Juxtapapillary duodenal diverticula early and late clinical and therapeutical implications

The aim of this paper is to identify the early and late implications of JPDD for biliary pathology, as well as for endoscopic therapy and classical surgery dealing mainly with lithiasis. This paper is based on a retrospective study comprising a number of 675 ERCP performed on 601 patients between 1997-2007, out of which 399 cases were followed by therapeutic measures. A total of 79 procedures were performed on 65 cases with JPDD. The main criteria were: gender, age, indications regarding the performance of ERCP+/-ES, complications that occurred while carrying out these procedures. In all the cases examined (601) the percentage of JPDD reported was of 10.81%. The rate of complications in the sphincterotomized patients without JPDD was 5.75% and the rate in the sphincterotomized patients with JPDD was 14.89%. In conclusion, the paper discusses the clinical and therapeutic implications of JPDD in biliary pathology. It has been found that JPDD is an important etiological cause for the late diseases occurring after cholelithiasis surgery. JPDD also leads to immediate therapeutic implications such as: difficult cannulation and high incidence of ERCP+/-ES complications.

[The reassessment of indications in laparoscopic cholecystectomy]

The gallstone, with its potentialy complications, claims a surgical solution in asymptomatic forms too, often traced out with the abdominal echography investigations circumstances. In all the countries, the symptomatic gallstone, is a surgicaly section, but, the asymptomatic gallstone is a surgicaly indication in some countries, too. A number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients to have gallstones. The indications can be extended to: young children, pregnant women, patients with very large gallstones diabetics, immuno-depressed (AIDS, radiation and multiple drug treatments). The asymptomatic gallstone seems to obtain in the last years, an extention of the surgicaly approach indications, the paper, suggesting a laparoscopic cholecystectomy assessment indications.

External drainage of the hepatic post hydatid remnant cavity

BACKGROUND AND AIM

The surgical management of the hepatic post hydatid remnant cavity includes conservative and radical methods. External drainage of the remnant cavity (with or without cavity-minimizing) is a simple conservative method that can be safely performed, and can be associated with endoscopic papillo-sphincterectomy (EPS) in case of cysto-biliary fistula.

METHODS

A retrospective study was performed on 112 patients operated in the Department of Surgery, "Caritas" Clinical Hospital, Bucharest between Jan 1997 and Feb 2007. Cavity was drained and the completely extraperitoneal approach for exteriorizing the drain was preferred, an original method conceived and put into practice by Prof. Dr. Burlui, using as pathway the round ligament, more precise the hepato-umbilical territory.

RESULTS

The mean hospital stay was 12 days, and follow-up till complete recovery was performed by clinical, ultrasound, CT-scan and X-ray contrast on the drainage tube. The drainage of the remnant cavity was maintained a mean period of 55 days (ranging 20 to 80), in accordance with the X-ray contrast control on the drainage tube. The postoperative morbidity was acceptable (remnant cavity infection was registered in 11% of the cases). Neither reintervention, nor mortality was registered.

CONCLUSIONS

the study shows that external drainage of the hepatic post hydatid remnant cavity can be applied in most of the parasite locations, especially for the central segments, with no hepatic parenchyma sacrifice, while total cavity fibrosis is achieved in a mean period of 55 days. This way we avoid a risky and laborious procedure (the anatomic or non-anatomic removal of a variable amount of normal hepatic tissue).

[Retroperitoneal pyogenic infections with uncertain etiopathogenesis. Diagnostic and therapeutic difficulties]

Retroperitoneal pyogenic collections can appear in most distinct pathological situations. Establishing the topography and pathogenic route are essential steps in developing the therapeutic attitude. Diagnosis of suppurative retroperitoneal process complicating a previously attested disease is less difficult. The challenges appears in that cases with atypical, clinical picture, which presents associated pathological states (diabetes mellitus, chronic alcoholism, behavioral disturbances), as well as in primary retroperitoneal infections (psoas abscess, infected retroperitoneal tumors) or in that situations in which the patient presents toxico-septic shock on admission. A retrospective study on the patients with retroperitoneal infections admitted in our Clinic between 1996 - 2006 was carried out. We selected the cases in which preoperative etiopathogenic diagnosis was uncertain (in some situations the exact etiopathogenic route remaining unknown even postoperatively). The aim of this study is to evaluate the factors contributing to this, and how therapeutic attitude was influenced.

[Surgical approach in acute necrotising pancreatitis]

Acute necrotising pancreatitis is a dramatic and often life-threatening disease with a high rate of mortality, varying between 30-70% and necessitating heavy medical care. The surgical attitude regarding acute necrotising pancreatitis is disputed between the supporters of drainage with closed abdomen and the supporters of laparatomy with open drainage. The goal of this study is the evaluation of the number of intervention required, the timing of the interventions and the mortality and morbidity in a group of patients with necrotising pancreatitis. The studied group consists in 112 patients with necrotising pancreatitis, treated in Surgical Clinic of Caritas "Prof. Dr. N. Cajal" Clinical Hospital, Bucharest during 1983-2005. Infection of pancreatic necrosis supervened in 55,35% of patients in this group, not any pancreatic necrosis becomes infected. Infected necrosis is not synonymous for abscessed of necrosis, in the same patient pancreatic necrosis, infected pancreatic necrosis and abscessed necrosis may coexist. Clinical and biological criteria are the decisive factors in the indication for surgical treatment, the radiology being decisive in the choice of the laparotomy approach. In the study group 50,89% of patients necessitated only one surgical intervention. Implicitly, more than half of the patients would have been suffered multiple useless planned staged relaparotomies. The mortality in our study group treated by the method of closed drainage was 25,89%.

Late choledochal pathology after cholecystectomy for cholelithiasis

After "simple" cholecystectomy for lithiasis, biliary disorders can appear, with the onset more than 3 years postoperative, like cholangitis or transitory jaundice. Meantime, a whole range of congenital abnormalities initially ignored can become manifest: biliary tract congenital dilatations, duodenal para-Vater diverticulum, Oddi stenosis.

AIM

to establish the pathological circumstances that determine late choledochal syndrome, including an analysis concerning the therapeutical approach in these cases. Patients with cholecystectomy complains of late biliary disorders (least 3 years symptom-free) between 1997-2005, were retrospectively studied. Exclusion criteria were intraoperative incidents or accidents, recognised incomplete surgical procedure, early difficult postoperative course. Therapeutical approach was endoscopical, surgical or conservative. 46 patients entered the study group; 38 underwent open cholecystectomy. Mean interval between operation and disturbances onset was 10 years. Following etiopathologic causes of late choledochal pathology were recorded: incomplete cholecystectomy, retained or primary common bile duct (CBD) stones, choledochal cyst or stenosis, Oddi stenosis, duodenal para-Vater diverticulum, anomaly biliary tree. Thirty patients undergone successful endoscopic treatment; in 8 cases endoscopy failed, in 2 cases open surgery was the first choice; 5 diagnostic endoscopic cholangiography with conservative treatment were performed; 1 patient refused any procedure. Cholecystectomy indication is regularly based on clinical and ultrasound examination criteria. Even a simple cholecystectomy can be followed after first 3 years by cholangitis, obstructive jaundice, caused by initially ignored biliary tract pathology. To avoid such omissions, routine intraoperative cholangiography and duodenal endoscopy should precede cholecystectomy. On the other side, cholecystectomy itself can cause late complaints: retained CBD stones, gallbladder stump, and iatrogenic stenosis. The duodenal para-Vater diverticulum seems to have a more important role in biliary disturbances, before and after cholecystectomy.

[Carcinoid tumors, leiomyosarcoma and invasive adenocarcinoma metastasis of the Treitz angle]

Our paper studies the quite rare occurrence of the digestive superior occlusive pathology, namely some causes which might induce partial or even total obstruction of the digestive tract, at the distal anatomical limits of the duodenum, also known as the Treitz angle. The first two described cases were carcinoid tumors, obstructive and ulcerated in the lumen of the same angle. The last two cases were an obstructive leiomyosarcoma and an invasive mesenteric metastasis from a right colon cancer, which cause a total external compression of the Treitz angle, clinically manifested as a complete food intolerance, as a first symptom. Concerning the clinical evolution, these are totally different lesions, malign, metastasis and neuroendocrine tumors, which occurred at the same level, had a totally different clinical evolution and surgical approach, only three of them developing at good postoperative course. The imaging, clinical and pathological diagnosis problems, the different specific surgical solutions, the postoperative care and finally the rarity of this level of obstruction of the small bowel, are the aim of this paper.

[Particular evolution of a jejunal tumor in one patient with multiples neoplasia]

The authors present the case of one male patient, 71 years old, known with serial neoplasia (right colon neoplasm 1983, left colon neoplasm 1987) for which there were performed several interventions. The patient was admitted first time in our Department in 1998 for a non specifically symptomatology; in particular anaemic syndrome. The first intervention was performed in June 1998, without finding anything pathological, despite the presumption of a third tumor on the remaining colonic territory, theory that was partially sustained by the paraclinical examinations. The second intervention was performed in February 2001, when it was found and extirpated a jejunal tumor, under Treitz angle, but after 9 months, when a new intervention was performed, we found a relapse tumor which was not extirpable. The aim of this study is to present the unpredictable versatility of small bowels tumors and the difficulty of establishing an early positive diagnose.

[Recessive hiccup of rare cause (compressive pleuro-pericardial lymphocele). Case report]

The authors discuss the case of a 40 year-old woman, which was performed surgery for a stenosant duodenal ulcer by bilateral troncular vagotomy and hemigastrectomy, using the Pean-Billroyh 1 anastomosis. Immediately after surgery untractable hicongh gradually set in which lasted over a 14 year, till the moment when a compressive pleuropericardic lymphocele, of the right phrenic nerve was revealed, a very long time growing cyst. After the surgical removal of the lymphocele was performed, which had compressed the right phrenic nerve, singultation totally disappeared, the patient has been monitorized through periodical medical checkings for more than 4 years. The period of 14 years when the patient constantly complained of steady untractable singultation has comprised 30 admission or more, to various surgical, gastroenterology and psychiatry wards. The patient was finally considered an incurable psychotic and was medically pensioned. The authors discuss a number of possible sequels of the initial gastric surgery which could have triggered untractable singultation, without being able to control them or totally ruling out the psychotic causes. There is natural suspicion cast of either existence or beginning of this cyst simultaneous with surgery since clinical tests and explorations were able to reveal it only after 14 years.

[Therapeutical options in lithiasic biliary fistula]

Chronic lythiasic cholecystitis is a disease distinguished by the pathologic changes because of the chronic inflammation of the biliary extrahepatic tree. Sometimes these morphological changes are associated with internal biliary fistulas arising spontaneously in patients with advanced calculus cholecystitis. The vast majority of fistulas result from the adherence of the inflamed gallbladder or common bile duct to an adjacent viscus and erosion of the gallstones into the adherent organ. The authors analyze an amount of 43 patients with bilio-biliary and bilio-digestive lythiasic fistulas, caused by the long evolution of chronic lythiasic atrophic cholecystitis, for 126 cases which were operated in the Surgery Department of the Caritas Clinic Hospital along 20 years. In these 126 cases the surgical strategy was determinated by the method of dealing with the pericolecystitis sclerotic blocks, by the identification methods of the biliary elements and by the approach of the main billiary way and digestive loops injuries occurred after suppressing the fistulae. The surgical solutions adapted for each separate case and the advantages of the axial drainage of prostheting the surgical reconstructions of the main biliary way as well as the results obtained along this project, are in fact the aims of this presentation.

[Controlled stomach fistula for acute operated ulcer. Case report]

The authors analyze the case of a 65 old woman which was hospitalized for sigmoidian stenosant and haemorrhagical neoplasm, confined to the colic wall, without peritoneal or hepatic metastases, and without peritoneal or parietal invasion. Surgical management included sigmoidectomy and termino-terminal anastomosis for reconstructing intestinal transit followed by peritoneal drainage. In early postoperative stage the aspect of generalized peritonitis occurs and there is suspicion of anastomotic fistulae. On surgery, acute and perforated gastric ulcer is found, located in close vicinity to the cardia, on the anterior side of the stomach. Suture of the perforation is undertaken with drainage of the peritoneal cavity, but successfully because fistulization of the sutured perforation followed. Under the given circumstances controlled drainage of the gastric fistulae was carried out, using a Folley probe extended through the fistulae orifice and through the anterior abdominal wall, lateral to the median incision. The blowing of the intragastric balloon and the setting into tension of the gastric wall to the front abdominal wall allowed the sealing of the fistulae route but it took about three months. This technical contrivance has afforded good postoperative evolution and recovery of the patient, who after five years from surgery is in a good condition and has no subjective complaints.

[Unusual hemorrhagic complication after surgery for severe generalized appendicular peritonitis]

The 22 year old male patient, was admitted in hospital for severe generalized peritonitis subsequent to acute perforated appendicitis and toxico-septic shock. On examination and relying on the previous history of the patient onset of the perforation was start assessed to have occurred some days earlier. Severe generalized, putrid peritonitis was found on surgery of the peritoneal cavity. Appendectomy was successfully carried out with a simple ligature of the appendix stump, and the ligature of the mezooappendix was performed without identifying the appendicular artery. Early in the postoperative stage there occurred diffuse bleeding localized in the peritoneal cavity. The source of the bleeding could not by found at the first reoperation. Subsequently the septic syndrome evolved simultaneously with the bleeding in a milder form, however, leading to growth in size of retroperitoneal hematoma. On marking the diagnosis, relying on CT examination, a new, second surgery was performed which afforded evacuation and drainage of the retroperitoneal hematoma. The authors have remarked and have tried to clear up the circumstances which had been conductive to the occurrence of hemorrhage, a thing absolutely unusual in the evolution of diffuse peritonitis by perforated acute appendicitis.

[An endoscopic treatment method for postoperative stenoses]

The endoscopic procedures include a great variety of procedures for the treatment of the upper and lower gastrointestinal bleeding of the benign and malign jaundice, of the primary or secondary gastrointestinal strictures. The authors present the case of a patient with a postcaustic oesophageal stricture for whom the surgical treatment was an esogastroanastomosis. Quite early in the postoperative course the anastomosis got, very tight due to a anastomotic fistula, and we succeed to dilate it with endoscopic procedures.

[Intraoperative exploratory endoscopy in surgery of the digestive tract]

The intraoperative endoscopy as a way of the range of the surgical exploration of the abdomen is a valuable procedure combining surgical and endoscopical maneuvers. It proved useful in following conditions: A. delicate surgical approach of the anatomical segment; B. equivocal findings of the conventional endoscopy; C. as a way of achieving therapeutical goals. In 56% of the cases a transperitoneal approach was used and in the rest of the cases a conventional technique. Sterilization was performed using glutaldehide 2%, 20 minutes before the intervention. The methods was used in 50 cases, concerning reinterventions, as well as primary diseases of unclear origin. Some were high-risk patients. Therapeutically benefit was proven in all cases.

[A rare cause of postoperative digestive hemorrhage]

Despite all the diagnosis's technical progress achieved in the past years, there are possible haemorrhagic complications after abdominal surgery, creating problems of diagnosis and treatment. The author presents a rare case of postoperative gastrointestinal bleeding due to an ulcer of the jejunal mucosa, located quite close to a hepaticojejunostomy. The mucosal ulcer, with consequent severe, massive bleeding was caused by the migration of a thread from the hepaticojejunostomy, proved by histopathological examination.

[Splenic hemangiosarcoma]

The authors present a case of splenic hemangiosarcoma which was encounter-a group including some 600 splenectomies. Hemangiosarcomas represent only 3% of all malignant splenic tumours. This clinical observation is of particular interest because of the extreme rarity of such cases. It is also interesting because of the conditions which have determined the intervention, as well as by the prolonged survival of the patient.

[Particular operations in surgery of gastric ulcer under the protection of vagotomy]

There are particular situations in the frame of the surgery of gastric ulcers, when the use of classical techniques--such as extensive resections, or sub-total resections--represents a risk factor and raising doubts about the vital prognosis of the patient (dehiscence, fistula, etc.). This is especially true for highplaced lesions, the removal of which supposes either an upper polar resection, or an almost total gastrectomy. This raises some problems with suture which are doubtful, as well as the risk of the "small stomach" syndrome or the risk of accelerated evacuation. The authors suggest several possibilities for the surgery of gastric ulcers under the protection of vagotomy, which allow a good immediate and late evolution. These include the medio-gastric resection, the so-called "saddle" resection, and the excision-suture resection, all being carried out under the protection of vagotomy associated to piloro-plastia. Making use of these procedures the authors have been able to maintain a more conservative attitude with regard to the stomach pouch, and to avoid some of the sequellae of the operated stomach.

[Surgery of operative lesions of the principal biliary passages]

The authors present their experience acquired in 30 cases of surgical interventions performed for the correction of accidental lesions of the main biliary pathway. The essential parameters are discussed in this paper, which determine the degree of difficulty of the corrective interventions. Indications are also discussed concerning tactical and technical aspects depending on the level of the lesion, as well as in relation with its type. The authors present some particular aspects of prostheses used in the derivations which they have made with a corrective purpose.