Laparoscopic gastrectomy for gastric adenocarcinoma. Long-term results.

BACKGROUND: The objective of our paper is to report on the long-term results of patients with gastric cancer treated by mini-invasive surgery with "intention-to-treat" laparoscopy. PATIENTS AND METHODS: Between June 1993 and January 2006, 130 patients comprising 94 men and 36 women with gastric adenocarcinoma were prospectively selected by two surgical teams in three hospitals based on a prior agreement (CHU Charleroi, Belgium, Centre Hospitalier de Luxembourg and Zumárraga Hospital, Spain). Patients with adenocarcinoma of the cardia were excluded. Mean age of patients was 68 years (range, 37-85 years). RESULTS: Post-operative mortality within 60 days of operation was 6 patients; 109 patients were therefore properly followed up for an average of 49 months (range, 2-153 months).Average survival time for 10 non-resected patients was 4.5 months. Average survival rate for all 14 palliatively resected patients was 6.9 months. Actuarial 5-year survival rate for R0-type surgery was 35%. Global actuarial 5-year survival rate after resective surgery was 31%. CONCLUSIONS: Laparoscopic gastrectomy with any kind of lymphadenectomy is a major but safe operation with acceptable mortality and morbility rates in patients with advanced gastric cancer, usually in poor general condition. Laparoscopic gastrectomy for locally advanced cancers is equivalent to laparotomy as far as long-term oncological results are concerned.

Diagnostic and treatment of Zenker's diverticulum: review of our series pharyngo-esophageal diverticula.

BACKGROUND/AIMS: Clinical aspects and preneoplastic potential of Zenker's diverticulum justify its surgery. The clinical signs of the patients and the size of the diverticulum determine the surgical technique. METHODOLOGY: Between January 1974 and December 1995, 32 patients underwent surgery in our department. In order to compare the surgical technique, we divided the patients into 3 groups: group A (cricopharyngeus myotomy: 15 patients (46.9%)), group B (myotomy with diverticulectomy: 15 patients (46.9%)) and group C (myotomy with diverticulopexy: 2 patients (6.7%)). The chi-square test was used for statistical analysis, p < 0.05. RESULTS: Local or regional anaesthesia was used in 7 patients from group A (46.6%); 5 patients from group B (33.3%) and all the patients from group C (100%). General anaesthesia was used in 8 patients from group A (53.4%), 10 patients from group B (66.7%) and 0 patients from group C (0%). The overall mortality was 0%. The mean postoperative stay in group A was 6 +/- 2 days (3-10 days); in group B was 11.6 +/- 6.4 days (5-25 days) and in group C was 3.5 +/- 0.7 days (3-4 days). The mean postoperative stay in patients with local or regional anaesthesia was 5.3 +/- 1.6 days (3-9 days) and in patients with general anaesthesia, 10.9 +/- 6.1 days (4-25 days). No statistically significant difference was found between the anaesthetic technique and the surgical technique (p = 0.193), between the surgical technique and the mean postoperative stay (p = 0.596) and between the anaesthetic technique and the mean postoperative stay (p = 0.166). CONCLUSIONS: Cricopharyngeus myotomy is the main surgical technique, however, in diverticula longer than 3 cm of diameter it is mandatory to associate diverticulectomy. Diverticulopexy is indicated in patients of advanced age with a high surgical risk. Local or regional anaesthesia facilitates the identification of the diverticulum intraoperatively and reduce the mean postoperative stay, however, there is no statistical significant difference.

Cholecyst-thoracic fistula. A rare complication of lithiasic cholecystitis.

A 64-year-old male patient was studied for repeated right basal pneumonia of long duration. A computed tomography scan showed a cholecystitis of concealed evolution. Surgery revealed fistulization toward the thorax, with the passage of multiple calculi of a biliary origin to the chest cavity. We report the first described case to our knowledge of cholecyst-thoracic fistula secondary to cholecystitis of long evolution.

Surgical treatment of congenital dilatation of the biliary system.

Six out of 1,612 patients operated on for biliary diseases between January 1974 and January 1985, had Caroli's disease. A summary of the clinical records is included. The treatment performed was: external drainage in a patient with sepsis, who did not improve and died; left hepatic lobectomy and biliary-jejunal diversion in two patients; right extended lobectomy in one patient; distal spleno-renal shunt in a patient with severe biliary cirrhosis and recurrent hemorrhage from esophageal varices. The last patient suffered from a combination of a choledochal cyst and dilatation of the left intrahepatic branches, and underwent complete resection of the choledochal cyst, and biliary jejunal anastomosis on a porta-hepatis using a Roux-en-Y jejunal loop. Currently, five patients are recovering and are free of symptoms. The authors discuss the indications for liver resection and resection of a choledochal cyst.

Recurrent acute pancreatitis as a complication of cystic fibrosis: report of one case treated surgically.

We present the case of a young woman previously diagnosed with cystic fibrosis (CF) manifested primarily by respiratory symptoms and pancreatic exocrine insufficiency. Only 0.5% of these patients suffer from episodes of recurrent acute pancreatitis, the majority of which respond to conservative treatment. In this case, recurrent episodes of acute pancreatitis made it necessary to perform a surgical pancreatic drainage procedure.

Arterial reperfusion in human orthotopic liver transplantation by anastomosis of the celiac trunk to the right or left hepatic artery of the recipient.

Fifteen orthotopic liver transplants were performed from 23 April 1986 to June 1987 in 14 patients (age range 3-56 years). In 12 transplants, extracorporeal bypass was used. The installation was effected by suprahepatic and infrahepatic cava-caval and portaportal anastomoses. Arterial anastomosis was realized after reperfusing the graft through the vena porta. In 13 transplants the donor celiac trunk was anastomosed to the receptor's right hepatic artery. In one ten year-old girl, the donor celiac trunk was anastomosed to the left hepatic artery. In one patient who underwent retransplantation for rejection, the donor organ had two separate hepatic arteries and the right and left hepatic arteries were respectively anastomosed to the right and primitive hepatic arteries of the receptor. All patients were followed up periodically by Doppler echography and trimethyl-Br IDA 99 mTc scan, which, consistently confirmed the permeability of the anastomosis and dependent vessels, and the good perfusion and function of the grafts, which were free of infarcted areas. Three patients died at 30 and 31 days and postmortem studies demonstrated vascular permeability. Angiography was performed in one patient, evidencing a good vascular caliber in the hepatic arteriography.

[The surgical treatment of esophageal leiomyomas: a report of 9 cases and a review of the literature]. / Tratamiento quirúrgico de los leiomiomas esofágicos: aportación de nueve casos y revisión de la literatura.

We report a series of 9 leiomyomas of the esophagus treated surgically. We review the literature, emphasizing diagnostic and therapeutic aspects, calling special attention to the good results obtained by submucosal enucleation of the tumor.

Results of surgical treatment of hepatic hydatidosis: current therapeutic modifications.

Hepatic hydatidosis is an endemic disease that affects vast segments of the populations of various countries in the Mediterranean region, South America, the Pacific, and temperate zone nations that possess large numbers of sheep. Four hundred and ten patients bearing 561 hydatid cysts were treated at 2 major hospitals in Madrid, Spain in the period 1974-1989. In order to establish the modifications in diagnostic and therapeutic management introduced as a result of modernization of our clinical facilities and improved technological standards, they were divided into 2 groups: group A corresponded to the period 1974-1984, and group B, corresponded to the period 1985-1989. Since no effective parasiticide agent is available, hepatic hydatidosis must be treated surgically. Today's better knowledge and advancements in liver surgery have made it possible to extirpate the cyst completely with little risk and improved results; hepatic resection should only be considered in exceptional cases; aspiration, drainage procedures, or partial resections of the cyst yield inferior results. We have had no relapse of the hydatid disease in the liver or in any other abdominal site.

[Results of esophagus extirpation without thoracotomy]. / Ergebnisse nach Oesophagusexstirpation ohne Thoracotomie.

Between January 1978 and May 1988 229 patients have been treated because of malignant and benign conditions of the oesophagus by oesophagectomy without thoracotomy at the Surgical University Hospital "Doce de Octubre" Madrid. 132 patients suffered from oesophageal carcinoma, 68 from carcinoma of the cardia, 9 from carcinoma of the hypopharynx and 20 from different benign oesophageal diseases. Tumor staging and surgical tactics are described. The postoperative mortality was 6.9%, which could principally be put down to respiratory complications (31.2%). The 5-year survival rate of oesophageal carcinoma was 11.9%, that of cardial carcinoma 48.3%.

[Intraoperative cholangiography: its value in simple cholelithiasis]. / Colangiografía intraoperatoria: valor en la colelitiasis simple.

The present study evaluates the benefits of systematic intraoperative cholangiography (CIO) in 144 patients without preoperative suspicion of choledocholithiasis. Eleven (7.6%) of the intraoperative cholangiographies were considered abnormal by the surgeon and the presence of choledocholithiasis (3/11, 27%) was confirmed in only three cases. Pathology of the main bile duct that had been unsuspected preoperatively was found in only 2% (3/144). We conclude that routine intraoperative cholangiography of patients without preoperative suspicion of choledocholithiasis increases the cost of surgery, prolongs operative time, exposes the patient to radiation and sometimes yields false positives (5%) that lead to unnecessary exploration of the choledochus, which is accompanied by a potential increase in morbidity and a real prolongation of the postoperative hospital stay.

Results of surgery for cancer of the rectum with sphincter conservation. A randomized study on instrumental versus manual anastomosis.

We present results obtained in a group of patients included in a randomized study from 1979 to 1985 for evaluation of mechanical anastomosis after anterior resection for cancer of the rectum; 113 patients were operated on, 58 with manual and 55 with instrumental anastomosis. There was no significant difference in morbidity or mortality between the groups. The incidence of anastomotic fistulas (clinical and subclinical) was similar (12% vs. 15%), although a large number of tumors in the lower third of rectum was treated by manual anastomosis. Concerning late complications, more stenoses, although mainly asymptomatic, were detected after instrumental anastomosis (15% vs. 6%). The incidence of local recurrence within 3 years was quite similar in the 2 groups (about 15%), and usually occurred in patients who already had generalized disease.

Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1,856 cases. GEEMO (Groupe Européen Etude Maladies Oesophagéennes) Multicentric Retrospective Study.

A retrospective analysis of 1,856 patients treated by esophageal achalasia in 23 different surgical departments from seven countries is reported. The predominant symptom was dysphagia (100%), pain, vomiting and weight loss (76.1%). The most useful diagnostic methods were: barium meal (85%), manometry (100%), endoscopy (100%) and 99mTc (100%). Conservative treatment (5.45%) was useful in 5.8% only. Dilatation (16.9%) produced amelioration in 65.9%. Thoracotomy was used in 20.9% and middle line laparotomy in 79.2%. Heller esophagomyotomy was performed in 99.52% associated with anterior fundoplasty in 79.8% and postero-lateral (Mark IV) in 9.75%. Most of the patients were controlled through barium meal, esophagoscopy, esophageal manometry, pHmetry and 99mTc ingestion. Good results after Heller's myotomy with anterior fundoplication were 81.7% and poor 7.2%. Recurrence of achalasia was present in 184 patients. A new esophagomyotomy was performed on 58.6% and distal esophageal resection in 62 (35.3%). In total, 988 patients were reviewed once a year. Absence of gastroesophageal reflux was shown in 73.9% of the explored patients.