Vascular invasion is not a risk factor in oesophageal cancer recurrence.

AIM: The outcome of the treatment of oesophageal cancer remains poor despite improved treatment modalities and recurrence remains a major problem despite improved staging and treatment. The aim was to identify the independent risk factors responsible in the recurrence of oesophageal cancer. METHODS: The patients who had elective oesophagectomy (n = 244) with curative intent were studied. One hundred and eighty four patients had surgery alone, 44 patients had neo-adjuvant chemotherapy and surgery while 16 patients had neo-adjuvant chemotherapy, surgery and adjuvant chemotherapy. We have analyzed patients who had surgery alone (n = 184). Data was collected for demography, type of operation, histology, staging (TNM), vascular invasion (VI), differentiation of tumour, type of chemotherapy and recurrence of tumour. RESULTS: The median age was 67 years (IQR 60, 71). The T1, T2, T3 distribution was 10%, 24% and 66% respectively. Forty percent had no nodal involvement (N0) and 60% had N1 stage disease. Twenty three percent of patients had vascular invasion. Univariate analysis of histo-pathological factors identified lymph node yield (p = 0.06), curative resection R0 (p = 0.004) and vascular invasion (VI) (P = 0.69) as prognostic indicators of recurrence. Multivariate analysis showed that number of lymph nodes yielded (p = 0.01) and R0 resection remain independent indicators of recurrence of tumour. However, VI (p = 0.2) and age at disease onset (p = 0.8) were not indicators of recurrence in oesophageal cancer patients. CONCLUSION: R0 and lymph node yield may help to predict the recurrence of oesophageal cancer. However the presence of VI may not be a significant risk factor in disease recurrence.

Dissection efficiency during laparoscopic oesophageal dissection.

Advanced techniques in laparoscopic surgery have led to an increased need for appropriate training in instrument handling and dissection. Recent developments in computer video technology have facilitated critical analysis of surgical technique. Video deconstruction of oesophageal hiatal dissection during six laparoscopic fundoplication procedures was undertaken. The procedures were performed by surgeons with a wide range of surgical experience, and the investigators analysing performance were blinded to their level of training. Sequential five-second video segments were analysed in detail by 3 investigators. A taxonomy list was developed to describe individual types of movement. The number and time per movement was assessed and a degree of efficiency was assigned. An efficient movement was defined as one that advances the dissection towards a recognised goal. The total oesophageal dissection time varied from 10 minutes (min) to 25 min (mean 16 min). The mean number of actions performed was 173 (range 120-272). A mean of 7 min was spent separating tissues (range 5-13), with 6 min spent grasping and positioning tissue (range 3-8). The amount of time spent in inefficient movement varied from 3 to 14 min (mean 7 min). The greatest variation between operators was seen in the efficiency of tissue separation when using dissecting instruments. Inexperienced operators spent a lot more time performing additional movements such as scope cleaning, observation and instrument exchange. This technique of video deconstruction can identify key areas for improvement. This could be used for trainee assessment and to provide constructive feedback. Future development in this area could enhance training in advanced laparoscopic techniques.

Routine day-case laparoscopic cholecystectomy.

BACKGROUND: A prospective study was carried out to assess the feasibility of performing true day-case laparoscopic surgery in a district general hospital. METHODS: All patients admitted consecutively under the care of one surgeon for laparoscopic cholecystectomy were included in the study. Selection criteria for a day-case procedure included an American Society of Anesthesiologists grade of I or II and the availability of a responsible carer at home. Patients were discharged 4-6 h after surgery with a standard analgesia pack and a contact number for advice. All patients were contacted by telephone on the day after discharge. A postal questionnaire was sent to the first 100 patients to assess satisfaction with the day-case process. RESULTS: Of 357 patients admitted for laparoscopic cholecystectomy over a 24-month period, 154 (43.1 per cent) were operated on as day cases on a morning theatre list. Twenty-two patients required an overnight stay (14.3 per cent), three because of conversion to an open procedure. One patient was readmitted for neck pain. Eighty-two (92.1 per cent) of 89 patients were either satisfied or very satisfied with the day-case procedure. CONCLUSION: This study has demonstrated a low rate of overnight stay (14.3 per cent) and readmission (1.9 per cent), and a high degree of patient satisfaction for day-case laparoscopic cholecystectomy.

Laparoscopic management of large paraesophageal hiatal hernia.

BACKGROUND: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus. METHODS: Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure. RESULTS: Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death. CONCLUSIONS: Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.

Excision of laparoscopic port sites increases the likelihood of wound metastases in an experimental model.

BACKGROUND: Case reports of patients developing tumor metastases at port sites following laparoscopic surgery have prompted the development of preventive strategies to address this potential problem, including local excision of the port sites. While it has been suggested that this strategy could be used clinically, its efficacy has not been established. METHODS: Twenty four immune-competent Dark Agouti rats underwent laparoscopy and standardized intraperitoneal laceration of an implanted abdominal flank tumor, using an established laparoscopic cancer model. Rats were randomized to either control (n = 12) or wound excision (n = 12) groups. Both groups underwent laparoscopy using carbon dioxide (CO2) insufflation and two mini-laparoscopy ports. In the wound excision group, one of the port site wounds was excised following desufflation of the abdominal cavity. One week later, the port site wounds were excised for histological examination. RESULTS: Wound involvement with tumor was significantly more common following wound excision than with untreated control wounds (nine of 12 vs two of 12, p = 0.002). In the wound excision group, tumor metastases arose preferentially in the excised port site wound. CONCLUSION: This study suggests that excision of laparoscopy port site wounds following laparoscopic surgery for cancer does not prevent the subsequent development of port site tumors. Furthermore, the excision of port sites may actually increase the risk of tumor metastases arising in port sites, suggesting that the clinical application of this strategy should be avoided pending further evaluation.

Laparoscopic fundoplication for patients with symptoms but no objective evidence of gastroesophageal reflux.

In general terms, all patients who undergo a laparoscopic fundoplication procedure should have objective evidence of gastroesophageal reflux. However, occasionally patients without objective evidence of reflux disease are referred for surgery. This study assessed the outcome of a highly selected group of patients who underwent laparoscopic fundoplication without objective evidence of reflux at either preoperative endoscopy or pH monitoring. Data from all patients undergoing laparoscopic fundoplication in our department over a 9-year period from December 1991 to January 2001 were collected prospectively. From a total of 1,003 patients, a subgroup of 15 patients was identified who had no evidence of ulcerative oesophagitis at endoscopy or abnormal reflux on 24-h pH monitoring. Eight of these patients had typical symptoms of reflux (four had predominantly heartburn, four had predominantly volume regurgitation) and seven patients had atypical symptoms such as cough, bloating, chest pain, or sore throat. All patients had tried medication for acid suppression before surgery, with five gaining little or no benefit. The mean acid exposure time was 2% (range 0.1-3.6%). A correlation between typical symptoms and reflux events of over 50% was noted in three patients. All patients underwent laparoscopic fundoplication, with one conversion to an open procedure. Mean patient satisfaction score (0-10 linear score) was 8.7 at 3 months and 1 year postoperatively. Three patients failed to improve following surgery. These three all had atypical symptoms, a symptom correlation of less than 50% with acid reflux on pH monitoring, and two of the three had a poor response to medication. All other patients benefited symptomatically from surgery. We concluded that the absence of objective evidence of reflux should not always preclude patients from a laparoscopic fundoplication. Carefully selected patients with typical reflux symptoms can have a good outcome. However, patients who do not have typical symptoms and who respond poorly to acid suppression are not likely to benefit from surgery.

Adult small bowel Dieulafoy lesion.

A 47 year old woman presented with melaena and haemodynamic instability. Preliminary investigations failed to locate the source of bleeding. At laparotomy an arteriovenous malformation was identified in the distal ileum. Histology revealed this to be of the Dieulafoy type. This is the first published case of a histologically proved ileal Dieulafoy lesion in an adult.

Double blind, randomised, placebo controlled study of a platelet activating factor antagonist, lexipafant, in the treatment and prevention of organ failure in predicted severe acute pancreatitis.

BACKGROUND: Platelet activating factor (PAF) is believed to amplify the activity of key mediators of the systemic inflammatory response syndrome (SIRS) in acute pancreatitis, resulting in multiorgan dysfunction syndrome. We tested the hypothesis that a potent PAF antagonist, lexipafant, could dampen SIRS and reduce organ failure in severe acute pancreatitis. METHODS: We conducted a randomised, double blind, placebo controlled, multicentre trial of lexipafant (100 mg/24 hours intravenously for seven days commenced within 72 hours of the onset of symptoms) involving 290 patients with an APACHE II score >6. Power calculations assumed that complications would be reduced from 40% to 24%. Secondary end points studied included severity of organ failure, markers of the inflammatory response, and mortality rate. FINDINGS: Overall, 80/138 (58%) patients in the placebo group and 85/148 (57%) in the lexipafant group developed one or more organ failures. The primary hypothesis was invalidated by the unexpected finding that 44% of patients had organ failure on entry into the study; only 39 (14%) developed new organ failure. Organ failure scores were reduced in the lexipafant group only on day 3: median change -1 (range -4 to +8) versus 0 (-4 to +10) in the placebo group (p=0.04). Systemic sepsis affected fewer patients in the lexipafant group (13/138 v 4/148; p=0.023). Local complications occurred in 41/138 (30%) patients in the placebo group and in 30/148 (20%) in the lexipafant group (20%; p=0.065); pseudocysts developed in 19 (14%) and eight (5%) patients, respectively (p=0.025). Deaths attributable to acute pancreatitis were not significantly different. Interleukin 8, a marker of neutrophil activation, and E-selectin, a marker of endothelial damage, decreased more rapidly in the lexipafant group (both p<0.05); however, absolute values were not different between the two groups. INTERPRETATION: The high incidence of organ failure within 72 hours of the onset of symptoms undermined the primary hypothesis, and power calculations for future studies in severe acute pancreatitis will need to allow for this. Lexipafant had no effect on new organ failure during treatment. This adequately powered study has shown that antagonism of PAF activity on its own is not sufficient to ameliorate SIRS in severe acute pancreatitis

Early increase in intestinal permeability in patients with severe acute pancreatitis: correlation with endotoxemia, organ failure, and mortality.

Sepsis accounts for 80% of deaths from acute pancreatitis. This study aimed to investigate early changes in intestinal permeability in patients with acute pancreatitis, and to correlate these changes with subsequent disease severity and endotoxemia. The renal excretion of enterally administered polyethylene glycol (PEG) 3350 and PEG 400 was measured within 72 hours of onset of acute pancreatitis to determine intestinal permeability. Severity was assessed on the basis of APACHE II scores and C-reactive protein measurements. Serum endotoxin and antiendotoxin antibodies were measured on admission. Eight-five patients with acute pancreatitis (mild in 56, severe in 29) and 25 healthy control subjects were studied. Urinary excretion of PEG 3350 (median) was significantly greater in patients who had severe attacks (0.61%) compared to those with mild disease (0.09%) and health control subjects (0.12%) (P <0. 0001), as was the permeability index (PEG 3350/400 excretion) (P <0. 00001). The permeability index was significantly greater in patients who subsequently developed multiple organ system failure and/or died compared with other severe cases (0.16 vs. 0.04) (P = 0.0005). The excretion of PEG 3350 correlated strongly with endotoxemia (r = 0.8; P = 0.002). Early increased intestinal permeability may play an important role in the pathophysiology of severe acute pancreatitis. Therapies that aim to restore intestinal barrier function may improve outcome.