Long-term survivors of esophageal cancer: disease-specific quality of life, general health and complications.

INTRODUCTION: The aim of our study was to assess the quality of life as well as secondary cancers/diseases and esophagectomy-related or unrelated interventions in the long-term course of surgery. PATIENTS AND METHODS: Out of 417 patients who underwent esophageal resection for cancer between September 1985 and November 2003, 85 were defined as long-term survivors (≥5 years). Fifty patients still alive in November 2008 complied with our inclusion criteria. The general (QLQ-C 30, version 3.0) as well as the esophagus specific quality of life (QLQ-OES 18) were analyzed with the help of the EORTC QLQ-questionnaires. RESULTS: The median observation interval since the operation was 100.1 (range 60-238) months. A median Global Health Status of quality of life (EORTC QLQ-C 30) of 66.7 was found (range 16.7-100). Among the functioning scores, emotional (83.3 (range 16.7-100)) and cognitive functioning (83.3 (range 0-100)) were highest. The esophagus-specific quality of life (EORTC QLQ-OES 18) revealed a median value (scale 0-100) of 0 each for dysphagia and difficulties with swallowing saliva, whilst reflux was a major problem with a score of 50.0 (range 0-100). CONCLUSION: Our results show that long-term survival with a good quality of life is possible after curative esophagectomy for carcinoma.

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining.

BACKGROUND: It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer. METHODS: We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1-3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, localization, surgical technique (transhiatal/transthoracic), grading, pT1-subclassification (pT1a, pT1b sm 1-3), pL-, pV-status, and D2-40 labeling. Simple regression was applied for the following continuous predictors: age and tumor size. All significant variables of univariate analysis were included in the multivariate analysis. For this purpose, we used the General Liner Models's analysis (forward stepwise). In a third step, the Kruskal-Wallis test with post hoc comparisons was intended to define the cut-off value of parameters tested. RESULTS: Only the following variables gained statistical significance in univariate analysis: sex, histological tumor type, grading, pT1-subclassification, lymphatic infiltration, microvascular infiltration, D2-40 immunostaining, and tumor size (P < 0.05). Variables reaching significance in multivariate analysis were tumor size (P = 0.017) and pV-status (P = 0.037). In the Kruskal-Wallis test with post hoc comparisons, the cut-off value of tumor size was 2 cm (model P = 0.002) and between the categories (P < 0.05). CONCLUSIONS: Lymph node positivity and lymphatic vessel infiltration did not linearly increase with sm tumor infiltration depth. The risk category of lymph node involvement in superficial esophageal cancer exists according to our prediction model on the basis of tumor size of >2 cm and microvascular infiltration. The hitherto common sm levels 1-3 classification of submucosal cancers appears to display a lesser impact than previously assumed with regard to prediction of potential lymph node metastases and consequently the indication for endoscopic or surgical therapy.

Three different types of surgeon-specific stress reactions identified by laparoscopic simulation in a virtual scenario.

BACKGROUND: Minimally invasive surgery causes higher mental strain for surgeons than conventional surgery and is significantly more stressful in consecutive cases. This study aimed to investigate whether individual stress responses are associated with intraoperative alterations of manual surgical skills and technical errors of the laparoscopic surgeon. METHODS: The LapSim virtual reality simulator was used. Stress measurement was carried out for 18 surgeons performing a virtual cholecystectomy using the LapSim simulator in the context of the patient simulator provided by the METI Corporation. In the course of the study, the surgeons were exposed to different external stressors (S1-S4) in defined intervals. The activity of the sympathetic nervous system was evaluated by skin resistance with the help of a sympathicograph. RESULTS: Three different surgeon-specific stress reactions (SSR) could be identified. The first, SSR-1, with significant stress reactions during the study without recovery, showed larger laparoscopic extensions of movement but fewer intraoperative complications than SSR-2 (recovery after the stress reactions) or SSR-3 (without significant stress reactions). CONCLUSIONS: The mental load of the laparoscopic surgeon might be highly optimized by continuous activity of the sympathetic nervous system. The question of what extent or quality of stress produces adverse effects remains unclear.

Developments in esophageal surgery for adenocarcinoma: a comparison of two decades.

BACKGROUND: The objective of this study was to examine outcomes in patients undergoing esophageal resection for adenocarcinoma at our institution during a 20-year period and, in particular, to address temporal trends in long-term survival. METHODS: Out of 470 patients who underwent esophagectomy for malignancy between September 1985 and September 2005, a total number of 175 patients presented with esophageal adenocarcinoma. Patients enrolled in this study included AEG (adenocarcinoma of the esophagogastric junction) type I tumors only. Time trends were studied comparing two decades, 9/1985 to 9/1995 (DI) and 10/1995 to 9/2005 (DII). RESULTS: The overall survival was significantly more favourable in patients undergoing esophageal resection for adenocarcinoma in the recent time period (DII, 10/1995 to 9/2005) as compared to the early time period (DI, 9/1985 to 9/1995) (log rank test: p = 0.0329). Significant differences in the recent decade were seen based on lower ASA-classifications, earlier tumor stages, and the operative procedure with a higher frequency of transhiatal resections (p < 0.05). 30-day mortality improved from 8.3% to 3.1% during the 20-year time-interval, thus without statistical significance. CONCLUSION: Based on our experience, overall survival is improving over time for adenocarcinoma of the esophagus. Factors that may play an important role in this trend include early diagnosis and improved patient selection through better preoperative staging, improved surgical technique with a tailored approach carefully evaluated by physiologic patient status, comorbidity and tumor extent.

Impact of laparoscopic adjustable gastric banding on obesity co-morbidities in the medium- and long-term.

BACKGROUND: The authors evaluated the impact of laparoscopic adjustable gastric banding (LAGB) on obesity-associated diseases in a series at 3 to 8 years postoperatively, namely diabetes, pulmonary disease, hypertension and knee joint pain. METHODS: 145 morbidly obese patients underwent LAGB with mean age 38 years and preoperative BMI 48.5 kg/m2 (range 34-77). Changes in BMI and excess BMI loss (EBL) were evaluated. RESULTS: 138 of the 145 patients (95%) were available for full follow-up. At last follow-up, BMI had dropped to 34.0 +/- 6.4 SD kg/m2, and mean EBL was 61.9 +/- 26.1%. Prevalence of obesity-associated disease was significantly reduced: diabetes decreased from 10% to 4%, treatment-requiring pulmonary disease from 15% to 5%, hypertension from 43% to 27%, and knee pain from 47% to 38%. CONCLUSION: Following gastric banding, >75% of patients suffering from obesity-related disease had significant decrease or resolution of their co-morbidities.

The value of scoring achalasia: a comparison of current systems and the impact on treatment--the surgeon's viewpoint.

Heller myotomy in patients with achalasia promises better long-term success than pneumatic dilation, especially in younger patients, and therefore has evolved as the primary treatment option. The aim of this study was to evaluate the impact of different disease-specific severity scores on achalasia treatment. Fifty consecutive patients undergoing pneumatic dilation (n = 25) or myotomy (n = 25) were assessed pre- and postinterventionally by clinical evaluation using the Eckardt Score, the Vantrappen Classification, and the Adams's Stages, as well as by radiologic and manometric studies and by subjective evaluation. The Eckardt Score and the Vantrappen Classification correlated significantly with each other. The Eckardt Score, because of its widest range and interval-level measurement properties converting the score to the Eckardt Stages, tends toward being the most useful system for clinical practice. The indication for myotomy or dilation therapy can not be set by a specific cut-off point in any system and remains an individual decision, including the aspects of the patient's age and failed prior options.

[Rectal carcinoma: is too much neoadjuvant therapy performed? Proposals for a more selective MRI based indication]. / Rektumkarzinom: Behandeln wir zu häufig neoadjuvant? Vorschläge zu einer selektiveren, MRT-basierten Indikation.

The present-day optimised surgery (concept of total mesorectal excision) with quality assurance by standardized pathologic examination, advances in radiotherapy and the possibilities of high-spatial-resolution MR imaging require reconsideration of pros and contras of neoadjuvant therapy and respective data. According to the resulting new proposal neoadjuvant long-course radiochemotherapy is indicated for patients with 1) fixed questionably R0 resectable tumors, 2) mobile tumors with the MRT finding of tumor involving the mesorectal fascia or 1 mm or less from it, 3) low rectal tumors extending below the levator origin and invading beyond the muscularis propria. If a high risk of local recurrence becomes apparent during surgery (tumor perforation, incision into or through tumor) or after pathologic examination (incomplete mesorectal excision, tumor 1 mm or less from the circumferential resection margin) adjuvant radiochemotherapy is indicated. In case of lymph node metastasis postoperative chemotherapy is given.

[Achalasia in circumscribed scleroderma]. / Achalasie bei zirkumskripter Sklerodermie.

HISTORY: A 38-year-old man had been suffering from circumscribed scleroderma for 12 years. Dysphagia had been diagnosed 5 years ago and for the last 2 years he had retrosternal dysphagia for solid and liquid food. His symptoms had increased markedly 6 months before presenting at our hospital and the patient had lost 15 kg of weight. 2 months ago, a percutaneous endoscopic gastrostomy (PEG) had been inserted at another hospital. INVESTIGATIONS: The patient presented in a reduced general and nutritional state. The routine laboratory tests and tumor markers were within normal range. Endoscopy showed a moderately dilated esophagus with food remnants. It was not possible to pass the cardia without exerting pressure. Esophageal manometry and barium upper gastrointestinal series revealed the classical findings of achalasia. THERAPY AND COURSE: An extramucosal Heller myotomy with anterior semifundoplication (Dor's procedure) was performed. The postoperative course was uneventful and the patient was able to take solid and liquid food without any dysphagia. CONCLUSION: The association of achalasia and circumscribed scleroderma has not been described in medical publications yet. The entity could possibly be based on common autoimmune mechanisms and an analogous pathogenesis with resulting fibrosis.

Changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy in patients with Conn's syndrome.

BACKGROUND: Primary hyperaldosteronism caused by an aldosterone-producing adenoma of the adrenal gland is regarded as the most common type of endocrine hypertension. The aim of this study was to analyze the changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy recorded in patients with Conn's syndrome compared to patients with hormone-inactive incidentaloma and its possible influence by the surgical approach. METHODS: From February 1994 to March 2004, 40 patients underwent endoscopic adrenalectomy for Conn's syndrome. All patients had arterial hypertension over a median period of 84 (5-240) months and were pretreated with an aldosterone antagonist in 76.3% and with specific antihypertensive medication in 85%. Over the same period of time, endoscopic adrenalectomy was carried out in 80 patients with incidentaloma. Of these, 41 (53.2%) displayed arterial hypertension requiring drug therapy. RESULTS: The adrenal gland was resected using the retroperitoneal in 25 and the transperitoneal approach in 15 patients with Conn's syndrome. Conversion to an open procedure was required in two patients. Intraoperative increases in blood pressure necessitating antihypertensive therapy were observed in 17 of 40 patients (44.7%), in 11 of 40 patients (28.9%) blood pressure peaks of >200 mmHg (> 1 min) were noted. Differences between the preoperative and maximum intraoperative blood pressure were significant for the retroperitoneal approach only (systolic: p = 0.0001; diastolic: p = 0.0005), but not for the transperitoneal technique. The increase in intraoperative blood pressure in patients with Conn's syndrome was significantly higher, for both systolic (p < 0.0001) and diastolic (p = 0.0037) readings, compared to that in patients with incidentaloma undergoing endoscopic adrenalectomy during the same period of time. CONCLUSION: Our results demonstrate that relevant intraoperative increases in blood pressure occur in patients with Conn's syndrome despite prior therapy with an aldosterone antagonist, necessitating specific precautionary measures during anesthesia. Intraoperative blood pressure was significantly higher for the retroperitoneal than for the transperitoneal procedure, which leads us to advocate the latter approach for endoscopic adrenalectomy.

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course.

BACKGROUND: Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma. METHODS: Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed. RESULTS: There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (> 1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05). CONCLUSION: After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.

Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma.

BACKGROUND: The aim of this study was to report the frequency of post-operative recurrent laryngeal nerve paralysis (RLNP) following resection for esophageal carcinoma. PATIENTS AND METHODS: Four hundred and four patients were studied. Diagnosis of post-operative RLNP was performed by indirect laryngoscopy. Tumour characteristics, surgical approach and perioperative morbidity and mortality following esophageal resection were recorded. RESULTS: Sixty patients were diagnosed with post-operative RLNP, of whom 47 had a unilateral and 16 a bilateral lesion. RLNP was more frequently diagnosed after transhiatal resection with cervical esophagogastrostomy as compared to abdomino-thoracic resection (p=0.06). A higher rate of post-operative pneumonia was evident in patients with RLNP (33 of 63 as opposed to 90 of 341; p=0.027). CONCLUSION: RLNP is associated with a significant morbidity, especially pulmonary complications after resection of esophageal cancer.

[Quality of life after subtotal resection and gastrectomy for gastric cancer]. / Lebensqualität nach subtotaler Magenresektion und Gastrektomie beim Magenkarzinom.

Recently, quality of life has become a main objective in surgical therapy. Apart from the oncological consequences, the quality of results after gastric carcinoma resection are mainly determined by social and psychological aspects of life, early postoperative complications, and long-term nutritive/functional parameters. Of 338 patients who underwent gastric resection for adenocarcinoma of the stomach, quality of life was assessed in 73 recurrence-free patients by means of the Gastrointestinal Life Quality Index (GLQI). The median age was 71.9 years, and surgery had been carried out at least 1 year prior to the investigation (median follow-up 4.5 years). Patients with subtotal gastric resection displayed significantly higher GLQI scores (120 [97-138] points) than patients with gastrectomy (116 [70-139] points;p=0.047). Among partial parameters of the life quality index, physical functions were significantly better after subtotal resection (p=0.040), while the emotional status (p=0.147) and social activities (p=0.337) did not differ between the two groups. Abdominal symptoms (p=0.081) and the nutritional function (p=0.228) were insignificantly different. The number of meals (4 vs. 5 meals per day) and the loss of weight since surgery (5 vs. 10 kg) were less after subtotal resection than after gastrectomy. However, the latter parameter did not reach statistical significance.

Technical alternatives in laparoscopic placement of an adjustable gastric band: experience of two German university hospitals.

BACKGROUND: The technique of laparoscopic adjustable gastric banding (LAGB), although relatively well standardized, has some "weak points". METHODS: We analysed the experience of 2 German university clinics in order to suggest technical alternatives that can be helpful in difficult situations. RESULTS: Between April 1997 and May 2002 115 patients in Cologne (87 females, 28 males) with median BMI 49.5 kg/m(2) and mean age 39 years (19-54), and 112 patients in Mainz (91 females, 21 males) with median BMI 48 kg/m(2) and mean age 35 years (18-57) underwent LAGB, using the Lap-Band. LAGB was performed through 5 ports (3 10-mm, 1 18-mm, and 1 5-mm in Cologne and 4 10-mm and 1 18-mm port in Mainz). The pars flaccida technique by means of a fan-shaped Endo-Retractor was used in both clinics. Mean duration of follow-up was 3.2 years (SD 1.0) in the Cologne group with complete investigation in all except 4 patients. In the Mainz group, mean duration of follow-up was 2.7 years (SD 1.0) with complete investigation in all except 9 patients. CONCLUSIONS: Some technical aspects such as induction of pneumoperitoneum, band position, band fixation, band malposition and port-related complications are discussed.

[Iatrogenic perforation of the esophagus during transesophageal echocardiography. A rare cause of severe dysphagia]. / Iatrogene Osophagusperforation bei transösophagealer Echokardiographie. Eine seltene Ursache schwerer Dysphagie.

HISTORY: A 65-year-old patient underwent transesophageal echocardiography which caused a perforation of the upper esophagus. Three months after esophagostomy and gastrostomy the reconstruction was accomplished by a colon interposition graft. The patient postoperatively developed an ischemic necrosis of the graft, followed by a cervical fistula. Food intake and swallowing became impossible. DIAGNOSIS: X-ray examinations revealed the cervical fistula and a stenotic colon graft. TREATMENT AND COURSE: The retrosternal colon graft was replaced by a gastric interposition graft, which was anastomosed with the cervical esophagus. The postoperative follow-up was normal at first. Increasing retention of secretion in the remaining esophagus however caused dilatation and a cervival fistula again, as well as a pleural empyema. After transthoracic resection of the esophagus the patient was finally free of symtoms, and gained weight on unrestricted food intake. CONCLUSION: Transesophageal echocardiography is a common diagnostic procedure with a low complication rate. Even though serious complications may occur in rare cases, the patient must be informed about the risk. The perforation of the esophagus is an emergency situation that requires surgical treatment immediately. Primary reconstruction and preservation of the esophagus is the recommended strategy.

Heller myotomy for failed pneumatic dilation in achalasia: how effective is it?

OBJECTIVES: This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy. METHODS: Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression. RESULTS: Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery. CONCLUSIONS: Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.

[Dolichomegaesophagus in achalasia. Therapy by esophogectomy in an aged patient]. / Dolichomegaösophagus bei Achalasie. Therapie durch Osophagusresektion bei einer alten Patientin.

HISTORY AND CLINICAL FINDINGS: A 78-year-old woman suffered from achalasia since 63 years with a progressive decompensation over the last year. 53 years ago, treatment with the Stark Dilator and 24 years ago, pneumatic dilation had been carried out. Currently, the patient presented with dysphagia for liquid and solid food, with permanent retrosternal pain and regurgitation for every meal, leading to a weight loss of 10 kg. INVESTIGATIONS: The barium esophagogram showed a marked dilation of the esophagus with retinated secretions and food. The cardia had a maximum width of 15 mm. On endoscopy, reflux esophagitis and an insufficient lower esophageal sphincter were evident. TREATMENT AND COURSE: Transhiatal esophageal resection with gastric pull-up and cervical esophagogastrostomy was performed. The postoperative course was without complications and normal alimentation could be restored with a marked improvement of preoperative symptoms. CONCLUSION: Esophageal resection and gastric pull up is the more favourable treatment option in elderly patients with decompensated achalasia and dolichomegaesophagus compared to a gastric tube for alimentation--adjusted to the individual surgical risk.

Prognostic factors for cryotherapy of colorectal liver metastases.

BACKGROUND: Cryotherapy is a local ablative treatment option for non-resectable liver tumours. We aimed to identify prognostic indicators, that may allow better selection or stratification for adjuvant therapies of patients. METHODS: Fifty-five patients had cryotherapy for colorectal liver metastases. The patient-, tumour- and operative details were recorded prospectively. Mean follow up was 24 months. A uni- and multivariate analysis for possible prognostic factors was performed. RESULTS: There was a trend towards better survival for patients with unilobar liver metastases, preoperative serum levels of carcinoembrional antigen (CEA) not exceeding 20 ng/ml and patients undergoing 'R0'-treatment. Patients with multiple or large (>4 cm) liver metastases, patients undergoing cryotherapy combined with liver resection and patients receiving blood transfusion intraoperatively, especially when exceeding 4 units packed red cells, had a significantly impaired survival in univariate analysis. In multivariate analysis (Cox regression) the amount of intraoperative blood transfusion was the only independent prognostic indicator. CONCLUSION: Intraoperative blood transfusion has a negative impact on survival following hepatic cryotherapy for colorectal liver metastases and should be avoided by refinement of surgical technique whenever possible. Patients with multiple liver metastases or metastases of more than 4 cm in size have an impaired prognosis-therefore trials of adjuvant therapies following hepatic cryotherapy for colorectal liver metastases should include number and size of metastases for stratification of patient groups.

[Surgical treatment of colorectal liver metastases]. / Chirurgische Therapie von Lebermetastasen kolorektaler Karzinome.

Resection is the only curative treatment of colorectal liver metastases proofed by a long-term follow-up. The operation is indicated if the metastases are completely removable with sufficient liver parenchyma remaining after resection and if the patient is fit for surgery. The resection is not indicated in cases with non resectable extrahepatic tumours and lymph node metastases distal the hepatoduodenal ligament. The postoperative mortality amounts to about 5 % and the 5-year-survival-rates range between 20 and 40 % depending on the selection of patients. Aims of new concepts of operative therapy are the improvement of resectability by preoperative portal vein embolization, the resection combined with local destructive methods and preoperative chemotherapy. Additionally, new drugs for adjuvant treatment after resection of metastases are studied. The interdisciplinary discussion of the course before and after therapy is essential for the individual optimal treatment.