The treatment of portal hypertension by videolaparoscopy in situs inversus totalis.

A rare case of a 32-year-old male with situs inversus totalis viscerum admitted to hospital for hematemesis owing to portal hypertension of Laennec cirrhosis was treated for the first time by videolaparoscopic surgery. Situs inversus diagnosis was confirmed by thoracic radiography, electrocardiogram, echocardiogram, abdominal echography and computed tomography. Upper gastrointestinal endoscopy showed esophageal varices and large varices in the fundus of the stomach. A successful operation (azygo-portal disconnection, splenic artery ligation without splenectomy; transesophageal suturing of esophageal varices without opening the esophagus and cholecystectomy), was performed by videolaparoscopy. The uneventful postoperative evolution (4-day hospitalization) reinforces the viability of the videolaparoscopic approach and the possibility of the application of this procedure even to situs inversus totalis organorum.

Laparoscopic cholecystectomy in children and adolescents.

During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzi's Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this techniques include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.

Laparoscopic mesh repair antireflux surgery for treatment of large hiatal hernia.

SUMMARY: One of the most frequently occurring anatomic failures after laparoscopic fundoplication is migration of the wrap into the chest, with or without disruption. This so-called 'slipped' Nissen fundoplication may be the result of inadequate closure of the diaphragmatic crura or rupture of the sutures or disruption of the muscle fibers approached. From January 2000 to December 2002, a total of seven patients (four male) with a mean age of 56 years (range 22-72 years), were considered for laparoscopic antireflux procedure using DACRON mash to reinforce the crural hiatal closure. The patients were operated under general anesthesia; laparoscopy was performed by classical approach with five trocars. The mean operative time was 120 minutes (range 40-240 min). There were no deaths. The average of postoperative hospital stay was 3.5 days (range, 3-5). Patients returned to normal activities usually on postoperative day 10 (range, 7-15). The follow-up time was at least 2 years. There was only one late complication related to the use of DACRON mesh at the hiatus, due to migration of the mesh into the esophageal lumen causing disphagia. In conclusion the mesh repair antireflux surgery is a good alternative for closing the diaphragmatic defect in large hiatal hernias or to correct this problem in case of recurrence or Barrett's esophagus.

Video laparoscopy for the treatment of bleeding esophageal varices.

Bleeding from esophageal varices is the major cause of death in patients with portal hypertension. The ideal surgical procedure should effectively control bleeding, with as little impairment of liver function as possible and with low rates of encephalopathy. Based on this objective, we propose the azygoportal disconnection (APD) with splenic artery ligation, and suturing of the gastric and esophageal varies without opening the esophagus, by video laparoscopy. With the patient placed in a semigynecologic position, we use five trocars, and the intervention begins by dissection of the diaphragmatic hiatus and isolation of the esophagus. Then devascularization of the gastric fundus is accomplished. After that, dissection and ligature between clips of the splenic artery are performed. The surgery proceeds with dissection and ligation of the vessels of the lesser curvature. After orally introducing a 12-mm Fouchet probe, we suture the varices of the distal esophagus transmurally, with interrupted sutures. The procedure is accomplished with a floppy Nissen valve. Between March 1994 and May 1995, four patients were treated with this method, two men and two women with a mean age of 54 years. All of them had hepatic cirrhosis. Three patients were classified Child B and the other Child C. Surgical indication in all subjects was persistent bleeding of the esophageal varices, after failure of such clinical attempts as endoscopic sclerosis and tamponade with the Sangstaken-Blakemore balloon. The operation mean time was 177 min. Neither bleeding nor hemodynamic changes occurred during the surgery. The patients were sent to the intensive care unit (ICU) postoperatively for a mean time of 3 days, and they were discharged from the hospital between days 8 and 10. The evolution demonstrated stabilization of the hepatic function and regression of the varices from grades III and IV to grade I. No bleeding recurred. Although this study had a small number of patients, we believe that this operation made by mini-invasive technique permits a quick recovery, reducing the global morbidity of this procedure.

Experimental esophageal carcinogenesis: technical standardization and results.

The aim of this research was to determine the occurrence of epidermoid carcinoma of the esophagus induced by diethylnitrosamine (DEN) in Wistar rats. DEN was administered (250-300 g) in drinking water (10 mg/kg body weight) to four groups of rats for 72 h/week, for a duration of 90, 120, 150, or 200 days (groups T90, T120, T150, and T200). Ten animals whose drinking water did not contain DEN constituted the control group. All rats were sacrificed and their esophaguses studied macro- and microscopically. The control group did not exhibit either carcinomas or preneoplasic lesions. The T120 and T200 groups presented, respectively, 47 and 58 in situ carcinomas; 1 and 20 submucosal carcinomas (P < 0.05); 4 and 17 microinvasive carcinomas (P < 0.05); 4 and 11 advanced carcinomas (P < 0.05); and 1 and 1 cases of benign hyperplasia. Pulmonary and liver carcinomas were also found in the T200 group. The majority of advanced macroscopic lesions in the T200 group were polypoid, exophytic, and not microscopically invasive in the esophageal wall. This research confirms the effectiveness of the DEN in bringing about carcinogenesis in the Wistar rat esophagus and also shows that the lesions are dosage dependent.