Feasibility of laparoscopic restorative proctocolectomy without diverting stoma

AIM

Restorative proctocolectomy performed before the advent of laparoscopy had evolved to frequently omit a diverting stoma. Our aim was to assess the impact of a diverting stoma on postoperative outcomes following laparoscopic restorative proctocolectomy.

METHOD

Data on all patients undergoing a laparoscopic restorative proctocolectomy at our institution were prospectively collated in a database.

RESULTS

Between November 2004 and February 2010, 71 patients (38 females) underwent laparoscopic restorative proctocolectomy. Indications included familial adenomatous polyposis (n=34), ulcerative colitis (n=35), indeterminate colitis (n=1) and Lynch syndrome (n=1). Laparoscopic restorative proctocolectomy was performed as a one-stage procedure in 49 patients, and after a sub-total colectomy in 22. Seven patients in each group underwent the formation of a diverting stoma. Nine patients required conversion to open surgery. Sixteen patients experienced at least one postoperative complication. The postoperative morbidity was 29% (n=4/14) and 21% (n=12/21) in patients with and without a stoma (p=0.8), and the rate of fistula was 21% and 5%, respectively (p=0.08). Seven percent of patients with a stoma and 16% without stoma had an intra-abdominal collection (p=0.7). Nine patients required reoperation. The reoperation rate was not influenced by the presence or absence of a diverting stoma.

CONCLUSION

Laparoscopic restorative proctocolectomy can be performed safely without a diverting stoma in selected patients.

Functional results after the Orr-Loygue transabdominal rectopexy for complete rectal prolapse

PURPOSE

The aim of this study was to assess functional results after Orr-Loygue transabdominal rectopexy for complete rectal prolapse.

METHODS

Thirty-one consecutive patients operated on for complete rectal prolapse between 1995 and 1998 were evaluated preoperatively and postoperatively with regard to anal incontinence, constipation, evacuation difficulties, and overall satisfaction with a standardized questionnaire. Anal continence assessment was based on a clinical scoring system.

RESULTS

After a mean follow-up of 28 +/- 13 (range, 12-57) months, no prolapse recurred. Preoperative and postoperative rates of incontinence were 81 percent (25/31) and 55 percent (17/31), respectively (P < 0.03). Continence improved in 24 (96 percent) of the 25 patients who were incontinent before surgery. The mean incontinence score decreased from 11.7 +/- 7.8 preoperatively to 3.2 +/- 4.2 postoperatively (P < 0.001). The self-reported constipation rate was 61 percent (19/31) before surgery and 71 percent (22/31) after surgery (P = nonsignificant). Constipation appeared or worsened in 16 patients (52 percent), whereas it disappeared or improved in 8 (26 percent; P = nonsignificant). Evacuation difficulties increased significantly after surgery from 23 percent (7/31) to 61 percent (19/31; P < 0.003). Ninety-seven percent of patients reported good or very good satisfaction.

CONCLUSIONS

Transabdominal Orr-Loygue rectopexy resulted in improved continence and a high satisfaction level. Despite a significant postoperative increase in evacuation difficulties, only a 10 percent (nonsignificant) increase in the self-reported constipation rate was observed.

[Aerobilia: a rare consequence of anaerobic acute cholecystitis: a case report]

Acute acalculous cholecystitis is rare in non critically ill or postoperative patients. We report a case of acute acalculous cholecystitis with secondary bile infection with Clostridium perfringens. Ultrasound and tomodensitometry revealed diffuse aerobilia. The germ in this case report is atypical and contrasts with the very discrete clinical findings. Aerobilia, secondary to the development of bacteria in the biliary tract falsely suggested a bilio-digestive fistula. Treatment included a simple cholecystectomy associated with 7 days of antibiotherapy.

[Colonic actinomycosis. Clinical, endoscopic and histological aspects in one patient]

Colonic location of actinomycosis must be distinguished from infected colonic carcinoma and other colonic inflammatory pseudotumors. The diagnosis is often made by histological examination of the tumor. Initial treatment consists in surgery, followed by an antibiotic treatment. We report the case of a 32-year old woman with a right colonic actinomycosis.

[Spontaneous colonic ischemia]

Spontaneous ischemic colitis is a frequent disease, affecting mostly elderly people and predominantly localised on the left and sigmoid colon. It is due to alterations of small vessels of the colon and/or modifications of the splanchnic blood flow. Spontaneous evolution is generally favorable with restitution ad integrum of the disease colon. The diagnosis of ischemic colitis is established from the clinical picture, CT-scan and colonoscopy. Surgery, under the form of colonic resection, is required in 15% of cases approximately, in case of colonic necrosis.

[Analysis of the drainage fluid after cephalic duodenopancreatectomy: a reliable clinical criterion]

The authors have retrospectively analysed the drainage fluid of 39 patients undergoing Whipple's operation over a 18-year period. The aim of the study was to assess whether the volume and amylase concentration of the drainage fluid were good criteria of healing of the pancreatico-jejunal anastomosis. The patients have been divided into two groups: Group I (30 patients) with no complications at the pancreatico-jejunostomy--Group II (9 patients) with a pancreatic leak. The analysis of the volume, amylase concentration and amylase index (Log of the amylase concentration x volume) showed that the groups had clearly different profiles: in group I all three criteria were rapidly decreasing, while they remained abnormally high in group II. Those criteria may help the clinician in the monitoring of individual patients; they also may prove useful in prospective studies evaluating new means of prevention of this anastomosis.

Anastomic dehiscence and severe peritonitis

Fifteen years of experience in the management of postoperative complications following GI surgery are reviewed. In the surgical ICU of the Hôpital Saint Antoine, Paris, France, a referral center for these conditions, 385 cases of postoperative peritonitis and 500 cases of enterocutaneous fistulas were observed from 1980 to 1995. Original techniques of management are described in surgical treatment: temporary stomas, intubation irrigation of leaks situated on the upper GI tract, primary closure of the abdominal wall without tension. New methods of intensive care of intestinal conditions have also been designed: control and/or obturation of complex enterocutaneous fistulas, reinfusion of chyme into the distal small bowel and continuous enteral nutrition. In accordance with their experience in this field, the authors review the most controversial points of surgical technique and intensive care.