Genomic catastrophes frequently arise in esophageal adenocarcinoma and drive tumorigenesis

Oesophageal adenocarcinoma (EAC) incidence is rapidly increasing in Western countries. A better understanding of EAC underpins efforts to improve early detection and treatment outcomes. While large EAC exome sequencing efforts to date have found recurrent loss-of-function mutations, oncogenic driving events have been underrepresented. Here we use a combination of whole-genome sequencing (WGS) and single-nucleotide polymorphism-array profiling to show that genomic catastrophes are frequent in EAC, with almost a third (32%, n=40/123) undergoing chromothriptic events. WGS of 22 EAC cases show that catastrophes may lead to oncogene amplification through chromothripsis-derived double-minute chromosome formation (MYC and MDM2) or breakage-fusion-bridge (KRAS, MDM2 and RFC3). Telomere shortening is more prominent in EACs bearing localized complex rearrangements. Mutational signature analysis also confirms that extreme genomic instability in EAC can be driven by somatic BRCA2 mutations. These findings suggest that genomic catastrophes have a significant role in the malignant transformation of EAC.

A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time?

OBJECTIVE

The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it.

SUMMARY BACKGROUND DATA

Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve.

METHODS

The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience.

RESULTS

The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided.

CONCLUSIONS

A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.

Laparoscopic Nissen fundoplication

OBJECTIVE

The authors laparoscopic approach for a Nissen fundoplication is presented.

SUMMARY BACKGROUND DATA

The technique has been undertaken in 155 patients over 29 months, with 137 patients having been observed for more than 3 months.

METHODS

Three hundred sixty degree fundoplication was undertaken using three or four sutures to secure the wrap. Short gastric vessels were not divided, and the anterior wall of the stomach was used to construct the wrap around the esophagus with a large bougie in position.

RESULTS

The operation was not completed laparoscopically in 19 patients because a satisfactory wrap could not be achieved. Ten patients undergoing laparoscopic fundoplication underwent a subsequent operation related to the laparoscopic procedure within 6 months, and there was one postoperative death. Seven other patients were readmitted to the hospital several days subsequent to their discharge, four because of pulmonary emboli. Of 137 patients who have been observed for more than 3 months, 133 patients are well and currently are free from reflux symptoms.

CONCLUSIONS

In uncomplicated cases, laparoscopic fundoplication has similar advantages to laparoscopic cholecystectomy. In spite of the fact that it has not yet achieved the overall usefulness of open fundoplication, it seems likely that laparoscopic fundoplication will be used increasingly in the treatment of patients with gastroesophageal reflux disease.

Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels

OBJECTIVE

To determine whether division of the short gastric vessels (SGVs) and full mobilization of the gastric fundus is necessary to reduce the incidence of postoperative dysphagia and other adverse sequelae of laparoscopic Nissen fundoplication.

SUMMARY BACKGROUND DATA

Based on historical and uncontrolled studies, division of the SGVs has been advocated during laparoscopic Nissen fundoplication to improve postoperative clinical outcomes. However, this modification has not been evaluated in a large prospective randomized trial.

METHODS

One hundred two patients with proven gastroesophageal reflux disease presenting for laparoscopic Nissen fundoplication were prospectively randomized to undergo fundoplication with (52 patients) or without (50 patients) division of the SGVs. Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded. Patients were blinded to the postoperative status of their SGVs. Clinical assessment was performed by a blinded independent investigator who used multiple standardized clinical grading systems to assess dysphagia, heartburn, and patient satisfaction 1, 3, and 6 months after surgery. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, and distal esophageal acid exposure and radiologic assessment of postoperative anatomy were also performed.

RESULTS

Operating time was increased by 40 minutes (median 65 vs. 105) by vessel division. Perioperative outcomes and complications, postoperative dysphagia, relief of heartburn, and overall satisfaction were not improved by dividing the SGVs. Lower esophageal sphincter pressure, acid exposure, and esophageal emptying times were similar for the two groups.

CONCLUSION

Division of the SGVs during laparoscopic Nissen fundoplication did not improve any clinical or objective postoperative outcome.

Laparoscopic Nissen fundoplication: five-year results and beyond

HYPOTHESIS

Laparoscopic Nissen fundoplication provides long-term relief of symptoms of gastroesophageal reflux disease.

DESIGN

Prospectively evaluated case series.

SETTING

University teaching hospital.

PATIENTS

From September 1991 to December 1999, we performed more than 900 laparoscopic antireflux procedures. The outcome for patients who underwent surgery between September 1991 and June 1994 (178 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the first procedure onward.

INTERVENTIONS

Long-term follow-up for 5 or more years after laparoscopic Nissen fundoplication was obtained by an independent investigator who interviewed patients using a structured questionnaire.

MAIN OUTCOME MEASURES

Prospective evaluation of clinical symptoms using a structured questionnaire.

RESULTS

Outcome data covering a period of 5 or more years after surgery was available for 176 patients (99%), with 2 patients lost to follow-up. Nine patients died (8 of unrelated causes) at some stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence, questionnaire data were available for 166 patients at a median follow-up of 6 years (range, 5-8 years). Three patients (1.7%) underwent revision surgery for recurrent reflux; 87% of the 176 patients remained free of significant reflux. Reoperation was required for dysphagia in 7 patients (3.9%), 2 for a tight wrap and 5 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a paraesophageal hiatus hernia in 13 patients (7.3%). Of the reoperations, 56% were performed within 12 months of the original procedure, and 22% during the second year of follow-up. Further surgery was uncommon after 2 years. The long-term outcome was considered "good or excellent" by 90% of patients.

CONCLUSIONS

The long-term outcome of laparoscopic Nissen fundoplication is similar to that following open fundoplication. Good results are obtained in most patients.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND

In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux.

METHODS

Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed.

RESULTS

Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome.

CONCLUSION

Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

PURPOSE

As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway.

PATIENTS AND METHODS

This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation).

RESULTS

Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76).

CONCLUSION

Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

An evaluation of prognostic factors and tumor staging of resected carcinoma of the esophagus

OBJECTIVE

To evaluate prognostic factors and tumor staging in patients after esophagectomy for cancer.

SUMMARY BACKGROUND DATA

Several reports have questioned the appropriateness of the sixth edition of the International Union Against Cancer (UICC) TNM guidelines for staging esophageal cancer. Additional pathologic characteristics, besides the 3 basic facets of anatomic spread (tumor, node, metastases), might also have prognostic value.

METHODS

All patients who underwent resection of the esophagus for carcinoma between January 1995 and March 2003 were extracted from a prospective database. Univariate and multivariate analysis was performed to identify prognostic factors for survival. The goodness of fit and accuracy of 3 staging models (UICC-TNM, Korst classification, Rice classification) predicting survival were assessed.

RESULTS

A total of 292 patients (mean age, 63 years) underwent esophagectomy. The 5-year overall survival rate was 29% (median, 21 months). pT-, pN-, pm-stage, and radicality of the resection were independent prognostic factors. Subdivision of T1 tumors into mucosal and submucosal showed significant differences in 5-year survival between both groups: 90% versus 47%, respectively (P = 0.01). Subdivision of pN-stage into 3 groups based on the number of positive nodes (0, 1-2, and >3 nodes positive) or the lymph node ratio (0, 0.01-0.2, and >0.2) also refined staging (P = 0.001 and P < 0.001, respectively). The current subclassification of M1 (M1a and M1b) is not warranted (P = 0.41). The staging model of Rice was more accurate than the UICC-TNM classification in predicting survival.

CONCLUSION

This study supports the view that the current (6th edition) UICC-TNM staging model for esophageal cancer needs to be revised.

Effect of laparoscopy on immune function

BACKGROUND

Laparoscopic surgery is believed to lessen surgical trauma and so cause less disturbance of immune function. This may contribute to the rapid recovery noted after many laparoscopic operations. Preservation of both systemic and intraperitoneal immunity is particularly important in surgery for sepsis or cancer and so an understanding of the impact of laparoscopy on immune function is relevant.

METHODS

Literature on immunological changes following laparoscopy and open surgery was identified from Medline, along with cross-referencing from the reference lists of major articles on the subject.

RESULTS AND DISCUSSION

Despite a few contradictory reports, systemic immunity appears to be better preserved after laparoscopic surgery than after open surgery. However, the local intraperitoneal immune system behaves in a particular way when exposed to carbon dioxide pneumoperitoneum; suppression of intraperitoneal cell-mediated immunity has been demonstrated in a number of studies. This feature may be clinically important and should be acknowledged when considering laparoscopic surgery in patients with malignancy or sepsis.

Gasless laparoscopy may reduce the risk of port-site metastases following laparascopic tumor surgery

OBJECTIVE

To compare the incidence of port-site metastases in an experimental tumor model following tumor manipulation during laparoscopy aided by conventional insufflation with laparoscopy using a gasless technique.

SETTING

An experimental model applied in a research laboratory.

PARTICIPANTS AND INTERVENTIONS

Malignant tumors were implanted in the abdominal wall of 24 rats. Twelve rats underwent tumor laceration at laparoscopy with carbon dioxide insufflation, and 12 rats underwent the same procedure during gasless laparoscopy achieved by abdominal wall suspension. Rats were killed 1 week later and were examined for evidence of tumor metastases. The surgical wounds were examined microscopically by a histopathologist who was unaware of the operative technique used and the site of origin of the specimens.

MAIN OUTCOME MEASURE

Histologically confirmed tumor metastasis to laparoscopic port wounds.

RESULTS

Growth of the primary tumor was equal in both groups. Wound metastases were less likely in the gasless laparoscopy group (3 of 12 vs 10 of 12; P = .01, Fisher exact test).

CONCLUSION

The use of laparoscopy without gas insufflation may reduce the risk of wound metastasis following laparoscopic surgery for cancer.

Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer

BACKGROUND

Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant treatment mandate analysis of more contemporary cohorts.

METHODS

Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models.

RESULTS

A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio [OR] 1.47, P = 0.016; OR 1.35, P = 0.001) and pneumonia (OR 2.29, P = 0.002; 1.56, P = 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4, P = 0.035). Respiratory comorbidities (OR 3.81, P = 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51, P = 0.032) or respiratory failure (OR 8.7, P < 0.001), but not anastomotic leak (OR 2.22, P = 0.074), were independent risk factors for death. MIE (OR 0.11, P < 0.001) and thoracic epidural analgesia (OR 0.12, P = 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications.

CONCLUSIONS

Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.

Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial

OBJECTIVE

Determine whether absorbable or nonabsorbable mesh in repair of large hiatus hernias reduces the risk of recurrence, compared with suture repair.

BACKGROUND

Repair of large hiatus hernia is associated with radiological recurrence rates of up to 30%, and to improve outcomes mesh repair has been recommended. Previous trials have shown less short-term recurrence with mesh, but adverse outcomes limit mesh use.

METHODS

Multicentre prospective double blind randomized controlled trial of 3 methods of repair: sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome-hernia recurrence assessed by barium meal radiology and endoscopy at 6 months. Secondary outcomes-clinical symptom scores at 1, 3, 6, and 12 months.

RESULTS

A total of 126 patients enrolled: 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Among them, 96.0% were followed up to 12 months, with objective follow-up data in 92.9%. A recurrent hernia (any size) was identified in 23.1% after suture repair, 30.8% after absorbable mesh, and 12.8% after nonabsorbable mesh (P = 0.161). Clinical outcomes were similar, except less heartburn at 3 and 6 months and less bloating at 12 months with nonabsorbable mesh; more heartburn at 3 months, odynophagia at 1 month, nausea at 3 and 12 months, wheezing at 6 months; and inability to belch at 12 months after absorbable mesh. The magnitudes of the clinical differences were small.

CONCLUSIONS

No significant differences were seen for recurrent hiatus hernia, and the clinical differences were unlikely to be clinically significant. Overall outcomes after sutured repair were similar to mesh repair.

Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication

Postoperative paraoesophageal hiatus hernia occurred in 17 of 253 patients who underwent laparoscopic fundoplication at five different hospitals. Ten patients have undergone subsequent surgical revision, eight by an open technique and two by laparoscopy. This complication may have important implications for the technique of laparoscopic fundoplication, as it is possible that routine posterior repair of the diaphragmatic hiatus may greatly reduce the risk. Early postoperative contrast radiology may also achieve earlier diagnosis, enabling correction to be undertaken by laparoscopy.

Minimally invasive versus open esophagectomy for patients with esophageal cancer

BACKGROUND

Minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) has been shown to have clinical advantages, but selection bias is present.

METHODS

All patients undergoing MIE or OE for cancer between 1999 and 2007 were eligible for analysis. To minimize selection bias, only patients who also met the selection criteria for the thoracoscopic approach were included in the open esophagectomy group.

RESULTS

Fifty-six patients underwent MIE and 98 OE. No significant differences in demographics or pathologic data between groups occurred, with the exception of thoracic epidural analgesia (OE 98%, MIE 71.1%, p < 0.001), and neoadjuvant treatment (OE 50.5%, MIE 71.4%, p = 0.016). Morbidity and in-hospital death were not significantly different. Duration of surgery was longer in MIE (250 vs 209 minutes, p < 0.001) and blood loss less (320 mL vs 857 mL, p < 0.001). Intensive care unit stay was shorter in MIE (3.0 vs 6.8 days, p = 0.022). The relative risk (RR) for in-hospital death was 0.57 (p = 0.475) if the patients underwent MIE. After adjusting for thoracic epidural analgesia, the RR was 0.29 (p = 0.213) for the MIE group. The RR for surgical morbidity was 1.47 (p = 0.154) for patients undergoing MIE. Neoadjuvant treatment increased the RR for surgical morbidity to 1.78 (p = 0.028). No difference between the two groups concerning survival occurred.

CONCLUSIONS

The MIE is comparable with the OE. In MIE, neoadjuvant treatment increased the risk of surgical morbidity. Thoracic epidural analgesia in MIE reduced the risk of in-hospital death and should be considered for all patients undergoing esophagectomy.

Antireflux surgery in the laparoscopic era

BACKGROUND

The recent development of laparoscopic techniques for fundoplication has created renewed interest in surgery for gastro-oesophageal reflux disease, leading to reports of large clinical series from many centres. However, controversy remains about technical aspects of laparoscopic antireflux surgery, with no consensus yet reached about a standard operative technique. It is important, therefore, to reassess critically the results of laparoscopic surgery for reflux disease, so that its current status can be determined.

METHODS

Published outcome studies for laparoscopic antireflux surgery, as well as selected studies from the era of open antireflux surgery, were reviewed to assess outcomes.

RESULTS

The results of case series for laparoscopic antireflux surgery with short- and medium-term follow-up, as well as the early results of randomized trials, confirm that this approach reduces the early overall morbidity of surgery for reflux disease. However, certain complications may be more common, for instance paraoesophageal hiatus herniation, pneumothorax and oesophageal perforation, requiring surgeons to use specific strategies which can help to avoid these problems. Published studies and trials do not support the routine or selective application of a posterior partial fundoplication technique or routine division of the short gastric vessels during Nissen fundoplication.

CONCLUSION

At present, a short loose Nissen fundoplication performed laparoscopically, with or without division of the short gastric vessels, is an appropriate surgical approach for gastro-oesophageal reflux disease. However, long-term outcomes following laparoscopic antireflux surgery will not be available for some years, and must be awaited before the final status of the various laparoscopic techniques can be confirmed.

Wound metastases following laparoscopic and open surgery for abdominal cancer in a rat model

The recent application of laparoscopic resection techniques to malignant disease has raised safety concerns due to metastasis to surgical access wounds. The significance and incidence of this problem are controversial. In the present study a rat model, in which an implanted tumour was lacerated, was used to investigate whether application of laparoscopic techniques for malignant abdominal disease leads to an increased risk of tumour dissemination and implantation within the peritoneal cavity, and abdominal wall wounds. Malignant cells were implanted into the abdominal wall of 42 rats, resulting 7 days later in the growth of a tumour measuring 20-25 mm in diameter. There were three control groups: no surgery (n = 6); blunt manipulation of the tumour laparoscopically (n = 6); and blunt manipulation of the tumour at laparotomy (n = 6). Twenty-four rats underwent surgical laceration of the tumour capsule at either laparoscopy (n = 12) or laparotomy (n = 12). All rats were killed 1 week later, and examined for macroscopic evidence of tumour metastasis. The abdominal surgical wounds were excised for independent microscopic examination by a histopathologist. Growth of the primary tumour was greater in rats that had an operation than in unoperated controls, and was greater after laparotomy. However, wound metastases were five times more likely after laparoscopic tumour laceration than after the same procedure through an open incision (ten of 12 rats versus two of 12, P = 0.0033). Wound metastases following laparoscopic tumour manipulation are an important and real problem, with significant implications for the application of laparoscopic techniques to excise malignant disease in humans.

Quality of life following total mastectomy with and without reconstruction versus breast-conserving surgery for breast cancer: A case-controlled cohort study

BACKGROUND

Patient-reported outcomes and quality of life following mastectomy are not well understood. This study evaluates the quality of life following surgery for breast cancer and compares outcomes following breast-conserving surgery versus total mastectomy with or without reconstruction.

METHODS

A case-controlled cross-sectional study was conducted using the validated BREAST-Q™ questionnaire and a study-specific questionnaire to determine patient's views about surgical outcomes. Questionnaires were completed by patients following breast-conserving surgery and total mastectomy with or without reconstruction and by controls without breast cancer. A one-way ANOVA was used to compare mean BREAST-Q™ scores between groups and post hoc analysis using Tukey's and Kruskal-Wallis tests.

RESULTS

BREAST-Q™ questionnaires were completed by 400 women (123 controls, 97 breast conservations, 93 mastectomies without reconstruction, 87 mastectomies with reconstruction). Women who had undergone mastectomy and reconstruction had higher scores in satisfaction with breast and sexual well-being domains compared with women who had breast-conserving surgery, and women who had total mastectomy without reconstruction had the lowest scores in these two domains. There was no difference in psychosocial well-being between the groups. Women who had undergone breast-conserving surgery scored the lowest in the physical well-being chest domain and the majority reported breast asymmetry.

CONCLUSION

Our study suggests that women who undergo total mastectomy and breast reconstruction for cancer achieve a quality-of-life outcome that is at least as good as that following breast-conserving surgery. Furthermore, breast conservation has been found to be associated with lower physical well-being (i.e., more pain and discomfort) in the chest area and poorer sexual well-being outcomes.

MicroRNA profiling of Barrett's oesophagus and oesophageal adenocarcinoma

BACKGROUND

The genetic changes that drive metaplastic progression from squamous oesophageal mucosa toward intestinal metaplasia and adenocarcinoma are unclear. The aberrant expression of microRNAs (miRNAs) is involved in the development of cancer. This study examined whether miRNAs play a role in the development of oesophageal adenocarcinoma.

METHODS

RNA was extracted from mucosa of normal oesophageal squamous epithelium, normal gastric epithelium, Barrett's oesophagus with intestinal metaplasia and oesophageal adenocarcinoma obtained from 16 individuals. Expression profiles of 377 human miRNAs were determined by microarray analysis and selected miRNAs were analysed further using real-time reverse transcription-polymerase chain reaction (RT-PCR) in tissues from 32 individuals.

RESULTS

Microarray analyses identified 44 miRNAs likely to have altered expression between various mucosal samples. Of these, miR-21, miR-143, miR-145, miR-194, miR-203, miR-205 and miR-215 were chosen for validation by real-time RT-PCR. Tissue-specific expression profiles were observed, with miR-21, miR-143, miR-145, miR-194 and miR-215 significantly upregulated in columnar tissues compared with normal squamous epithelium. Expression of miR-143, miR-145 and miR-215 was lower in oesophageal adenocarcinoma than in Barrett's oesophagus. Levels of miR-203 and miR-205 were high in normal squamous epithelium and low in columnar epithelia. MiR-205 levels were lower in gastric epithelium than in both Barrett's oesophagus and adenocarcinoma.

CONCLUSION

Expression of miRNA might define disease states in oesophageal epithelium. Dysregulation of specific miRNAs could contribute to metaplastic and neoplastic processes in the oesophageal mucosa.

Circulating Serum Exosomal miRNAs As Potential Biomarkers for Esophageal Adenocarcinoma

BACKGROUND

The poor prognosis and rising incidence of esophageal adenocarcinoma highlight the need for improved detection methods. The potential for circulating microRNAs (miRNAs) as biomarkers in other cancers has been shown, but circulating miRNAs have not been well characterized in esophageal adenocarcinoma. We investigated whether circulating exosomal miRNAs have potential to discriminate individuals with esophageal adenocarcinoma from healthy controls and non-dysplastic Barrett's esophagus.

METHODS

Seven hundred fifty-eight miRNAs were profiled in serum circulating exosomes from a cohort of 19 healthy controls, 10 individuals with Barrett's esophagus, and 18 individuals with locally advanced esophageal adenocarcinoma. MiRNA expression was assessed using all possible permutations of miRNA ratios per individual. Four hundred eight miRNA ratios were differentially expressed in individuals with cancer compared to controls and Barrett's esophagus (Mann-Whitney U test, P < 0.05). The 179/408 ratios discriminated esophageal adenocarcinoma from healthy controls and Barrett's esophagus (linear regression, P < 0.05; area under receiver operating characteristic (ROC) > 0.7, P < 0.05). A multi-biomarker panel (RNU6-1/miR-16-5p, miR-25-3p/miR-320a, let-7e-5p/miR-15b-5p, miR-30a-5p/miR-324-5p, miR-17-5p/miR-194-5p) demonstrated enhanced specificity and sensitivity (area under ROC = 0.99, 95% CI 0.96-1.0) over single miRNA ratios to distinguish esophageal adenocarcinoma from controls and Barrett's esophagus.

CONCLUSIONS

This study highlights the potential for serum exosomal miRNAs as biomarkers for the detection of esophageal adenocarcinoma.

Laparoscopic versus open splenectomy for immune thrombocytopenic purpura

BACKGROUND

We sought to determine whether laparoscopic techniques can reduce the operative morbidity of surgery in patients undergoing splenectomy for immune thrombocytopenic purpura (ITP).

METHODS

All patients (60) undergoing splenectomy for ITP at the Royal Adelaide Hospital from January 1985 to November 1995 were reviewed. Results of patients undergoing open operation were obtained by means of retrospective case note review, whereas details of all patients undergoing laparoscopic splenectomy were collected prospectively and maintained on a computerized database.

RESULTS

Forty-seven patients underwent splenectomy with an open technique and 13 with a laparoscopic technique. Patient groups were demographically similar. All laparoscopic procedures were completed with the laparoscopic technique. An accessory spleen was also removed at laparoscopic operation from two (15%) patients and at open operation from three patients (6%). Two more accessory spleens were missed at the original procedure, one at open operation and one at laparoscopic operation. These required later removal by using open and laparoscopic techniques, respectively. Blood and platelet transfusion requirements were reduced by the laparoscopic approach. Although mean operating times were similar (87 versus 88 minutes), laparoscopic splenectomy was associated with a greatly reduced postoperative hospital stay (10 versus 2 days, median; p < 0.0001) and no major morbidity. Long-term normalization of platelet counts was similar for the two techniques. The laparoscopic approach resulted in a reduction in hospital treatment costs from $4224 to $2238 per case (cost savings of $1986 per case).

CONCLUSIONS

Laparoscopic splenectomy results in improved clinical outcomes and reduced costs for patients undergoing elective splenectomy for ITP.

Port-site metastases following laparoscopic surgery

BACKGROUND

Application of laparoscopy to the resection of malignancy has been followed by a literature describing cases of metastatic involvement at laparoscopic port sites. These include patients who underwent surgery for early stage carcinoma and instances following laparoscopic procedures during which tumours were not dissected.

METHODS

Recently published clinical and experimental studies, and case reports related to this problem are reviewed; their relevance is discussed.

RESULTS

Experimental studies incorporating bench top and large animal models have confirmed that tumour cells may be redistributed to port sites during laparoscopic surgery either directly from contaminated instruments or indirectly via the insufflation gas. Small animal models suggest that the incidence of wound metastasis is increased following conventional laparoscopic surgery, and that it may be decreased by gasless laparoscopy or helium insufflation. This evidence suggests that the development of port-site metastases depends not only on the physical redistribution of tumour cells but also on the specific insufflation gas used, possibly because of influences on local metabolic or immune factors acting at the wound site.

CONCLUSION

Further research in this area is urgent. Until the issue is better understood, patients undergoing laparoscopic surgery for malignancy should be entered into clinical trials.

Totally endoscopic Ivor Lewis esophagectomy

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened.

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS

Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication.

DESIGN

A multicenter, prospective, double-blind, randomized controlled trial.

SETTING

Nine university teaching hospitals in 6 major cities in Australia and New Zealand.

PARTICIPANTS

One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study.

INTERVENTIONS

Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication.

MAIN OUTCOME MEASURES

Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment.

RESULTS

Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures.

CONCLUSIONS

At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up

OBJECTIVE

To determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients.

SUMMARY BACKGROUND DATA

Dividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery.

METHODS

Between May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator.

RESULTS

There were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels.

CONCLUSIONS

Division of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of "wind-related" problems.