I. El Nakadi

Nissen versus Toupet fundoplication: Results of a randomized and multicenter trial

BackgroundLaparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after a laparoscopic NF or TF.Patients and methodsInclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF and 63 TF were performed. The severity of symptoms was assessed before and after the procedure.ResultsOne hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high after one or three years regardless of the type of fundoplication performed.ConclusionsFunctional complications after NF are not avoided with TF.

Minimally invasive approach to Boerhaave's syndrome: A pilot study of three cases

BackgroundBoerhaave’s syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives.Material and methodsOver a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting.ResultsEsophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively.ConlusionsBoerhaave’s syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.

Small cell carcinoma of the esophagus: a multicentre Rare Cancer Network study.

Small cell carcinoma of the esophagus (SCCE) is a rare and aggressive malignant tumor with a poor prognosis. The aims of this retrospective study were to analyze the epidemiology, clinical characteristics, and treatment outcomes of these patients. Between 1994 and 2004, 24 patients with SCCE from several centers were reviewed for data on demographics, presenting symptoms, diagnosis, disease stage, type of treatment, and outcome. SCCE occurs in the sixth decade: median age (interquartile range [IQR]): 65 (59-69) years with a male predominance (63%). The most common complaining symptoms were rapidly progressive dysphagia (79%), weight loss (54%), and retrosternal/epigastric pain (46%). The tumor arises primarily in the middle (52%) or in the lower (35%) third of the esophagus. History of tobacco and alcohol exposure was present in 90% and 70% of case, respectively. Extensive disease was present in 13 cases (54%) at initial diagnosis. The overall median survival (IQR) was 11 (8-20) months for all 24 patients, and the 2-year overall survival was 25.1%. Four patients were alive more than 2 years after treatment. Chemotherapy increased the survival compared with symptomatic management in extensive disease (median survival [IQR]: 9.5 [6-14] vs. 6 [4-7] months, P= 0.05). In limited disease, concurrent chemo-radiotherapy was more effective than non-concurrent treatment (median survival [IQR]: 36 [14-93] vs. 11 [9-15] months, P= 0.04). Two patients were treated by surgery and chemoradiation therapy with a survival of 35 and 66 months. Chemotherapy is the cornerstone of treatment of SCCE in all stage. For limited disease SCCE, concurrent chemo-radiotherapy is the primary choice compared with sequential approach. The role of surgery was not assessable in our study.

Increased nerve density in deep infiltrating endometriotic nodules.

Background/Aims: Deep infiltrating endometriosis is a very painful condition and the mechanism of pain is still poorly understood. Pain and hyperalgesia can partly be explained by an increased number of nerve structures in the painful lesion. In order to clarify this issue, we assessed the nerve density in deep infiltrating endometriotic nodules of the posterior vagina and in the adjacent healthy vaginal tissue of the same patient. Methods: A prospective clinical and pathological study of 31 cases of deep infiltrating vaginal endometriotic nodules was conducted. Fifteen patients were in the proliferative phase and 16 in the secretory phase. The nerve density was studied by immunohistochemistry with the monoclonal antibody NF against neurofilaments in deep infiltrating endometriosis and in the adjacent unaffected vaginal tissue in the proliferative and in the secretory phases. Neurofilaments constitute the main structural elements of neuronal axons and dendrites. Results: The nerve density was significantly different in the endometriotic nodule than in the adjacent unaffected vaginal tissue (p = 0.0013). The same significant difference was found between endometriotic nodules and the unaffected vagina in the proliferative phase (p = 0.009) and in the secretory phase (p = 0.04). This difference was not significant between the proliferative and the secretory phases in the endometriotic lesions and in the controls. Conclusions: We hypothesize that the significantly increased number of nerve structures in the endometriotic nodules may contribute to the occurrence of severe and neuropathic pain that characterizes these lesions

Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature.

Primary repair of large hiatal hernia is associated with high recurrence rate. The use of prosthetic mesh to reinforce the cure seems to lead to less recurrence. Unfortunately, this procedure is still controversial in regard of the possible complications that may occur. We report here 3 cases of complications related to mesh placement in hiatal hernia surgery: an esophageal perforation, an intragastric migration, and a fundic erosion. When a patient complains of epigastric pain or dysphagia with no peritoneal signs, in the postoperative course of mesh placement, an upper endoscopy should be achieved to rule out those complications. The patient must be informed about the mesh placement and he must notify the endoscopist in case of an upper gastrointestinal endoscopy.

How should we treat mucinous appendiceal neoplasm? By laparoscopy or laparotomy? A case report.

Abstract Appendicular mucocele (AM) usually denotes a dilatation of the appendiceal lumen as a result of mucus accumulation that may be related to various neoplastic and non-neoplastic processes. Most of them are discovered incidentally. Treatment consists in complete resection avoiding rupture of the cyst in the peritoneal cavity. Indeed, rupture of such a cystic lesion in the peritoneal cavity can induce a catastrophic complication such as ‘pseudomyxoma peritonei’(PMP). Therefore, some authors recommend an open surgical treatment. Currently, the debate concerning the best surgical technique to adopt for AM remains controversial. We report a case of AM found incidentally and treated by laparoscopy. The macroscopic aspect of the appendix suggested the diagnosis intra-operatively and every effort was made to avoid cystic rupture during appendicular resection. The histopathological diagnosis was mucinous cystadeno-ma. The patient is doing well at 2-year follow-up. The reported case and literature review show us that AM is not a contra-indication for laparoscopic surgery, but major concern resides in the early recognition of such a lesion at laparoscopy and in taking appropriate precautionary measures to avoid rupture in the peritoneal cavity.

Actinomycotic Abscess of the Anterior Abdominal Wall : a Case Report and Literature Review

Abstract Actinomycosis is a rare, chronic, suppurative, pseudotumoral illness caused by an anaerobic gram positive organism usually Actinomyces israelii which can mimick a tumoral pathology leading to a mutilating surgical resection. We report a case of abdominal actinomycosis and a literature review.

Wilkie's syndrome

A superior mesenteric artery syndrome (SMAS) was diagnosed in two young women with, respectively, a 2- and 1-year history of postprandial vomiting and epigastric pain. The patients underwent a laparoscopic duodenojejunal bypass, and resumed a normal diet on the fifth postoperative day. The patients are still symptom-free with patent anastomosis on gastrointestinal radiographic control at 24 and 6 months, respectively, following their operation. Herein we also describe the varying clinical presentation of this rare syndrome, as well as treatment options. We conclude that laparoscopic duodenojejunostomy offers a new therapeutic approach to SMAS. It is reliable and safe; the operating time is acceptable; and diet recovery and hospital stay are both short. However, these preliminary results still need to be confirmed by further observations.

Intraperitoneal follicular dendritic cell sarcoma: role of chemotherapy and bone marrow allotransplantation in locally advanced disease?

We describe a case of a 44 year-old woman diagnosed with follicular dendritic cell sarcoma (FDCS). FDCS is a very rare disease affecting the dendritic antigen presenting cells and is often misdiagnosed. Surgery is considered the best treatment modality, followed by chemotherapy. In our case, surgical excision was not possible, therefore the patient received two lines of chemotherapy followed by bone marrow allotransplantation, then a third line of chemotherapy with a complete metabolic response seen on PET/computed tomography (CT) follow-up 29 months later. A review of the literature has been performed.