Laparoscopic Repair of Larrey Hernia: A Case Report and Literature Review.

Morgagni-Larrey hernia is a rare pathology resulting from an anterior diaphragmatic defect. Diagnosis is often made in adulthood due to the lack of symptoms associated with this condition. Various surgical techniques have been reported for its treatment, but no standard approach has been established due to its rarity. Here, we present the case of a 42-year-old patient with a symptomatic Larrey hernia successfully treated with a laparoscopic approach. The rationale for documenting this case lies in contributing to the understanding and management of this rare condition.

Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review.

AIM: Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome. METHODS: A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed. RESULTS: The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation. CONCLUSIONS: Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.

Acute appendicitis and pregnancy: diagnostic performance of magnetic resonance imaging.

BACKGROUND: The aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant women. METHODS: The study was conducted in 2 referral centers in Brussels, Belgium, between March 1st 2009 and January 31st 2017. Pregnant women who presented with abdominal pain and underwent MRI were included. Baseline characteristics, clinical, laboratory, and ultrasound test results were extracted retrospectively from the electronic medical charts. MRI exams were prospectively reevaluated by an experienced radiologist blinded to patient outcome and MRI findings. Visualization of the appendix and assessment of gastrointestinal, genitourinary, and vascular systems were recorded. The diagnosis of acute appendicitis was confirmed by pathology exam. RESULTS: In total, 85 patients were included. The appendix was identified in all patients on MRI and acute appendicitis was suspected in 7. The diagnosis was confirmed in 6 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI were 100% (95% confidence interval [95% CI]: 54.1%-100%), 98.7% (95% CI: 93.2-99.9%), 85.7% (95% CI: 46.1-97.7%), and 100%, respectively. In contrast, the sensitivity, specificity, PPV, and NPV of the combination of clinical exam, laboratory findings and/or ultrasound were 100% (95% CI: 54.1%-100%), 62% (95% CI: 50.4-72.7%), 16.7% (95% CI: 13.1-20.96%), and 100%, respectively. CONCLUSION: MRI is reliable in confirming or excluding acute appendicitis during pregnancy, with a rate of visualization of the appendix approaching 100%. Efforts should be focused on the implementation of MRI as a first-line imaging exam in the workup of suspected acute appendicitis during pregnancy.

Selection criteria for surgical treatment of pudendal neuralgia.

AIMS: Pudendal neuralgia is the clinical expression of a chronic compression of the pudendal nerve. The diagnosis is based on a set of five criteria, called Nantes criteria. Four of the criteria are clinical and the last requires evaluation of the anesthetic response to CT-guided infiltration of the pudendal nerve. The aim of our study is to evaluate the relevance of anesthetic test response to select patients for surgery, and whether this criterion can be used to predict its success. METHODS: Retrospective analysis of a cohort of 34 patients undergoing surgical treatment. In our cohort, we included six patients with negative CT-guided pudendal nerve infiltration test. RESULTS: Of the 28 patients that met all five Nantes criteria, 64% (18 patients) responded well to surgery. In contrast, 100% of the six patients with a negative anesthetic test failed to show an amelioration of symptoms after surgical treatment (P = 0.006). In our analysis, there was no significant difference in surgery response when men were compared to women (P = 0.387), when procedure was unilateral or bilateral (P = 0.562), or when duration of symptoms was long (P = 0.412). We observed a difference in terms of age between the group of responders and non-responders, although this difference did not reach the threshold of significance (P = 0.216). CONCLUSIONS: The selection of candidates for surgery should always include a single diagnostic anesthetic injection of the pudendal nerve, as the fifth of the Nantes criteria is an effective predictor of the success of surgery. Neurourol. Urodynam. 36:663-666, 2017. © 2016 Wiley Periodicals, Inc.

Results of surgical treatment of uncontrollable upper gastrointestinal hemorrhage using endoscopy.

BACKGROUND/AIMS: Acute hemorrhage of the upper gastrointestinal tract occurs at a rate of 50 to 100 per 100,000 annually in the Western adult population. With the increased use of therapeutic endoscopy, the role of surgery is decreasing; surgical intervention is now only used in cases of failure of endoscopic hemostasis. The goal of this study is to determine whether there are predictive factors associated with high-risk post-operative mortality. METHODOLOGY: This retrospective study included 30 patients treated from March 1996 to September 2008 at Brugmann Hospital. These patients presented with upper gastrointestinal non-variceal hemorrhage that was treated first endoscopically then surgically for recurrent hemorrhage. Multiple risk factors (variable and fixed) and parameters were evaluated to determine their influence on mortality. RESULTS: Of 30 patients, 10 (33%) developed recurrent hemorrhage following surgical treatment. A total of 8 (26.6%) deaths occurred of which 4 were related to hemorrhage. Three deaths occurred after the first intervention and 5 occurred after a second intervention. Logistic regression analysis revealed that the total number of blood units transfused and the presence of at least one surgical reintervention both significantly increased mortality rate (p = 0.0426 and p = 0.0068). Other parameters were not significant. However, there is a lack of power due to the small sample size. CONCLUSION: For recurrent massive upper gastrointestinal hemorrhage following endoscopic treatment and necessitating more than 19 blood transfusions, early surgical intervention is recommended and surgical reintervention should be avoided. If reintervention is necessary, radical surgery is recommended. However, the small number of patients treated over a 12-year period limits the results of this study, and these results may represent simple coincidences.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty.

BACKGROUND: Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB). METHODS: Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting. RESULTS: There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months). CONCLUSIONS: Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

Septic shock in digestive surgery: a retrospective study of 89 patients.

BACKGROUND/AIMS: septic shock is the most severe systemic inflammatory response to infection. Septic shock is associated with organ dysfunction and with major circulatory failure. The aim of this work is to study the impact of septic shock in digestive surgery. This is a retrospective study. METHODOLOGY: Between January 2001 and March 2008, we selected patients hospitalized in the intensive care unit who underwent digestive surgery and who developed septic shock during the same hospitalization were selected: 89 patients were enrolled in this group which included 53 men and 36 women (sex ratio M/W 1.47), and the age average was 71.5 years. They were divided into two subgroups: preoperative septic shock (62/89) and postoperative (27/89). The majority of septic shock occurred in patients who developed an inflammatory disease and an organ perforation. Esophagogastric surgery generates the most postoperative septic shock. RESULTS: The overall mortality was 54%. The most frequent complications were digestive and pulmonary. The germ most frequently encountered is Escherichia coli. The majority of patients received a combination of two or three antibiotics. The empirical antibiotic therapy most frequently administered was a combination of piperacillin/ tazobactam and amikacin. DISCUSSION: The results observed in the present study are, for the most part, in agreement with those found in the literature. However, the question of the most effective antibiotic therapy remains open. CONCLUSION: In digestive surgery, septic shock is pathology with significant mortality (54%). The germ most frequently responsible is Escherichia coli. The most frequently administered empirical antibiotic therapy is a combination of amikacin and piperacillin.