Abstracts - Chirurgie Kongress

68.11
A rare complication following laparoscopic roux-en-Y gastric bypass: a case of acute mesenteric and
portal venous thrombosis
F. C. Grafen, V. Neuhaus, T. Köstler, O. Schöb (Schlieren)
Objective: Acute mesenteric and portal venous thrombosis (MPVT) is a rare complication following
laparoscopic Roux-en-Y gastric bypass. MPVT is a severe potentially life-threatening diagnosis. There
are only few reports about this entity, which shows non-specific clinical presentation. Being sensitized
to this complication may avoid delay in diagnosis and therapy.
Methods: A 52-year-old male with a long history of diet-refractory morbid obesity with a body-massindex
of 43 kg/m 2 underwent a laparoscopic antecolic distal Roux-en-Y gastric bypass. The intervention
passed uncomplicated. He had an uneventful postoperative course and was discharged on 6th
postoperative day showing an excellent physical condition. 23 days postoperatively he presented with
nausea, upper abdominal pain which progressed during 10 days accompanied by tiredness. The CTscan
showed mesenteric, portal and lienal venous thrombosis. Interestingly he had withdrawn the
postoperative DVT-prophylaxis (Fragmin 10000 units/d) 12 days postoperatively which was prescribed
for at least 21 days. The patient was placed on intravenous heparin followed by diagnostic laparotomy.
Explorative laparotomy showed viable bowel with increased vulnerability to manipulation. A
mesenteric venous catheter for thrombolysis (1,5 mio. units/24h urokinase) was placed. Three days
later portography showed an already reopened lienal vein and a chance for extending thrombolysis
into the portal vein.
Results: Acute mesenteric and portal venous thrombosis is a very rare complication of laparoscopic
gastric bypass procedures. In literature we have found different therapeutic approaches. A main therapy
could consist of open thrombectomy or local thrombolysis. Mortality rate is 20 to 50% and in case
of delayed diagnosis even higher.
Conclusion: Acute MPVT is a rare complication which shows unspecific symptoms which can lead to
delay of diagnosis. CT-scan is the gold standard and diagnostic in up to 90% of patients. Diagnosis
needs to be confirmed by laparoscopy/-tomy and definitively excludes bowel infarction. Pain out of
proportion to clinical findings should raise the idea of an acute or delayed MPVT following gastric
bypass surgery.
68.12
Role of sacral nerve modulation for constipation after rectal prolapse repair
J. Robert-Yap, G. Zufferey, K. Skala, B. Roche (Genève)
Objective: Constipation is a common symptom after abdominal surgery for a full thickness rectal prolapse.
Management of persistent symptoms of constipation is difficult and consists of conservative
therapy and/or eventual surgery. One of these new treatments is sacral nerve modulation (SNM). It involves
stimulation of the sacral nerve by an electronic pulse generator, similar to a cardiac pacemaker.
It is a minimally invasive procedure which is performed in 2 stages. It results in a sensory and motor
effect in the pelvic floor and its organs and has been shown to regulate bowel function in incontinence
and/or constipation.
Methods: From January 2003 to December 2007, 5 female patients median age 67 years, range 53
- 86 years had been tested. Patients had constipation symptoms despite rectal prolapse repair. We reviewed
all 5 SNM test operations performed in post rectal prolapse repair patients. Of these 5 patients,
3 had a Wells rectopexy and 2 had a rectopexy combined with total perineal repair. Additional previous
procedures included 1 sigmoidectomy and 2 vaginal suspensions by promontofixation.
Results: 4 on 5 patients tested with constipation had positive results: an 80% success rate. The Wexner
constipation score decreased from 18 in pre-implantation to 10 in definitive implantation. There were
no complications.
Conclusion: SNM is a minimally invasive procedure. Our results show an 80% success rate using SNM
in 5 cases of constipation after rectal prolapse repair with no complications. SNM has the advantage
of a test phase to assess efficacy. It is a good treatment option to offer patients who have ongoing
symptoms after rectal prolapse surgery.
68.13
Surgical management of gastroesophagal reflux disease (GERD) due to delayed gastric emptying
(DGE)
M. Matter, J.-M. Calmes, J. Prior, N. Demartines (Lausanne)
Objective: Severe GERD with extra-intestinal manifestations and DGE is an underestimated group of
patients. Medical conservative treatments will fail and classical anti-reflux surgery is inappropriate.
Methods: We report 2 cases. The first is a 65 year-old woman with a 10 years history of severe secondary
bronchopneumopathy and an 8 years history of dyspepsia. Symptoms improved temporary
after helicobacter pylori (HP) treatment. Because of recurrence, multiple endoscopies were performed,
revealing severe gastritis with bile reflux suggesting gastroduodenal dyskinesia and a hiatal hernia.
Despite many conservative treatments, biliary gastritis persisted and in parallel the severity of the
bronchopneumopathy increased with endoscopy proven episodes of bronchoaspiration. The second
patient is a 64 year-old woman with 5 years of GERD resisting to in-hospital high dose PPI. Many endoscopies
demonstrated successively esophagitis, gastritis and duodenitis. Investigations in both
patients included abdominal ultrasound, oesophageal Ph-manometry, and a technetium solid meal
demonstrating a significant DGE.
Results: Surgery in both was a duodenal switch with an alimentary loop of 50-70 cm. The first had
an open procedure, which included a floppy Nissen, and the second had a laparoscopic operation.
Patients were discharged at 11th and 5th postoperative day respectively. Recovery was uneventful with
normal diet, quick relief of severe reflux symptoms in both. After one and 2 months respectively, a new
technetium meal demonstrated a normal gastric emptying in the first and no change in the other.
Conclusion: In GERD, surgery can be proposed as an option following failure of conservative treat-
48 swiss knife 2009; special edition
ment. Post-operative morbidity such as gas bloat syndrome is sometimes imputed to surgery. In some
patients it is also necessary to consider and treat combined functional motility disorders like DGE.
Surgery of DGE includes total duodenal diversion of Holt and Large associated with a high morbidity,
and duodenal switch. The latter is less aggressive regarding intestinal integrity (no gastric resection)
and motility (pylorus preservation and no vagotomy). We confirm that it can be performed safely with
an open or with a minimal invasive technique.
68.14
Functional parathyroid cyst of an upper parathyroid gland. Case report
M. Matter, E. Lantheman, M. Huebner, N. Demartines (Lausanne)
Objective: Parathyroid cysts are rare and represent less than 1% of primary hyperparathyroidism.
Methods: An 87 year-old woman was admitted in emergency because of her deteriorating condition
with severe confusion. She complained of dysphagia for 10 days. Following discovery of severe hypercalcemia
(3.46, N