As originally published in 1993: En bloc and standard esophagectomies by thoracoscopy. Updated in 1996.
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Disease-Free Survival↗
Biomedical subjects
J M Collard
Publications and source records attributed to J M Collard.
Heller-Dor procedure for achalasia: from conventional to video-endoscopic surgery.
A Heller-Dor procedure was performed by laparotomy (group A: n = 8) or by laparoscopy (group B: n = 12) after failure of one to 17 sessions of intraluminal dilatations (n = 13) or as a primary treatment of oesophageal achalasia (n = 7). The oesophagomyotomy was extended over the thoracic oesophagus by thoracoscopy in two patients having vigorous achalasia. Injury to the oesophageal mucosa occurred in two group A patients who had previously been dilated. At follow-up (range: 1 to 113 months), 6 patients of group A (75%) and 10 of group B(83.3%) had no residual dysphagia. The four patients (group A: n = 2; group B: n = 2) who complained of heartburn prior to the operation were asymptomatic, only one group A patient developed symptoms of reflux, and oesophageal pH-monitoring was normal in the 6 group B patients investigated at follow-up. The laparoscopic approach reduces the magnitude of the operation, and the magnified overview permits precise dissection of the intraparietal adhesions which may develop after numerous sessions of dilatation.
Adult↗
[Lymph node excision in cancer of the esophagus].
This paper analyses the surgical literature devoted to lymph node clearance for cancer of the esophagus. Involvement of a small number of lymph nodes by the neoplastic process does not preclude long-term survival and even cure. The superiority of the 3-field dissection over the 2-field dissection, although suggested in the available studies, should be confirmed by a prospective randomized study. Extensive lymph node clearance protects many patients from local recurrence, and allows to staging of the neoplastic disease and selection of those patients who are eligible for adjuvant therapy.
Belgium↗
Esophageal replacement: gastric tube or whole stomach?
BACKGROUND: The stomach can be used either in its entirely or as a greater curvature tube for esophageal replacement. METHODS: The study compares the gastric tube (group A; n = 112) to the whole stomach whose lesser curvature is denuded (group B; n = 100) in terms of technical complication and alimentary comfort. The clinical results are substantiated by assessment of the eating performance of patients and control subjects at a test meal, measurement of the gastric dimensions before and after both tailoring procedures, and intraarterial staining of the gastric wall. RESULTS: Major differences between the two groups are cervical anastomosis stenoses (22.3% versus 6% [A versus B]; p = 0.008), fistulas (7.9% versus 1%; p = 0.0209), number of meals and snacks per day (4.6 versus 4; p = 0.0275), sensation of early fullness at meals (52.4% versus 17.8%; p < 0.0001), ratings given to the long-term alimentary comfort (presymptomatic condition = 10 points) (7.6 versus 8.8 out of 10 on average; p < 0.0001), and calories consumed in 1 minute at a test meal (59% [p < 0.05] versus 77% of those consumed by control subjects). The volume of the stomach is reduced by a range of 21.4% to 47.2% after tubulization (group A) whereas it increases by a range of 4.9% to 17.4% after denudation of the lesser curve (group B). Intraarterial staining of the gastric wall reveals the poor vascularity of the upper-most segment of the greater curve. CONCLUSION: Slight increase of the gastric capacity and maintenance of the submucosal vascular network account for the better results achieved with the whole stomach.
Adolescent↗
Carcinoembryonic antigen measurements in the management of esophageal cancer: an indicator of subclinical recurrence.
BACKGROUND: Detection of subclinical recurrence after surgical resection of esophageal cancer would allow earlier treatment of recurrent disease and potentially offer a better outcome for rescue therapy. METHODS: The utility of serum carcinoembryonic antigen (CEA) assay was evaluated in the management of patients with esophageal cancer. RESULTS: Serum carcinoembryonic antigen was measured preoperatively in 74 patients. Elevation of the CEA level (> 5 ng/mL) was present in 14 patients (19%). There was no relationship between preoperative CEA elevation and the stage of the tumor or the patients' survival. Eighty-three patients had CEA assay at regular follow-up intervals after resection. Objective evidence of recurrent disease was determined at similar intervals by chest radiography and abdominal and thoracic computed tomography scans. During follow-up, 53 of 83 patients developed recurrence. Postoperative elevation of CEA levels occurred in 32 patients, resulting in a sensitivity of 55% for detecting recurrent disease. Twenty-nine of the 32 patients who developed CEA elevation had objective evidence of metastatic disease. In 13 patients, the rise in CEA levels predated objective evidence of recurrence by a median of 4 months (range 3 to 35), and in 16 patients, it occurred concomitantly. The specificity with which an elevated postoperative CEA level indicated recurrence was high, 90%, with a positive predictive value of 91%. CONCLUSIONS: Postoperative CEA elevation is highly predictive of recurrent disease. In 16% of patients, elevation of CEA was the earliest objective sign of recurrence; such elevation should prompt consideration of adjuvant therapy.
Adenocarcinoma↗
Role of videoassisted surgery in the treatment of oesophageal cancer.
The author analyses the pros and cons of the so-called minimally invasive oesophageal surgery for cancer, in the light of his own experience and the major studies reported in the surgical literature and recent congresses. He concludes that, although radical oesophagectomies are feasible on selected patients, a major oesophageal operation carried out through small parietal incisions remains an invasive procedure owing to the magnitude of the internal dissection and the relatively poor general condition of the patients. In contradistinction, both exploratory thoracoscopy and laparoscopy are very attractive alternatives to the classic tools of diagnosis and staging.
Endoscopes↗
Laparoscopic antireflux surgery. What is real progress?
OBJECTIVE: The authors aim to substantiate, with objective arguments, potential advantages of laparoscopic versus open antireflux surgery in the light of the recent crude experience of the Louvain Medical School Hospital. METHODS: Seventy-two consecutive patients with disabling gastroesophageal reflux disease ([GERD], n = 56), symptomatic hiatal hernia without GERD (n = 5), or unsatisfactory outcome after unsuccessful antireflux procedure (n = 11) were operated on by laparotomy (n = 28), laparoscopy (n = 39), or thoracotomy (n = 5). The antireflux procedure was a subdiaphragmatic Nissen fundoplication (n = 60), an intrathoracic Nissen fundoplication (short esophagus, n = 3), a subdiaphragmatic 240 degrees fundoplication (severe motility disorders, n = 3), a Lortat-Jacob repair (hiatal hernia without GERD, n = 5), and a duodenal diversion (delayed gastric emptying, n = 1). RESULTS: Major postoperative morbidity included two pulmonary embolisms (one laparoscopy patient and one laparotomy patient), and one hemothorax (one thoracotomy patient). Mean hospital stay was 6.4 days for laparoscopy, 7.8 days for laparotomy, and 12.5 days for thoracotomy. Postoperative morphine consumption (patient-controlled analgesia) averaged 47 mg/48 hrs (laparoscopy) versus 46 mg/48 hrs (laparotomy with primary antireflux surgery) (p > 0.05). Although 93% of the laparoscopy patients returned to work within 3 weeks after surgery, 92% of the laparotomy and thoracotomy patients resumed their activity after more than 6 weeks. At follow-up, 87.5% of the patients were asymptomatic or had inconsequential symptoms, 9.8% had disabling side effects, and 2.7% had persistent or recurring esophageal symptoms. There were four parietal herniations, i.e., one incisional hernia and one recurrence of a repaired umbilical hernia in the laparotomy group, and two herniations of the wrap into the chest--probably related to a premature return to manual work--in the laparoscopy group. Three laparoscopy patients were dissatisfied with the esthetics of their scars. Lower esophageal sphincter pressure and esophageal acid exposure in the laparoscopy patients who were investigated were normal in 100% and 95%, respectively. CONCLUSIONS: Laparoscopy is a good approach for achieving successful antireflux surgery in selected cases. However, its fails to substantially reduce postoperative complication rate and discomfort, duration of the hospital stay, and the risk of esthetic sequela. Early return to work is questionable for manual workers. The subdiaphragmatic Nissen fundoplication is not an all-purpose antireflux procedure.
Adult↗
Plasmids for heavy metal resistance in Alcaligenes eutrophus CH34: mechanisms and applications.
Alcaligenes eutrophus CH34 is the main representative of a group of strongly related strains (mostly facultative chemolithotrophs) that are well adapted to environments containing high levels of heavy metals. It harbors the megaplasmids pMOL28 and pMOL30 which carry resistance determinants to Co2+, Ni2+, CrO(4)2-, Hg2+, Tl+, Cd2+, Cu2+ and Zn2+. Among the best characterized determinants are the cnr operon (resistance to Co, Ni) on pMOL28 and the czc operon on pMOL30 (resistance to Co, Cd and Zn). Although the two systems reveal a significant degree of amino acid similarity in the structural genes, the regulation of the operons is different. The resistance mechanism in both cases is based on efflux. The efflux mechanism leads to a pH increase outside of the cytoplasmic membrane. Metals are sequestered from the external medium through the bioprecipitation of metal carbonates formed in the saturated zone around the cell. This latter phenomenon can be exploited in bioreactors designed to remove metals from effluents. The bacteria are immobilized on composite membranes in a continuous tubular membrane reactor (CTMR). The effluent continuously circulates through the intertubular space, while the external surface of the tubes is in contact with the growth medium. Metal crystals are eventually removed by the effluent stream and collected on a glass bead column. The system has been applied to effluents containing Cd, Zn, Co, Ni and Cu. By introducing catabolic plasmids involved in the aerobic degradation of PCBs and 2,4-D into metal-resistant A. eutrophus strains, the application range was widened to include effluents polluted with both organic and inorganic substances. Biosensors have been developed which are based on the fusion of genes induced by metals to a reporter system, the lux operon of Vibrio fischeri. Bacterial luciferases produce light through the oxidation of fatty aldehydes. The gene fusions are useful both for the study of regulatory genes and for the determination of heavy metal concentrations in the environment.
Alcaligenes↗
Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum.
We present an endoscopic technique of division of the common wall between the esophagus and the hypopharyngeal (Zenker's) diverticulum. The novelty of the technique, as compared with endoscopic sutureless coagulating methods, consists of stapling the esophageal to the diverticular wall using the Endo-GIA 30 stapler (US Surgical Corp, Norwalk, CT), which protects the neck from any contamination from the digestive lumen and ensures optimal hemostasis of the wound edges. The stapler has been designed such that perforation of the bottom of the diverticulum is not likely. The technique has been applied to 6 patients.
Esophagoscopy↗
En bloc and standard esophagectomies by thoracoscopy.
Subtotal esophagectomy was attempted by right thoracoscopy on 13 patients, 10 having cancer and 3 long caustic stenosis. Thoracoscopy was converted into thoracotomy in 2 patients, owing to loss of selectivity in one-lung ventilation in 1 and injury to a right intercostal artery flush to the aorta in the other. One patient with cancer underwent an esophageal bypass operation only, owing to tumor invasion into the lung at exploratory thoracoscopy. The ten esophagectomies that could be performed in totality by thoracoscopy consisted of seven en bloc resections of the esophagus with extensive lymph node clearance in the posterior mediastinum, and three standard resections without any lymph node dissection. Postoperative complications included one death due to hepatic failure, two cases of acute pneumonitis, and one persistent chest wall discomfort at the trocar sites. Up to 51 lymph nodes were found in the resected specimens of the cancer patients. Six of the 7 cancer patients who were discharged from the hospital after esophagectomy completed by thoracoscopy were alive at 2 to 20 months of follow-up. Five of them were disease free. The study shows that esophageal resections as extensive as those carried out by thoracotomy can be performed by thoracoscopy. It suggests that prompt management of untoward injury to any mediastinal structure adjacent to the esophagus is less easy by thoracoscopy than by thoracotomy, and that classic complications of open thoracic surgery may occur after thoracoscopy as well.
Burns, Chemical↗
A new type of Alcaligenes eutrophus CH34 zinc resistance generated by mutations affecting regulation of the cnr cobalt-nickel resistance system.
Spontaneous mutants that were resistant to zinc were isolated from Alcaligenes eutrophus CH34 containing either the native plasmid pMOL28 or a derivative derepressed for its self-transfer, pMOL50. With the cured plasmid-free derivative of CH34, strain AE104, such mutants were not detected. The mutations, which were shown to be located in the plasmid, increased the level of the nickel and cobalt resistance determined by the cnr locus. The chromate resistance closely linked to the cnr locus was not affected by these mutations. In the Znr mutants, the resistance to zinc and nickel was constitutively expressed. Uptake studies showed that the zinc resistance in a Znr mutant resulted from reduced accumulation of zinc ions in comparison with that in the plasmid-free strain. Reduced accumulation of zinc was also observed to a lesser degree in the parental strain induced with nickel, suggesting that zinc interferes with the Ni2+ and Co2+ efflux system. A 12.2-kb EcoRI-XbaI restriction endonuclease fragment containing the cnr locus was cloned from plasmid pMOL28 harboring the mutation and shortened to an 8.5-kb EcoRI-PstI-PstI fragment conferring resistance to zinc, nickel, and cobalt. The 12.2-kb EcoRI-XbaI fragment was also reduced to a 9.7-kb BamHI fragment still encoding weak resistance to nickel and cobalt but not to zinc. Complementation studies demonstrated the recessivity of the cnr mutations with a Znr phenotype. Such mutations thus allow positive selection of mutants affected in the expression of the cnr operon.
Alcaligenes↗
Rapid method for purification of soil DNA for hybridization and PCR analysis.
Monitoring of microbial DNA in soils by dot blot hybridization and PCR analysis is a useful technique for gaining insight into the survival and impact of genetically modified micro-organisms released in the environment. Most methods of DNA isolation from soils require a large number of purification steps rendering them unsuitable for quantitative analysis of multiple samples. Here we describe a very rapid method for the isolation and purification of multiple samples of soil DNA that can be used directly for dot blot hybridization and PCR analysis. Soil DNA extracts are prepared by lysozyme/SDS treatment at pH 9.0 and purified by ammonium acetate precipitation and Sephadex G50 gel filtration. In a practical application of this method, sandy soil samples were seeded with Alcaligenes eutrophus cells and exposed to high temperature (42 degrees C) or desiccation. As a result, the number of culturable A. eutrophus cells which could be recovered from the soil samples quickly declined. However, the concentration of a marker gene encoding resistance to cadmium, cobalt and zinc (czc) remained unaltered.
Alcaligenes↗
[Trans-laparoscopy surgery, a passing fashion or progress?].
Since the first laparoscopic cholecystectomy performed in 1987 by Philippe Mouret in Lyon (France), there has been a real revolution in the field of visceral surgery: more and more operations are performed by this mini-invasive surgical method: lithiasis of the common bile duct, Nissen and Heller procedure, truncal vagotomies, abdominal and thoracic, supra-selective vagotomies, hernia, appendectomy, band sections during intestinal occlusion, resection of the colon and rectum, oesophagectomies ... In Belgium, more than 3,000 cholecystectomies have been listed in a national registry in which the modalities and complications of this laparoscopic approach have been scrutinized. During the years to come, there will be an important technological development which will make this procedure easier, safer and quicker. Consequences of this new approach cannot completely be foreseen but there are some drawbacks: possible simplification of well established surgical techniques in order to facilitate the laparoscopic approach, causing a deterioration of the long term results, teaching and training difficulties for young and older surgeons, very costly equipment.
Cholecystectomy, Laparoscopic↗
Quality of life three years or more after esophagectomy for cancer.
The quality of life and alimentary comfort of 17 patients with esophageal cancer who were disease free more than 3 years after an esophageal resection were evaluated by analyzing responses to a follow-up questionnaire. Fourteen patients had subtotal esophagectomy and gastric pull-up to the neck. Three patients underwent a total esophagopharyngolaryngectomy, the digestive continuity being restored by means of an isoperistaltic colon segment interposed between the base of the tongue and the stomach. Current body weight, when compared with that existing postoperatively, was increased in 13 patients and unchanged in four. The number of meals per day was an average of 2.8, but 12 patients took additional snacks between main meals (2.3 as a mean). The major long-term complaints were a sensation of early fullness during eating in 11 patients, dysphagia in three, diarrhea in two, cough-induced vomiting in two, and postprandial sweating in two. Ratings given by self-evaluation of current alimentary comfort in comparison with that predating the initial esophageal symptoms ranged from 3 of 10 to 10 of 10 (mean 7.1/10). Thirteen patients led active lives, seven at home and six employed outside the home. The present survey suggests that most disease-free patients may obtain a satisfactory quality of life after esophagectomy and gastric or colonic pull-up; long-term alimentary comfort is conditioned mainly by the small capacity of the esophageal substitute.
Adult↗
Intrathoracic Nissen fundoplication: long-term clinical and pH-monitoring evaluation.
From 1976 until April 1989, 31 intrathoracic total fundoplications were performed for reflux esophagitis and irreducible hiatus hernia. In the first 16 patients (group 1) the operation was complicated with acute perforation of the wrap in 4 cases, bronchogastric fistula in 1, and herniation of the wrap higher in the chest in 1. Technical modifications were applied to 15 more recent patients (group 2). These are enlargement of the hiatus, looseness of the wrap and its appropriate anchorage, avoidance of forceps when handling the stomach, care with the vagi, and efficient gastric decompression in the postoperative period. The postoperative course was always uneventful in group 2. Twenty-six patients, who still have their initial wrap, were considered for clinical evaluation: 11 from group 1 (mean follow-up, 81.5 months) and 15 from group 2 (mean follow-up, 32.8 months). All are free from any symptom of reflux; gas-bloat syndrome is infrequent and dysphagia is relieved. Twenty-four-hour pH monitoring, performed in 14 patients (3 from group 1 and 11 from group 2) (mean follow-up, 42 months), was normal in 13; a pathological upright reflux (time pH less than 4, 8.4%) was demonstrated in one symptom-free woman in whom endoscopy was unremarkable. Mechanisms of complications experienced in group 1 are analyzed in the light of the technical evolution of the procedure, and the place of the intrathoracic total fundoplication in the management of short esophagus is defined, considering the other available surgical techniques.
Cardia↗
[Distal splenorenal anastomosis in the treatment of digestive hemorrhage in portal hypertension].
One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.
Adolescent↗
Recurrent pleuro-pericarditis due to gastrodiaphragmatic fistula.
A 61-year-old woman presented with recurrent pleuro-pericarditis following Nissen fundoplication. A diagnosis of anterior gastrodiaphragmatic fistula was made. The suspected etiology of the fistula was local ischemia. This kind of fistula, although exceptional, should always be considered in the presence of unexplained recurrent pleuro-pericarditis after fundoplication.
Diaphragm↗
Gastrodiaphragmatic fistula after transabdominal Nissen fundoplication. An unusual complication.
A 60-year-old woman developed a gastrodiaphragmatic fistula as a late complication of transabdominal Nissen fundoplication. For 6 years, she had complained of chest pain and was considered to have pericarditis. At reoperation the fistulous track was found and easily resected. No other causative factor could be identified.
Diaphragm↗