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Abstract: Background: Although resection is the only treatment option that offers a chance for prolonged survival in pancreatic cancer, R2 resections are controversial and not a generally accepted approach. Methods: A systematic review and meta-analysis of studies of patients with pancreatic cancer was performed to analyze R2 resections in comparison with palliative surgical bypass procedures. Trials were identified by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to February 2011. Results: Four cohort studies were identified comparing 138 patients with R2 resections with 261 patients undergoing surgical bypass procedures. Morbidity and mortality were increased in the R2 resection group, with pooled risk ratios of 1.75 (95% confidence interval [CI], 1.35–2.26; P < .0001) and 2.98 (95% CI, 1.31–6.75; P = .009), respectively. R2 resections were associated with longer operating times (mean difference, 164 minutes; 95% CI, 127–201 minutes; P < .00001) and hospital stays (mean difference, 5 days; 95% CI, 1–9 days; P = .02). Pooled median survival times were 8.2 months for R2 resection and 6.7 months for palliative bypass procedures. Conclusions: Planned palliative R2 resections are not justified in patients with pancreatic cancer. [Copyright &y& Elsevier]

Background & Aims: There is controversy about the best way to treat esophageal anastomotic leakage. We evaluated the effects of treatment with self-expanding metal stents in patients with esophageal anastomotic leakage after esophagectomy or gastrectomy for cancer. Methods: We investigated outcomes and procedure-related complications of 115 patients who received endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy at a university hospital from 2004 to 2009. We also performed a systematic literature review on stent therapy and compared outcomes with that of other treatment regimens for esophageal anastomotic leakage. Results: Among the 115 patients who received stents, the in-hospital mortality rate was 9% and complete anastomotic healing was achieved in 70% (95% confidence interval [CI], 64%–76%). Stent dislocation occurred in 53% of the patients (95% CI, 43%–62%), in all patients with esophagocolonostomy, in 61% with esophagojejunostomy, and in 49% with esophagogastrostomy. Three percent of patients (95% CI, 1%–5%) needed laparotomy to remove dislocated stents. Elective endoscopic stent removal was performed in 80% of the patients after a median of 54 days (range 17–427 d); 12% of these patients developed symptomatic anastomotic strictures after stent removal. Conclusions: Anastomoses completely heal in 70% of patients that receive endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy. Stent therapy should be used in the management of patients with adequately perfused esophageal anastomotic leakage. However, stent dislocation remains a common problem after surgery. [Copyright &y& Elsevier]

Background: Different transgastric access techniques for natural orifice transluminal endoscopic surgery (NOTES) have been described. Objective: To evaluate different methods of transluminal access with regard to leak pressures after the procedure. Design and Setting: Experimental endoscopic study in an ex vivo porcine stomach model. Methods: The following endoscopic techniques for transgastric access were evaluated in 34 stomachs: (1) 1.5-cm to 2-cm linear incision, (2) balloon dilation after needle-knife puncture, (3) via a short submucosal tunnel, and (4) via an extended submucosal tunnel. For techniques 3 and 4, a submucosal tract was endoscopically created by physically separating the mucosa from the muscularis. Mucosal incisions were closed by the standardized application of clips. Handsewn gastric closure after a linear needle-knife incision served as a positive control, whereas, open 1.5-cm to 2-cm gastrotomies were negative controls. After the procedure, pressures to liquid leakage were recorded. Results: The unclosed controls demonstrated leakage at mean (SD) 2 ± 2 mm Hg, which represents a baseline system resistance. The handsewn gastric closure after linear incision leaked at 50 ± 7 mm Hg. The needle-knife gastrotomy, the balloon dilation, the short submucosal tunnel, and the extended submucosal tunnel leaked at 37 ± 15 mm Hg, 41 ± 24 mm Hg, 44 ± 13 mm Hg, and 87 ± 19 mm Hg, respectively. There were significant differences in leakage pressures between the group with the extended submucosal tunnel and all other transgastric access techniques (all P ≤ .002). Conclusions: The extended submucosal tunnel yielded the best leak resistance, which is superior to standard transgastric access methods and rival handsewn interrupted stitches. [Copyright &y& Elsevier]

We report the case of a 61-year-old patient, operated on for adenocarcinoma of the esophagus in 2002, who presented in 2007 with a hydrocele and palpable mass of the right testis. Operative exploration and orchiectomy were performed. Histopathology revealed a testicular and epididymidal metastasis from the esophageal adenocarcinoma. Only a few testicular metastases have been reported from gastrointestinal cancers. No case of testicular metastasis from esophageal cancer, including Barrett''s carcinoma has been reported. In most cases, the testicular tumor was accompanied by a hydrocele. Therefore, cancerous and metastatic lesions should be considered in the management of hydrocele and testicular masses. [Copyright &y& Elsevier]