Selected publications from PubMed
Surgical treatment of Hinchey III diverticulitis is still controversial, with debate between the proponents of laparoscopic lavage and those proponents of sigmoid resection. In this latter group there is debate between the laparoscopic and open approaches and between anastomosis and colostomy. Laparoscopy may be challenging in the setting of acute inflammation but allows peritoneal lavage, drainage of abscesses and bowel resection, offering enhanced patient recovery and reduced morbidity. A recent meta-analysis of 3 randomized controlled trials comparing laparoscopic lavage versus surgical resection concludes that laparoscopic lavage is associated with reduced operating time, shortened postoperative stay and a lower surgical reintervention rate at 12 months. By contrast, postoperative mortality rate at the index operation and 90 postoperative days, surgical reintervention during the index hospitalization and at 90 days, and Clavien-Dindo grade I-III complications favoured emergency sigmoid resection although they did not achieve statistical significance. Laparoscopic lavage was associated with a significant increase in postoperative intra-abdominal abscess formation within 90 days, which may explain the higher unplanned reintervention rate in the laparoscopic lavage group. Laparoscopic lavage is non-inferior to sigmoid resection although in this group of patients may be necessary an increased number of late procedures related to ongoing sepsis, mainly due to intra-abdominal abscess. Patients undergoing these unplanned procedures may be exposed to increased morbidity. The video presents the case of a patient with acute diverticulitis Hinchey III who was initially treated with laparoscopic lavage and had persistent sepsis. 3 days after the index surgery, a laparoscopic sigmoidectomy with colostomy was performed. After the unplanned procedure the patient had a normal postoperative course with discharge in the 5th postoperative day. Surgical treatment of Hinchey III acute diverticulitis is still controversial. Laparoscopic lavage seems a useful tool in selected patients but it may be associated with an increased need for unplanned procedures that may increase morbidity.
Published
Mar 2021
Spontaneous rupture of the esophagus, the so-called Boerhaave’s syndrome, was first described in 1724 by Hermann Boerhaave as direct observation of Baron van Wassenaer, the Grand Admiral of the Dutch fleet. Nowadays, esophageal perforations are most commonly iatrogenic, caused during diagnostic and therapeutic endoscopic procedures. Less common causes are spontaneous perforation, foreing body ingestion, trauma, operative injury and tumours. Independently of the etiology, esophageal perforation is a surgical emergency associated with significant morbidity and mortality. Surgical therapy has been the dominant treatment but recent developments resulted in the expansion of treatment options to include nonoperative, endoscopic and hybrid approaches.
Published
Nov 2020
The stomach is located in the upper left quadrant of the abdomen. Its anterior aspect is related to the left hepatic lobe, diaphragm, transverse colon and greater omentum. Its posterior face is related to the pancreas, spleen and splenic artery, adrenal gland, left kidney and diaphragm. AnteriorPosteriorLeft hepatic lobePancreasDiaphragmSpleenTransverse colonLeft adrenal glandGreater omentumLeft kidney It has an irregular shape with two curvatures: lesser curvature (right side) and greater curvature (left side). The greater omentum is inserted on the greater curvature. Parts of the stomach · Cardias: is the most proximal part of the stomach, adjacent to the lower esophageal sphincter. · Fundus: is the part of the stomach that is above the esophagogastric junction. · Body: between the fundus and the antrum. · Antrum: most distal part of the stomach, its limit in the lesser curvature is the incisura angularis. · Pylorus: is a sphincter that divides the stomach from the duodenum. The stomach wall is composed of four layers: serosa, muscle layer, submucosa and mucosa. Vascularization The arterial vascularization to the stomach is based on the celiac trunk with three main supplies: the left gastric artery (coronary), the hepatic artery and the splenic artery. The left gastric artery, located in the lesser curvature, has anastomosis with the pyloric artery (branch of the hepatic artery) and it can give rise to a branch that transverses the lesser omentum and irrigates the left hepatic lobe. The greater curvature is irrigated by the right and left gastroepiploic arteries, being the former a branch of the hepatic artery and the latter a branch of the splenic artery. Venous drainage The venous web is parallel to the arterial web and drains in it majority to the portal vein although in the gastroesophageal junction the drainage may be to the vena cava through diaphragmatic veins. Lymphatic drainage The lymphatic drainage is originated in the deepest sector of the mucosa to create a web of interweaved in the submucosal layer and in the subserosa. There are three major drainage areas: hepatic, left gastric and splenic. Lymph nodes are divided into groups according to the Japanese classification: GroupLocation1Right paracardial2Left paracardial3Lesser curvaturel4Greater curvature5Suprapyloric6Infrapyloric7Left gastric artery8Common hepatic artery9Celiac trunk10Splenic hilium11Splenic artery12Hepatic hilium13Posterior duodenopancreas14Superior mesenteric artery15Middle colic artery16Paraaortic Type of gastrectomyD1 lymphadenectomyD2 lymphadenectomyTotal1 to 6D1 + 7, 8, 9, 10*, 11, 12Distal1, 3, 4, 5, 6D1 + 7, 8, 9, 10*, 11, 12 10* the performance of the lymphadenectomy of group 10 is discretional and requires a splenectomy. Gastric innervation Gastric nerve supply is both sympathetic and parasympathetic. The sympathetic innervation follows the arterial supply. The parasympathetic innervation arrives to the stomach from the vagal nerves. The left vagal nerve or anterior is not always a single trunk and can be divided into three branches; immediately before the cardias it sends small branches to the fundus and through the lesser omentum it sends branches to the liver, gallbladder, pylorus and duodenum. It gives rise to the nerve of Latarjet, parallel to the lesser curvature and that ends in the “crows fool” at the level of the incisura angularis. The posterior or right vagal nerve is usually a single trunk. Near the cardias it gives rise to a posterior and left branch called the “criminal nerve of Grassi”. The posterior Latarjet nerve descends the lesser curvature.
Published
Aug 2020
Corrosive ingestion is a potentially lethal event that affects 60,000 people in the USA and 15,000 people in the UK every year. Accidental ingestion by children accounts for 80% of the cases worldwide whereas in adults most ingestions are intentional. CT scan is considered a reliable and reproducible examination that enables transmural digestive necrosis assessment, improving the selection of patients for surgery. Patients with transmural necrosis should undergo surgery as it may be life-saving. Late sequelae are usually treated by endoscopy. Emergency management and treatment require a multidisciplinary approach.
Published
May 2020
Surgical resection remains the most important curative treatment modality for non metastatic esophageal cancer. Historically, two approaches to esophagectomy have coexisted: the transhiatal esophagectomy (THE) and the transthoracic esophagectomy (TTE). The mortality rate in the open era ranged between 3 and 10% and the 5-year-survival rate was 20-30%. Recent years have seen an improvement in the outcomes due to several facts, such as improved patient care and selection with improvement in perioperative care, neoadjuvant treatments and centralization of surgery in high-volume centres. Minimally invasive esophagectomy (MIE) was developed in the 1990s and was popularized in the last decade. Several meta-analyses support the following concepts: Minimally invasive esophagectomy is associated with fewer respiratory complications. MIE is associated with a reduction in morbidity. MIE is associated with faster postoperative recovery. Nonetheless, MIE is technically demanding and programs to introduce the technique are needed. Two classic trials, the TIME-trial (comparing thoraco-laparoscopic vs open esophagectomy) and the MIRO-trial (laparoscopic + thoracotomy vs open esophagectomy) have shown that MIE is associated with: Less blood loss. Lower rate of respiratory infection. Shorter hospital stay. Better quality of life. The quality of the specimen seems comparable between open and MIE techniques in radicality and number of lymph nodes. Long term oncological outcomes (from the TIME-trial) showed no differences at 1-year and 3-years. OPEN APPROACH Transthoracic esophagectomy The distal esophagus and its locoregional lymph nodes in the posterior mediastinum are dissected through an upper abdominal incision. The upper abdominal lymph nodes (including paracardial, lesser curvature and left gastric artery) are dissected and a D1+ or D2 lymphadenectomy is performed. Via a left cervical incision, the cervical esophagus is dissected and the intrathoracic esophagus is dissected bluntly and stripped. A gastric tube is made and positioned in the prevertebral plane to create an anastomosis in the neck. Transthoracic esophagectomy There are several techniques using a transthoracic esophagectomy: Ivor-Lewis: right thoracotomy and laparotomy. McKeown: three stage with neck incision. Sweet: left thoraco-abdominal incision. Both three and two stage esophagectomies involve esophageal resection, creation of a gastric tube, two field lymphadenectomy (celiac trunk and mediastinum) and a cervical anastomosis in three stage esophagectomy and intrathoracic anastomosis in Ivor-Lewis. Differences between approaches The HIVES trial comparing TTE with THE showed no differences regarding in-hospital mortality but higher postoperative complications in the TTE group (pulmonary complications and chyle leakage) with longer postoperative hospital stay. Although there was not a statistically significant difference in 5-year survival, it was 29% in the THE group and 39% in the TTE group. Nonetheless,when the tumor was located in the distal esophagus rather than the esophagogastric junction, an absolute survival benefit of 14% was seen with the TTE. Moreover, in patients with one to eight positive nodes in the resection specimen, 5 year locoregional disease free survival favored the TTE (64% vs 23%). With this data, we can conclude that patients with distal esophageal cancer and limited nodal burden may benefit from a more extensive nodal dissection via a TTE. MINIMALLY INVASIVE ESOPHAGECTOMY (MIE) Recent studies have shown that lymph node yield and surgical margins are similar and perhaps superior with MIE compared to open approaches (TIME-trial and MIRO-trial). The main disadvantage of MIE is that it is technically challenging and needs careful introduction via a structured program. Minimally invasive esophagectomy is associated with less operative trauma and consequently less morbidity. Fewer pulmonary complications are reported during thoracoscopy compared to thoracotomy and, if the prone position is used, omitting complete lung block, even fewer pulmonary complications are expected. In laparoscopic transhiatal dissection there is probably less manipulation and retraction of the mediastinum and thus, fewer hemodynamic complications. FUTURE RESEARCH There are some ongoing randomized controlled trials comparing open esophagectomy with the thoracoscopic approach assisted by robot (ROBOT trial) and there are also RCTs that will compare MIE with open and hybrid techniques (ROMIO trial). Other trials will compare the McKeown and Ivor-Lewis MIE procedures (ICAN trial).
Published
Feb 2020
Hiatal hernia recurrence after laparoscopic repair has been reported in a significant percentage of patients, from 1.2% to 66%. Some authors have reported lower recurrence rates after mesh repair, but due to the differences in technique, type of mesh, and shape and size of the hernia, this data is still controversial. Laparoscopic repair of paraesophageal hernias yields excellent relief of symptoms and improved quality of life despite a high rate of radiographically identified recurrence. Unfortunately there is no universally accepted definition of paraesophageal hernia recurrence. Most of the series rely on barium esophagography, endoscopy or esophageal manometry to document recurrence, with rates being quite high, reaching 66%. Nonetheless, most studies report a symptomatic recurrence rate as low as 3 – 3.5% of cases. Thus, the clinical relevance of radiographic recurrence is controversial. A 2013 study from Johns Hopkins University (Baltimore, USA) reported a correlation between a hiatal hernia recurrence > 2 cm by barium esophagography and significant symptom worsening. Oelschlager et al. reported radiographic recurrence as the greatest vertical height of stomach ≥ 2 cm above the diaphragm. Many studies have reported little or no difference in heartburn, regurgitation, dysphagia, chest pain or satisfaction in patients with and without radiographic recurrence of hiatal hernias. Thus, only a small percentage of patients need reoperation (around 3% in the Luketich et al. large series) When a recurrence is radiographically and clinically diagnosed, the patient should undergo a complete preoperative evaluation. A paper from the University of Creighton group (Nebraska, USA) published in 2006 recommends a preoperative evaluation consisting of: 1. Esophagogram to determine the size of the hiatal hernia and the length of the esophagus. 2. Upper endoscopy to determine the presence or absence of cancer, Barrett’s esophagus, peptic stricture, short esophagus, gastroparesis, Cameron’s ulcer and the type and size of the hiatal hernia. 3. Manometry: the fundoplication pressure and relaxation should be assessed at each centimeter. Relaxation below 85% should be considered abnormal. Normal fundoplication pressure is 20-35 mmHg. 4. pH monitoring: performed selectively in patients with bad response to proton-pump inhibitors, or with endoscopic findings of esophagitis. Hiatal hernia recurrence can be classified into 4 groups: Ia: the entire wrap along with the gastroesphageal junction migrates cephalad. Ib: the wrap remains below the diaphragm but the stomach and the gastroesophageal junction slip cephalad. II: true paraesophageal hernia. III: defective initial construction of the wrap using the gastric body rather than the fundus. Patients with a surgically correctable disorder that is not responsive to aggressive medical management should be candidates for reoperation. The patient should be aware of the difficulty of the operation and of the complications associated with it. 2% to 20% conversion rates have been reported, as well as 16% to 20% of gastric perforation, 25% of pneumothorax and a low rate of reoperation, around 2%. Nonetheless, patients improve with redo surgery. It has been demonstrated in cohort studies that the laparoscopic approach to reoperative hiatal hernia repair is safe and effective. The key steps of reoperative hiatal hernia repair are the following: 1. Entry – insufflation 2. Adhesiolysis: establishing a plane between the caudate lobe and the preaortic fascia continuing into the right crus. 3. Hiatal dissection. 4. Identification and preservation of the vagus nerves: care must be taken dissecting the 12 and 6-7 o’clock positions. The identification of the nerves on the proximal esophagus is easier than distally. 5. Takedown of the previous fundoplication. 6. Crural closure: a mesh may be necessary. 7. Intraoperative endoscopy: identify the true gastroesophageal junction by applying pressure with a grasper and correlating with intra-luminal findings. 8. Evaluation of esophageal length: lengthening procedures may be necessary if it is less than 2.5 cm. 9. Fundoplication. Conclusions Despite the lack of a universally accepted definition of hiatal hernia recurrence, most authors agree that a symptomatic patient with a hiatal hernia recurrence in esophagogram ≥ 2 cm should be considered as having a recurrent hiatal hernia. Evaluation with upper endoscopy, manometry and pH monitoring should be performed to rule out other causes of the symptoms. In patients with no other causes and with a radiographic hiatal hernia recurrence, with symptoms that do not improve despite proton pump inhibitors, surgery should be advised. Both patient and surgeon should be aware of the higher complication rate associated with reoperative surgery even though clinical outcomes are satisfactory.
Published
Jan 2020
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