Use of a preperitoneal prosthesis for strangulated groin hernia

BACKGROUND

Prostheses are widely used in the elective treatment of adult groin hernias. Their use for strangulated hernias remains controversial because of the potential risk of sepsis.

METHODS

Thirty-five patients with a strangulated groin hernia were treated by insertion of a prosthetic mesh via a midline preperitoneal approach. Nine patients needed an intestinal resection for irreversible necrosis without peritonitis, and an appendicectomy was carried out in three others.

RESULTS

There were two postoperative wound infections, neither in patients who had an intestinal resection. No mesh had to be removed. The recurrence rate was one of 35 after mean follow-up of 4.2 years.

CONCLUSION

A strangulated groin hernia can be repaired safely with prosthetic mesh. When an intestinal resection is carried out with sufficient care to minimize infective complications, the use of mesh is not contraindicated.

[Celioscopic approach in surgical treatment of morbid obesity. Technique and results]

Three hundred and twenty Laparoscopic Adjustable Silicone Gastric Banding (LASGB) procedures have been performed in our institution from September, 1993 to January, 1997 for the treatment of morbid obesity. Before the first human operation a new prototype of the silicone band for laparoscopic use has been devised and a new surgical protocol developed in a preliminary animal lab programme. All the patients were morbidly obese (92-200 kg). The conversion rate to laparotomy has been very low (1.25%). Early complications have been rare. Pouch dilatation and/or stomach slippage has been the only significant late complication. The rate of this complication has been considerably improved by reducing the pouch volume and by putting more gastro-gastric sutures. The post-operative weight loss of LASGB has been comparable with our series of VBG and ASGB.

Advantages of inferior vena caval flow preservation in combined transplantation of the liver and heart

Only a few cases of combined liver and heart transplantation have been reported in the literature, and no standard surgical procedure has yet been established. We report the successful transplantation of both liver and heart in a 28-year-old patient suffering from homozygous beta-thalassemia. We used Belghiti's technique of inferior vena caval flow preservation for liver transplantation, which avoids inferior vena cava occlusion by a side-to-side caval anastomosis. Applied to combined liver and heart transplantation, preservation of caval flow during liver transplantation may allow early discontinuation of cardiopulmonary bypass and, thus, minimize the general consequences of prolonged bypass.

Surgical approach in severe bleeding peptic ulcer

Hospitalisation and surgery for uncomplicated peptic ulcers have decreased over the past 20 to 30 years, but the total number of operations for bleeding peptic ulcer has increased. Haemorrhage remains the most common complication of peptic ulcer and also the one with the highest mortality rate. Emergency operations to control the bleeding have a mortality rate in the range of 10% to 20%. With the advent of endoscopic haemostasis, the hospital mortality rate is reduced, by reducing rebleeding and emergency operation rate. Emergency operative intervention is clearly indicated for patients with active haemorrhage refractory or inaccessible to endoscopic haemostasis. Combination of successful endoscopic haemostasis and elective early operative intervention favorably influences mortality only if applied to selected patient at high risk of rebleeding and death before sequelae of shock. For those at low risk for recurrent haemorrhage, early operation would be associated with an unacceptable operative risk. Truncal vagotomy and pyloroplasty, with ulcer oversew is the best surgical approach for elective and emergency operation in poor risk patients with duodenal ulcer haemorrhage. Proximal gastric vagotomy and ulcer oversew may be chosen in selected good risk patient. Gastric ulcers are associated with an increased risk of recurrent haemorrhage and malignancy. A more radical procedure (partial gastrectomy) should be favoured since it reduces bleeding recurrence rate without increasing mortality.

Successful tricuspid valve replacement and pulmonary valvulotomy for carcinoid heart disease

A case of successful tricuspid valve replacement with a mechanical prosthesis and pulmonary valvulotomy for carcinoid heart disease is reported. The patient was a 61 years old women. The primary tumor was in the terminal ileum. Liver metastasis and carcinoid syndrome were present since 8 years. After cardiac surgery, the patient survived 38 months and late death was related to disseminated metastasis. Even in case of metastasis, carcinoid tumor is slow growing. Without cardiac operation for correction of valvular lesions, terminal symptoms and death may often be related to cardiac operation for correction of valvular lesions, terminal symptoms and death may often be related to cardiac failure rather than to tumoral growth. Thus, even in presence of metastasis, cardiac surgery may be mandatory to improve both quality of life and survival.

Acute diverticulitis in heart transplant recipients

Immunosuppressed patients are susceptible to complicated diverticulitis, but reports of this complication are scarce in heart graft recipients. To estimate the prevalence of acute diverticulitis in heart graft recipients, we retrospectively reviewed the cases of diverticulitis in a series of 143 patients who underwent orthotopic heart transplantation in a period of 10 years. Six (4%) of these developed acute diverticulitis and required colectomy. All of them were male patients and were older than 50 years. Four patients underwent urgent laparotomy and colon resection with end colostomy (Hartmann procedure). The two other patients suffered from diverticulitis without generalized peritonitis and underwent laparoscopic sigmoidectomy with direct transanal end-to-end anastomosis. The postoperative outcomes of these six patients were satisfactory. As are other immunosuppressed patients, heart graft recipients are susceptible to diverticulitis. Early surgical management may be safe in well-compensated patients.

Combined liver-spleen-small intestine grafting in a rat model: role of transplanting additional lymphoid tissue on survival

The aim of this study was to develop suitable models of combined intestinal grafting to examine the enhancing effect of intestinal grafting with additional lymphoid tissue using 30% of the liver mass and the whole spleen on recipient survival in the absence of immunosuppression. Grafts from DA (RT1a) rats were transplanted orthotopically to PVG (RT1(1)) recipients according to the following design: group 1 (n = 6), en bloc 30% liver/entire SB/spleen; group 2 (n = 7), en bloc 30% liver/SB; group 3 (n = 7), SB/spleen and group 4 (n = 7), SB control for the preceding groups. The orthotopic nature and proximal interposition of the SB graft allowed the assessment of protection afforded by components of the cluster on the SB graft using survival endpoints. Although group 4 hosts survived half as long compared to other groups, statistical significance was reached only in the case of group 1; group 1 MST equalled 15.3 days, significantly higher than group 4 (p = 0.01). Acute rejection was present in every grafted tissue and was equivalent whether liver was included or excluded in the cluster. GVHD was absent postoperatively using clinical or histological criteria; recipient spleens showed hyperplasia, donor spleens depicted lymphocytic depletion on histology. This study determined that statistically proven enhanced survival was obtained only after grafting 30% liver plus spleen with the entire SB. GVHD was rare in the fully allogeneic system despite transplanting a massive load of lymphoid tissue. The surgical models used in this study employing liver in the cluster, address the important question of how best to evaluate the role of heterotopic accessory liver grafting in providing tolerance to co-transplanted small intestine.

Laparoscopic-assisted colectomy in heart transplant recipients

Reports of laparoscopy in heart graft recipients are scarce and, to our knowledge, laparoscopic colectomy has not yet been reported in heart transplant patients. The magnitude and the tolerance of the hemodynamic changes induced by pneumoperitoneum are unknown in heart graft recipients, who have a denervated heart and are "preload-dependent". The authors report the clinical courses of 2 heart graft recipients who developed acute diverticulitis without perforation or peritonitis and who underwent laparoscopic-assisted colectomy without complications.

Placebo-controlled clinical trial of mesalazine in the prevention of early endoscopic recurrences after resection for Crohn's disease. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID)

OBJECTIVE

Endoscopic postoperative recurrences occur early after 'curative' surgery for Crohn's disease. Pentasa has been shown to be effective in the maintenance treatment of quiescent Crohn's disease. The aim of this study was to test the efficacy of a 12-week oral intake of Claversal in the prevention of endoscopic recurrences after 'curative' resection for ileal, colonic or ileocolonic Crohn's disease. We conducted a multicentre double-blind controlled trial comparing Claversal (1g tid) with placebo, starting within 15 days after surgery. The macroscopic normality of the two anastomotic segments was assessed at surgery. Patients were clinically and biologically evaluated twice (6-week interval), and colonoscopy was performed at 12 weeks. Endoscopic relapse was defined by any anastomotic ulcerations or stenosis and staged according to a four-grade score.

RESULTS

Between May 1989 and May 1991 12 centres included 126 patients, 70 women and 56 men, aged 33 +/- 12 years (range 16-70) in the study. Disease locations were ileal, colonic and ileocolonic in 45, 6 and 49%, respectively. Claversal and placebo groups were similar at inclusion, except for ESR (37 +/- 26 vs. 27 +/- 23 mm/h in the Claversal and placebo groups, respectively; P < 0.05). Nine patients were withdrawn from the study. Adverse reactions occurred only in six patients. Five patients were excluded for protocol violation. Finally, 106 patients could be evaluated at 12 weeks (55 Claversal and 51 placebo). An endoscopic relapse was observed in 50% and 63% of the Claversal and placebo groups, respectively (P = 0.16), with a similar grade distribution. Claversal was well tolerated.

CONCLUSIONS

Our study confirms that a large proportion of endoscopic recurrences occur within 3 months of resection in Crohn's disease. There was a slight trend towards greater efficacy of Claversal; it could be worthwhile trying higher dosages and/or 5-ASA compounds with different intestinal release profiles.

Abdominal wall metastasis and peritoneal carcinomatosis after laparoscopic-assisted colectomy for colon cancer

We report a case of a port-site recurrence with diffuse peritoneal carcinomatosis after laparoscopic-assisted right hemicolectomy. The interval between resection of the colonic adenocarcinoma and diagnosis of the recurrence was short (1 month), suggesting that intraperitoneal dissemination and tumour implantation on surgical wounds may represent the principal mechanism of recurrence after laparoscopic surgery. Review of the literature shows an alarming increase in the occurrence of this devastating complication. Although beneficial to the patient in the immediate post-operative period, the adequacy of laparoscopic-assisted colectomy in tumour is increasingly under question.

Acute liver failure. Diagnosis, management and results after orthotopic liver transplantation

From february 1989 till october 1992, we performed 13 orthotopic liver transplantations on 8 patients admitted with the diagnosis of fulminant hepatic failure. The mortality of this affection, despite many treatments is very high, from 60 to 90% at three months according to the literature. Liver transplantation seems to be actually the treatment of choice in many cases. The purpose of this study is to review current concepts about this affection, indications for liver transplantation and results in our small series with a survival rate of 85% at 3 months, 75% at 6 months and 1 year.

Laparoscopic Placement of Adjustable Silicone Gastric Band in the Treatment of Morbid Obesity: How to Do It

BACKGROUND: laparoscopic placement of the adjustable silicone gastric band (ASGB) was begun in our institution in 1992. METHODS: this work started on the animal model first. In the animal laboratory, details of laparoscopic dissection around the pig's stomach were defined. A new prototype of the adjustable silicone band for laparoscopic use was devised. The first human laparoscopic ASGB procedure was performed in our institution on September 1, 1993; 37 patients have undergone this operation by May, 1994. There were 33 women and four men. The average pre-operative weight was 114 kg (92160 kg). The mean BMI was 42 kg m(2) (37-50 kg m(2)). RESULTS: no major operative difficulty has been encountered. Immediate post-operative outcome was uneventful except for one patient. CONCLUSION: the technique of laparoscopic ASGB is described. Preliminary weight loss is comparable to open ASGB and vertical gastroplasty, provided that the surgeon has mastered laparoscopy and open bariatric surgery.

Adverse effect of abdominal operations on production of interferon-gamma

OBJECTIVE

To assess the effects of abdominal operations on the production of cytokines as one of the mechanisms of postoperative immunosuppression.

DESIGN

Prospective study.

SETTING

University hospital, Belgium.

SUBJECTS

19 Selected patients who underwent operations for benign (n = 10) or malignant (n = 9) diseases.

INTERVENTIONS

Whole blood was collected in heparinised tubes before operation and on postoperative days 1, 2, 3, 5, 7, and 9. After 1/10 dilution in culture medium the whole blood cells were stimulated with 5 micrograms/ml phytohaemagglutinin and 25 micrograms/ml lipopolysaccharide, and incubated at 37 degrees C in 5% carbon dioxide. Concentrations of interleukin 1 (IL-1), tumour necrosis factor alpha (TNF alpha), and interleukin 6 (IL-6) were measured at 24 hours, and interferon-gamma and interleukin 2 (IL-2) were measured at 72 hours, with commercially available assays.

OUTCOME MEASURES

Production of the monokines IL-1, TNF alpha, and IL-6, and of the lymphokines IL-2 and interferon-gamma, postoperatively. The monokines were expressed as a percentage of the preoperative values/monocyte, and the lymphokines as a percentage of preoperative values/lymphocyte.

RESULTS

Production of IL-1 and TNF alpha, but not IL-6, decreased immediately after operation then returned to preoperative values. Production of IL-2 and interferon-gamma were significantly reduced immediately after operation, and that of interferon-gamma was still depressed on the ninth postoperative day.

CONCLUSION

Cytokine production is altered after abdominal operations. The production of interferon-gamma may be a more sensitive indicator of altered immune response and vulnerability to infections and tumour growth than concentrations of other cytokines.

Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity. A preliminary report

A first approach to laparoscopic placement of the adjustable silicone gastric band (ASGB) was begun in our institution in 1992. This work started on an animal model first. In the animal lab, details of laparoscopic dissection around the stomach have been defined. A new prototype of the adjustable silicone band for laparoscopic use has been devised. Four voluntary patients underwent this operation on the 1st, 2nd, and 3rd of September 1993. All the patients were female and the average weight was 116 kg (102-120 kg). The mean body mass index was 43 kg/m2 (36-49 kg/m2). No major operative difficulty was encountered. Immediate postoperative outcome was uneventful.

Laparoscopic adrenalectomy in pheochromocytoma and Cushing's syndrome. Reflections about two case reports

Laparoscopic adrenalectomy is possible as well on the left as on the right side using a percutaneous transabdominal approach. The exposure of the glands seems better than it could be achieved with an open method. In combination with intraoperative infusion of nicardipine, a calcium-channel blocker, the laparoscopic removal of a pheochromocytoma was performed safely and under stable conditions. In case of Cushing's syndrome, the laparoscopic approach reduces the problems related to poor healing. In all cases of laparoscopic adrenalectomy, this approach could offer the clear advantages of smaller incisions, reduced postoperative pain and incisional discomfort as well as complications related to large and invasive procedure and finally allows quicker recovery. Moreover, conversion to open surgery remains always possible, if needed.

[Long-term results in ileo-anal reservoirs in the treatment of ulcero-hemorrhagic rectocolitis]

The authors report long term results of 53 ileo-anal anastomosis for ulcerative colitis. They used a "J" pouch technique with anastomosis to the anal canal after mucosectomy of the lower rectum. An upstream ileostomy should be created and left in place for two to three months. Early morbidity primarily involves pelvic or parietal infectious problems, while late complications comprise pelvic fistulae, obstructive events, and episodes of pouch inflammation. Functional results improve over the first year and remain stable thereafter. The major long term problem remains that of pouch inflammation its treatment, and the understanding of its pathophysiology.

Cytokines and organ transplantation. A review

Cytokines regulate both aspecific inflammatory responses and specific immune responses. Inflammatory changes occur in the organ transplant as a result of tissue trauma and ischemia/reperfusion in the organ donor and at the time of transplant operation. There is a possibility that cytokines play a role in mediating theses changes. These aspecific inflammatory changes may not only affect graft function but also influence graft immunogenicity (enhanced MHC and adhesion molecule expression) and thus, vulnerability to rejection. Cytokines orchestrate the specific immune response elicited by organ transplantation. Relevance of cytokines to the rejection reaction is multifactorial in nature: 1) promotion of the proliferation an differentiation of specific alloreactive T and B cells clones and differentiation and activation of CTL and NK cells, 2) chemotactic effect and induction of the expression of adhesion molecules, 3) enhancement of MHC class I and II expression, and 4) direct cytotoxic effect on the target grafted cells. Therefore, modulation of cytokine activity either specifically (monoclonal antibody, soluble receptor, etc.) or aspecifically (cyclosporin, FK 506, Rapamycin, steroids, etc.) is essential in controlling graft rejection. Determination of circulating cytokines and cytokines measurement within the biological fluids produced by an organ transplant may help in the diagnosis of rejection episodes and other complications following organ transplantation.