Minimally invasive oesophagectomy for cancer in patients with HIV/AIDS: considerations and future directions.

The impact of HIV/AIDS on the treatment of oesophageal neoplasms remains undefined due to a lack of adequate data. We present our experience in treating patients with HIV/AIDS who have oesophageal cancer using minimally invasive techniques and discuss important key factors during perioperative management. Two men with HIV/AIDS underwent minimally invasive oesophagectomies in our department, with adequate clinical and oncological outcomes. Minimally invasive oesophagectomy can be safe and has the well-established benefits of minimally invasive techniques, offering good perioperative results and oncological outcomes in patients with HIV/AIDS. Multimodality therapy is crucial.

High mortality rate of oesophageal perforation is associated with delayed hospital admission : a prospective observational case series study.

BACKGROUND: To assess mortality rate of oesophageal perforation cases and study their etiology, diagnosis and management in a single specialized UK centre. PATIENTS AND METHODS: A prospective observational study was performed between January 2012 and January 2015. All consecutive patients admitted with acute iatrogenic or spontaneous esophageal perforation were included. Anastomotic leak patients were excluded. Patients were managed conservatively, endoscopically, surgically or with a combination of the above. Primary outcome was mortality rate and its association with time to hospital admission. Secondary outcomes were nature of perforation, anatomic location, type of management as well as length of hospital stay and surgical complication rate. RESULTS: There were 13 cases included. Mean patients' age was 58.3 years. Overall 90-day mortality rate was 38.4% (n=5), while 30-day mortality rate 30.8% (n=4). Admission within 24 hours of perforation was recorded in 69.2% of patients (n=9). The main anatomic location of perforation was the lower third of the esophagus in 53.8% (n=7). Operative management was adopted in 53.8% of cases (n=7). Mean hospital stay was 58.3 days. Mean follow-up was 3.1 years, while no patient developed any complication from the perforation or surgery. CONCLUSIONS: Mortality following esophageal perforation is at approximately 40%, while there is a significant impact of time of presentation on prognosis.

Minimally invasive oesophagectomy and emerging complications: intercostal lung hernia.

Lung herniation is a rare entity, defined as a protrusion of the lung above the normal confines of thorax; it is caused by increased intrathoracic pressure and defects or weakness of the chest wall. Intercostal lung hernia can occur spontaneously or following thoracic trauma or surgery. Postoperative hernias are more commonly associated with less extensive surgical procedures, such as thoracoscopic surgery or mini-thoracotomy incisions, rather than with major thoracic procedures. We describe the first reported case of postoperative intercostal lung hernia following two-stage totally minimally invasive oesophagectomy for cancer, together with its successful surgical repair.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review.

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Is sentinel node biopsy reliable in large breast tumors?

PURPOSE: The value of sentinel lymph node biopsy (SNB) in patients with larger breast tumors (diameter > 3 cm) has been questioned due to high false-negative rates reported from initial studies. The aim of this study was to analyze the safety and prognostic reliability of SNB in this group of patients. METHODS: During a 6-year period (2001-2007), 84 women with mean age 51.7 +/- 11.6 years diagnosed with a breast tumor larger than 3 cm in diameter on pathological analysis were retrospectively identified from the database of our institution. Sentinel node identification was performed after injection of blue dye subcutaneously at the subareolar area. The sentinel node specimen was sent for frozen section analysis. Regardless of the SNB results, all patients underwent completion axillary clearance. RESULTS: Breast surgery consisted of mastectomy in 62 patients (73.8%) and partial mastectomy in 22 patients (26.2%). There were 69 invasive ductal cancers (82.1%), 14 lobular cancers (16.6%) and one case of anaplastic carcinoma (1.3%). Nine tumors (10.7%) were identified to be multifocal after the histopathological report. The mean number of sentinel nodes removed was 1.5 +/- 0.7 (range 1-4) while SNB detection was not feasible in three patients (3.6%). Of 56 positive SNBs, seven (12.5%) were not identified by routine hematoxylin and eosin staining during frozen section analysis but were detected by subsequent immunohistochemistry on the final histopathological report. All patients with multifocal tumors presented nodal metastases on pathological analysis (100%), while the rate of nodal metastatic disease in patients with unifocal tumors was 16% (12 patients), although no statistical significance was documented. The overall false-negative rate, defined as the percentage of all node-positive tumors in which the SNB was negative, was 14.3%. The false-negative rate was significantly higher for the group of patients with multifocal tumors (55.5%) compared to the group with unifocal tumors (9.3%) (p < 0.001). CONCLUSIONS: The present study indicates that sentinel node biopsy is feasible in patients with larger breast tumors (max. diameter > 3 cm), with comparable false-negative and sentinel detection rates (14.3% and 96.4%, respectively). Larger tumor size seems to be associated with increased incidence of nodal metastases while multifocality appears to be related to increased false-negative rates; hence completion axillary clearance should be initially considered for these cases.