Low grade dysplasia in Barrett's esophagus: Should we worry?

The optimal management for low-grade dysplasia (LGD) in Barrett's esophagus is unclear. In this article the importance of LGD is discussed, including the significant risk of progression to esophageal adenocarcinoma. Endoscopic surveillance is a management option but is plagued by sampling error and issues of suboptimal endoscopy. Furthermore endoscopic surveillance has not been demonstrated to be cost-effective or to reduce cancer mortality. The emergence of endoluminal therapy over the past decade has resulted in a paradigm shift in the management of LGD. Ablative therapy, including radiofrequency ablation, has demonstrated promising results in the management of LGD with regards to safety, cost-effectiveness, durability and reduction in cancer risk. It is, however, vital that a shared-decision making process occurs between the physician and the patient as to the preferred management of LGD. As such the management of LGD should be "individualised."

Retraction-related liver lobe necrosis after laparoscopic gastric surgery.

BACKGROUND: Liver retraction is necessary for optimal exposure during laparoscopic gastric surgery. Though transient venous congestion of the retracted lobe of the liver is invariably seen during operations, major parenchymal injury is rare. We describe a case of Nathanson liver retractor-induced left lobe liver necrosis and review the pertinent literature. CASE REPORT: A 78-year-old man underwent a laparoscopic-assisted total gastrectomy for gastric cancer. A Nathanson liver retractor was used to retract a large fatty left liver lobe. The operation was prolonged due to splenic bleeding requiring splenectomy. On the second postoperative day, the patient deteriorated rapidly and developed multi-organ failure. A computerized tomogram confirmed necrosis of the left lobe of the liver with gas in the liver parenchyma. The necrotic liver lobe was excised at reoperation. The patient died from a postoperative myocardial infarction. DISCUSSION: Though minor liver injuries, in the form of intraoperative trauma and congestion, are common with laparoscopic liver retraction, major lacerations and necrosis are rare. Prolonged surgery and enlarged fatty liver lobe increases the risks of major injury. In our report, we discuss various types of retractor-related liver injuries and their management and highlight the importance of intermittent release of retraction during prolonged surgery.

Ratio of metastatic lymph nodes to total number of nodes resected is prognostic for survival in esophageal carcinoma.

INTRODUCTION: The role of the number of metastatic nodes in esophageal cancer surgery is of interest. We assess predictors of survival after oesophagectomy for esophageal and gastroesophageal junction malignancy. METHODS: Prospective data of consecutive patients undergoing oesophagectomy and systematic lymphadenectomy between 1991 and 2007. RESULTS: Of 224 patients, 148 patients (66%) had adenocarcinoma, 70 (31%) squamous cell carcinoma, and 6 (2.6%) were other tumor types. Five-year survival was 43% with hospital mortality of 3.5%. Locoregional recurrence occurred in 14%. The total number of affected nodes significantly reduced survival (four or more metastatic nodes). Further analysis of the ratio of nodes affected to the total number resected showed a significant decrease in survival as the percentage of positive nodes increased (p < 0.001). CONCLUSIONS: Patients undergoing surgery for esophageal cancer should be staged according to a minimum total number of metastatic lymph nodes and ratios because this more accurately predicts survival than current staging systems.

Laparoscopic duodenojejunostomy for the treatment of superior mesenteric artery (SMA) Syndrome: case series.

Superior mesenteric artery (SMA) syndrome is an atypical, rare cause of both acute and chronic high intestinal obstruction. Identification of this syndrome can be a diagnostic dilemma and is frequently made by exclusion. The most characteristic symptoms are postprandial epigastric pain, eructation, fullness, and voluminous vomiting. Symptoms are caused by compression of the third portion of the duodenum against the posterior structures by a narrow-angled SMA. When nonsurgical management is not possible or the problem is refractory, surgical intervention is necessary. In this article, we report a case series of SMA syndrome in 3 patients with radiologic evaluation confirming compression of the third portion of the duodenum by the SMA with resultant proximal dilatation. The patients all successfully underwent laparoscopic duodenojejunal anastomosis.

Barrett's oesophagus: intestinal metaplasia is not essential for cancer risk.

OBJECTIVE: Barrett's oesophagus is the main identifiable risk factor for oesophageal adenocarcinoma. It has been suggested that only patients with intestinal metaplasia are at risk of cancer, but the British Society of Gastroenterology (BSG) guidelines suggest that glandular mucosa is all that is needed. The aim of this study was to quantify the risk of adenocarcinoma in columnar-lined lower oesophagus, with or without specialized intestinal metaplasia. MATERIAL AND METHODS: All patients who had endoscopic biopsies of the lower oesophagus between 1980 and 1994 in a single-centre teaching hospital were included in the study. All histological specimens were re-examined and reported according to whether they contained columnar epithelial-lined lower oesophagus, glandular mucosa, with or without intestinal metaplasia. The primary outcome measure was the development of adenocarcinoma. RESULTS: In total, 712 patients were identified. Of these, 379 (55.1%) were found to have specialized intestinal metaplasia (SIM), and the remaining 309 (44.9%, p = NS) were reported as having glandular mucosa (GM). The median follow-up for patients was 12 years (range 8-20 years). Twenty-eight patients went on to develop adenocarcinoma (4.1%) during the follow-up period - 17 in the SIM group (4.5%) and 11 in the GM group (3.6%, p =NS). The oesophageal malignancy rate was 0.34% per year (SIM 0.37%, GM 0.30%; p =NS). CONCLUSIONS: Patients who have glandular mucosa on biopsy without intestinal metaplasia have a similar cancer risk to those with specialized intestinal metaplasia.

Bilateral ovarian metastases from carcinoma of the gallbladder.

BACKGROUND: Metastasis of carcinoma of the gallbladder to other intra-abdominal organs is recognised, but is rare. Ovarian metastases can mimic the clinical and morphological appearances of primary ovarian tumours, making the diagnosis difficult particularly when the primary source is not apparent. CASE: A patient presented with abdominal pain and was found to have gallstones and bilateral ovarian masses. Tumour markers were all normal. The patient developed jaundice and was subsequently operated on for the gallstones and ovarian masses. Histology showed these to be metastases from a gallbladder carcinoma. CONCLUSION: Presentation of ovarian metastases can cause diagnostic difficulty. Careful evaluation of the digestive tract should be considered in patients presenting with ovarian masses of uncertain origin.

The use of 5-aminolaevulinic acid as a photosensitiser in photodynamic therapy and photodiagnosis.

Photodynamic therapy (PDT) is a treatment for cancer and pre-malignant conditions, which involves the administration of a photosensitising agent followed by exposure of the tissue to light. 5-Aminolaevulinic acid (ALA) is a naturally occurring compound in the haem biosynthetic pathway, which is metabolised to a photosensitive product, protoporphyrin IX (PpIX). The major advantage of ALA when compared to synthetic photosensitisers is the rapid metabolism, which significantly reduces the period of cutaneous photosensitivity. This review focuses on the development of ALA as a photosensitiser in photodynamic therapy and photodiagnosis, and the wide range of clinical applications in which ALA is now being used as a therapeutic modality.