Intussusception of the bowel in adults:A review

Intussusception of the bowel is defined as the telescop-ing of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment.This condi-tion is frequent in children and presents with the classic triad of cramping abdominal pain,bloody diarrhea and a palpable tender mass.However,bowel intussusception in adults is considered a rare condition,accounting for 5% of all cases of intussusceptions and almost 1%-5%of bowel obstruction.Eight to twenty percent of cases are idiopathic,without a lead point lesion.Secondary intus-susception is caused by organic lesions,such as inflam-matory bowel disease,postoperative adhesions,Meckel's diverticulum,benign and malignant lesions,metastatic neoplasms or even iatrogenically,due to the presence of intestinal tubes,jejunostomy feeding tubes or after gas-tric surgery.Computed tomography is the most sensitive diagnostic modality and can distinguish between intus-susceptions with and without a lead point.Surgery is the definitive treatment of adult intussusceptions.Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected.Reduction of the intussuscepted bowel is considered safe for benign lesions in order to limit the extent of resection or to avoid the short bowel syndrome in certain circumstances.

Surgical approaches of resectable synchronous colorectal liver metastases:Timing considerations

AIM: To compare the safety and efficacy of simultaneous versus two stage resection of primary colorectal tumors and liver metastases. METHODS: From January 1996 to May 2004, 103 colorectal tumor patients presented with synchronous liver metastases. Twenty five underwent simultaneous colorectal and liver surgery and 78 underwent liver surgery 1-3 mo after primary colorectal tumor resection. Data were retrospectively analyzed to assess and compare the morbidity and mortality between the surgical strategies. The two groups were comparable regarding the age and sex distribution, the types of liver resection and stage of primary tumors, as well as the number and size of liver metastases. RESULTS: In two-stage procedures more transfusions were required (4 ± 1.5 vs 2 ± 1.8, pRBCs, P < 0.05). Chest infection was increased after the two-stage approach (26% vs 17%, P < 0.05). The two-stage procedure was also associated with longer hospitalization (20 ± 8 vs 12 ± 6 d, P < 0.05). Five year survival in both groups was similar (28% vs 31%). No hospital mortality occurred in our series. CONCLUSION: Synchronous colorectal liver metastases can be safely treated simultaneously with the primary tumor. Liver resection should be prioritized over colon resection. It is advisable that complex liver resections with marginal liver residual volume should be dealt with at a later stage.

An ongoing dispute in the management of severe pancreatic fistula:Pancreatospleenectomy or not?

The aim of this manuscript is to review controversies in managing severe pancreatic fistula after pancreatic surgery.Significant progress in surgical technique and perioperative care has reduced the mortality rate of pancreatic surgery.However,leakage of the pancreatic stump still accounts for the majority of surgical complications after pancreatic resection.Various strategies have been employed in order to manage pancreatic fistula.Nonetheless high grade pancreatic fistula evokes controversy in relation to the choice of treatment.A Medline search was performed,with regard to conservative treatment options versus completion pancreatectomy for the management of pancreatic fistula grade C.Pancreatic fistula rates remain unchanged with an incidence ranging from 5%-20% and this is considered as the most important cause of postoperative death.Many authors claim that completion pancreatectomy has probably lost its role in favour of interventional radiology procedures,while others believe that completion pancreatectomy continues to have a place in the management of patients with severe clinical deterioration after pancreatic fistula who do not respond to non-surgical interventions.There is no agreement on the best clinical management of severe pancreatic fistula after pancreatic surgery.Completion pancreatectomy is reserved for patients not improving with conventional measures.

Does clamping during liver surgery predispose to thrombosis of the hepatic veins? Analysis of 210 cases

AIM:To test whether clamping during liver surgery predisposes to hepatic vein thrombosis.METHODS:We performed a retrospective analysis of 210 patients who underwent liver resection with simultaneous inflow and outflow occlusion.Intraoperatively,flow in the hepatic veins was assessed by Doppler ultrasonography during the reperfusion phase.Postoperatively,patency of the hepatic veins was assessed by contrast-enhanced CT angiography,when necessary after 3-6 mo follow up.RESULTS:Twelve patients(5.7%) developed intraoperative liver remnant swelling.However,intraoperative ultrasonography did not reveal evidence of hepatic vein thrombosis.In three of these patients a kinking of the common trunk of the middle and left hepatic veins hindering outflow was recognized and was managed successfully bysuturing the liver remnant to the diaphragm.Twenty three patients(10.9%) who developed signs of mild outflow obstruction postoperatively,had no evidence of thrombi in the hepatic veins or flow disturbances on ultrasonography and contrast-enhanced CT angiography,while hospitalized.Long term assessment of the patency of the hepatic veins over a 3-6 mo follow-up period did not reveal thrombi formation or clinical manifestations of out flow obstruction.CONCLUSION:Extrahepatic dissection and clamping of the hepatic veins does not predispose to clinically important thrombosis.