Total thoracic oesophagectomy for oesophageal carcinoma: has it been worth it?

OBJECTIVE: Anastomotic recurrence is a major cause of late mortality following oesophago-gastrectomy (OG) for carcinoma of the oesophagus and oesophago-gastric junction using either the Ivor Lewis or left thoraco-abdominal approach with intra-thoracic anastomosis. The aim of this study was to determine whether the more extensive total thoracic oesophagectomy (TTO) with cervical anastomosis would reduce the anastomotic recurrence rate while maintaining acceptable operative morbidity and mortality. METHODS: From January 1988 to December 1996, 108 total thoracic oesophagectomies and 66 oesophago-gastrectomies were performed with curative intent in 174 patients (125 males, mean age 62.4 years) with carcinoma (squamous cell carcinoma in 34 and adenocarcinoma in 140) of the middle (31 patients) and lower (44 patients) oesophagus and oesophago-gastric junction (99 patients). RESULTS: Minor complications occurred in 37 (34%) total thoracic oesophagectomy and 18 (27%) oesophago-gastrectomy patients, major complications in 15 (14%) and 5 (8%) and peri-operative death in 5 (4.6%) and 7 (11%) patients, respectively. Anastomotic leakage occurred in 10 (9%) total thoracic oesophagectomy and 5 (8%) oesophago-gastrectomy patients, and was fatal in 1 (1%) and 4 (6%). There was no incidence of tumour at or within 5 mm of the proximal limit in the total thoracic oesophagectomy group and this was reflected in the complete absence of anastomotic recurrence. In the oesophago-gastrectomy group there was a positive proximal resection margin in 13 (20%) and 13 anastomotic recurrences (22% of peri-operative survivors). The 5-year survival (including operative mortality) was 29% for total thoracic oesophagectomy compared with 21% for the other techniques (P = 0.028 log rank test). Median survival was 25.2 months after total thoracic oesophagectomy and 15.8 after oesophago-gastrectomy. CONCLUSIONS: Total thoracic oesophagectomy can be performed in oesophageal cancer patients with comparable morbidity to that of lesser resections. Incomplete proximal resection and anastomotic recurrence did not occur in this series of 108 total thoracic oesophagectomies and this is reflected in an increased medium term survival. The improved survival is most apparent for tumours of the oesophago-gastric junction.     

Anastomotic Leak Prophylaxis Using a Vapor-Heated Fibrin Sealant: Report on 738 Gastric Bypass Patients

Background: Excluding pulmonary embolism, anastomotic leak is the leading cause of death and major morbidity in patients undergoing open or laparoscopic gastric bypass operations. We observed a number of these leaks (11 out of 1,120 Micropouch^SM gastric bypass [MGB] patients; 0.9%). The majority (80%) required emergency laparotomy and drainage, massive fluid resuscitation, and aggressive nutritional support. Therefore, we designed a 2-year, prospective study to determine the therapeutic efficacy of vapor-heated fibrin sealant to prevent anastomotic leaks at the gastro-jejunostomy (GJS) site. Methods: Between April, 2000 and March, 2002, 738 patients underwent a primary (n=671) or revisionary (n=67) MGB procedure.The gastric reservoir was limited to the cardia of the stomach. Vapor-heated fibrin glue 1 cc was applied circumferentially to a 12-mm, non-banded GJS anastomosis. Once activated, fibrin sealant polymerized into a soft, closely adherent gel. No omental patch was used to cover the fibrin-sealed anastomosis. Results: Of 738 patients, 2 required emergency laparotomy for leaks and 2 for adhesive bands that contributed to a distal small bowel obstruction.There were no anastomotic leaks at the fibrin-sealed GJS sites. No gastro-gastric or gastro-enteric fistulas were recorded. Conclusion. Fibrin sealant applied to the GJS site appears to have eliminated anastomotic leaks in our Micropouch^SM gastric bypass patients. These results suggest that fibrin glue application may contribute to "leak prophylaxis" in patients undergoing open Rouxen-Y gastric bypass. Glue placements may also benefit patients undergoing a laparoscopic Roux-en-Y procedure, wherein anastomotic leaks have been reported early in the learning curve.     

Surgical treatment of anastomotic leaks after oesophagectomy.

OBJECTIVE: To determine the optimum management of anastomotic leaks after oesophagectomy. METHODS: We undertook a retrospective review of 23 patients who developed anastomotic leakage, out of 389 patients undergoing oesophagectomy with gastric interposition. The presentation, diagnosis, and treatment of the leaks, and patient outcomes are analysed. RESULTS: Leaks occurred from 3 to 23 (median=7.5) days after surgery. Clinical features included fever (57%), leucocytosis (52%), dysphagia (4%), coughing bile (4%), wound infection (13%), pneumothorax (35%), pleural effusion (70%) and septicaemia (70%). All but one leak was due to variable degree of gastric tip necrosis. Contrast swallow showed leakage in only 14 (61%) patients, whereas oesophagoscopy confirmed all the leaks. Surgical treatment (resection of necrotic stomach and either immediate or staged re-anastomosis, or end-oesophageal exteriorisation) was the primary treatment in 17 patients of whom 15 survived to discharge. Two out of the 6 patients treated non-surgically died. CONCLUSIONS: Diagnosis of anastomotic leakage after oesophagectomy is difficult due to its variable presentation and the unreliability of contrast swallow. Gastric tip necrosis is by far the most common cause. We feel our preferred strategy of immediate surgical treatment of symptomatic leaks is justified by the favourable outcome in the majority of patients.     

Risk factors for airway complications within the first year after lung transplantation.

OBJECTIVE: Lung transplantation (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective cohort study we looked at possible predictors of AC within the first year after LTx. METHODS: Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age: 48 years [range 15-66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor variables (age, gender, PaO(2)/FiO(2), mechanical ventilation, ischemic time and preservation solution) and recipient variables (age, diagnosis, length, gender, pre-operative steroids, smoking, cytomegalovirus matching, LTx type, anastomotic type, wrapping and bypass) were evaluated in an univariate and multivariate model. RESULTS: Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) during the first year after LTx. In a univariate analysis (321 airway anastomoses at risk), anastomotic type (7/17 [Telescoping] vs 48/304 [End-to-end]; p=0.011), recipient length (p=0.0012), donor ventilation (>50-70h<; p=0.0015) and recipient male gender (43/191 [M] vs 12/130 [F]; p=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping technique (p=0.0495), recipient length (p=0.0029) and donor ventilation (p=0.003). CONCLUSIONS: Tall recipients and those receiving lungs from donors with prolonged ventilation have an increased risk to develop bronchial anastomotic problems. An end-to-end anastomosis should be preferred. Airway complications remain a matter of concern after lung transplantation.     

Erythropoiesis and renal transplant pregnancy

OBJECTIVE: To examine erythropoiesis in renal transplant pregnancies. METHODS: Retrospective cohort study of 30 renal transplant cases and 30 age, smoking and parity-matched healthy controls with normal index pregnancy. Retrospective chart review and assay of frozen antenatal serum (for serum erythropoietin concentration [serum EPO]), transferrin receptor protein [TfR], ferritin, folate and B12) were performed. The linear regression equation for normal pregnancy controls was used to calculate predicted [serum EPO] and the observed/predicted (O/P) log [serum EPO] was plotted. The relationship between [serum EPO] and haemoglobin (Hb) among transplant cases was considered to be different from that among controls if the slope of the O/P log [serum EPO] versus Hb regression was significantly different from zero. RESULTS: The transplant (14 cadaveric) to conception interval was (median [range]) 33.5 [4, 189] months. Immunosuppressants were azathioprine (n = 25), cyclosporine (n = 22) and/or prednisone (n = 25). Cases were more often primiparous (20 vs. 7 [controls]; p = 0.01), had pre-existent hypertension (20 vs. 0 [controls]; p < 0.001), developed new/increased hypertension or pre-eclampsia (28 vs. 0 [controls]; p < 0.001) and an antenatal rise in creatinine (14 vs. 2 [controls]; p < 0.001). In early pregnancy, cases had similar EPO (15.2 [2.6, 84.6] vs. 15.7 [6.4, 41.0] [controls] U/L) but lower Hb (101 [65, 129] vs. 116 [106, 150] g/L; p < 0.001). Twenty-two (73%) cases had Hb < 100 g/L (vs. 4 [controls]; p < 0.0001); Hb was comparable at 6 wk postpartum. With advancing gestational age (GA), Hb remained stable and serum EPO increased in both groups. The slope of the O/P log [serum EPO] versus Hb for transplant cases was significantly different from zero within both the 17-28 wk (slope +/- SEM: 0.010 +/- 0.002; p < 0.0001) and the 29-42 wk GA categories (0.006 +/- 0.003; p = 0.02). Cases showed smaller rises in serum TfR (change 481 [- 1471, 2780]) vs. 1119 [- 698, 4195] [controls] ng/mL; p = 0.005). CONCLUSIONS: Anaemia frequently complicates renal transplant pregnancies, in which serum EPO is inappropriately low and the rate of erythropoiesis blunted.     

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

BACKGROUND: A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery. METHODS: A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome. RESULTS: Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01). CONCLUSIONS: The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.     

Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass

OBJECTIVE: To document the effect of anastomotic leaks on morbidity and mortality after Roux-en-Y gastric bypass (RYGB) for obesity. DESIGN: Prospectively collected data on 840 consecutive patients who underwent RYGB between 1998 and 2005. Multivariate logistic regression analysis was used to determine the effect of anastomotic leaks on postoperative morbidity independent of sex, age, preoperative body mass index, access (open vs laparoscopic), calendar year of RYGB, and comorbidities. P < .05 was considered significant. RESULTS: A total of 36 patients (4.3%) developed leaks after RYGB. Patients who developed anastomotic leaks had a significantly higher overall complication rate (61% vs 20%, P < .001), mortality (14% vs 4%, P = .01), and duration of hospital stay (24.5 vs 4.5 days, P < .001) compared with patients who did not develop leaks. In a multivariate logistic regression model, anastomotic leaks increased the likelihood of mortality (odds ratio [OR], 15; 95% confidence interval [CI], 3-80; P = .002) and overall complications (OR, 6; 95% CI, 3-13; P < .001), specifically sepsis (OR, 27; 95% CI, 2-472; P = .02), renal failure (OR, 16; 95% CI, 3-99; P = .003), small-bowel obstruction (OR, 11; 95% CI, 2-68; P = .008), internal hernia (OR, 10; 95% CI, 2-51; P = .008), thromboembolism (OR, 9; 95% CI, 3-27; P < .001), and incisional hernia (OR, 5; 95% CI, 2-13; P = .001). CONCLUSIONS: Anastomotic leaks significantly increase the likelihood of developing additional life-threatening complications after RYGB. Close and aggressive monitoring is recommended for early detection and management of added complications, should they occur.     

Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile?

BACKGROUND: The aim of our study was to evaluate the use of intraoperative colonoscopy in laparoscopically assisted left-sided colon resection for the assessment of anastomosis. MATERIALS AND METHODS: All consecutive laparoscopically assisted left-sided colon resections performed at our department between May 2001 and February 2006 were included in this study. After colon resection and reanastomosis, an intraoperative colonoscopy was performed to detect anastomosis risk. RESULTS: A total of 122 patients were enrolled in this study. In 73 patients (59.84%), the anastomosis was checked via colonoscopy (the study group, (SG), whereas the control group (CG) consisted of 49 (40.16%) patients without colonoscopy. Of the 122 patients, 65 (53.28%) underwent a laparoscopically assisted sigmoid resection, 45 (36.89%) a laparoscopically assisted sigmoid rectum resection, 4 (3.28%) a laparoscopically assisted anterior rectum resection, and 8 (6.56%) a laparoscopically assisted left hemicolectomy. In the study group, 5 (6.85%) anastomotic leakages were intraoperatively detected and oversewn. A total of 6 (4.92%) anastomotic leakages occurred in the early postoperative period (SG: 4 [5.47%] vs. CG: 2 [4.08%]; P = 0.541). CONCLUSIONS: Intraoperative evaluation of anastomosis prevents early anastomotic insufficiency because intraoperative identification of leaks allows for repair during surgery. Nevertheless, a certain rate of anastomotic dehiscence occurs in every kind of colon resection. The sometimes increased rate of dehiscence in laparoscopic-assisted colon resection can be reduced by intraoperative colonoscopy.     

Prophylactic splenectomy for splenic vein thrombosis in patients undergoing resection for chronic pancreatitis

AIM: Chronic pancreatitis (CP) is the leading cause of splenic vein thrombosis (SVT). SVT occurs in about 15 % of patients with CP. The risk of variceal bleeding in SVT is approximately 10 %. Splenectomy is indicated in symptomatic SVT but its role in asymptomatic SVT is discussed controversially. Aim of our study was to evaluate the outcome of splenectomy performed during pancreatic resection in patients with CP and asymptomatic SVT. METHODS: 33 of 198 patients undergoing resection for CP underwent concomitant prophylactic splenectomy for asymptomatic SVT. Perioperative data were compared in the groups of patients with or without splenectomy. Follow-up was complete in 84 % (average 31 months). RESULTS: Median operative time, postoperative morbidity, reoperation rate and mortality were not different in patients with or without splenectomy. The median number of blood units transfused was higher in patients with prophylactic splenectomy (6 vs 4 units; p < 0.01). One complication of splenectomy (postoperative bleeding) occurred (3 %). During follow-up no variceal bleeding, no episode of postsplenectomy sepsis or thrombosis due to temporary thrombocytosis occurred. CONCLUSIONS: Complications of prophylactic splenectomy are rare and less frequent than reported episodes of variceal bleeding. In the presence of asymptomatic SVT splenectomy should be considered during pancreatic resection to facilitate surgery and to avoid further variceal bleeding.     

Sinistral portal hypertension. Splenectomy or expectant management.

Splenectomy has been considered the treatment of choice for patients with bleeding from sinistral portal hypertension (SPH) and varices, but is controversial for asymptomatic patients. To further define the role of splenectomy for SPH, the authors compared the clinical presentations and outcomes of 25 patients treated with splenectomy with those of 12 observed patients. Clinical features were similar except for transfusions administered (60% vs. 25%, p < 0.05), hemoglobin (9.8 +/- 2.2 g/dL vs. 12.5 +/- 2.1 g/dL, p < 0.05), and history of prior bleeding episodes (56% vs. 8%, p < 0.05), splenectomy versus no splenectomy, respectively. At 3 years, neither survival (78% vs. 64%, p = 1.0) nor new or recurrent bleeding (16% vs. 24%, p = 0.2) differed, splenectomy versus no splenectomy, respectively. The authors conclude that in the absence of prior bleeding episodes, anemia, or severe hemorrhage, observation of patients with SPH is justified.     

Management of biliary tract complications after orthotopic liver transplantation

INTRODUCTION: Despite improved survival, biliary complications remain a significant cause of morbidity following orthotopic liver transplantation. The aim of this study was to review the incidence, treatment and optimum management pathway of biliary complications at the Scottish Liver Transplant Unit. MATERIALS AND METHODS: All patient data were collected prospectively onto a database at the Scottish Liver Transplant Unit with review of hospital records for validation. RESULTS: A total of 379 consecutive orthotopic liver transplants were performed in 333 adult patients between November 1992 and September 2001. Biliary complications occurred in 55 grafts (51 patients) (14.6%) and their incidence decreased with time. Biliary complications occurred in 29 (10.9%) of the 265 choledocho-choledochostomies compared with 14 (25%) of the 56 with T-tubes. Twenty-eight biliary leaks occurred, 22 of which were anastomotic. Seventeen anastomotic leaks were successfully treated non-operatively. Eight patients with biliary leaks subsequently developed an anastomotic stricture. Of the 30 anastomotic strictures, stent insertion was successful in resolving six of 14 (42%) early anastomotic strictures compared with one of 12 (8%) late anastomotic strictures (p = 0.0479). Six (38%) of the 16 early anastomotic strictures required surgery for complete resolution, compared with 12 (86%) of the 14 late anastomotic strictures (p = 0.0106). CONCLUSION: The incidence of biliary complications has decreased with time. The abandonment of choledocho-choledochostomy over a T-tube has been justified. A combination of conservative, endoscopic, and radiological management has been effective in treating biliary leaks and early anastomotic stricture. However endoscopic or radiological stenting was ineffective in the management of late anastomotic strictures, which were best treated by surgical intervention.     

Anastomotic leaks after esophagectomy for esophageal cancer: a comparison of thoracic and cervical anastomoses.

BACKGROUND AND OBJECTIVES: Esophagogastric anastomotic leaks remain a significant problem after esophagectomy for esophageal cancer. Many investigators have reported that leaks are more frequent after cervical, as opposed to thoracic, esophagogastric anastomoses. We conducted a retrospective review to assess the effect of anastomotic location (thoracic or cervical) on anastomotic leak incidence and severity. METHODS: Seventy-four consecutive patients with esophageal cancer underwent esophagectomy and esophagogastric anastomoses at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, resection margin status, adjuvant therapy, cancer survival, anastomotic location, anastomotic leaks, and operative mortality. RESULTS: Cervical anastomoses were done in 19 patients and thoracic anastomoses were done in the other 55 patients. The two groups were similar with respect to age, gender, histology, stage, adjuvant therapy, and overall survival. Operative mortality for the entire group of 74 patients was 4% (3 patients). Resection margins were positive for residual tumor in 2 of 19 (11%) patients with cervical anastomoses and 9 of 55 (16%) patients with thoracic anastomoses (p=0.42). Leaks complicated 1 of 19 (5%) cervical and 9 of 55 (16%) thoracic esophagogastric anastomoses (p=0.21). Positive resection margins and anastomotic leaks were not significantly related (p=0.54). One of 9 (11%) leaks in the thoracic group proved fatal. CONCLUSIONS: In our experience cervical esophagogastric anastomoses do not have a higher incidence of leaks than thoracic anastomoses.     

Cost-Benefit and Efficacy of Aprotinin Compared with epsilon-Aminocaproic Acid in Patients Having Repeated Cardiac Operations: A Randomized, Blinded Clinical Trial

Background: Aprotinin and epsilon-aminocaproic acid are routinely used to reduce bleeding during cardiac surgery. The marked difference in average wholesale cost between these two drug therapies (aprotinin, $1,080 vs. epsilon-aminocaproic acid, $11) has generated significant controversy regarding their relative efficacies and costs.

Methods: In a multicenter, randomized, prospective, blinded trial, patients having repeated cardiac surgery received either a high-dose regimen of aprotinin (total dose, 6 x 106 kallikrein inactivator units) or epsilon-aminocaproic acid (total dose, 270 mg/kg).

Results: Two hundred four patients were studied. Overall (data are median [25th-75th percentiles]), aprotinin-treated patients had less postoperative thoracic drainage (511 ml [383-805 ml] vs. 655 ml [464-1,045 ml]; P = 0.016) and received fewer platelet transfusions (0 [range, 0-1] vs. 1 [range, 0-2]; P = 0.036). The surgical field was more likely to be considered free of bleeding in aprotinin-treated patients (44% vs. 26%; P = 0.012). No differences, however, were seen in allogeneic erythrocyte transfusions or in the time required for chest closure. Overall, direct and indirect bleeding-related costs were greater in aprotinin- than in epsilon-aminocaproic acid-treated patients ($1,813 [$1,476-2,605] vs. $1,088 [range, $511-2,057]; P = 0.0001). This difference in cost per case varied in magnitude among sites but not in direction.     

Oesophageal cancer in patients with head and neck cancers: therapeutic implications

AIM OF THE STUDY: To determine therapeutic and prognostic implications of an associated head and neck primary cancer in patients undergoing oesophagectomy for squamous cell carcinoma of the oesophagus. PATIENTS AND METHODS: Between 1982 and 2000, 868 patients with oesophageal cancer were operated in our institution, including 78 (9%) who underwent oesophagectomy for associated oesophageal and head and neck cancers; the latter was synchronous (n = 52) or anterior metachronous (n = 26). Influence of head and neck cancer on the treatment of oesophageal carcinoma was analysed retrospectively in terms of surgical therapeutic strategy and survival. RESULTS: Oesophageal resection consisted of oeso-pharyngolaryngectomy (n = 14, 17.9%), subtotal oesophagectomy (n = 62, 79.5%) and cervical oesophagectomy (n = 2, 2.6%). Radical resection (R0) was obtained in 85% of cases. Postoperative mortality rate was 5 % (4/78). Main complications were pulmonary (18% = 14/78) and anastomotic leaks (14% = 11/78), all of them cervical. Follow-up (mean = 25 +/- 27 months) was complete for all 78 patients. Five-year survival after R0 resection was 25%. Survival pronostic factors were denutrition, complete resection, and pT status of oesophageal tumor. CONCLUSION: In patients with associated carcinomas of oesophagus and head and neck, agressive treatment -including an oesophagectomy- allowed a 5-year survival rate more than 25% without increased mortality or morbidity rates, compared with patients operated on for isolated oesophageal carcinoma.     

Evolution of anastomotic techniques in oesophageal surgery: experience at the Milan University Department of Surgery

Despite the fact that the incidence and severity of postoperative complications after oesophagectomy have substantially decreased over the past two decades, anastomotic leakage is still a potentially catastrophic event. In this article, the experience of a single surgical unit is analysed. Over the period from 1992 to 2003, 435 oesophagectomies with oesophagogastroplasty were performed at the Milan University Department of Surgery. The overall mortality rate was 1.6%. The incidence of anastomotic leakage was 8.5% (6.5% for intrathoracic anastomoses and 14% for cervical anastomoses), and the mortality rate due to leakage was 13.5%. The authors discuss the factors associated with anastomotic leakage by comparing their personal experience with data from the international literature.     

Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques

HYPOTHESIS: Although perceived as a more technically demanding and time-consuming technique, the hand-sewn gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with fewer complications and lower costs than stapled techniques. DESIGN: A retrospective medical record review of prospectively collected data. SETTING: University hospital. PATIENTS: One hundred eight consecutive patients undergoing laparoscopic RYGB between January 1, 1999, and December 31, 2001. INTERVENTION: Three techniques were compared: hand-sewn anastomosis (HSA), circular-stapled anastomosis (CSA), and linear-stapled anastomosis (LSA). MAIN OUTCOME MEASURES: Operative costs, including the cost of stapling devices, the cost of sutures, and operative times, were compared. Rates of anastomotic strictures, leaks, marginal ulcers, bleeding, and wound infections were determined. RESULTS: Eighty-seven patients underwent HSA; 13, CSA; and 8, LSA. Supply costs per patient were higher for CSA ($955) and LSA ($435) than for HSA ($2) (P<.001). The mean +/- SEM operative time for laparoscopic RYGB was longer when performing CSA than HSA or LSA (285 +/- 22 vs 215 +/- 8 and 204 +/- 28 minutes, respectively; P<.001). Stricture rates were higher after CSA than HSA and LSA (4 [31%] of 13 patients vs 3 [3%] of 87 patients and 0 of 8 patients, respectively; P<.01). The wound infection rate was higher after CSA than HSA and LSA (3 [23%] of 13 patients vs 1 [1%] of 87 patients and 0 of 8 patients, respectively; P<.001). There was no difference in anastomotic bleeding, and no anastomotic leaks occurred. CONCLUSIONS: In this experience, hand-sewn gastrojejunostomy during laparoscopic RYGB reduced operating room supply costs and was completed faster than stapled techniques. However, these differences may reflect the learning curve because these techniques were used early in our experience. Lower postoperative stricture and wound infection rates seem to be the primary benefits of the HSA technique.     

The effect of intravenous ketoprofen on postoperative epidural sufentanil analgesia in children.

We compared the effect of IV ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia after major surgery. We used a prospective, randomized, double-blinded, placebo-controlled, parallel-group study design in 54 children aged 1-15 yr who received a standardized anesthetic. Either IV ketoprofen or saline was administered in addition to an epidural sufentanil infusion, which was adjusted as required clinically. The study drug infusions were discontinued when pain scores were <3 on 0-10 scale for 6 h at a sufentanil infusion rate of 0.03 microg x kg(-1) x h(-1). Children in the ketoprofen group had a better analgesic effect, as shown by decreased need for sufentanil (mean [10th-90th percentiles] 8.3 [3.1-15.1] microg/kg vs 12.5 [6.2-18.9] microg/kg; P = 0.002) and earlier possibility to discontinuation of the epidural sufentanil (11 [46%] vs 3 [13%]; P = 0.014) before the end of the 72-h study period. In the ketoprofen group, median (range) pain scores were lower during activity at 24 h (2 [0-5] vs 5 [0-7]; P = 0.01) and at 72 h (0 [0-3] vs 2 [0-6]; P = 0.033), and fewer children had inadequate pain relief during activity at 24 h (0 vs 5; P = 0.037). Children who received ketoprofen required fewer infusion rate adjustments (12 [4-20] vs 17 [6-42]; P = 0.016). In the ketoprofen group, the incidence of desaturation (1 [4%] vs 6 [26%]; P = 0.035) and fever (3 [12%] vs 11 [48%]; P = 0.008) was less than that in the placebo group. We conclude that ketoprofen improved postoperative pain in children. IMPLICATIONS: We compared the effect of the IV nonsteroidal antiinflammatory drug ketoprofen versus placebo as adjuvants to epidural opioid analgesia with sufentanil. The continuous IV nonsteroidal antiinflammatory drug improved pain after major surgery in children receiving an epidural opioid. Although ketoprofen reduced epidural sufentanil requirements, the incidence of opioid-related adverse effects was not changed.     

Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference?

INTRODUCTION: Curative oesophageal resection for carcinoma may be carried out by either the transhiatal or the Ivor-Lewis transthoracic technique. The aims of this study were to compare the morbidity, 30-day mortality and long-term survival of the two techniques in the treatment of oesophageal carcinoma and to provide data to calculate the sample sizes for a prospective randomized trial. METHODS: Results from 44 series published between January 1986 and December 1996 were reviewed. Thirty-three papers reported results on 2675 patients having transhiatal (THO) and 29 papers reported results on 2808 patients having Ivor-Lewis oesophagectomy (ILO). RESULTS: The two groups were comparable in terms of age, sex and stage of the disease. There was no apparent difference in postoperative morbidity between the two groups with respect to respiratory complications (24% for THO, 25% for ILO), cardiovascular complications (12.4% for THO, 10.5% for ILO), wound infection (8.8% for THO, 6.2% for ILO) and chylothorax (2.1% for THO, 3.4% for ILO). The transhiatal group appeared to have a higher incidence of anastomotic leaks (16% for THO, 10% for ILO), anastomotic strictures (28% for THO, 16% for ILO) and recurrent laryngeal nerve injuries (11.2% for THO, 4.8% for ILO). The 30-day mortality was 6.3% for transhiatal and 9.5% for Ivor-Lewis oesophagectomy. Overall long-term survival at 5 years was similar (24% for THO, 26% for ILO). CONCLUSIONS: The surgical approach to oesophagectomy was not an important determinant of morbidity and long-term survival in patients with oesophageal carcinoma. Transhiatal oesophagectomy was associated with a higher incidence of anastomotic complications and recurrent laryngeal nerve injury. Ivor-Lewis oesophagectomy had a higher mortality. In order to demonstrate a significant difference in morbidity or long-term survival between the two techniques 3100 patients would be required in each arm of a prospective randomized trial.