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At least 235 records · Page 13Linked to original sources
PubMed2004

Causes of small bowel obstruction after laparoscopic gastric bypass.

BACKGROUND: Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass is not a rare complication, occurring in approximately 3% of patients. The goal of this study was to review the causes and timing of small bowel obstruction as an aid to diagnosis, treatment, and prevention. METHODS: The records of consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass at the authors' center from 4/99 to 7/03 were retrospectively reviewed. All the patients had a laparoscopic handsewn gastrojejunostomy and a stapled jejunojejunostomy. The Roux limb was placed retrocolically in the first 405 patients and antecolically in the next 1,310 patients. RESULTS: Altogether, 1,715 patients underwent a total laparoscopic Roux-en-Y gastric bypass at the authors' bariatric center. In 51 patients, 55 small bowel obstructions occurred (3%) during a median follow-up period of 21 months (range, 1-52 months). Small bowel obstruction developed in 27 (7%) of the retrocolic patients, as compared with 24 (2%) of the antecolic patients (p < 0.001, chi-square). The causes of small bowel obstruction were adhesive bands (n = 14), obstruction at the jejunojejunostomy from kinking or narrowing (n = 13), internal hernia or external compression at the transverse mesocolon (n = 11), internal hernia through the jejunal mesentery (n = 8) incarcerated abdominal wall hernia (n = 4), and other (n = 5). For patients in whom small bowel obstruction developed in the first 3 weeks after their bypass surgery bowel resection was required in 19 of 24 patients, as compared with 6 of 31 patients in whom obstruction develop after 3 weeks (p < 0.001, chi-square). CONCLUSIONS: Early small bowel obstructions tend to result from technical problems with the Roux limb and require revision of the bypass or small bowel resection significantly more often than late obstructions. The latter group of obstructions usually result from adhesions or hernias, which could be handled laparoscopically without bowel resection. The position of the Roux limb (retrocolic vs antecolic) appeared to influence the incidence of small bowel obstruction. In the current series, changing the position of the jejunal bypass limb from retrocolic to antecolic significantly decreased the overall incidence of small bowel obstruction because it eliminated one of the most common sites for obstruction: the mesocolon.

Gastric Bypass↗
PubMed2004

A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy.

BACKGROUND: With the aim of preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy (PPPD), we devised a new reconstruction method in which the pancreas and the bile duct are anastomosed to the proximal jejunum brought through the transverse mesocolon, and the duodenum is antecolically anastomosed to the jejunum below the mesocolon. The right gastric artery is divided in order to place the stomach, the duodenum, and the jejunum in a straight line. METHODS: Thirty patients underwent PPPD with the new reconstruction method (n = 12) or the conventional method (all anastomoses performed retrocolically; n = 18). Early and late complications were compared between the two groups. RESULTS: Delayed gastric emptying occurred respectively in 1 patient (8%) and 13 patients (72%) operated on by the new and conventional method (P <0.001). The incidences of other complications did not differ significantly between the two groups. CONCLUSIONS: The new reconstruction method may prevent delayed gastric emptying after PPPD.

Bile Ducts↗
PubMed2005

Treatment of nonadhesive bowel obstruction following gastric bypass.

BACKGROUND: Bowel obstruction secondary to internal hernias following laparoscopic and open gastric bypass is well reported. The number of gastric bypasses being performed in the United States continues to increase. As many patients undergo surgery at centers geographically distant from their home, increasing numbers of patients will present to their local emergency rooms with abdominal complaints that will need to be addressed by general surgeons who are not performing bariatric surgery. METHODS: Review of a prospective database of patients operated on in a general surgery practice performing bariatric surgery. RESULTS: Over a 14-month period, 9 patients requiring operative intervention presented to our practice with nonadhesive bowel obstruction following both open and laparoscopic bariatric surgery. Causes of obstructions included cicatrical narrowing in the Roux limb at the transverse mesocolon defect (1 patient) and internal hernias through the transverse mesocolon (5 patients), Petersen's hernia (2 patients), and at the jejunojejunostomy (1 patient). Seven patients were treated laparoscopically and 2 underwent laparotomy. Our diagnostic and operative approach is described. CONCLUSIONS: Surgeons, including those not performing bariatric surgery, will be treating more patients with bowel obstruction following gastric bypass in the future. The etiology and management of bowel obstruction after gastric bypass differs from the conventional management of bowel obstruction. When surgery is required, most of these patients can be treated laparoscopically.

Anastomosis, Roux-en-Y↗
PubMed2006

Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?

Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.

Adult↗
PubMed2002

[Laparoscopic colonic splenic flexure mobilization: surgical technique].

The clue of the mobilization of the splenic flexure is a complete division of the root of the transverse mesocolon along the pancreas. After the section of the terminal part of the inferior mesenteric vein, the retrogastric cavity is opened and the root of the mesocolon is cut from the right to the left onto the parieto-colic attachment. Thereafter the coloepiploic attachments are divided. The retromesocolic dissection is continued from top to bottom without opening the Gerota's fascia.

Colon↗
PubMedDate not supplied

En bloc resection for locally advanced cancer of the pancreas: is it worthwhile?

The benefit of radical surgical resection of contiguously involved structures for locally advanced pancreatic cancer is unclear. The aim of this study was to examine patient outcome after extended pancreatic resection for locally advanced tumors and to determine if any subset of extended resection affected outcome. We retrospectively reviewed the records of 116 patients with adenocarcinoma of the pancreas, who underwent extirpative pancreatic surgery between 1987 and 2000. Of the 116 patients, 37 (32%) required resection of surrounding structures (group I), and 79 patients (68%) underwent standard pancreatic resections (group II). In all cases, all macroscopic disease was excised. In group I a total of 46 contiguously involved structures were resected: vascular in 25 patients (54%), mesocolon in 16 (35%) (colic vessels in 3, colon in 13), adrenal in three (7%), liver in one (2%), stomach in one (2%) (for a tumor in the tail of the pancreas), and multiple structures in four. Excision of regional blood vessels included the superior mesenteric vein and/or portal vein in 16, hepatic artery in five, and celiac axis in four. No differences between groups I and II were detected for any of the following parameters: age, sex, history of previous operation, estimated blood loss, or hospital stay. For the entire cohort the morbidity and mortality were 38% and 1.7%, respectively, and these rates were similar in the two groups. Adjuvant therapy was administered to more than 90% of patients in both groups. However, patients in group I were more likely to have received neoadjuvant therapy (76% vs. 42%, P = 0.001). Total pancreatectomy and distal pancreatectomy were more often performed in group I (P = 0.005). Additionally, the median operative time was longer (8.5 hours compared to 6.9 hours (P = 0.0004)). Both groups had similar rates of microscopically positive margins and involved lymph nodes, as well as total number of lymph nodes removed. The median survival was 26 months for patients in group I and 16 months for patients in group II (P = 0.08). The median disease-free survival for groups I and II was 16 months and 14 months, respectively (P = 0.88). In comparing patients in group I, who underwent vascular resection vs. mesocolon (colon or middle colic vessels) resection, the median survival was 26 months and 19 months, respectively (P = 0.12). We were unable to detect a difference in outcome for patients with locally advanced cancers requiring extended pancreatic resections compared to patients with standard resections. En bloc resection of involved surrounding structures, to completely extirpate all macroscopic disease, may be of benefit in selected patients with locally advanced disease, particularly when combined with preoperative chemoradiation therapy.

Adenocarcinoma↗
PubMed1993

[Abdominal actinomycosis].

Twelve years after adnexectomy, performed for actinomycosis of the left ovary, a 32-year-old woman developed abdominal and back pain. A solid tumour was palpated in the left lower abdomen. Colon contrast examination revealed a subtotal stenosis in the sigmoid colon, while sonography showed a complete stenosis of the left ureter with left hydronephrosis. Relaparotomy demonstrated a stone-hard tumour at the rectosigmoid junction, which involved the right ovary and ureter, as well as having infiltrated the retroperitoneum, predominantly on the left. After resection of the sigmoid colon, uterus and right ovary, as well as of the ureteric stenosis with reanastomosis, the further course was without complication. Histological examination confirmed actinomycosis of the left ovary, sigmoid colon and pelvic mesocolon. Therapy with amoxycillin, 500 mg three times daily, was started. As the patient had worn an intrauterine pessary for several years, primary infection of the uterus with spread into the abdominal cavity via tube and ovaries is likely to have been the course of events. The recurrence was probably caused by reactivation of residual actinomycetes in the retroperitoneum and pelvic mesocolon.

Abdomen↗
PubMed2005

Endometrioid adenocarcinoma arising from endometriosis of the mesenterium of the sigmoid colon.

This report presents a case of endometrioid adenocarcinoma arising from endometriosis of the mesenterium of the sigmoid colon following total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyoma of the uterus and infiltrating pelvic endometriosis, and hormone replacement therapy. A 62-year-old woman presented with an abdominal tumor. Based on the diagnosis of mesocolonic tumor, sigmoidectomy with lymph node resection was performed. The tumor cells were immunopositive for cytokeratin 7, but negative for cytokeratin 20, and the tumor was histologically diagnosed as endometrioid adenocarcinoma of the mesocolon. Hyperestrogenism has been implicated as a risk factor for the development of cancer from endometriosis. The patient had been receiving high-dose unopposed estrogens for 14 years after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Physicians should recognize that endometriosis-associated neoplasms are able to cause symptoms or signs such as abdominal and/or pelvic pain, pelvic mass, and vaginal bleeding, especially if the patient has been treated with hormone replacement therapy. It is important to recognize the possibility of tumors arising from endometriosis when evaluating intestinal or mesenteric neoplasms in women, even in the patient who has previously undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, particularly if the patient has a history of endometriosis and has received hormone replacement therapy.

Carcinoma, Endometrioid↗
PubMed1977

Jejunal intussusception following small bowel bypass for morbid obesity.

In 600 patients who have undergone small bowel bypass for the treatment of morbid obesity, we have encountered three patients who developed intussusception in the bypassed intestine. Diagnosis in these cases has been difficult but in two patients with surgical marker clips applied to the transected fixed jejunum as well as to the adjacent mesocolon, diagnosis was made easier by the radiographic finding of separation of these clips. Clinical symptoms are difficult to evaluate and valuable time may be wasted before a diagnosis is arrived at. Once a diagnosis is made, operation with either reduction or resection of the area of intussusception should be carried out with refixation of the bowel to the mesocolon and reapplication of surgical marker clips. These marker clips are of great value in the diagnosis of intussusception occurring in the bypassed loop.

Adult↗
PubMed1997

Spiral computed tomography and operative staging of gastric carcinoma: a comparison with histopathological staging.

BACKGROUND: Much controversy exists as to the value of computed tomography (CT) in the preoperative staging of gastric cancer, because of its limited ability to identify correctly lymph node (LN) metastases, invasion of adjacent organs, or hepatic and peritoneal metastases. Spiral CT scanners have a number of potential advantages over conventional scanners, including the absence of respiratory misregistration, image reconstruction smaller than scan collimation permitting overlapping slices and optimisation of intravenous contrast enhancement. AIM: To compare the performance of spiral CT and operative assessment against formal (TNM) pathological staging. PATIENTS AND METHODS: A study of 105 consecutive patients who underwent both spiral CT and operative staging was performed. All CT scans were reviewed by a radiologist who commented on tumour location and size, evidence of adjacent organ invasion, lymph node metastases to both N1 and N2 nodes, and evidence of hepatic and peritoneal metastases. All patients underwent careful operative assessment at the time of surgery, along the lines suggested by Rohde and colleagues. RESULTS: Spiral CT remained poor at identifying LN metastases to both N1 and N2 lymph nodes, with sensitivity ranging from 24 to 43%; specificity, however, was 100%. Operative staging was superior, with sensitivities between 84 and 94%, but specificity was much lower (63-74%). Spiral CT correctly detected 13 of 17 cases of invasion of either the colon or the mesocolon (sensitivity 76%) compared with 16 of 17 cases at operative staging (sensitivity 94%). Spiral CT correctly identified three of six cases with invasion of the pancreas (sensitivity 50%) compared with six of six cases on operative staging (sensitivity 100%). Spiral CT correctly identified 12 of 17 cases of peritoneal metastases (sensitivity 71%) and four of seven cases of hepatic metastases (sensitivity 57%). CONCLUSION: Whilst spiral CT remains poor at identifying lymph node metastases, it correctly identified most cases with invasion of either the colon or the mesocolon and half the cases of pancreatic invasion. It was of value in detecting peritoneal metastases and some cases with hepatic metastases. At present, at Leeds General Infirmary spiral CT is performed routinely on all patients with gastric cancer and a selective staging laparoscopy policy is adopted in those patients in whom the status of the peritoneal cavity and liver is in doubt.

Adult↗
PubMed1999

Transverse coloplasty pouch. A novel neorectal reservoir.

BACKGROUND: The functional results after complete rectal excision can be improved by a neorectal reservoir. We recently developed a new technique for the formation of a small colon pouch, which we named the transverse coloplasty pouch. The technique demonstrated favorable functional results in an animal model. We report the first description of the human 'transverse coloplasty pouch' according to our early clinical experience. METHODS: The technical steps in the formation of the transverse coloplasty pouch are described in detail, illustrated and discussed. After completion of the total mesorectal excision, a purse-string suture is fitted to the distal opening of the mobilized colon. The anvil of a circular stapler is secured by tying the purse-string suture. The colon is opened longitudinally, starting 2 cm proximal to the rim of the anvil. Depending upon the size of the colon, the incision measures 7-9 cm. In analogy to a pyloroplasty, the transverse coloplasty pouch is formed by lateral traction and the transverse opening is closed by running sutures. The continence-preserving neorectal reconstruction is completed by either a stapled anastomosis or a handsewn end-to-end pouch-anal anastomosis. CONCLUSION: The advantages of the transverse coloplasty pouch are the simplicity of the technique and the facilitated tension-free anastomosis of the neorectum to the dentate line. This is a particular advantage in obese patients with a thick mesocolon and in individuals with a narrow muscular pelvis and/or a short mesocolon.

Humans↗
PubMed2005

Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis.

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

Adult↗
PubMedDate not supplied

[Intermesenteric anastomoses].

This work is based on dissection and the analysis of the arteriographies of two mesenteric arteries and it analyses the type of intermesenteric anastomoses and their importance in surgical practice. The morphological varieties of Riolan's arcade depends on its pillars, as well as on the eventual presence, especially in the middle part of the transversal mesocolon, of the secondary arcades; it seems that the colic wall necrosis depends less upon the location of the lesion or the level of the suture of the arcade, but more so on the stretch of the destruction of the mesocolon. The intermesenteric trunk, a second way of intermesenteric anastomoses is a embryological remaining, non-functional in normal conditions, but capable to partially or completely replace the Riolan's arcade when the later is sutured or interrupted.

Angiography↗
PubMed2003

[Uncommon case of incomplete left paraduodenal hernia].

Internal hernias are very rare. The hernial orifice, sac and content are situated inside the abdomen. Paraduodenal hernias are relatively rare congenital malformations and account about 50 per cent of all internal hernias. The cause of this malformation is the incomplete rotation of the mid-gut. Right and left paraduodenal hernias are different, varying in anatomic structure and embryological origin. In right paraduodenal hernia the small bowel is partially or completely localised behind the mesocolon of the ascending colon, in left paraduodenal hernia behind the mesocolon of the descending colon. That is why the widely used name "mesocolic" hernia is more convenient, because it refers on the pathogenesis of the disorder. The complaints can vary from recurrent atypical abdominal pains to the complete small bowel obstruction, but often there are no complaints. Abdominal CT scan and the barium meal provide the best diagnostic approach for paraduodenal hernias, but it will be recognised very often only at an emergency operation. A case of small bowel obstruction caused by incomplete left paraduodenal hernia discovered after swallowing a foreign body is described with pathogenesis, diagnosis and possible treatments for the disease.

Aged↗
PubMedDate not supplied

Diverticular disease of right colon. Clinical variants and personal experience.

Diverticular disease of the right colon is not common, especially in western countries. It occurs in two different clinical forms, known as the "usual" and "hidden" variants. The diagnosis is not always easy, especially in the latter variant, because sometimes barium enema and CT scan are unable to distinguish this form from cancer. The final diagnosis is only intraoperative. In our experience, from 1994 to 2004, we observed 4 cases of complicated right-sided diverticulitis. Three of these patients had symptoms mimicking acute appendicitis, such as fever and abdominal pain. Only 2 of them underwent surgical treatment consisting of a right standard hemicolectomy. The 4th patient had no inflammatory symptoms, but had a history of right-sided abdominal pain and diarrhoea. Laboratory data showed only hypochromic anaemia. Barium enema and CT scan highlighted a vegetating mass in the ascending colon causing irregular severe stenosis of the lumen and hyperdensity of mesocolic fatty tissue. Surgical treatment consisted in a right hemicolectomy. Macroscopically, the mass involved the caecum and ascending colon. Enlarged lymph-nodes were present in the thickness of the mesocolon, but not in other districts. Histological examination revealed diffuse diverticular disease complicated by perforation of many diverticula into the mesocolon.

Diverticulosis, Colonic↗
PubMed1988

[Oxygen partial pressure after rectal oxygen insufflation-- experimental animal studies].

An oxygen diffusion through the mucosa of the colon into the vessels of the submucous coat was provable after rectal insufflation of an oxygen-gas mixture by animal experimental investigations in rabbits. Significantly higher pO2 values in the blood of the mesocolon veins, the portal vein, in the arterial and venous mixed blood of the liver parenchyma, and in the arterial vessels of the mesocolon are measurable after rectal application of oxygen during a time of 40 minutes. The oxygen therapy after rectal oxygen insufflation is established by animal experiments.

Administration, Rectal↗
PubMed1987

Mesenteric cysts.

Mesenteric cysts continue to be of special interest because of their diverse presentation and the lack of definitive diagnostic tests. Nine patients with mesenteric cysts were treated at St. Agnes Hospital between 1973 and 1984. The most common location was in small bowel mesentery (67%) followed by the mesocolon (33%). The mesenteric cysts were incidental findings in four of the nine patients (45%). Enucleation was the treatment of choice in eight patients (88%), followed by right hemicolectomy in one patient. Two patients had complications, one wound infection and one urinary tract infection. Simple enucleation has proven to be adequate treatment in most instances. Large bowel resection may be necessary when mesenteric cysts are located in the mesocolon and enucleation is not feasible without compromising the blood supply to the adjacent bowel.

Adolescent↗
PubMed1983

[The excluded jejunal loop in the shape of a question mark. A simplified technic].

The question mark-shaped loop is a simplified excluded loop which combines the advantages of being prepared as rapidly as the Tomoda procedure modified by Hivet and of having the same functional benefits as Roux's Y-shaped loop. It is essentially an omega-shaped loop the afferent segment of which is severed a few centimetres upstream of its higher point. The two sections can be sutured manually or with mechanical staplers. The loop can be brought up through the mesocolon as easily as the Y-shaped loop without dissection of the mesentery and can be used to re-establish continuity after total gastectomy. It can also be passed through the mesocolon and behind the stomach to perform hepato-jejunal anastomoses. Finally, it can be used for double or triple derivations in the conservative treatment of chronic pancreatitis.

Common Bile Duct↗