The use of autologous fascia lata graft in the laparoscopic reinforcement of large hiatal defect: initial observations of the surgical technique

Background

Even though there is no consensus, many authors believe that in the cases of large hiatal defects, structurally altered crura and/or absence of peritoneal lining, a crural reinforcement should be performed. Reinforcement could be performed with different techniques and different type of mesh, either synthetic or biologic. The disadvantages of mesh repair include the possibility of serious complications and increased costs especially in the usage of composite or biologic mesh.

Methods

The study includes 10 cases of reinforced primary suture line of the pillars with autologous fascia lata, in elective laparoscopic repair of the giant PEH with a large hiatal defect and friable crura. After intraopreative confirmation of the large hiatal defect (hiatal surface area of more than 8 cm²) and friable crura, an autologous fascia lata graft was harvested in the usual manner and placed in on-lay fashion to reinforce the pillar suture line. We analyzed surgical technique, complications, and initial follow-up of the patients.

Results

Average hiatal surface area (HSA) in our series was 10.6 cm² (range 8.1 to 14.4 cm²). The average duration of operation was 203.9 min/3.4 hours (range 160–250 min). Except for a mild hematoma in the harvesting region that resolved spontaneously, there were no procedure related complications and 30 days mortality rate was zero. The average postoperative length of stay was 6.5 days (5–8 days). Out of 10 patients, 5 completed the annual follow-up visit, while 8 completed a 6- month follow-up visit. So far there is no hernia recurrence and/or problems with swallowing function. However, one patient has felt a mild discomfort in the harvested region that does not influence normal daily activities.

Conclusions

Autologous fascia lata graft hiatal reinforcement represents a technically feasible, easy, and available option for the on-lay reinforcement of large hiatal defects with friable crura in the laparoscopic repair of giant PEHs.

Laparoscopic repair of hiatal hernias: experience after 200 consecutive cases

INTRODUCTION

Repair of hiatal hernias has been performed traditionally via open laparotomy or thoracotomy. Since first laparoscopic hiatal hernia repair in 1992, this method had a growing popularity and today it is the standard approach in experienced centers specialized for minimally invasive surgery.

OBJECTIVE

In the current study we present our experience after 200 consecutive laparoscopic hiatal hernia repairs.

METHODS

A retrospective cohort study included 200 patients who underwent elective laparoscopic hiatal hernia repair at the Department for Minimally Invasive Upper Digestive Surgery, Clinic for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2004 to December 2013.

RESULTS

Hiatal hernia types included 108(54%) patients with type 1, 30 (15%) with type III, 62 (31%) with giant paraesophageal hernia, while 27 (13.5%) patients presented with a chronic gastric volvulus. There were a total of 154 (77%) Nissen fundoplications. In 26 (13%) cases Nissen procedure was combined with esophageal lengthening procedure (Collis-Nissen), and in 17 (8.5%) Toupet fundoplications was performed. Primary retroesophageal crural repair was performed in 164 (82%) cases, Cleveland Clinic Foundation suture modification in 27 (13.5%), 4 (2%) patients underwent synthetic mesh hiatoplasty, 1 (0.5%) primary repair reinforced with pledgets, and 4 (2%) autologous fascia lata graft reinforcement. Poor result with anatomic and symptomatic recurrence (indication for revisional surgery) was detected in 5 patients (2.7%).

CONCLUSION

Based on the result analysis, we found that laparoscopic hiatal hernia repair was a technically challenging but feasible technique, associated with good to excellent postoperative outcomes comparable to the best open surgery series.

Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature

Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.

Bloodless esophageal replacement in children with corrosive esophageal strictures--report of two cases

BACKGROUND

Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children.

METHODS

We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus.

RESULTS

No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course.

CONCLUSION

In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.

Minimally invasive surgery in the treatment of gastric cancer

Unlike benign pathology, progress of laparoscopy in performing cancer surgery has been slow because of fear of safety and oncological adequacy. However, the initial fear has been replaced by optimism as the results from a numerous studies have shown equivalent if not superior results to open surgery. Laparoscopic gastrectomy is safe and oncologic adequate, but time consuming and technically demanding procedure. Laparoscopic surgery has gained wide acceptance in the treatment of early gastric cancer, especially of the distal stomach. The use of laparoscopic surgery for the treatment of advanced gastric cancer remains controversial. Another open question that need complete evaluation is cost-effectiveness analysis of minimally invasive and open approach.

Minimally invasive esophagectomy in the treatment of esophageal cancer

In the Western countries, the incidence of esophaeal carcinoma is 3-6 cases per 100,000 persons. g Despite tremendous success of other therapeutic options, surgical treatment still represents the best therapeutic option whenever possible. For the long period, debate has centered on which of the a vailable surgical procedures is superior-transhiatal or transthoracic esophagectomy. Minimally invasive esophagectomy (MIE) could offer both minimally invasive approach and proper mediastinal lymph node dissection. Minimally invasive esophagectomy is safe and adequate, but time consuming and technically demanding procedure. It is procedure reserved for the surgeons experienced in open esophagectomy for cancer, and specially trained in advanced minimally invasive procedures. Even in that case, learning curve is steep.

Primary esophageal diffuse large B-cell lymphoma: report of a case

Primary esophageal lymphoma is very rare, with fewer than 25 cases documented in the English-language literature. We report a case of primary diffuse large B-cell lymphoma of the esophagus in a 42-year-old woman. Barium esophagogram revealed almost complete esophageal obstruction at the level of the cervical esophagus, and flexible endoscopy showed a circumferential submucosal tumor covered with intact mucosa. Neck magnetic resonance imaging (MRI) showed a wide cervical mass circumferentially encompassing the lumen of the cervical esophagus. Biopsies taken with multiple forceps during flexible and rigid esophagoscopy were nondiagnostic. Finally, external esophageal wall biopsies taken during neck exploration provided information that helped us establish the diagnosis. Pathohistological findings confirmed non-Hodgkin's lymphoma of the diffuse large B-cell type. The patient was treated with combined immunochemotherapy, consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP), followed by irradiation. A complete response was achieved, and 3 years after diagnosis and treatment the patient was disease-free.

[Traumatic rupture of the right hemidiaphragm]

The right hemidiaphragm rupture, caused by blunt force, occurs rarely and often is overlooked because of immediate management of life-threatening injuries. Our paper presents 31-year-old female patient, admitted as emergency case due to traffic accident injuries. Physical examination revealed diminished respiratory mobility of the right hemothorax, along with the impaired respiratory sound to the right infrascapular aspect, diffuse painful sensitivity of the abdomen and limited mobility of the lower extremities. X-ray examination of the chest verified the tight hemidiaphragm elevation without any signs of bone structure fractures and hydro-pneumothorax. Computerized tomography of the abdomen and small pelvis showed the rupture of the right diaphragmatic cupola with the prolaps of the right hepatic lobe, sacral fracture and fracture of both ischial rami. The surgery verified the rupture of the right hemidiaphragm in transversal direction of about 10 cm long, with partial prolaps of liver to the right hemithorax. Surgical intervention included the insertion of thoracic drain and liver mobilization by severing the falciform ligament. The operation was completed by interrupted sutures of the right hemidiaphragm and hematomas in the retroperitoneum were incised. Postoperative course was uneventful, and oral nutrition was initiated on day 4. The patient was discharged 18 days after the surgery. Preoperative diagnostics, attentive intraoperative examination and early surgical treatment significantly reduce morbidity and mortality of patients with traumatic diaphragmatic rupture.

[Treatment of gastrointestinal hemorrhage manifestation induced by nonsteroidal anti-inflammatory agents]]

INTRODUCTION

The risk of upper gastrointestinal tract bleeding in the patients taking NSAID estimates 1% per year. Bleeding stops spontaneously in approximately 80% of all cases. Persistent and repeated bleeding (expecialy during the initial hospitalization) still represent the serious clinical problem. In this group of patients, mortality rate is between 6-10%, which in the USA counts 10-20000 patients per year.

AIM OF THE STUDY

The purpose of this review is to update the current knowledge of the use of different therapeutic strategies in patients with NSAID induced upper gastrointestinal bleeding.

RESULTS

Proton pump inhibitors (PPI) therapy is effective as a prevention of NSAID induced acidopeptic lesions, and also represents the first and best therapeutic option for the treatment of complications, such as upper gastrointestinal bleeding. In the last three decades use of early flexibile (diagnostic and therapeutic) endoscopy, agressive acidosupression (PPIs), and surgical treatment in restrictive indications, resulted in decreasing of the mortality rates from 25-35% to 6-10%. When PPIs and flexible endoscopy are not sufficient in the control of upper gastrointestinal bleeding, use of systemic hemostatic drugs could be taken into consideration.

CONCLUSION

Multidisciplinary approach, precise diagnostic and therapeutic critearia would probably result in better outcome of patients with active upper gastrointestinal bleeding.

[Gastrointestinal stromal tumors (GIST) of the stomach as a cause of upper gastrointestinal bleeding]

Gastrointestinal stromal tumors (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. GIST is currently defined as a gastrointestinal tract mesenchymal tumor containing spindle cells (less commonly epitheloid cells or rarely both) and showing CD 117 (c-kit protein) positivity in more than 95% of cases. Although they may arise throughout the gut, the commonest site are stomach (60-70%), small intestine (20-30%), colorectum (5%) and esophagus (up to 5%). Rarely, GISTs develop in the retroperitoneum, omentum or mesentery. GIST originates from the intestinal cell of Cajal (ICC). ICCs are located in and around the myenteric plexus and are thought to function as intestinal pacemaker cells. Historicaly, GIST were often misclassified as leiomyomas or leiomyosarcomas. Subsequently, it has been determined that GISTs have distinct ultrastructural features and immunophenotypical markers compared with smooth muscle and smooth muscle tumors. GIST predominantly occur in middle aged and older patients, with no significant difference in the sex incidence. Data from the recent population study suggest an incidence of about 10-22 cases per million persons per year. Clinical presentation of GIST varies widely, and depends on tumor size and location. GISTs that caused symptoms tended to be larger with an average size of 6cm versus 2cm for asymptomatic GISTs. Symptoms are most commonly related to mass effect or bleeding. GISTs can grow very large before producing symptoms. Commonest symptom of gastric GIST is manifest or occult bleeding. Abudant, life-threateting bleeding that require urgent surgery is rare. For patient with primary, localized, nonmetastatic GIST, complete surgical resection represents the only chance for cure. Lymhadenectomy is not necessary, because lymph node metastasis is very rare. The 5 year survival rate in patients with resected primary GISTs ranges from 48-65%. Conventional chemotherapy and radiation therapy is ineffective in the treatment of GIST. Imatinib mesilate (a tyrosine kinase inhibitor) was confirmed to be effective against metastatic or unresectable GISTs.

[Dieulafoy's lesion: rare cause of massive upper gastrointestinal bleeding]

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.

[Upper gastrointestinal bleeding as a surgical complication of primary gastric lymphoma]

Primary gastric lymphomas are of the extranodal non-Hodgkin type. The gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphomas and accounts 30-45% of all extranodal lymphomas. Gastrointestinal lymphomas occurs in the stomach in 55-70% of cases. Primary gastric lymphoma is relatively rare tumor accounting 1-7%, of all gastric malignancies. An increased incidence has been documented recently. The median age of diagnosis is approximately 60 years old, and disease affects an equal number of men and women. The initial symptoms may be vague and nonspecific leading to delayed establishment of diagnosis up to several years. Many patients came down late with advanced disease and complications such as upper gastrointestinal bleeding. Twenty to thirty percent may present with occult bleeding or hematemesis et melena while gastric obstruction and perforation are less common. Gastric bleeding can also occur as a complication of chemotherapy. The incidence of gastric bleeding in patients receiving chemotherapy is up to 11%. In most cases surgical resection is necessary to achieve hemostasis. Given the rate of surgical complications, especially gastric bleeding, there is still an important role for surgeon in the multimodal treatment of patients with primary gastric lymphoma.

[Systemic hemostatic drugs]

Understanding the haemostatic changes is crucial in developing strategies for the management of haemorrhage syndroma. In recent years, the revised model of coagulation ("cell based" model) provided a much more authentic description of the coagulation process. Pharmacological intervention, especially desmopresin, antifibrinolytics (synthetics and nature) and increasingly recombinant activated factor VII are being used in prevention and therapeutically to control bleeding of variety etiologies. Skillfull surgery combined with blood saving methods and careful management of blood coagulation will all help in sucessfull haemorrhage prevention and treatment, and reduce unnecessary blood loss and transfusion requirements and its attendant risks. Among the all avalaible tests, the use of thromboelastography has allowed for more detailed dynamic assessment of the various steps of hemostasis.

[Less frequent causes of upper gastrointestinal bleeding]

Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.

Iron deficiency anemia and its importance in gastroenterology clinical practice

Iron deficiency anemia (IDA) is a universal problem involving individuals of all ages and both sexes and is a common cause of referral to medical departments. This anemia is one of the most common types of anemia. IDA impairs growth and intellectual development in children and adolescent. In women IDA is most common in reproductive period because of menstrual and pregnancy iron losses. IDA affects roughly 10-30% of all pregnancies and, among others morbidities, may contribute of developing postpartum depression. Among other adult patient, chronic occult gastrointestinal bleeding is the leading cause of IDA. Approximately, one third of patients with anemia have iron deficiency and up to two thirds of patients with IDA have serious gastrointestinal lesions detected with esophagogastroduodenoscopy and colonoscopy, including 10-15% with malignancy. However, in practice not all anemic patients undergo appropriate diagnostic tests to detect iron deficiency. Furthermore, a substantial proportion of patients with IDA do not undergo endoscopic evaluation. The approach to its investigation and subsequent therapy depends upon a comprehensive understanding of iron metabolism and heme synthesis. Once diagnosis of iron deficiency or IDA is established, evaluation for the cause of anemia must be appropriate performed and treatment must include corrective replenishment of body stores.

The significance of lymphonodal micrometastasis in the patients with gastric adenocarcinoma

Micrometastasis is defined as microscopical deposit of malignant cells, less than 2mm in diameter, separated from the primary tumor. This does not include discontinous growth in peritumoral region, but include microinolvement of regional lymph nodes. The literature on micrometastases, with special resperct to nodal micrometastasis, and their implications in gastric adenocarcinoma have been reviewed. Immunohistochemical detection offer the best accuracy for detection of nodal micrometastasis. Molecular techniques are more sensitive than method of immunohistochemical detection, but methods are compromised with false positive results caused by various sources of biological contamination. It is more than obvious that there is no definite agreement neither about risk factors, nor definitive clinical significance of micrometastatic node involvement in the patients with gastric adenocarcinoma. At present, the role of occult lymph node involvement proved its significance in two major fields: defining criteria for limited surgical dissection in the patients with early (sm) carcinoma in respect to detection of micrometastatic tissue in sentinel lymph node, and distinguishing the category of pN0 (Mi+) patients with potential benefit of postoperative adjuvant therapy.

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma

AIM: To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma.

METHODS: Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach.

RESULTS: We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present.

CONCLUSION: It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery]

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.