Video-assisted mediastinoscopic resection compared with video-assisted thoracoscopic surgery in patients with esophageal cancer

Objective

The purpose of this study was to explore the indications of radical vedio-assisted mediastinoscopic resection for esophageal cancer.

Methods

The data of 109 patients with T1 esophageal cancer who underwent video-assisted mediastinoscopic resection (VAMS group) in Third Affiliated Hospital of Soochow University Hospital from December 2005 to December 2011 were collected in the study for comparison with the 58 patients with T1 esophageal cancer who underwent video-assisted thoracoscopic surgery (VATS group) in Zhongshan Hospital, Fudan University. The perioperative safety and survival were compared between the two groups.

Results

All operations were successful in both groups. One perioperative death was noted in the VATS group. The incidences of post-operative complications were not significantly different between these two groups, whereas the VAMS group was favorable in terms of operative time (P<0.001) and blood loss (P<0.001), and a significantly larger number of chest lymph nodes were dissected in the VATS group compared with the VAMS group (P<0.001). Long-term follow-up showed that the overall survival was not significantly different between these two groups (P=0.876).

Conclusions

T1N0M0 esophageal cancer can be as the indication of VAMS radical resection. VAMS radical resection can be considered as the preferred option for patients with poor pulmonary and cardiac function or a history of pleural disease.     

Surgical Management Of 3 Cases With Huge Tracheoesophageal Fistula With Esophagus Segment in situ As Replacement Of The Posterior Membranous Wall Of The Trachea

Objective

Tracheoesophageal fistula (TEF) is an uncommon and potentially life-threatening complication of blunt chest trauma. The objectives of this report are to describe our surgical experience in three patients with huge TEF and to evaluate the short-term results of surgical management in this potentially life-threatening complication of blunt chest trauma.

Methods

Three patients with huge TEF (5.2-7.0 cm in diameter) after blunt chest trauma were kept in supine position, then the neck was excided and esophagus was free, double breasted suture and clench and mutilation were performed successively over the same level of superior aperture of thorax. The thoracic esophagus was then located in situ at the membrane portion where the trachea was incomplete. Meanwhile, the stomach was then freed through a middle abdominal incision and pulled through the posterior tunnel of the sternum to the neck. Last, an anastomosis between esophagus and tubular stomach was performed over left neck.

Results

All three patients recovered well after the operation. They were able to take liquids and then solids beginning ten days after the procedure. One year post-operation, they were able to resume normal activity.

Conclusions

The surgical management of patients with huge TEF by esophageal exclusion (cervical gastroesophagostomy) and use of esophagus segment in situ as replacement of the posterior membranous wall of the trachea is feasible.     

Impact of body mass index on survival of esophageal squamous carcinoma patients in southern China

Background

Although high body mass index (BMI) increases risk for developing esophageal adenocarcinoma (EAC), the prognostic influence of BMI is unknown in esophageal squamous carcinoma.

Methods

BMI was calculated using measured height and weight at the first diagnosis and categorized as overweight (25 to 29.9 kg/m²), normal (18.5 to 24.9 kg/m²) or underweight (<18.5 kg/m²). Survival was compared by using the log-rank test on the Kaplan-Meier life table. Multivariate Cox regression analysis was used to evaluate whether BMI was an independent prognostic factor for disease-specific survival (DSS).

Results

Among 1,176 esophageal squamous carcinoma patients, 146 (12.4%) were categorized as overweight, and 277 (23.6%) underweight. More patients in the underweight group had anemia (P=0.001), weight loss (P=0.035) and R1 resection (P<0.001). Less patients in the underweight group received adjuvant chemotherapy (P=0.01). Patients in the overweight group had a higher incidence rate of high blood pressure (P<0.001), diabetes (P<0.001) and coronary artery diseases (P<0.001). Moreover, more patients in the overweight group had a lower TNM stage (P=0.003). In the univariated analysis, high BMI was significantly associated with better DSS (P=0.013).

Conclusions

After adjusting for covariates enrolled for study, high BMI was an independent prognostic factor in weight loss esophageal squamous carcinoma patients.     

Noninvasive positive pressure ventilation for the treatment of acute respiratory distress syndrome following esophagectomy for esophageal cancer: a clinical comparative study

Objective

To evaluate the therapeutic efficacy of noninvasive positive pressure ventilation (NPPV) in the treatment of acute respiratory distress syndrome (ARDS) following esophagectomy for esophageal cancer.

Methods

In this retrospective evaluation, we included 64 patients with ARDS following esophagectomy for esophageal cancer between January 2009 and December 2011. The primary evaluations were 28-day fatality and actual fatality. The secondary evaluations were sex, age, onset time, pH value, PaO₂/FiO₂, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE-II) score, and presence or absence after surgery of major surgery-related complications such as cardiac arrest, anastomotic fistula, and acute renal dysfunction.

Results

NPPV applied as the first-line intervention for ARDS following esophagectomy for esophageal cancer avoided intubation in 30 patients (30/64, 48.4%). There were no significant differences in gender, age, PaO₂/FiO₂, SOFA score, or APACHE-II score between the NPPV group and the patients who required invasive positive pressure ventilation (IPPV group) (P>0.05) at the time of onset, while differences in the PaO₂/FiO₂ (P<0.05) after 24 h of NPPV and presence of major surgery-related complications were highly significant (P<0.01).

Conclusions

NPPV may be an effective option for the treatment of ARDS/acute lung injury (ALI) following esophagectomy for esophageal cancer. However, conversion to invasive mechanical ventilation should be considered in patients with severe postoperative complications such as acute renal dysfunction and cardiac arrest and in those with PaO₂/FiO₂ <180 after 2 h of NPPV.KEYWORDS : Noninvasive positive pressure ventilation (NPPV), esophagectomy, acute respiratory distress syndrome (ARDS)     

Results of the introduction of a minimally invasive esophagectomy program in a tertiary referral center

Background

Esophagectomy is accompanied by a high postoperative complication rate. Minimally invasive esophageal surgery appears to be a promising technique that might be associated with a lower pulmonary morbidity rate. The objective of this study was to describe the implementation of minimally invasive esophageal surgery in a tertiary referral center and to compare the results of our first series of minimally invasive esophagectomies (MIE) to conventional open esophagectomies.

Methods

MIE was implemented after several procedures had been proctored by a surgeon with extensive experience with MIE. Preoperative characteristics and the postoperative course of patients who underwent a transthoracic esophagectomy were prospectively registered. Morbidity and overall hospital stay were compared between minimally invasive and open resections performed in the same period.

Results

A total of 90 consecutive esophageal cancer patients underwent a transthoracic resection, 41 patients by means of a minimally invasive approach. Preoperative characteristics were comparable for both groups. The duration of surgery was longer in the MIE group (6.0 vs. 5.2 hours, P<0.001) and median blood loss was lower [100 vs. 500 mL (P<0.001)]. There was only a trend towards a shorter hospital stay in the MIE group (11 vs. 13 days, P=0.072), pulmonary complications occurred in 20% of patients in the MIE group vs. 31% in the open group (P=0.229). The overall complication rate was 51% in the MIE group vs. 63% in the open group, P=0.249.

Conclusions

Implementation of MIE in our center was successful and it appears to be a safe technique for patients with potentially curable esophageal carcinoma.KEY WORDS : Esophageal cancer, surgical technical, complications, thoracoscopy     

Albert-Lembert versus hybrid-layered suture in hand sewn end-to-end cervical esophagogastric anastomosis after esophageal squamous cell carcinoma resection

Background

Hand sewn cervical esophagogastric anastomosis (CEGA) is regarded as preferred technique by surgeons after esophagectomy. However, considering the anastomotic leakage and stricture, the optimal technique for performing this anastomosis is still under debate.

Methods

Between November 2010 and September 2012, 230 patients who underwent esophagectomy with hand sewn end-to-end (ETE) CEGA for esophageal squamous cell carcinoma (ESCC) were analyzed retrospectively, including 111 patients underwent Albert-Lembert suture anastomosis and 119 patients underwent hybrid-layered suture anastomosis. Anastomosis construction time was recorded during operation. Anastomotic leakage was recorded through upper gastrointestinal water-soluble contrast examination. Anastomotic stricture was recorded during follow up.

Results

The hybrid-layered suture was faster than Albert-Lembert suture (29.40±1.24 min vs. 33.83±1.41 min, P=0.02). The overall anastomotic leak rate was 7.82%, the leak rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (3.36% vs. 12.61%, P=0.01). The overall anastomotic stricture rate was 9.13%, the stricture rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (5.04% vs. 13.51%, P=0.04).

Conclusions

Hand sewn ETE CEGA with hybrid-layered suture is associated with lower anastomotic leakage and stricture rate compared to hand sewn ETE CEGA with Albert-Lembert suture.     

Thoracoscopic purse string technique for minimally invasive Ivor Lewis esophagectomy

Objective

Thoracolaparoscopic esophagectomy with chest anastomosis (TLE-chest) is increasingly performed for middle and lower esophageal cancer; however, gastroesophageal anastomosis for this surgery remains both challenging and inefficient. To address this issue, we previously reported our MIE technique with Ivor-Lewis anastomosis. Here we present the video to introduce our TLE-chest operation procedures.

Methods

TLE-chest with a combined thoracoscopic and laparoscopic technique was performed by one group of surgeons. From October 2011 to September 2013, 80 esophageal cancer patients were treated with TLE-chest using this improved anastomotic technique.

Results

The surgery was successful for all patients, although the anastomosis in one patient required intraoperative manual repair. No patients required open conversion. In this video, dissociation of stomach, and dissection of lymph nodes, creation of gastric tube and staple line embedding, jejunostomy were carried out by laparoscopic surgery. Dissection of esophageal cancer and mediastinal lymph nodes were done through rib 3 or 4 by a 3-4 cm video-assisted right anterior minithoracotomy, then esophago-gastric anastomosis was performed in right thoracic cavity This video shows the R0 resection of T3N0M0 esophageal cancer. Totally, 36 lymph nodes were dissected, including 21 mediastinal lymph nodes and 15 abdominal lymph nodes. The patient recovered well and was discharged on day 8 after the surgery, with good short term outcomes.

Conclusions

A safe, cost effective purse string stapled anastomotic technique has been presented for TLE-chest in our video. It is consistent with the oncology principles.     

Effects of oxidative stress on mitochondrial content and integrity of human anastomotic colorectal dehiscence: a preliminary DNA study

BACKGROUND:

Anastomotic dehiscence is one of the most severe complications of colorectal surgery. Gaining insight into the molecular mechanisms responsible for the development of anastomotic dehiscence following colorectal surgery is important for the reduction of postoperative complications.

OBJECTIVE:

Based on the close relationship between surgical stress and oxidative stress, the present study aimed to determine whether a correlation exists between increased levels of reactive oxygen species and colorectal anastomotic dehiscence.

METHODS:

Patients who underwent surgical resection for colorectal cancer were divided into three groups: patients with anastomotic dehiscence (group 1); patients without dehiscence who underwent neoadjuvant radiochemotherapy (group 2); and patients without anastomotic dehiscence who did not undergo neoadjuvant radiochemotherapy (group 3). Quantitative polymerase chain reaction and real-time polymerase chain reaction assays were performed to measure nuclear DNA and mitochondrial DNA (mtDNA) content, and possible oxidative damage to nonmalignant colon and rectal tissues adjacent to the anastomoses.

RESULTS:

mtDNA content was reduced in the colon tissue of patients in groups 1 and 2. Rectal mtDNA was found to be more damaged than colonic mtDNAs in all groups. The 4977 bp common deletion was observed in the mtDNA of tissues from both the colon and rectum of all patients.

DISCUSSION:

Patients in groups 1 and 2 were more similar to one another than to group 3, probably due to higher levels of reactive oxygen species in the mitochondria; the greater damage found in the rectum suggests that dehiscence originates primarily from the rectal area.

CONCLUSIONS:

The present study of mtDNA analyses of normal human colon and rectal tissues from patients with colorectal cancer is among the first of its kind.     

Partial esophagogastrostomy with esophagogastric anastomosis below the aortic arch in cardiac carcinoma: characteristics and treatment of postoperative anastomotic leakage

Background

Anastomotic leakage is a severe and common complication for surgeries of cardiac cancer. Here we explore the clinical features, diagnosis, and treatment strategies of anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis.

Methods

From January 2009 to December 2013, 1,196 patients with cardiac carcinoma underwent esophagectomy and esophagogastric anastomosis in Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences. Of them, 25 patients developed symptomatic anastomotic leakage. Their clinical data were retrospectively reviewed.

Results

Among these 25 patients with anastomotic leakage, three died after active treatment and fifteen healed with thoracic drainage time 18-115 days. The left seven patients who did not heal until discharge developed chronic infection sinus of anastomotic leakage. Without infection symptoms, they were discharged 30-100 days after surgery with nasoenteral tube and thoracic drainage.

Conclusions

Anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis can be classified into five subtypes: occult type, left thoracic type, right thoracic type, mediastinal type, and mixd type. Subtyping of anastomotic leakage is useful and convenient for diagnosis and treatment.     

Endoscopic assessment of children with esophageal atresia: Lack of relationship of esophagitis and esophageal metaplasia to symptomatology

BACKGROUND:

Late complications of esophageal atresia (EA), particularly esophagitis and Barrett’s esophagus, are increasingly being recognized. With the exception of patients with dysphagia associated with esophageal stricture, it is unknown whether patient symptomatology can predict endoscopic findings.

METHODS:

Data regarding the digestive symptoms of patients who were referred to the EA multidisciplinary clinic from October 2005 to October 2008, and underwent upper gastrointestinal endoscopic evaluation, were systematically collected. Macroscopic and histological findings were analyzed. Endoscopy was considered normal if no esophagitis, intestinal metaplasia or gastric metaplasia (GM) was discerned.

RESULTS:

Sixty-three patients underwent endoscopy. Eighteen had dysphagia related to an esophageal stricture needing dilation and were subsequently excluded from the analysis. Forty-five patients (26 girls) with a median age of 7.3 years (range 0.4 to 17.9 years) were evaluated. Twenty-six patients (58%) were normal at endoscopy, 14 patients (31%) had esophagitis and 16 patients (36%) had GM. No intestinal metaplasia or adenocarcinoma was detected. Six patients with abnormal endoscopy results were asymptomatic. No correlation between digestive symptoms and endoscopy results was found.

CONCLUSION:

The present cross-sectional study showed that symptomatology was not predictive of abnormal endoscopy in EA patients. Esophagitis or GM may be discovered, even in the absence of symptoms, suggesting that physicians cannot rely solely on symptomatology to accurately evaluate the extent of these esophageal complications in this population.     

A novel method for lymphadenectomy along the left laryngeal recurrent nerve during thoracoscopic esophagectomy for esophageal carcinoma

Background

Due to limited space in the left upper mediastinum, complete dissection of lymph nodes (LN) along left recurrent laryngeal nerve (RLN) is difficult. We herein present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position for esophageal carcinoma. The method, suspension the esophagus and push aside trachea, allows en bloc lymphadenectomy along the left RLN from the below aortic arch to the thoracic inlet.

Methods

Between September 2014 and September 2015, a total of 110 consecutive patients with esophageal carcinoma were treated with thoraco-laparoscopic esophagectomy with cervical anastomosis in the semi-prone position. Outcomes between those who received surgery with the novel method and conventional surgery were compared.

Results

Fifty patients underwent the novel method and sixty received conventional surgery. The operative field around the left RLN was easier to explore with the novel method. The estimated blood loss was less (23.7±8.2 vs. 34.2±10.3 g, P=0.001), and the number of harvested LNs along the left RLN was greater (6.4±3.2 vs. 4.1±2.8 min, P=0.028) in the novel method group, while the duration of lymphadenectomy along left RLN was longer in the novel method group (28.2±3.9 vs. 20.3±2.8 min, P=0.005). The rate of hoarseness in the novel and conventional groups was 10% and 16.7%, respectively. No significant difference in postoperative morbidity related to the left RLN was noted between the groups.

Conclusions

The novel method during semi-prone esophagectomy for esophageal carcinoma is associated with better surgeon ergonomics and operative exposure.     

How well does pathologic stage predict survival for esophageal adenocarcinoma after neoadjuvant therapy?

Background

Cancer staging systems are designed to predict survival and stratify patients. The 7^th edition of the American Joint Commission on Cancer (AJCC7) staging system for esophageal cancer was modeled using survival data on patients who underwent esophagectomy without induction or adjuvant therapy. In the United States, the standard of care for patients with locally advanced tumors often includes neoadjuvant therapy. The prognostic value of the pathologic stage for these patients is unknown.

Methods

Data from the Surveillance Epidemiology and End Results (SEER) were used to identify 1,243 patients with adenocarcinoma of the esophagus who underwent surgery after neoadjuvant therapy from 1988-2009. Included in the analysis were pathologically-staged, non-metastatic patients who had radiation as part of their neoadjuvant therapy. The AJCC7 staging system and an alternate system were modeled using Kaplan-Meier survival methods. The two systems were compared using log-rank chi-squared statistics, with large chi-squared values indicating accuracy in survival prediction.

Results

The AJCC staging system was able to predict survival for patients who had neoadjuvant therapy (P<0.001, chi-squared =81.8); however, there was little distinction between stage subgroups. Patients with neoadjuvant radiotherapy had improved survival for pathologic stage II and III disease. An alternative, simpler staging system was better able to stratify patients with neoadjuvant therapy (P<0.001, chi-squared =100.5).

Conclusions

The current AJCC staging system is able to predict survival in esophageal adenocarcinoma patients undergoing neoadjuvant therapy, however, there is less distinction among stage subgroups. An alternative, simpler stage grouping may better stratify patients receiving neoadjuvant therapy.     

The Role of Esophageal Stent Placement in the Management of Postesophagectomy Anastomotic Leak

Background/Aim:

Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem.

Settings and Design:

Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study.

Patients and Methods:

From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated.

Statistical analysis:

None.

Results:

One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%).

Conclusion:

Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.     

A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease

Aim

The aim of this retrospective observational study was to investigate the effect of on-pump versus off-pump coronary artery bypass grafting (CABG) for patients with coronary artery diseases (CAD).

Methods

A retrospective observational study was performed using a propensity score analysis in 290 consecutive patients undergoing CABG between April 2009 and March 2014, of them, 54 patients undergoing off-pump CABG (OPCABG) were matched with 54 patients undergoing on-pump CABG (ONCABG) by propensity score. The perioperative complications and hospital mortality were documented.

Results

Preoperative characteristics were comparable in both groups following propensity matching. Postoperative myocardial infarction (MI) incidence was lower in OPCABG group than in ONCABG group (3.7% vs. 14.8%, P=0.046); both hospital mortality and the major complications rates were similar in the two groups after propensity adjustment for preoperative characteristics.

Conclusions

The perioperative complications are similar in both off-pump and on pump CABG groups, the short-term effect of OPCABG is similar to that of ONCABG.     

Obesity portends increased morbidity and earlier recurrence following liver transplantation for hepatocellular carcinoma

Background

Obesity has been associated with poor oncologic outcomes following pancreatoduodenectomy for pancreatic cancer. However, there is a paucity of evidence on the impact of obesity on postoperative complications, oncologic outcome and survival in patients with hepatocellular carcinoma (HCC) undergoing orthotopic liver transplantation (OLT).

Methods

From a database of over 1000 patients who underwent OLT during 1996–2008, 159 patients with a diagnosis of HCC were identified. Demographic data, body mass index (BMI), perioperative parameters, recurrence and survival were obtained. Complications were grouped according to Clavien–Dindo grading (Grades I–V).

Results

There were increased incidences of life-threatening complications in overweight (58%) and obese (70%) patients compared with the non-obese patient group (41%) (P < 0.05). Furthermore, the incidence of recurrence of HCC was doubled in the presence of overweight (15%) and obesity (15%) compared with non-obesity (7%) (P < 0.05). Time to recurrence also decreased significantly. Differences in mean ± standard deviation survival in the overweight (45 ± 3 months) and obese (41 ± 4 months) groups compared with the non-obese group (58 ± 6 months) did not reach statistical significance.

Conclusions

These findings indicate that BMI is an important surrogate marker for obesity and portends an increased risk for complications and a poorer oncologic outcome following OLT for HCC.     

Comparison of clinicopathologic features and survival between eastern and western population with esophageal squamous cell carcinoma

Background

Esophageal squamous cell carcinoma (ESCC) is the major histologic subtype of esophageal cancer, characterized by a high mortality rate and geographic differences in incidences. It is unknown whether there is difference between “eastern” ESCC and “western” ESCC. This study is attempted to demonstrate the hypothesis by comparing ESCC between Chinese residents and Caucasians living in the US.

Methods

The data sources of this study are from United States SEER limited-use database and Shanghai Cancer Registries by Shanghai Municipal Center for Disease Control (SMCDC). Consecutive, non-selected patients with pathologically diagnosed ESCC, between January 1, 2002 and December 31, 2006, were included in this analysis. 1-year, 3-year and 5-year survival estimates were computed and compared between two populations. A Cox proportional hazards model was used to determine factors affecting survival differences.

Results

A total of 1,718 Chinese, 1,624 Caucasians ESCC patients with individual American Joint Commission on Cancer (AJCC) staging information were included in this study. The Caucasian group had a significantly higher proportion of female patients than Chinese (38.24% vs. 18.68% P<0.01). ESCC was diagnosed in Chinese patients at an earlier age and stage than Caucasians. Generally, Chinese patients had similar overall survival rate with Caucasian by both univariate and multivariate analysis. Overall survival was significantly worse only in male Caucasians compared to Chinese patients (median survival time, 12.4 vs. 14.5 months, P<0.01, respectively).

Conclusions

ESCC from eastern and western countries might have some different features. These differences need to be taken into account for the management of ESCC patients in different ethnic groups.     

Modified Cattell's pancreaticojejunostomy,buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study

Background:

Pancreatic anastomotic leak is one of the most serious complications following pancreaticoduodenectomy (PD). Various factors have been implicated as contributors to pancreatic anastomotic leaks, the incidence of which has been as high as 28% in some series.

Objectives:

We describe technical modifications to Cattell''s technique for pancreaticojejunostomy (PJ), with buttressing of ‘soft’ pancreases and use of an isolated biliopancreatic loop for reconstruction following a PD.

Methods:

We report our early experience using this technique in 50 patients who underwent PD between May 2002 and June 2006.

Results:

There was no mortality in our series. The postoperative morbidity rate was 32% (16/50), with major complications occurring in seven (14%) patients. Pancreatic leak occurred in one patient (2%) and bile leak in one patient (2%). Both patients were managed conservatively.

Conclusions:

Reconstruction after PD using an isolated biliopancreatic loop and modifications to Cattell''s technique for PJ, with buttressing of the soft pancreas, can be performed with a low risk of pancreatic anastomotic leakage.     

Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile?

Background:

Because survival after pancreaticoduodenectomy for cancer is limited, it is difficult to assess longterm pancreaticojejunal anastomotic patency. However, in patients with benign disease, pancreaticojejunal anastomotic stenosis may become problematic. What happens when pancreaticojejunal anastomosis revision is undertaken?

Methods:

Patients undergoing pancreatic anastomotic revision after pancreatic head resection for benign disease between 1997 and 2007 at the Medical University of South Carolina were identified. A retrospective chart review and analysis were undertaken with the approval of the Institutional Review Board for the Evaluation of Human Subjects. Longterm follow-up was obtained by patient survey at a clinic visit or by telephone.

Results:

During the study period, 237 patients underwent pancreatic head resection. Of these, 27 patients (17 women; median age 42 years) underwent revision of pancreaticojejunal anastomosis. Six patients (22%) had a pancreatic leak or abscess at the time of the index pancreatic head resection. The indication for revision of anastomosis was intractable pain. All patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP), which indicated anastomotic stricture in 18 patients (63%). Nine other patients underwent exploration based on clinical suspicion caused by recurrent pancreatitis and stenosis was confirmed at the time of surgery. Six patients (22%) had perioperative complications after revision. The median length of stay was 12 days. There were no perioperative deaths; however, late mortality occurred in four patients (15%). Six of 23 survivors (26%) at the time of follow-up (median 56 months) reported longterm pain relief.

Conclusions:

Stricture of the pancreaticojejunal anastomosis after pancreatic head resection presents with recurrent pancreatitis and pancreatic pain. MRCP has good specificity in the diagnosis of anastomotic obstruction, but lacks sensitivity. Pancreaticojejunal revision is safe, but rarely effective, as a means of pain relief in patients with the pain syndrome associated with chronic pancreatitis.     

The potential impact of contemporary developments in the management of patients with gastroesophageal reflux disease undergoing an initial gastroscopy

BACKGROUND:

Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett’s esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.

OBJECTIVE:

To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.

METHODS:

Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.

RESULTS:

Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett’s esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett’s esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.

CONCLUSIONS:

Among patients presenting with GERD-like symptoms, the prevalence of Barrett’s esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.     

Perioperative blood transfusion is not associated with overall survival or time to recurrence after resection of perihilar cholangiocarcinoma

Background

Perioperative blood transfusions have been associated with worse oncological outcome in several types of cancer. The objective of this study was to assess the effect of perioperative blood transfusions on time to recurrence and overall survival (OS) in patients who underwent curative-intent resection of perihilar cholangiocarcinoma (PHC).

Methods

This retrospective cohort study included consecutive patients with resected PHC between 1992 and 2013 in a specialized center. Patients with 90-day mortality after surgery were excluded. Patients who did and did not receive perioperative blood transfusions were compared using univariable Kaplan–Meier analysis and multivariable Cox regression.

Results

Of 145 included patients, 80 (55.2%) received perioperative blood transfusions. The median OS was 49 months for patients without and 41 months for patients with blood transfusions (P = 0.46). In risk-adjusted multivariable Cox regression analysis, blood transfusion was not associated with OS (HR 1.00, 95% CI 0.59–1.68, P = 0.99) or time to recurrence (HR 1.00, 95% CI 0.57–1.78, P = 0.99). In addition, no differences in effect were found between different types of blood products transfused.

Conclusion

Blood transfusion was not associated with survival or time to recurrence after curative resection of PHC in this series. The alleged association is presumably related to the circumstances necessitating blood transfusions.