Partial Splenic Infarction as a Complication of Laparoscopic Floppy Nissen Fundoplication

Single-incision transgastric resection for gastric gastrointestinal stromal tumors in anatomically challenging locations

Surgical resection is the mainstay treatment for resectable gastrointestinal stromal tumors (GISTs). However, resection in anatomically challenging locations, such as near the gastroesophageal junction, lesser curve and fundus, remain technically challenging. We herein report the outcomes of the largest series of patients who underwent single-incision transgastric resection of an intraluminal gastric GIST. Our reduced-port resection technique for intraluminal GISTs in these anatomically challenging locations involves a single incision in the left hypochondrium, deepened to access the gastric lumen, with the surgery completed in a transgastric manner. A total of 22 patients received surgery with this technique at the National University Hospital in Singapore from November 2012 to September 2020. The median operative time was 101 (range 50-253) min, with no conversions to open surgery, median lesion size 3.6 (range 1.8-8.2) cm and median postoperative length of stay 5 (range 1-13) days. There was no 30-day mortality and no recurrence during the follow-up period. Our laparoscopic approach for reduced-port transgastric excision of intraluminal GISTs allows for adequate surgical clearance, convenient extraction and secure gastrostomy closure with low morbidity.

Dynamic MRI Evaluation of the Gastric Fundus and Splenic Circulation to Assess the Gastric Breves Dissection during Laparoscopic Nissen Fundoplication

AIM:

We aimed to evaluate the possible effects of dissecting gastric breves (GB) during the Laparoscopic Nissen Fundoplication (LNF) on the gastric fundus and splenic circulation using dynamic Magnetic Resonance Imaging (MRI).

METHODS:

In total 14 patients with gastroesophageal reflux disease (GERD) that was diagnosed with esophagogastroduodenoscopy and 24 - hour PH monitorization and undergoing LNF surgery were included. All patients underwent LNF surgery between October 2006 and March 2010. All patients were evaluated regarding gastric fundus and splenic circulation one week before and 15 days after the surgery with dynamic MRI. Alteration of the signal intensity before and after surgery was used to assess gastric fundus and splenic circulation.

RESULTS:

We detected a significant decrease in DeMeester score before and after surgery (p < 0.001). There were no statistical differences between preoperative and postoperative dynamic MRI measurements of the spleen, anterior wall measurements, posterior wall measurements in different MRI phases (Bonferroni corrected p < 0.01). Postoperative measurements of anterior and posterior gastric wall measurements were comparable (Bonferroni corrected p < 0.0033).

CONCLUSIONS:

We did not detect any significant differences in the abovementioned tissues regarding perfusion.

Asymptomatic partial splenic infarction in laparoscopic floppy Nissen fundoplication and brief literature review

Short gastric vessels are divided during the laparoscopic Nissen fundoplication resulting in splenic infarct in some cases. We report a case of laparoscopic floppy Nissen fundoplication with splenic infarct that was recognized during the procedure and provide a brief literature review. The patient underwent a laparoscopic floppy Nissen fundoplication. We observed a partial infarction of the spleen. She reported no pain. A follow-up computed tomography scan showed an infarct, and a 3-month abdominal ultrasound showed complete resolution. Peripheral splenic arterial branches have very little collateral circulation. When these vessels are occluded or injured, an area of infarction will occur immediately. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from splenic infarct. In conclusion, we believe that the real incidence is probably much higher because many cases of SI may have gone undiagnosed during or following an operation, because some patients are asymptomatic. We propose to check spleen carefully for the possibility of splenic infarct.

Perioperative risk of laparoscopic fundoplication: safer than previously reported-analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2009

BACKGROUND

Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional.

STUDY DESIGN

The study population included all patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2009 who underwent laparoscopic fundoplication with or without related postoperative ICD-9 codes. Comorbidities, intraoperative occurrences, and 30-day postoperative outcomes were collected and logged into statistical software for appropriate analysis. Postoperative occurrences were divided into overall and serious morbidity.

RESULTS

A total of 7,531 fundoplications were identified. Thirty-five percent of patients were younger than 50 years old, 47.1% were 50 to 69 years old, and 16.8% were older than 69 years old. Overall, 30-day mortality was 0.19% and morbidity was 3.8%. Thirty-day mortality was rare in patients younger than age 70 years, occurring in 5 of 10,000 (0.05%). Mortality increased to 8 of 1,000 (0.8%) in patients older than 70 years (p < 0.0001). Complications occurred in 2.2% of patients younger than 50 years, 3.8% of those 50 to 69 years, and 7.3% of patients older than 69 years. Serious complications occurred in 8 of 1,000 (0.8%) patients younger than 50 years, 1.8% in patients 50 to 69 years, and 3.9% of those older than 69 years.

CONCLUSIONS

Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.

Clinical implications of sleeve gastrectomy as a source of spleen infarction or ischemia

Splenic arterial demarcation has been observed during laparoscopic sleeve gastrectomy (LSG). The present study aims to detect its actual incidence during LSG and clarify its clinical significance. This is a prospective observational study of 287 consecutive patients that underwent LSG by the same surgical team over 3 years. In all patients, the gastric fundus was mobilized using a standard technique. Before withdrawal of the pneumoperitoneum, the spleen was exposed and carefully inspected for evidence of arterial demarcation. Patients with a clear demarcation were followed with Doppler ultrasound. Computed tomography scan with oral contrast was performed to rule out septic complications. Median preoperative body mass index was 46 kg/m(2) (range 35.1-78). Median operative time was 58 min (range 42-185), median hospital stay was 3 days (range 3-45), and overall morbidity rate was 8.6%. Intraoperative demarcation of the upper splenic pole was evident in 12 patients (4.1%). Eleven patients had uneventful postoperative course. One patient raised temperature of 38.5°C at the 7th postoperative day and was readmitted for further treatment. Once afebrile, the patient was discharged on the 10th postoperative day and continued on prophylactic low molecular weight heparin (tinzaparin, 7,500 U sc.) for 20 days. Splenic discoloration following LSG is an uncommon complication with minimal clinical significance, which could be related to hematoma, venous congestion, or ischemia. The possibility of a late splenic abscess cannot be ruled out. No risk factors can be identified preoperatively.

Splenic infarction following conventional open gastrectomy in patients with gastric malignancy: a CT-based study

PURPOSE

The aim of this CT-based study was to investigate the frequency of splenic infarction (SI) following conventional open gastrectomy performed for gastric malignant neoplasms.

METHODS

20 patients who underwent subtotal or total gastrectomy, omentectomy, and D2 lymph node dissections preserving the spleen for gastric malignant neoplasms were retrospectively reviewed. Patients with postoperative CT scans within 3 months were enrolled in this study. CT imaging was performed with a 64-row multidetector CT scanner. Abdominal CT scan with precontrast and postcontrast portal phase images was performed on 19 of the patients, while pulmonary CT angiography was performed on 1 patient for chest pain. Second postoperative control abdominal CT images were also present for 3 of the 5 patients with SI. These examinations were also reviewed for the evolution of the SI's.

RESULTS

SI was detected in 5 of the patients (25%) at a postoperative early stage. A single infarct area was detected in 4 of the 5 patients while two distinct infarct areas were present in one patient. The infarct areas in two patients disappeared on the second postoperative control CT. A decrease in the size of the SI area in 1 patient was also detected on the second postoperative control CT scan.

CONCLUSION

The frequency of SI as a complication of abdominal surgeries tends to increase in CT-based studies. We have detected the highest frequency in the literature and suggest that SI, especially when accompanying D2 lymphadenectomy, should be included in the list of early stage gastrectomy complications.