Replaced common hepatic artery from superior mesenteric artery during pancreaticoduodenectomy.

The hepatic arterial anatomy is highly variable. A 67 year female with pancreatic mass and replaced common hepatic artery originating from the superior mesenteric artery underwent pancreaticoduodenectomy (PD). The anomalous vessel was discovered on preoperative CT scan and MRI. The vessel was dissected and preserved as it passed dorsal to the pancreas. Preservation of the blood supply to the liver and biliary tree is important after PD to prevent biliary fistula and hepatic ischaemia.

Esophageal papillomatosis complicated by squamous cell carcinoma in situ.

We present a case of esophageal papillomatosis with underlying squamous cell carcinoma in situ. An esophageal lesion resected from a 74-year-old woman demonstrated histological findings characteristic of squamous cell papilloma (fibrovascular core and numerous finger-like projections covered with hyperplastic squamous epithelium) and severe dysplasia characteristic of squamous cell carcinoma. The relation of squamous papilloma and squamous cell carcinoma is discussed. It is suggested that esophageal squamous cell papilloma is a premalignant lesion.

Hiatal hernia recurrence: 2004.

BACKGROUND: The incidence of laparoscopic hiatal hernia recurrence is less than ideal. The reasons are more theoretical than objective, as the literature has little data in support of specific mechanisms of recurrence. METHOD: A recent literature review using all Internet-available, English-language articles on laparoscopic hernia repair was completed. RESULTS: A multitude of mechanisms of recurrence are suggested, but only surgeon inexperience, postoperative vomiting, heavy lifting, and retention of the hernia sac are supported by data. CONCLUSION: The incidence of hiatal hernia recurrence has stabilized. The role of an onlay mesh prosthesis for the prevention of hiatal hernia recurrence is under investigation, and long-term results are awaited.

Cystosarcoma phyllodes of the breast: a clinicopathological study of 11 cases.

Eleven cases of phyllodes tumour were managed at a single institute over 12 years period. All patients were females, the mean age was 48 years, painless breast lump was the commonest presentation, the left breast was affected in (55%), the upper outer quadrant was the most commonly involved site (60%). Four cases were malignant and the remaining 7 were benign. The diagnostic accuracy rate of fine needle aspiration cytology and intraoperative frozen section was 17% and 37.5% respectively. Adequate treatment was wide local excision in benign cases and simple mastectomy in malignant tumour. At a mean follow-up of 37 months the local recurrence and distant metastasis rate was 27% and 9% respectively.

Endoscopic SIS injection into the lower oesophageal sphincter in dogs.

AIM: To determine the usefulness of endoscopically-delivered small intestinal submucosa (SIS) as a scaffold in enhancing the lower oesophageal sphincter (LOS) pressures. METHODS: Six dogs were endoscopically injected--four with the SIS and two with its glycerin carrier. Manometry was performed prior to injection and every four weeks post-op. RESULTS: Adequate and site correct injections were made in four dogs. In one dog, significant augmentation of pressures were obtained at four weeks. None had significant changes in pressure at eight weeks, differences in length at either four or eight weeks or significant differences in the thickness of the examined layers. Four of the six had capillary cushions on pathological examination. The dog injected with the carrier had a loose and disorganise collection, while the others were well organised. CONCLUSION: SIS is a biologically compatible material. Lack of an animal model for gastro-oesophageal reflux disease (GORD) makes determining the ability of injections of SIS to combat reflux problematic.

The laparoscopic reoperation of failed Heller myotomy.

BACKGROUND: Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require reoperation to control persistent, or recurrent symptoms of dysphagia. We report our experience with laparoscopic reoperation for failed Heller myotomy. METHODS: Between 1996 and 2001, 5 patients underwent reoperative laparoscopic Heller myotomy. The mean age was 39 years. The presenting symptoms were persistent dysphagia ( n = 3), recurrent dysphagia ( n = 1), and weight loss ( n = 1). The mean duration between 1st surgery and recurrence of symptoms was 2 months and the mean duration between surgeries was 27.5 months. All operations were completed laparoscopically. RESULTS: There were no intraoperative or postoperative complications. Incomplete gastric myotomy was the cause of all 5 primary surgical failures. The mean hospital stay was 2 days. Mean follow-up was 12.8 months. Results were excellent in 2 patients who reported no dysphagia postoperatively (dysphagia grade 0) and good in 3 patients (60%) who all reported improvement in swallowing (dysphagia grade I-II). CONCLUSION: Laparoscopic reoperation for failed Heller myotomy is feasible with encouraging preliminary results.

The effect of diaphragmatic stressors on recurrent hiatal hernia.

Hiatal disruption is one of the common mechanisms of failure after Nissen fundoplication. We investigated the correlation between various diaphragm stressors and disruption of the diaphragmatic closure. Thirty-seven patients with a hiatal hernia recurrence of 2 cm or greater, as proven by esophagram, endoscopy, or operative findings, were included. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire for the study group and a control group of 50 patients without hiatal hernia recurrence. Logistic regression was used to determine the significant predictors of hiatal hernia recurrence. Three predictors emerged in the final model: weight lifting (P < 0.0174), vomiting (P < 0.0313) and hiccoughing (P < 0.2472). Of these, only vomiting and weight lifting were significant. The odds ratio for weight lifting is OR = 3.662 (95% CI: 1.256-10.676), and for vomiting it is OR = 4.938 (95% CI: 1.154-21.126). Vomiting or heavy weight lifting is a significant predictor of hiatal hernia recurrence.

An unusual case of gastric volvulus after laparoscopic paraesophageal hernia repair.

Laparoscopic surgery for paraesophageal hernia is well accepted. However, the complications of this relatively new procedure have not been thoroughly investigated. Only four cases of recurrent volvulus after paraesophageal hernia repair have been reported. A 52-year-old man presented with a large right-side paraesophageal hernia. He experienced a retroperitoneal midgastric volvulus despite correct orientation of the stomach distally and proximally. We report an unusual complication that seems congenital in origin. Diagnostic and corrective measures are suggested.

Bilateral choroidal metastases as the initial presentation of breast carcinoma.

A 64 year old female presented with a right eye visual impairment. On examination, the visual acuity was decreased on the right side. Slit lamp examination showed bilateral non-pigmented choroidal lesions. Physical examination was unremarkable; bilateral mammogram, however, showed a mass in the left breast, the biopsy from which confirmed the lesion as infiltrative carcinoma. Other tests were normal apart from the isotope bone scan which showed evidence of metastatic disease. She received a short course of radiotherapy to both eyes as well as a 6-month course of chemotherapy. At 6 months follow-up, the choroidal lesions were no longer present and the visual acuity had stabilized. Choroidal metastasis as the initial presentation of breast carcinoma is unusual. Any patient with an ocular tumour should undergo a systemic check-up to rule out an underlying malignancy.

Esophageal shortening during the era of laparoscopic surgery.

An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia > or = 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.

Type IV hiatal hernia post laparoscopic Nissen fundoplication: report of a case.

A postoperative hiatal hernia is a rare but serious complication of fundoplication. We report herein a 62-year-old female who presented with abdominal pain and vomiting 2 years following laparoscopic Nissen fundoplication. At laparotomy, the stomach and the transverse colon were intrathoracic (type IV hiatal hernia); the esophageal hiatus was markedly dilated with no evidence that they had been approximated. At 18 months follow-up, she is doing very well apart from occasional heartburn. A high index of suspicion is needed to diagnose postoperative hiatal hernias. A routine closure of the crura with nonabsorbable suture material and an avoidance of iatrogenic pneumothorax may help to reduce the occurrence of this problem.

Laparoscopic reoperative antireflux surgery.

BACKGROUND: Antireflux operations for gastroesophageal reflux disease whether performed open or laparoscopically can fail and may require reoperation to control new, recurrent symptoms or operation-related complications. We report our experience with the laparoscopic reoperation for failed antireflux procedures. METHODS: Between 1995 and 2000, 37 patients underwent laparoscopic reoperative antireflux procedures. The mean age and weight were 52 years and 181.5 pounds. The main presenting symptoms were heartburn (n = 18), respiratory reflux (n = 4), chest pain (n = 3), regurgitation (n = 1), and dysphagia (n = 10). The mean duration between the first operation and recurrence of symptoms was 18 months, and the duration between the two procedures was 25 months. The operation was completed laparoscopically in 32 patients (86.5%): Nissen fundoplication (n = 27) and Toupet fundoplication (n = 9). RESULTS: Intraoperative and postoperative complications occurred in 6 and 14 patients, respectively. Fundoplication disruption was the most common cause of primary surgery failure. The mean hospital stay was 4 days. At a mean follow-up of 26.5 months, results were excellent to good (65%), fair (21.5%), and poor (13.5%). CONCLUSION: Laparoscopic reoperative antireflux procedures are technically feasible with acceptable preliminary results.

Cecal herniation through the foramen of Winslow after laparoscopic Nissen fundoplication.

Laparoscopic Nissen fundoplication is the treatment of choice for medically refractive gastroesophageal reflux disease. Cecal herniation is an exceedingly rare complication of this procedure. We report the case of a 51-year-old woman who presented 2 months after a successful laparoscopic Nissen fundoplication with heartburn and epigastric pain that radiated to her back. Abdominal films showed an air-filled loop in the left upper quadrant. At surgery, the patient had a redundant loop of cecum, which had herniated through the foramen of Winslow over the stomach and was positioned beneath the left hemidiaphragm. The cecum was not ischemic. A right hemicolectomy was performed to prevent recurrence. The patient recovered fully and has had no further problems. This is the first report of such a case.

The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia.

BACKGROUND: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing. METHODS: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment. Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length two standard deviations below the mean for height was considered abnormally short. RESULTS: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's esophagus was the most sensitive test for predicting the need for a lengthening procedure. CONCLUSIONS: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.