International Journal of Surgical Research 2015, 4(2): 11-14 DOI: 10.5923/j.surgery.20150402.01

Laparoscopy in Upper Gastro-Intestinal non Tumoral Pathologies: Our Experience in a Low Income Country

Toure Alpha O.1,*, Foba Mamadou Lassana1, Ka Ousmane1, Cisse Mamadou1, Konate Ibrahima2, Dieng Madieng1, Toure Cheikh T.1

1General Surgery Department, Le Dantec Hospital, Avenue Pasteur, Dakar, Senegal 2Surgery and surgical specialties Department, Gatson Berger University, Saint, Louis, Senegal

Abstract The aim of our study was to evaluate the contribution of laparoscopy in non-tumoral Upper GastroIntestinal (UGI) diseases in our working conditions. This was a retrospective descriptive study in General Surgery Department of Le Dantec University Hospital in Dakar on a period of 10 years (January 2003 to January 2013). We included 162 cases patients treated by laparoscopy for acute or chronic UGI disease. The pathologies encountered were hiatal hernia in 18.5% of cases (n = 30); achalasia in 13% of cases (n = 21); ulcerative pyloroduodenal stenosis in 55.5% of cases (n = 90); perforated duodenal ulcer in 13% of cases (n = 21). We performed truncal vagotomy and gastric bypass, Nissen Rossetti fundoplication, Heller Myotomy and ulcer sutures as laparoscopic procedures. The average length of surgery was 84 minutes (22mn - 130mn). Six cases of operating incidents were recorded (1 case of accidental injury of a left hepatic artery and 5 esophagal perforations). Conversion to laparotomy was required in 12 cases (7.4%). The delay of oral feeding varied between 1 and 4 days with an average of 2.5 days. Postoperative courses were uneventful in 152 patients (93.8%). Nine postoperative complications were found: gastroparesis (4 patients), postoperative peritonitis (1 case), and dysphagia (4 patients). A death was noted in 1 case by postoperative peritonitis secondary to sepsis. The mean hospital stay was 7 days with extremes ranging from 3 to 10 days. Keywords Laparoscopy, Hiatal hernia, Duodenal ulcer complications, Achalasia

pathologies, laparoscopic procedures, conversion factors, 1. Introduction duration of surgery, delay to oral feeding, length of hospital stay, morbidity and mortality. Laparoscopic surgery implants itself increasingly in the treatment of digestive diseases in our sub-Saharan countries Table 1. Patients’ epidemiological datas despite our limited means [1]. Thus, after cholecystectomy, Mean age Gender Patients indications extend to upper gastro-intestinal (UGI) tract (mini - max) M F Ratio diseases such as progressive complications of duodenal ulcer Acute 34,5 years 20 1 20 and certain disorders of the cardia. The aim of our study was pathologies (20-63 years) to evaluate the contribution of laparoscopy in non-tumoral Chronic 36,8 years 87 54 1,6 UGI diseases in our working conditions. pathologies (17-82 years) 35,7 years Total 107 55 1,9 (17-82 years) 2. Patients and Methods This was a retrospective descriptive study in General 3. Results Surgery Service of the University Hospital Le Dantec in Dakar on a period of 10 years (January 2003 to January The pathologies encountered were: 2013). We included all patients treated by laparoscopy for - Hiatal hernia with gastroesophageal reflux rebel to acute or chronic UGI disease. Thus, we collected 162 cases. medical treatment in 18.5% of cases (n = 30); Epidemiological data on patients were listed in Table 1. - Achalasia in 13% of cases (n = 21); The following data were studied: nature of the - Ulcerative pyloroduodenal stenosis in 55.5% of cases (n = 90); * Corresponding author: - Perforated duodenal ulcer in 13% of cases (n = 21). [email protected] (Toure Alpha O.) Published online at http://journal.sapub.org/surgery All patients with pyloroduodenal stenosis underwent Copyright © 2015 Scientific & Academic Publishing. All Rights Reserved truncal vagotomy performed laparoscopically. Gastric

12 Toure Alpha O. et al.: Laparoscopy in Upper Gastro-Intestinal non Tumoral Pathologies: Our Experience in a Low Income Country bypass consisted of a gastro-jejunostomy through a mini patients), dysphagia well treated by endoscopic median laparotomy or pyloroplasty by a right mini-subcostal pneumatic dilatation. incision. Indications for surgery were detailed in Table 2. A death was noted in 1 case by postoperative peritonitis Table 2. Surgical Indications secondary to septic shock. The patient initially received laparoscopic suturing of a duodenal ulcer perforation. Number Pathologies Surgical procedures The mean hospital stay was 7 days with extremes ranging of cases from 3 to 10 days. Pyloro-duodenal Vagotomy + Pyloroplasty 16 stenosis Vagotomy + Gastro-jéjunostomy 74 Hiatal hernia Nissen-Rossetti Fundoplication 30 4. Discussion Achalasia Heller Myotomy 21 Our indications of laparoscopic surgery in non-tumor UGI Duodenal Suture – omental flap – peritoneal 21 diseases are dominated by progressive complications of perforation lavage duodenal ulcer such as pyloric stenosis and perforation of The average length of surgery was 84 minutes (22mn - duodenal ulcer which constitute 68.5% of our indications. 130mn): Outside the duodenal ulcer perforation or gastrointestinal bleeding associated with the use of anti-inflammatory, such • For truncal vagotomy and gastric bypass, the average complications, especially the pyloric stenosis, have become duration was 75mn with extremes of 30mn and 130 mn; rare in Western countries because of early diagnosis and • For Rossetti-Nissen fundoplication, the average is 45 access to eradication treatment of Helicobacter pylori, a minutes with extremes of 22 and 110 minutes; frequency with which stenosis is less than 8.5% [2, 3]. • For cardiomyotomy, the average length of 120mn with Contrary to the trend observed in developed countries, ulcer extremes of 75mn and 130mn; pyloric stenosis is still common in developing countries. • For the treatment of perforated ulcer, the average time is Indeed it represents 50 to 80% of all complications of ulcer 80 minutes with extremes of 50mn and 120mn. disease [4, 5]. Hiatal hernia, which represent our second Six cases of operating incidents were recorded (3.70% of indication, constitute only 13% of our series. This low rate is patients) including: explained by the fact that the surgical treatment of • 1 case of accidental injury of a left hepatic artery symptomatic hiatal hernia is conceivable only in case of of occurred during a truncal vagotomy and required a medical treatment failure [4]. Our 3rd indication of hemostatic clip; laparoscopic surgery for UGI diseases is represented by • and 5 esophagal perforations repaired by vicryl suture. achalasia (12.4%). It is rarely encountered in our context. Conversion to laparotomy was required in 12 cases (7.4%): This is explained by the very low incidence of about 1/100000 / year [6]. • Perforated duodenal ulcer: 3 conversions were Ulcerative pyloric stenosis is, in our practice, the first necessary due to the impossibility to visualize the evolution complication of ulcer. The truncal vagotomy perforated ulcer under laparoscopy; associated with gastric bypass is the intervention that we • Vagotomy: Converting midline laparotomy was master and practice the most for several years because less observed in 5 patients (3.8%). It was due to the mutilating than partial gastrectomy and more feasible that difficulty in identifying the vagus nerve in 1 case the supra-selective vagotomy [7, 8]. The limit we observe for (0.6%), with the presence of adhesions related to a fully conducted laparoscopic procedure is the cost of chlamydial peri-hepatitis in one patient (0.6%); endoscopic staplers and long duration of a possible manual • in 1 patient, the cause of the conversion was an laparoscopic gastrointestinal anastomosis. hypertrophic left hepatic lobe that prevented access to Laparoscopy can confirm the diagnosis of peritonitis and the esophageal hiatus (0.6%); clarify its cause. It must treat ulcer perforation and ensure • and in 3 other patients (1.85%) occurred perforations of adequate peritoneal toilet. Different techniques are available the esophagus that could not be sutured under to treat perforation: simple suture, suture associated with laparocopy. omental flap, suture combined with vagotomy and The delay of oral feeding varied between 1 and 4 days with pyloroplasty or application of biological glue [9]. In our an average of 2.5 days. Postoperative courses were practice, we perform a simple suture associated with omental uneventful in 152 patients (93.8%). Nine postoperative flap and peritoneal lavage. Some authors systematically complications were found: perform the surgical treatment of the ulcer. But recent • After vagotomy, there was gastroparesis due to publications question this surgery over peritonitis [2, 9, 10, non-functional pyloroplasty in 4 patients; 11, 12]. • 1 case of postoperative peritonitis was noted after Surgical treatment for symptomatic hiatal hernia is treatment of a perforated ulcer secondary to suture understandable therefore that there is a failure of medical and dehiscence; dietetic treatment, and especially to avoid lifetime medical • After fundoplication, there was, in 4 patients (13.3% of treatment. [13] The introduction of laparoscopy is relatively

International Journal of Surgical Research 2015, 4(2): 11-14 13

new in our practice. Our motivation stems from the recommendations that indicate the gastrojejunostomy when observation that the Nissen-Rossetti fundoplication formerly the pylorus is very sclerosis inflammatory or when gastric performed by laparotomy is perfectly reproducible by dilatation is greater [6, 21, 22, 23]. The morbidity of laparoscopy at the cost of lower parietal trauma [14, 15]. laparoscopic surgery in ulcer perforation varies between 6 to Persistent dysphagia occurs in 1-3% of cases in multicentric 18% in Western series. These rates are lower than those of series. Non-randomized comparative series have suggested laparotomy as regards the wound infections and respiratory that the intervention of Nissen-Rossetti (total fundoplication infections [11]. In our series, the morbidity rate is 2 cases or without division of short vessels) is significantly associated 10%. We noted no parietal complication. The main with a higher incidence of dysphagia but the only morbidity factors of surgery laparoscopic perforated randomized study evaluating the influence of the short duodenal ulcer are: advanced age (over 70 years), subjects vessels section, including a small number of patients, has not with visceral defects (ASA III and IV) initial shock of the confirmed this difference. Iterative endoscopic dilatations condition and the inexperience of the surgeon [10, 11, 12, are sometimes necessary with a failure rate ranging from 36 24]. A single case of mortality was objectified by to 50% [8]. postoperative peritonitis after a suture of peptic ulcer The laparoscopic approach is standardized in our service perforation. for the management of achalasia, however, rarely The postoperative mortality after laparoscopy is lower encountered in our practice [13]. In our study, Heller than 10% [25]. The reported mortality factors are mainly myotomy was performed 21 times. She is the most advanced age, the faults, the state of preoperative shock, the appropriate method regarding the recurrence rate of 40% for occurrence of complications and late response time (over 24 patients treated with non-surgical methods [13, 16, 17]. The hours) [11, 12]. The deaths we recorded occurred early in our mini-invasive approach has enabled a reduction in morbidity, series and was due to bad ulcer suturing. length of hospital stay and return time to normal activity, The mean time of oral feeding was 2.5 days, with extremes with improved symptoms rated as good or excellent in 94% of 1 and 4 days. This early feeding time determines the of treated patients. Rare cases of intraoperative incidents resumption of transit. It is one of the benefits of laparoscopy such as esophageal perforations may justify a conversion [15, 26, 27]. [18]. But in most cases, they manage to be sutured The overall mean hospital stay was 7 days with extremes laparoscopically. of 3 and 10 days in our study. In the Nissen-Rossetti We noted low laparoscopic conversion rate of 7.4%. In the fundoplication by laparoscopy, the average hospital stay in UGI surgery, the study of Coelho reveals that conversion rate our series is similar to Capelluto is 3.2 days [28]. It must from 8% for the first 100 patients to 2% after 492 patients is nevertheless admit that this hospital stay can be shorter when related to the sample size and the learning curve [19]. we will overcome the fear of the immediate postoperative Conversion causes are usually represented by adhesions, dysphagia which disappears spontaneously. The duration of hemorrhage, hypertrophy of the left hepatic lobe, perforation hospitalization of our patients who underwent truncal of the esophagus and technical problems related to vagotomy associated with gastric drainage was 7.3 days. laparoscopic equipment inherent to laparoscopic surgery in That can seem long compared to 5,4 to 6 days described by our conditions of exercise [19]. In the surgery of duodenal the authors [7, 9]. It is explained by the maintaining of the ulcer, major conversion factors reported in the literature are gastric tube after surgery for 5 days to reduce the risk of the technical difficulties, large ulcers (6-10 mm according to occurrence of gastroparesis. Guirat and Kafih), the occurrence of intraoperative complications, and ulcers friable banks [10, 11]. In our study we found nine cases of post-operative 5. Conclusions complications. In the Nissen-Rossetti fundoplication, Laparoscopy is feasible in our context of developing persistent dysphagia after surgery could be avoided by countries characterized by the technical sub-equipment. His carrying out a wide retroesophageal window and making a influence on the therapeutic strategy of non-tumoral UGI valve whose height would not exceed 2 to 3 cm. This diseases, in terms of reducing the surgery time, make it a explains our persistent dysphagia endoscopic dilation rate of major tool for these pathologies treatment. The short 13.3% which is different from 3% of Coelho’s Series whose post-operative disability and rapid reintegration allow a size is more important [19]. Sledzianovski et al conclude that reduction of the cost of health care. 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