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PubMed1994

Complications of transhiatal esophagectomy.

A total of 23 papers published between 1981 and 1992, reporting a total of 1,353 patients, were reviewed for intraoperative and postoperative complications of transhiatal esophagectomy. Intraoperative complications included massive bleeding, tracheal injuries, cardiac arrhythmias, and incidental splenectomies. Even though the chest was not opened, the commonest postoperative complications were pulmonary. Leakage from the cervical anastomosis was seen in as many as 15% of all patients, but almost all resolved spontaneously. Postoperative benign strictures were seen in almost as many patients. Hoarseness due to recurrent laryngeal nerve injury, symptomatic gastro-esophageal reflux, chylothorax, Horner's syndrome, subphrenic abscess, hiatal hernia, and biliary cutaneous fistula were some of the other postoperative complications. An overview of these complications is presented, along with suggested methods of avoiding them and their treatment. The overall mortality for the 1,353 patients was 7.17%.

Esophageal Neoplasms↗
PubMedDate not supplied

Pancreas-preserving total gastrectomy for proximal gastric cancer.

Lymph node (LN) dissection along the upper border of the pancreas is one of the essential parts of curative surgery for gastric cancer, and the distal portion of the pancreas was frequently resected for complete removal of LNs along the splenic artery. However, pancreatic juice leakage, subphrenic abscess, and postoperative diabetes were common complications in patients treated by pancreatic resection. To avoid these problems a new surgical procedure, the pancreas-preserving operation, was developed by Maruyama in 1979. We found that lymphatic channels from the stomach did not flow into the pancreas parenchyma, and that the spleen, splenic artery, and fatty connective tissue including nodes could be removed completely without dissection of the pancreas parenchyma and splenic vein. The preserved pancreas receives its arterial blood supply through the transverse pancreatic artery, and its preservation prevents postoperative diabetes. A total of 299 patients were treated by this procedure. The operative mortality rate was 0.3%, the hospital death rate 1.6%, and the surgical complications rate 19.6%. The cumulative 5-year survival rate for those with stage II was 70.5% and for those with stage III 54.1%. These results were superior to those of the pancreas resection group.

Gastrectomy↗
PubMed1990

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones.

A total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shock-wave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gallstone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.

Adult↗
PubMed1993

Surgical results of left lobectomy and left hepatectomy in 70 noncirrhotic patients. A preliminary evaluation before performing liver transplantation from living related donors.

As a preliminary step before performing liver transplantation using living related donors, a comparative study was undertaken to determine the specific operative risk of left lobectomy (n = 54) compared to left hepatectomy (n = 16) in noncirrhotic patients. No postoperative death was observed in either group and no patients required reoperation. The mean hospital stay was longer after left hepatectomy than after left lobectomy (23 +/- 15 days vs 10 +/- 3 days, P < 0.05). The postoperative course was uneventful in 94% of the patients after left lobectomy and in 44% after left hepatectomy (P < 0.001). The peroperative transfusion rate was higher after left hepatectomy than after left lobectomy (38% vs 4%, P = 0.001). The postoperative collection rate was higher after left hepatectomy than after left lobectomy (25% vs 6%, NS). No biliary fistulas or subphrenic abscesses were noted after left lobectomy; however, these were observed in 19% and 12% of the cases, respectively, after left hepatectomy. Although conventional liver resection is quite different from graft harvesting in living related transplantation, our study demonstrates that the morbidity rate is significantly higher after left hepatectomy than after left lobectomy.

Adult↗
PubMed1976

[Complications of the vagotomy during the operation and in the early postoperative period (author's transl)].

426 subdiaphragmatic vagotomy operations were performed by the authors. On basis of the results obtained they give full details of the complications arising in the course and in the early postoperative period after vagotomy, and also of the possibilities preventing these complications. They call the attention to the more frequent injuries of the spleen and the oesophagus, and to the increasing number of the subphrenic abscess. Finally, they emphasize the low mortality rate of the vagotomy in comparison to the traditional gastric resections.

Diaphragm↗
PubMed1997

Pediatric pheochromocytoma. A 36-year review.

Fourteen children (10 boys and 4 girls, aged 8 to 17 years) had 20 pheochromocytomas treated over a 36-year period from 1959 to 1995 inclusive. Nine patients had 11 tumors before 1980; 5 children had 9 tumors up to 1987. There were no new children with pheochromocytomas at our hospital from 1988 to 1995. Hypertension, sweating, headache, and visual blurring were the most common symptoms and signs (average 5 months). The most reliable biochemical investigations were the urinary catecholamines and norepinephrine. Before 1980, intravenous pyelography and angiography were most successful in localizing the tumor, but since then ultrasonography and computerized tomography have been the radiological investigations of choice. Early involvement of the anesthesiologist in the preoperative control of the hypertension is essential; blood pressure (BP) control was achieved with phenoxybenzamine. The main anesthetic drugs used were: sodium thiopental, fentanyl, methoxyflurane, isoflurane, nitrous oxide, and metocurine. Sixteen tumors were adrenal and 4 were extra-adrenal (1 intrathoracic and 1 extradural). All except 2 tumors were completely resected; they ranged in size from 1.3 to 14 cm. Ligation of the tumor's venous drainage was usually associated with a sudden, temporary fall in systemic BP. There were 2 children with malignant tumors. Four patients had five recurrences (second pheochromocytoma) within 6 years, and all were heralded by a return of their original symptoms and signs. One girl was left with no adrenal tissue. The only complication was in a boy with a large, partly-resected malignant right adrenal tumor who had a subphrenic abscess drained and was left with a temporary bile fistula, cirrhosis, and chronic pain. All children were normotensive when discharged from hospital and remain alive and well with a follow-up of 7 to 36 years. There were no deaths. Long-term follow-up is essential. Key word Pheochromocytoma

Adolescent↗
PubMed1990

Capnocytophaga infection involving a portal-systemic vascular shunt.

Capnocytophaga sp., a microaerophilic gram-negative isolate of the human oral cavity, has previously been reported to cause sinusitis, empyema, wound infections, conjunctivitis, subphrenic abscess, osteomyelitis, bacteremia, cervical abscess, and endocarditis. We report the unusual case of infection with this organism at the anastamotic site of a splenorenal portosystemic vascular shunt. In this case, the pathogenesis is presumed to be bacteremia related to mucosal trauma from endoscopic injection sclerotherapy or bacteremia secondary to dental infection. The characteristics and antibiotic sensitivities of Capnocytophaga are reviewed.

Bacterial Infections↗
PubMedDate not supplied

Necrosis of intraabdominal esophagus and proximal third of the stomach after proximal gastric vagotomy and fundoplication.

Lesser curve necrosis is a rare but known complication of proximal gastric vagotomy (PGV). Incidence seems to increase when PGV is combined with fundoplication. In reports of this complication, the necrosis was of various sizes, but generally limited to the lesser curve. We report a 54-year-old patient with hiatus hernia, severe peptic esophagitis, and increased acid output who developed necrosis of the whole intraabdominal esophagus, cardia, and proximal third of the stomach after PGV and fundoplication with division of several short gastric vessels. A proximal gastric resection with intrathoracic esophagogastric anastomosis had to be performed. After drainage of a subphrenic abscess, the patient made a complete recovery. When combining PGV with a fundoplication, an increased risk of necrosis of the stomach must be considered. Division of the short gastric arteries should be avoided and the original Nissen fundoplication is preferred.

Esophagus↗
PubMed1994

Risks and benefits of antireflux operations in neurologically impaired children.

Gastro-oesophageal reflux (GER) in neurologically impaired children often causes feeding problems and complications of oesophagitis and is frequently resistant to medical treatment. Fifty neurologically impaired children underwent anterior gastropexy as anti-reflux operation, combined with gastrostomy in 23, between 1976 and 1992. There was no operative mortality. There were 25 early complications in 14 patients and 9 late complications in 9 patients. Twelve patients needed 17 re-operations for delayed gastric emptying [4], intestinal obstruction [3], para-oesophageal hernia [3], oesophageal stenosis [4], and recurrent GER, revision of gastrostomy, subphrenic abscess (one each). Nine patients died during the follow up period. Death in two children was related to the operation (incarcerated para-oesophageal hernia and blow-out of the stomach). Out of 41 survivors, the operation was judged successful in 35. It is concluded that antireflux operations in neurologically impaired children carry a high risk of complications. Preoperative identification of risk factors is not possible. The improvements in the quality of life achieved in the majority of patients outweigh the risks.

Adolescent↗
PubMed1997

Transcatheter arterial embolization-induced bilious pleuritis in a patient with hepatocellular carcinoma.

A 52-year-old man with hepatocellular carcinoma (HCC) was admitted with cough and fever. He had undergone four series of treatments, including transcatheter embolization and chemoembolization with lipiodol and anticancer drugs, over the previous 2 years. Computed tomography demonstrated dilated hepatic ducts, localized necrosis in the right hepatic lobe, and subphrenic abscess. He died of respiratory failure, because of increased effusion of the right pleura, about 3 weeks after admission. Autopsy revealed adhesions in the lower lobes of the right lung, diaphragm, and liver, with granulomas with bile pigment. A fistula was observed from the necrotic regions of the right hepatic lobe to the pleura through the diaphragm. A tumor thrombus in the portal trunk was histologically confirmed as well and moderately differentiated HCC with trabecular arrangement. Direct invasion of HCC with necrotic tissue to the pleura through the diaphragm appeared to have caused the respiratory failure. Although bilious pleuritis is a rare complication of transcatheter arterial embolization (TAE), it should be considered as an adverse effect of TAE in patients with a dilated hepatic duct.

Antineoplastic Agents↗
PubMed2001

Surgical complications and treatment during resection for malignancy of the high bile duct.

From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.

Adult↗
PubMed2002

Anatomic resection for severe blunt liver trauma in 100 patients: significant differences between young and elderly.

The liver is the organ most commonly injured during blunt abdominal trauma. As our society ages, emergency surgery for active elderly patients increases, but data on aggressive emergency hepatic resection remain scarce in the literature. The purpose of this study was to determine whether the elderly (70 years of age or older) can tolerate major liver injury and subsequent hepatic resection. We investigated 100 patients who were treated by an anatomic resection for severe blunt liver trauma (29 elderly patients who were 70 years of age or older and 71 young patients who were younger than 70 years of age) in a retrospective study. The elderly patients were more severely injured as demonstrated by a higher Injury Severity Score, a lower Glascow Coma Scale, and lower survival (80.3% vs. 65.5%; p < 0.05). The total number of associated injuries was greater in elderly patients. Motor vehicle accidents were responsible for 71.8% of the injuries in the young group, and the predominant mechanism in the elderly patients was also motor vehicle accidents (51.7%). The 71 anatomic hepatic resections performed on the young patients included right hemihepatectomy (n = 45), left lateral segment resection (n = 14), bisegmentectomy (n = 5), and others. The 29 anatomic hepatic resections performed for the elderly patients were right hemihepatectomy (n = 15), left lateral segment resection (n = 5), left hemihepatectomy (n = 4), and others. Pneumonia, subphrenic abscess, and urosepsis occurred at a significantly higher frequency in elderly patients than in young patients. Our data clearly indicated that (1) the mechanism of injury, grade of associated intraabdominal injuries, distribution of surgical procedures, and complications differ significantly between young and elderly patients; and (2) the survival rate (65.5%) in elderly patients may be sufficient to consider anatomic hepatic resection to be a useful, safe procedure.

Accidents, Traffic↗
PubMed2003

Laparoscopic Roux-en-Y gastric bypass: initial 2-year experience.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP)-essentially a restrictive bariatric procedure-is currently considered the gold standard for the surgical treatment of morbid obesity. Open surgery in obese patients is associated with a high risk of cardiopulmonary complications, wound infection, and late incisional hernia. Laparoscopic surgery has been shown to reduce perioperative morbidity and to improve postoperative recovery for various procedures. Herein we present our results with laparoscopic RYGBP after an initial 2-year experience. METHODS: A prospective database was created in our department beginning without the first laparoscopic bariatric procedure. To provide a complete follow-up of 6 months, the results of all patients operated on between June 1999 and August 2001 were reviewed. Early surgical results, weight loss, correction of comorbidities, and improvement of quality of life were evaluated. RESULTS: A total of 107 patients were included. There were 82 women and 25 men, with a mean age of 39.7 years (range, 19-58). RYGBP was a primary procedure in 80 cases (49 morbidly obese and 31 superobese patients) and a reoperation after failure or complication of another bariatric operation in 27 cases. Mean duration of surgery was 168 min for morbidly obese patients, 196 min for surperobese patients, and 205 min for reoperated patients (p <0.01). Conversion to open surgery was necessary in two cases. A total of 22 patients (20.5%) developed complication. Nine of them (8.4%) required reoperation for leak (five cases, or 4.6%), bowel occlusion (three cases, or 2.8%), or subphrenic abscess (one case, or 0.9%). mortality was 0.9%. Major morbidity decreased over time (first two-thirds, 12.5%, last third, 2.7%). major morbidity decreased over time (first two-thirds, 12.5%; last third, 2.7%). Excess weight loss of -50% was achieved in >80% of the patients, corresponding to a loss of 15 body mass index (BMI) units in morbidly obese patients and 20 BMI units in superobese patients. In the vast majority of patients, comorbidities improved or disappeared over time and quality of life improved. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is feasible, but it is a very complex operation. Indeed, it is associated with a long and steep learning curve, as reflected in the high number of major complications among our first 70 patients. The learning curve probably includes between 100 and 150 patients. With increasing experience, the morbidity rate becomes more acceptable and comparable to that of open RYGBP. The results in terms of weight loss and correction of comorbidities are similar to those obtained after open surgery, at least in the short term. However, only surgeons with extensive experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.

Adult↗
PubMed2003

The clinical spectrum of band erosion following laparoscopic adjustable silicone gastric banding for morbid obesity.

BACKGROUND: Morbid obesity is effectively treated by restrictive surgery. A severe complication associated with gastric banding is gastric erosion. We review here our experience over a 5-year period. METHODS: A total of 1496 patients underwent gastric banding. Eighty-five percent of patients were available for follow-up. When band erosion was diagnosed, laparoscopic removal was performed. RESULTS: Band erosion was identified in 17 patients (1.13%). The time from primary operation to diagnosis of band erosion ranged from 3 weeks to 45 months (mean, 19 months). Clinical manifestations included weight gain in 2 (11.6%), band system leak in 1 (5.8%), chronic port-cutaneous fistula in 2 (11.6%), neglected peritonitis in 1 (5.8%), left subphrenic abscess in 2 (11.6%), but most commonly, protracted port-site infection that occurred in 7 patients (40.6%). CONCLUSIONS: Patients were effectively treated by band removal and suturing of the stomach wall. We suggest that different pathologies contribute to the same complication depending upon the time of presentation. We recommend a high index of suspicion in order to diagnose this life-threatening complication.

Adult↗
PubMed2005

Experience with laparoscopic gastric resection: results and outcomes for 37 cases.

BACKGROUND: This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. METHODS: A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. RESULTS: Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). CONCLUSIONS: Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.

Female↗
PubMed2000

Intrahepatic lithiasis: a Western experience.

Intrahepatic lithiasis (IHL) is a very rare disease in Europe and no gold-standard treatment has yet been codified. The aim of our study is to report our personal experience of IHL detected in 20 patients (6 males [30%] and 14 females [70%]) between January 1982 and December 1991. Eleven (55%) of these cases presented with only IHL, 7 cases (35%) had IHL associated with gallbladder or common bile duct stones, while 2 (10%) were affected by secondary IHL caused by previous biliodigestive anastomosis-induced stricture. The diagnosis was determined by cholangiography in all patients, by ultrasound in 94.7%, and by computed tomography in 70%. The surgical procedures used were as follows: liver resection in 12 patients (60%); various types of biliodigestive anastomosis in 6 cases (30%); choledocholithotomy with a simultaneous removal of stones from the hepatic duct in 2 patients (10%). The intraoperative mortality rate was nil. Complications consisted of 2 subphrenic abscesses, 1 septicemia, and 1 bowel occlusion. Two patients (10%) dropped out of the follow-up, 2 (10%) died 2 years after surgery for reasons not connected with the disease, 1 (5%) died from suppurative cholangitis 6 months after surgery, 2 (10%) had recurrent stones and were treated by extracorporeal lithotripsy and endoscopic stone removal, while the remaining 13 patients (65%) are symptom-free at follow-up which varied between 6 months and 11 years. Liver resection is the treatment of choice when IHL is confined to one lobe of the liver. When IHL affects the entire liver, a resection of the main involved area should be performed whenever possible. Other options include hepatoduodenal anastomosis using the interposed jejunal loop to enable endoscopic or combined treatment of recurrent stones.

Adult↗
PubMed2003

Right hepatectomies without vascular clamping: report of 87 cases.

BACKGROUND/PURPOSE: Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. METHODS: From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 +/- 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). RESULTS: There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 +/- 2.7 units. The mean operative length was 280 +/- 60 min and the mean hospital stay was 12.8 +/- 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. CONCLUSIONS: In our experience with major liver resections, vascular clamping is not necessary.

Adult↗
PubMed1983

Infection among 210 patients with surgically staged Hodgkin's disease.

To determine the incidence and types of infections in Hodgkin's disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkin's disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkin's disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkin's disease after splenectomy.

Adolescent↗