Length of Barrett's esophagus in the presence of low-grade dysplasia, high-grade dysplasia, and adenocarcinoma.

INTRODUCTION: The identification and follow-up of ultra-short Barrett's esophagus (BE) is controversial. BE surveillance guidelines emphasize mainly on long-segment BE. However, in practice a substantial proportion of esophageal adenocarcinoma (EAC) are found close to the gastro-esophageal junction (GEJ). Our study aims to chart the length of BE when low-grade dysplasia (LGD), high-grade dysplasia (HGD) and EAC arise in BE. METHODS: Endoscopic findings from all cases with a diagnosis of LGD and HGD in BE between June 2014 and June 2019, and 100 consecutive cases of EAC diagnosed between June 2018 and August 2019, were reviewed. Additionally, 438 consecutive gastroscopies were reviewed to identify 100 cases of non-dysplastic BE. RESULTS: 99 cases of LGD and 61 cases of HGD were reviewed. LGD and HGD when diagnosed, was located in BE ≤ 1 cm in 20% and 18% cases, respectively. LGD and HGD when diagnosed, was located in BE ≤ 3 cm in 48.5% and 40.9% cases, respectively. LGD and HGD when diagnosed in BE ≤ 3 cm was found at index endoscopy in 67% and 42% cases, respectively. Of the 100 cases of EAC, only 23 had concurrent visible BE, with BE higher than the level of EAC in seven. EAC when found, had its proximal extent ≤ 1 cm from GEJ in 22% and ≤ 3 cm from GEJ in 40% cases. Of the 100 non-dysplastic BE, 53% were ≤ 1 cm and 78% were ≤ 3 cm long. CONCLUSION: Almost 20% of all dysplasia in BE occurs in BE < 1 cm. Over 40% occurs in BE < 3 cm. Similarly, 20% of EAC occurs within 1 cm of GEJ and 40% occur within 3 cm. A majority of dysplasia diagnosed within 3 cm of the GEJ is found on index endoscopy. We propose that all lengths of columnar lined epithelium above the GEJ are recognized as BE and subjected to a thorough biopsy protocol.

Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy.

BACKGROUND: Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler. METHODS: Perioperative data were extracted from a contemporaneously collected database of all consecutive esophagectomies for cancer with intrathoracic anastomoses performed in the Trent Oesophago-Gastric Unit between January 2015 and April 2018. Anastomotic techniques: circular stapled versus semi-mechanical, were evaluated and outcomes were compared. The primary outcome was anastomotic leak rate. Secondary outcomes included anastomotic stricture, overall complication rates, length of stay (LOS) and 30 day all-cause mortality. RESULTS: One hundred and fifty-nine consecutive esophagectomies with intrathoracic anastomosis were performed during the study period. There were no significant differences between the two groups in terms of age, American Society of Anaesthesiologists score, Charlson comorbidity index and neoadjuvant therapies received. Circular stapled anastomoses were performed in 85 patients, while 74 patients received a semi-mechanical anastomosis. Clavien-Dindo complications II or more were higher in the circular stapled group (p = 0.02). There were 16 (10%) anastomotic leaks overall, three (4%) in semi-mechanical group versus 13 (15%) in the circular stapled group (p < 0.019). There was no statistically significant difference between the two groups in terms of LOS, 30-day mortality or the need for endoscopic dilatation of the anastomosis at 3 months follow-up. CONCLUSION: The move from a circular stapled to a semi-mechanical intrathoracic anastomosis has been associated with a reduced postoperative anastomotic leak rate following esophagectomy for esophageal cancer.

Appendicitis in paediatric age group: correlation between preoperative inflammatory markers and postoperative histological diagnosis.

INTRODUCTION: Clinical diagnosis of appendicitis can be challenging, particularly in the paediatric age group. There is an increased risk of perforation in paediatrics; therefore, a need for sensitive and specific diagnostic tool is mandatory. AIM: The aim of this study is to evaluate the role of preoperative inflammatory markers in supporting the clinical diagnosis of appendicitis in the paediatric age group. MATERIALS AND METHODS: Retrospective study of 268 emergency paediatric appendicectomies performed in a District General Hospital in Wales, over a period of seven years (2002-2009). The data collected from hospital database include preoperative inflammatory markers, C-reactive protein (CRP) and white blood cells count (WBCC) and post-operative histology. Statistical analysis was performed using Fisher's exact test. RESULTS: The median age group in the study was 12 (2-16). 141 (53%) patients were <12 years, while 127 (47%) patients were 12-16 years old. Male : female ratio = 1 : 1 (134 each). Inflammatory markers were not done for 94 patients (35%). CRP was done for 149 cases (55.6%), while WBCC was done for 172 cases (64%). Both markers were done together for 147 cases (54.8%). Histology was positive (inflamed / gangrenous appendix) in 202 cases (75.4%). Eight cases were associated with Enterobious vermicularis infestation and one patient had carcinoid tumour. The sensitivity and specificity of CRP were 82% and 60%, respectively, with positive predictive value (PPV) of 87% (P<0.0001), while those of WBCC were 80% and 59%, respectively, with PPV of 88% (P<0.0001). The sensitivity and specificity of both markers together were 80% and 70%, respectively, with PPV= 81% (P = 3.11E-8). 94 patients (35%) had an appendicectomy operation based on clinical diagnosis alone without preoperative inflammatory markers having been tested. In 28 cases (30%) out of these, postoperative histology revealed normal appendix (P = 0.18). CONCLUSION: CRP and WBCC are simple tests that can provide a significant role supporting the clinical diagnosis of acute appendicitis in the paediatric age group.