Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy.

This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.

Trends in the management of esophageal carcinoma based on provider volume: treatment practices of 618 esophageal surgeons.

Controversy exists regarding optimal treatment practices for esophageal cancer. Esophagectomy has received focus as one of the index procedures for both hospital and surgical quality despite a relative paucity of controlled trials to define best practices. A survey was created to determine the degree of heterogeneity in the treatment of esophageal cancer among a diverse group of surgeons and to use high-volume (HV) (>/=15 cases/year) and low-volume (LV) (<15 cases/year) designations to discern specific differences in the management of esophageal cancer from the surgeon's perspective. Based on society rosters, surgeons (n = 4000) in the USA and 15 countries were contacted via mail and queried regarding their treatment practices for esophageal cancer using a 50-item survey instrument addressing demographics, utilization of neoadjuvant chemoradiotherapy, and choice of surgical approach for esophageal resection and palliation. There were 618 esophageal surgeons among respondents (n = 1447), of which 77 (12.5%) were considered HV. The majority of HV surgeons (87%) practiced in an academic setting and had cardiothoracic training, while most LV surgeons were general surgeons in private practice (52.3%). Both HV and LV surgeons favored the hand-sewn cervical anastomosis and the stomach conduit. Minimally invasive esophagectomy is performed more frequently by HV surgeons when compared with LV surgeons (P = 0.045). Most HV surgeons use neoadjuvant therapy for patients with nodal involvement, while LV surgeons are more likely to leave the decision to the oncologist. With a few notable exceptions, substantial heterogeneity exists among surgeons' management strategies for esophageal cancer, particularly when grouped and analyzed by case volume. These results highlight the need for controlled trials to determine best practices in the treatment of this complex patient population.

Diagnostic laparoscopy for patients with potentially resectable pancreatic adenocarcinoma: is it cost-effective in the current era?

INTRODUCTION: For patients with potentially resectable pancreatic cancer, diagnostic laparoscopy may identify liver and peritoneal metastases that are difficult to detect with other staging modalities. The aim of this study was to utilize a population-based pancreatic cancer database to assess the cost effectiveness of preoperative laparoscopy. MATERIAL AND METHODS: Data from a state cancer registry were linked with primary medical record data for years 1996-2003. De-identified patient records were reviewed to determine the role and findings of laparoscopic exploration. Average hospital and physician charges for laparotomy, biliary bypass, pancreaticoduodenectomy, and laparoscopy were determined by review of billing data from our institution and Medicare data for fiscal years 2005-2006. Cost-effectiveness was determined by comparing three methods of utilization of laparoscopy: (1) routine (all patients), (2) case-specific, and (3) no utilization. RESULTS AND DISCUSSION: Of 298 potentially resectable patients, 86 underwent laparoscopy. The prevalence of unresectable disease was 14.1% diagnosed at either laparotomy or laparoscopy. The mean charge per patient for routine, case-specific, and no utilization of laparoscopy was $91,805, $90,888, and $93,134, respectively. CONCLUSION: Cost analysis indicates that the case-specific or routine use of laparoscopy in pancreatic cancer does not add significantly to the overall expense of treatment and supports the use of laparoscopy in patients with known or suspected pancreatic adenocarcinoma.

Psychiatric illness delays diagnosis of esophageal cancer.

Evidence suggests that patients with psychiatric illnesses may be more likely to experience a delay in diagnosis of coexisting cancer. The association between psychiatric illness and timely diagnosis and survival in patients with esophageal cancer has not been studied. The specific aim of this retrospective cohort study was to determine the impact of coexisting psychiatric illness on time to diagnosis, disease stage and survival in patients with esophageal cancer. All patients with a diagnosis of esophageal cancer between 1989 and 2003 at the Portland Veteran's Administration hospital were identified by ICD-9 code. One hundred and sixty patients were identified: 52 patients had one or more DSM-IV diagnoses, and 108 patients had no DSM-IV diagnosis. Electronic charts were reviewed beginning from the first recorded encounter for all patients and clinical and demographic data were collected. The association between psychiatric illness and time to diagnosis of esophageal cancer and survival was studied using Cox proportional hazard models. Groups were similar in age, ethnicity, body mass index, and history of tobacco and alcohol use. Psychiatric illness was associated with delayed diagnosis (median time from alarm symptoms to diagnosis 90 days vs. 35 days in patients with and without psychiatric illness, respectively, P < 0.001) and the presence of advanced disease at the time of diagnosis (37% vs. 18% of patients with and without psychiatric illness, respectively, P= 0.009). In multivariate analysis, psychiatric illness and depression were independent predictors for delayed diagnosis (hazard ratios 0.605 and 0.622, respectively, hazard ratio < 1 indicating longer time to diagnosis). Dementia was an independent risk factor for worse survival (hazard ratio 2.984). Finally, psychiatric illness was associated with a decreased likelihood of receiving surgical therapy. Psychiatric illness is a risk factor for delayed diagnosis, a diagnosis of advanced cancer, and a lower likelihood of receiving surgical therapy in patients with esophageal cancer. Dementia is associated with worse survival in these patients. These findings emphasize the importance of prompt evaluation of foregut symptoms in patients with psychiatric illness.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing.

BACKGROUND: For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans. METHODS: The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting. RESULTS: The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods. CONCLUSION: According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Serum leptin levels, hepatic leptin receptor transcription, and clinical predictors of non-alcoholic steatohepatitis in obese bariatric surgery patients.

BACKGROUND: Non-alcoholic steatohepatitis (NASH) is a major cause of liver disease in morbidly obese patients. Clinical predictors of NASH remain elusive, as do molecular mechanisms of pathogenesis. METHODS: A series of 35 morbidly obese patients undergoing bariatric surgery had a liver biopsy performed for standard histologic analysis. In addition, RNA was obtained from liver tissue and analyzed for leptin receptor gene expression. Regression analysis was used to correlate clinical variables, including serum leptin levels and hepatic leptin receptor gene expression, with the presence of histologically confirmed NASH. RESULTS: Of the 35 subjects enrolled, 29% had steatosis only, 60% had NASH, and 11% had normal liver histology. Among the clinical variables studied, only diabetes mellitus was an independent predictor of NASH. There was a trend toward lower levels of mRNA encoding the long form of the leptin receptor in hepatic tissue from patients with NASH compared to those with steatosis only. CONCLUSIONS: Diabetes mellitus is associated with an increased risk of NASH in obese patients. Downregulation of hepatic leptin receptor may play a role in the pathogenesis of NASH.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury.

OBJECTIVE: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. METHODS: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. RESULTS: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. CONCLUSIONS: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Ten-year trend in the national volume of bile duct injuries requiring operative repair.

BACKGROUND: The objectives of this study were to determine the national proportions and mortality rate for bile duct injuries resulting from laparoscopic cholecystectomy (LC) that required operative reconstruction for repair over a 10-year period and to investigate the major factors associated with the mortality rate in this group of patients. METHODS: Using the Nationwide Inpatient Sample (NIS) of >7 million patient records per year, we extracted and analyzed data for LC during the years 1990-2000. Procedures that involved biliary reconstructions performed as part of another primary procedure were excluded. Using the Statistical Package for the Social Sciences (SPSS), we used procedure-specific codes that enabled us to calculate national estimates for LC for the time period under review. We then calculated biliary reconstruction procedures that occurred after LC for this cohort of patients. Finally, we analyzed in-hospital mortality, as well as the patient, institutional, and outcome characteristics associated with biliary reconstructions. RESULTS: The percentage of cholecystectomies performed laparoscopically has increased over the years for which data are available (from 52% in 1991 to 75% in 2000). Despite this increase, the mortality rate for this group of patients has remained consistently low over the study period (mean, 0.45%; range 0.33-0.58%). Within this group of patients, the average rate of bile duct injuries requiring operative repair was 0.15% for the years under study. The reconstruction rates ranged from 0.25% in 1992 to 0.09% in 1999. For 2000, the most recent year for which data are available, biliary reconstruction was performed in 0.10% of all patients who underwent LC. The average mortality rate for patients undergoing biliary reconstruction for the years 1991 to 2000 was 4.5%. After multivariate analysis, age, African American ethnicity, type of admission, source of admission, and hospital location, and teaching status were all found to correlate significantly with death after-biliary reconstruction. CONCLUSIONS: These data show an increase in the percentage of cholecystectomies performed laparoscopically over the years under study and an associated low mortality rate. In contrast, although the number of bile duct injuries appears to be decreasing, these procedures continue to be associated with a significant mortality rate.

Effects of dietary energy during gestation and lactation on reproductive performance of sows: a cooperative study. S-145 Committee on Nutritional Systems for Swine to Increase Reproductive Efficiency.

A cooperative experiment involving 999 litters was conducted at seven stations to assess the reproductive performance of gilts and sows fed different levels of energy during gestation and lactation (21 d) for three consecutive parities. Treatments consisted of two gestation (G) and two lactation (L) diets in a 2 x 2 factorial arrangement. Gestation treatments were diets fed to provide normal (5.9 Mcal/d, NG) or high (7.4 Mcal/d, HG) energy intake; lactation treatments were diets that contained 0 (NL) or 9% added fat (HL). Sows were provided ad libitum access to feed during the lactation period. Feeding the higher energy level during gestation increased pig birth weight (P < .01) and pig weight gain to weaning (P < .01). Sows that had been fed the higher level of energy during gestation (HG) ate less feed during lactation (P < .01) and lost more weight during lactation (P < .01). Increasing lactation energy intake by adding fat resulted in greater pig weight gains to 21 d of age (P < .01). Sows fed the HG-NL combination had fewer pigs on d 21 than all other treatment groups (G x L; P < .01). There was a G x L x parity interaction (P < .05) for days to estrus after weaning. Sows on the NG-HL or HG-NL treatments had increased days to estrus in Parity 1 (P < .05), whereas those on the NG-NL treatments had increased days to estrus in Parities 2 and 3 (P < .05). The HG-HL treatment minimized days to postweaning estrus during the three-parity study.(ABSTRACT TRUNCATED AT 250 WORDS)

Reproductive performance of sows fed elevated calcium and phosphorus levels during growth and development.

A cooperative regional study (S-145) involving 586 farrowings was conducted at five state experiment stations (Georgia, Mississippi, South Carolina, Tennessee and Virginia) to determine the influence of feeding elevated Ca and P levels during growth and development on general reproductive efficiency and longevity of confined, housed females kept for three consecutive parities. Two dietary Ca and P levels (100 vs 150% of 1979 NRC-recommended amounts) were fed ad libitum from weaning to 100 kg. A diet containing .8% Ca and .6% P was limit-fed to all gilts and to all sows during gestation and lactation. Growth rate and feed efficiency from weaning to 100 kg were similar (P greater than .10) for gilts fed 100 vs 150% Ca and P levels. A similar total number of litters (292 vs 294) was farrowed by each previous treatment group. From the previously-fed-100% Ca and P group, 78 and 65% of the sows that completed the first parity completed the second and third farrowing, respectively. Similarly, from the previously-fed-150% Ca and P group, 81 and 57% completed the second and third farrowing, respectively. Across all locations, total pigs born, live pigs born, stillborns, birth weight, number and weight of pigs at 21 d of age, sow weight at 110 d of gestation and at weaning did not differ (P greater than .10) between the two previously fed sow groups. There were significant location and farrowing effects, but most two-way interactions with Ca and P levels were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)