A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort.

BACKGROUND AND AIMS: Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS: From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS: Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ±â€…20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

Acute esophageal necrosis: Case report of an unknown entity.

INTRODUCTION: Acute Esophageal Necrosis Syndrome (AENS) is a rare and unknown clinical entity, defined as a diffuse circumferential black-appearing friable esophageal mucosa going from the distal esophageal mucosa to the gastroesophageal (GE) junction. Esophagogastroduodenoscopy (EGD) remains the gold standard in making diagnosis. PRESENTATION OF CASE: We report here the case of a 45-year-old man with necrosis of the esophagus treated conservatively. Regression of the lesion but persistence of ulcerations were seen on the endoscopic follow-up. Distal esophageal stenosis was then diagnosed and treated by endoscopic dilation. DISCUSSION: Diagnosis of AENS must be considered when an old patient, with multiple comorbidities, presents an upper digestive hemorrhage. Upper endoscopy is mandatory. Treatment is in most of the cases conservative. Esophageal stenosis is a frequent complication. CONCLUSION: Although AENS is a rare clinical entity, it should not be dismissed by doctors, avoiding useless surgical management. This pathology remains nevertheless associated with a considerable mortality rate.

Outcome of exfoliative rejection after isolated intestinal transplantation in an adult: case report.

A 34-year-old-man with short-bowel syndrome received an isolated small bowel graft. On postoperative day (POD) 11, ileal biopsy specimen demonstrated mild to moderate rejection that did not respond to corticosteroid bolus therapy. On POD 14, endoscopy and histologic examination revealed exfoliative rejection that was not controlled after 14 days of therapy with thymoglobulin. On POD 95, the patient underwent surgery again because of intestinal obstruction. The graft was removed 6 months after transplantation because of continuous severe abdominal pain with weight loss. After enterectomy, the patient developed multiple-organ failure and died on POD day 8. This case underlines the severity of exfoliative rejection and suggests that early enterectomy be performed when the diagnosis is made, before deterioration of clinical status and development of infectious and nutritional complications.

Esophageal varices in chronic intestinal insufficiency in absence of portal hypertension or liver cirrhosis: case report.

We report the case of a 62-year-old man with short-bowel syndrome, referred for intestinal transplantation, who had esophageal varices (EV) due to superior vena cava (SVC) thrombosis. Pretransplantation work-up revealed protein S deficiency. Results of liver function tests were normal. Upper endoscopy showed grade II to III EV in the upper and middle segments of the esophagus. Computed tomography demonstrated thrombosis of the jugular, subclavian, and SVC veins and marked collateral vessels in the chest. Transient elastography yielded normal findings. A liver biopsy specimen showed a normal aspect of the liver, without fibrosis or liver cirrhosis. Presence of EV in a patient with chronic intestinal insufficiency may be related to collateral venous circulation associated with SVC thrombosis in the absence of portal hypertension. In this situation, an isolated intestinal graft is indicated.

Gastrojejunocolic fistula after gastric surgery for duodenal ulcer: case report.

Gastrojejunocolic fistulae, a late complication of gastroenterostomy, are presently uncommon. Patients can present with symptoms of a fistula 20 years or more after their original gastric surgery. The knowledge of this rare condition can allow prevention, through a better operative strategy and a medical treatment at the phase of stomal ulcer with proton pump inhibitor and Helicobacter pylori eradication. We present a case of gastrojejunocolic fistula and discuss the modern management of this condition. Its etiological, clinical, and surgical features were briefly discussed.

[Bening enterogenital fistulas arising from the digestive tract: three cases]. / Fistules entérogénitales d'origine digestive bénigne: à propos de trois cas.

Fistulas between the female genital tract and the digestive tract occur after obstetrical, oncological, or post-operative complications. We report herein 3 rare cases of enterogenital fistulas: one colouterine fistula and one colotubal fistula in a patient with diverticulitis, and one ileovaginal fistula in a patient with Crohn's disease. Vaginal discharge was frequent and incited patients to consult a gynecologist. Better knowledge of enterogenital fistulas is necessary to enable earlier diagnosis and apply specific treatment. The incidence of colovaginal fistulas is increasing in diverticular disease because of increased prevalences of hysterectomies and diverticular disease.

Open inguinal hernia repair by plug and patch: the value of fibrin sealant fixation.

BACKGROUND: Prosthetic meshes give excellent results in groin hernia repair. However, although recurrence rates are very low, chronic pain remains frequent and mesh fixation may play a role in the occurrence of this complication. The use of fibrin sealant to secure the mesh may represent a useful alternative for the prevention of chronic pain. The aim of this study is to confirm that the mesh may be secured by spraying fibrin sealant and to assess the reduction in the incidence of chronic pain. METHODS: Seventy hernias were operated on in 57 patients and were evaluated on a prospective basis. The procedure involved placement of a plug and patch mesh which was secured with fibrin sealant alone. These patients were compared to a matched retrospective series of 57 patients who underwent the same procedure, except that conventional non-absorbable suture was used to secure the mesh. RESULTS: The two groups were equivalent for inclusion criteria and preoperative data. The complication rate was similar in the two groups. The operative time was shorter in the fibrin sealant group: 7 min for unilateral hernia (p=0.0017) and 16 min for bilateral hernia (p=0.0008). The length of hospital stay was also shorter in the fibrin sealant group (1.8 days vs. 2.5 days: p < 0.0001). There was no recurrence in the fibrin sealant group after a minimum follow-up of 12 months and no recurrence in the suture group after a minimum follow-up of 25 months. Finally, a significant reduction in chronic pain was observed in the fibrin sealant group (3.5% vs. 22.8%: p=0.042). CONCLUSION: This study confirms the effectiveness of fibrin glue in securing prosthetic meshes and reducing chronic inguinal pain.

Traumatic avulsion of the intrapancreatic common bile duct: case report.

Injuries of the extra hepatic biliary tree following blunt trauma to the abdomen are rare. We present a case of avulsion of the intrapancreatic common bile duct. Very often the lesion is not identifiable until the signs of jaundice and biliary ascites occur. Intraoperative cholangiography is mandatory for the diagnosis, but the noninvasive magnetic resonance cholangiopancreatography could readily depict the injury of the extrahepatic bile duct preoperatively. When the diagnosis is late the corner stone of treatment is biliary diversion and definitive repair after complete resolution of sepsis with a choledochojejunostomy.

Concomitant leiomyoma and leiomyosarcoma of the oesophagus.

Leiomyosarcoma of the oesophagus is a malignant tumor that originates from smooth muscle cells. The filiation between oesophageal leiomyoma and leiomyosarcoma is controversial, with few cases reported in literature. The authors describe un uncommon situation with the simultaneous presence of a leiomyoma and a leiomyosarcoma of the oesophagus in a 75 year-old man, which have been successfully treated with surgical resection. It could probably be a case of a malignant transformation of a previous pre-existing multiple non-confluent leiomyoma.

[Rupture of a pancreaticoduodenal artery aneurysm with median arcuate ligament syndrome: report of a case]. / Rupture d'un anévrisme des arcades duodénopancréatiques associé à une sténose du tronc coeliaque: à propos d'un cas.

Aneurysms of pancreaticoduodenal arteries represent only 2% of all aneurysms of digestive arteries. Occurrence of these aneurysms are favoured by stenosis or occlusion of the celiac axis. Aneurysm rupture is frequent and carries a mortality rate of 20%. Computed tomography with intravenous contrast and selective coeliomesenteric arteriography can make the diagnosis of this disease which can be treated by either surgery or embolotherapy. We report the case of a patient with a ruptured aneurysm of the pancreaticoduodenal arcades mimicking a perforated duodenal ulcer, and successfully treated by surgical ligation.

Anatomy of the presacral venous plexus: implications for rectal surgery.

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.

[Retained fecalith after laparoscopic appendicectomy]. / Coprolithe résiduel, après appendicectomie coelioscopique.

The subhepatic abscess due to retained fecalith is a rare complication following appendicectomy. The incidence of this complication is probably going to increase due to high rate of laparoscopic appendicectomy. We report 2 cases of subhepatic abscess 1 and 2 years after laparoscopic appendectomies. This potentially serious complication could be preventing with technical recommendations. When it occurs, this complication has to be directly treated by surgical drainage, percutaneous drainage couldn't be successful because it leaves fecalith in its place which is a cause of recurrence. Our reports are the first to use a laparoscopic treatment of this complication.

Anatomical study of the blood supply of the coxal bone: radiological and clinical application.

The aim of this work was to study the arterial blood supply of the coxal bone in order to optimize radiological embolization and to minimize the risk of postoperative osteonecrosis. Ten fresh cadavers were dissected after intra-arterial injection of colored resin. All the collateral vessels running to this bone were described and counted. On 25 dry bones, the vascular foramina were measured with the aid of a millimetric gauge and a vascular map was created. The posterior part of the ilium appears to be twice as well vascularized as the anterior part. Fractures of the posterior arch of the pelvis are theoretically more hemorrhagic. The presence of the iliolumbar artery in contact with the sacroiliac joint increases the risk with open book or shearing fractures. The artery of the ischium, a collateral of the pudendal artery, supplies the posterior and lateral parts of the acetabulum and the artery of the roof of the acetabulum, its superior and lateral parts. The branches of the anterior and posterior divisions of the obturator artery supply the superior part of the surroundings of the obturator foramen and the antero-inferior and postero-inferior parts of the acetabulum. The Kocher approach may injure the artery of the ischium. Letournel's extended lateral approach and Mears' triradiate approach may injure the artery of the ischium and the artery of the roof of the acetabulum. The risk of osteonecrosis appears to be theoretically increased if one adds an endopelvic approach. The anterior approach to the acetabulum appears to be that which theoretically leads to the least devascularization. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0029-2.

[Endometriosis of the rectus abdominis muscles]. / Endométriose des muscles grands droits de l'abdomen.

The authors report three cases of endometriosis of the rectus abdominis muscle, presenting as a mass of the abdominal wall associated with pain during menstruation in women with a history of cesarean section. Treatment consisted in wide surgical resection followed by prosthetic abdominal wall repair in one recurrent case. Abdominal wall endometriosis is a rare disease that can be explained by grafting of endometrial cells to the abdominal wall during laparotomy for pelvic surgery, particularly cesarean section. Isolation of the abdominal wall during cesarean section and irrigation of the abdominal wall at the end of the operation are two theoretical measures designed to prevent endometrial cell engraftment. When abdominal wall endometriosis occurs, only radical surgical resection can prevent recurrence.

[Abdominal emergencies in type IV ehlers-Danlos syndrome]. / Urgences abdominales du syndrome d'Ehlers-Danlos de type IV.

Ehlers-Danlos syndrome denotes a group of inherited connective tissue diseases comprising nine types. Type IV Ehlers-Danlos syndrome is the most life-threatening form. It is characterized by a type III collagen deficiency resulting in arterial fragility and death from vascular rupture or bowel perforation. This disease involves a col 3A1 gene mutation. We report the case of a 44 year-old woman with type IV Ehlers-Danlos syndrome. The medical history of our patient included bowel necrosis and two vascular ruptures. We indicate data required to establish Ehlers-Danlos syndrome diagnosis and guidelines for patient management.