Biomedical subjects

P J Kestens

Publications and source records attributed to P J Kestens.

At least 19 recordsLinked to original sources

PubMed2001

Skeletonizing en bloc esophagectomy for cancer.

OBJECTIVE: To evaluate the long-term outcome of patients with esophageal cancer after resection of the extraesophageal component of the neoplastic process en bloc with the esophageal tube. SUMMARY BACKGROUND DATA: Opinions are conflicting about the addition of extended resection of locoregional lymph nodes and soft tissue to removal of the esophageal tube. METHODS: Esophagectomy performed en bloc with locoregional lymph nodes and resulting in a real skeletonization of the nonresectable anatomical structures adjacent to the esophagus was attempted in 324 patients. The esophagus was removed using a right thoracic (n = 208), transdiaphragmatic (n = 39), or left thoracic (n = 77) approach. Lymphadenectomy was performed in the upper abdomen and lower mediastinum in all patients. It was extended over the upper mediastinum when a right thoracic approach was used and up to the neck in 17 patients. Esophagectomy was carried out flush with the esophageal wall as soon as it became obvious that a macroscopically complete resection was not feasible. Neoplastic processes were classified according to completeness of the resection, depth of wall penetration, and lymph node involvement. RESULTS: Skeletonizing en bloc esophagectomy was feasible in 235 of the 324 patients (73%). The 5-year survival rate, including in-hospital deaths (5%), was 35% (324 patients); it was 64% in the 117 patients with an intramural neoplastic process versus 19% in the 207 patients having neoplastic tissue outside the esophageal wall or surgical margins (P <.0001). The latter 19% represented 12% of the whole series. The 5-year survival rate after skeletonizing en bloc esophagectomy was 49% (235 patients), 49% for squamous cell versus 47% for glandular carcinomas (P =.4599), 64% for patients with an intramural tumor versus 34% for those with extraesophageal neoplastic tissue (P <.0001), and 43% for patients with fewer than five metastatic nodes versus 11% for those with involvement of five or more lymph nodes (P =.0001). CONCLUSIONS: The strategy of attempting skeletonizing en bloc esophagectomy in all patients offers long-term survival to one third of the patients with resectable extraesophageal neoplastic tissues. These patients represent 12% of the patients with esophageal cancer suitable for esophagectomy and 19% of those having neoplastic tissue outside the esophageal wall or surgical margins.

Adenocarcinoma↗

PubMed1999

Erythromycin enhances early postoperative contractility of the denervated whole stomach as an esophageal substitute.

OBJECTIVE: To determine whether early postoperative administration of erythromycin accelerates the spontaneous motor recovery process after elevation of the denervated whole stomach up to the neck. SUMMARY BACKGROUND DATA: Spontaneous motor recovery after gastric denervation is a slow process that progressively takes place over years. METHODS: Erythromycin was administered as follows: continuous intravenous (i.v.) perfusion until postoperative day 10 in ten whole stomach (WS) patients at a dose of either 1 g (n = 5) or 2 g (n = 5) per day; oral intake at a dose of 1 g/day during 1.5 to 8 months after surgery in 11 WS patients, followed in 7 of them by discontinuation of the drug during 2 to 4 weeks. Gastric motility was assessed with intraluminal perfused catheters in these 21 patients, in 23 WS patients not receiving erythromycin, and in 11 healthy volunteers. A motility index was established by dividing the sum of the areas under the curves of >9 mmHg contractions by the time of recording. RESULTS: The motility index after IV or oral administration of erythromycin at and after surgery was significantly higher than that without erythromycin (i.v., 1 g: p = 0.0090; i.v., 2 g: p = 0.0090; oral, 1 g: p = 0.0017). It was similar to that in healthy volunteers (i.v., 1 g: p = 0.2818; oral, 1 g: p = 0.7179) and to that in WS patients with >3 years of follow-up who never received erythromycin (i.v., 1 g: p = 0.2206; oral, 1 g: p = 0.8326). The motility index after discontinuation of the drug was similar or superior to that recorded under medication in four patients who did not experience any modification of their alimentary comfort, whereas it dropped dramatically parallel to deterioration of the alimentary comfort in three patients. CONCLUSIONS: Early postoperative contractility of the denervated whole stomach pulled up to the neck under either i.v. or oral erythromycin is similar to that recovered spontaneously beyond 3 years of follow-up. In some patients, this booster effect persists after discontinuation of the drug.

Adolescent↗

PubMed1998

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases.

BACKGROUND: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown. OBJECTIVE: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases. METHODS: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS). RESULTS: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12-44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence. CONCLUSIONS: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.

Adolescent↗

PubMed1998

Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy.

BACKGROUND: The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture. METHODS: A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GIA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies. RESULTS: The cross-sectional area was 225 +/- 15.7 mm2 (mean +/- standard error of the mean) for the 16 semimechanical anastomoses versus 136 +/- 15 mm2 for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 +/- 13.5 mm2 in 29 patients without dysphagia to 107.5 +/- 4.7 mm2 in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 +/- 16 mm2 in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 +/- 5.5 mm2 to 174.6 +/- 8.1 mm2, with concomitant symptomatic relief (p = 0.0277). CONCLUSIONS: The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. Inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy.

Anastomosis, Surgical↗

PubMed1998

The denervated stomach as an esophageal substitute is a contractile organ.

OBJECTIVE: To determine whether the denervated stomach as an esophageal substitute is an inert conduit or a contractile organ. SUMMARY BACKGROUND DATA: The motor response of gastric transplants to deglutition suggests that the stomach pulled up to the neck acts as an inert organ. METHODS: The gastric motility of 11 healthy volunteers and 33 patients having either a gastric tube (GT) (n = 10) or their whole stomach (WS) (n = 23) as esophageal replacement was studied with perfused catheters during the fasting state, after a meal, and after intravenous administration of erythromycin lactobionate. A motility index was established for each period of recording by dividing the sum of the areas under the curves of all contractions of >9 mmHg by the time of recording. RESULTS: Over years, the denervated stomach recovers more and more motor activity, even displaying a real phase 3 motor pattern in 6 of the 10 WS patients and 1 of the 7 GT patients with >3 years of follow-up. Erythromycin lactobionate generates a phase 3-like motor pattern regardless of the length of follow-up. Extrinsic denervation of the whole stomach does not significantly modify the fasting motility index established >3 years after surgery (+17% on average, p > 0.05), but it reduces that in the fed period by an average of 62% (p = 0.0016). Tubulization of the denervated whole stomach lowers the fasting motility index by an average of 60% (p = 0.0248) and further impairs that in the fed period by an average of 67% (p = 0.0388). CONCLUSIONS: The denervated stomach as an esophageal substitute is a contractile organ that may even generate complete migrating motor complexes. Motor recovery is better in the fasting than in the fed period, and it is more marked in WS patients than in GT patients.

Adolescent↗

PubMed1997

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients.

BACKGROUND: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. METHODS: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. RESULTS: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. CONCLUSIONS: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage.

Adolescent↗

PubMed1997

Adult polycystic liver disease: is fenestration the most adequate operation for long-term management?

OBJECTIVE: The aim of this study was to evaluate the immediate and long-term results in a retrospective series of patients with highly symptomatic adult polycystic liver disease (APLD) treated by extensive fenestration techniques. A classification of APLD was developed as a stratification scheme to help surgeons conceptualize which operation to offer to patients with APLD. SUMMARY BACKGROUND DATA: Treatment options for APLD remain controversial, with partisans of fenestration techniques or combined liver resection-fenestration. METHODS: Clinical symptoms, performance status, liver volume measurement by computed tomography (CT), and morbidity were recorded before surgery and after surgery. Adult polycystic liver disease was classified according to the number, size, and location of liver cysts and the amount of remaining liver parenchyma. Follow-up was obtained by clinical and CT examinations in all patients. RESULTS: Ten patients with highly symptomatic APLD were operated on using an extensive fenestration technique (by laparotomy in 8 patients and by laparoscopy in 2 patients, 1 of whom conversion to laparotomy was required). The mean preoperative liver volume was 7761 cm3. There was no mortality. Postoperative morbidity occurred in 50%, mainly from biliary complications, requiring reintervention in two cases. Massive intraoperative hemorrhage occurred in one patient. During a mean follow-up time of 71 months (range, 17 to 239 months), all patients were improved clinically according to their estimated performance status. The mean postoperative liver volume was 4596 cm3, which represents a mean liver volume reduction rate of 43%. However, in type III APLD, despite absence of clinical symptoms, a significant increase in liver volume was observed in 40% of the patients. CONCLUSIONS: Extensive fenestration is effective in relieving symptoms in patients with APLD. Hemorrhage and biliary complications are possible consequences of such an aggressive attempt to reduce liver volume. The procedure can be performed laparoscopically in type I APLD. A longer follow-up period is mandatory in type II APLD, to confirm the usefulness of the fenestration procedure. In type III APLD, significant disease progression was observed in 40% of the patients during long-term follow-up. Fenestration may not be the most appropriate operation for long-term management of all types of APLD.

Adult↗

PubMed1996

Laparoscopic splenectomy in adults and children: experience with 31 patients.

BACKGROUND: Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported. METHODS: Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included idiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm. RESULTS: Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 8% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2. CONCLUSIONS: Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.

Adolescent↗

PubMed1996

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↗

PubMed1996

[Surgical treatment of chronic pancreatitis with predominant cephalic involvement by double Wirsung duct diversion and restoration of permeability of the cephalic duct].

The aim of this study is to assess the long-term results of an original surgical technique for the treatment of patients suffering from painful chronic pancreatitis. From 1981 to 1994, 54 patients with chronic painful pancreatitis were operated, by means of an original duct drainage procedure, named by the authors "double drainage" because it consists of a large transduodenal sphincterotomy and a long pancreatic duct, accompanied by repermeabilization of the cephalic pancreatic duct. This procedure was used exclusively for type I pancreatitis with major lesions in the head of the gland (calcified stones, narrowing of the ducts, inflammatory process). There were 40 men and 14 females in this series. No perioperative mortality and a low morbidity (22%) were observed. Mean follow-up in 52 patients was 56 months (median: 59.5 months). The 5- year actuarial survival was 85.2% and 81% were free of pain (91% when the pancreatic duct was dilated to > 6 mm) versus 63% when the pancreatic duct was (6 mm) (p < 0.01). These excellent results should serve as a baseline for any alternative treatment of this category of painful chronic pancreatitis patients.

Actuarial Analysis↗

PubMed1995

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↗

PubMed1995

Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team.

BACKGROUND: This study was performed to assess the exact performance of the conventional way of stapling colorectal anastomoses. Information collected from 1000 consecutive anastomoses performed by one surgical team could be considered as reliable reference with which results obtained by new approaches could be compared. METHODS: One thousand consecutive anastomoses were performed from 1979 to 1992. Characteristics of the procedure, intraoperative events, mortality rate, complications, and clinical outcome were detailed. RESULTS: There were 528 men and 472 women (age range, 20 to 90 years; average age, 63 years). Anastomoses were constructed by means of a circular stapler loaded with the largest cartridge in 82.3% of the cases. Imperfections were identified during operation in 124 cases. A diverting colostomy was performed in 127 cases. Postoperative mortality rate averaged 2.2%. Clinical anastomotic leaks developed in 35 patients: in 11.4% after low stapling (less than 5 cm from the dentate line) and in 2.2% after high stapling. The presence of a diverting colostomy influenced the leakage rate in patients with very low anastomoses. Total failure rate (death, definitive colostomy) as a result of anastomotic leak was 1.6%. Among the 933 survivors who had follow-up examination, the incidence of bad functional results decreased from 10% at the first attendance to 4.3% at the last one. Transanal dilatation and restapling were required for symptomatic narrowing in three and one patients, respectively. CONCLUSIONS: The conventional way of stapling colorectal anastomoses in reliable, but it requires strict observance of the rules for anastomosing intestine and a careful check of the stapled sutures. Results obtained by new approaches could be compared with these data.

Anastomosis, Surgical↗

PubMed1994

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura.

Laparoscopic splenectomy was performed on eight patients with idiopathic thrombocytopenic purpura refractory to medical treatment. Preoperative infusion of immunoglobulin G gamma-globulin was used to boost the platelet count. Accessory spleens were sought by preoperative computed tomography and peroperative examination of the usual anatomical locations. Seven patients underwent successful laparoscopic splenectomy, with a mean postoperative stay of 3.6 days. One patient with an accessory spleen detected before operation but not during laparoscopy required conversion to open surgery for control of haemorrhage from the splenic hilum. Another patient had a transient pancreatic fistula. Laparoscopic splenectomy is feasible and sfe in patients with idiopathic thrombocytopenic purpura. Long-term results require evaluation as detection of accessory spleens can prove difficult during laparoscopy.

Adolescent↗

PubMed1994

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↗

PubMed1994

[Ileo-anal anastomosis in hemorrhagic-ulcerative rectocolitis and familial adenomatous polyposis: is it mandatory to perform resection of the endo-anal mucosa?].

The aim of this study was to assess the clinical outcome after ileal pouch-anal anastomosis with mucosectomy for ulcerative colitis and for familial adenomatous polyposis, and to characterize the histology of the stripped endoanal mucosa with particular reference to the ulcerative colitis activity, adenomatous polyps and dysplasia. Twenty-eight patients were operated, 16 for ulcerative colitis (group I) and 12 for familial adenomatous polyposis (group II). In group I, there were no intraoperative complications, but mucosectomy was tedious in 10 patients (62%) and the anastomosis was performed under some degree of tension in 10 patients (62%). In group II, there was a direct injury of the internal sphincter by a posterior tear during the mucosal stripping in one case. Mucosectomy was easy to perform in 8 patients (67%) and 10 anastomoses (84%) were performed under tension. In both groups, there were no postoperative complications related to the mucosectomy or to the anastomosis itself. Functional results were good, with a normal continence in 80% of ulcerative colitis patients and 92% of familial adenomatous polyposis patients. Review of histological sections of the stripped anal mucosa in group I showed chronic active ulcerative colitis in 8 patients (50%), chronic non-active ulcerative colitis in 4 (25%) and quiescent ulcerative colitis in 4 (25%). There was only one case of moderate dysplasia in a patient with a Dukes A carcinoma. In group II, anal mucosa showed micropolyps in all cases with mild dysplasia in 3 cases (25%) and moderate dysplasia in 9 (75%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adenomatous Polyposis Coli↗

PubMed1993

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↗

PubMed1993

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↗

PubMed1992

Acute localized diverticulitis: optimum management requires accurate staging.

Between 1977 and 1989, 151 patients were treated in our institution for acute sigmoid diverticulitis. Thirty-one patients were operated on for diffuse peritonitis, and were excluded from the study. One hundred twenty patients had localized disease. There were 59 men and 61 women, with a mean age of 60 years (range, 30 to 87 years). Thirteen were under 40 years of age. A "phlegmonous" diverticulitis (no pericolic abscess) was diagnosed in 78 cases (group I). A pericolic abscess was identified in 42 cases (group II). The medical treatment was successful in 97% of the patients of the group I. Only 15 patients required a delayed elective resection for recurrence or chronic complications, within the next 24 months. There were no operative deaths. All the other patients were doing well after a mean follow-up of 5 years (9-144 months), without any disease-related death. Patients presenting with a localized pericolic abscess (group II, n = 42) were initially treated either conservatively (n = 22) or by a more or less extensive drainage (n = 20). There were two deaths in the "conservative" group. Primary or delayed colonic resection was indicated in 34 cases because of uncontrolled sepsis, recurrence or secondary chronic complications. It is concluded that accurate classification of the disease is essential. If no peritonitis has developed, the presence of an abscess is the main determinant in both prognosis and treatment. Most patients who develop an acute phlegmonous diverticulitis do well with conservative treatment, and prophylactic resection is not indicated. Curative colectomy is reserved for patients developing persistent complications over the next few months.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗