Transthoraco-phrenic esophageal transection with paraesophago-gastric devascularization and splenectomy using a stapler

BACKGROUND/AIMS: Surgery remains the most reliable treatment for bleeding esophageal varices. The aim of this study was to introduce the operative technique of transthoraco-phrenic esophageal transection with paraesophagogastric devascularization using a stapler and to evaluate surgical results. METHODS: Forty-five patients underwent the procedure; an elective procedure was performed in 22 patients (bleeders) and a prophylactic procedure in 23 patients (nonbleeders). Twenty-nine patients were classified as Child's A, 15 as B and 1 as C. Previous sclerotherapy had been performed in 5 patients. RESULTS: No hospital deaths occurred. No patients developed postoperative anastomotic leakage, encephalopathy, or any complications related to phrenicotomy. Three patients bled postoperatively from recurrent esophageal varices. Cumulative 5-year bleeding rates were 5.0% in bleeders and 6.6% in non-bleeders. Two patients died due to bleeding varices. Cumulative 5-year survival rates were 72.1% and 78.8% in patients classified as Child's A and Child's B, respectively. CONCLUSIONS: This procedure may be indicated for a majority of Child's A or B patients. Although the advantages of this procedure must be evaluated further, it may be an alternative when injection sclerotherapy and endoscopic ligation fail.     

Comparison of a modified Sugiura procedure with portal systemic shunt for prevention of recurrent variceal bleeding in cirrhosis

BACKGROUND: There is no agreement on the management of patients with cirrhosis and recurrent variceal bleeding after failure of medical or endoscopic treatments or both. Portal systemic shunts are highly effective in preventing rebleeding but are associated with a high incidence of chronic encephalopathy. This study compared the results of a slightly modified Sugiura procedure (esophageal transection plus esophagogastric devascularization plus splenectomy) with those of nonselective portal systemic shunts in patients with previous variceal bleeding. METHODS: Fifty-four patients were included in this randomized controlled study between January 1984 and April 1989. The major end point was chronic encephalopathy. Secondary end points were recurrent variceal bleeding, survival, ascites, and hepatocellular carcinoma. RESULTS: Twenty-seven patients were assigned to each group. The rate of chronic encephalopathy was significantly (p = 0.002) lower after modified Sugiura procedure than after portal systemic shunt. Recurrent variceal bleeding was more frequent after modified Sugiura procedure than after portal systemic shunt, but the difference is not significant. One-, two-, and three-year survival rates were 93%, 81%, and 67%, respectively, in the modified Sugiura group and 78%, 66%, and 39%, respectively, in the portal systemic shunt group (p = 0.044). CONCLUSIONS: These results suggest that the modified Sugiura procedure is better overall than the nonselective portal systemic shunt in the management of patients with cirrhosis and recurrent variceal bleeding. Although the rebleeding rate is higher after the modified Sugiura procedure, this does not seem to affect mortality in these patients.     

The changing spectrum of treatment for variceal bleeding

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Alteration of serotonergic innervation in the suprachiasmatic nucleus of the rat following removal of input fibers from retina and lateral geniculate nucleus

We report the results of sclerotherapy in 20 patients with bleeding gastric varices due to hepatic schistosomiasis. In an endemic area, patients with hepatic schistosomiasis, and bleeding gastric varices seen on endoscopy to be inferior extension of esophageal varices, were treated with emergency endoscopic injection just proximal to the cardia. Hemostasis was achieved in 17. Obliteration of varices was achieved in all patients with sclerotherapy, combined with surgery. Thirteen patients who had not been operated on in the past and consented to surgery underwent esophagogastric devascularization with splenectomy. Surgery was carried out as an emergency in the three patients who did not respond to sclerotherapy and electively in 10 patients after control of bleeding. After surgery, sclerotherapy was required for remnant varices. One patient with Child-Pugh grade C cirrhosis died of hepatic encephalopathy after control of the bleed. During a median follow-up of 9 months (range, 1-25 months), recurrence of bleeding in one patient and recurrent varices in two others were controlled with sclerotherapy. One patient had a fatal hemorrhage at home. We conclude that sclerotherapy effectively controls acutely bleeding type 1 gastric varices. Combined with esophagogastric devascularization and splenectomy, long-term results may be encouraging in patients with hepatic schistosomiasis.     

Endoscopic variceal ligation. Experience in 78 patients

Endoscopic variceal ligation (EVL) is a new alternative to sclerotherapy in the treatment of esophageal variceal hemorrhage, which results in strangulation, necrosis and scar formation of varices without systemic or local adverse effect. From May 1, 1991 through July 1, 1992, EVL was performed in 78 consecutive patients, in 35 of them it was performed during active massive bleeding, and active bleeding was controlled by the initial session in 31 patients. With repeated EVL treatment, 32 patients had their varices obliterated. The varices had reduced in size in other patients. No ligation-related complications were observed. This procedure is a safe, effective and rather simple method to treat esophageal varices, especially in patients with poor liver function and recurrent bleeding after devascularization or shunt surgery.     

An alternate low risk technique for esophageal transection in the Sugiura-Futagawa procedure

The Sugiura-Futagawa procedure is an effective non-shunting operation to treat bleeding esophageal varices. The goal of the esophageal transection is the interruption of submucosal varices. The rate of esophageal fistula reported after transection is 5 to 8 per cent. This complication has high morbidity and mortality rates. The technique and results of an alternate variant of the esophageal transection are described. After devascularization of the esophagus is achieved, the anterior muscular layer is opened, and the entire mucosal cylinder is dissected free from the muscular layer. Without opening the mucosa, a circumferential continuous running suture with fine non-absorbable material is placed, involving both mucosa and submucosa, interrupting the varicose veins. Our experience with this technique has been encouraging, having observed no stenosis or fistulization in 10 patients on whom we operated. Re-bleeding rate is low (10% in this series). The advantages of this modification are: 1) since we do not cut open the mucosal layer, we believe that the risk of fistulization is reduced, and 2) it allows an early initiation of oral feeding, thus reducing the hospital stay.     

Optimizing laparoscopic splenectomy. Technical details and experience in 59 patients

BACKGROUND: Laparoscopic splenectomy (LS), like other advanced laparoscopic procedures, is still an evolving procedure. The indications for surgery, criteria for patient selection, and operative technique are not yet well defined. We have therefore modified the standard technique for performing LS in an attempt to optimize the procedure. METHODS: Over the past 2 years, we have performed LS in 59 patients. The last 43 patients were operated using a standardized technique that we believe to be optimal. It includes the routine use of the right lateral position, operating through three trocars, the mass transection of the splenic vasculature with a vascular endoscopic stapler, and the use of a self-retaining retrieval bag. RESULTS: The average operating time was 79 min. Average blood loss was 95 cc, and average postoperative hospitalization was 2.3 days. There was one intraoperative complication and one postoperative complication. These results are superior to those we achieved earlier in our own experience, as well as to similar series that have been published recently. CONCLUSIONS: In our experience, the use of this new technique resulted in relatively short procedures with low morbidity. We believe that these results justify the use of LS as the procedure of choice for elective splenectomy in patients with normal or moderately enlarged spleens.     

Portal hypertension in schistosomiasis: a long-term follow-up of a randomized trial comparing three types of surgery

The long-term follow-up of patients with the severe form of Manson's schistosomiasis who had had elective surgical treatment for portal hypertension, in a randomized trial, was clinically evaluated. Of 94 patients, proximal splenorenal shunting was performed in 32, esophagogastric devascularization with splenectomy in 32 and distal splenorenal shunting in 30. Patients were observed during a mean of 85.7 +/- 33.1 mo, excluding nine patients (9.6%) who were lost to follow-up. Recurrence of upper gastrointestinal tract bleeding occurred in 24.1% of the patients, without statistical differences among the three groups, but rebleeding because of varices was more frequent after esophagogastric devascularization with splenectomy. Hepatic encephalopathy was significantly higher after proximal splenorenal shunting (39.3%) when compared with distal splenorenal shunting (14.8%) and with esophagogastric devascularization with splenectomy (0%). Lethality was also significantly higher after proximal splenorenal shunting (42.9%) when compared with distal splenorenal shunting (14.8%) and with esophagogastric devascularization with splenectomy (7.1%). Indirect hyperbilirubinemia was absent after esophagogastric devascularization with splenectomy and more frequent after distal splenorenal shunting (52%) although also present after proximal splenorenal shunting (29.6%). Esophagogastric devascularization with splenectomy was demonstrated to be the best option because of the absence of encephalopathy and because of low mortality rates. Hepatic encephalopathy occurred after distal splenorenal shunting but in a lesser percentage than after proximal splenorenal shunting. The higher incidence of encephalopathy and lethality proscribes proximal splenorenal shunting in Manson'schistosomiasis.     

Laparoscopy-assisted devascularization of the lower esophagus and upper stomach in the management of gastric varices

Devascularization of the lower esophagus and the upper stomach is one method of treating patients with clinically significant gastric varices. We describe a new method of laparoscopically-assisted devascularization which has been applied in seven patients with esophagogastric varices. Three of the seven patients had an episode of gastric variceal bleeding, and the remaining four had moderate to large gastric varices with red color signs. The operative procedure was carried out without pneumoperitoneum by using an ordinary forceps and laparoscopic instruments through a small skin incision (3-5 cm); the abdominal wall was elevated with a U-shaped retractor. The operative field was obtained by laparoscopic and direct vision illuminated by laparoscopic light. The procedure time ranged from 100 to 180 minutes with minimal blood loss (70-320 g). No complications were encountered. All patients could be discharged within one week; postoperative pain was minimal and all patients returned to work early. Follow-up (mean 11.4 months) showed no recurrence of gastric varices although, due to an incomplete procedure in two cases, two patients were treated additionally by endoscopic injection of histoacryl.     

Breast cancer detection by daughters of women with breast cancer

The preferred therapy for genuine stress incontinence is surgery. The Burch procedure is considered by many to be the gold standard for surgical treatment of genuine stress incontinence. The Burch procedure requires the elevation of the anterior wall of the vagina to the level of the origin of the paravaginal fascia by suspension from Cooper's ligaments. The laparoscopic performance of the Burch procedure by suturing or by endoscopic stapler mesh technique results in a decrease in the length of hospital stay, faster recovery, much shorter catheterization and less scarring due to the smaller incisions. The laparoscopic procedure provides results similar to the open operation if a meticulous technique is used. Long-term follow-up will be necessary before these procedures can be generally offered as a therapeutic alternative.     

Synthesis and dopamine receptor selectivity of the benzyltetrahydroisoquinoline, (R)-(+)-nor-roefractine

Colonic variceal bleeding is a rarity and is most commonly due to portal hypertension. The present report describes a patient with portal hypertension due to portal vein thrombosis who, following esophageal transection and successful sclerotherapy, developed a massive lower gastrointestinal bleeding from colonic varices. The literature is reviewed, and the pathophysiology of this complication is discussed. Possible etiologies of this condition may be esophageal transection and devascularization, successful sclerotherapy, and extensive thrombosis of the portal vein resulting in obliteration of the coronary-azygous anastomotic system. In such a situation other potential sites of portosystemic anastomoses, such as the colon, may be opened up, resulting in the development of colonic varices. Indeed, the incidence of colonic varices in two series after sclerotherapy for esophageal varices was 60-100%. Of 33 candidates evaluated for liver transplantation, colonic varices were found in 1.     

Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance

Continuous bleeding from a Mallory-Weiss tear required laparoscopic surgery to halt the bleeding. The oversewing of the laceration at the esophagogastric junction was readily performed under video control with endoscopic guidance and the bleeding ceased. To stop bleeding from such a tear, we prefer to use this modern approach.     

Laparoscopic colo-rectal surgery

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.     

Laparoscopic suture closure of perforated peptic ulcer. A nonrandomized comparison with open surgery

BACKGROUND: Laparoscopic vs open suture in the surgical treatment of perforated peptic ulcer were compared in a retrospective study. METHODS: The outcome of 10 patients having the laparoscopic procedure was compared with the outcome of 17 patients treated with suture via laparotomy during the same time period. RESULTS: The mortality rate and the complication rate were comparable. The laparoscopic procedure was more time consuming; hospital stay did not differ. CONCLUSIONS: The results indicate that surgery for perforated peptic ulcer can be performed with the laparoscopic technique with an outcome comparable to open surgery. No obvious advantages to the patient were noted with the laparoscopic method.     

Laparoscopic splenectomy in beta-thalassemia major patients. Advantages and disadvantages

BACKGROUND: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. METHODS: Laparoscopic splenectomy was undertaken in 12 beta-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. RESULTS: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3-6 days. CONCLUSIONS: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications.     

A novel therapeutic approach for rectal varices: a case report of rectal varices treated with double balloon-occluded embolotherapy

We present a patient with continuous melena, diagnosed as rectal varices bleeding. She had a history of esophageal varices, which was treated by endoscopic ligation therapy. Eight years after the treatment of esophageal varices, the continuous melena began. Colonoscopic examination showed that the melena was caused by rectal varices, which were so severe that they could not be treated by either endoscopic sclerotherapy or surgical devascularization. Taking into considering the overall risk of treating rectal varices, we chose the approach of double balloon-occluded embolotherapy (DBOE) with 5% ethanolamine oleate with iopamodol as a liquid embolic material. DBOE is one of the interventional radiology techniques (Morita et al., Acta Hepatol Jpn 1994;35:109-120), but in this case was a completely new and novel clinical procedure for rectal varices. After the DBOE therapy, the condition of rectal varices was markedly improved. Thus, DBOE might be a new tool for treating inoperable rectal varices.     

Laparoscopic distal resection of the pancreas with the preservation of the spleen

Management of the pancreatic diseases is still a challenge to the laparoscopic technique. Some experience has been gained in the laparoscopic exploration of the pancreas and staging in cancer. Anatomically the accessibility of the distal pancreas provides the laparoscopic approach technically feasible. Patient and method: A case of insuloma in the tail of the pancreas is presented, where distal pancreatic resection was performed laparoscopically with the preservation of the spleen. In a 55 years old female patient with typical clinical symptoms of hyperinsulinism CT identified a 3 cm large solid tumor in the tail of the pancreas. Complete mobilization of the distal pancreas was enhanced by the use of an ultrasonic dissector (UltraCision). The pancreas is detached from the splenic hilum after dividing the spleen vessels. The pancreas is transected proximally by laparoscopic linear stapler. Preservation of the short gastric vessels provides the necessary blood supply of the spleen following division of the splenic artery and vein. Thus removal of the spleen is not a necessary step in this procedure. The operation was carried out within 4.5 hours. Postoperative course was uneventful, the patient left the hospital on the 5th postoperative day. Advantages of the procedure were the earlier mobilization and shorter recovery time, less postoperative pain. The procedure can be safely performed with a good experience in both pancreatic and laparoscopic surgery.     

Laparoscopic splenectomy. Technique and results in a series of 27 cases

Between early 1992 and December 1994, laparoscopic splenectomy was performed in 27 patients with idiopathic thrombocytopenia (ITP), hairy-cell leucemia, HIV, or Hodgkin's disease. In all cases medical treatment, especially cortisone therapy, failed. In Hodgkin's disease the splenectomy was combined with liver biopsies and dissection of parailiacal, paraaortic, and mesenteric lymph nodes for abdominal staging. The operation was performed using four trocars; the splenic vessels were divided by a linear stapler. In general the spleen was removed in a bag through a slightly enlarged trocar incision or after morcellation. Three patients needed a small laparotomy for the removal (laparoscopic assisted). In a recent case of Hodgkin's disease the intact spleen was removed via posterior colpotomy. In 22 of 27 cases (81%) the operation was finished laparoscopically. Five times a conversion to conventional laparotomy was necessary because of bleeding of enlarged lymph nodes at the hilum. Wound infections occurred in two cases. In one patient with ITP the platelet count did not improve and continuous blood loss led to relaparotomy at the 1st postoperative day. No surgical bleeding was found. All patients tolerated a fluid diet at the 1st postoperative day and hospitalization time was 4.4 days (range 3-14). Regarding the low complication rate and the advantages of a smaller abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy and laparoscopic abdominal staging has a substantial benefit for the patients.     

Laparoscopic Nissen fundoplication for gastroesophageal reflux disease: clinical experience and outcome in first 100 patients

Using retrospective chart review, the authors evaluated the results of laparoscopic Nissen fundoplication in their first 100 patients. All patients were diagnosed with gastroesophageal reflux disease. More than 90% of the patients in this series were symptomatically improved, and 92% of those studied endoscopically had healed esophagitis and intact fundoplication. No deaths, esophageal injuries, or splenic injuries occurred. Laparoscopic fundoplication can be performed safely and efficiently. Using a linear stapler enables rapid and safe fundi mobilization. Selective manometrics and ambulatory pH monitoring provide excellent results. Laparoscopic Nissen is safe and as effective as the open procedure. Research centers have noted some differences in postoperative function of the lower esophageal sphincter, but symptomatically patient satisfaction is comparable.     

Extra-anal mucosectomy: laparascopic-assisted endorectal pull-through using a prolapsing technique

BACKGROUND/PURPOSE: The mucosectomy of the aganglionic rectal mucosa has been performed transabdominally in the Soave procedure. Recently, mucosectomy with transanal approach was reported both in the laparoscopic and the open surgical procedure. However, the operative view and working field are restricted because the dissection has to be done in the anal canal. The authors report an innovative approach, an extra-anal mucosectomy, to perform mucosectomy in the Soave procedure for Hirschspung's disease in combination with the laparoscopic-assisted prolapsing technique. METHODS: Four patients underwent laparoscopic surgery for Hirschsprung's disease with extra-anal mucosectomy between 1995 and 1997. One 10-mm and 5-mm ports were used throughout the operation. The rectum was pulled out through the anal canal to create a rectal prolapse and was divided outside the anal canal. The mucosectomy was performed in the everted rectal mucosa outside the anal canal to the level of dentate line. The colon was sutured to the anal mucosa 2 mm above the dentate line. Mean operative time was 3 hours. RESULTS: The present technique made the whole mucosectomy possible under direct observation. CONCLUSION: The extra-anal mucosectomy in conjunction with a laparoscopic-assisted prolapsing technique seems to be a safe and reliable modality in the surgical treatment of Hirschsprung's disease.