Laparoscopic antireflux surgery--technique and results.

Although gastroesophageal reflux disease (GERD) can be effectively treated by proton-pump inhibitors, surgery is still the only means of definitive cure of the disease. After introduction of laparoscopic surgery, there has been a clear trend to surgical repair of the incompetent cardia. The indications for surgical treatment are: endoscopically proven esophagitis, persistent or recurrent complaints under medical treatment, esophageal stricture and/or pH-metrically proven acid reflux as well as reflux-induced coughing (chronic aspiration). Although the laparoscopic antireflux operations is a technically demanding procedure, it can be performed with similar results as compared to conventional surgery. The operative technique is reported in detail. From January 1992 to March 1997, 146 consecutive patients with GERD have been operated on laparoscopically. The overall conversion rate was 8.2% (n = 12). 133 patients were operated on according to the Nissen procedure including hiatoplasty. The Toupet operation was performed in only one case. 84 men and 42 women had a mean age of 49 years (20-76). The median duration of symptoms was 48 months (1-600). Except five patients all had medical treatment for at least 2 years. Twice pneumatic balloon dilatation of an esophageal stricture was necessary preoperatively. The median operation time was 210 minutes (70-660). Conversion to open surgery because of intraoperative complications was necessary in 6 patients. Postoperative complications occurred in 14 patients, all of them being successfully treated conservatively. No patient died. 121 patients (90.3%) had follow up examinations for at least 6 months. Retreatment was necessary in 5 cases: 1x slipped Nissen (laparoscopic repair), 1x intrathoracic hernia (conventional reoperation), 2x dysphagia > 4 months postoperatively (endoscopic balloon dilatation) and 1x recurrent ulcer (conventional operation). With a correct indication, laparoscopic Nissen repair for GERD is a suitable, safe and definitive treatment.

[Prosthetic bilateral laparoscopic hernioplasty. Extra-peritoneal approach]. / Ernioplastica laparoscopica bilaterale protesica. Accesso pre-peritoneale.

The use of prosthetic mesh in inguinal hernia repairs is becoming increasingly popular. In recent years different laparoscopic procedures for prosthetic repair of inguinal hernias have been developed. The authors describe their initial experience with a totally extra-peritoneal prosthetic approach in laparoscopic repair of bilateral inguinal hernias. From November 1993 to May 1994, ten consecutive patients with bilateral primary inguinal hernias underwent laparoscopic repair under general anesthesia. A totally extra-peritoneal approach has been performed beginning through a 2 centimeter vertical midline sub-umbilical incision. Two additional trocars have been inserted on the midline: a 10/12 mm one halfway between the umbilicus and the pubis and 5 mm one 2 cm above the pubis. Average operative time was 141 minutes. Two cases were converted to traditional open Stoppa procedure because of holes made in the peritoneum during blunt dissection of the hernia sac. In the remaining 8 cases a polypropylene mesh of about 8 cm in height and 13 cm in length have been placed on each hernia site. No major complications have been observed and recovery was quick in all cases. In conclusion we think that laparoscopic hernia repair through a totally extra-peritoneal approach is technically feasible for general surgeons trained in laparoscopic surgery. Nevertheless the operation in costly and the patient's benefit in terms of rapid recovery, complications and recurrences has not yet been demonstrated in controlled prospective trials.

[The use of totally implantable systems (TIS) for long-term endovenous therapy]. / Utilizzo dei sistemi totalmente impiantabili (STI) per la terapia endovenosa prolungata.

The availability of a long-term central venous access for the management of neoplastic and chronic patients is extremely important in order to achieve an easy and safe infusion of chemotherapeutic drugs, blood components, and parenteral nutrition. The authors evaluated 26 adult patients (25 with malignant tumors and 1 with severe asthma) in whom implantable catheter systems were placed subcutaneously between February 1989 and March 1992. Catheters were inserted through the cephalic vein in 13 cases, the subclavia vein in 8 cases and jugular vein in 5 cases. The mean function time was 262 days in deceased patients and 155 in alive ones. There were no infective or thromboembolic complications. The authors, in agreement with the literature, confirm that TIS represent a safe and easy access for a long term i.v. therapy, with a very low complication rate. Furthermore, comfort of the patients is substantially improved and nursing care is greatly facilitated.

Functional and morphological effects of defibrotide on renal ischemia.

Defibrotide (Df) has been reported to protect various organs from ischemic damage. The aim of this study was to evaluate the effect of Df on renal function and morphology after warm kidney ischemia. Divided into two groups, 14 pigs underwent bilateral renal clamping for 90 min. One group (7 pigs) was treated with Df (32 mg/kg per h) for 6 h, whereas the control group received 5000 IU of heparin. Serum levels of blood urea nitrogen (BUN) and creatinine measured for 6 days were significantly higher in the control group (peak 26.8 +/- 16.7 vs 11.0 +/- 2.9 mmol/l and 501.2 +/- 351.4 vs 230.2 +/- 68.0 mumol/l P < 0.05). Renal biopsy evidenced a lesser extent of tubular and endothelial damage in Df-treated animals. In conclusion, Df provided relevant protection against renal ischemic injury.

[Pseudo-continent perineal colostomies after amputation of the rectum for cancer]. / Colostomies périnéales pseudo-continentes après amputation rectale pour cancer.

From February 1989 to February 1982, 23 pseudocontinent perineal colostomies (PC), performed after abdominoperineal excision for rectal carcinoma, were evaluated. Perineal colostomy was performed using a free autotransplant of smooth muscle, according to Schmidt, associated with colonic irrigations. This procedure was proposed to the younger and more alert patients without advanced rectal carcinoma. These 23 cases represented 35% of the rectal extirpations performed during the same period. Four patients did not accept a PC and preferred, after being fully informed about both types of colostomies, to have a classical iliac colostomy which they thought to be safer. The advantages of this procedure were mainly psychological, as the body scheme and corporeal image were not disturbed. Continence was evaluated in only 21 cases, because two patients had non-specific complications (necrosis of the colonic extremity, and colonic perforation due to enema material). Ten patients were incontinent to flatus, but did not have to wear a sanitary towel, while 11 patients had occasional, minor soiling, requiring the use of a sanitary towel. None of the patients had major incontinence requiring a secondary iliac colostomy. When asked what they thought of results, none said that they were dissatisfied. The degree of satisfaction was subjective and was not correlated with the quality of functional results as seven patients declared themselves satisfied although they had minor soiling, and conversely, two patients were not completely satisfied, even though they had no soiling. Six months after operation, the muscular transplanted ring had disappeared in half of the patients, but this did not seem to have any repercussion of the quality of functional results.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of lymphocele following renal transplantation by laparoscopic surgery.

We describe a new technique for internal drainage of lymphocele following renal transplantation performed by laparoscopy. After induction of the pneumoperitoneum, using the cautery hook, a wide opening in the lymphocele peritoneal wall has been performed allowing the lymph flow to enter the peritoneal cavity. A portion of the omentum has been pushed inside the lymphocele cavity and fixed to the parietal peritoneum in order to avoid closure of the peritoneal window. A postoperative CT scan control has shown the complete disappearance of the fluid collection. Internal drainage of lymphocele performed by laparoscopy allows a radical treatment with minimal trauma for the patient and has therefore potential advantages over the other current procedures.