Louis Goncette

Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy

BACKGROUND The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture. METHODS A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GIA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies. RESULTS The cross-sectional area was 225 +/- 15.7 mm2 (mean +/- standard error of the mean) for the 16 semimechanical anastomoses versus 136 +/- 15 mm2 for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 +/- 13.5 mm2 in 29 patients without dysphagia to 107.5 +/- 4.7 mm2 in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 +/- 16 mm2 in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 +/- 5.5 mm2 to 174.6 +/- 8.1 mm2, with concomitant symptomatic relief (p = 0.0277). CONCLUSIONS The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. Inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy.

Management of pharyngoesophageal (Zenker's) diverticulum: which technique?

BACKGROUND Incomplete symptomatic relief of pharyngoesophageal (Zenkers) diverticulum after endoscopic stapling or laser division has been reported by some authors. The clinical relevance of cricomyotomy, although supported by experimental data, remains controversial. METHODS Operative procedures consisted of transcervical resection (n = 34, group I), transcervical resection plus cricomyotomy (n = 12, group II), transcervical cricomyotomy (n = 8, group III), transcervical cricomyotomy plus diverticulopexy (n = 47, group IV), endoscopic stapling division (n = 31, group V), and endoscopic laser division (n = 55; group VI). RESULTS The percentage of totally asymptomatic patients was significantly (p < 0.004) higher after open procedures (combined groups I to IV) than after endoscopic treatment (combined groups V and VI) regardless of the size of the pouch (< 3 cm, 85% versus 25%; > or = 3 cm, 86% versus 50%). The percentage of patients with no or occasional (ie, fewer than twice a week) symptoms was significantly (p < 0.001) higher after open procedures (98%) than after endoscopic treatment (57%) for less than 3-cm diverticula whereas it was not higher (p = 0.409) for 3-cm or greater pouches (open, 97%; endoscopic, 88%). Furthermore, this percentage was similar (p > 0.286) after endoscopic stapling division and after endoscopic laser division (< 3 cm, 50% versus 58%; > or = 3 cm, 96% versus 80%). It was also similar (p > 0.197) after resection alone (group I) and after open operations including myotomy (combined groups II to IV) (< 3 cm, 100% versus 98%; > or = 3 cm, 92% versus 100%). Unlike endoscopic stapling and division, laser division was complicated by mediastinitis (2 patients), and 1 patient was referred because of cervical esophageal disruption during laser division. Five of six postoperative fistulas after resection occurred in patients who did not have myotomy, and 4 patients were referred 12 to 49 years after resection without myotomy for true recurrence of the pouch. CONCLUSIONS Open techniques afford better symptomatic relief than endoscopic techniques, especially in patients with small diverticula. Endoscopic stapling and division is safer than laser division. Although very effective at midterm, resection without myotomy predisposes to the development of postoperative fistula and to recurrence of the pouch after many years.

Laparoscopic treatment of gallbladder duplication - A plea for removal of both gallbladders

AbstractBackground: Gallbladder duplication is a rare congenital condition, which can now be detected preoperatively by imaging studies. Methods: We report a case of duplicated gallbladder with symptomatic unilobar gallstones. Appropriate biliary workup (ultrasound, oral cholecystography, and intravenous cholangiography) allowed a correct preoperative diagnosis. Results: Laparoscopic treatment included selective removal of the diseased accessory gallbladder. However, postoperative acute cholecystitis and symptomatic gallstone occurred in the remaining main gallbladder, and laparoscopic reintervention was required 27 months later. Conclusions: This case illustrates the need for complete removal of both gallbladders during initial surgery. Precise intraoperative recognition of vascular and biliary anatomy—including abnormalities—is highlighted to avoid mistakes during surgery.

Pulmonary embolism findings on chest radiographs and multislice spiral CT

Multislice spiral CT is becoming an increasingly important tool for diagnosing pulmonary embolism. However, in many instances, a chest radiograph is usually performed as a first-line examination. Many parenchymal, vascular, and other ancillary findings may be observed on both imaging modalities with a highly detailed depiction of abnormalities on multislice CT. A comprehensive review of chest radiograph findings is presented with side-by-side correlations of CT images reformatted mainly in the frontal plane.

Radiologic findings of normal and compromised thoracic venous catheters.

We review the radiologic findings of normal positioning, malpositioning, and complications related to the more commonly used thoracic venous catheters. These include central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. The radiologist plays an important role in the early recognition of the complications of these catheters. The daily practice of chest radiology is intimately related to the evaluation of the integrity and correct placement of thoracic venous catheters. The purpose of this pictorial essay is to review radiologic findings of normal positioning, malpositioning, and complications related to the more common devices used, including central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. Many of the complications described are serious and may remain unrecognized for a long time; this may cause incorrect diagnosis and delayed treatment. The radiologist plays an important role in the early recognition of these complications. Malpositioning and complications often are more easily diagnosed with contrast-enhanced studies and computed tomography.

Pulmonary Sequestration Visualization of an Enlarged Azygos System by CT

The purpose of this study was to determine the prevalence of enlargement of the azygos system in the case of lung sequestration and its potential usefulness in the differential diagnosis of lower lobe opacities. Seven consecutive adult cases of pulmonary sequestrations were retrospectively enrolled; 4 sequestrations were proved surgically and all 7 angiographically. A group of 50 consecutive patients with a normal chest CT were used as controls. Another group consisted of 25 consecutive patients identified on the basis of an opacity in a posterobasal location on chest CT. For the 3 groups, the maximum diameter of the azygos and hemiazygos veins was measured, the level of measurement located between the upper poles of the kidneys and the confluence of inferior pulmonary veins into the left atrium. The diameter of the azygos veins (mean 10.4±5.1 mm) and of the hemiazygos veins (mean 7.1±3.0 mm) in the sequestration group was significantly larger than the diameter of the azygos and hemiazygos veins in the control group (mean 5.7±2.5 mm, and 3.4±2.4 mm, respectively), as well as in the study group (mean 5.9±2.6 mm and 3.3±2.6 mm, respectively). Our results suggest that enlargement of the azygos system in association with a posterobasal chest opacity, although nonspecific, may be a useful additional CT sign of sequestration.

Gastric pneumatosis with findings of retroperitoneal and mediastinal air

We report a case of gastric pneumatosis with findings of air in the retroperitoneal and mediastinal spaces demonstrated by plain radiographs and computed tomography. Pneumatosis was considered to be due to gastric distention caused by involvement of the gastric outlet by disseminated hepatocellular carcinoma and was possibly promoted by intake of steroids and local radiotherapy.

Embolies peripheriques au CT scanner multidetecteur : prevalence, clinique et implications techniques

Objectifs Determiner la prevalence et la localisation d’embolies pulmonaires (EP) peripheriques au CT scanner multidetecteur et en rapporter leur presentation clinique. Materiels et methodes Revue retrospective de 459 de dossiers CT de patients admis pour suspicion d’EP. Examen de l’ensemble du thorax effectue au CT multidetecteur (MX 8000, Philips, Cleveland, OH) avec collimation de 4 x 1 mm, pitch de 1,25, 120 Kv, 144 mAs. Embolies pulmonaires peripheriques (≥5eme ordre) analysees par 2 radiologues independants. Localisation des emboles par rapport au volume compris entre la crosse aortique (A) et le dome des coupoles diaphragmatiques (C). Revue des dossiers cliniques par 1 interniste avec analyse des examens complementaires effectues (Rx thorax, Scinti V/P, Echo Doppler). Resultats Cinquante cinq sur quatre cent cinquante neuf (12%) patients ont ete exclus pour mauvaise opacification ou raisons techniques. 108/404 (27 %) avaient une embolie pulmonaire dont 15/108 (14%) etaient peripheriques uniquement. Aucune embolie n’etait visualisee au dessus du plan passant par A. Deux patients avaient des embolies peripheriques situees sous C. Symptomatologie variable : dyspnee (80 %), douleurs (40 %), toux (13 %), hemoptysie (7 %). Les examens complementaires effectues montrent une performance variable pour detecter l’embolie. Conclusion L’EP peripherique n’est pas rare et s’accompagne de symptomes cliniques varies. La localisation de ces embolies ne justifie pas la realisation d’un CT scanner couvrant les sommets pulmonaires mais impose une opacification optimale des vaisseaux jusqu’aux sinus costo-diaphragmatiques.

Reflux gastro-oesophagien sur oesophage court : diagnostic radiologique et traitement chirurgical

RésuméL’œsophage court est une réalité anatomique chez près de 7 % des patients référés pour chirurgie antireflux. L’examen radiologique baryté comportant des clichés pris en position debout est le meilleur moyen d’apprécier l’irréductibilité de la jonction œso-gastrique sous le diaphragme. La fundoplicature intrathoracique selon Nissen réalisée par thoracotomie gauche est la meilleure technique chirurgicale pour obtenir un contrôle permanent et durable du reflux du contenu gastrique dans la lumière d’un œsophage court. Certains détails d’ordre technique doivent être impérativement respectés pour éviter des complications chirurgicales graves.SummaryShort esophagus is present in about 7 % of patients referred for antireflux surgery. Barium swallow study including X-rays taken in the upright position is the most appropriate method for assessing the irreducibility of the GE junction below the diaphragm. Permanent control of reflux is best achieved using the intrathoracic fundoplication technique according to Nissen. Strict observance of critical technical details is mandatory to make the procedure safe and successful.

3104 Que faire en cas d’affection aigue du colon chez l’adulte ? Une echographie, un scanner, des cliches conventionnels ou une endoscopie

Objectifs pedagogiques Preciser l’apport et les limites des techniques d’imagerie (echographie, scanner, radiologie conventionnelle) et le role de l’endoscopie en cas d’affection aigue du colon chez l’adulte. La semeiologie elementaire des affections infectieuses, inflammatoires, ischemiques et tumorales sont revues a la lumiere de ces differentes techniques.