[Giant adrenal cyst]. / Kyste surrénalien géant.

Adrenal cysts are a rare entity which makes their treatment somewhat tough. Discovered in a fortuitous way or in the course of explorations for very aspecific symptoms, it is necessary to decide on a case-by-case basis, and after a careful clinical examination, whether the lesion is to be treated through surgery or if a follow-up iconography is sufficient. Three main parameters will influence this choice: the functional status of the cyst, its malignant potential and the potential complications related to the cyst. Current recommendations suggest a surgical treatment for all symptomatic cysts, for functional cysts, for cysts with a diameter exceeding 5 cm, for hemorrhagic cysts and for cysts with malignant imaging potential. The progress and surgical advantages brought by the development of laparoscopy make it the first technique to be chosen.

Les kystes surrénaliens sont une entité rare, ce qui rend leur prise en charge mal systématisée. Découverte de façon fortuite ou dans les suites d'explorations pour des symptômes très aspécifiques, il faudra par une démarche clinique minutieuse décider au cas par cas si la lésion est redevable d'une intervention chirurgicale ou si un simple suivi iconographique est suffisant. Trois paramètres principaux influencent ce choix : le statut fonctionnel du kyste, le potentiel malin du kyste et les complications potentielles en rapport avec le kyste. Les recommandations actuelles suggèrent un traitement chirurgical pour tous les kystes symptomatiques, fonctionnels, dont le diamètre dépasse 5 cm, hémorragiques et avec un potentiel malin douteux à l'imagerie. Les progrès et les avantages chirurgicaux apportés par le développement de la laparoscopie en font la techique d'abord de choix.

Is there a proper way to treat shortened oesophagus? About a series of 67 patients.

INTRODUCTION AND OBJECTIVE: During the work-up of gastro-oesophageal reflux disease (GORD) patients, barium swallow may show a shortened oesophagus with a non-reducible gastro-oesophageal junction. In our department, in such cases, a Collis-Nissen operation is usually planned. But, the proper reducibility of the gastro-oesophageal junction (GOJ) in the abdomen is difficult to assess peroperatively. The aim of this study is to compare retrospectively the follow-up of an oesophageal lengthening procedure (Collis-Nissen gastroplasty) versus a standard Nissen in the management of patients with primary short oesophagus or secondary to previous Nissen fundoplication. PATIENTS AND METHODS: Between 01/2000 and 12/2009, 67 patients with a short oesophagus on X-Ray were operated on for proven GORD: 27 (Group A) underwent a Collis-Nissen fundoplication. In 40 patients (Group B), the GOJ was reduced easily and a standard Nissen fundoplication was judged sufficient by the experimented surgeon. Follow up included Quality of Life evaluation using the Gastrointestinal Quality of Life Index (GIQLI) and a barium swallow. RESULTS: 64 patients agreed to participate. Mean follow up was 46 months (4-122). Mean postoperative GIQLI score was 108 in group A, 97 in group B. Barium swallow was performed in 61 patients. In group A, seven patients out of 25 (28%) presented a intrathoracic migration on X-Ray while in group B, it was noted in 20 patients (55%). CONCLUSION: According literature, Collis gastroplasty allows a tension-free fundoplication to be performed to correct a shortened oesophagus. Though our series of brachy-oesophagus is small, it confirms a better outcome after a Collis-Nissen gastroplasty, compared to the classical Nissen fundoplication.

Laparoscopic treatment of Barrett's esophagus: long-term results.

BACKGROUND: Gastroesophageal reflux disease (GERD) is considered the main etiologic process in the metaplastic development of Barrett's esophagus (BE). The most serious complication of BE is the possible dysplastic evolution to esophageal carcinoma. Many treatments have been described to prevent the progression of BE. The outcomes of these interventions are controversial. The aim of this study was to assess whether laparoscopic fundoplication for GERD had an impact on the development of BE. METHODS: Prospective data were collected from patients who were treated with a laparoscopic fundoplication for BE. Data was collected and analyzed for a variety of clinical and pathologic outcomes. RESULTS: Laparoscopic fundoplications were completed between 1993 and 2001, with a total sample size of 92 (mean age 53 +/- 11.8 years). Each patient was diagnosed with GERD associated with BE confirmed by both endoscopy and biopsy. A laparoscopic fundoplication was performed in all patients (360 degree fundoplication in 81 patients and partial fundoplication in 11 patients). There was no postoperative mortality or major complications from the procedure. The mean postoperative stay was 3 +/- 1 days. Seventy patients (76% of the overall sample size) were followed up for a mean 4.2 +/- 2.6 years. Of the patients available for follow-up, 33% (n = 23) had a complete regression of their BE; 21% (n = 15) had a decrease in the degree of metaplasia/dysplasia; 39% (n = 27) had no significant change; and 7% (n = 5) experienced a progression of the BE. Five patients required further procedures for three reasons: (1) GERD recurrence (n = 2), (2) progression of BE (n = 2), and (3) intrathoracic migration (n = 1). No patients developed high-grade dysplasia or esophageal carcinoma. CONCLUSIONS: The results of this study suggest that laparoscopic fundoplication offers a safe and effective long-term treatment for BE. The procedure also demonstrated regression of BE in more than 50% of the sample size.

Clinical results of laparoscopic fundoplication at ten years after surgery.

BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery. METHODS: The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years. RESULTS: Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.

What becomes of patients one year after the intragastric balloon has been removed?

BACKGROUND: The BioEnterics Intragastric Balloon (BIB) is a saline-filled balloon recommended to remain in the gastric cavity for a maximum of 6 months. Is this short period sufficient to change patients' lifestyle and eating practices to maintain weight reduction after BIB removal? METHODS: 100 patients who received a BIB were included in this prospective study and followed for 1 year after BIB removal. The post-implantation follow-up visits took place monthly, during which the patient was seen by the surgeon, dietitian, and if necessary, psychologist. RESULTS: At BIB removal, mean weight loss for the group was 12.0 kg. Mean percent excess weight loss (%EWL) was 39.8%. 12 months after removal of the BIB, mean weight loss was 8.6 kg and mean %EWL was 26.8% for the group as a whole. CONCLUSIONS: The results 1 year after removal of the BIB were encouraging. Because the BIB is a temporary non-surgical and non-pharmaceutical treatment for obesity that is reversible and repeatable, we recommend it to patients who have previously failed traditional methods of weight reduction. Careful patient follow-up is of primary importance in avoiding complications and supporting efficacy of the treatment. Although 1 year follow-up cannot be considered long term, these results are encouraging. Concurrent behavior modification is needed for durable weight loss.

Intravaginal slingplasty: short term results.

BACKGROUND: Numerous surgical techniques have been described for the treatment of vaginal vault prolapses. In 1997, a new minimally invasive procedure was introduced by Petros: the infracoccygeal sacropexy, also known as Intravaginal Slingplasty (IVS). This technique is used to place a mesh in the recto-vaginal fascia and to reinforce the uterosacral ligament by placing a polypropylene tape between the perineum and the vaginal vault. Since July 2002, we have changed our approach to the treatment of vaginal vault prolapses and now perform IVS. The aim of this study was to report our early experience and short-term results with IVS. METHODS: Prospective single-institution non-randomized trial of patients who underwent IVS. Indications, intra- and post-operative complications were recorded as well as early post-operative results. RESULTS: 34 patients with a mean age of 60+/-13 years, were operated during a 12-month period. Surgical indications included rectoceles (n = 27), enteroceles (n = 26), cystoceles (n = 15) and hysteroceles (n = 9). 85% of the patients (n = 29) had more than one prolapse. Mean operative time was 63+/-19 minutes, with a 0% intra-operative complication rate. Post-operative complication rate was 2.9%: bleeding from an internal haemorrhoid required surgical haemostasis. Median post-operative stay was 3 days (range: 2-7 days). There was also one post operative complication (2.9%, a mesh erosion). Recurrence rate was 8.8% (two cystoceles and one rectocele recurred after surgery). CONCLUSION: Posterior IVS provides a safe and efficacious treatment for posterior vaginal vault prolapses. Long-term results are required to assess the functional results and recurrence rate of the technique.

[Adenocarcinoma of the pancreas. Palliative surgery]. / Adénocarcinome du pancréas. Chirurgie palliative.

In case of unresectable adenocarcinoma of the pancreas, laparoscopy can allow to perform gastric and biliary by-pass which will improve the quality of life at a lower cost than conventional surgery for the patients.

[Adenocarcinoma of the pancreas. Preoperative staging]. / Adénocarcinome du pancréas. Staging préopératoire.

The authors assess the value of laparoscopy in the preoperative staging of the adenocarcinoma of the pancreas to prevent unnecessary pancreatic resections in a disseminated disease. By laparoscopy, a macroscopic evaluation, a peroperative liver and pancreas ultrasonography as well as biopsies are possible and are more accurate in assessing the extent of the disease than other means.

Successful revascularization of an orthotopic liver transplant (OLT) with the recipient right gastroepiploic artery.

A technique for revascularizing the arterial supply to an orthotopic liver transplant (OLT) in a 55-year-old male afflicted with end-stage alcoholic liver cirrhosis with portal hypertension is reported. The presence of well-developed portosystemic collaterals and an unsuitable recipient common hepatic artery necessitated the dissection and liberation of the right gastroepiploic artery (RGEA) for its subsequent use as the recipient arterial source. Posttransplantation, save for an early biliary leak which was corrected promptly, the patient's evolution was uneventful. Two separate celiac angiographic series at 6 weeks and 20 months posttransplantation revealed an excellent flow through the recipient and donor arterial systems. Additionally, the RGEA demonstrated an adaptation in caliber when pre- and posttransplantation angiograms were compared. It was concluded that the RGEA is a suitable rescue option for revascularization of OLT's provided it satisfies elementary hemodynamic requirements.

[Surgical aspects of the treatment of adrenal gland diseases]. / Aspects chirurgicaux du traitement des affections surrénaliennes.

With the greatly enhanced accuracy of current endocrinologic diagnosis assisted by precise diagnostic imaging, together with greatly enhanced preparation of patients with endocrinopathy for safer anesthetic and surgical procedure (e.g. adrenal cortical cancers, cortisol and aldosterone producing adenomas and pheochromocytomas), operative procedures can be planned and conducted more precisely. For the surgeon, the strategy for treatment of functional and neoplastic disorders of the adrenal glands has essentially to consider the anatomy of the suprarenal glands, the deleterious effects of hormone excess before and during operation, the presumed nature of incidentally discovered adrenal mass and the size of the tumor.

Experience with a totally implantable catheter in adult patients: a single institution retrospective study of 114 cases.

One hundred and fourteen consecutive totally implantable catheters were inserted in 114 patients between April 1984 and April 1987. Catheters were inserted under neuroleptanalgesia, through the jugular vein in 101 cases or the internal saphenous vein in 13 cases. No problem was encountered during the insertion procedure. Infection occurred in 5.2% of the patients but removal of the device was required in only 2.6%. Occlusion of the catheter occurred in 6.1% of the patients but never during the first 2 months. This complication rate is lower than the one observed with external tunnelled catheters. The comfort of the patient is substantially improved and nursing care is greatly facilitated.

[Primary pulmonary hemangiopericytoma in children. Apropos of a case]. / Hémangiopéricytome pulmonaire primitif chez l'enfant. A propos d'un cas.

One case of primary pulmonary hemangiopericytoma in a 4 year child is reported; hemangiopericytoma has been found at any age and at any site, however pulmonary location has never been described before in a child under 10 years. Histology, natural history, prognosis and treatment are briefly discussed.