Laparoscopic Heller's cardiomyotomy in achalasia

Background: Inappropriate length of the myotomy incision along the stomach, the most common technical fault during Heller's cardiomyotomy, is related to the difficulty of identifying the gastro-esophageal junction, in particular during laparoscopic surgery. The goal of this study was to evaluate the contribution of endoscopy to gastro-esophageal junction identification during laparoscopic Heller's cardiomyotomy. Methods: In a group of 19 patients with intraoperative endoscopy with laparoscopic Heller's cardiomyotomy, surgical and endoscopic criteria for gastro-esophageal junction identification have been assessed. Then postoperative results of this group were compared with those of another group of 16 patients previously operated on without intraoperative endoscopy. Results: Endoscopic and laparoscopic criteria for gastro-esophageal junction identification were discordant in 11 patients (11/19, 58%). The cardia was in all these cases at a more distal site with endoscopic criteria. Complications ascribable to suboptimal technique were more frequent in the group without intraoperative endoscopy (7/16 patients) than in the other group (2/19 patients). Conclusions: Endoscopy during laparoscopic Heller's cardiomyotomy is of great assistance in identifying the cardia, and thereby could improve surgical outcomes. Received: 20 October 1998/Accepted: 20 January 1999     

Laparoscopic vs. Open Resection of Noninvasive Intraductal Pancreatic Mucinous Neoplasms

Required resection margins for noninvasive intraductal papillary mucinous neoplasms (IPMNs) are a controversial issue. Over a 10-year period we have resected IPMNs from the entire pancreatic gland with minimally invasive techniques and compared our survival and complication rates with open controls to see if any difference in resection margins and outcomes could be observed. Data were collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan–Meier curves were calculated and statistical analysis was performed using the log rank and Student’s T test for continuous variables. Chi square and Fisher’s exact tests were used for analyzing categorical variables. From March 1997 to Febuary 2006, we operated on 22 patients with noninvasive IPMNs, of which 9 (41%) were operated on laparoscopically and 13 (59%) using open techniques. Three patients underwent laparoscopic duodenopancreatectomy, compared to five in the open group. All resection margins were negative, but two patients required total pancreatectomy, both of which were performed laparoscopically. One of these was converted to open (11%) because of difficulty in reconstructing the biliary anastomosis. The overall complication rates were 56% for the laparoscopic group and 85% for the open group. Twenty-two percent of the laparoscopic group required reoperation and 11% required percutaneous drainage, compared to 15 and 23% in the open group, respectively. All patients are alive after a mean of 20 months (range = 2–43) in the laparoscopic group and 37 months (range = 1–121) in the open one (p > 0.05). Laparoscopic resection of noninvasive IPMNs of the entire pancreatic gland has similar complication and survival rates as open procedures. As a result, the laparoscopic approach is appropriate for noninvasive IPMNs of the entire pancreatic gland; however, larger cohorts are needed to see if any approach has superior outcomes. Because of these favorable results, studies are currently underway to see if the minimally invasive approach is also appropriate for invasive IPMNs.     

Combined ascending aorta rupture and left main bronchus disruption from blunt chest trauma

After blunt chest trauma, early diagnosis of associated bronchial, vascular, and esophageal injuries must be attempted, as those lesions may be produced by the same mechanism. We report a case of successful management of associated bronchial transection and injury of the ascending aorta. Aortic repair required cardiopulmonary bypass and the use of prosthetic materials, although gross contamination of the mediastinum from the bronchial disruption is a theoretical contraindication to such a procedure. A separate approach to the vascular and airway injuries allowed successful management of both lesions.     

Association of cutaneous myxoma, recurrent cardiac myxoma and Cushing's syndrome (Carney's complex). Description of a case and review of the literature

The authors report the case of a rare clinical syndrome which has recently been called Carney's complex or "myxomas, spotty pigmentation and endocrine overactivity". Three components of this complex are described: cutaneous myxomas, Cushing's syndrome of unpredictable evolution treated by bilateral adrenalectomy for multiple adrenal adenoma and left atrial myxoma which recurred twice. The authors review the literature and discuss the practical implications of this new syndrome which may be familial. The role of echocardiography, the key investigation for the detection of the myxoma and follow-up of these patients who have a high risk of recurrence, is underlined.