Achalasia-like disorder after laparoscopic adjustable gastric banding: a reversible side effect?

Literature data concerning the effect of laparoscopic adjustable gastric banding (LAGB) on esophageal motility are conflicting. Achalasia-like disorder involving the absence of esophageal peristalsis and impaired esophago-gastric junction (EGJ) is probably under-estimated and can result in failure and band removal. The aim of our study was to focus on cases of achalasia-like disorder and study its evolution after band deflating or removal. LAGB patients with food intolerance and whose esophageal manometry confirmed dysmotility were selected from our database. Achalasia-like disorder was defined as the absence of esophageal peristalsis (< 20% contraction waves) with impairment of EGJ relaxation. Manometric control was performed after removal or band deflating; functional results were assessed. Eleven patients among 20 (55%) with esophageal motility disorders (EMD) fitted the manometric criteria of achalasia-like disorder with a mean EGJ resting pressure of 32.1 cmH(2)O and a EGJ relaxation pressure of 24.2. Nine patients out of 11 underwent band removal which resulted in the resolution of their symptoms. The other two underwent band deflation. Manometric control after band removal showed both a decrease in resting and relaxation EGJ pressures (mean of 9.5 and 6.5 cmH(2)O) and a recovery of wave contractions in 87.5% of cases. Four patients underwent revision surgery due to weight regain with a successful outcome. Achalasia-like disorder is a manometric diagnosis and accounts for a significant part of symptomatic EMD after LAGB. It often results in band removal, allowing some reversibility of the disorders.

Post-operative pressure lability and cardiac baroreflex in normotensive patients as a function of age.

BACKGROUND: Pressure lability may be linked to the loss of the cardiac baroreflex. The reduction of the sensitivity of the cardiac baroreflex has not been delineated in the post-operative period according to age in normotensive patients. This study addresses pressure lability and slope of the cardiac baroreflex as a function of age. METHODS: Patients were allocated to the following three groups: young (20-39 years, n=7), middle aged (40-59 years, n=7) and elderly (60-79 years, n=6), and studied before minor intra-abdominal surgery under CO(2) peritoneal insufflation and nitrous oxide-isoflurane-sufentanil anesthesia, up to 24 h after extubation. An electrocardiogram and non-invasive beat-by-beat pressure monitoring (Finapres) allowed offline calculation of the sensitivity of the cardiac baroreflex ('sequence' technique) and standard deviation (SD) of heart rate (HR; HR variability) and systolic blood pressure (SBP; pressure lability). RESULTS: Before anesthesia, (a) an inverse relationship was observed between the slope of the cardiac baroreflex and age and (b) a trend (P<0.09) existed between the slope of the cardiac baroreflex and pressure lability, irrespective of age. During the early post-operative period, young patients returned to their baseline slope of the cardiac baroreflex; no inverse relationship between increased SD of SBP and decreased SD of RR interval was observed. Middle-aged and elderly patients displayed a depressed slope of the cardiac baroreflex both before and after anesthesia. CONCLUSION: At variance with the pre-operative period, no simple inverse relationship was observed between increased pressure lability and depressed HR variability in young patients during the early post-operative period.

Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases.

BACKGROUND: Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure. METHODS: A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis. RESULTS: There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER. CONCLUSIONS: Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.

Characterization of reflux events after fundoplication using combined impedance-pH recording.

BACKGROUND: Laparoscopic fundoplication effectively controls symptoms of gastro-oesophageal reflux disease (GORD) and decreases acid reflux, but its impact on non-acid reflux is not known. The aim of the study was to characterize reflux events after fundoplication using oesophageal combined multichannel intraluminal impedance (MII)-pH monitoring, to demonstrate its efficacy on acid as well as non-acid reflux events. METHODS: Thirty-six patients in whom ambulatory MII-pH recording was performed after laparoscopic fundoplication were reviewed retrospectively. There were 23 symptomatic and 13 asymptomatic patients, whose results were compared with those of 72 healthy volunteers. RESULTS: Oesophageal acid exposure was low in all but one operated patient, and there was no difference between those with and without symptoms. The median number of reflux events over 24 h was lower after fundoplication (11 in operated patients compared with 44 in healthy volunteers; P < 0.001). Almost all reflux events were non-acid after surgery whereas acid reflux episodes were predominant in healthy volunteers. Proximal reflux events were less common in operated patients. Non-acid reflux events were significantly associated with symptoms after surgery in some patients. CONCLUSION: Fundoplication restores a competent barrier for all types of reflux. Reflux events are mostly non-acid after surgery, and such events may be positively correlated with symptoms.

[Laparoscopic pancreatic resections]. / Résections pancréatiques par laparoscopie.

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

[Hepatobiliary cystic tumors. Clinical, radiological and histopathological study of 7 cases]. / Cystadénomes et cystadénocarcinomes hépatobiliaires.

OBJECTIVES: Hepatobiliary cystic tumors are rare, but must be correctly diagnosed because of their potential malignancy. We report the clinical, radiological, pathological and evolutive characteristics of 7 cases of hepatobiliary cystic tumors. MATERIAL AND METHODS: Complete clinical charts were available. Radiological and pathological documents were reviewed. RESULTS: There were 4 females and 3 males (median age, 58.7 yrs). In 3 cases, the presenting symptom was the palpation of a mass in the right upper abdominal quadrant. In 6 cases, pre-operative imaging studies showed a cystic intra-hepatic mass, containing vegetations and/or septa in 5 cases. In the remaining case, the radiological appearance showed a heterogeneous liver mass. Two patients were treated by pericystectomy and 5 by radical hepatectomy. At macroscopic examination, tumors were usually large (range: 2-24 cm) and multilocular. Histological diagnosis was: cystadenoma with mesenchymous stroma (2 cases), mucinous cystadenoma (2 cases), mucinous cystadenocarcinoma (2 cases), giant cell cystadenocarcinoma (1 case). The mean duration of follow up was 60 months. Two patients, both with cystadenocarcinomas, died after respectively, 21 and 34 months with metastatic dissemination. Five patients are alive without evidence of disease after a delay ranging from 14 to 144 months. CONCLUSION: Radical surgical treatment of cystic hepatobiliary tumors is necessary to obtain histopathological examination of the complete specimen, which is essential for a correct evaluation of the malignant potential of the lesion, and for prolonged survival, even in cases of locally invasive tumors.

Cystic endocrine tumors of the pancreas: clinical, radiologic, and histopathologic features in 13 cases.

Cystic endocrine tumors of the pancreas are rare and raise difficult clinical problems. Our aims were to reevaluate the diagnostic and therapeutic strategy and to assess their histopathologic characteristics. Thirteen cystic endocrine tumors diagnosed in 10 patients were included. Clinical, radiologic, and pathologic data were reviewed. There were 6 male and 4 female patients (median age, 46 yrs). Six patients had evidence of multiple endocrine neoplasia type 1 (MEN1) disease. Four had a functional endocrine syndrome. Ten tumors were visible on imaging studies. The most suggestive radiologic features were the existence of a peripheral hypervascular rim (10 cases) and images of cyst into cyst (two cases). On gross and histologic examinations, two distinct types were present. Macrocystic tumors (six cases) were unilocular and limited by a thick wall containing nests of tumor cells. Microcystic tumors (seven cases) were characterized by the presence of multiple cystic spaces directly lined by tumor cells. Surgical resection was performed in all cases. Three patients had lymph node metastases at the time of diagnosis. One patient is dead with metastatic dissemination. The others are alive without recurrence or metastasis. The diagnosis of endocrine tumor must be considered for any pancreatic cyst discovered in a patient with a history of MEN1 syndrome or with clinical features suggestive of this syndrome. Cystic pancreatic endocrine tumors must be treated by surgical resection because of their possible malignant evolution.

Complete response of an HIV negative gastric Kaposi's sarcoma (KS) patient with peritoneal carcinomatosis by liposomal daunorubicin treatment.

We report the first case of an HIV negative patient with gastric Kaposi's sarcoma (KS) and peritoneal carcinomatosis in whom a complete response (CR) was obtained after liposomal daunorubicin administration. The patient presented with epigastric pain and hematemesis. Upper gastric endoscopy with multiple biopsies showed gastric involvement by KS. The whole physical examination and the thoraco-abdomino-pelvic CT scans showed no other localization. A total gastrectomy was performed. Histological examination confirmed the diagnosis of KS with involvement of regional lymph nodes and peritoneal lesions. Six cycles of liposomal daunorubicin were given. Post-treatment coelioscopic control was normal. The patient received another six adjuvant cycles of liposomal daunorubicin. The patient is in complete remission six months after the end of treatment. Liposomal daunorubicin is a promising treatment in the non HIV patient with visceral KS.

Laparoscopic fundoplication for gastroesophageal reflux: effects on esophageal motility.

Laparoscopic Nissen-Rossetti fundoplication is now recognized as a valid therapy for the treatment of gastroesophageal reflux disease. This retrospective study evaluates the effects of laparoscopic fundoplication on esophageal motility and correlates these effects to postsurgical symptoms. A total of 123 patients underwent laparoscopic fundoplication at our institution. Pre- and postoperative esophageal manometric data were analyzed with regard to the effect of surgery and postsurgical outcome. Postoperative lower esophageal sphincter pressure was significantly increased compared wtih preoperative values (1.7 +/- 0.8 kPa vs 0.9 +/- 0.7 kPa). Duration and amplitude of esophageal body contractions were not modified. The percentage of deglutition-induced complete peristaltic waves and the velocity of propagation were significantly decreased after surgery (P < 0.05). Postoperative symptoms were significantly correlated with postoperative lower esophageal sphincter pressure only. Laparoscopic fundoplication significantly increases lower esophageal sphincter pressure. It significantly decreases esophageal body peristaltic efficiency, a decrease that is most likely of minor clinical significance.

[Pneumatosis cystoides intestinalis, treated with laparoscopic colectomy]. / Pneumatose kystique intestinale, colectomie laparoscopique.

The authors report a case of pneumatosis cystoides intestinalis which, after failure of medical treatment, was treated by laparoscopic partial colectomy. Surgical treatment is a last resort and the laparoscopically-assisted approach seems to be a good indication in colectomy for pneumatosis cystoides intestinalis.

[Colonic diverticulosis and laparoscopy. Analysis of a series of 60 cases]. / Diverticulose colique et laparoscopie. Analyse d'une série de 60 cas.

AIM: This is a retrospective analysis of a series of 60 cases diverticular disease. MATERIAL AND METHOD: From May 1991 to April 1999, 60 laparoscopic colorectal resections were performed for diverticulitis. RESULTS: Conversion to a classical procedure was necessary in 3 patients (5%). There was no mortality and 9 postoperative complications (3 reoperations). The mean length of hospital stay was 9 days, and 6.3 days for patients in whom surgery was performed after January 1998. CONCLUSION: Laparoscopic surgery for diverticular disease is associated with acceptable morbidity and mortality rates and a short median postoperative stay.

Left ventricular loading modifications induced by pneumoperitoneum: a time course echocardiographic study.

UNLABELLED: The intraperitoneal insufflation of carbon dioxide during laparoscopic procedures is associated with an increase in mean arterial pressure and systemic vascular resistance. To evaluate the time course of the circulatory changes related to intraabdominal pressure variation, we used transesophageal echocardiography in 10 patients anesthetized for laparoscopic cholecystectomy. Left ventricular dimensions, fractional area shortening (FAS), and left ventricular afterload assessed by the left ventricular end-systolic wall stress (LVESWS) were measured from echocardiographic data before insufflation, during pneumoperitoneum, and during exsufflation. Three minutes after the onset of pneumoperitoneum, we observed a 25.7% +/- 10.5% (mean +/- SD) increase in mean arterial pressure, a 49.1% +/- 14.4% increase in LVESWS, and a 17.0% +/- 16.2% decrease in FAS. All measured variables returned to preinsufflation values after 30 min of pneumoperitoneum and thereafter were no longer significantly affected by postural changes (10 degrees head-up position) or pneumoperitoneum exsufflation. We conclude that the circulatory changes associated with pneumoperitoneum are transient and are probably mediated by factors other than intraabdominal pressure variations. IMPLICATIONS: Insufflation of gas into the abdominal cavity results in hemodynamic changes during laparoscopic procedures. We found that echocardiographic and blood pressure effects associated with gas insufflation were transient, indicating mediation by factors besides intraabdominal pressure.

[Heller's esocardiomyotomy without anti-reflux procedure by the laparoscopic approach. Analysis of a series of 27 cases]. / Oesocardiomyotomie de Heller sans anti-reflux par voie laparoscopique. Analyse d'une série de 27 cas.

From November 1992 to June 1996, 27 laparoscopic Heller's myotomies without antireflux procedure were performed. One mucosal tear occurred and was treated by open surgery. There was no mortality; one case of sepsis with a good outcome was observed on the converted patient. The mean length of hospital stay was 5.5 days. The immediate functional result was good in all cases. Postoperative esophageal manometry showed a significant reduction of the LES pressure, and post-operative pHmonitoring showed one case of reflux. The long term functional result was good in 81% of cases, moderate in 19% (slight reflux in 3 cases and dysphagia in 2 cases). No failure and no reoperation occurred in this series. This procedure has been applied to all patients with achalasia since December 1992.

Laparoscopic colo-rectal surgery: analysis of 113 cases.

BACKGROUND/AIMS: The aim of the study is to relate our five years experience with laparoscopic colorectal surgery. MATERIALS AND METHODS: One hundred-thirteen procedures were performed between October 1990 and February 1996, 7% of which were performed as emergencies. Elective indications (93%) included 45 cancers, 31 cases of diverticulosis, 18 cases of benign tumor, and 11 other reasons. Procedures performed were sigmoidectomy (61 cases), rectal resection (12 cases), segmental colectomy (15 cases), right hemicolectomy (14 cases) and restoration of continuity following a Hartmann's procedure (5 cases) and miscellaneous (6 cases). RESULTS: Operative complications occurred in 14% of the cases. The conversion rate to laparotomy was 6%. Post operative complications occurred in 14% of the patients. Reoperation was performed in 7% of the cases and overall mortality was 1.7%. Mean length of hospital stay was 9.6 days. Long-term oncology results demonstrated no recurrence for DUKES stage A disease followed-up from 5 to 65 months, and 2 recurrence on 11 DUKES B or C. All DUKES D patients died in an average of 17 months. No abdominal wall metastases were seen during the follow-up period in 45 patients with cancer who were treated. CONCLUSIONS: Laparoscopic colo-rectal surgery is technically feasible and has an acceptable complication rate. The best indications are treatment of benign disorders, principally excision of polyps and treatment of uncomplicated diverticulosis. This is also a good approach to treat degenerated polyps (DUKES A). The procedure should be assessed in curative excision of DUKES B or C disease.

Laparoscopic Nissen-Rossetti fundoplication. First results.

From January 1992 to July 1994, 148 patients with symptomatic gastroesophageal reflux and/or hiatal hernia underwent Nissen-Rossetti fundoplication by a laparoscopic approach. There was no conversion and no postoperative death. The main intraoperative complications were hemorrhage (n = 12), pleural opening (n = 5), and gastric perforation (seromuscular effraction) (n = 1). Laparoscopic reoperation was necessary in two patients as a result of bleeding, and there were two cases of food impaction. The median hospital stay was 4.9 days; 117 patients were observed for follow-up for 3-31 months (median 6.2 months). Eleven cases of dysphagia extending beyond 2 months have been observed. In five of those cases, endoscopic dilatation provided effective treatment of dysphagia and in four others, a further laparoscopic intervention enabled a cure to be obtained. Eighty-four percent are satisfied with their decision to have the operation. The laparoscopic Nissen-Rossetti fundoplication can be carried out safely and effectively with positive results similar to those obtained with the open procedure and with all of the advantages of the minimally invasive approach.