Barbara Chella

Endoscopic Diverticulotomy for the Treatment of Zenker's Diverticulum: Results in 102 Patients with Staple-Assisted Endoscopy

Endoscopic diverticulotomy for the treatment of Zenkers diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30 ± 21.74 versus 29.38 ± 5.68 mm Hg; p < .01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision, predictable resolution of symptoms, and reduced morbidity.

Thoracoscopic esophagectomy: Are there benefits?

Between 1991 and 1995, 18 patients affected by a resectable intramural tumor of the esophagus underwent esophagectomy with thoracoscopic dissection of the esophagus. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty, and in 1 case, through cervical coloplasty. One cirrhotic patient died in the postoperative period due to a cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate, 5.5%; morbidity rate, 33.3%). After a median follow-up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series, and those reported by other authors, do not seem to indicate evident advantages at present for the minimally invasive procedure during resection of the esophagus for cancer. Currently, there is no indication that this procedure should be used for standard clinical use. Wider randomized trials, performed in selected centers only, and longer follow-up are needed to further evaluate the procedure.

Laparoscopic treatment of paraesophageal and large mixed hiatal hernias

AbstractBackground: Laparoscopic treatment of large mixed hiatal hernias was attempted in eight patients. Methods: One patient (12.5%) was converted to open surgery due to difficulty in repositioning the LES into the abdomen resulting from a shortened esophagus. One left pleural tear occurred intraoperatively and was repaired without further consequence. Median duration of the operation was 150 min (range 120–300 min). Results: No postoperative complications were recorded. All patients are asymptomatic after a median follow-up of 14 months (range 7–15 months). Correct repositioning of the stomach was confirmed by radiological evaluation 1 month after surgery. Early functional results are good. (One asymptomatic gastroesophageal reflux was detected and medical treatment was undertaken). Conclusions: Laparoscopic crural repair and fundoplication are feasible even in paraesophageal and large mixed hiatal hernias. Advantages of the minimally invasive approach are clear in terms of morbidity, patient comfort, and duration of hospital stay. Nevertheless, long-term assessment is required to confirm the effectiveness of the laparoscopic approach in patients with large mixed hiatal hernias.

Relapsing cutaneous Mycobacterium chelonae infection in a lung transplant patient

Lung transplant is a successful method for treating end-stage respiratory failure. Patients with immunosuppression or chronic lung diseases are accepted to be at augmented risk of infection [1]. The association of lung disease and pharmacological immunosuppression in lung transplant patients is associated with a major risk of infection that is one of the leading causes of morbidity and mortality in this group [2]. Mycobacterial infections and, in recent years, nontuberculous mycobacteria (NTM) represent a dangerous complication for solid organ transplanted recipients [3]. Treatment of NTM infection is more challenging in these patients because of drug resistance and interaction with immunosuppressive agents and enhanced toxicity. Several NTM can produce disease in solid organ transplant patients [4]. A small group of NTM is represented by rapidly growing mycobacteria as Mycobacterium fortuitum, Mycobacterium chelonae (MC)/Mycobacterium abscessus (MA) and Mycobacterium smegmatis. Known collectively, being almost identical, MC and MA were identified only with bio-molecular technology evolution, introducing ribosomal gene sequencing [5]. A review of the literature suggests that MC causes localized skin infection in immunocompetent hosts and disseminated disease in immunocompromised patients [6]. In these patients, cutaneous lesions present as red to violaceous subcutaneous nodules that evolve in abscess with multiple fistulas oozing serous or purulent fluid. Lesions can become painful only when large. Generalized symptoms of infection are typically absent [2]. Pulmonary lesions occur in about one-third of patients with cutaneous disease. Diagnosis is made by tissue culture or pathology, but is rarely immediate because of the great variability of pattern, partially depending on host’s immunological status [7]. In January 2002, a 58 years old man, underwent a single lung transplant because of rapidly progressive chronic obstructive pulmonary disease (COPD). He had complicated postoperative course including reperfusion injury, critical illness polyneuropathy and renal impairment, requiring assisted ventilation and haemodialysis for 3 months. On 97th postoperative day, thoracotomic scar presented a painless nodular cutaneous lesion 10 cm in length, with overlying pustules discharging purulent exudate 4 days later (Fig. 1). Physical examination evidenced no sign of systemic infection. At that time he was on cyclosporine 175 mg (2.4 mg/kg), prednisone 25 mg and azathioprine 100 mg, with a serum creatinine of 3.1 mg/dl and a creatinine clearance of 12.21 ml/min. Cyclosporine concentration was maintained around 300 ng/ml. Histopathology of skin biopsies showed polymorphonuclear infiltrate, mimicking bacterial infection. Cultures prepared for bacteria, fungi and mycobacteria were negative. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies (TBB) excluded rejection and pulmonary infection. Conservative treatment was performed. Affected skin excision and ‘wet to dry’ dressings were repeated twice a day until the 15th day, when skin lesion appeared completely healed. As renal function was still impaired (creatinine clearance of 20 ml/min), empiric antibiotic therapy was postponed. Cyclosporine predose ‘trough’ (C0) level was tapered down from 300 to 180 ng/ml.

Laparoscopic surgery and rectal prolapse: Personal experience

SummaryLaparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is to evaluate clinical and functional results in 4 patients subjected to laparoscopic rectopexy according to Wells. From 1993 through 1995, 4 females (mean age 53.7 years, range 22 to 76 years) affected from complete rectal prolapse with faecal incontinence underwent this procedure. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, biofeedback and electrostimulation, all patients were re-evaluated by means of a clinical examination, anorectal manometry and defecography. Preliminary results seem satisfactory and may allow this approach to be used instead of the traditional open surgery.ZusammenfassungDie Laparoskopie gewinnt bei der Behandlung benigner kolorektaler Affektionen immer mehr an Bedeutung. Ziel unserer Untersuchung war die Bewertung der klinischen und funktionellen Ergebnisse bei vier Patientinnen, die sich einer laparoskopischen Rektopexie nach Wells unterziehen mußten. Zwischen 1993 und 1995 wurden vier Frauen (Durchschnittsalter 53,7 Jahre [22 bis 76 Jahre]) mit einem kompletten Rektumprolaps mit fäkaler Inkontinenz auf diese Weise operiert. Sechs Monate post-operativ, nach Beendigung eines Rehabilitationsprogrammes mit Kinesiotherapie, Biofeedback und Elektrostimulation, wurde bei allen Patientinnen eine klinische Untersuchung durchgeführt. Die ersten Ergebnisse sind zufriedenstellend und sprechen für den Einsatz dieser Vorgehensweise anstelle der bisherigen traditionellen offenen Operationsmethode.