Jean-Jacques Houben

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.

Results of Silastic Ring Vertical Gastroplasty More Than 6 Years after Surgery: Analysis of a Cohort of 214 Patients

Background: Among the different techniques of surgical treatment for morbid obesity, silastic ring vertical gastroplasty (SRVG) is an alternative, effective and easily reproducible technique. The aim of this study is to evaluate a cohort of patients >6 years after SRVG for morbid obesity. Methods: From 1991 to 1996, 273 consecutive patients were eligible for SRVG. The evaluation criteria included weight loss, evolution of co-morbidities, long-term morbidities, satisfaction of patients and quality of life. Results: Among these 273 patients, 1 patient died in the postoperative period (0.4%). Postoperative morbidities occured in 27 patients (10%). The long-term follow-up involved 213 patients (78%). Late postoperative complications consisted of outlet stoma stenosis (14%), staple-line dehiscence (5.6%) and incisional hernia (8.5%). 23 patients (10%) needed a re-do operation. Co-morbidities drastically improved. BMI fell from 45.3 to 30.7. Failure of SRVG was statistically associated with male gender and super-obese patients. 69% of the patients were satisfied, and 73% would recommend this operation. Conclusion: SRVG is very effective in a selected group of morbidly obese patients.

Squamous cell carcinoma of the esophagus: multimodal therapy in locally advanced disease.

The aim of this prospective study is to report our experience in the multimodal management of locally advanced esophageal squamous cell carcinoma (LAESC; stage III cTNM), focusing on the results of chemoradiotherapy followed by surgery. These findings were compared to the results of a standard group of patients with locally advanced esophageal carcinoma (LAEC; stage III pTNM) treated in our center with surgery alone. Sixty-one patients with LAESC underwent preoperative chemoradiotherapy (5-fluorouracil cisplatin) with concomitant 45 Gray radiotherapy in a 5-week course. Transthoracic esophagectomy was performed 4 to 5 weeks after the end of the neoadjuvant therapy. Thirty-eight patients underwent surgery, and 37 of them had resections (resectability: 97% in the multimodal group; 84% in the standard surgical series; p 0.07). The R0 (complete) resection rate was 78% compared to 56% in the standard surgical group (p < 0.03). Eleven patients had no residual tumor in the resected specimen (pathologic complete response: pCR: 30%). The operative mortality rate was 19% compared with 8.8% in the standard series. The overall median survival of the resected patients was 21 months, with a 5-year survival rate of 11% (14% in the surgical group; NS). The 3-year and 5-year survival rates were 34% for the pCR group and respectively 5% and 0% for the group with pathologic incomplete response (pIR; p < 0.05). The median survival was 28 months for the pCR patients and 19 months for the pIR group. In this non-randomized trial, preoperative chemoradiotherapy in LAESC seems to increase the resectability and R0 resection rates, to allow a higher pCR rate and a longer survival only in the pCR group, at the expense of an inadequate increase in operative mortality. This multimodal treatment cannot be proposed as a standard procedure unless less toxic regimens are developed, increasing the benefits with better local and distant failure control and decreasing operative mortality. Despite many technical advances, esophageal cancer still represent a therapeutic challenge. Major improvements in the management of this disease include preoperative risk evaluation [1], preoperative staging with more accurate detection of local involvement and distal spread leading to a better adapted treatment [1]. Other important improvements are the standardization of the surgical techniques and the advances in perioperative care. The poor prognosis for esophageal cancer in the Occidental countries is related to the lower operability rate of patients in poor general condition with associated chronic heart, pulmonary, and/or liver diseases and associated tobacco and alcohol abuse. Another important factor is the lower resectability rate, related to the advanced stage of the disease at presentation, with regional lymph node involvement, adjacent structure infiltration, and especially distant spread in 20% to 30% of the patients [2]. A late diagnosis, with esophageal tumor penetrating through the esophageal wall and regional lymph node involvement, seen in more than 75% of the patients [3], compromises the resectability and decreases significantly the 5-year survival rate (15% to 20%) [4]. Therefore, efforts must be focused on the initial use of preoperative combined therapy to induce downstaging of the primary lesion, to eliminate the potential for metastases, and consequently to improve long-term survival. Although the multimodal approach is theoretically sound, its worth remains unproved and its use remains controversial because of the conflicting data emerging from phase II and phase III trials. The aim of this study is to report our experience in the multimodal management of esophageal squamous cell carcinoma in locally advanced disease, focusing on the results of chemoradiotherapy followed by surgery. These findings were compared to those emerging from a historical group of patients with locally advanced esophageal cancer treated in our center with surgery alone. Patients and Methods Between 1990 and 1995, 198 patients with esophageal cancer were assessed in our department. Sixty-one patients presented with locally advanced squamous cell carcinoma. Operability was evaluated by risk analysis, including performance status and respiratory, cardiac, and liver function evaluation. Patients with high surgical risk were considered inoperable. Loco-regional resectability was assessed with laryngoscopy, Correspondence to: I. El Nakadi, M.D., e-mail: ielnakad@ulb.ac.be bronchofibroscopy, esophagogastroscopy, barium swallow, mediastinal and esophageal computed tomography (CT), and endoscopic ultrasonography (US). The carcinoma was considered “locally advanced” when preoperative staging by mediastinal CT and endoscopic US revealed a T3/T4 with any N tumor [5]. Distant metastases were assessed with lung and abdominal CT with or without liver US. This assessment led to preoperative cTNM staging including 3 T3N0, 41 T3N1, 1 T3Nx, 4 T4N0, 11 T4N1 and 1 T4Nx. Resected tumors were classified according to pTNM staging [5]. The following nonrandomized multimodal strategy was applied prospectively. All operable patients (n 48) underwent a preoperative chemoradiotherapy including a chemotherapy regimen of cisplatin (CDDP) 15 mg/m with 5-fluorouracil (5-FU) 750 mg/m from day 1 to day 5. Concomitantly a 45 GY radiotherapy was delivered in 25 fractions over 5 weeks with a linear accelerator (Fig. 1). The chemotherapy regimen was repeated during the fifth week. Following this treatment, patients were questioned about dysphagia relief or improvement. The objective reassessment of the preoperative treatment for operability and resectability was carried out 2 to 3 weeks after chemoradiotherapy. The resectability was reevaluated with endoscopy, barium swallow, CT scan, and endoscopic US. The clinical response to treatment was classified as complete response, incomplete response (partial and minimal), no change, or progression according to the World Health Organization (WHO) criteria [6]. Patients with disease progression underwent an additional course of radiotherapy; those with partial or complete response underwent surgery (Fig. 2). Patients evaluated as inoperable or those who rejected the protocol were treated with chemoradiotherapy with or without esophageal endoprosthesis. This protocol included the same chemotherapy regimen associated with a dose of 60 GY radiotherapy.

Biliary Pleural Fistula as a Complication of Radiofrequency Ablation for Liver Metastasis

Abstract Radiofrequency ablation (RFA) recently emerged as an efficient and safe local ablative method to treat unresecable liver tumours. Currently however, the full spectrum of potential complications of RFA remains undetermined. We report a case of severe biliary complication, associating main bile duct stricture and biliary pleural fistula, arising after extensive RFA for unresectable liver metastasis of central location. Treatment consisted of external drainage of the pleural effusion and internal endoscopic drainage via a biliary stenting. This description of a life-threatening complication emphazises the need to better knowledge of the contraindications of RFA, particularly for the treatment of large tumours at proximity of main bile ducts.

Prenatal diagnosis of atypical gastroschisis

Perinatal ultrasonography is very important for thedetection, identification, and follow-up of abdominalwall defects. The ability to distinguish between typesof abdominal wall defects and reach a correct diag-nosis is not always easy. We present two unusualcases of gastroschisis with change in the ultrasono-graphic appearance as pregnancy progressed anddiscuss perinatal management.

Skin lesions, elevated serum lipase level and abnormal bone scintigraphy

A 60-year-old man was referred for joint and bone pain, and skin lesions on the lower limbs. Bone scintigraphy showed increased tracer uptake in the metacarpal bones and interphalangeal joints of both hands, in the calcaneus and metatarsal bones, and in the right humerus, femur and tibia (a–c). Biological work-up revealed a very high lipase level (3,000 IU/l, normal <60 IU/l) and a normal amylase value. FDG PET/CT detected a large hypermetabolic mass in the tail of the pancreas and liver metastases. It also showed multiple skin hot spots on both legs, corresponding to panniculitis (d, e). Surgery was performed and histopathology revealed an acinar cell carcinoma of the pancreas. Acinar cell carcinomas of the pancreas represent 1– 2 % of all exocrine pancreatic tumours [1]. Lipase released into the bloodstream in large amounts (and also amylase and trypsin in some cases, although in our patient the amylase level was normal) is responsible for the digestion of subcutaneous fat (panniculitis) and can affect articular surfaces of joints (arthritis) as well as the intramedullary fat of bones [2]. Our patient presented with all three manifestations of the disease. The same pattern can be observed in patients with acute pancreatitis [3–5]. After tumour removal, the lipase level dropped significantly and the painful condition improved. D. Luyx : E. Laurent :M. Van der Schueren :M. Lonneux Department of Nuclear Medicine, Centre Hospitalier Interrégional Edith Cavell, Brussels, Belgium

Intussusceptions in Adults: Clinical Course and Associated Lesions

Intussusception in adults is rare. The authors report 18 cases and illustrate the pathological and clinical findings. Intussusception is usually secondary to a benign small bowel lesion or to a malign