Barrett’s oesophagus and nissen fundoplication. The significance of postoperative oesophageal pH measurement

Aim — Background

Barrett’s oesophagus is a condition caused by acid reflux from the stomach to the oesophagus for a prolonged period of time. Patients with Barrett’s oesophagus are at significant risk of developing oesophageal adenocarcinoma. This risk decreases with antireflux surgery. Treatment of gastroesophageal reflux disease (GERD) by Nissen fundoplication surgery has a success rate of 85–90%. The aim of this study is to highlight the significance of oesophageal pH measurement as part of the postoperative follow-up of patients diagnosed with Barrett’s oesophagus who undergo the Nissen fundoplication procedure.

Patients and methods

Between 2010 and 2012, eleven patients with Barrett’s oesophagus underwent Nissen fundoplication in our clinic, followed by 48h wireless oesophageal pH-metry monitoring.

Results

All patients reported relief of GERD typical symptoms. Mean DeMeester score of 1.5 was measured at the fifth postoperative month.

Conclusion

Prevention of oesophageal adenocarcinoma in patients with Barrett’s oesophagus is crucial. These patients are exposed to a great risk of adenocarcinoma development, not only owing to the potential progression of Barrett’s oesophagus to adenocarcinoma, but also because of the decreased capacity to experience typical GERD symptoms. Given the possibility of antireflux surgery failure and the fact that symptoms may be an unreliable indicator of GERD presence, postoperative oesophageal pHmetry is mandatory.     

Is there room for improvement in esophageal cancer surgery? Results of a prospective protocol for individualization of surgical treatment

Background

Despite improvements in multimodality approach , overall survival of esophageal cancer (EC) is still very low. Because of the rarity of the disease and the lack of large prospective studies, several controversies exist regarding the optimal type of surgery and the use of adjuvant and neoadjuvant therapy. Traditionally, the debate for the extent lymphadenectomy is between transhiatal esophagectomy with 1-field lymphadenectomy (THE-1FL) and transthoracic esophagectomy with 2-field lymphadenectomy (TTE-2FL). The purpose of this study is to evaluate the effect of optimal patient selection for submission to each procedure, on overall survival.

Methods

Patients with EC were prospectively enrolled in a database and a protocol of individualized surgical treatment of EC (PISTEC) was applied to patients with resectable disease. PISTEC is based on patient’s physical status and disease stage, with intent to select the appropriate surgical procedure for each patient.

Results

From 01/2006 to 12/2011, 61 patients with EC were individualized according to the PISTEC. Of them, 52.4 % were submitted to THE-1FL and 31.1 % to TTE-2FL. The 30-day mortality rate was 4.9 %. The 5-year overall survival rate was 54.9 % and recurrence was observed in 27.5 % of patients. The estimated 5-year overall survival of patients with stages 0, I, II, III and IV was 100, 100, 92.9, 45 and 0 %, respectively.

Conclusion

The algorithm proposed by the PISTEC aims at balancing perioperative risks with oncological benefit. When type of surgery is individualized, the outcomes regarding survival are favorable. This effect could probably be enhanced with the concurrent application of neoadjuvant treatment.     

Place of hyperthermic intraperitoneal chemotherapy in the armament against pancreatic adenocarcinoma: A survival,mortality and morbidity systematic review

Pancreatic adenocarcinoma is one of the deadliest types of cancer worldwide, with a 5-year survival rate of 8% despite recent treatment advancements. The present systematic review aimed to investigate the role of hyperthermic intraperitoneal chemotherapy (HIPEC) following surgical resection for pancreatic adenocarcinoma, with or without peritoneal carcinomatosis. A systematic search of the MEDLINE and SCOPUS electronic databases was performed according to PRISMA guidelines. All possible relevant articles published between January 1980 and May 2019 were retrieved using multiple search terms associated with HIPEC and pancreatic adenocarcinoma. The initial search resulted in 1,244 reports, which condensed to 41 reports following screening of titles and abstracts, and subsequently to four reports following full-text thorough examination. The four reports included involved a prospective cohort study of HIPEC use in resectable pancreatic adenocarcinoma, and three retrospective studies of HIPEC use following cytoreductive surgery for peritoneal carcinomatosis due to pancreatic adenocarcinoma, resulting in a total of 47 patients. The overall survival ranged between 2 and 62 months, and the hospital mortality rate was 8.5%. Morbidity (34%) was mainly attributed to anastomotic leak or respiratory failure. Due to the small sample size and low quality of evidence of the included studies, no valid conclusions could be drawn. Therefore, further studies are required to justify the use of HIPEC as an adjuvant therapy in resectable pancreatic adenocarcinoma, while cytoreductive surgery and HIPEC in peritoneal carcinomatosis of pancreatic origin seems not only not useful but also unsafe at this level of evidence.