Search

OBJECTIVE: To compare overall survival of patients with a cCR undergoing active surveillance versus standard esophagectomy.SUMMARY OF BACKGROUND DATA: One-third of patients with esophageal cancer have a pathologically complete response in the resection specimen after neoadjuvant chemoradiotherapy. Active surveillance may be of benefit in patients with cCR, determined with diagnostics during response evaluations after chemoradiotherapy.METHODS: A systematic review and meta-analysis was performed comparing overall survival between patients with cCR after chemoradiotherapy undergoing active surveillance versus standard esophagectomy. Authors were contacted to supply individual patient data. Overall and progression-free survival were compared using random effects meta-analysis of randomized or propensity score matched data. Locoregional recurrence rate was assessed. The study-protocol was registered (PROSPERO: CRD42020167070).RESULTS: Seven studies were identified comprising 788 patients, of which after randomization or propensity score matching yielded 196 active surveillance and 257 standard esophagectomy patients. All authors provided individual patient data. The risk of all-cause mortality for active surveillance was 1.08 [95% confidence interval (CI): 0.62-1.87, P = 0.75] after intention-to-treat analysis and 0.93 (95% CI: 0.56-1.54, P = 0.75) after per-protocol analysis. The risk of progression or all-cause mortality for active surveillance was 1.14 (95% CI: 0.83-1.58, P = 0.36). Five-year locoregional recurrence rate during active surveillance was 40% (95% CI: 26%-59%). 95% of active surveillance patients undergoing postponed esophagectomy for locoregional recurrence had radical resection.CONCLUSIONS: Overall survival was comparable in patients with cCR after chemoradiotherapy undergoing active surveillance or standard esophagectomy. Diagnostic follow-up is mandatory in active surveillance and postponed esophagectomy should be offered to operable patients in case of locoregional recurrence.

Background Cholecystectomy alters bile release dynamics from pulsatile meal-stimulated to continuous, and results in retrograde duodeno-gastric bile reflux (DGR). Bile is implicated in mucosal injury after gastric surgery, but whether cholecystectomy causes esophagogastric mucosal inflammation, therefore increasing the risk of metaplasia, is unclear. Study Design This study examined whether cholecystectomy-induced DGR promotes chronic inflammatory mucosal changes of the stomach and/or the esophagogastric junction (EGJ). Four groups of patients were studied and compared with controls. A group of patients was studied before and 1 year after cholecystectomy; 2 further groups were studied long-term post-cholecystectomy (LTPC) at 5 to 10 years and 10 to 20 years. All underwent abdominal ultrasound and upper gastrointestinal endoscopy with gastric antral and EGJ biopsies, noting the presence of gastric bile pooling. Biopsy specimens were stained for Ki67 and p53 overexpression, and the bile reflux index (BRI) was calculated. Results At endoscopy, bile pooling was observed in 9 of 26 (34.6%) controls, in 8 of 25 (32%) patients pre-cholecystectomy, in 15 of 25 (60%) 1 year post-cholecystectomy patients (p = 0.047), and 23 of 29 (79.3%) LTPC patients (p = 0.001). Bile reflux index positivity at the EGJ increased from 19% of controls through 41% of LTPC patients (p = 0.032). Ki67 was overexpressed at the EGJ in 19% of controls, but in 62% of LTPC patients (p = 0.044); p53 was overexpressed at the EGJ in 19% of controls compared with 66% of LTPC patients (p = 0.001). Conclusions Duodeno-gastric bile reflux was more common in patients with gallstones than in controls, and its incidence doubled after cholecystectomy. This was associated with inflammatory changes in the gastric antrum and the EGJ, evident in most LTPC patients. Ki67 and p53 overexpression at the EGJ suggests cellular damage attributable to chronic bile exposure post-cholecystectomy, increasing the likelihood of dysplasia. Further studies are required to determine whether DGR-mediated esophageal mucosal injury is reversible or avoidable, and whether surveillance endoscopy is indicated after cholecystectomy.

OBJECTIVE: Gallbladder removal is associated with an increased incidence of gastroesophageal reflux, but the mechanism is unclear. Cholecystokinin (CCK) release, which causes gallbladder contraction, is inhibited by bile in the duodenum. This study investigates the effect of cholecystectomy on meal-stimulated CCK secretion. METHODS: Three groups of patients were studied. Group 1 (n = 15) were normal controls. Group 2 (n = 27) were patients with symptomatic gallstones. Group 3 (n = 25) were patients who had undergone cholecystectomy. Meal-stimulated CCK levels were measured by radioimmunoassay at defined time points for 60 min after a standard corn oil-based meal. RESULTS: Fasting CCK levels were similar in all three groups. In postcholecystectomy patients, meal-stimulated plasma CCK levels were significantly elevated compared with controls: median (range) integrated CCK values for 60 min were 116 (28–209) in controls, 123 (20–501) in gallstone patients, and 176 (63–502) after cholecystectomy. CONCLUSIONS: This study suggests that cholecystectomy causes an exaggerated meal-stimulated CCK response. Because CCK is known to relax the lower esophageal sphincter, these findings may help explain the increased incidence of gastroesophageal reflux seen after cholecystectomy.

RESULTS: Of 500 prospectively enrolled patients, wound complications occurred in 17.8% and mesh infections in 2.2%. Risk factors from MLR were tobacco use (odds ratio [OR] 2.17), active infection at surgery (OR 2.07), previous VHR (OR 2.64), uncontrolled diabetes (OR 2.01), enterotomy or presence of stoma (OR 2.65), and BMI >26 kg/m (OR 1.08 per unit BMI). Charges associated with hospital stay and follow-up care were obtained (Table). From these data, a mathematical equation was developed that predicts the percentage postoperative complication risk and cost for care over 1 year. The equation is not functional due to its complexity. It was converted to an app (CeDAR) available on iTunes and Droid store, which allows easy usability during patient interaction. It demonstrates percentage risk and difference if preoperative variables are improved. Since April, CeDAR has been downloaded thousands of times in more than 65 countries.

TO THE EDITOR: The outcome for patients with esophageal carcinoma is poor. This reflects in part the aggressive nature of the disease and also the fact that the majority of patients have advanced disease at presentation. It has been previously shown that two-thirds of patients with esophageal cancer present with symptoms for 3 months or more and with at least 14 lbs weight loss (1). Furthermore, only 17% of the general population would identify difficulty swallowing as being attributable to underlying malignancy. In addition, the majority of people are not aware of “cancer of the esophagus” and only 12% are familiar with its symptoms (2). In contrast, over 90% of people are familiar with the symptoms of breast cancer. Awareness programs highlight the significance of dysphagia and weight loss, but in our experience patients frequently note persistent or distressing hiccupping. We present one such case.

A 16-year-old jockey presented with right upper quadrant pain after a kick from a horse. CT revealed a parenchymal laceration (A, arrows), involving the right liver, with a focal collection of contrast consistent with active extravasation (A, arrowhead). He was hemodynamically stable and was managed nonoperatively. Serial imaging demonstrated gradual resolution of the hematoma. A CT performed 7 months postinjury demonstrated a persistent abnormal collection of contrast in the right liver (B, arrowhead) and differential enhancement of the posterior part of the right liver compared with the anterior part of the right liver and left liver (B, arrows). Angiography with the catheter in the common hepatic artery demonstrated a fistula (C) from the right hepatic artery to the right hepatic vein (C, arrow). This was successfully embolized. A CT 2 months later demonstrated the coils in good position, but an area of abnormal enhancement persisted in the right lobe of the liver. An angiogram with the catheter in the celiac axis demonstrated occlusion of the hepatic artery but revealed multiple collaterals from the inferior phrenic artery (D, small arrows), the left gastric artery (D, curved arrows), and the superior mesenteric artery supplying the arterio-venous fistula (arrow indicates right hepatic vein). A right hepatectomy was performed to prevent the development of intractable portal hypertension. We speculate that angiography with embolization at the time of initial trauma may have prevented the development of an established fistula and subsequent surgery. A B

Ventilatory support for 24 h after surgery is standard practice in many units after oesophagectomy, especially for patients in whom respiratory problems are anticipated. Weaning difficulties may occur, however, and there is increasing evidence that mechanical ventilation is associated with alveolar trauma. A deliberate change in policy was instituted in the authors' unit in January 1990 to make early extubation mandatory in all patients undergoing elective oesophagectomy, apart from those in whom serious perioperative problems were encountered. The present study compared two sets of patients: group 1 (n = 36) underwent oesophagectomy in the year before the policy change and group 2 (n = 45) oesophagectomy in the year after. The two groups were similar in age, sex and respiratory risk factors. Early extubation was carried out in 38 patients in group 2 compared with eight in group 1 (P < 0·001). Only two patients in group 2 required prolonged ventilation compared with ten in group 1 (P < 0·005). No patient in group 2 required reventilation compared with seven in group 1 (P < 0·005), and no patient in group 2 who had undergone early extubation required delayed ventilation. The mean ventilation time and length of stay in the intensive care unit were significantly reduced following the policy change. Early extubation after elective oesophagectomy is an attainable goal and results in a significant reduction in both the morbidity rate and cost of surgery.

Malignant duodenocolic fistulas are rare; the most common cause is carcinoma of the ascending or hepatic flexure of the right colon. Thirteen cases reported to date have been treated by right hemicolectomy combined with a Whipple procedure, with a 46 percent 2.5-year survival. A case is reported in which stapling devices facilitated an extended Whipple procedure.