Usefulness of over-the-scope clipping system for closing digestive fistulas

BACKGROUND AND AIM

Therapeutic endoscopy has recently evolved into the treatment of complex gastrointestinal (GI) postoperative leakage, especially with over-the-scope clips (OTSC). We describe our 2-year experience of 30 patients treated for digestive fistulas using the OTSC device.

METHODS

This was a retrospective study conducted on patients referred for GI fistulas in two French hospitals. Technical aspects, clinical outcomes and closure rates were recorded.

RESULTS

Thirty patients were treated for GI leaks: 19 (63%) had a gastric fistula after laparoscopic sleeve gastrectomy (LSG); the others had rectovaginal, urethrorectal, rectovesical, gastrogastric, gastrocutaneous, esophagojejunal fistulas and colorectal anastomotic leak. Average follow up was 10.4 months. Eighteen (60%) had undergone previous endoscopic or surgical treatment. Orifice size was 3-20 mm (average 7.2 mm). Successful OTSC placement was achieved in 30 out of 34 attempts. There were four intraoperative undesired events (13.3%) but these were successfully managed. Overall success rate was 71.4% and 16 patients (53%) recovered with primary efficacy. Six patients (20%) required a subsequent endoscopic treatment. Eight patients (26.7%) required surgery for failure. In nine cases, we used one or more additional endoscopic procedures concomitantly with the OTSC combining self-expandable metal stents, standard clips and glue injection. Healing rate after LSG fistula was 88.9%, which was significantly higher than the overall rate (P = 0.01).

CONCLUSION

OTSC placement seems to be safe and effective for the treatment of GI fistulas. Better results were seen in leaks after LSG.

Effects of bariatric surgery on cardiac ectopic fat: lesser decrease in epicardial fat compared to visceral fat loss and no change in myocardial triglyceride content

OBJECTIVES

This study investigated the effect of bariatric surgery (BS)-induced weight loss on cardiac ectopic fat using 3T magnetic resonance imaging in morbid obesity.

BACKGROUND

Heart disease is one of the leading causes of mortality and morbidity in obese patients. Deposition of cardiac ectopic fat has been related to increased heart risk. Whether sustained weight loss can modulate epicardial fat or myocardial fat is unknown.

METHODS

Twenty-three morbidly obese patients underwent 1H-magnetic resonance spectroscopy to determine myocardial triglyceride content (MTGC), magnetic resonance imaging to assess epicardial fat volume (EFV), cardiac function, and computed tomography visceral abdominal fat (VAF) measurements at baseline and 6 months after BS.

RESULTS

The BS reduced body mass index significantly, from 43.1±4.5 kg/m2 to 32.3±4.0 kg/m2, subcutaneous fat from 649±162 cm2 to 442±127 cm2, VAF from 190±83 cm2 to 107±44 cm2, and EFV from 137±37 ml to 98±25 ml (all p<0.0001). There was no significant change in MTGC: 1.03±0.2% versus 1.1±0.2% (p=0.85). A significant reduction in left ventricular mass (118±24 g vs. 101±18 g) and cardiac output (7.1±1.6 l/min vs. 5.4±1.0 l/min) was observed and was statistically associated with weight loss (p<0.05). The loss in EFV was limited (-27±11%) compared to VAF diminution (-40±19%). The EFV variation was not correlated with percentage of body mass index or VAF loss (p=0.007). The ratio of %EFV to %VAF loss decreased with sleep apnea syndrome (1.34±0.3 vs. 0.52±0.08, p<0.05).

CONCLUSIONS

Six-month BS modulates differently cardiac ectopic fat deposition, with a significant decrease in epicardial fat and no change in myocardial fat. Epicardial fat volume loss was limited in patients with sleep apnea. (Impact of Bariatric Surgery on Epicardial Adipose Tissue and on Myocardial Function; NCT01284816).

Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report

Background

Mesenteric panniculitis is a rare chronic fibrosing inflammatory disease that typically affects the adipose tissue and mesentery of the small intestine but may also affect the mesosigmoid and the mesocolon. The pathology of this disease remains unclear despite association with some malignancies or inflammatory disorders. We report a case of mesocolic panniculitis and a literature review of its clinical presentation, imaging findings, associated conditions and treatment options.

Case presentation

A 64 year-old Caucasian man was admitted to the gastroenterology department for severe weakness, left lower quadrant abdominal pain, weight loss and diarrhoea. Physical examination revealed a palpable firm mass occupying the entire left part of the abdomen. Abdominal CT-scan showed fatty infiltration of the mesosigmoid and left mesocolic fat which was strongly suggestive of panniculitis. Laparoscopic surgery revealed an inflamed and edematous mesocolon and mesosigmoid; the sigmoid mucosa appeared petechial which was suggestive of venous ischemia. Histological examination of surgical biopsies revealed mesocolic panniculitis. Despite exhaustive investigation, no associated conditions were found and the cause was classified as idiopathic. Surprisingly, the patient clinically improved without therapeutic intervention other than supportive care.

Conclusion

Although mesenteric panniculitis is most often a radiographic diagnosis without clinical symptomatology, it can also present with significant general status alteration. We report a case of mesocolic panniculitis complicated by development of an inflammatory mass associated with ischemic colitis. Mesenteric panniculitis is a difficult diagnosis to make which typically requires histologic confirmation. The overall prognosis is good with supportive treatment.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND

Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding.

OBJECTIVE

To assess a new, totally endoscopic strategy to manage anastomotic fistulas.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENTS

This study involved 27 consecutive patients from July 2007 to December 2009.

INTERVENTION

This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant.

MAIN OUTCOME MEASUREMENTS

Technical success, mortality and morbidity, migration of the stent.

RESULTS

Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient.

LIMITATIONS

Moderate sample size, nonrandomized study.

CONCLUSION

An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of "stent-guided regeneration and re-epithelialization"

BACKGROUND

Iatrogenic intestinal tract perforation and anastomotic disunion traditionally required surgical treatment. Complete anastomotic break was considered until now as an absolute contraindication for endoscopic management.

OBJECTIVE

The aim of this series was to show that endoscopic management is able to treat a spectrum of bowel wall breaks, from focal perforation to complete anastomotic disunion.

SETTING

A single-center prospective cohort study.

PATIENTS

Nine consecutive patients with nonmalignant gastrointestinal perforations were treated with endoscopic stenting between 2005 and 2008. Perforations were related to endoscopic perforations (4 cases: 2 esophageal and 2 colorectal), postoperative fistula or leakage (2 cases: 1 colorectal anastomosis and 1 esophageal), and complete anastomotic disunion (3 cases: 2 ileoanal anastomosis and 1 esophagogastric anastomosis).

INTERVENTIONS

All 9 patients underwent endoscopic installation of fully covered stents under endoscopic and radiologic guidance, sometimes associated with simultaneous endoscopic collection drainage. Oral feeding was resumed when radiologic contrast studies showed no residual leak.

RESULTS

The outcome in all 9 patients was favorable. Two migrated stents were replaced, and 2 stents were spontaneously expelled without consequence. All stents were withdrawn within an average of 5 weeks.

LIMITATIONS

Uncontrolled pilot study, small sample size.

CONCLUSION

The successful endoscopic management of bowel wall breaks ranging from perforation to complete postoperative disunion with fully covered stent could support a new concept of "stent-guided regeneration and re-epithelialization." Controlled trials are needed before this new endoscopic treatment can be proposed as a substitute for traditional treatments.

Experience of two trauma-centers with pancreatic injuries requiring immediate surgery

BACKGROUND/AIMS

Pancreatic injury from blunt trauma is infrequent. The aim of the present study was to evaluate a simplified approach of management of pancreatic trauma injuries requiring immediate surgery consisting of either drainage in complex situation or pancreatectomy in the other cases.

METHODOLOGY

From January 1986 to December 2006, 40 pancreatic traumas requiring immediate surgery were performed. Mechanism of trauma, clinical and laboratories findings were noted upon admission, classification of pancreatic injury according to Lucas' classification were considered. Fifteen (100%) drainages were performed for stage I (n=15), 60% splenopancreatectomies and 40% drainage was achieved for stage II (n=18), 3 Pancreaticoduonectomies and 2 exclusion of duodenum with drainage and 2 packing were performed for stage IV (n=7).

RESULTS

There were 30 men and 10 women with mean age of 29+/-13 years (15-65). Thirty-eight patients had multiple trauma. Overall, mortality and global morbidity rate were 17% and 65% respectively, and the rates increased with Lucas' pancreatic trauma stage.

CONCLUSIONS

Distal pancreatectomy is indicated for distal injuries with duct involvement, and complex procedures such as pancreaticoduodenectomy should be performed in hemodynamically stable patients.

Coloproctectomie totale avec anastomose iléoanale en deux temps vidéoassistée. Expérience initiale de 12 cas

AIM OF THE STUDY

This study reports our early experience in two-stage video assisted restorative proctocolectomy (RPC).

PATIENTS AND METHODS

From May 1999 to May 2003, 12 video assisted RPCs were performed (mucosal ulcerative colitis: n = 11; familial adenomatous polyposis: n = 1). These patients were matched for age, gender, body mass index and indication for surgery, with 12 patients who underwent RPC by laparotomy (open group).

RESULTS

Median operative time was significantly longer in the video assisted RPC group (400 min; range: 360-490) vs open group (300 min; range: 210-390) (P = 0.003). A conversion in midline laparotomy (under the umbilicus) was necessary in 3/12 patients (25%) in the video assisted RPC group. Return to bowel function and oral intake occurred two days earlier after video assisted RPC (respectively, P = 0.009 and P = 0.0001) but length of stay was not significantly shorter in this group. A complication occurred in 3/12 patients (25%) in both groups, which lead to a reoperation in one patient in the open group (ns).

CONCLUSION

Two-stage videoassisted RPC is feasible at the cost of a lengthening of operative time, Nevertheless postoperative results after video assisted RPC are comparable to those obtained after RPC by laparotomy.

[Cystic lymphangioma of the lesser omentum]

INTRODUCTION

Cystic lymphangiomas of the abdomen are rare tumors. These tumors are discovered fortuitously or during a complication.

OBSERVATION

In a 5 year-old child, examined in an emergency because of suspected appendicitis, two cystic lymphangiomas of the small omentum were discovered, one measuring 10 cm and the other 7 cm and attached to the first with posterior extension in the lesser sac of the peritoneum.

COMMENTS

The majority of abdominal cystic lymphangiomas are discovered in the early years of life. There are two major revelation lodes: a tumoral syndrome with pain or a complication (torsion, infection, rupture). The treatment is surgical with excellent prognosis.