Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction.

OBJECTIVES: Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy. METHODS: Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented. RESULTS: With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatisfaction. CONCLUSIONS: The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients' satisfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.

Ultrasound-based prediction of cephalic vein cutdown success prior to totally implantable venous access device placement.

BACKGROUND: Surgical venous cutdown is a method for totally implantable venous access device (TIVAD) insertion. The main drawback of this technique is its higher failure rate when compared with the percutaneous approach, which is mostly related to anatomic variations of the cephalic vein. The aim of this study was to assess preoperative ultrasound imaging as a tool to predict cephalic vein cutdown failure for TIVAD insertion. METHODS: Ultrasound and operative reports of a cohort of patients undergoing TIVAD insertion by cephalic vein cutdown were reviewed. Ultrasound venous (vein visibility, diameter, length, subcutaneous depth, vein path, and subclavian junction visibility) and patient variables were tested by logistic regression as predictors of TIVAD insertion failure. RESULTS: One hundred sixty consecutive patients underwent cephalic vein cutdown for attempted TIVAD insertion. An inability to visualize the vein on the preoperative ultrasound examination (odds ratio, 4.39; 95% confidence interval, 1.57-12.30; P < .05) and depth of the vein (odds ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .042) were predictors of failure of TIVAD insertion by cephalic vein cutdown. CONCLUSIONS: Preoperative ultrasound examination allows identifying patients at risk of failure of TIVAD insertion by cephalic vein cutdown. Preoperative ultrasound examination constitutes an efficient tool for choosing the most appropriate surgical approach and improving patient comfort.

Complex abdominal wall defect repair using biologic porcine matrix.

BACKGROUND: The management of patients with complex abdominal wall defect (CAWD) is challenging, and requires appropriate surgical planning, and intensive patient preparation in order to minimize postoperative complications. The aim of this work was to review the management of CAWD using one-stage repair with biologic mesh. METHODS: We retrospectively reviewed patients with CAWD having undergone repair with biologic mesh between January 2013 and October 2014. Demographics, preoperative assessment, intraoperative management and postoperative outcomes were assessed. RESULTS: A total of 15 patients were included. Biologic mesh was used for hernia repair with primary fascial closure (N.=12) or for bridging of the abdominal wall defect (N.=3). Seven patients presented postoperative complications Clavien-Dindo grade ≥3, and among them six required reoperation but no one required the mesh explantation. After a follow-up period of 12 months, four patients presented hernia recurrence and two required a later surgery. CONCLUSIONS: The use of biologic mesh allows single-stage repair of complex abdominal wall defects. The procedure involves significant postoperative morbidity, and requires intensive preoperative multidisciplinary preparation.

Repair of Large Abdominal Wall Defects Using Total Anterior Aponeurotic Flap: Anatomical Feasibility Study and Comparison with Ramirez's Technique.

In this cadaveric study, we explored the feasibility of a maximal mobilization of the superficial abdominal fascia, in a continuous flap, to achieve a tension-free covering of midline defects. The aponeurosis of the external oblique muscle was incised along the anterior axillary line and then detached up to the anterior rectus sheath. The latter was opened between the external and the internal oblique aponeurosis while keeping the continuity with the external oblique fascia. The obtained flap was solid and uninterrupted. The width gain reached 15 ± 3 cm on each sides, providing tissue advancement 60% longer than Ramirez's technique (n = 8). The described technique allows large covering with respect to the anatomical planes. Further clinical tests should evaluate the validity of such concept in the repair of giant and asymmetrical hernias.

Laparoscopic-assisted percutaneous endoscopic gastrostomy in two patients who failed percutaneous endoscopic gastrostomy.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a common procedure to obtain a feeding tube. However, this technique might imply several difficulties and complications. The inability to transilluminate the abdominal wall may occur frequently, especially in obese or multi-operated patients. With the emergence of minimally invasive surgery, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) might provide a safe and efficient alternative. PRESENTATION OF CASES: We report hereby two cases of patients having undergone LAPEG in our institution. Conventional PEGs were deemed impossible because of the absence of transillumination and motivated a surgical approach. Two obese patients with a Body Mass Index (BMI) of 31 and 45kg/m(2) respectively presented neurological condition (stroke and Parkinson's disease) requiring a feeding tube. While a PEG was unsuccessful (impossibility to transilluminate), a LAPEG was attempted. The procedure and the recovery were uneventful. DISCUSSION: There are different techniques for gastrostomy tube placement: open gastrostomy, PEG and radiologic procedure. The PEG is associated with a significant risk of bowel perforation. LAPEG seems to be an interesting option in order to avoid an open gastrostomy in patients in whom a PEG cannot be performed. This is especially true in obese patients, where a transillumination cannot be performed. It offers an endoscopic view of the stomach simultaneously to the laparoscopic approach that allows a potential decrease of major complications. CONCLUSION: While the literature reports mainly pediatric cases, we present herein two successful LAPEG in adult obese patients. In case of impossibility to perform PEG, this technique allows a safe direct visualization of the stomach and other adjacent organs.

Routine chest X-ray is not mandatory after fluoroscopy-guided totally implantable venous access device insertion.

BACKGROUND: The aim of this study is to determine whether systematic postoperative chest X-ray is required after totally implantable venous access port device (TIVAD) placement under fluoroscopic control. METHODS: A retrospective chart review of all consecutive patients with fluoroscopy-guided TIVAD insertion from July 10, 2009 to April 16, 2012 was conducted at the Geneva University Hospitals (n = 927). Patients with an available postoperative chest X-ray were included, regardless of approach (open or percutaneous) and venous access site (subclavian, cephalic, jugular, etc.). Exclusion criteria were incomplete data and preexisting pneumothorax or hemothorax. RESULTS: Eight hundred ninety-one patients were included. First-intention venous cutdown was performed in 878 patients (98.5%), with success rates of 79.4% and 88.2% when targeting the left and right cephalic veins, respectively. Percutaneous access was the chosen first-intention procedure for 12 patients (1.3%). Eight-hundred thirty-six (93.8%) insertions were performed only by the open approach and 53 (5.9%) implantations required at least one venous puncture. Two implantations were performed using previous central venous accesses. Immediate complications associated with TIVAD placement and detected on the postoperative chest X-ray consisted of 1 asymptomatic pneumothorax, 1 symptomatic hemothorax, and 2 malpositions of the catheter. One additional pneumothorax was discovered during the first night after TIVAD insertion in a patient who became symptomatic. CONCLUSIONS: The very low incidence of immediate complications detected by postprocedural chest X-ray suggests that such a control is not mandatory as a routine method after fluoroscopy-guided TIVAD insertion mainly performed by venous cutdown. X-ray should be performed only in cases of clinical suspicion.

Damage control surgery by keeping the abdomen open during pregnancy: favorable outcome, a case report.

BACKGROUND: Acute abdomen in advanced pregnancy is one of the most challenging surgical situations. In life-threatening situations, despite optimal management, foetus distress and preterm delivery may occur. Although laparostomy is a useful treatment of abdominal sepsis, its successful management has not been reported previously in pregnant women. CASE: 30-year-old woman at 23 week of pregnancy was investigated for non-specific abdominal pain. Surgical exploration revealed extensive ischemic bowel necrosis. Multiple segmental resections were performed and abdomen was left open with vacuum assisted dressing, maintained for 48 hours. At the third surgical look the continuity was restored and abdominal wall closed. The foetal condition stayed unperturbed under pharmacologic tocolysis. Pregnancy was carried to full term delivery. CONCLUSION: Open abdomen strategy can be successfully applied in pregnant woman.

Acute ulcerative jejunal diverticulitis: case report of an uncommon entity.

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Its reported incidence varies from 0.05% to 6%. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life threatening and require early surgical treatment. We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome. Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography (CT). As a result of the clinical and biological signs of early peritonitis, an emergency surgical exploration was performed. The first jejunal loop showed clear signs of jejunal diverticulitis. Primary segmental jejunum resection with end-to-end anastomosis was performed. Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis. The patient made an excellent rapid postoperative recovery. Jejunal diverticulum is rare but may cause serious complications. It should be considered a possible etiology of acute abdomen, especially in elderly patients with unusual symptomatology. Abdominal CT is the diagnostic tool of choice. The best treatment is emergency surgical management.