Fistula Following Laparoscopic Sleeve Gastrectomy: a Proposed Classification and Algorithm for Optimal Management.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an accepted restrictive procedure with a hormonal component. There is no definitive course of treatment for post-LSG fistula; it remains a feared complication. We aimed to classify post-LSG fistulas and propose an algorithm to optimize their treatment. METHODS: Following primary and revisional LSG in obese patients, a retrospective observational study of fistulas was undertaken. Radiological studies were performed to identify anatomically distinct types of fistulas. An algorithm was elaborated for the classification and evolving treatment of each type of fistula. RESULTS: Twenty post-LSG fistulas were studied (13 [2.5%] from our center, 7 referred) with a mean body mass index of 43.1 ± 10.2 kg/m2 (32.0-76.0) and mean age of 33.1 ± 11.4 years (20.0-56.0). In all cases, the clinically suspected diagnosis was radiologically confirmed by water-soluble upper gastrointestinal series and double-contrast abdomino-pelvic CT scan. Three anatomical fistula types were characterized: type I, a small leak with no collection; type II, a leak with associated intra-abdominal abscess; and type III, a leak with multiple internal or external abscesses, a complex fistula. In accord with our algorithm, patients without sepsis received conservative treatment initially; this was sufficient for type I leaks. Type II abscesses received internal or external percutaneous drainage, and in some cases, stenting or endoprosthesis. Surgery was reserved for failure of conservative options and type III fistula. In cases of sepsis, surgery was mandatory. CONCLUSION: A radiologically defined, anatomically based classification system and treatment algorithm proved effective in clinical management of post-LSG fistula.

Laparoscopic procedure for suspected appendicitis. A prospective study in 283 consecutive patients.

Between September 1990 and December 1993, 283 consecutive patients were admitted with clinical symptoms of acute appendicitis. These patients underwent primary laparoscopic approach so that an appendicectomy could be performed by this method. In 49 cases (17.3%), primary laparoscopic examination corrected the preoperative diagnosis and the appendix was left in situ. Appendicectomy was performed in 234 cases (149 women, 85 men) with a mean age of 30 years. Requirement for open surgery occurred in 29 cases. The main cause of unsuccessful procedures was inflammation due to local or generalized peritonitis. Median operative time for a successful procedure was 60 min (range, 25-160). Four postoperative complications (one related to laparoscopic procedure), one case of wound infection, and no mortality resulted. After laparoscopic appendicectomy, the median hospital stay was 3 days (range, 1-16). These results suggest that a laparoscopic approach for suspected appendicitis is reliable, allowing abdominal exploration and safe appendicectomy.

[Intraoperative systematic cholangiography in celiopscopic cholecystectomy]. / Cholangiographie per-opératoire systématique au cours des cholécystectomies par coelioscopie.

OBJECTIVES: Laparoscopic cholecystectomy has become the therapeutic gold standard in uncomplicated cases of cholelithiasis. This study evaluated the feasibility and the results of intra-operative cholangiography during laparoscopic cholecystectomy. METHODS: Intra-operative cholangiography was attempted in 126 consecutive patients undergoing laparoscopic cholecystectomy. Common bile duct stones were detected according to the following criteria: a) clinically (history of jaundice or pancreatitis); b) biologically (aminotransferase > 2 N, alkaline phosphatase > 2 N, total bilirubin > 20 mumol/L); c) ultrasonographically (diameter of the common bile duct > 12 mm, presence of gallbladder stones < 10 mm); d) calculation of the multifactorial score of Huguier. RESULTS: An intraoperative cholangiography was performed in 116 patients (92%), for a mean duration of 16 minutes (range: 9-25 min). Two anomalies of the biliary tree were detected. Ten common bile duct stones were detected (8.6% with 50% success of laparoscopic extraction). One false positive case had justified a surgical exploration of the common bile duct. The sensitivity of preoperative criteria was 80%. No morbidity or postoperative biliary complications were related to the intraoperative cholangiography. CONCLUSIONS: Routine intraoperative cholangiography should be systematically performed during laparoscopic cholecystectomy, providing anatomical information of the biliary tree and detecting, in 1.7% of cases, unsuspected common bile duct stones which could be treated during the same operative procedure.