Completely Minimally Invasive Esophagectomy Versus Hybrid Esophagectomy for Esophageal and Gastroesophageal Junctional Cancer: Clinical and Short-Term Oncological Outcomes.

BACKGROUND: Minimally invasive surgery for resectable esophageal and gastroesophageal junctional (GEJ) cancer significantly reduces morbidity when compared with open surgery, as is evident from published landmark trials. Comparison of outcomes between hybrid esophagectomy (HE) and completely minimally invasive esophagectomy (CMIE) remains unclear. OBJECTIVE: We aimed to ascertain whether CMIE is associated with less postoperative complications compared with HE without oncological compromise. METHODS: All consecutive two-stage HEs and CMIEs performed between 2016 and 2018 were included. All procedures were performed with an intrathoracic anastomosis. Primary clinical outcomes were pulmonary infective and overall complications within 30 days of surgery, while primary oncological outcomes included overall survival (OS) and disease-free survival (DFS) at both 6 months and to date. Secondary outcomes included intraoperative variables and postoperative clinical parameters. RESULTS: Overall, 98 patients had CMIEs and 49 patients had HEs. There were no baseline differences between the two groups. Thirty-day postoperative pulmonary infection rates were lower in the CMIE group compared with the HE group (12.2% vs. 28.6%; p = 0.014), and 30-day overall postoperative complication rates were also lower following CMIE (35.7% vs. 59.2%; p = 0.007). OS and DFS were similar between the two groups at 6 months (p = 0.201 and p = 0.109, respectively). CONCLUSIONS: CMIE is associated with less pulmonary infective and overall postoperative complications compared with HE for resectable esophageal and GEJ cancer. No intergroup difference was observed regarding short-term survival and cancer recurrence in patients undergoing CMIE and HE. A randomized controlled trial comparing the two operative approaches is required to validate these findings.

Rumination syndrome: Assessment of vagal tone during and after meals and during diaphragmatic breathing.

BACKGROUND: Pathophysiology of rumination syndrome (RS) is not well understood. Treatment with diaphragmatic breathing improves rumination syndrome. The aim of the study was to characterize vagal tone in patients with rumination syndrome during and after meals and during diaphragmatic breathing. METHODS: We prospectively recruited 10 healthy volunteers (HV) and 10 patients with RS. Subjects underwent measurement of vagal tone using heart rate variability. Vagal tone was measured during baseline, test meal and intervention (diaphragmatic (DiaB), slow deep (SlowDB), and normal breathing). Vagal tone was assessed using mean values of root mean square of successive differences (RMSSD), and area under curves (AUC) were calculated for each period. We compared baseline RMSSD, the AUC and meal-induced discomfort scores between HV and RS. Furthermore, we assessed the effect of respiratory exercises on symptom scores, and number of rumination episodes. KEY RESULTS: There was no significant difference in baseline vagal tone between HV and RS. During the postprandial period, there was a trend to higher vagal tone in RS, but not significantly (P > .2 for all). RS had the higher total symptom scores than HV (P < .011). In RS, only DiaB decreased the number of rumination episodes during the intervention period (P = .028), while both DiaB and SlowDB increased vagal tone (P < .05 for both). The symptom scores with the 3 breathing exercises showed very similar trends. CONCLUSIONS AND INFERENCES: Patients with RS do not have decreased vagal tone related to meals. DiaB reduced number of rumination events by a mechanism not related to changes in vagal tone.

Role of 3D in minimally invasive esophagectomy.

PURPOSE: Two-stage minimally invasive esophagectomy (MIE) has gained popularity in the surgical treatment of esophageal cancer. MIE's limitation is embedded in the construction of intrathoracic anastomosis. Various anastomotic techniques have been reported; however, the mechanical one remains the most commonly adopted. This pilot study aims to describe an efficient, safe, and reproducible way of performing a hand-sewn intrathoracic esophagogastric anastomosis in conjunction with short-term results using 2D and 3D thoracoscopic approaches. METHODS: A total of n = 13 patients (mean age 67.4) underwent MIE for distal esophageal or gastroesophageal junction adenocarcinoma between January and September 2016. Resection was performed in prone position, and the esophagogastric anastomosis was constructed in an end-to-side manner in two layers with barbed knotless suture. A 2D thoracoscopic approach was used in n = 10 patients (77%) and a 3D approach in n = 3 (23%). RESULTS: n = 8 patients (61.5%) had neo-adjuvant chemotherapy and n = 5 (38.5%) had primary surgery. The mean operating time was 420 min, and the average length of stay was 10 days with no associated mortality. n = 1 (7.7%) developed a radiological leak that did not require an intervention. Thoracoscopic approach with the glasses-based 3D optical system using the angulating-tip 100° camera provided a far superior view for precise lymphadenectomy in combination to an efficient and safe construction of the anastomosis. CONCLUSION: The barbed knotless suturing technique in MIE is an efficient and safe method of constructing the esophagogastric anastomosis with promising short-term outcomes. A 3D thoracoscopic approach appears to be superior in performing the anastomosis to that of a 2D technique.

Laparoscopic transgastric removal of eroding gastric band: a different approach.

Gastric banding is a popular method for the treatment of morbid obesity. Amongst complications, gastric erosion remains uncommon but could prove fatal. Multiple techniques, from open surgery to endoscopic and standard laparoscopic technique for their removal, have been previously detailed in the literature. However, only a few reports have mentioned their total laparoscopic transgastric removal in the literature. Herein, we report a successful removal of an eroding gastric band with its technical suggestion in a 43-year-old female patient 22 months following its application.

Association between Oesophageal Diverticula and Leiomyomas: A Report of Two Cases.

We report two rare cases of female patients presenting with oesophageal leiomyoma associated with oesophageal diverticulum, both of whom were surgically managed. Oesophageal leiomyoma and oesophageal diverticulum are uncommon as separate entities and rare as combined disease presentation. Clinicians need to be aware of the rare combination of the two entities and need to be able to exclude the presence of a tumour (benign or malignant) within a diverticulum and so plan the optimum treatment. Herein, we present two cases of oesophageal leiomyoma within oesophageal diverticulum and we try to elucidate the association between the two. To date, there is no consensus whether a diverticulum is secondary to a leiomyoma or, on the contrary, a leiomyoma arises within a diverticulum.

A mystifying mass.

A 57-year-old male was referred by his general practitioner (GP) to hospital with right upper quadrant pain and a palpable mass (10 × 9 cm). He had been assessed by his GP several weeks earlier and represented as initial treatment failed. On his second presentation a mass was evident and thought to represent cholecystitis by the referring GP. However, the correct and prompt use of appropriate radiological imaging enabled swift diagnosis and management of atypical acute appendicitis through microbial specific therapy. Atypical appendicitis delays diagnosis and treatment which represents greater levels of appendiceal ischaemia and heightened perforation risk. This case study highlights the non-surgical management of acute atypical appendicitis and also reinforces the use of appropriate imaging modalities.

The stem cell organisation, and the proliferative and gene expression profile of Barrett's epithelium, replicates pyloric-type gastric glands.

OBJECTIVE: Barrett's oesophagus shows appearances described as 'intestinal metaplasia', in structures called 'crypts' but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands. METHODS: Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry. RESULTS: Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell. CONCLUSIONS: Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus.

Concomitant jejunal sarcomatoid carcinoma and gastric GIST in patient with polymyalgia rheumatica: A case report.

INTRODUCTION: Sarcomatoid carcinoma (SCA) of the small bowel is an extremely rare tumor with only 21 cases reported in literature and GISTs are relatively rare gastrointestinal neoplasms. PRESENTATION OF CASE: We report a case of an 85 year-old female admitted with intestinal obstruction in June 2010. She suffered from polymyalgia rheumatica and was under surveillance for a presumed gastric GIST. A laparotomy was performed with resection of the jejunal obstruction and complete excision of the gastric mass. Histology confirmed a gastric GIST and sarcomatoid carcinoma of the small bowel. The patient was discharged 21 days after the operation and died on the 88th post-operative day. DISCUSSION: Synchronous GISTs and other malignancies have been reported over the last years with increasing frequency. Sarcomatoid carcinoma of the small bowel is an aggressive neoplasm with poor survival rates and surgery is the cornerstones of treatment. Given its unpredictable clinical behaviour and concomitant association with other malignancies, GISTs require adequate surgical resection with careful, long-term follow-up. CONCLUSION: This is the first case of concomitant gastric GIST with Sarcomatoid carcinoma of the small bowel, and the first report of sarcomatoid small bowel carcinoma in association with polymyalgia rheumatica.

Endoscopic mucosal resection of a solitary metastatic tumor in the stomach: a case report.

Endoscopic mucosal resection (EMR) is increasingly being utilized in the management of early gastric cancer. Metastatic cancer of the stomach is uncommon. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) that was successfully excised with EMR. A 71-year-old man presented with iron deficiency anemia, he had undergone a radical nephrectomy for RCC 3 years previously. Upper gastrointestinal endoscopy revealed a malignant-appearing 10 × 12 mm polyp in the stomach. Histopathology of the biopsy revealed that it was a metastasis from RCC, confirmed by immunohistochemistry with Vimentin and CAM 5.2 positivity. Computed tomography and bone scanning revealed no other metastases. Simultaneous laparoscopy and upper gastrointestinal endoscopy revealed that the lesion was localized to the gastric mucosa. EMR of the tumor en bloc was performed successfully. Histology confirmed a complete excision. He had an uneventful postoperative course and is well 15 months after surgery, without any tumor recurrence.

Real-time outcome monitoring following oesophagectomy using cumulative sum techniques.

AIM: To examine the feasibility of prospective, real-time outcome monitoring in a United Kingdom oesophago-gastric cancer surgery unit. METHODS: The first 100 hybrid (laparoscopic abdominal phase, open thoracic phase) Ivor-Lewis oesophagectomies performed by a United Kingdom oesophago-gastric cancer surgery unit were assessed retrospectively using cumulative sum (CUSUM) techniques. The monitored outcome was 30-d post-operative mortality, with the accepted mortality risk defined as 5%. A variable life adjusted display (VLAD) was constructed by plotting a graph of cumulative mortality minus cumulative mortality risk on the y axis vs sequential case number on the x axis. This was modified to a zeroed VLAD by preventing the plot from crossing the y = 0 axis - essentially creating two plots, one examining trends where cumulative mortality was higher than mortality risk (i.e., worse than expected outcomes) where y > 0, and vice versa. Alert lines were set at y = ± 2. At any point where a plot breaches an alert line, it is felt that the 30-d post-operative mortality rate has deviated significantly from that expected and an internal review should be performed. RESULTS: One hundred cases were assessed, with a mean age of 66.4 years, mean T stage of 2.1, and mean N stage of 0.48. Three cases were commenced using a laparoscopic technique and converted to open surgery due to technical factors. Median length of inpatient stay was 15 d. The crude 30 d mortality was 5% and the incidence of clinically significant anastomotic leak was 6%. The VLAD demonstrated a plot of cumulative mortality minus cumulative mortality risk (i.e., 5% per case) which remained in the range -1.4 to +0.5 excess mortalities. With the alert set at two greater or fewer than predicted mortalities, this method does not approach the point of triggering internal review. It is however arguable that a run of performance that is better than expected, causing the plot to be well below y = 0, would mask a subsequent run of poor performance by requiring a rise of greater than two excess mortalities to trigger the alert line. The zeroed VLAD removes this problem by preventing the plot that is examining above expected mortality from passing below y = 0, and vice versa. In this study period, no audit triggers were reached. It is therefore possible to independently assess runs of good, or poor performance and so target internal audit to the appropriate series of cases. It is important to note this technique allows targeted internal review, in response to both above and below average outcomes. This study has demonstrated the feasibility of prospective outcome monitoring using the above techniques, actual real-time implementation has the potential to pick up and reinforce good practices when performance is better than predicted, and provide an early warning system for when performance falls below that predicted. Further development is possible, including more patient specific risk adjustment using the oesophago-gastric surgery physiological and operative severity score for the enumeration of mortality and morbidity score. CONCLUSION: CUSUM techniques provide a potential method of prospective, real-time outcome monitoring in oesophageal cancer surgery.

Scrotal reconstruction with a free greater omental flap: A case report.

We report a case of Fournier's gangrene, where we used the greater omentum as a free flap for scrotal reconstruction and outline the advantages over previously described methods. The greater omentum was harvested using a standard open technique. The deep inferior epigastric vessels were passed through the inguinal canal into the scrotal area as recipient vessels. The detached greater omental flap was prefabricated into a three-dimensional sac prior to inset and microvascular anastomoses. The flap was then covered by skin graft. The reconstruction had shown good early results with complete survival of the flap, as well as good functional and esthetic outcome at six months. The greater omentum can therefore be used as a free flap for scrotal reconstruction. It allows easy prefabrication and flap inset. The deep inferior epigastric vessels are also suitable recipient vessels.