Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?

STUDY AIM: Aim of this study was to assess symptomatic and objective outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery. PATIENTS AND METHOD: Between November 1992 and December 1998, 92 patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Intraoperative endoscopy was routinely performed. Sixty patients had primary surgery (PS); 32 patients had surgery after unsuccessful pneumatic dilatation (PD) (n = 22), or botulinum toxin (Botox) injection (n = 10). RESULTS: The mean operative time and the incidence of postoperative dysphagia were similar in the two groups. The incidence of intraoperative mucosal tears was 5% in the PS group and 12.5% in the PD/Botox group (P = NS). Mucosal tears occurred more frequently during the first 30 operations (17% vs 3.2%, P < 0.05). Median follow-up was 28 months (range 4-76). An abnormal esophageal acid exposure was documented in 2 patients in the PS group (7.7%), and in two patients in the PD/Botox group (13.3%) (P = NS). Lower esophageal sphincter pressure significantly decreased in both groups (P < 0.01). The mean percentage of radionuclide residual activity in the esophagus at 1 and 10 minutes significantly decreased in both groups (P < 0.01). CONCLUSION: There is only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by PD and/or Botox. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.     

Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?

PURPOSE: The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects. PATIENTS AND METHODS: Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed. RESULTS: Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported. CONCLUSIONS: In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.     

Posterior lamellar reconstruction: a comprehensive review of the literature

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages.

We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: “posterior lamella,” “eyelid reconstruction,” “tarsoconjunctival,” “flap,” and “graft.” Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search.

The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there’s no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon’s choice. The use of biomaterials can avoid possible complications of the donor site.     

Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes

Transoral stapled diverticulo‐esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid‐90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty‐eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann–Whitney test. Twenty‐eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long‐term results have to be evaluated.     

Locoregional therapy and systemic cetuximab to treat colorectal liver metastases

AIM: To investigate efficacy and safety of second-line treatment with irinotecan-loaded drug-eluting beads (DEBIRI) and cetuximab (DEBIRITUX) of unresectable colorectal liver metastases.METHODS: Patients with the following characteristics were included in the study: unresectable hepatic metastases from colorectal carcinoma (CRC-LM), progression after first line chemotherapy (any type of chemotherapeutic drug and combination was allowed), second line treatment (mandatory), which included for each patient (unregarding the KRas status) two cycles of DEBIRI (using 100-300 μm beads loaded with irinotecan at a total dose 200 mg) followed by 12 cycles of cetuximab that was administered weekly at a first dose of 400 mg/m² and then 250 mg/m²; good performance status (0-2) and liver functionality (alanine aminotransferase and gamma-glutamyl transferase not exceeding three times the upper limit of normal, total bilirubin not exceeding 2.5 mg/mL). Data were collected retrospectively and included: tumor response (evaluated monthly for 6 mo then every 3 mo), overall response rate (ORR), KRas status, type and intensity of adverse events (G according to the Common Terminology Criteria for Adverse Events v3.0, CTCAE), overall survival (OS) and progression free survival (PFS).RESULTS: Forty consecutive cases of CRC hepatic metastases were included in the study. Median duration of DEBIRITUX was 4.4 mo (range, 4.0-6.5). Sixteen patients (40%) received the planned 2 cycles of DEBIRI and an average of 10 cetuximab cycles. ORR of the whole sample was 50%, in particular 4 patients were complete responders (10%) and 16 (40%) partial responders. The most observed side effects (G2) were: post-embolization syndrome (30%), diarrhea (25%), skin rushes (38%) and asthenia (35%). The retrospective evaluation of KRas status (24 wild type, 16 mutated) showed that the group of patients with wild type KRas had ORR significantly higher than mutant KRas. Median follow-up was 29 mo (8-48 range); median PFS was 9.8 mo and OS was 20.4 mo. Future randomized trials are required in this setting to establish a role for DEBIRITUX compared with systemic chemotherapy.CONCLUSION: DEBIRITUX seems to be efficacious after first line chemotherapy for the treatment of unresectable CRC-LM.     

Melanoma antigen genes 1 and 2 are differentially expressed in human gastric and cardial carcinomas

BACKGROUND: MAGE genes encode for tumor-rejection antigens and are expressed in tumors of different histologic types but not in normal tissues, with the exception of testis and placenta. The aim of this study was to evaluate the frequency of MAGE-1 and -2 expression in gastric and in cardial carcinomas; these conditions have been described as two distinct diseases, having different etiologies, epidemiologic patterns, and gene mutations. METHODS: Two groups of patients were studied: patients with distal gastric carcinoma and patients with carcinoma of the cardia. A group of patients with intestinal metaplasia in the gastric mucosa and controls were also included. All of them underwent upper GI endoscopy. Paired biopsy specimens were taken for routine histology and for RNA extraction, to study the expression of MAGE-1 and -2 genes. RESULTS: None of the intestinal metaplastic samples or controls expressed MAGE-1 and -2 at detectable levels. Whereas 40% of the gastric cancer patients expressed either MAGE-1 or -2, 26.6% transcribed both. In the cardial cancer group, 20% of the cases expressed at least one MAGE, and only 6.6% expressed both genes. These results might reinforce the concept that cancer of the cardia is a distinct neoplastic disease with regard to esophageal and gastric (distal) carcinomas. CONCLUSIONS: Here we show that MAGE gene expression occurs in advanced stages of gastric and cardial cancer and therefore appears to be a late event. This might point to a reconsideration of their potential role in cancer immunotherapy.     

High-Dose Famotidine in the Maintenance Treatment of Refractory Esophagitis: Results of a "Medium-Term" Open Study

Forty-four patients with esophagitis refractory to standard H2-blocker therapy, who had healed after a 4- to 16-wk course with either 20-40 mg omeprazole or ranitidine at doses of 300-600 mg daily in a randomized double-blind study, commenced a 3-month maintenance course of therapy with 40 mg bid famotidine. The aims of this investigation were to assess the effectiveness of this regimen in preventing recurrence of esophagitis lesions and symptoms in this subgroup of patients with therapy-resistant disease and to verify whether patients previously healed with omeprazole have a higher recurrence rate than those healed with ranitidine. The results of the study show that, despite the high dose of famotidine, 48% of patients relapsed within 3 months, a third of whom were asymptomatic. Moreover, previous omeprazole treatment is associated with a significantly higher risk of recurrence.