-
[show abstract]
[hide abstract]
ABSTRACT: In 2012, an innovative approach for staged in situ liver transection was proposed that could allow for even more aggressive major hepatectomies. Otherwise, after 25 years, laparoscopy became "traditional" and other minimally invasive techniques continue to be developed but their indications deserve further investigation. Less aggressive treatment in non-complicated diverticulitis becomes more popular, and even antibiotic treatment has been challenged by a randomized study. In colorectal oncology, local resection or observation only seems to become a valuable approach in selected patients with complete response after neo adjuvant chemoradiation. Finally, enhanced recovery pathways (ERAS) have been validated and is increasingly accepted for colorectal surgery and ERAS principles are successfully applied in other surgical fields.
Revue médicale suisse 01/2013; 9(369):96-9.
-
[show abstract]
[hide abstract]
ABSTRACT: Liver vascularization is known to present with several different variations. Generally, a normal vascular anatomy is reported in up to 50-80 % of cases. For this reason, a precise preoperative mapping of the hepatic vascularization prior to pancreatic surgery is essential to avoid injuries and subsequent complications. We report here a case of a young patient scheduled for Whipple procedure, who presented an arterial pattern type Michels IV, variation reported in 0.6 to 3 % in the literature. Another interesting particularity of this case was the fact that the right hepatic artery had a prepancreatic course. We think that every surgeon performing hepatopancreatic surgery should have heard of this special and rare situation.
Journal of Gastrointestinal Surgery 01/2013; · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the impact of preoperative immunonutrition (IN) on postoperative morbidity in patients at risk of malnutrition undergoing major gastrointestinal (GI) surgery.
The combination of malnutrition and major GI surgery entails high morbidity. The Nutritional Risk Score (NRS) reliably identifies patients who need preoperative nutrition; the optimal nutritional formula for these patients still needs to be defined. In all, 152 patients with a NRS≥3 and undergoing elective major GI surgery were randomized between IN or isocaloric-isonitrogenous nutrition (ICN) given for 5 days preoperatively. Patients and caregivers were blinded for the allocated intervention. Thirty days complication rate was the primary endpoint. Infections, length of hospital stay and compliance were considered as secondary outcomes.
Overall, 145 patients were available for analysis; the 73 patients in the IN group matched well with the 72 ICN patients with regards to patient's and surgical characteristics. In all, 39 IN and 33 ICN patients experienced a total of 48 and 50 postoperative complications, respectively (P=0.723). Both groups did not differ significantly concerning infectious (13 vs 9) complications. Independent risk factors for overall complications were malignant disease (odds ratio (OR)=4.304; confidence interval (CI) 1.317-14.002) and operative time (OR=1.004; CI 1.000-1.008).
In patients at nutritional risk, complications, infections and hospital stay after major GI surgery were comparable regardless of preoperative supplementation with IN or ICN.
European journal of clinical nutrition 05/2012; 66(7):850-5. · 3.07 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Inguinal hernias are frequent and have an enormous socio-economic impact. Surgical treatment is indicated in most of the patients to relieve symptoms and to prevent complications. Modem treatment should focus on low complication and recurrence rates, short recovery times, and--last but not least acceptable costs. Inguinal hernia repair can be carried out by an open or minimal invasive approach. Surgery is traditionally performed under general anesthesia, but local or locoregional anesthesia are other feasible options. Nowadays, inguinal hernia surgery can easily performed as an outpatient procedure. However, stringent selection criteria, an optimized infrastructure and a close and standardized follow-up are mandatory prerequisites in order to obtain excellent results under secure conditions.
Revue médicale suisse 06/2011; 7(300):1354-6.
-
[show abstract]
[hide abstract]
ABSTRACT: Malnutrition concerns up to 50% at in-hospital admission. Its diagnosis and treatment are fundamental parts of the surgical approach because nutritional status directly influences the clinical outcome. The Nutritional Risk Score (NRS-2002) represents the recommended screening tool by the European Society of Parenteral and Enteral Nutrition (ESPEN). Patients with a score > or = 3 and aged > 70 years old, should receive a nutritional support during 7-14 day before surgery. Depending on patient's clinical conditions, the enteral route of administration should be preferred. Despite strong evidence in favor of nutritional supplementation, much effort must be done to implement these supportive strategies in the everyday clinical practice.
Revue médicale suisse 06/2011; 7(300):1358-61.
-
[show abstract]
[hide abstract]
ABSTRACT: Appendicular tumors are mostly found incidentally in up to 1.5% of all appendectomies. Neuroendocrine tumors are the commonest malignancies, and are associated with an excellent long-term prognosis. While small lesions located at the appendicular tip can be treated with simple appendectomy, advanced tumors require right hemicolectomy. Goblet cell carcinoids are rare tumors showing a mixed phenotype. Long-term outcome is impaired, and for most cases a right hemicolectomy is mandatory. Colonic-type adenocarcinomas have a similar behavior like conventional colonic cancer and should be treated similarly. Mucinous neoplasias possess the characteristic of extensive mucin production with intraperitoneal spread. Treatment options are ranging from right hemicolectomy to multivisceral resection with intraperitoneal chemotherapy.
Revue médicale suisse 06/2011; 7(300):1362-5.
-
British Journal of Surgery 06/2011; 98(6):885; author reply 885-6. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: There is strong evidence for the beneficial effects of perioperative nutrition in patients undergoing major surgery. We aimed to evaluate implementation of current guidelines in Switzerland and Austria.
A survey was conducted in 173 Swiss and Austrian surgical departments. We inquired about nutritional screening, perioperative nutrition and estimated clinical significance.
The overall response rate was 55%, having 69% (54/78) responders in Switzerland and 44% (42/95) in Austria. Most centres were aware of reduced complications (80%) and shorter hospital stay (59%). However, only 20% of them implemented routine nutritional screening. Non-compliance was because of financial (49%) and logistic restrictions (33%). Screening was mainly performed in the outpatient's clinic (52%) or during admission (54%). The nutritional risk score was applied by 14% only; instead, various clinical (78%) and laboratory parameters (56%) were used. Indication for perioperative nutrition was based on preoperative screening in 49%. Although 23% used preoperative nutrition, 68% applied nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from 3 days (33%), to 5 (31%) and even 7 days (20%).
Although malnutrition is a well-recognised risk factor for poor post-operative outcome, surgeons remain reluctant to implement routine screening and nutritional support according to evidence-based guidelines.
European journal of clinical nutrition 02/2011; 65(5):642-7. · 3.07 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).
Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups.
Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group.
In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.
World Journal of Surgery 02/2011; 35(4):826-33. · 2.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients at nutritional risk reveal an increased morbidity. Fast-track (FT) programs in colonic surgery have shown reduced complications and hospital stay. We aimed to assess the effect of FT programs on patients at nutritional risk.
In a randomized trial (NCT00556790), we compared complications after open colonic surgery with either a FT program or standard care (SC). A subgroup analysis was performed in 67 patients for whom a prospective nutritional risk score (NRS) was available.
The SC and FT groups did not differ regarding patient characteristics or prevalence of NRS ≥ 3 (SC 8/31, FT 7/36, p = 0.569). Patients with SC had more complications (14/31 vs. 8/36, p = 0.044) and a longer hospital stay (9 vs. 5 days, p < 0.0001). No major complication occurred in patients with an NRS <3. Patients at nutritional risk had a high complication rate regardless of SC or FT (6/8 and 5/7, respectively, p = 1.000). Median hospital stay was shorter in FT (7 (range 5-30) days) versus SC patients (14.5 (range 8-30) days, p = 0.164).
Patients with a NRS ≥ 3 have an increased postoperative morbidity even within a FT program. They should be identified by nutritional screening and might benefit from nutritional supplements.
Digestive surgery 11/2010; 27(5):436-9. · 1.37 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness.
All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded.
After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0.25-12) months. The overall published complication rate was 5.4 per cent and the biliary complication rate 0.7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent.
SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications.
British Journal of Surgery 10/2010; 97(10):1476-80. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients undergoing major gastrointestinal surgery are at increased risk of developing complications. The use of immunonutrition (IN) in such patients is not widespread because the available data are heterogeneous, and some show contradictory results with regard to complications, mortality and length of hospital stay.
Randomized controlled trials (RCTs) published between January 1985 and September 2009 that assessed the clinical impact of perioperative enteral IN in major gastrointestinal elective surgery were included in a meta-analysis.
Twenty-one RCTs enrolling a total of 2730 patients were included in the meta-analysis. Twelve were considered as high-quality studies. The included studies showed significant heterogeneity with respect to patients, control groups, timing and duration of IN, which limited group analysis. IN significantly reduced overall complications when used before surgery (odds ratio (OR) 0·48, 95 per cent confidence interval (c.i.) 0·34 to 0·69), both before and after operation (OR 0·39, 0·28 to 0·54) or after surgery (OR 0·46, 0·25 to 0·84). For these three timings of IN administration, ORs of postoperative infection were 0·36 (0·24 to 0·56), 0·41 (0·28 to 0·58) and 0·53 (0·40 to 0·71) respectively. Use of IN led to a shorter hospital stay: mean difference -2·12 (95 per cent c.i. -2·97 to -1·26) days. Beneficial effects of IN were confirmed when low-quality trials were excluded. Perioperative IN had no influence on mortality (OR 0·90, 0·46 to 1·76).
Perioperative enteral IN decreases morbidity and hospital stay but not mortality after major gastrointestinal surgery; its routine use can be recommended.
British Journal of Surgery 10/2010; 98(1):37-48. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Treatment of colonic diverticular disease has evolved over the past years. Most episodes are simple and can be successfully treated with antibiotics alone. For complicated diverticulitis, a strong trend is developing towards less invasive therapies including interventional radiology and laparoscopic lavage in an effort to avoid the morbidity and discomfort of a diverting colostomy. Based on a better understanding of the natural history of the disease, the indication to prophylactic colectomy after a few episodes of simple diverticulitis has been seriously challenged. For those patients who need a colectomy, single port laparoscopy, NOTES and transanal specimen extraction are being proposed. However larger studies are needed to confirm the hypothetical advantages of these evolving techniques.
Revue médicale suisse 06/2010; 6(254):1277-81.
-
[show abstract]
[hide abstract]
ABSTRACT: Hernia repair one of the most frequently performed operations in general surgery. With the introduction of tension-free mesh repair, recurrence rates dropped well below 5% for open and laparoscopic procedures. However, chronic postoperative pain remains a widely neglected complication with a high socio-economic impact. It occurs in about 10-20% of patients after hernia repair. We review the different types of post-herniorrhaphy pain with the typical diagnostic features and we conclude with a pragmatic algorithm based on our clinical experience.
Revue médicale suisse 06/2010; 6(254):1288-91.
-
[show abstract]
[hide abstract]
ABSTRACT: Promising new technologies are emerging in digestive surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single Port Access Surgery. They both aim to limit the surgical morbidity by decreasing the number of parietal accesses. The feasibility in human is obviously demonstrated, but numerous issues remain concerning the safety of these techniques. Furthermore, the expected advantages are not clearly demonstrated until now in the literature. In the future, it will be advisable to standardize techniques, in order to allow large clinical studies and to limit the potential complications of these approaches.
Revue médicale suisse 06/2010; 6(254):1298-300.
-
British Journal of Surgery 03/2010; 97(4):618; author reply 618-9. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The severity and most appropriate treatment of diverticulitis in young patients are still controversial. The aim of this study is to compare young patients (<or=50 years) with older patients (>50 years) regarding clinical and radiologic parameters of acute left colonic diverticulitis and to determine whether differences exist in presentation and treatment.
We reviewed medical records of 271 consecutive patients with left colonic acute diverticulitis admitted to our institution from 2001 through 2004: 71 patients were aged 50 years or younger and 200 patients were older than 50. Clinical and radiologic parameters were analyzed. Conservative treatment was standardized, and included antibiotic therapy and bowel rest. Criteria for emergency surgical treatment were diffuse peritonitis, pneumoperitoneum, and septic shock.
Conservative treatment alone was successful in 64 patients (90.1%) in the younger group and in 152 patients (76%) in the older group (P = .017). The percentage of patients requiring surgery at admission or during the hospital stay was significantly lower in younger than in older patients (5.6% vs 20.5%, P = .007), and the percentage of patients requiring emergency end colostomy was higher (although not significantly) in the older group (1.4% vs 9.0%, P = .059). No differences in rate of successful conservative treatment were observed between patients with a first episode and those with recurrence in either age group (P = .941 in the younger group; P = .227 in the older group).
Young age is not a predictive factor of poor outcome in the management of first or recurrent episodes of acute diverticulitis. Patients older than 50 years more frequently need emergency surgical treatment.
Diseases of the Colon & Rectum 03/2010; 53(3):333-8. · 3.13 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite advertising for NOTES in 2009, single trocart laparoscopic surgery is about to become a new standard in selected indications. As other important topics, the limits of oncological surgery are extended due to a systematic multidisciplinary approach. To discuss every publication would be difficult and our review will focus on a selected number of papers of importance for daily practice. As examples, the management of acute calculous cholecystitis, gastro-esophageal reflux, inguinal and incisional hernia repair as well as colorectal surgery are presented.
Revue médicale suisse 01/2010; 6(233):204-8.
-
British Journal of Surgery 11/2009; 96(12):1494; author reply 1496. · 4.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Electrical stimulation is a new way to treat digestive disorders such as constipation. Colonic propulsive activity can be triggered by battery operated devices. This study aimed to demonstrate the effect of direct electrical colonic stimulation on mean transit time in a chronic porcine model. The impact of stimulation and implanted material on the colonic wall was also assessed. Three pairs of electrodes were implanted into the caecal wall of 12 anaesthetized pigs. Reference colonic transit time was determined by radiopaque markers for each pig before implantation. It was repeated 4 weeks after implantation with sham stimulation and 5 weeks after implantation with electrical stimulation. Aboral sequential trains of 1-ms pulse width (10 V; 120 Hz) were applied twice daily for 6 days, using an external battery operated stimulator. For each course of markers, a mean value was computed from transit times obtained from individual pig. Microscopic examination of the caecum was routinely performed after animal sacrifice. A reduction of mean transit time was observed after electrical stimulation (19 +/- 13 h; mean +/- SD) when compared to reference (34 +/- 7 h; P = 0.045) and mean transit time after sham stimulation (36 +/- 9 h; P = 0.035). Histological examination revealed minimal chronic inflammation around the electrodes. Colonic transit time measured in a chronic porcine model is reduced by direct sequential electrical stimulation. Minimal tissue lesion is elicited by stimulation or implanted material. Electrical colonic stimulation could be a promising approach to treat specific disorders of the large bowel.
Neurogastroenterology and Motility 08/2009; 22(1):88-92, e31. · 3.41 Impact Factor
