The surgical management of spontaneous esophageal perforation (Boerhaave's syndrome) ‒ 20 years of experience.

Spontaneous esophageal perforation (Boerhaave's syndrome) is an uncommon and challenging condition with significant morbidity and mortality. Surgical treatment is indicated in the large majority of cases and different procedures have been described in this respect. We present the results of a mono-institutional evaluation of the management of spontaneous esophageal perforation over a 20-year period. The charts of 25 patients with spontaneous esophageal perforation treated at the Surgical Department of the University Hospital of Lausanne were retrospectively studied. In the 25 patients, 24 patients were surgically treated and one was managed with conservative treatment. Primary buttressed esophageal repair was performed in 23 cases. Nine postoperative complications were recorded, and the overall mortality was 32%. Despite prompt treatment postoperative morbidity and mortality are still relevant. Early diagnosis and definitive surgical management are the keys for successful outcome in the management of spontaneous esophageal perforation. Primary suture with buttressing should be considered as the procedure of choice. Conservative approach may be applied in very selected cases.

[Non-neoplastic esophageal stenosis: not always so benign]. / Sténose œsophagienne non-néoplasique: pas toujours si bénigne.

Esophageal intramural pseudodiverticulosis is a rare pathology whose etiology is unknown, but which is frequently associated with three highly prevalent entities: esophageal reflux disease, esophageal candidosis and alcoholic esophagitis. With conservative treatment the course of these pathologies is usually benign. However, some severe cases are resistant to conservative treatment and may require more aggressive management. We here present the case of patient suffering from a severe esophagitis complicated by chronic mediastinitis with life-threatening repercussions, requiring esophagectomy as treatment.

La pseudodiverticulose œsophagienne intramurale est une pathologie rare, d'étiologie inconnue, mais fréquemment associée à trois entités hautement prévalentes: la maladie de reflux, la candidose œsophagienne et l'œsophagite alcoolique. L'évolution de ces pathologies est habituellement bénigne avec un traitement conservateur. Certains cas sévères nécessitent toutefois une prise en charge plus agressive. Nous présentons ici le cas d'un patient souffrant d'une œsophagite sévère compliquée d'une médiastinite chronique avec des répercussions menaçant sa survie, ayant nécessité une prise en charge chirurgicale agressive.

Cost-effective utilization of a private facility to perform outpatient surgery in public hospital waiting list patients.

BACKGROUND: Public hospitals' long waiting lists make outpatient surgery in private facilities very attractive provided a standardized protocol is applied. The aim of this study was to assess this kind of innovative collaboration in abdominal surgery from a clinical and economical perspective. METHODS: All consecutive patients operated on in an outpatient basis in a private facility by a public hospital abdominal surgeon and an assistant over a 5-year period (2004-2009) were included. Clinical assessment was carried out from patients' charts and satisfaction questionnaire, and economic assessment from the comparison between the surgeons' charges paid by the private facility and the surgeons' hospital salaries during the days devoted to surgery at the private facility. RESULTS: Over the 5 years, 602 operative procedures were carried out during 190 operative days. All patients could be discharged the same day and only 1% of minor complications occurred. The patients' satisfaction was 98%. The balance between the surgeons' charges paid by the private facility and their hospital salary costs was positive by 25.8% for the senior surgeon and 12.6% for the assistant or, on average, 21.9% for both. CONCLUSION: Collaboration between an overloaded university hospital surgery department and a private surgical facility was successful, effective, safe, and cost-effective. It could be extended to other surgical specialities.

Redistribution of gastric blood flow by embolization of gastric arteries before esophagectomy.

BACKGROUND: Anastomotic leak remains a common and potentially deleterious complication after esophagectomy. Preoperative embolization of the left gastric artery and splenic artery (PAE) has been suggested to lower anastomotic leak rates. We present the results of our 5-year experience with this technique. METHODS: All patients undergoing PAE before esophagectomy since introduction of this technique in 2004 were compared in a 1:2 matched-pair analysis with patients without PAE. Matching criteria were type of anastomosis, neoadjuvant treatment, comorbidity, and age. Data were derived from a retrospective chart review from 2000 to 2006 that was perpetuated as a prospective database up to date. Outcome measures were anastomotic leak, overall complications, and hospital stay. RESULTS: Between 2000 and 2009, 102 patients underwent esophagectomy for cancer in our institution with an overall leak rate of 19% and a mortality of 8%. All 19 patients having PAE since 2004 were successfully matched 1:2 to 38 control patients without PAE; both groups were similar regarding demographics and operation characteristics. Two PAE (11%) and 8 control patients (21%) had an anastomotic leak, but the difference was statistically not significant (p=0.469). Overall and major complication rates for PAE and control group were 89% versus 79% (p=0.469) and 37% versus 34% (p=1.000), respectively. Median intensive care unit and hospital stay were 3 versus 3 days (p=1.000) and 22 versus 17 days (p=0.321), respectively. CONCLUSIONS: In our experience, PAE has no significant impact on complications and anastomotic leak in particular after esophagectomy.

A tailored approach for the treatment of indirect inguinal hernia in adults--an old problem revisited.

PURPOSE: A patent processus vaginalis peritonei (PPV) presents typically as an indirect hernia with an intact inguinal canal floor during childhood. Little is known however about PPV in adults and its best treatment. METHODS: A cohort study included all consecutive patients admitted for ambulatory open hernia repair. In patients with a PPV, demographics, hernia characteristics, and outcome were prospectively assessed. Annulorrhaphy was the treatment of choice in patients with an internal inguinal ring diameter of <30 mm. RESULTS: Between 1998 and 2006, 92 PPVs (two bilateral) were diagnosed in 676 open hernia repairs (incidence of 14%). Eighty nine of the 90 patients were males, the median age was 34 years (range: 17-85). A PPV was right-sided in 67% and partially obliterated in 66%. Forty-one patients had an annulorrhaphy and 51 patients had a tension-free mesh repair. The median operation time was significantly shorter in the annulorrhaphy group (38 vs. 48 min, P<.0001). In a median follow-up period of 56 months (27-128), both groups did not differ concerning recurrence (1/41 vs. 2/51), chronic pain (3/41 vs. 4/51), and hypoesthesia (5/41 vs. 9/51). There was however a clear trend to less neuropathic symptoms in favor of annulorrhaphy (0/41 vs. 5/51, P < 0.066). CONCLUSIONS: PPV occurs in 14% of adults undergoing hernia repair. In selected patients, annulorrhaphy takes less time and is associated with equally low recurrence but less potential for neuropathic symptoms.

Fibrin sealant for mesh fixation in endoscopic inguinal hernia repair: is there enough evidence for its routine use?

Fibrin sealing has recently evolved as a new technique for mesh fixation in endoscopic inguinal hernia repair. A comprehensive Medline search was carried out evaluating fibrin sealant for mesh fixation, and finally 12 studies were included (3 randomized trials, 3 nonrandomized trials, and 6 case series). The trials were assessed for operative time, seroma formation, recovery time, recurrence rate, and acute and chronic pain.There was a trend toward decreased operative times for fibrin sealing compared with mechanical stapling; however, the results for seroma formation remained contradictory. The most important finding was the reduced postoperative pain. Recovery times were lower after fibrin sealing and the recurrence rates showed no differences.Fibrin sealing for mesh fixation in the endoscopic inguinal hernia surgery is a promising alternative to mechanical stapling, which can be safely applied. As the overall quality of published data remains poor, further well-designed studies are needed until fibrin sealing can replace mechanical stapling as a new standard for mesh fixation.

Neuropathy after herniorrhaphy: indication for surgical treatment and outcome.

BACKGROUND: Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. METHODS: In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel's sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. RESULTS: Forty-three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45-95 min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12 months (preoperative 74 [range: 53-87] months versus 0 [range: 0-34] months; p<0.0001). CONCLUSIONS: The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.

Identification of tumor-associated antigens by large-scale analysis of genes expressed in human colorectal cancer.

Despite the high prevalence of colon cancer in the world and the great interest in targeted anti-cancer therapy, only few tumor-specific gene products have been identified that could serve as targets for the immunological treatment of colorectal cancers. The aim of our study was therefore to identify frequently expressed colon cancer-specific antigens. We performed a large-scale analysis of genes expressed in normal colon and colon cancer tissues isolated from colorectal cancer patients using massively parallel signal sequencing (MPSS). Candidates were additionally subjected to experimental evaluation by semi-quantitative RT-PCR on a cohort of colorectal cancer patients. From a pool of more than 6000 genes identified unambiguously in the analysis, we found 2124 genes that were selectively expressed in colon cancer tissue and 147 genes that were differentially expressed to a significant degree between normal and cancer cells. Differential expression of many genes was confirmed by RT-PCR on a cohort of patients. Despite the fact that deregulated genes were involved in many different cellular pathways, we found that genes expressed in the extracellular space were significantly over-represented in colorectal cancer. Strikingly, we identified a transcript from a chromosome X-linked member of the human endogenous retrovirus (HERV) H family that was frequently and selectively expressed in colon cancer but not in normal tissues. Our data suggest that this sequence should be considered as a target of immunological interventions against colorectal cancer.

The role of COX-2 in rectal cancer treated with preoperative radiotherapy.

Radiotherapy is one of the principal modalities of rectal cancer treatment, and the ability to predict radio resistance could potentially improve survival through a targeted treatment approach. Cyclooxygenase-2 (COX-2) may protect against damage by irradiation that would justify the use of COX-2 inhibitors. The purpose of this study was to investigate the potential role of COX-2 in tumor response and outcome of patients with rectal cancer treated preoperatively with radiotherapy. Using immunohistochemistry, we examined COX-2 expression in 88 surgical specimens of rectal cancer treated preoperatively and in 26 pretherapeutic biopsies. We tested whether COX-2 expression was correlated with clinico-pathologic parameters and with survival and local recurrence. COX-2 was expressed in 50% of the pretherapeutic tumor biopsies and in 88.6% of post-irradiated surgical samples. COX-2 expression was correlated only with enhanced tumor inflammation (p = 0.03) and with tumor volume exceeding 30 cc (p = 0.05). COX-2 was not significantly correlated with patient survival, but none of the patients with COX-2 negative tumors did recur locally, whereas 80% of patients with local recurrences have COX-2 positive tumors. We conclude that COX-2 expression is overexpressed in the majority of rectal cancers treated with radiotherapy and likely plays a role in local relapse.

[Surgery]. / Chirurgie.

2007 was marked by a growing trend towards minimal invasive surgery and enhanced recovery, especially in visceral surgery. In comparison to the laparoscopic revolution in the eighties, Natural orifice transluminal endoscopic surgery (NOTES) must be watched on closely, and will probably have to be taken into account in a near future. Minimal invasive procedures in oesophageal cancer surgery have proved both efficient and oncologically safe. Implementation of Fast track protocols now permits a much faster patient's return to normal daily activity. In hepatobiliary and pancreatic surgery, multidisciplinary efforts have been done to better select patients, widen the indications and increase efficiency.

Immunogenicity of the carcinoembryonic antigen derived peptide 694 in HLA-A2 healthy donors and colorectal carcinoma patients.

Carcinoembryonic antigen (CEACAM5) is commonly overexpressed in human colon cancer. Several antigenic peptides recognized by cytolytic CD8+ T-cells have been identified and used in colon cancer phase-I vaccination clinical trials. The HLA-A*0201-binding CEA(694-702) peptide was recently isolated from acid eluted MHC-I associated peptides from a human colon tumor cell line. However, the immunogenicity of this peptide in humans remains unknown. We found that the peptide CEA(694-702) binds weakly to HLA-A*0201 molecules and is ineffective at inducing specific CD8+ T-cell responses in healthy donors. Immunogenic-altered peptide ligands with increased affinity for HLA-A*0201 were identified. Importantly, the elicited cytolytic T lymphocyte (CTL) lines and clones cross-reacted with the wild-type CEA(694-702) peptide. Tumor cells expressing CEA were recognized in a peptide and HLA-A*0201 restricted fashion, but high-CEA expression levels appear to be required for CTL recognition. Finally, CEA-specific T-cell precursors could be readily expanded by in vitro stimulation of peripheral blood mononuclear cell (PBMC) from colon cancer patients with altered CEA peptide. However, the CEA-specific CD8+ T-cell clones derived from cancer patients revealed low-functional avidity and impaired tumor-cell recognition. Together, using T-cells to demonstrate the processing and presentation of the peptide CEA694-702, we were able to corroborate its presentation by tumor cells. However, the low avidity of the specific CTLs generated from cancer patients as well as the high-antigen expression levels required for CTL recognition pose serious concerns for the use of CEA694-702 in cancer immunotherapy.

Molecular and immunological evaluation of the expression of cancer/testis gene products in human colorectal cancer.

Tumor-specific gene products, such as cancer/testis (CT) antigens, constitute promising targets for the development of T cell vaccines. Whereas CT antigens are frequently expressed in melanoma, their expression in colorectal cancers (CRC) remains poorly characterized. Here, we have studied the expression of the CT antigens MAGE-A3, MAGE-A4, MAGE-A10, NY-ESO-1 and SSX2 in CRC because of the presence of well-described HLA-A2-restricted epitopes in their sequences. Our analyses of 41 primary CRC and 14 metastatic liver lesions confirmed the low frequency of expression of these CT antigens. No increased expression frequencies were observed in metastatic tumors compared to primary tumors. Histological analyses of CRC samples revealed heterogeneous expression of individual CT antigens. Finally, evidence of a naturally acquired CT antigen-specific CD8(+) T cell response could be demonstrated. These results show that the expression of CT antigens in a subset of CRC patients induces readily detectable T cell responses.

Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy.

BACKGROUND: Laparoscopic surgery during pregnancy is a challenging procedure that most surgeons are reluctant to perform. The objective of this study was to evaluate whether laparoscopic appendectomy and cholecystectomy is safe in pregnant women. The management of these situations remains controversial. We report a single center study describing the successful management of 16 patients during pregnancy. METHODS: More than 3,356 laparoscopic procedures were performed in our institutions between May 1990 and June 2005. Sixteen of these patients were operated on in the second and third trimester between 22 and 32 weeks of estimated gestational age. We performed 11 laparoscopic appendectomies and 5 laparoscopic cholecystectomies. We also reviewed the management and operative technique used in these patients. RESULTS: In this study, the laparoscopic appendectomy or cholecystectomy was performed successfully in all patients. Three patients were in their second trimester, weeks 22, 23, and 25, and 13 were in the third trimester, weeks 27 (three patients), 28 (five patients), 31 (three patients), and 32 (two patients). No maternal or fetal morbidity occurred. Open laparoscopy was performed safely in all patients and all patients delivered healthy babies. CONCLUSION: From our experience laparoscopic management of appendicitis and biliary colic during pregnancy is safe, however the second trimester is preferable for laparoscopic cholecystectomy. Pregnancy is not a contraindication to the laparoscopic approach to appendicitis or symptomatic cholelithiasis. We believe that laparoscopic operations, when performed by experienced surgeons, are safe and even preferable for the mother and the fetus.

[Treatment of acute diverticulitis]. / Traitement actuel de la diverticulite colique.

In Western countries, diverticular disease is a frequent condition and the prevalence of which increases with age. Acute diverticulitis is its most frequent complication. CT-scan is now the best exam for diagnosis of acute diverticulitis, classification of its severity, and for follow-up. It can also, when necessary, allow percutaneous drainage of pericolic abscesses. Treatment of acute diverticulitis is most often conservative. Surgery outside acute events is now considered as a technique with extremely low morbidity and mortality. In this situation, laparoscopy represents nowadays the technique of choice for safe sigmoid surgery.

Is the effect of inguinal field block with 0.5% bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S(+) ketamine?

OBJECTIVE: The aim of the study was to assess whether coadministration of S(+) ketamine or ketorolac would enhance or prolong local analgesic effect of bupivacaine after inguinal hernia repair. DESIGN: Prospective double-blind randomized study evaluating pain intensity after surgery under general anesthesia. SETTING: Outpatient facilities of the University Hospital of Lausanne. PATIENT: Thirty-six ASA I-II outpatients scheduled for elective day-case inguinal herniorraphy. INTERVENTION: Analgesia strategy consisted of a wound infiltration and an inguinal field block either with 30 mL bupivacaine (0.5%) or with the same volume of a mixture of 27 mL bupivacaine (0.5%) + 3 mL S(+) ketamine (75 mg) or a 28 mL bupivacaine (0.5%) + 2 mL ketorolac (60 mg). Postoperative analgesic regimen was standardized. OUTCOME MEASURES: Pain intensity was assessed with a Visual Analog Scale, a verbal rating score, and by pressure algometry 2, 4, 6, 24, and 48 hours after surgery. RESULTS: The 3 groups of patients experienced the highest Visual Analog Scale pain score at 24 hours, which was different from those at 6 and 48 hours (P < 0.05). Apart from a significantly lower pain sensation (verbal rating score) in the ketorolac group at 24 and 48 hours and only at 48 hours with ketamine, there were no other differences in pain scores, pain pressure thresholds, or rescue analgesic consumption between groups throughout the 48-hour study period. CONCLUSION: The addition of S(+)-ketamine or ketorolac only minimally improves the analgesic effect of bupivacaine. This may be related to the tension-free hernia repair technique associated with low postoperative pain.

Laparoscopic cholecystectomy as a day surgery procedure: implementation and audit of 136 consecutive cases in a university hospital.

Laparoscopic cholecystectomy (LC) has been routinely performed since 1989 at our institution, and patients were traditionally admitted for 2 days. In 1996 we implemented a protocol for LC as a day surgery procedure at our center. Although initially reported by others, it has not yet been introduced as routine in Switzerland. The objective of this prospective study was to determine acceptability and safety of LC as an outpatient procedure in a university hospital. Data were collected prospectively for 136 LCs between January 1996 and December 2001. Patients were selected for the study if they wanted to go home within less than 24 hours, had no previous jaundice, and had no anesthetic contraindication. Systematic preoperative liver function tests and hepatic ultrasonography were performed. All patients were admitted on the day of operation. LC was performed using a three-trocar technique. Systematic cholangiography was performed, and all the procedures were completed laparoscopically. There were no common bile duct explorations. Postoperative complications were the following: nausea in seven patients, a minor umbilical hematoma in two. According to patient preference, 101 (74%) were discharged after an overnight stay (less than 24 hours) and 32 (24%) on the same day. The unplanned admission rate was 2%, and none of the patients was subsequently readmitted. The reasons for unplanned admissions were two patients with persistent nausea and one patient for whom an overnight stay was scheduled who presented with a ruptured subcapsular hematoma of the liver. Altogether, 97% of the patients were satisfied with the care they received. Operative costs were not significantly different when comparing inpatient and outpatient LC. The main postoperative savings were in the postoperative costs. Our results confirm that LC as a day surgery procedure is safe, effective, and acceptable to patients and their relatives. These results were achieved by using selection criteria that considered not only the surgical pathology but also the individual and by using appropriate techniques and planned postoperative analgesia.