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Pectus excavatum is the most common congenital anomaly of the chest wall. Surgical management of this problem has evolved to encompass many modifications of Dr Ravitch's initial groundbreaking repair to include the insertion of mesh, metal struts, and bars to bolster the repair through open and minimally invasive approaches. This report presents a case of right ventricular outflow tract obstruction from a dislodged pectus bar after a modified Ravitch procedure. The presentation, diagnosis, and management of this exceedingly rare complication are described, and the discussion also provides clinical pearls and inspiration for future research directions that are based on this experience.

Early postnatal experiences are important for shaping the development of the stress response and may contribute to the later emergence of alcohol use disorders. We have previously found that early life sleep disruption impairs social development and alters GABA neurons in the brain of adult prairie voles, a socially monogamous rodent that displays natural ethanol preference in the laboratory. However, it is unclear whether these effects on social behavior are due, in part, to overall anhedonia and/or altered behavioral response to stress. To address this question, litters containing prairie vole pups were sleep disrupted by gentle cage agitation for 7 consecutive days from postnatal days (P) 14 to 21 (early life sleep disruption, or ELSD group) or allowed to sleep undisturbed (Control). Adult voles underwent a 2-bottle choice ethanol drinking procedure integrated with a single session of footshocks. Ethanol intake after footshock was measured as well as c-Fos immunoreactivity in the lateral and central amygdala. ELSD animals showed increased ethanol consumption and increased neural activity in these amygdala regions after footshock compared to control animals. There were no differences in baseline ethanol drinking prior to exposure to a stressor. These results suggest that early life sleep disruption in prairie voles does not produce anhedonia but can have long-lasting effects on stress reactivity. In addition to shaping species-typical social behavior, early life sleep may be important in the development of stress induced ethanol consumption and the activation of limbic pathways associated with stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

BACKGROUND Frozen section is a standard of care procedure during thoracic surgery when an immediate diagnosis is needed. An alternative procedure is intraoperative cytology. Video-assisted thoracic surgery is currently widely used for thoracic surgical procedures. The aim of this study was to assess intraoperative cytology together with frozen section for accuracy, turnaround time, and total response time during video-assisted thoracic surgery. METHODS We included patients having video-assisted thoracic surgery between August 2018 and February 2019 at our institution. A cytopathologist and a surgical pathologist independently performed intraoperative cytology and frozen sections, respectively. Final histologic diagnosis was the reference standard. Intraoperative cytology, frozen section turnaround, and total response times were analyzed. RESULTS A total of 52 specimens from 27 patients were included. The intraoperative cytology correlated with final histology in 98% of cases. Frozen section correlated with final histology in 100% of cases. Intraoperative cytology turnaround and total response times were equal (mean, 4.35 minutes; range, 2-15 minutes). Mean frozen section turnaround and response times were 26.2 minutes (range, 9-61 minutes) and 36.7 minutes (range, 16-90 minutes), respectively. We found a statistically significant difference between intraoperative cytology and frozen section turnaround time and total response times (P < .001). CONCLUSIONS This study highlights that intraoperative cytology could be as accurate as frozen section and considerably faster during video-assisted thoracic surgery (P < .001). Total response time could potentially be used as a quality metric for video-assisted thoracic surgery.

Introduction Lymph node sampling by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the state of art procedure for staging the mediastinum and hilar regions in lung cancer patients. Our experience of implementing the real-time cytopathology intervention (RTCI) process for intraoperative EBUS-TBNAs is presented. This study is aimed to describe in detail the RTCI process for EBUS-TBNAs, and assess its utility and diagnostic yield before and after its implementation in parallel to conventional rapid on-site evaluation (c-ROSE). Methods A retrospective review of all EBUS-TBNAs between July 2016 and July 2017 at the University of Rochester Medical Center was performed. Final diagnoses, patient clinical data, and number of non-diagnostic samples (NDS) were reviewed. The numbers of NDS obtained from EBUS-TBNAs with no cytology assistance (NCA), with RTCI and with c-ROSE were analysed. Results Non-diagnostic lymph node samples were found in 20 out of 116 (17%), three out of 114 (2.6%) and 33 out of 286 (11.5%) cases with NCA, RTCI and c-ROSE, respectively. Application of statistical analysis revealed significant difference in the NDS between the groups of cases in the operating room with NCA and RTCI (P = .005). The different settings and variables between the cases performed using RTCI in the operating room and those assisted with c-ROSE in the bronchoscopy suite preclude legitimate comparison. Conclusion Our results indicate that the use of RTCI could yield a significantly low proportion of NDS when assisting EBUS-TBNA of mediastinal and hilar lymph node for lung cancer patients enhancing the diagnostic efficiency of the procedure.

Study Objectives. Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) commonly cooccur. Approaches to research and treatment of these disorders have been segregated, despite overlapping symptomology. We and others have hypothesized that comorbid TBI + PTSD generates worse symptoms than either condition alone. We present a mouse model of comorbid TBI + PTSD to further explore this condition. Methods. A mouse model of TBI + PTSD was generated using the single prolonged stress (SPS) protocol in combination with the controlled cortical impact (CCI) protocol. This resulted in four experimental groups: control, TBI, PTSD, and TBI + PTSD. Behavioral phenotyping included gait analysis, contextual fear conditioning, acoustic startle response, and prepulse inhibition. Results. Mice in the TBI + PTSD group showed a significantly impaired gait compared to their counterparts with TBI alone as well as control mice. Mice in the TBI + PTSD group showed significantly impaired contextual fear recall compared to controls. Prepulse inhibition testing revealed intact acoustic startle and auditory sensory gating. Conclusions. These results indicate that SPS paired with CCI in mice produces unique behavioral impairments in gait and fear recall that are not present in either condition alone. Further studies are underway to examine additional behavioral, physiological, and pathological phenotypes in this combined model of TBI + PTSD.

Introduction Sleep disturbances are common in elderly patients and may contribute to disease progression in certain populations (e.g., Alzheimer’s Disease). Light therapy is a simple and cost-effective intervention to improve sleep. Primary barriers to light therapy are 1) poor acceptability to use of devices and 2) inflexibility of current devices to deliver beyond a fixed spectrum and throughout the entirety of the day. However, dynamic, tunable lighting integrated into the native home lighting system can maximize short-wavelength light in the morning and minimize short-wavelength light in the evening, thus entraining circadian rhythms and treating sleep disturbances, and overcome these limitations. We determined the feasibility of implementing a whole-home tunable lighting system as a potential sleep intervention. Methods Tunable LED lights were installed throughout the homes of healthy older adults already enrolled in an existing study with embedded home assessment platforms (ORCATECH study; n=4 subjects in n=3 homes). In ORCATECH, continuous data on room location, activity, sleep, and general health parameters are collected at minute-to-minute resolution over months to years of participation. This single arm longitudinal design collected participants’ light usage in addition to ORCATECH outcome measures. Primary outcomes for this pilot study included the feasibility and patient acceptability. Exploratory outcomes were sleep metrics (sleep time, latency, efficiency), mobility (room transitions and actigraphy), and overall health indices (weekly body weight, self-report general health questionnaires) both pre- and post-intervention. Results Two subjects terminated the study citing technical difficulties with the lights and a preference for brighter illumination. Of the remaining 2 participants, sleep metrics were explored over a 12-month period spanning pre- and post-installation of lights. Nightly duration in bed was compared with minute-to-minute room entry data and actigraphy with high inter-measure reliability. Conclusion These data support that tunable whole-home lighting systems are reasonably acceptable and feasibly implemented using an automated platform for continuous data collection. Quantification of sleep over long periods of time is robust and reliable in the home environment of elderly subjects. These results will inform implementation of future large-scale lighting intervention studies in patients at risk for developing Alzheimer’s Disease. Support (if any) Hartford Gerontological Center Interprofessional Award, Pacific Northwest National Laboratory, OHSU ORCATECH

Introduction Sleep problems are common in humans with post-traumatic stress disorder (PTSD). Rapid eye movement (REM) sleep is involved in processing emotional memories; it is often disrupted in those with PTSD, and may be related to increased anxiety. Single prolonged stress (SPS) is a protocol used to model PTSD in rats, however little is known about how this model impacts sleep in mice. Prior research suggests SPS produces short term disturbances in REM sleep and increases in anxiety-like behavior, but further validation of this model is needed to understand how SPS impacts sleep and anxiety-like behaviors in mice specifically, as they have greater potential for transgenic manipulation Methods C57BL6/J mice underwent a SPS protocol in which they were tube-restrained for 2 hours, followed by a 15 minute forced swim in a group, ether exposure until loss of consciousness, and 10 days of social isolation. Following SPS, mice were tested for anxiety-like behavior in a light-dark box and sleep was measured from surgically implanted EEG and EMG leads. Time spent in wake, REM sleep, and non-REM sleep was quantified for 24 continuous hours in SPS and Control mice. Results There were no significant effects of SPS on the amount of time spent in any vigilance state, or in sleep-wake transitions. However, SPS-exposed mice showed significantly more anxiety-like behavior. EEG power spectra were analyzed in relevant frequency bands during each sleep state, and exploratory analyses were conducted Conclusion Minimal effects on sleep macroarchitecture were seen in mice 10 days after SPS. It is possible that sleep disturbances seen immediately after trauma exposure (such as in prior studies in rats) may have diminished over time. Further studies will need to include additional timepoints and analysis of sleep microarchitecture following SPS, and in other mouse models of PTSD, in order to more comprehensively examine changes in sleep. Support (if any) VA CDA #IK2 BX002712, Portland VA Research Foundation, Medical Research Foundation

Sleep complaints are an early clinical symptom of neurodegenerative disorders. Patients with Parkinson's disease (PD) experience sleep disruption (SD). The objective of this study was to determine if preexisting, chronic SD leads to a greater loss of tyrosine hydroxylase (TH) within the striatum and the substantia nigra following chronic/progressive exposure with the neurotoxin, 1-methyl-2-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Male mice underwent chronic SD for 4 weeks, then injected with vehicle (VEH) or increasing doses of MPTP for 4 weeks. There was a significant decrease in the plasma corticosterone levels in the MPTP group, an increase in the SD group, and a return to the VEH levels in the SD+MPTP group. Protein expression levels for TH in the striatum (terminals) and substantia nigra pars compacta (dopamine [DA] cell counts) revealed up to a 78% and 38% decrease, respectively, in the MPTP and SD+MPTP groups compared to their relevant VEH and SD groups. DA transporter protein expression increased in the striatum in the MPTP versus VEH group and in the SN/midbrain between the SD+MPTP and the VEH group. There was a main effect of MPTP on various gait measures (e.g., braking) relative to the SD or VEH groups. In the SD+MPTP group, there were no differences compared to the VEH group. Thus, SD, prior to administration of MPTP, has effects on serum corticosterone and gait but more importantly does not potentiate greater loss of TH within the nigrostriatal pathway compared to the MPTP group, suggesting that in PD patients with SD, there is no exacerbation of the DA cell loss.

Safety margins in pulmonary metastasectomy are not yet well defined. We hypothesize that histological subtype, size of the lesion and local growth characteristics must be taken into consideration during metastasectomy. This study was conducted to examine and classify growth patterns at resection margins and define the relationships between aggressive local growth, metastasis size and local recurrence to direct metastasectomy.Histologic sections of pulmonary metastases were prospectively collected and haematoxylin-eosin stains were systematically evaluated and classified by their pattern of lung tissue infiltration. Logistic regression was used to model the association between the subgroups of colorectal, renal cell and epithelial cancers and melanomas and sarcomas.From 183 patients, 412 lung specimens were removed, which contained 459 pulmonary metastases. We found that 58% of all lesions had microscopic signs of aggressive local dissemination. The metastases showed histology-specific patterns of local growth: sarcoma was associated with pleural infiltration; colorectal metastases with interstitial spread and aerogenous spread of floating cancer cell clusters; and melanoma with perivascular growth and with lymph vessel involvement. Aggressive patterns of growth had an increasing probability of around 3% for each additional millimetre of metastasis diameter. Local intrapulmonary recurrence was significantly more common in association with interstitial growth and pleural penetration as well as safety margins 7 mm.Approximately 40% of all lung metastases have a smooth surface and might be resected with small margins. Growth characteristics within the lung differ with the histologic subtype and safety margins should generally increase with the size of the metastasis.

Background The current American Joint Committee on Cancer Seventh Edition (AJCC7) pathologic staging for esophageal adenocarcinoma (EAC) is derived from data assessing the outcomes of patients having undergone esophagectomy without neoadjuvant treatment and has unclear significance in patients who have received multimodality therapy. Lymph nodes with evidence of neoadjuvant treatment effect without residual cancer cells may be observed and are not traditionally considered in pathologic reports, but may have prognostic significance. Methods All patients who underwent esophagectomy after completing neoadjuvant therapy for EAC at our institution between 2006 and 2012 were reviewed. Slides of pathologic specimens were reexamined for locoregional treatment-response nodes lacking viable cancer cells but with evidence of acellular mucin pools, central fibrosis, necrosis, or calcifications suggesting prior tumor involvement. Kaplan-Meier survival functions were estimated, and Cox proportional hazards regression models were used to compare staging models. Results Ninety patients (82 men) underwent esophagectomy after neoadjuvant therapy for EAC (mean age, 61.8 ± 8.9 years). All patients received preoperative chemotherapy, and 50 patients also underwent preoperative radiotherapy. Median Kaplan-Meier survival was 55.6 months, and 5-year survival was 35% (95% confidence interval, 19% to 62%). A total of 100 treatment-response nodes were found in 38 patients. For patients with limited nodal disease (62 ypN0-N1), the presence of treatment-response nodes was associated with significantly worse survival ( p = 0.03) compared with patients lacking such nodes. Adjusting for patient age and AJCC7 pathologic stage showed the presence of treatment-response nodes significantly increased the risk of death (hazard ratio, 2.7; 95% confidence interval, 1.1 to 6.9; p = 0.04). When stage-adjusted survival was modeled, counting treatment-response nodes as positive nodes offered a better model fit than ignoring them. Conclusions Treatment-response lymph nodes detected from esophagectomy specimens in patients having undergone neoadjuvant chemotherapy or combined chemoradiation for EAC provide valuable prognostic information, particularly in patients with limited nodal disease. The current practice of considering lymph nodes lacking viable cancer cells, but with evidence of tumor necrosis, as pathologically negative likely results in understaging. Future efforts at revising the staging system for EAC should consider incorporating treatment-response lymph nodes in the analysis.

The detection of gastroesophageal reflux (GERD) via pH testing is the key component of the evaluation of patients considered for antireflux surgery. Two common pH testing systems exist, a multichannel, intraluminal impedance-pH monitoring (MII-pH) catheter, and wireless (Bravo®) capsule; however, discrepancies between the two systems exist. In patients with atypical symptoms, MII-pH catheter is often used preferentially. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH and the Bravo wireless capsule in a population of patients with mixed respiratory and typical symptoms. The study population consisted of 66 patients tested with MII-pH and Bravo pH testing within 90 days between July 2009 and 2013. All patients presented with laryngo-pharyngo-respiratory (LPR) symptoms. Patient demographics, symptomatology, manometric and endoscopic findings, and pH monitoring parameters were analyzed. Patients were divided into four comparison groups: both pH tests positive, MII-pH negative/Bravo positive, MII-pH positive/Bravo negative, and both pH tests negative. Nearly half of the patients (44 %) had discordant pH test results. Of these, 90 % (26/29) had a negative MII-pH but positive Bravo study. In this group, the difference in the DeMeester score was large, a median of 29.3. These patients had a higher BMI (28.5 vs. 26.1, p = 0.0357), were more likely to complain of heartburn (50 vs. 23 %, p = 0.0110), to have a hiatal hernia, (85 vs. 53 %, p = 0.0075) and a structurally defective lower esophageal sphincter (LES, 85 vs. 58 %, p = 0.0208). In patients with LPR symptoms, we found a high prevalence of discordant esophageal pH results, most commonly a negative MII-pH catheter and positive Bravo. As these patients exhibited characteristics consistent with GERD (heartburn, defective LES, hiatal hernia), the Bravo results are likely true. A 24-h MII-pH catheter study may be inadequate to diagnose GERD in this patient population.

Background Five-year survival after the surgical treatment of esophageal cancer has traditionally been reported to be as low as 15%. More recently, the improvement of clinical staging involving PET/CT and the introduction of neoadjuvant chemo-radiation have each altered the survival outcomes of patients with this lethal disease. The impact of these factors on survival trends has not been well described in literature. The aim of this study was to analyze the survival trends after esophagectomy for esophageal adenocarcinoma at a high-volume center. Methods The study population consisted of 471 consecutive patients undergoing esophagectomy for esophageal adenocarcinoma at a university-based medical center between January 1, 2000 and July 31, 2017. Clinical variables were collected for three groups based on the date of esophagectomy and were compared (Group 1: 2000–2004, Group 2: 2005–2011, Group 3: 2012–2017). Survival was compared via the Kaplan-Meier (KM) method. Results The 471 patients had a median age of 64.0 years (range 27.0–86.2) and 395/471 (84%) were male. Dysphagia (282/471, 60%), heartburn (63/471, 13%) and chest pain (29/471, 6%) were the most common presenting symptoms. The majority of the patients underwent transhiatal esophagectomy (n = 279, 59.1%) and en-bloc esophagectomy (n = 85, 18.0%). Staging with PET/CT was utilized in 316/471 patients (67%) with 6% of Group 1, 76% of Group 2 and 100% of Group 3, P Conclusion This analysis reveals an improvement in 5-year survival after esophagectomy from 30% to 47% over the past two decades. Similarly, 10-year survival has improved from 23% to 37%. The evolution of better clinical staging and advancements in neoadjuvant therapy likely played a vital role in these trends. In contrast to the earliest cohort, PET/CT is now routinely utilized in the staging of esophageal cancer. Further, other than those with early stage disease, all patients are currently evaluated for neoadjuvant chemo-radiation. Notably, the 5-year survival rate for the most recent cohort (2012–2017) approaches 50% and would likely be higher if patients with esophageal adenocarcinoma treated endoscopically were included. Improvements in staging and treatment paradigms for esophageal adenocarcinoma have resulted in significant progress towards cure. Disclosure All authors have declared no conflicts of interest.

e15580 Background: Trimodality treatment (tx) with neoadjuvant chemoradiation (CRT) followed by esophagectomy is standard tx for locally advanced EGJ cancer. Post-operatively, there is no strong consensus about role of routine surveillance imaging. At the University of Rochester, patients (pts) have surveillance CT scans every 4-6 months (mos) for the first 2 years post-esophagectomy and every 6-12 mos for the next 3 years. Methods: Pts were identified who underwent esophagectomy for T1-T3 EGJ cancer between January 2011 and December 2015 at our institution. Objectives were to describe the impact of timing and methods of recurrence detection (MoRD) on patient outcomes. Recurrence-free (RFS) and overall survival (OS) were graphed via the Kaplan-Meier method. Results: 138 pts underwent esophagectomy for EGJ cancer: 107 (77.5%) were male, median age was 64, and 116 patients (84.1%) had adenocarcinoma. 112 pts (81.2%) had neoadjuvant CRT. The entire cohort’s median OS was 38.4 mos. 68 pts (49.3%) relapsed with a median RFS of 20.0 mos. Recurrence was detected by routine imaging in 36 pts (52.9%), imaging triggered by symptoms in 27 pts (39.7%), and symptoms alone in 5 pts (7.4%). Post-relapse median OS was 2.3 mos when detected based on symptoms alone, 5.0 mos when detected by imaging triggered by symptoms, and 13.7 mos when detected by routine scans (log-rank p = 0.041). There was no significant association between baseline patient/tumor characteristics or pathologic response and MoRD . 53 patients (77.9%) received salvage/palliative tx with a median of 2 tx (IQR = 1). There was no significant association between MoRD and number of salvage/palliative tx. Conclusions: 49.3% of pts relapsed after esophagectomy for EGJ cancer, consistent with current literature. Almost half of relapses were detected based on symptoms despite routine imaging. Increased OS for pts with relapse detected by routine scans is likely related to lead time bias, but may also be related to increased tx intensity or less aggressive tumors. MoRD did not have a measurable impact on number of lines of post-relapse tx. Prospective randomized trials are needed to determine real benefit of regular surveillance scans among EGJ cancer survivors.

32 Background: Trimodality treatment with neoadjuvant chemoradiation (CRT) followed by surgery is a standard treatment for esophageal/GEJ (E/GJ) cancers. Following esophagectomy, there is no strong consensus about optimal surveillance and routine imaging. At our institution, patients have surveillance CT scans every 4-6 months for the first 2 years post-surgery and every 6-12 months for the next 3 years. Methods: An IRB-approved chart review was performed identifying patients who underwent surgical resection for locally advanced E/GJ cancer between January 2011 and December 2015 at the University of Rochester. Study objectives were to describe timing of and methods used to detect recurrence as well as their impact on patient outcomes. Recurrence-free (RFS) and overall survival (OS) were graphed via the Kaplan-Meier method. Results: 138 patients underwent surgical resection for E/GJ cancer during the study period: 107 (77.5%) were male, median age was 64, and 116 patients (84.1%) had adenocarcinoma. 111 patients (80.4%) received neoadjuvant CRT. Median OS for entire cohort was 43.4 months. 65 patients (47.1%) relapsed with a median RFS of 19.8 months. Recurrence was detected by routine imaging in 34 patients (52.3%), imaging triggered by symptoms in 25 patients (38.5%), and symptoms alone in 6 patients (9.2%). Median OS post-relapse was 1.5 months when detected based on symptoms alone, 5.0 months when detected by imaging triggered by symptoms, and 13.5 months when detected by routine scans (Log-rank p = 0.046). There were no significant associations between baseline patient /tumor characteristics and subsequent method of recurrence detection. Conclusions: 47.1% of patients suffered relapse after trimodality therapy for E/GJ cancer, consistent with published literature. Almost half of these were detected based on symptoms despite routine imaging. Increased OS for patients with relapse detected by routine scans is likely related to lead time bias, but may be related to increased treatment intensity, or due to less aggressive tumors. Prospective randomized trials are needed to determine the true benefit of regular surveillance scans among esophageal cancer survivors.

Background Current diagnostic techniques establishing gastroesophageal reflux disease as the underlying cause in patients with respiratory symptoms are poor. Our aim was to provide additional support to our prior studies suggesting that the association between reflux events and oxygen desaturations may be a useful discriminatory test in patients presenting with primary respiratory symptoms suspected of having gastroesophageal reflux as the etiology. Methods Thirty-seven patients with respiratory symptoms, 26 with typical symptoms, and 40 control subjects underwent simultaneous 24-h impedance–pH and pulse oximetry monitoring. Eight patients returned for post-fundoplication studies. Results The median number (interquartile range) of distal reflux events associated with oxygen desaturation was greater in patients with respiratory symptoms (17 (9–23)) than those with typical symptoms (7 (4–11, p

Purpose Patients with pulmonary metastases (PM) from soft-tissue sarcomas (STS) have historically been treated with surgery and/or chemotherapy. Since 2001, we have treated PM with stereotactic body radiation therapy (SBRT). We postulated that SBRT for PM from STS would yield excellent local control (LC) and overall survival (OS). Methods and Materials Fifty-two patients with PM from STS, diagnosed between 1990 and 2006 at the University of Rochester, were retrospectively reviewed. Most patients received multimodality treatment comprising of surgery, chemotherapy, and/or radiation. SBRT used the Novalis ExacTrac patient positioning platform, vacuum bag immobilization, and relaxed end-expiratory breath hold techniques. Results Leiomyosarcoma (23%), malignant fibrous histiocytoma (19%), and synovial sarcoma (15%) were the most common histologies. Forty-eight percent initially presented with PM, whereas 52% developed PM at a median of 0.7 (0.3–7.3) years after initial diagnosis. Median follow-up from diagnosis of PM was 0.9 (0.3–7.3) years. Fifteen patients underwent SBRT to 74 lesions. Median number of lesions treated was 4 (1–16) per patient and 3.5 (1–6) per session. Preferred dose and fractionation was 50 Gy in 5 Gy fractions. Three-year LC was 82%. No patients experienced Grade ≥3 toxicity. Median OS was 2.1 (0.8–11.5) years for patients treated with SBRT, and 0.6 (0.1–7.8) years for those who never received SBRT (p = 0.002). Conclusions SBRT provides excellent LC of PM and may extend OS. SBRT should be considered for all patients with PM from STS, particularly those who are not surgical candidates. Further investigation is warranted to establish criteria for the use of SBRT for STS patients with PM.

Malignant solitary fibrous tumor (MSFT) is a rare neoplasm. Three cases of MSFT with unusual features, including 1 pleural and 2 extrapleural, are reported. A 64-year-old woman with a large right thoracic MSFT and episodes of severe hypoglycemia experienced resolution of her hypoglycemia immediately after resection of the MSFT. A 27-year-old woman with primary retroperitoneal MSFT had pulmonary metastases 10 months after resection of the primary tumor. A 54-year-old man with an intracranial solitary fibrous tumor suffered from multiple pulmonary metastases and local recurrence 21 and 28 months after resection of the primary tumor, respectively. All 3 cases of solitary fibrous tumor displayed malignant features. The tumor cells in each case were positive for CD34 and Bcl-2, but negative for cytokeratin, smooth muscle actin, S-100, and c-kit. In addition, the tumor cells in the case with concomitant hypoglycemia were strongly positive for insulin-like growth factor-II. The histopathologic diagnostic criteria for MSFT, the differential diagnosis with other spindle cell tumors, and the mechanism of MSFT-derived hypoglycemia via insulin-like growth factor-II are discussed.

Studies of positron emission tomography (PET) have focused mainly on tumor staging. The role of PET in predicting survival has received less attention. We sought to assess the relationship of pretreatment maximum standard uptake value (SUV(max)) to survival in surgical patients with esophageal cancer.The study consisted of 72 esophagectomy patients (60 with adenocarcinoma) undergoing resection between July 2005 and April 2009. PET combined with computed tomography (PET-CT) was performed at a single center, and SUV(max) was recorded prior to any therapy. Survival was assessed at a median follow-up of 19 months.The median SUV(max) was 6.25. A receiver operating characteristic curve identified SUV(max) 4.5 to optimally discriminate survival. Patients with low SUV(max) (4.5) had significantly (p = 0.0003) better survival than those with high SUV(max) (or=4.5). Stage 3 patients with low SUV(max) had significantly better survival (p = 0.0069) than those with high SUV(max). Likewise, N1 disease patients with low SUV(max) had significantly better survival (p = 0.008) than those with high SUV(max). Multivariate analysis identified SUV(max) to be an independent predictor of survival (p = 0.0021).Pretreatment PET-CT SUV(max) independently predicts survival in patients with esophageal carcinoma undergoing resection. SUV(max) may be a valuable marker of tumor biology that could potentially be exploited for prognostic and therapeutic purposes.

Summary Aims Uncommon cases of lung metastasis from different types of uterine neoplasms with a long tumour-free interval after hysterectomy are reported. Methods and results Four cases were retrieved from our surgical pathology archives. Case 1 was a 68-year-old woman who had three pulmonary nodules 23 years after hysterectomy for low-grade endometrial stromal sarcoma (LGESS). The nodules obtained with video-assisted thoracic surgeries were consistent with metastatic LGESS. Case 2 was a 36-year-old woman who had numerous bilateral pulmonary nodules 6 years after hysterectomy for leiomyoma. A transthoracic biopsy revealed benign metastasising leiomyoma. Case 3 was a 77-year-old woman who had a large lung mass with satellite nodules 17 years after hysterectomy with bilateral salpingo-oophorectomy and subsequent radiotherapy for endometrial endometrioid adenocarcinoma (EEA). The biopsied and resected lung tumour was consistent with metastatic EEA. Case 4 was a 51-year-old woman who underwent total hysterectomy and subsequent radiotherapy for endocervical adenocarcinoma 12 years ago and lung lobectomy for metastatic disease 8 years ago. She then developed two pulmonary lesions 14 months ago, and these resected after radiotherapy were metastatic endocervical adenocarcinoma. Conclusions A review of the literature revealed that late pulmonary metastasis from uterine neoplasms is rare but not negligible. Immunohistochemical studies and molecular tests, together with detailed clinical information and imaging findings, are important for rendering a diagnosis.

Proof of the relationship between gastroesophageal reflux disease (GERD) and respiratory symptoms remains a challenge. Our aim was to determine the association between reflux events and O(2) desaturation in GERD patients with primary respiratory symptoms (RS) compared to those with primary esophageal symptoms (ES) using ambulatory monitoring systems.One thousand eight hundred fifty-one reflux episodes were detected by multichannel intraluminal impedance (MII)-pH testing in 30 patients with symptoms of GERD (20 RS, ten ES.) All patients underwent simultaneous 24-h MII-pH and continuous O(2) saturation monitoring via pulse oximetry. Reflux-associated desaturation events were determined by correlating synchronized 24-h esophageal pH and/or impedance and O(2) desaturation.One thousand one hundred seventeen reflux events occurred in patients with RS and 734 in those with ES. Nearly 60% of these 1,851 reflux events were associated with O(2) desaturation. Markedly more events were associated with O(2) desaturation in patients with RS (74.5%, 832/1,117) than in patients with ES (30.4%, 223/734, p0.0001). The difference in reflux desaturation association was more profound with proximal reflux--80.3% with RS vs. 29.4% with ES (p0.0001).A remarkably high prevalence of O(2) desaturation associated with gastroesophageal reflux was noted in patients with RS. Given further study, simultaneous combined esophageal reflux and O(2) saturation monitoring may prove a useful diagnostic tool in this difficult group of patients.

Bile acids and acid are implicated in the development of Barrett's esophagus. Evidence suggests that Barrett's esophagus intestinal metaplasia may occur via induction of caudal homeobox gene 2 (CDX2). We hypothesized that induction of CDX2 by bile acids may be due to ligand-dependent transactivation of epidermal growth factor receptor (EGFR).Human mucosal epithelial cells (SEG-1) were treated for 0 to 24 h with up to 300 microM deoxycholic acid (DCA) at pH 7 or 5 with or without (w/wo) antibodies against EGFR ligand-binding site (Mab528, 3-5 mug/ml). Treatment with 100 ng/ml EGF served as control. CDX2 mRNA expression was determined by real-time polymerase chain reaction. EGFR activation was analyzed by Westerns of phosphorylated EGFR tyrosines.Acid (pH 5) increased the induction of CDX2 mRNA expression caused by DCA. CDX2 mRNA induction was markedly reduced by EGFR blockade with Mab528. Each treatment (pH 5, DCA or pH 5 plus DCA) activated the EGFR on all tyrosines tested but in different time courses. Phosphorylation by DCA was inhibited by Mab528. Activation of EGFR by DCA at pH 5 resulted in EGFR degradation, while that by DCA alone did not.Thus, CDX2 induction by DCA w/wo acid occurs through ligand-dependent transactivation of the EGFR. The variations in EGFR degradation pattern with DCA or DCA at pH 5 indicate differential transactivation pathways. The molecular pathogenesis of Barrett's esophagus may occur via bile-stimulated cell signaling through the EGFR.

Introduction Clinical evidence strongly suggests that bile acids are important in the development of Barrett’s esophagus, although the mechanism remains unknown. Caudal-related homeobox 2 (CDX2) is a transcription factor recently implicated in early differentiation and maintenance of normal intestinal epithelium and is suggested to play a key role in the pathogenesis of intestinal metaplasia in Barrett’s esophagus.

Anastomotic leaks remain a significant clinical challenge following esophagectomy with foregut reconstruction. Despite an increasing understanding of the multiple contributing factors, advancements in perioperative optimization of modifiable risks, and improvements in surgical, endoscopic, and percutaneous management techniques, leaks remain a source of major morbidity associated with esophageal resection. The surgeon should be well versed in the principles underlying the cause of leaks, and strategies to minimize their occurrence. Appropriately diagnosed and managed, most anastomotic leaks following esophagectomy can be brought to a successful resolution.

Over the past several years, endoscopic ablation and resection have become a new standard of care in the management of Barrett esophagus (BE) with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). Risk factors for failure of endoscopic therapy and the need for subsequent esophagectomy have not been well elucidated. The aims of this study were to determine the efficacy of radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) in the management of BE with HGD or IMC, to discern factors predictive of endoscopic treatment failure, and to assess the effect of endoscopic therapies on esophagectomy volume at our institution. Data were obtained retrospectively for all patients who underwent endoscopic therapies or esophagectomy for a diagnosis of BE with HGD or IMC in our department between January 1, 2004, and December 31, 2012. Complete remission (CR) of BE or HGD or IMC was defined as 2 consecutive biopsy sessions without BE or HGD or IMC and no subsequent recurrence. Recurrence was defined by the return of BE or HGD or IMC after initial remission. Progression was defined as worsening of HGD to IMC or worsening of IMC to submucosal neoplasia or beyond. Overall, 57 patients underwent RFA with or without EMR for BE with HGD (n = 45) or IMC (n = 12) between 2007 and 2012, with a median follow-up duration of 35.4 months (range: 18.5-52.0 months). The 57 patients underwent 181 ablation sessions and more than half (61%) of patients underwent EMR as a component of treatment. There were no major procedural complications or deaths, with only 2 minor complications including 1 symptomatic stricture requiring dilation. Multifocal HGD or IMC was present in 43% (25/57) of patients. CR of IMC was achieved in 100% (12/12) at a median of 6.1 months, CR of dysplasia was achieved in 79% (45/57) at a median of 11.5 months, and CR of BE was achieved in 49% (28/57) at a median of 18.4 months. Following initial remission, 28% of patients (16/57) had recurrence of dysplasia (n = 12) or BE (n = 4). Progression to IMC occurred in 7% (4/57). All patients without CR continue endoscopic treatment. No patient required esophagectomy or developed metastatic disease. Overall, 6 patients died during the follow-up interval, none from esophageal cancer. Factors associated with failure to achieve CR of BE included increasing length of BE (6.0 ± 0.6 vs 4.0 ± 0.6cm, P = 0.03) and shorter duration of follow-up (28.5 ± 3.8 months vs 49.0 ± 5.8 months, P = 0.004). Shorter surveillance duration (17.8 ± 7.6 months vs 63.9 ± 14.4 months, P = 0.009) and shorter follow-up (21.1 ± 6.1 months vs 43.2 ± 4.1 months) were the only significant factors associated with failure to eradicate dysplasia. Our use of esophagectomy as primary therapy for BE with HGD or IMC has diminished since we began using endoscopic therapies in 2007. From a maximum of 16 esophagectomies per year for early Barrett neoplasia in 2006, we performed only 3 esophageal resections for such early disease in 2012, all for IMC, and we have not performed an esophagectomy for HGD since 2008. Although recurrence of BE or dysplasia/IMC was not uncommon, RFA with or without EMR ultimately resulted in CR of IMC in all patients, CR of HGD in the majority (79%), and CR of BE in nearly half (49%). No patient treated endoscopically for HGD or IMC subsequently required esophagectomy. In patients with BE with HGD or IMC, RFA and EMR are safe and highly effective. The use of endoscopic therapies appears justified as the new standard of care in most cases of BE with early esophageal neoplasia.

Pairing a previously neutral conditioned stimulus (CS; e.g., a tone) to an aversive unconditioned stimulus (US; e.g., a footshock) leads to associative learning such that the tone alone comes to elicit a conditioned response (e.g., freezing). We have previously shown that an extinction session that occurs within the reconsolidation window attenuates fear responding and prevents the return of fear in pure tone Pavlovian fear conditioning. Here we sought to examine whether this effect also applies to a more complex fear memory. First, we show that after fear conditioning to the simultaneous presentation of a tone and a light (T+L) coterminating with a shock, the compound memory that ensues is more resistant to fear extinction than simple tone-shock pairings. Next, we demonstrate that the compound memory can be disrupted by interrupting the reconsolidation of the two individual components using a sequential retrieval+extinction paradigm, provided the stronger compound component is retrieved first. These findings provide insight into how compound memories are encoded, and could have important implications for PTSD treatment.

Purpose Screening for esophageal adenocarcinoma (EAC) has not become policy in part over concerns in identifying the high-risk group. It is often claimed that a significant proportion of patients developing EAC do not report preexisting reflux symptoms or prior treatment for gastroesophageal reflux disease (GERD). As such, our aim was to assess the prevalence of GERD symptoms, proton pump inhibitor (PPI) use and Barrett's esophagus (BE) and their impact on survival in patients undergoing esophagectomy for EAC. Methods The study population consisted of 345 consecutive patients who underwent esophagectomy for EAC between 2000 and 2011 at a university-based medical center. Patients with a diagnosis of esophageal squamous cell carcinoma and those who underwent esophagectomy for benign disease were excluded. The prevalence of preoperative GERD symptoms, defined as presence of heartburn, regurgitation or epigastric pain, PPI use (>6 months) and BE, defined by the phrases “Barrett's esophagus,” “intestinal epithelium,” “specialized epithelium,” or “goblet cell metaplasia” in the patients' preoperative clinical notes were retrospectively collected. Overall long-term and stage-specific survival was compared in patients with and without the presence of preoperative GERD symptoms, PPI use, or BE. Results The majority of patients (64%; 221/345) had preoperative GERD symptoms and a history of PPI use (52%; 179/345). A preoperative diagnosis of BE was present in 34% (118/345) of patients. Kaplan–Meier survival analysis revealed a marked survival advantage in patients undergoing esophagectomy who had preoperative GERD symptoms, PPI use or BE diagnosis (P ≤ .001). The survival advantage remained when stratified for American Joint Committee on Cancer stage in patients with preoperative PPI use (P = .015) but was less pronounced in patients with GERD symptoms or BE (P = .136 and P = .225, respectively). Conclusion These data show that the oft-quoted statistic that the majority of patients with EAC do not report preexisting GERD or PPI use is false. Furthermore, a diagnosis of BE is present in a surprisingly high proportion of patients (34%). There is a distinct survival advantage in patients with preoperative GERD symptoms, PPI use, and BE diagnosis, which may not be simply owing to earlier stage at diagnosis. Screening may affect survival outcomes in more patients with EAC than previously anticipated.

Background Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia. Methods Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared. Results Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia. Conclusion These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.

Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional.The study population included all patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2009 who underwent laparoscopic fundoplication with or without related postoperative ICD-9 codes. Comorbidities, intraoperative occurrences, and 30-day postoperative outcomes were collected and logged into statistical software for appropriate analysis. Postoperative occurrences were divided into overall and serious morbidity.A total of 7,531 fundoplications were identified. Thirty-five percent of patients were younger than 50 years old, 47.1% were 50 to 69 years old, and 16.8% were older than 69 years old. Overall, 30-day mortality was 0.19% and morbidity was 3.8%. Thirty-day mortality was rare in patients younger than age 70 years, occurring in 5 of 10,000 (0.05%). Mortality increased to 8 of 1,000 (0.8%) in patients older than 70 years (p0.0001). Complications occurred in 2.2% of patients younger than 50 years, 3.8% of those 50 to 69 years, and 7.3% of patients older than 69 years. Serious complications occurred in 8 of 1,000 (0.8%) patients younger than 50 years, 1.8% in patients 50 to 69 years, and 3.9% of those older than 69 years.Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.

Introduction Endoscopic mucosal resection (EMR) and ablation technologies have markedly changed the treatment of early esophageal neoplasia. We analyzed treatment and outcomes of patients undergoing multimodal endoscopic treatment of early esophageal neoplasia at our institution. Methods Recordsofpatientsundergoingendoscopictreatmentforesophageallow-gradeintraepithelialneoplasia(LGIN,n=11), high-grade intraepithelial neoplasia (HGIN, n=24), or T1N0M0 neoplasia (n=10), presenting between 2007 and 2009, were reviewed. Outcomes included eradication of neoplasia/intestinal metaplasia, development of metachronous neoplasia, and progression to surgical resection. Results There were 45 patients, 96% male, with a mean age 67 years. The degree of neoplasia prior to intervention was intramucosal (8) or submucosal (2) carcinoma in 10, HGIN in 24, and LGIN in 11. Patients underwent a total of 166 procedures (median 3/patient, range 1–9). These included 120 radiofrequency ablation sessions, 38 EMRs, and 8 cryoablations. Mean follow-up was 21.3 months. Neoplasia and intestinal metaplasia were eradicated in 87.2% and 56.4% of patients, respectively, while 15.4% developed metachronous neoplasia. Three patients underwent esophagectomy. No patient developed unresectable disease or died. Conclusion Endoscopic treatment of early esophageal neoplasia is safe and effective in the short term. A minority of treated patients developed recurrent neoplasia, which is usually amenable to further endoscopic therapy. Complications are relatively minor and uncommon. Endoscopic therapy asthe initial treatment for early esophagealneoplasia isanemergingstandardofcare.

BACKGROUND: Although esophagectomy provides the highest probability of cure in patients with esophageal cancer, many candidates are never referred for surgery. We hypothesized that esophagectomy for esophageal cancer is underused, and we assessed the prevalence of resection in national, state, and local cancer data registries. STUDY DESIGN: Clinical stage, surgical and nonsurgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988 to 2004), the Healthcare Association of NY State registry (HANYS 2007), and a single referral center (2000 to 2007). SEER identified a total of 25,306 patients with esophageal cancer (average age 65.0 years, male-to-female ratio 3:1). HANYS identified 1,012 cases of esophageal cancer (average age 67 years, M:F ratio 3:1); stage was not available from NY State registry data. A single referral center identified 385 patients (48 per year; average age 67 years, M:F 3:1). For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race, and gender. RESULTS: Surgical exploration was performed in 29% of the total and only 44.2% of potentially resectable patients. Esophageal resection was performed in 44% of estimated cancer patients in NY State. By comparison, 64% of patients at a specialized referral center underwent surgical exploration, 96% of whom had resection. SEER resection rates for esophageal cancer did not change between 1988 and 2004. Males were more likely to receive operative treatment. Nonwhites were less likely to undergo surgery than whites (odds ratio 0.45, p < 0.001). CONCLUSIONS: Surgical therapy for locoregional esophageal cancer is likely underused. Racial variations in esophagectomy are significant. Referral to specialized centers may result in an increase in patients considered for surgical therapy.

Given our aging population, patients with an intrathoracic stomach are an increasing clinical problem. The timing of repair remains controversial, and most reports do not delineate morbidity of emergent presentation. The aim of the study was to compare the morbidity and mortality of elective and emergent repair. Study population consisted of 127 patients retrospectively reviewed undergoing repair of intrathoracic stomach from 2000 to 2006. Repair was elective in 104 and emergent in 23 patients. Outcome measures included postoperative morbidity and mortality. Patients presenting acutely were older (79 vs. 65 years, p

Modern-day concepts about the pathogenesis of an intrathoracic stomach include crural diaphragm muscular deterioration, loss of phrenoesophageal ligament integrity, and presence of abdominothoracic pressure gradients. The role of spinal abnormalities has received little attention. Based on clinical observation, we hypothesized that kyphosis and other spinal diseases are components of the pathophysiology of an intrathoracic stomach.The study population consisted of 98 patients (men, n = 22; women, n = 76; mean age 69.4 years) undergoing operations for type III or IV hiatal hernia with an intrathoracic stomach. Twenty-four age- and gender-matched control patients without hiatal hernia undergoing pulmonary or pleural procedures were used for comparison. Chest radiographs were assessed for spinal abnormalities, including degree of kyphosis, measured from superior T4 to inferior T12 (modified Cobb method), spinal fractures, osteoporosis, and scoliosis. Statistical analyses included two-sample t-test and Fisher's exact test.Patients with intrathoracic stomach had a greater degree of kyphosis than control patients (Cobb angle, 50.2 degrees versus 39.7 degrees; p0.001). This difference was most pronounced in women (Cobb angle, 51.7 degrees versus 40.4 degrees; p0.001), although the difference in men was not significant (Cobb angle, 45.0 degrees versus 38.1 degrees; p = 0.25). Patients with an intrathoracic stomach had significantly more vertebral fractures (37 of 98 [38%] versus 3 of 24 [13%]; p0.05). There was no difference in prevalence of degenerative changes (51 of 98 [52%], versus 13 of 24 [54%]), osteopenia (30 of 98 [31%] versus 6 of 24 [25%]), and scoliosis (27 of 98 [28%] versus 6 of 24 [25%]).Patients with an intrathoracic stomach have a higher degree of kyphosis and more vertebral fractures than age- and gender-matched controls. These data suggest that change in spinal curvature can be important in the pathogenesis of the intrathoracic stomach, a growing problem of our aging population.

The development of high-resolution (HRM) catheters and software displays of manometric recordings in color-coded pressure plots has changed the diagnostic assessment of esophageal disease. HRM may offer advantages over conventional methods, including improved identification of motility disorders, hiatal hernia, and outflow obstruction, and ease interpretation.HRM studies were obtained in 50 healthy volunteers and 106 patients. HRM was performed using a 36-channel catheter, with sensors spaced at 1-cm intervals. Manometric findings were classified into abnormalities of the gastroesophageal barrier and those of the esophageal body and validated by comparison with endoscopic and radiographic diagnostic methods.The mean time for HRM was significantly lower than that for a conventional method (8.1versus 24.4 minutes; p0.0001). A structurally defective lower esophageal sphincter (LES) was present in 53 (57.3%) patients, a hypertensive LES in 6 (7.8%), and impaired LES relaxation in 17 patients (16.7%). Validating the LES findings, 86.3% (44 of 51) of patients with a defective sphincter by HRM had radiographic or endoscopic evidence of a hiatal hernia, and 80% (41 of 51) had a positive pH study, endoscopic erosive esophagitis, or Barrett's esophagus. Evidence of a hiatal hernia by HRM was seen in 33 (56%) patients; a hiatal hernia was seen in 91% (30 of 33) of these on endoscopy and 81% (17 of 21) on barium swallow. Fifty-eight patients (54.7%) had an abnormal body motility.HRM studies are shorter than those using conventional methods. Interpretation is image based, and correlation with objective endoscopic and physiologic findings confirms the accuracy of interpretation. The introduction of HRM is a significant advance in the outpatient evaluation of esophageal function.

The increasing adoption of endoscopic therapies and expectant surveillance for patients with high grade dysplasia (HGD) in Barrett's esophagus has created considerable controversy regarding the ideal treatment choice. Confusion may be due, in part, to a limited understanding of the outcomes associated with surgical resection for HGD and extrapolation of data derived from patients undergoing an esophagectomy for invasive cancer. The purpose of our study was to document the perioperative and symptomatic outcomes and long-term survival after esophagectomy for HGD of the esophagus.The study population consisted of 38 patients who underwent esophagectomy for biopsy-proven HGD between 10/1999 and 6/2005. Three patients were excluded from analysis due to obvious tumor on upper endoscopy. Patients were evaluated regarding ten different foregut symptoms and administered a ten-question appraisal of eating and bowel habits. Outcome measures included postoperative morbidity and mortality, the prevalence of invasive cancer in the esophagectomy specimens, symptomatic and functional alimentary results, patient satisfaction, and long-term survival. Median follow-up was 32 months (range, 7-83).Thirty-day postoperative and in-hospital mortality was zero. Complications occurred in 37% (13/35), and median length of stay was 10 days. Occult adenocarcinoma was found in 29% (10/35) of surgical specimens (intramucosal in four; submucosal in five; and intramuscular in one with a single positive lymph node.) Patients consumed a median of three meals per day, most (76%, 26/34) had no dietary restrictions, and two-thirds (23/34) considered their eating pattern to be normal or only mildly impacted. Meal size, however, was reported to be smaller in the majority (79%, 27/34) of patients. Median body mass index (BMI) decreased slightly after surgery (28.6 vs 26.6, p0.05), but no patient's BMI went below normal. The number of bowel movements/day was unchanged or less in a majority (82%) of patients after surgery. Fifteen of 34 (44%) patients reported loose bowel movements, which occurred less often than once per week in 10 of the 15. One patient had symptoms of dumping. Mean symptom severity scores improved for all symptoms except dysphagia and choking. Four patients developed foregut symptoms that occurred daily. Most patients (82%) required at least one postoperative dilation for dysphagia. Almost all (97%) patients were satisfied. Disease-free survival was 100%, and overall survival was 97% (34/35) at a median of 32 months.Esophagectomy is an effective and curative treatment for HGD and can be performed with no mortality, acceptable morbidity, and good alimentary outcome. These data provide a gold standard for comparison to alternative therapies.

Dysphagia following esophagectomy with cervical esophagogastric anastomosis is common and often can be attributed to anastomotic stricture. The prevalence, risk factors, symptomatic and endoscopic severity, and response to dilation of such strictures, however, are poorly defined. In the present study the population consisted of 42 patients undergoing esophagectomy with gastric pull-up and cervical anastomosis. Any complaint of postoperative dysphagia was investigated with upper endoscopy. Patients undergoing endoscopy were entered into a prospective randomized trial of graduated balloon versus bougie-over-a-guidewire dilation that will be part of a future report. Dysphagia was assigned a standardized severity score, and stricture diameter pre-dilation was classified as minimal (>12 mm), mild (9–12 mm), moderate (5–8 mm), or severe (

RESULTS: Only 59% (882/1,498) of black patients underwent esophagectomy when recommended compared with 77% (10,212/13,329) of whites, 82% (464/567) of Asians, and 72% of (646/898) Hispanics (p

To evaluate the relationship between the acute inflammatory response after surgical trauma and changes in hepatic cytochrome P450 3A4 activity, compare changes in cytochrome P450 3A4 activity after procedures with varying degrees of surgical stress, and to explore the time course of any potential drug-cytokine interaction after surgery.Prospective, open-label study with each patient serving as his or her own control.University-affiliated, acute care, general hospital.A total of 16 patients scheduled for elective repair of an abdominal aortic aneurysm (n = 5), complete or partial colectomy (n = 6), or peripheral vascular surgery with graft (n = 5).Cytochrome P450 3A4 activity was estimated using the carbon-14 [14C]erythromycin breath test (ERMBT) before surgery and 24, 48, and 72 hrs after surgery. Abdominal aortic aneurysm and colectomy patients also had an ERMBT performed at discharge. Blood samples were obtained before surgery, immediately after surgery, and 6, 24, 32, 48, and 72 hrs after surgery for determination of plasma concentrations of interleukin-6, interleukin-1beta, and tumor necrosis factor-alpha. Clinical markers of surgical stress that were collected included duration of surgery, estimated blood loss, and volume of fluids administered in the operating room.ERMBT results significantly declined in all three surgical groups, with the lowest value at the time of the 72-hr study in all three groups. There was a trend toward differences in ERMBT results among groups that did not reach statistical significance (p =.06). The nadir ERMBT result was significantly and negatively correlated with both peak interleukin-6 concentration (r(s) = -.541, p =.03) and log interleukin-6 area under the curve from 0 to 72 hrs (r(s) = -.597, p =.014). Subjects with a peak interleukin-6 of100 pg/mL had a significantly lower nadir ERMBT compared with subjects with a peak interleukin-6 of100 pg/mL (35.5% +/- 5.2% vs. 74.7% +/- 5.1%, p.001).Acute inflammation after elective surgery was associated with a significant decline in cytochrome P450 3A4 activity, which is predictive of clinically important changes in the metabolism of commonly used drugs that are substrates for this enzyme.

Introduction: Accurate and complete identification of patients with symptoms secondary to gastroesophageal reflux disease has been a clinical challenge. This has led to the classification, perhaps erroneously, of some patients as "functional heartburn". 48-hour wireless pH monitoring has been shown to increase the diagnostic yield of reflux detection. We hypothesize that 96-hour monitoring would further increase reflux detection rate. Methods: The study population consisted of 31 patients who underwent 96-hour wireless pHmonitoring between February 2012 and October 2013.Patients with incomplete studies due to capsule dislodgement or failed signal transmission, achalasia, previous antireflux or gastric bypass surgery were excluded. Patient demographics, presenting symptoms, manometric and pHmonitoring parameters were collected and compared. Patients were divided into pH negative, single day positive or multiple day positive groups for comparison. All studies were done off PPI medications for at least 7 days. A positive study was defined by DeMeester score >14.72 on any day. Results: Eighteen (58%) of the 31 patients were negative on all 4 days, 7 (23%) were positive on a single day and 6 (19%) were positive on multiple days. Thirteen percent of the patients (4/31) were only positive on day 3 or day 4 and would have been considered normal on a 48 hour study. Lower esophageal sphincter (LES) parameters correlated with the number of pH positive days including LES overall length ( σ=-0.43, p=0.02), IBP (σ=0.41, p=0.02) and IRP (σ=-0.54, p=0.003). Mean axial separation between the LES and CD, 0.16cm in pH negative, 0.66cm in patients with one day positive and 0.26 in patients with multiple days positive (p=0.1506). Conclusions: 96 hour wireless pH monitoring identified pathologic esophageal acid exposure in 13% of patients who would have been considered normal on 48 hour study. These patients are more likely to have less profound alteration in characteristics of the gastroesopahgeal barrier including LES length and axial crural diaphragm separation. Prolonged 96-hour pH monitoring may be necessary before classifying patients as GERD negative or functional heartburn.

© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc underwent video-assisted thoracoscopic right middle lobectomy with use of a camera port, an instrument port, and a 1.5-cm access incision in the axilla with no rib spreading. The pathologic appearance was consistent with a carcinoid tumor. Six months later the patient noticed that her “right breast was gone.” Computed tomography of the chest revealed intrathoracic migration of the right breast implant with suspected rupture (Fig 2, asterisk). The patient was taken back to the operating room and underwent video-assisted thoracoscopic removal of the breast implant (Fig 3). The Remaining free silicone was removed with iced saline-soaked sponges. The axillary defect was identified as the site of implant herniation and was closed with a prosthetic mesh. The patient had an unremarkable recovery. Intrathoracic herniation of a breast implant has been reported in association with open thoracotomy [1]. To our knowledge, this is the first reported case after a videoassisted thoracoscopic surgical procedure. Closing the intercostal defect can be considered to prevent such a complication.

Introduction: The identification of esophagogastric junction (EGJ) outflow obstruction via high resolution manometry (HRM) is increasingly common and of unclear clinical significance. The objective of this study was to review the HRM characteristics of EGJ outflow obstruction and to assess how this diagnosis translates into clinical practice. Methods: A retrospective review was conducted of 1105 symptomatic patients who underwent HRM between 9/09 and 8/12. EGJ outflow obstruction was defined as an elevated 4 second lower esophageal sphincter integrated relaxation pressure (IRP). Patients with elevated IRP were divided into 3 groups: achalasia, mechanical obstruction (large hiatal hernia, postoperative and neoplasia) and functional obstruction (no obvious underlying cause). Clinical and demographic data, presenting symptoms, upper endoscopic findings, treatment and posttreatment outcomes were compared among the groups. Results: Of the 1105 patients studied, 237 (21%) had an elevated IRP. Sixty four percent were female with a mean age of 56.8±15.4 years. Mechanical causes of obstruction were most common (100/237, 42%) including postoperative in 50, large hiatal hernia in 48 and esophageal cancer in 2. Achalasia was present in 75 patients (32%). The remaining 62 (26%) had an elevated IRP without evidence of mechanical obstruction. Dysphagia was the primary presenting symptom in 85% of patients in the achalasia group, 31% of the mechanical group and 13% of the functional group (p,0.009). Interestingly, upper respiratory symptoms were significantly more common in patients with functional outflow obstruction (26% vs. 1% achalasia and 4% mechanical, p,0.001). The mean IRP also varied amongst the clinical groups, highest in achalasia 31.0±11.7mmHg, intermediate in mechanical obstruction (23.5 ±8.6 mmHg) and lowest in the functional group (18.7±3.8 mmHg) p,0.001. A similar pattern was seen in the mean intra-bolus pressures 28.6±15.0 mmHg, 20.1±7.4 mmHg and 14.9±4.0 mmHg, respectively. Nearly 40% (22/57) of the patents with functional outflow obstruction parameters were pH positive suggesting GE barrier failure despite the manometric findings. Fundoplication was performed in 9 of these 22 patients (41%) with good response. Five of the remaining functional patients underwent treatment; myotomy in one and Botox in 4. Conclusions: The predominant etiologies of EGJ outflow obstruction are mechanical obstruction and achalasia. Mechanical causes should be excluded before functional outflow obstruction is diagnosed and treated. HRM parameters of functional outflow obstruction may be present in a subset of patients with pH positive GERD. The ideal management of patients with symptomatic functional obstruction remains unclear.

INTRODUCTION: As pre-operative chemoradiation followed by esophagectomy has become standard therapy in patients with resectable esophageal adenocarcinoma (EAC), traditional pathological staging has become a less useful prognostic tool. The 7th edition of the American Joint Commission on Cancer (AJCC7) staging system for EAC is derived from data on patients undergoing esophagectomy without neoadjuvant therapy and classifies lymph node status by the number of involved lymph nodes. Lymph node harvest (LNH) and lymph node positivity ratio (LNPR) have been suggested to be prognostic indicators but have not found widespread support. In an effort to develop a valid staging model in the era of neoadjuvant therapy, we compared the predictive value of LNH and LNPR to AJCC7 staging in a large cohort of patients undergoing resection for EAC. METHODS: The study population consisted of 316 patients who underwent R0 esophagectomy for EAC from 1/00 to 12/11 (86% male; mean age 64.0±10.3 years). Survival functions were estimated using the KaplanMeier method. Classification thresholds for both LNPR and LNH were derived by recursive partitioning using conditional inference trees comparing survival functions. Based on these analyses, LNPR was stratified and Cox proportional hazards regression models were used to compare predictive value of lymph node categorization strata. RESULTS: Median lymph node harvest was 12 (IQR 7-20). 51% of patients were N0, 29% N1, 13% N2. Median overall survival was 63.4 months (95%CI 40.6 92.3) and 5-year overall survival was 50.7% (95%CI 45.0 57.2). Eighty-three patients (26%) received neoadjuvant chemotherapy, radiation therapy or both. In patients who received neoadjuvant therapy and had no lymph node metastasis identified (40/83; 48%), recursive partitioning analysis yielded a LNH threshold of 15 for discrimination of survival functions. LNH ≥ 15 was associated with a significant survival advantage (3-year survival 95 vs. 38%; p = 0.000022). Similarly, recursive partitioning analysis yielded LNPR categories of less than 20%, 20-40%, or greater than 40% as significantly discriminant of survival functions. In patients who received neoadjuvant therapy, LNPR was more predictive of survival than number of positive lymph nodes as categorized by AJCC7 (p=0.00018 vs. 0.033). In the 256 patients who received no neoadjuvant therapy, LNH was not a significant predictor of survival after node negative resection, although LNPR was a stronger predictor of survival than the current nodal staging system (p-value 0.000015 vs. 0.05). CONCLUSION: For patients receiving neoadjuvant therapy, both LNH and LNPR are more predictive of survival than the number of lymph node metastases detected in esophagectomy specimens. A minimum LNH of 15 is necessary to establish reliable N0 staging in this cohort.

Introduction: Prospective randomized trials document long term relief of gastro-esophageal reflux (GERD) symptoms in 85% of patients following antireflux surgery. One of the key challenges, in the decision to pursue antireflux surgery, is assuring that the patients symptoms are actually caused by GERD. Mathematical calculations of the relationship of reflux events to the occurrence of symptoms have been proposed as a mechanism to support GERD as the underlying cause of both typical and atypical reflux symptoms. The symptom index (SI) and Symptom Association Probability (SAP) are the most commonly calculated measures in clinical use. The clinical utility of these measures is unclear and unexplored with respect to antireflux surgery. Methods: The study population included 66 patients (mean age 52.6 years; 58% female) undergoing laparoscopic fundoplication fromNovember 2006 to October 2011. All were pH-positive (DeMeester Score >14.72) with either cough, heartburn and/or regurgitation, in which SI (positive ≥50%) and SAP (positive ≥95%) were calculated preop. Symptom outcome after surgery was categorized as ‘improvement', ‘no change' and ‘worsening' in their symptoms. All available data were logged into SPSS (version 18) for statistical analyses. Results: At the time of pH testing heartburn was recorded in 51 (84%), regurgitation in 22 (33%) and cough in 21 (32%) patients. One or both symptom indices were positive in 85% (56/66) and both negative in 15% (10/66) of the patients. Cough was significantly less associated with positive SI and/or SAP when compared to heartburn and regurgitation (SI 19% vs. 72.5% and 81.8%; p