open bariatric surgery were enrolled in this prospective and randomized study. Anaesthesia and surgical techniques were standardized. Patients were ventilated with a tidal volume of 10 mL kg-1 of ideal body weight, a mixture of oxygen and nitrous oxide (FiO2 = 40%) and respiratory rate was adjusted to maintain end-tidal carbon dioxide at a level of 30-35 mmHg. After abdominal opening, patients in Group 1 had a PEEP of 8 cm H2O applied and patients in Group 2 had a VCM followed by PEEP of 8 cm H2O. This manoeuvre was defined as lung inflation by a positive inspiratory pressure of 40 cm H2O maintained for 15 s. PEEP was maintained until extubation in the two groups. Haemodynamics, ventilatory and arterial oxygenation parameters were measured at the following times: T0 = before application of VCM and/or PEEP, T1 = 5 min after VCM and/or PEEP and T2 = before abdominal closure. RESULTS: Patients in the two groups were comparable regarding patient characteristics, surgical, haemodynamic and ventilatory parameters. In Group 1, arterial oxygen partial pressure (PaO2) and arterial haemoglobin oxygen saturation (SaO2) were significantly increased and alveolar-arterial oxygen pressure gradient (A-aDO2) decreased at T2 when compared with T0 and T1. In Group 2, PaO2 and SaO2 were significantly increased and A-aDO2 decreased at T1 and T2 when compared with T0. Arterial oxygenation parameters at T1 and T2 were significantly improved in Group 2 when compared with Group 1. CONCLUSION: The addition of VCM to PEEP improves intraoperative arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.

[Unusual variation of the splenic artery]. / Variante originale de l'artère splénique.

The authors describe an exceptional variation of the splenic artery found on a preoperative angiogram and confirmed after surgery on splenopancreatectomy specimens. Total duplication of the splenic artery is herein reported for the first time and suggest the need for a new classification of digestive arteries anomalies.

Left-sided omental torsion: CT appearance.

A 34-year-old male presented with exquisite left flank pain. Computed tomography showed a hyperdense vascular structure surrounded by whirling linear streaks situated in the greater omentum under the splenic flexure of the colon. Omental stranding extended caudally into the pelvis where part of the inflamed omentum entered a left inguinal hernia sac. Surgery revealed left-sided torsion of the greater omentum. Left-sided omental torsion is infrequent and pre-operative diagnosis is rarely established. The CT findings of an omental fatty mass with a whirling pattern is characteristic of omental torsion. Preoperative diagnosis is important because conservative management has been suggested.

Continuous versus intermittent portal triad clamping for liver resection: a controlled study.

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.

[Aberrant origin of the splenic artery]. / Orgine aberrante de l'artére splénique.

We report an incidental finding of an aberrant origin of the splenic artery described here for the first time.

Routine use of total hepatic vascular exclusion in major hepatectomy is not necessary.

The prime concert of a hepato-biliary surgeon undertaking liver resection is to minimise blood loss and prevent air embolism through the control of the major vascular structures. Several methods to achieve this are now available and include in particular clamping of the hepatic pedicle and total vascular exclusion. Both techniques are detailed as well as their benefits and drawbacks. For conventional liver resections, total vascular exclusion has no advantage over clamping of the hepatic pedicle in preventing blood loss and is associated with additional morbidity. This technique should be selectively used in patients with tumours involving major hepatic veins or the inferior vena cava.

Appraisal of the order of revascularization in human liver grafting: a controlled study.

BACKGROUND: By current convention, the liver graft is revascularized, first with portal blood flow, and thereafter with arterial blood flow. Although experimental studies showed no detrimental effects of primary arterialization, this order of revascularization has not been investigated in clinical transplants. STUDY DESIGN: Twenty-nine patients were included in our controlled study to investigate and compare, by means of a technical procedure that permits either initial arterial revascularization (IAR) or initial portal revascularization (IPR), the effects of graft revascularization by IAR and by IPR in clinical transplants. RESULTS: Patients were equally divided in the IAR group (n = 15) and the IPR group (n = 14), and were homogeneous in terms of recipients and graft characteristics. Graft reperfusion was uniform and diffuse in all grafts with IAR versus 10 (71%) with IPR (p < 0.05). After reperfusion, the time taken for completion of the procedure was shorter in the IAR group (159 +/- 28 versus 242 +/- 39 minutes) (p < 0.01). Both mean blood transfusions and antifibrinolytic requirements were lower in the IAR group: 5.4 +/- 1.8 versus 7.6 +/- 3.5 packed red cell units, and 13% versus 50%, respectively (p < 0.05). Postoperative ASAT level, clotting factor V level, and bile flow were not different between the two groups. Early postoperative vascular or biliary complications did not occur. During a mean follow-up of 16 months (range, 7-20), one hepatic artery thrombosis occurred in the IPR group, and one anastomotic biliary stricture occurred in each group. CONCLUSION: Under adequate portal decompression, LAR is a safe option and results in better graft reperfusion, shorter post revascularization phase, and reduced transfusion and antifibrinolytic requirements.

High preoperative serum alanine transferase levels: effect on the risk of liver resection in Child grade A cirrhotic patients.

Despite careful selection of cirrhotic patients with hepatocellular carcinoma (HCC), liver resection remains associated with a greater risk than in patients without underlying liver disease. In this study we assessed by multivariate analysis parameters associated with in-hospital mortality and morbidity in a selected group of 108 Child-Pugh A cirrhotic patients undergoing liver resection of HCC. The overall incidences of in-hospital deaths and postoperative complications were 8.3% and 48.1%, respectively. By univariate analysis, the preoperative serum alanine transferase (ALT) level (p = 0.001) and intraoperative transfusions (p = 0.01) were significantly associated with in-hospital death; however, only the serum ALT concentration was an independent risk factor. In-hospital mortality rates in patients whose serum ALT was below 2N (twofold the upper limit of the normal value), between 2N and 4N, and more than 4N were 3.9%, 13.0%, and 37.5%, respectively. An ALT level greater than 2N was predominantly observed in patients with a hepatitis C virus infection and significantly associated with histologic features of superimposed active hepatitis. Patients with an ALT level greater than 2N experienced an increased incidence of postoperative ascites (58% versus 32%, p = 0.01), kidney failure (16% versus 0%, p = 0.0003), and upper gastrointestinal bleeding (6.4% versus 0%, p = 0.02). These results indicate that the preoperative ALT level is a reliable predictor of in-hospital mortality and morbidity following liver resection in Child-Pugh A cirrhotic patients. Cirrhotic patients with ALT > 2N should undergo only a limited resection; if a larger resection is required, those patients should be considered for nonsurgical therapy or liver transplantation.

[Radiation-induced esophageal cancer. Presentation of a case and review of the literature]. / Cancer de l'oesophage radio-induit. Présentation d'un cas et revue de la littérature.

Esophageal cancer induced by radiation is uncommon. Irradiation of the head, the neck, the chest and the abdomen may cause an esophageal cancer several years later. Therefore, regular gastroscopy and biopsy of esophageal mucosa are strongly recommended in symptomatic patients. Surgery combined or not with radiotherapy seems to be the most effective treatment for this kind of cancer. We report a case of squamous cell carcinoma of the esophagus diagnosed 13 years after chemotherapy and radiotherapy for Hodgkin disease stade IIIb.

Vascular occlusion techniques for liver resections.

Prevention of intraoperative blood loss during liver resection is of prime concern. Intraoperative blood loss has indeed repeatedly been shown to adversely influence the short-term prognosis of patients undergoing liver resection. There is in addition evidence that it could be associated with an increased risk; of recurrence in patients operated for an hepato-biliary malignancy through impairment of the patient's immune response. The prime concern of the hepato-biliary surgeon is to minimize blood loss through the control of the major vascular structures this may be achieved in several ways that range from segmental portal control to total hepatic vascular occlusion. The type of vascular occlusion should be selected according to the indication and in particular location of the tumour and presence of an associated underlying liver disease, the patient's cardiovascular status and the experience of the operator. Aim of the authors is to describe the various types of vascular control as well as their benefits and drawbacks so as to use the most appropriate technique according, to each patient' requirements.

Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study.

OBJECTIVE: The authors compared operative course of patients undergoing major liver resections under portal triad clamping (PTC) or under hepatic vascular exclusion (HVE). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by PTC or HVE. Specific complications and postoperative hepatocellular injury mediated with two procedures have not been compared. METHODS: Fifty-two noncirrhotic patients undergoing major liver resections were included in a prospective randomized study comparing both the intraoperative and postoperative courses under PTC (n = 24) or under HVE (n = 28). RESULTS: The two groups were similar at entry, but eight patients were crossed over to the other group during resection. In the HVE group, hemodynamic intolerance occurred in four (14%) patients. In the PTC group, pedicular clamping was not efficient in four patients, including three with involvement of the cavohepatic intersection and one with persistent bleeding due to tricuspid insufficiency. Intraoperative blood losses and postoperative enzyme level reflecting hepatocellular injury were similar in the two groups. Mean operative duration and mean clampage duration were significantly increased after HVE. Postoperative abdominal collections and pulmonary complications were 2.5-fold higher after HVE but without statistical significance, whereas the mean length of postoperative hospital stay was longer after HVE. CONCLUSIONS: This study shows that both methods of vascular occlusion are equally effective in reducing blood loss in major liver resections. The HVE is associated with unpredictable hemodynamic intolerance, increased postoperative complications with a longer hospital stay, and should be restricted to lesions involving the cavo-hepatic intersection.