Prognostic significance of intraperitoneal free cancer cells obtained by laparoscopic peritoneal lavage in patients with gastric cancer.

Laparoscopy is a safe and useful method for examining the local extent and regional spread of disease in patients with gastric cancer. Peritoneal dissemination remains a frequent type of recurrence after surgical treatment. The aim of this study was to determine the prognostic value of intraperitoneal free cancer cells (IFCCs) detected by laparoscopic peritoneal lavage. Forty-nine patients with advanced gastric cancer underwent laparoscopy with cytologic examination for staging. Peritoneal lavage was performed when ascites was not present. Aspirated fluid from the peritoneal cavity was centrifuged and subjected to cytologic examination using Giemsa and Papanicolaou staining methods. Patients were surgically treated and followed for a minimum of 5 years. IFCCs were detected in 41% of the patients. In eight cases (16.3%) laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Patterns of recurrence after curative resection included the following: peritoneal (n = 3), local (n = 4), liver (n = 1), and other (n = 1). All patients who tested positive for IFCCs had peritoneal recurrence. The absence of IFCCs was associated with improved overall survival (21 months for a 95% confidence interval of 7.4 to 34.6 vs. 4 months for a 95% confidence interval of 2.4 to 5.6). Overall survival adjusted for type of resection also demonstrated a favorable outcome for patients who were negative for IFCCs. The following conclusions were drawn: (1) laparoscopic peritoneal lavage cytology may be useful in identifying patients at high risk for peritoneal relapses and may alter treatment, and (2) lFCCs provide additional prognostic information in patients with gastric cancer.

Preoperative assessment in cases of adult megacolon suffering from moderate malnutrition.

Acquired megacolon is a chronic disease associated with constipation and malnutrition. Surgical treatment may be required for the alleviation of the intestinal symptoms, emphasizing the interest of nutritional assessment in this population. In a prospective study of 33 patients suffering from acquired megacolon and requiring either anterior resection or pull-through operation, standard anthropometric and biochemical measurements as well as the PNI of Buzby and Mullen were preoperatively assessed. Mean age of the population was 49 +/- 13 y, with 17 males and 16 females. The combined nutritional score indicated 63.6% of the population were malnourished (21/33) of the patients, whereas the Prognostic nutritional index (PNI) revealed 3 high-risk cases (9.1%), 9 with moderate risk (27.3%), and reduced risk for all others. Indeed, 39.4% (13/33) of the patients displayed surgical or septic problems. Chi-square analysis confirmed that both studied criteria were significantly associated with complications (p < 0.05), as morbidity was restricted predominantly to cases with unfavorable Prognostic nutritional index (PNI) results or clear signs of nutritional deficit. Both PNI and conventinoal nutritional assessment are valuable tools for the screening of these surgical candidates. Artificial alimentation was not used in this experience, but deserves consideration in selected patients. Nutritional status improved in the late postoperative period, with normalization of bowel function.

Effect of total parenteral nutrition with different lipid emulsions of human monocyte and neutrophil functions.

Parenteral nutrition (TPN) with lipid emulsions is claimed to be associated with impaired monocyte (M) and neutrophil (N) functions. Long-chain triglycerides (LCT) and a mixture containing 50% medium-chain triglycerides (MCT) and 50% LCT, currently used in nutritional therapy with TPN, were evaluated for their ex vivo effects on human N and M chemotaxis, phagocytosis, bacterial killing, and oxidative metabolism by nitroblue tetrazolium reduction test. Cell functions were examined in a randomized, crossover, blind trial in 10 malnourished patients with gastric cancer. Prior to the operation (2 wk), central TPN (40 kcal/kg) with 25% of caloric energy provided as LCT or MCT/LCT emulsion was infused over 48 h. After the crossover period fat-free TPN was given over 48 h. Function tests were done for N and M before and after each lipid emulsion infusion. Every cell function test performed for each patient was controlled by another test done in healthy adult volunteers and the results were compared with the normal range of values previously established for a healthy adult population. All the patients completed the studies without complications. Crossover validity was statistically established. Bacterial killing was the only function reduced in neutrophils after LCT emulsion (% killed bacteria = 79.0 +/- 8.5 versus 67.4 +/- 19.2; P < 0.05), although this function remained within the normal range values in 80% of the patients. In conclusion, the lipid emulsions did not affect any monocyte functions and only moderately decreased neutrophil bacterial killing.

Phase II trial of etoposide (V), adriamycin (A), and cisplatinum (P) in patients with metastatic gastric cancer.

The efficacy and toxicity of a combination of etoposide (100 mg/m2 i.v. on days 1 to 3), Adriamycin (20 mg/m2 i.v. on days 1 and 8) and cisplatinum (40 mg/m2 i.v. on days 2 and 8) repeated every 4 weeks as an outpatient regimen were assessed in 29 consecutive patients with metastatic gastric cancer with measurable disease. Five of these patients were refractory to 5-Fluorouracil, Adriamycin, and Mitomycin C. Three of these previously treated patients responded to the etoposide. Adriamycin, cisplatinum (VAP) therapy. An overall objective response rate of 72.5% was achieved, including 14% that were complete responses. The median duration of response was 6.0 months; median overall survival was 7.2 months, overall one-year survival was 34.4%. Hematologic toxicity was intense, particularly among patients with lower performance status. Three patients died as a consequence of nadir sepsis episodes.

Reduction of pancreatic enzyme content and mortality in experimental acute pancreatitis in rats.

A previous report has shown that undernutrition reduces the mortality of acute experimental pancreatitis probably by decreasing pancreatic enzyme content. Cerulein in physiological doses reduces the enzyme content of the pancreas without any harmful effect on the organ. The aim of the present study was to asses the effect of acute reduction of pancreatic enzyme content on the outcome of acute pancreatitis. Two groups of male Wistar rats weighing 230-250 g were studied: group I, 12-h fasted animals, and group II, ad libitum-fed animals who received cerulein at the inframaximal dose (0.2 microgram kg-1 h-1) for 2 h. Cerulein administration resulted in the reduction of the pancreatic contents of chymotrypsinogen (71%), trypsinogen (55%), proelastase (60%), amylase (62%) and cathepsin B (45%) (P < 0.05). However, no significant reduction in pancreatic phospholipase content was observed. Acute pancreatitis was induced in group I after 12-h fasting and in group II at the end of cerulein infusion by retrograde injection o 0.5 ml of 2.5% Na+ taurocholate into the pancreatic duct. Ascites volume and the degree of histologically observed lesions were similar in both groups, but 72-h mortality was 56% in the control group (10/ 18) and 23% (5/22) in the cerulein group (P < 0.05). We speculate that the reduction of pancreatic enzyme content may exert its beneficial effect in acute pancreatitis by decreasing the quantity of pancreatic enzymes reaching the circulation and consequently their pathogenic effects.

Mononuclear phagocytic system in acute pancreatitis.

1. Functional alterations of the mononuclear phagocytic system (MPS) may be an important factor in the pathogenesis of infection in acute pancreatitis (AP). In the present study, MPS activity was investigated in rats and hepatic blood flow (HBF) was also determined. 2. A total of 122 male Wistar rats were divided into three groups: 1, AP group (N = 51); 2, sham-operated (SO) (N = 49); 3, intact group (IG) (N = 22). AP was induced by retrograde injection of 0.5 ml of 2.5% sodium taurocholate saline into the main biliopancreatic duct under ketamine chloride anesthesia. SO animals were submitted to the same surgical steps as AP animals except for AP induction. 3. Each experimental group was subdivided into two subgroups. The first subgroup was submitted to the study of MPS activity as follows: each group was injected with colloidal 198Au and liver clearance parameters were determined 2 h (N = 11), 12 h (N = 10) and 24 h (N = 10) later in the AP group, and 2 h (N = 9), 12 h (N = 10) and 24 h (N = 11) later in the SO group. In the second subgroup, HBF was assessed using 131I-bromosulphalein at 2 h (N = 10) and 24 h (N = 10) in the AP group and at 2 h (N = 10) and 24 h (N = 10) in the SO group. The IG was submitted to both radioactive tracer studies. Each animal was used for only one experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic damage during acute pancreatitis in the rat.

We studied the alterations in the metabolism of liver mitochondria in rats with acute pancreatitis. Male Wistar rats were allocated to a control group (group I) and to five other groups corresponding to 2, 4, 12, 24 and 48 h after the induction of acute pancreatitis by the injection of 5% sodium taurocholate into the pancreatic duct. Sham-operated animals were submitted to the same surgical steps except for the induction of acute pancreatitis. Mitochondrial oxidation and phosphorylation were measured polarographically by determining oxygen consumption without ADP (basal respiration, state 4) and in the presence of ADP (activated respiration, state 3). Serum amylase, transaminases (ALT and AST) and protein were also determined. Ascitic fluid, contents of amylase, trypsin and total protein were also determined and arterial blood pressure was measured in all groups. In ascitic fluid, trypsin and amylase increased reaching a maximum at 2 and 4 h, respectively. Serum amylase increased at 2 h reaching a maximum at 4 h. Serum transaminase levels increased at 12 and 24 h. After 2 h (and also 4 h) there was an increase in state 4 respiration (45.65 +/- 1.79 vs 28.96 +/- 1.50) and a decrease in respiration control rate (3.53 +/- 0.09 vs 4.45 +/- 0.08) and in the ADP/O ratio (1.77 +/- 0.02 vs 1.91 +/- 0.01) compared to controls (P < 0.05). These results indicate a disruption of mitochondrial function, which recovered after 12 h. In the 48-h groups there was mitochondrial damage similar to that occurring in ischemic lesion. Beat-to-beat analysis (30 min) showed that arterial blood pressure remained normal up to 24 h (111 +/- 3 mmHg) while a significant decrease occurred in the 48-h group (91 +/- 4 mmHg). These data suggest biphasic damage in mitochondrial function in acute pancreatitis: an initial uncoupled phase, possibly secondary to enzyme activity, followed by a temporary recovery and then a late and final dysfunction, associated with arterial hypotension, possibly related to ischemic damage.

Modifications of tissue blood flow in acute pancreatitis.

1. Acute pancreatitis (AP) was induced by ductal injection of 2.5% sodium taurocholate saline solution. Plasma and red blood cell (RBC) volume and visceral organ blood flow were evaluated by a radioisotopic method (51Cr tracers) in 45 adult male Wistar rats (22 submitted to AP and 23 controls) 4 h after AP induction. 51Cr-albumin was used to measure plasma volume and 51Cr-RBC was used to measure RBC volume. 2. Changes in tissue hematocrit reflect alterations in tissue blood flow, since reduction in blood flow increases microvascular erythrocyte sequestration. To evaluate the tissue blood flow, we introduce a "tissue hematocrit index" calculated by relating 51Cr-RBC and 51Cr-albumin specific activities measured in visceral organ biopsies. Application of this index to the control and AP groups showed a decrease in blood flow in all visceral organs of the AP group which was reflected by an increase in tissue hematocrit index (2.5-fold for kidneys, 2-fold for pancreas and lungs, 1.6-fold for liver, and 1.2-fold for spleen). 3. As expected, there was an increase in blood hematocrit and a decrease in plasma volume in the AP group, but there were no significant alterations in RBC volume. However, an unequal decrease in blood flow in various tissues such as kidneys, lungs, pancreas and liver was detected in the AP group. 4. This approach provides an easy and simple way to evaluate possible therapeutic protocols for the treatment of acute pancreatitis by measuring effects on visceral blood flow and plasma and blood volumes.

Resection for achalasia of the esophagus.

One hundred and twenty-two patients with advanced mega-esophagus managed by esophagectomy without thoracotomy and cervical gastroplasty were evaluated. Sixty-nine patients were followed up for periods of 6 months to 16 years. Clinical assessment included X-ray studies and endoscopy of the cervical esophagus and mobilized stomach. The most common postoperative complications were pleural effusion (22.1%) and cervical fistula (8.2%). Mortality was 4.18%. Regurgitation was the most frequent complaint in the late follow-up, followed by heartburn. Both symptoms were related to esophagitis and diffuse gastritis. Diarrhea and dumping also occurred due to vagotomy and pyloromyotomy performed at the same time as esophagectomy. The endoscopic study demonstrated esophagitis in 25.5% of the patients, and diffuse erosive gastritis in 12.7%. The symptoms and late complications were handled by clinical measures and careful endoscopic follow-up. Gastroplasty was considered a good procedure for replacing the esophagus, solving the serious problem of dysphagia and for providing nutritional improvement for the patient.

Resection of a fibrolamellar carcinoma of the liver originating in the caudate lobe.

Liver tumors rarely arise in the caudate lobe and resection of such tumors is even more rare. Spigel's lobe resection, first described by Ton Thac Tung, is a very unusual operation and the technique has not been clearly established. Recently, successful resections of the caudate lobe of the liver have been reported. Since Edmonson's first report in 1956, fibrolamellar carcinoma of the liver (FLC) has been recognized as a distinct variant of hepatocellular carcinoma. It occurs, without sexual preference, primarily in adolescents and young adults. Usually, FLC is found in noncirrhotic livers and rarely associated with hepatitis B virus. This tumor presents a high resectability rate (48-100%) with a good prognosis and a mean survival of 68 months. We report a case of fibrolamellar carcinoma arising in the caudate lobe of the liver. Resection of the caudate lobe of the liver was carried out with no morbidity.

Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker's diverticulum.

BACKGROUND/AIM: Zenker's diverticulum treatment was done by endoscopic management of the elderly and debilitated patients without general anesthesia. MATERIALS/METHODS: With this technique, the septum between the diverticulum and the esophageal lumen is sectioned with a diathermic knife. Since the upper esophageal sphincter (UES) is certainly included in the mass sectioned, this accounts for the success of the procedure. RESULTS: Manometric assessment of the UES was done in 5 patients before the endoscopic treatment. The mean pressure was 54.6 cm H2O and the mean length of 3 cm. A significant (p < 0.05) reduction in maximum pressure occurred postoperatively--mean 26.8 cm H2O. There was no significant variation in length of the UES. CONCLUSION: The maintenance of this basal pressure may be explained by the preservation of the circular muscle structure of the region, with sphincter-like characteristics.

Achalasia: a prospective study comparing the results of dilatation and myotomy.

BACKGROUND/AIMS: In a prospective and randomized clinical study, the operative method and dilatation in the initial stage of megaesophagus were evaluated. METHODOLOGY: Forty patients in the initial stage of megaesophagus, managed by forced hydrostatic dilatation of the cardia (20 patients-DILAT Group) or by esophagocardiomyotomy associated with esophagofundopexy (20 patients-Group OP) were followed-up for three years, in terms of clinical, radiographic, endoscopic, manometric and pH monitoring. RESULTS: 1) Both procedures can be performed without significant morbidity or mortality. 2) The two procedures are similar regarding ongoing suppression of dysphagia. 3) Radiologically, the methods are equivalent, since they promote significant elimination of contrast stasis and maintenance of the esophageal diameter. 4) Endoscopic follow-up did not differentiate the procedures in terms of the development of reflux esophagitis, with a rate of only 5% for each group of patients. 5) Manometry demonstrated that surgery produced a significantly greater reduction of the LESP as compared to dilatation, although the latter also determined a marked drop in the maximum basal pressure of the LES. 6) Neither procedure altered the length of the LES. 7) With prolonged esophageal pH monitoring, dilatation demonstrated a greater propensity for reflux as compared to surgery. CONCLUSION: Both methods offer benefits in the treatment of the initial stage of megaesophagus, although esophageal pH monitoring indicates that dilatation provokes a greater index of esophageal acid exposition time.

Lugol dye endoscopy for analysis of esophageal mucosa in achalasia.

BACKGROUND/AIMS: Esophageal cancer in achalasia is often diagnosed in the advanced stage, which makes for a poor prognosis. Therefore, the aim of this report is to analyze the macroscopic features of the esophageal mucosa, employing lugol's solution in order to improve the early detection of carcinoma. METHODOLOGY: From April 1994 to January 1996, the macroscopic features of esophageal mucosa were studied in 64 patients with chagasic or idiopathic achalasia. Conventional endoscopy was employed using lugol's solution for staining. RESULTS: Macroscopically, the mucosa was classed as normal (22 cases), with opacification (22 cases) or with opacification and surface irregularities (20 cases). Conventional endoscopic examination failed to identify any neoplastic lesion in this series. However, upon staining, unstained or poorly stained areas were observed in 11 patients, and in one of these, at the opacified mucosa with irregularities, the poorly stained area was diagnosed as intraepithelial neoplasia. CONCLUSIONS: Slight macroscopic changes that are characteristic of intramucous carcinoma may not be noticeable in the altered mucosa of achalasia found in about two-thirds of patients. By using lugol, the outline of unstained or poorly stained areas permits directed biopsies. This procedure was important in the detection of histological changes, especially the early diagnosis of esophageal carcinoma, which could not be diagnosed by conventional endoscopic examination.

Surgical treatment of pancreatic ascites and pancreatic pleural effusions.

BACKGROUND/AIMS: Massive ascites and pleural effusions are uncommon but well-documented complications of chronic pancreatitis. The present study reviews the results of surgical management of pancreatic ascites and pleural effusions of pancreatic origin. PATIENTS AND MATERIALS: From forty-nine patients with chronic pancreatitis presenting with ascites and/or pleural effusion of pancreatic origin, 31 were surgically treated. RESULTS: Nineteen had ascites only, ten pleural effusions and two presented with both conditions. Diagnosis of the internal pancreatic fistula was based on the findings of high amylase levels and elevated albumin content of the peritoneal and pleural exudates. Failure of medical therapy was the indication of surgical treatment in all patients. Thirteen were submitted to internal pancreatic drainage, 17 to external drainage and one to distal pancreatic resection. Eight of 17 externally drained patients were reoperated for intraperitoneal abscesses (2), infected pseudocyst (1), pain recurrence (3) and pancreatic fistula (2); whereas reoperation occurred in only one of the 13 patients submitted to internal drainage (p < 0.05). CONCLUSIONS: Internal pancreatic drainage was the ideal surgical treatment for patients with pancreatic ascites and/or pleural effusion that did not respond to medical treatment. When this was not feasible external drainage was successfully used as an alternative to pancreatic resection.

Site of peptic ulcer. comparison of hydrochloric acid output, pepsinogen and gastrin serum levels.

BACKGROUND/AIMS: Basal (BAO) and maximum (PAO) hydrochloric acid output after Histalog stimulation, basal pepsinogen (SPL-B), at 60 (SPL-60) and at 90 minutes (SPL-90), and basal gastrin (BG) levels were measured and compared in different gastric (GU) and duodenal (DU) ulcer sites. MATERIAL AND METHODS: Fifty nine patients with peptic ulcer were grouped according to Johnson's classification for gastric ulcers: type I (15), type II (16) type III (12) GU and (16) DU. Fifteen normal subjects were studied as controls. RESULTS: The BAO was greater in the DU than in the control or GU groups. No significant difference was noted in the production of hydrochloric acid after stimulation with Histalog. The SPL-B, at 60 and at 90 minutes was higher in type II GU than in the DU group and controls. The SPL-60 was higher in type II GU patients than in type III GU. Basal gastrin was higher in group DU and types II and III GU compared to the type I GU patients and controls. CONCLUSION: The topographic criteria for differentiating peptic ulcers has low discrimination capacity based on comparison of mean values of HCl acid production, pepsinogen and gastrin serum levels both basal and after stimulation with Histalog due to heterogeneity of these variables in group studies. In these studies, peptic ulcers from different sites should not be grouped as distinct entities except for type II gastric ulcers.

Acid secretory response in the late follow-up of proximal gastric vagotomy for duodenal ulcer without Helicobacter pylori eradication.

BACKGROUND/AIMS: The profile of acid secretory responses was studied in 20 patients who had had proximal gastric vagotomy (PGV) surgery performed 11-22 years previously in order to treat duodenal ulcers (DU). The presence of Helicobacter pylori was detected in all of the patients. METHODOLOGY: The recurrence of DU was diagnosed in 10 patients and the other 10 remained without recurrence during the follow-up period. The control groups included 10 DU patients with refractory responses to H2 receptor antagonists and 10 "normal" subjects. Both control groups had untreated Helicobacter pylori infection. Measures of 1) basal acid output, 2) acid output for 30 min under continuous i.v. infusion of 0.2 ug/kg/h of pentagastrin acid, and 3) the response for 30 and 60 min after starting a sham feeding, modified by the "chew and spit" technique under simultaneous i.v. infusion of 0.2 ug/kg/h of pentagastrin were performed. Serum gastrin was measured during fasting and at sham feeding. The densities of the gastrin cells of antrum and duodenum were estimated by morphometric counting. RESULTS: Both basal output and acid response to sham feeding plus pentagastrin infusion were higher in the DU controls and DU recurrence patients. The response to pentagastrin infusion did not show any discriminant value. Fasting serum gastrin values increased after PGV, either with or without DU recurrence. Gastrin cell hyperplasia was not demonstrated in any of these groups. CONCLUSIONS: The secretory profile of patients with both late DU recurrence after PGV and Helicobacter pylori infection lies between DU patients refractory to the H2 receptor antagonist approach and those free of DU recurrence after PGV--both of them with current Helicobacter pylori infection. The characteristic pattern of late DU recurrence after PGV and untreated Helicobacter infection is that of increased basal acid output and higher acid secretion responsiveness to sham feeding plus pentagastrin in the presence of higher serum levels of gastrin.

Surgical treatment of cicatricial biliary strictures.

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience.

BACKGROUND/AIMS: The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied. METHODOLOGY: Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied. RESULTS: Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%). CONCLUSIONS: Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

Laparoscopic treatment of traumatic diaphragmatic hernia.

Traumatic diaphragmatic hernia is rare, but is of utmost importance due to its high morbidity and mortality. It is markedly important in patients with blunt abdominal trauma, and diagnosis is difficult because of the numerous associated injuries. A patient with few symptoms of chronic traumatic diaphragmatic hernia is described, who underwent surgery due to a gastric volvulus. Laparoscopic surgery permits repair of these injuries through an abdominal approach, avoiding a thoracic incision or selective intubation.

Endoscopic treatment of benign postanastomotic annular stricture of the cervical esophagus.

Although most patients presenting with a fibrotic stricture at an esophagocolic or esophagogastric anastomosis respond well to the classical dilation therapy, a number of them do not and are therefore considered to have a condition refractory to the classical method. In these cases, we performed fiberesophagoscopic section and segmentation of the stenosing ring itself, which did not exceed one cm in length, using appropriate equipment such as an electric endoscopic scalpel. Widening of the strictured segment was completed with successive dilations using a Maloney type bougie. Dysphagia disappeared after the endoscopic procedure in 21 (84%) of the 25 patients with stricture of the cervical anastomosis, after esophagocoloplasty or esophagogastroplasty, without any serious complications.