Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients.

BACKGROUND: The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication. METHODS: The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications. RESULTS: There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6). CONCLUSIONS: Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.

Acute bile duct injury. The need for a high repair.

BACKGROUND: An immediate repair is considered optimal in acute biliary duct injuries; however, it may prove to be a challenge, because such repairs are usually performed on small ducts whose viability cannot always be determined. METHODS: We performed a retrospective review of the charts of patients with acute bile duct injury who underwent repair at a tertiary care academic university hospital. A total of 204 patients with acute bile duct injury were seen between 1989 and 2002. Of these, 30 were repaired within minutes to hours after the injury. These patients were divided into two groups. Group I patients had a Roux-en-Y hepatojejunostomy below the hepatic junction; Group II patients had a Roux-en-Y hepatojejunostomy at the junction level. We then performed a long-term evaluation of anastomosis function in these patients, using clinical, radiological, and laboratory. RESULTS: Twenty-eight injuries were secondary to a laparoscopy; the other two resulted from open cholecystectomies. All of the patients suffered complex injuries with complete section of the duct and substance loss (Strasberg E). There were 12 patients in group I and 18 in group II. Three cases in group I (25%) and one in group II (5%) developed anastomosis dysfunction. Mean follow-up was 56 months (range, 12-80) in group I and 52 months (range, 10-76) in group II. Two cases in group I (16%) and none in group II (0) required reoperation (p < 0.05). CONCLUSIONS: In the acute setting, complex lesions should be treated with a high bilioenteric anastomosis (at the junction level) in the first attempt at repair. Lower-level anastomoses are associated with a higher dysfunction rate and the need for radiological manipulation and reoperation. Also, stenosis of the anastomosis secondary to undetected duct ischemia in the acute repair is more frequent in low bilioenteric anastomoses.

Small-diameter mesocaval shunts: a 10-year evaluation.

The use of small-diameter portosystemic shunts for the treatment of bleeding esophageal varices caused by portal hypertension has emerged as an outgrowth of the development of polytetrafluoroethylene vascular grafts, which allow the use of a narrow lumen. We report our experience with this type of graft over a 10-year period. Thirty-three patients with good liver function (Child-Pugh class A) were electively operated. The average age of these patients was 45 years (range 17 to 71 years). Twenty-nine patients had liver cirrhosis, one had portal fibrosis, and three had idiopathic portal hypertension. Operative mortality was 3%, and the rebleeding rate was 15%. Postoperative encephalopathy was observed in 14 patients (11%), three of whom had grade III to IV encephalopathy. The remaining 11 patients, had mild encephalopathy that was easily controlled. Postoperative angiography showed shunt patency in 81% of the patients, reduction in portal vein diameter in 33% of the patients, and portal vein thrombosis in 6%. Good postoperative quality of life was observed in 63% of the patients. Survival according to the Kaplan-Meier actuarial method was 81% at 12 months, 56% at 60 months, and 36% at 10 years. These shunts are a good alternative for patients being considered for surgery in whom other portal blood flow preserving procedures (i.e., elective shunts, devascularization with esophageal transection) are not feasible.

Is splenectomy necessary in devascularization procedures for treatment of bleeding portal hypertension?

OBJECTIVE: To investigate whether splenectomy as a part of devascularization procedures is necessary. DESIGN: Prospective, controlled, randomized trial. SETTING: University hospital, referral center. PATIENTS: A total of 55 patients (Child-Pugh class A and B) with a history of bleeding portal hypertension were treated by means of a modified Sugiura-Futagawa procedure. Twenty-three patients underwent splenectomy and 22 did not. METHODS: Postoperative outcome was recorded and comparison of the 2 groups was done with the Fisher exact test. Kaplan-Meier survival curves were constructed. Main outcome and postoperative differences between the patients who underwent splenectomy and those who did not were investigated. RESULTS: Both groups were comparable in the postoperative period. Significant differences were observed in transfusion requirements and postoperative portal vein thrombosis, both favoring the group without splenectomy. No differences in rebleeding, encephalopathy rate, operative time, or postoperative complications were observed. CONCLUSION: Splenectomy is not routinely necessary in devascularization procedures for bleeding portal hypertension.

Selective shunts for portal hypertension: current role of a 21-year experience.

The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child-Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.

Angiographic evaluation after portal blood flow preserving operations.

We carried out a prospective study comparing postoperative portal angiographic characteristics in patients with hemorrhagic portal hypertension treated electively by two different portal blood flow preserving procedures. Between 1986 and 1991, a total of 81 patients underwent operation: 38 selective shunts and 43 Sugiura-Futagawa procedures. Cirrhosis was shown by biopsy in 50 cases, 26 of them secondary to alcoholism. We found rebleeding in 5% of the patients, incapacitating postoperative encephalopathy in 8%, and an operative mortality of 7%. Fifty-two cases were evaluated in the postoperative period with angiography; 21 patients treated with a Sugiura-Futagawa operation were excluded due to portal vein thrombosis shown in the preoperative studies. Postoperative portal vein thrombosis was found in 11 cases (21%) [seven cases in the Warren group (21%) and four cases in the Sugiura-Futagawa group (20%)]. Decreased portal vein diameter was seen in eight cases (15%). The two procedures maintained hepatopedal portal blood flow, and no change was seen in relation to the preoperative state in 66% of the operated patients. We found no significant differences between the two procedures. Selection of procedure depends on the individual characteristics of each patient.

Survival and quality of life after portal blood flow preserving procedures in patients with portal hypertension and liver cirrhosis.

Between 1979 and 1991, 156 patients with histologically proven liver cirrhosis, good liver function, and bleeding portal hypertension underwent operation with portal blood flow preserving procedures (selective shunts: 101; Sugiura-Futagawa: 55). Long-term results of the procedures and the quality of life of the 145 patients who survived the operation were studied. During the observation period (range 3 to 156 months), 28 patients died. The main causes of death were liver failure and hepatoma. Twenty-three patients were lost for follow-up. Twenty-six patients (18%) developed 1 or more encephalopathic episodes. Four patients (3%) experienced rebleeding. One hundred eight patients (74%) had a good quality of life, and 26 (18%) had a poor quality of life. Eleven (15%) of 73 patients with a history of alcoholism continued drinking. Five-year survival for the selective shunt group was 81% and for the devascularization group was 83%. In 81% of the patients, portal blood flow was maintained. It is concluded that both procedures are effective in the long-term. Most patients are able to rehabilitate from the use of alcohol, and most of them have a good quality of life. For patients with good liver function (whose main problem is bleeding), surgery is the best choice of treatment.

[Surgery in portal hypertension. Which patient and which operation?]. / Cirugía en hipertensión portal. En qué paciente y cuál operación?

A prospective trial of a cohort of patients (N = 94) with portal hypertension and history of bleeding was selected for surgery based on strict clinical and laboratory criteria. All of them were treated with portal blood flow preserving procedures. The following selection criteria were used: good cardiopulmonary function without pulmonary hypertension and good liver function (Child-Pugh A). All patients were operated in an elective fashion and the operations performed were: selective shunts (N = 38) (distal splenorenal and splenocaval), low diameter mesocaval shunts (N = 13) and the esophagogastric devascularization with esophageal transection (Sugiura-Futagawa) (N = 43). Patients were selected for each operation according to their anatomical conditions. Sixty-one of the patients were cirrhotics. Operative mortality was 8% and rebleeding was observed in 5% of the cases. Postoperative encephalopathy was seen in seven patients (three selective shunts, two low diameter mesocaval shunts and two devascularizations). In 13 of 62 patients postoperatively evaluated by means of angiography, portal vein thrombosis was shown (seven selective shunts, two low diameter shunts and four devascularizations). Twenty-two patients with preoperative portal vein thrombosis (and treated with a Sugiura-Futagawa operation) were excluded from postoperative angiographic evaluation. Survival (Kaplan-Meier) was 85% at 60 months. Portal blood flow preserving procedures are the treatment of choice for patients with hemorrhagic portal hypertension and good liver function. The kind of operation is selected according to the individual anatomical status of the patient.

[Electrolyte solution with polyethylene glycol to cleanse the colon for colonoscopy or enema]. / Solución electrolítica con polietilenglicol en la limpieza colónica para colonoscopia o colon por enema.

The efficacy and safety of an electrolyte-polyethylene glycol solution (SE-PEG) for colonic lavage, was compared with standard bowel preparation (SBP) in a randomized blinded study of volunteers and patients undergoing colonoscopy and barium enema examination. Side effects, biochemical and hematologic changes and quality of examinations were monitored. Colonoscopy and barium enema was scored by colonic segment for type of residual stool and percentage of bowel wall visualized. For colonoscopy and barium enema, preparation with SE-PEG allowed better visualization and produced more optimal exams (8 vs 3; p less than 0.03) and (6 vs 4; p = NS) respectively. We conclude that colonic lavage with SE-PEG is an alternative bowel preparation method and is cheaper, more safe and effective than SBP procedure.

Role of the distal splenorenal shunt in management of variceal bleeding in Latin America.

In the early 1970s, we began to perform selective shunts on a regular basis for the treatment of portal hypertension. In a 15-year period, 177 patients (155 with liver cirrhosis) were treated with 3 kinds of selective shunts: the Warren shunt (128 patients) the end-to-end splenorenal shunt (29 patients), and the splenocaval shunt (20 patients). One hundred sixty-seven of the procedures were elective. Operative mortality was 14%, and survival for the Child's class A group was 75% at 1 year, 69% at 5 years, and 65% at 15 years. Incapacitating encephalopathy was observed in 7% of the patients, rebleeding in 6%, and shunt thrombosis in 6%. Postoperative portal vein alterations included reduced venous diameter (13%) and thrombosis (21%). Experience with the Warren shunt in schistosomiasis, a disease in which normal liver function is the rule in Latin American countries, is discussed. We believe that, when feasible, the selective shunts are the treatment of choice for portal hypertension in Latin American countries.

[Migration of a transhepatic T tube in iatrogenic lesion of the bile ducts. Report of a case]. / Migración de sonda en T transhepática en iatrogenia de vías biliares. Informe de un caso.

Benign strictures of the biliary tree present difficult problems in management. The method of transhepatic stenting constitutes an excellent and safe procedure and provides good results in this kind of surgery. It permits to fix firmly the stent, so that migration is not supposed to be possible, something frequently seen with conventional T tubes. We report on one patient with iatrogenic strictures of the biliary tree who was subjected to reconstructive surgery utilizing a transhepatic stent. On the sixth postoperative month, the patient presented migration of the stent to the Y-en-Roux intestinal loop. It was evacuated in the following hours, and the patient did not have any problem, remaining asymptomatic after that.

[Selective portal-systemic shunts for bleeding portal hypertension]. / Derivaciones portosistemicas selectivas en el manejo de la hemorragia por varices esofagogastricas.

At the beginning of the seventies, we began to perform regularly selective shunts for the treatment of portal hypertension. In a 15 year period, 177 patients (155 with liver cirrhosis) were operated with three kinds of selective shunts: 128 with a Warren shunt, 29 with an end to end renosplenic shunt and 20 with a splenocaval shunt. 167 cases were operated in an elective fashion. The 15 years global operative mortality, was 14.4%. Operative mortality of the Child A patients, was 11.6%. Survival for the Child A group was 74.6% at 1 year, 68.2% at 5 years and 64.6% at 15 years. Incapacitating encephalopathy was observed in 6.9%, rebleeding 6.2% and shunt thrombosis in 6.2%. Portal vein alterations in the postoperative period were observed: in 13.3% a reduction in diameter ocurred and in 20.5%, thrombosis was recorded. It is concluded that when feasible, the selective shunts are the treatment of choice for portal hypertension in those patients with good liver function.