[Laparoscopic fundoplication for gastroesophageal reflux. Apropos of our first 123 patients]

From July 1991 to March 1997, 123 patients underwent laparoscopic fundoplication. Surgical indications were as follows: either failure of medical therapy, or early recurrence of symptoms after interruption of medical treatment in young patients or large hiatal hernia associated with symptoms of reflux and/or symptoms of mediastinal compression. The type of the wrap was tailored to the preoperative manometry: circumferential fundoplication was achieved in patients with normal esophageal motility, and partial wrap in patients with altered motility. Short gastric vessels were not routinely divided. One hundred and eleven circumferential fundoplications were performed: 52 with division of short gastric vessels and 49 without, whereas there were 22 partial wraps. In 4 cases, it was necessary to switch to open surgery (conversion rate: 3.2%): 2 enlarged left liver lobes, one esophageal tear and one splenic injury. Six postoperative complications were observed (morbidity rate: 4.8%), one of whom was severe and led to the patient's death due to necrosis of the fundus. After a mean follow-up of 1.7 +/- 1.4 years, 4 patients have transient recurrent reflux, 3 patients have had annoying dysphagia requiring balloon dilatation in one case and reoperation in two cases. Four patients experienced a late thoracic migration: in one case after a violent physical effort, requiring urgent reoperation; in the other three cases, the migration remained asymptomatic. The pH- and manometric study performed in 41 consecutive patients before and after surgery allows objective evaluation of the results.

Laparoscopic surgery: A pioneer's point of view

For a surgeon who performed some of the first laparoscopic cholecystectomies, laparoscopic surgery is undoubtedly the main revolution in the last decade of this century. It is impossible not to be fascinated by the extraordinary changes introduced in our profession in less than 10 years. However, looking back in history, one realizes that laparoscopy is but one of those leaps forward that have always punctuated the evolution of our profession. Since the last century we have witnessed the advent of painless surgery, infectionless surgery, reconstructive surgery, microsurgery, surgery under extracorporeal circulation, organ replacement, and so on. We are in the time of scarless surgery, with no lengthy postoperative handicap. Maybe tomorrow will see surgery performed by remote-controlled robots and surgery at the molecule level. The laparoscopic revolution is particularly important because for the first time surgery no longer involves any physical contact between the surgeon's hand and the patient. Let us hope that this will not lead to total absence of a human relationship in the surgical operation. To avoid this possibility we must remain resolutely involved in the development of laparoscopic surgery; we must keep our minds open to the future advances of science and technology and integrate them in our operative procedures.

[Functional results of the laparoscopic treatment of gastroesophageal reflux (followup greater than 2 years)]

STUDY AIM

The of this study was to evaluate functional results in 70 patients operated on for gastroesophageal reflux disease with a follow-up > 2 years, by means of a questionnaire sent to them.

PATIENTS AND METHODS

Functional results were evaluated in the 60 patients who answered the questionnaire. The fundoplication (Nissen = 27, Nissen-Rosseti = 21, Toupet (n = 12) was laparoscopically performed with a mean follow-up of 3.4 years (range: 2-6.6 years). A circular wrap (either Nissen or Nissen-Rossetti) had been systematically performed except in patients who had an esophageal motility disorder, who had a partial wrap according to Toupet.

RESULTS

Three patients experienced recurrent symptoms of reflux (failure rate: 5%). Thirteen patients had mild dysphagia, requiring modification of the oral intake in two cases. No patient required dilatation. Fifty patients complained of postoperative side effects: flatulence (n = 40), meteorism (n = 24), abdominal pain (n = 16), diarrhea (n = 12), impossibility either to vomit (n = 16) or to belch (n = 20). Ten patients were symptom free and had neither symptoms of reflux nor side effects. Despite undesirable side effects, 46 patients (78%) were very satisfied with the operation, six (10%) were satisfied and five (8%) were disappointed.

CONCLUSION

Recurrent symptoms of reflux were rarely observed (5%) but postoperative side effects were frequent (67%). Side effects when present provide less discomfort than reflux itself. Patients must be aware of it prior to surgery. These results should be confirmed by further assessments.

Advances in laparoscopic surgery

After a brief account of the origins of laparoscopy and of its development into an interventional technique thanks to technical improvement, the author gives a dynamic state of the art in laparoscopic surgery, beginning with a description of his original classification method for laparoscopic procedures according to their level of use. Before tackling the highly controversial issue of laparoscopic surgery for cancer, he reviews in detail the various operations successfully performed by laparoscopy for the treatment of nonmalignant abdominal disorders and acute syndromes, all the while checking their results against those obtained with their open counterparts. As the various procedures are described, the interest of the laparoscopic approach becomes clearly visible, based on the excellent view of the operative field that allows diagnostic accuracy, thus avoiding unnecessary operations, and precise dissection with minimal damage. However, the laparoscopic approach is highly dependent on the surgeon's proficiency, itself depending on experience and therefore on the frequency of occurrence of the disorder, and on the progress in and availability of adequate equipments. The last chapter looks into the future of this ever-expanding approach and defines two great trends in its evolution, one accessible to the individual surgeon, the gradual adaptation of open procedures into laparoscopic ones, the other at the institutional level, in view of the huge financial support involved if high technologies are to be systematically integrated in this new surgery. What will the future be like?

[Ileocaecal tuberculosis. Apropos of a case]

The authors report a case of ileocaecal tuberculosis in a 27-year-old man with no particular risk factor for this disease. The initial diagnosis was terminal ileitis discovered at appendicectomy. The diagnosis of ileal tuberculosis was suspected in the presence of giant cell follicles on ileal biopsies, and was confirmed by the presence of AFB in the gastric intubation fluid. This patient presented known atypical pulmonary images for several years, which had never been investigated in more detail. A favourable course was observed in response to triple-agent, then double-agent antibiotic therapy. This case illustrates the fact that ileal tuberculosis still exists today, and that it does not exclusively affect "high-risk" patients.

[Digestive surgery using the celioscopic route. Prospects for the future]

Digestive surgery through the laparoscopic approach started to develop in March 1987 when the first laparoscopic cholecystectomy was performed. Thanks to the quick success achieved by the pioneers, most of the surgeons soon became aware of the advantages of the method. In the history of surgery, very few procedures have been fortunate enough to cause such a radical and sudden change in each surgeon's daily practice. Over a period of eight years, all the major procedures in digestive surgery have been performed through the laparoscopic approach ; it is now time to evaluate them. Only laparoscopic cholecystectomy has satisfied all the requirements for official approval, thus becoming the gold standard for the treatment of gallbladder lithiasis. However, the use of laparoscopy in the treatment of digestive diseases has already led to a number of major achievements, which makes it possible to outline its prospects. It will develop along two main lines, the first one being gradual transformation of open surgical procedures into laparoscopic procedures through adaptation of operative manoeuvres and design of new instruments. Any surgeon can achieve this transformation provided that he gets specific training. The second line of development will be the integration of high technologies into operative procedures. But this can only be achieved by multidisciplinary institutes endowed with huge financial resources. Patients derive such benefit from laparoscopic surgery that its practise has now reached the point of no-return. Laparoscopic surgery is part of the general evolution towards treatments involving less and less adverse side-effects. It is no doubt the surgery of the future.

[Treatment of esophageal fistulas after gastrectomy. Apropos of 4 cases]

The authors report 4 cases of esophageal fistula following a total gastrectomy. One patient died after a reoperation for a subphrenic abscess, another just before a coloplasty 3 months after an esophageal exclusion. Two patients have been successfully treated by an operation which comprised the removal of the fistula and an intra-thoracic esophago-jejunal anastomosis. This procedure, albeit risked, is probably a better option than the esophageal exclusion usually recommended, particularly in the patients with a malignant disease who have a short life expectancy.

Conversions and complications of laparoscopic cholecystectomy. Results of a survey conducted by the French Society of Endoscopic Surgery and Interventional Radiology

During 1991, 41 surgeons of the French Society of Endoscopic Surgery and Operative Radiology (SFCERO) performed 3,673 cholecystectome of which 2,955 were laparoscopic. Data for those patients in whom a conversion to laparotomy was necessary or a complication occurred were collected by a retrospective multicenter survey. Conversion was performed in 142 patients (4.8%): in 106 this was due to pathology in the subhepatic space; in 36 it was because of a complication related to the laparoscopy. There were 101 postoperative complications (morbidity 3.4%): 59 biliary and 42 non biliary complications and six deaths (mortality 0.2%). There were 18 bile duct injuries, one of which led to the death of the patient. Excluding conversions to laparotomy, these figures are comparable to those for open cholecystectomy. These results define the limits and advantages of laparoscopic cholecystectomy. Conversion to laparotomy remains a wise option in cases of technical difficulty or doubtful biliary anatomy.

Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases

Born in secret in 1987, developed in an atmosphere of skepticism and even hostility throughout 1988, the laparoscopic cholecystectomy triumphed in 1989-90 and caused a veritable revolution in the world of general surgery. The 700 consecutive cases that we report here reflect the spirit of these various periods. From prudently restrictive, our indications widened to include 90% of all patients with gallbladder lithiasis. Sclero-atrophic gallbladders constitute the greatest challenge for endoscopic maneuvers. This group of patients should be treated by the most experienced operators only. The figures for mortality (0.1%) and complications (3%) are very comparable and even better than those for traditional cholecystectomy. The quality of recovery is infinitely better; there is absence of pain, a short period of hospitalization, return to normal physical activity within 10 days, rapid return to work, and total preservation of the abdominal muscles for participation in sports activities. All these advantages are assets of the laparoscopic cholecystectomy which are not available to the 6% of patients for whom an intra-operative conversion to open surgery is necessary. These patients recover within the conditions of a traditional cholecystectomy which are far from being poor. The large multicenter studies, such as those carried out in France and Belgium recently involving 3,708 patients, arrive at identical conclusions. The laparoscopic cholecystectomy is on its way to becoming the gold standard of treatment for gallbladder lithiasis. It is the first successful step towards surgical techniques of the 21st century which will be carried out inside the musculo-cutaneous envelope of the unopened human body.

Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases

Born in secret in 1987, developed in an atmosphere of skepticism and even hostility throughout 1988, the laparoscopic cholecystectomy triumphed in 1989-90 and caused a veritable revolution in the world of general surgery. The 700 consecutive cases that we report here reflect the spirit of these various periods. From prudently restrictive, our indications widened to include 90% of all patients with gallbladder lithiasis. Sclero-atrophic gallbladders constitute the greatest challenge for endoscopic maneuvers. This group of patients should be treated by the most experienced operators only. The figures for mortality (0.1%) and complications (3%) are very comparable and even better than those for traditional cholecystectomy. The quality of recovery is infinitely better; there is absence of pain, a short period of hospitalization, return to normal physical activity within 10 days, rapid return to work, and total preservation of the abdominal muscles for participation in sports activities. All these advantages are assets of the laparoscopic cholecystectomy which are not available to the 6% of patients for whom an intra-operative conversion to open surgery is necessary. These patients recover within the conditions of a traditional cholecystectomy which are far from being poor. The large multicenter studies, such as those carried out in France and Belgium recently involving 3,708 patients, arrive at identical conclusions. The laparoscopic cholecystectomy is on its way to becoming the gold standard of treatment for gallbladder lithiasis. It is the first successful step towards surgical techniques of the 21st century which will be carried out inside the musculo-cutaneous envelope of the unopened human body.

A new biodegradable elastin-fibrin material; its use in urological, digestive and cardiovascular surgery

A new original artificial connective matrix mainly made of elastin and fibrin-like product is used to reinforce damaged tissues and to close and restore a loss of substance in several domains of surgery: all sites in the digestive system and urinary tract; besides, it can substitute for the pericardium in iterative heart operations. In all cases, the original tissue is restored ad integrum while the biodegradable material disappears completely, without any complications.

[Substitution for an experimental duodenal substance loss in the dog with an original bioreactive material]

The aim of this study was to evaluate the suitability of the Elastin Fibrin material as a patch to close a full thickness 1.5 cm diamater duodenal wall defect in the dog. This material originates from a reaction between elastin and fibrin monomers and is available in sheet form of differing thickness. Three Beagles underwent surgical creation of a duodenal defect ant the patch closure with elastin fibrin. Coelioscopic check of the patch was performed at day 8, 15, 39, 60, 90, 120. There was no morbidity or mortality. Macroscopic and histologic examination showed complete disappearance of the patch material and restitution of the duodenal wall at 6 months. These results suggest that in selected cases, evaluation in human may be justified.

[Veno-occlusive disease of the liver. Treatment by portocaval shunt]

A case of hepatic veno-occlusive disease revealed by abdominal pains and the rapid constitution of ascites in a 33-year old French female is reported. She had taken medicinal plants in order to loose weight. Liver biopsy showed typical histological changes consisting of centrizonal hemorrhagic necrosis and centrolobular vein obstruction with endophlebitis. Owing to an increase of ascites, a side-to-side portacaval shunt was performed. Eight months postoperatively, ascites had completely disappeared and the liver biopsy showed only a moderate centrolobular vein fibrosis. Five years later, the clinical state is normal.

[Statistical analysis of results of operative treatment of 223 cases of left colon cancer (author's transl)]

Statistical analysis of results of 223 operations for left colon cancer over a period of ten years is presented. The patients (age, condition), and the clinical expression (urgent or cold surgery) are discussed. The authors then give the lesions a sort of identity card of macroscopic findings (topography, local extension, invasion of glands, metastatic spread) to enable interpretation of the long-term survival results as a function of each parameter. Their conclusions are that, apart from left hemicolectomy conducted for oncological reasons or for safety of technique, no element demonstrates the superiority of standard left hemicolectomy over segmentary colectomy. They also adopt the principle of a proximal colostomy in certain cases that are difficult to treat, this procedure being for them a definite factor of security, but also a risk factor. An urgent bypass operation is conducted except when the lesion requires excision. If conditions are suitable for immediate re-establishment of continuity, which rarely happens, they carry out a systematic protective subjacent colostomy.

[Breakdown of the anastomosis after colectomy. The causes and prevention (author's transl)]

Over a period of 3 years the authors have carried out 184 colectomies with immediate restoration of continuity. In 25 of these operated patients the sutures broke down, i.e. 13.5% and 8 died, i.e. one patient out of 3. In the light of this series, the authors studied factors favouring breakdown, whether relative to the patient (age, sex, pathology, nature of the lesion) or the technic followed, i.e. in fact the surgeon (extent of the colonic resection, type and mode of anastomosis, modes of suture and drainage). Were studied also, in prevention, the first or contemporaneous construction of a colostomy, which according to the authors totally prevents breakdown of the subjacent anastomosis, but has its own complications.

[Critical study of electric activity of the small intestine in the dog]

Thanks to a cross-circulation, the authors caused to survive in the abdomen of a sacrificed dog, the whole of the small intestine, the motor activity of which was analysed by electro-enterography. This experimental preparation thus eliminates polygraphic recordings of all potential variations outside the small intestine, e.g. stomach, colon, diaphragm, muscle, myocardium. One thus obtains very pure tracings of the variations of potential originating in the small intestine, recorded from bipolar serous intestinal electrodes, they show the activity of the small intestine, consisting of a permanent basal electric rhythm on which are grafted spikes contemporary of motor phenomena. In the abdominal skin there were recorded only a cutaneous slow wave which was contemporary with the deep motor phenomena.

[Exploration and removal in focal infections of the liver (apropos of 32 resections in a 4-year period]

The surgeon can no longer be satisfied today, with a diagnosis of focal lesion of the liver. It is also necessary to give the precise localisation of the nodular image compared with the segments and vessels of the gland. The lesional topography is usually determined by coeliac arteriography but, in certain cases, complementary cavography becomes necessary. On knowledge of this hepatic angio-cartography, depends the choice of approach and the nature of the surgical operation, for there are easy methods of approach where, for example, removal may reasonably be attempted and, other segments which are difficult or impossible to approach, e.g. segments VIII and IV posteriorly. The authors report their experience of surgery of the liver between 1971 and April 1974 for 14 abscesses, 15 hydatid cysts, 5 tumours and 9 cases of trauma. They carried out 32 resections, 22 of the right lobe of the liver, 10 of the left lobe. The immediate results are studied in relation to the indications and techniques used.