Laparoscopic treatment of giant paraoesophageal hernias

Summary The authors report their experience of laparoscopic repair of large paraoesophageal hernias (POH). From February 1994 to January 1997, nine patients with a large POH containing at least 50% of the stomach have been treated laparoscopically. The surgical procedure included reduction of the herniated stomach, closure of the hiatal orifice, and construction of a circular fundoplication. There was no conversion into open surgery. One case of postoperative atelectasis was seen (morbidity: 12.5%). Postoperative X-Ray demonstrated the restoration of a normal anatomical arrangements as well as an effective anti-reflux fundoplication. Laparoscopy makes it possible to safely and efficiently repair large POHs with an acceptable morbidity. However, this type of operation requires a good training in laparoscopic surgery.     

Telescopic anastomosis in esophageal and gastric surgery

In 1991 we tried to adopt the telescopic anastomosis technique which had been used in bowel surgery made with the esophagus. In our method a 1.5-2 cm long stump of the distal esophagus is laid in the lumen end-to-side of the other organ (stomach, jejunum, large bowel). The oral the worst blood supplied part of the stomach has also removed and an end-to-end anastomosis has been made. We used this method in 125 patients until the end of 1997. In 89 cases during esophageal resections, and from it in 36 cases the anastomoses were made and-to-end, in 36 cases during total gastrectomies were made telescopic anastomosis leakage in the neck that healed after conservative treatment. We noticed advanced ischemic necrosis of the stomach used for replacement in 4 cases. Two of these patients healed after operative treatment. After gastrectomies all anastomosis healed without any complication. In 6 cases occurred anastomotic stenosis always after anastomotic leakage. 3 patients could be treated with dilatation, in 3 cases had to make reoperations due to stenosis. The authors emphasize that the method is simple, made in single lawyer, the sutures are not drained the lumen. They have not got strong opinion about the propensity for stenosis due to few cases.     

Coloplasty after esophagectomy in cancer. A retrospective study of morbidity and mortality

Aim of this study has been to evaluate retrospectively morbidity and mortality of 42 colon substitutions after resection for esophageal cancer. Colon substitution was the intervention of first choice in six patients. In the other patients the stomach was useless, because of previous gastric surgery (n = 14), of gastric involvement by the tumor (n = 21) or technical problem (n = 1). Patients have been separated in 2 groups: from 1969 to 1983 (group A, n = 22), and from 1983 to 1997 (group B, n = 20). Mortality and morbidity (all eventful postoperative course) have been collected for the 30 postoperative days. Total morbidity has been 57% as 77% in group A and 35% in group B (p < 0.05). Cervical and colo-colic leak have been the most common complications. Total mortality has been 14% as 22% in group A and 5% in group B (p < 0.1). In group A 3 patients died from anastomosis leak (intrathoracic or intraabdominal) and 2 from medical complications. In group B 1 patient died from unexplained sepsis. Our results show significative decrease of morbidity and mortality in group B. These results can be compared to those of gastroplasty for cancer or coloplasty for benign disease. In cancer of the esophagus, if stomach can not be used as substitutes, colon substitution is the best alternative, which can be used without increase of mortality and morbidity.     

Imaging of Human Skin Lesions Using Multipixel Fourier Transform Spectroscopy Fourier Transform Spectral Imaging

A novel spectral image-analysis system based on Fourier transformed spectroscopy combined with image processing has been used for the in vivo study of porphyrin localisation in human skin lesions. Fluorescence measurements were performed on patients with basal cell carcinomas (BCC) and acne. BCC lesions were examined after a 16-hour topical application of aminolaevulinic acid (ALA); for acne lesions, autofluorescence was studied. The results of fluorescence microscopy of BCC lesions revealed red fluorescence in the stratum corneum, epidermis, pilosebaceous units and in the tumour sites. The in vivo macroscopic examination showed higher protoporphyrin IX (PP) fluorescence in BCC lesions and in acne as compared to the surrounding normal tissue. An enhanced demarcation of the lesions' borders was obtained using the spectral similarity-mapping function. Paper received 21 May 1997; accepted in final form 23 July 1997.     

Indocyanine green fluorescence imaging ensures perfusion of the remnant stomach during laparoscopic splenectomy in a patient after distal gastrectomy: A case report

BackgroundAfter distal gastrectomy, ischemic necrosis of the remnant stomach is a rare but serious complication. For distal pancreatectomy or splenectomy, ensuring adequate blood supply to the remnant stomach is important for patients with a history of distal gastrectomy. We report a case of successful splenectomy with indocyanine green (ICG) used to evaluate the blood supply to the remnant stomach in a patient after distal gastrectomy.Case presentationA 65-year-old woman who underwent distal gastrectomy for gastric cancer a year earlier had a splenic tumor that was increasing in size. We planned laparoscopic splenectomy because there was a possibility of a malignant splenic tumor. Intraoperative ICG fluorescence imaging confirmed perfusion of the remnant stomach. The patient was discharged on postoperative day 8 after an uncomplicated postoperative course.ConclusionICG fluorescence imaging is useful for evaluating blood flow to the remnant stomach during laparoscopic splenectomy in patients after distal gastrectomy.     

A new technique for laparoscopic resection of a submucosal tumor on the posterior wall of the gastric fundus

Several reports have been published which describe the technique of using an Endo GIA to resect submucosal tumors on the anterior wall of the stomach. Lesions on the posterior wall, however, especially near the esophagocardiac junction (ECJ), are difficult to resect using these reported techniques. This is because the surgeon must divide the omentum and enter the omental bursa in order to use a similar extraluminal technique. Furthermore, special care must be taken to ensure that resections do not involve the ECJ and narrow the esophagus. In order to overcome these difficulties, we have proposed a new technique for the laparoscopic excision of a submucosal tumor located on the posterior wall of the gastric fundus. The principle of this procedure involves the intraluminal resection of the submucosal tumor, including the surrounding stomach wall, using the Endo GIA. This technique is safe, simple, and effective. We believe that we are the first to address the excision of a submucosal lesion by resecting the full thickness of the posterior gastric wall lesion intraluminally. Received: 11 November 1996/Accepted: 2 April 1997     

Is Preservation of the Remnant Stomach Safe During Distal Pancreatectomy in Patients Who Have Undergone Distal Gastrectomy?

Background

Whether the remnant stomach can be safely preserved when performing distal pancreatectomy (DP) in patients with a prior distal gastrectomy (DG) remains unclear because the remnant stomach and pancreatic body/tail share an arterial blood supply via the splenic artery (SPA).

Methods

A total of 18 patients with prior DG who underwent DP were enrolled in this study. Clinicopathologic data were retrospectively analyzed with a focus on management of the remnant stomach and complications related to ischemia of the remnant stomach. Additionally, intraoperative indocyanine green (ICG) fluorescence angiography was performed to visualize the blood flow and circulation in the remnant stomach.

Results

Ten patients underwent a standard DP (DP in conjunction with splenectomy and division of the SPA) with preservation of the remnant stomach. The entire stomach was preserved in seven patients, and three underwent concomitant partial resection of the remnant stomach. No patients in whom the entire remnant stomach was preserved developed postoperative complications associated with it, whereas two of the three patients who underwent partial resection of the remnant stomach developed severe ischemic complications. Intraoperative ICG fluorescence angiography revealed a caudally directed circulation of blood from the esophagogastric junction through the intramural capillary network in the remnant stomach.

Conclusions

When performing DP in patients with a prior DG, preservation of the entire remnant stomach was a safe procedure because of the presence of an intramural network that supplies blood to the remnant stomach. In contrast, partial resection of the remnant stomach could be dangerous because of the potential for severe ischemic complications.     

Laparoscopic Resectional Gastric Bypass in Patients with Morbid Obesity: Experience on 112 Consecutive Patients

Introduction  

Gastric bypass, without gastric resection of the distal excluded stomach, is the surgical treatment more frequently performed for morbid obesity. Several postoperative complications related to the “in situ” distal stomach have been described, and few cases of undetected gastric carcinoma located in this segment of stomach have been published. In this paper, we present our early postoperative results in patients submitted to laparoscopic gastric bypass with resection of distal stomach in patients with morbid obesity.     

The role of chronic gastric ulcer in carcinogenesis

Results of prolonged conservative treatment of patients with stomach ulcer are analyzed. Two groups of patients have been studied. Group 1 consisted of patients with long-term disease, incidence of stomach cancer in this group was 6.4%. Group 2 consisted of patients operated for stomach cancer and followed-up in cancer dispensary, 12.9% of them had the history of stomach ulcer. Based on anamnesis and results of morphological studies, cases of malignant transformation of chronic gastric ulcer have been revealed. It is demonstrated that prolonged conservative treatment of stomach ulcer in combination with high-grade dysplasia lead to potential risk of malignant transformation. The role of stomach mucosa contamination with herpes viruses was also studied. It is demonstrated that viral contamination is associated with immunodeficiency, maintains chronic inflammation in ulcer and promotes dysplasia progress.     

Laser-induced fluorescence diagnosis of stomach tumor

Lasers in Medical Science - The purpose of this study is to demonstrate the capabilities of laser spectral and video fluorescence diagnosis used for stomach tumors using 5-ALA photosensitizer. The...     

Phytobezoars of the stomach]

Literature data and the own authors' observations (76 cases), concerning the recognition and treatment of stomach phytobezoars following vagotomy and stomach resection are set forth in the paper. All these formations in the stomach were removed by means of the conservative procedures. Knowledge of the specificity of the phytobezoars manifestations in an operated stomach allows for better understanding and evaluation of the state of the patients who have been subjected to stomach resection of vagotomy.     

Prevention of gastric stasis by omentum patching after living donor left hepatectomy

Among 137 living liver donors who underwent partial hepatectomy between August 1997 and November 2010, 58 donated the left lobe of their liver, with or without the caudate lobe. Gastric stasis developed after surgery in 4 (7 %) of these 58 donors (Fig. 1); possibly because of dislocation of the stomach after hepatectomy and adhesion between the stomach and the cut surface of the liver. This complication is specific to left hepatectomy [1] and although not life-threatening, it is symptomatic and requires endoscopic or surgical intervention. We describe our surgical technic designed to prevent this complication. Fig. 1 Gastric stasis after living donor left hepatectomy. Fluorescent imaging study shows an enlarged stomach with no passage of radiofluorescence through the pylorus.     

Multivisceral operations for carcinoma of the upper stomach and cardia

In this study are noted technical problems regarding "en bloc" multiple organ resections and the anatomic and functional reconstruction for carcinoma of the upper stomach and cardia. From 1997 to 2002, a total of 264 patients with cancers of the stomach were operated in the service. 75 patients presented cancers localized at the proximal stomach and cardia (97.33% adenocc.). The rate of resectability was 27.77% (27 pt.). Types of operations in this series were: standard esophagogastrectomy in 7 patients; total gastrectomy with regional lymphadenectomy in 9 patients; 11 patients underwent "en bloc" multiple organ resection, with the removal of the stomach, partial or total esophagectomy and, occasionally, ablation of the spleen, pancreas, left hepatectomy, resection of the diaphragm and an extensive lymphadenectomy. Surgical mortality for the complex multivisceral resections was noted in 3 patients (8.88%). The global 5 years survival in the service is poor: 15.9%.     

Spectro-fluorescence analysis of ALA-induced protoporphyrin IX in differential diagnosis of stomach disease

The results of examination of 47 patients with confirmed diagnosis of cancer of the stomach (21 patients) or 26 suspects were analyzed. 2-4 hours after oral taking of Alasence in the dose 5-10 mg/kg, gastroscopy with spectrofluorescence analysis of ALA-induced protoporphyrin IX was performed. There were no toxic complications due to Alasence taking. The standard spectrodetector LESA-7 was used for fluorescence record registration. The fluorescence spectra were recorded in the range of 650-850 nm. The specific for protoporphyrin IX peak at 700 nm wavelength was analyzed. Fluorescent endoscopic diagnosis allowed to confirm stomach cancer in 21 patients, and to detect cancer in 7 patients, including 2 cases of cancer in situ. The contrast of protoporphyrin IX accumulation (tumor/norm ratio) ranged from 2.5 to 18, that was enough for differential diagnosis in the majority of cases. In analysis of spectrograms for correct contrast calculation it is necessary to take into account the own fluorescence, with was high in some cases.     

Gastric emptying after oesophagectomy as assessed by plasma paracetamol concentrations.

Gastric emptying after oesophagogastrectomy may be affected by opposing influences. Truncal vagotomy of the orthotopic stomach, as used by surgeons for peptic ulcer, results in delayed gastric emptying. The emptying of such a denervated stomach is affected by position and posture and may result in gastric "incontinence", particularly if associated with drainage procedures. It is possible that postural effects may outweigh the reduced motility if the vagotomised stomach is transplanted into the chest as after oesophagogastrectomy. Despite the effect that disturbed gastric emptying may have on nutrition and drug absorption there have been few studies concerning patients who have had oesophageal resection or bypass. We report our preliminary experience of an indirect method to estimate gastric emptying after oesophageal resection and bypass, using the absorption profile of paracetamol (acetaminophen). This technique is safe and has been shown to reflect gastric emptying accurately in the innervated stomach. With this technique we have shown that, even in the absence of a concomitant drainage procedure, oesophageal resection, or bypass, using the denervated stomach to restore alimentary continuity does not result in any detectable delay in gastric emptying.     

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目的 进一步评价短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合术的抗返流效果,探讨Ｒｏｕｘ淤积综合征的防治方法。方法 随访１９８９年７月至１９９７年６月完成的胃癌切除胃空肠短袢Ｒｏｕｘ－ｅｎ－ｙ吻合术１５１例,通过症状调查。消化道钡餐、罗镜并活检、Ｂ超、ＣＴ检查确定短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合术的抗返流效果及Ｒｏｕｘ淤积综合征的发病率。结果 １４３例（９５％）获随访结果,未发现有明显症状的返流性胃炎,无倾倒综合征和Ｒｏｕｘ淤积综合征。结论 扩大胃的切除范围,同时缩短Ｒｏｕｘ袢的长度可防治Ｒｏｕｘ淤积综合征,对空肠吻合口进行抗返流加工,短袢Ｒｏｕｘ－ｅｎ－Ｙ吻合抗返流效果满意。     

Poorly Differentiated Adenocarcinoma with Signet-Ring Cell Carcinoma in a Hyperplastic Polyp of the Stomach: Report of a Case

Hyperplastic polyps (HPs) of the stomach have been reported to be mostly benign. However, in rare cases, carcinomas have been found in HPs. We treated a 59-year-old Japanese male who underwent a total gastrectomy, and a gross examination of the resected stomach revealed a 4.8 × 3.8-cm polyp on the greater curvature of the antrum and multiple small polyps in the whole gastric mucosa. Histologically, the large polyp consisted mainly of hyperplastic foveolar epithelium, while the presence of variously colored lobules demonstrated a poorly differentiated adenocarcinoma mixed with signet-ring cell carcinoma. Hyperplastic polyps should therefore be carefully examined microscopically as a polypectomy specimen and in resected stomach specimens.     

Autoaugmentation demucosalized enterocystoplasty

Autoaugmentation demucosalized enterocystoplasty has been developed from the combination of the autoaugmentation technique, the use of the stomach and colon for bladder augmentation and the ability of the bowel and stomach to survive the removal of their epithelial lining. The initial combined approach used the stomach as the source of muscle, with the colon subsequently being used as an alternative. The operations have been applied in the laboratory and clinically, giving good results for bladder augmentation with both sources of enteric muscle, more reliably so and with a greater ease of separation of the mucosa when stomach muscle is used. There is hope that further research will improve the outcome of what is a technically challenging procedure.     

Laparoscopic resection of the stomach by Billroth-I technique

Laparoscopic resection of the stomach by Billroth-I technique is described. Previously different variants of laparoscopic Billroth-II resection and laparoscopy-assisted Billroth-I resection have been performed a complete variant of laparoscopic Billroth-I resection of the stomach the authors reported on Symposium of Endo-surgeons in 2004.     

GASTRIC CANCER IN THE BYPASSED SEGMENT AFTER OPERATION FOR MORBID OBESITY

A case is reported in which two separate adenocarcinomas were detected in the bypassed distal stomach 13 years after gastric stapling with loop gastro-enterostomy was performed for the treatment of morbid obesity. Retrograde endoscopy via the afferent loop was used to establish the diagnosis. Although gastritis and metaplasia have been described in the bypassed stomach, only one case of carcinoma in this area has previously been reported.