Esophagectomy for cancer in octogenarians.

Because of changes in life expectancy, there is an increasing number of elderly patients with esophageal cancer. The aim of this study was to assess the outcome of esophagectomy for cancer in patients 80 years or older. A retrospective review was performed of the records of all patients who underwent esophagectomy for cancer from 1992 to 2007. A cardiac and pulmonary evaluation was obtained on an individual basis in the younger patients and in all octogenarians. Among 560 patients with esophagectomy for cancer, 47 patients (8%) were octogenarians. The median age of the younger group (n= 513) was 63 years (interquartile range 56-71). Octogenarians had significantly more stage III disease (49% vs 31%, P= 0.02) but received less neoadjuvant therapy than younger patients (2% vs 21%, P= 0.0004). In octogenarians, the transhiatal resection was more common than in the younger group (79% vs 36%, P < 0.0001). Weight loss prior to surgery was similar in both groups, but body mass index was significantly lower in octogenarians (25 vs 28 kg/m(2) , P= 0.0002). Major complications occurred in 26% in octogenarians and 31% in the younger group (P= 0.51). Hospital mortality was similar (9% for octogenarians vs 4% in the younger group, P= 0.13). The median postoperative hospital stay was similar at 16 days (P= 0.69). There was no difference in cancer-related survival (median survival 48.9 vs 59.3 months, P= 0.31 log-rank test). Esophagectomy can be performed safely in carefully selected octogenarians with good cardiac and pulmonary function. Patients should not be denied an esophagectomy based only on their age.

Stereotactic radiosurgery for lung cancer.

Lung cancer is the most common cause of cancer death in both men and women in the United States. Anatomic lobectomy is the standard treatment and offers the best results for curative treatment of early stage non-small cell lung cancer (NSCLC). With an aging population, a significant proportion of patients are not surgical candidates at the time of diagnosis. In medically inoperable patients, standard external beam radiation has been offered as treatment, with suboptimal results. Stereotactic radiosurgery (SRS), a term coined by Leksell describes an approach using multiple convergent beams, precise localization with a stereotactic coordinate system, and rigid immobilization. It provides precise delivery of beams from multiple collimated paths which maximizes radiation delivery to the tumor, and minimizes the exposure of normal tissue. Early results with SRS are very encouraging, and prospective trials are underway in our institution and others to evaluate its role in early stage NSCLC. In article we review the role of stereotactic radiosurgery for the treatment of lung cancer.

A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold.

INTRODUCTION: Identifying gastroesophageal reflux disease as the cause of respiratory and laryngeal complaints is difficult and depends largely on the measurements of increased acid exposure in the upper esophagus or ideally the pharynx. The current method of measuring pharyngeal pH environment is inaccurate and problematic due to artifacts. A newly designed pharyngeal pH probe to avoid these artifacts has been introduced. The aim of this study was to use this probe to measure the pharyngeal pH environment in normal subjects and establish pH thresholds to identify abnormality. METHODS: Asymptomatic volunteers were studied to define the normal pharyngeal pH environment. All subjects underwent esophagram, esophageal manometry, upper and lower esophageal pH monitoring with a dual-channel pH catheter and pharyngeal pH monitoring with the new probe. Analyses were performed at 0.5 pH intervals between pH 4 and 6.5 to identify the best discriminating pH threshold and calculate a composite pH score to identify an abnormal pH environment. RESULTS: The study population consisted of 55 normal subjects. The pattern of pharyngeal pH environment was significantly different in the upright and supine periods and required different thresholds. The calculated discriminatory pH threshold was 5.5 for upright and 5.0 for supine periods. The 95th percentile values for the composite score were 9.4 for upright and 6.8 for supine. CONCLUSION: A new pharyngeal pH probe which detects aerosolized and liquid acid overcomes the artifacts that occur in measuring pharyngeal pH with existing catheters. Discriminating pH thresholds were selected and normal values defined to identify patients with an abnormal pharyngeal pH environment.

Plasma DNA: a molecular marker of surgical insult and postoperative recovery in esophageal cancer.

AIM: To assess plasma DNA changes intraoperatively, to relate plasma DNA to the magnitude of the surgical insult and to monitor the changes during the postoperative recovery period. MATERIAL AND METHOD: Prospective study of 35 patients with esophageal cancer who had esophagectomy of different magnitudes: 19 esophagectomy without thoracotomy and 16 esophagectomy with thoracotomy. The plasma DNA was measured prior to surgery, throughout the course of the operation on four different intervals, and on postoperative days 1, 3, 5, and 7. RESULTS: A significant difference was seen in the median plasma DNA intraoperatively between the two groups: esophagectomy without thoracotomy, 507 ng/ml/min (range 211-2,708), esophagectomy with thoracotomy, median 1,098 ng/ml/min (range 295-22,284; p = 0.014). Postoperative complications were identified in 6 patients who demonstrated a significant elevation in plasma DNA on postoperative days 5 and 7. CONCLUSION: Plasma DNA increases during surgery as a result of cell damage and the rise correlates with the magnitude of surgery. The descent of plasma DNA postoperatively correlates with surgical recovery. Elevation of the plasma DNA during the postoperative period correlates with postoperative complications. Plasma DNA is an objective molecular marker of surgical insult and can be used to monitor postoperative recovery after esophagectomy.

Long-term outcome of antireflux surgery in patients with Barrett's esophagus.

OBJECTIVE: To assess the long-term outcome of antireflux surgery in patients with Barrett's esophagus. SUMMARY BACKGROUND DATA: The prevalence of Barrett's esophagus is increasing, and its treatment is problematic. Antireflux surgery has the potential to stop reflux and induce a quiescent mucosa. Its long-term outcome, however, has recently been challenged with reports of poor control of reflux and the inability to prevent progression to cancer. METHODS: The outcome of antireflux surgery was studied in 97 patients with Barrett's esophagus. Follow-up was complete in 88% (85/97) at a median of 5 years. Fifty-nine had long-segment and 26 short-segment Barrett's. Patients with intestinal metaplasia of the cardia were excluded. Fifty patients underwent a laparoscopic procedure, 20 a transthoracic procedure, and 3 abdominal Nissen operations. Nine had a Collis-Belsey procedure and three had other partial wraps. Outcome measures included relief of reflux symptoms (all), patients' perception of the result (all), upper endoscopy and histology (n = 79), and postoperative 24-hour pH monitoring (n = 21). RESULTS: At a median follow-up of 5 years, reflux symptoms were absent in 67 of 85 patients (79%). Eighteen (20%) developed recurrent symptoms; four had returned to taking daily acid-suppression medication. Seven patients underwent a secondary repair and were asymptomatic, increasing the eventual successful outcome to 87%. Recurrent symptoms were most common in patients undergoing Collis-Belsey (33%) and laparoscopic Nissen (26%) procedures and least common after a transthoracic Nissen operation (5%). The results of postoperative 24-hour pH monitoring were normal in 17 of 21 (81%). Recurrent hiatal hernias were detected in 17 of 79 patients studied; 6 were asymptomatic. Seventy-seven percent of the patients considered themselves cured, 22% considered their condition to be improved, and 97% were satisfied. Low-grade dysplasia regressed to nondysplastic Barrett's in 7 of 16 (44%), and intestinal metaplasia regressed to cardiac mucosa in 9 of 63 (14%). Low-grade dysplasia developed in 4 of 63 (6%) patients. No patient developed high-grade dysplasia or cancer in 410 patient-years of follow-up. CONCLUSIONS: After antireflux surgery, most patients with Barrett's enjoy long-lasting relief of reflux symptoms, and nearly all patients consider themselves cured or improved. Mild symptoms recur in one fifth. Importantly, dysplasia regressed in nearly half of the patients in whom it was present before surgery, intestinal metaplasia disappeared in 14% of patients, and high-grade dysplasia and adenocarcinoma were prevented in all.

The crura and crura-sphincter pressure dynamics in patients with isolated upright and isolated supine reflux.

The reason why patients with isolated supine reflux do not reflux in the upright position and patients with isolated upright reflux do not reflux in the supine position is unknown. Our objective was to determine the characteristics of the crura, lower esophageal sphincter, crura-sphincter dynamics, and esophageal body on manometry, endoscopy, and X-ray in patients with isolated upright and isolated supine reflux. Eighty consecutive patients with isolated upright reflux were compared with 82 consecutive patients with isolated supine reflux. Manometrically there was no difference in lower esophageal sphincter characteristics and esophageal contractions between the two groups. The prevalence of a hiatal hernia on manometry was similar between upright and supine refluxers (88% vs 88%). Upright refluxers had shorter hiatal hernias [median (interquartile range) 1.1 (0.65-1.8) vs 1.2 (1-2.3), P < 0.046)]. The median crural pressure, crura-sphincter pressure gradient, and crura-sphincter pressure ratio in upright refluxers was 14.96 (9.5-21.27), 3.28 (1.7-12.2), and 1.33 (0.87-2.8) mm Hg, respectively. These values were significantly higher (P < 0.001) in supine refluxers at 21.43 (16.6-29.9), 10.66 (4.3-19.7), and 2.1 (1.3-4.2) mm Hg, respectively. We conclude that the significantly higher crural pressure in patients with supine reflux acts as a mechanical ring and as a physiologic protector against the unfolding of the sphincter in the postprandial and upright periods. Higher crura-sphincter pressure gradient and larger-size hiatal hernias in patients with supine reflux results in pressurization of the hernia sac and subsequent reflux when these patients are in a supine position.