Superiority of anti-reflux stent compared with conventional stents in the palliative management of patients with cancer of the lower esophagus and esophago-gastric junction: results of a randomized clinical trial

Palliation of inoperable esophageal cancer with covered stents aims to relieve progressive dysphagia and improve health-related quality of life (HRQoL). Introducing a stent across the esophagogastric junction in lower third tumors may predispose to unchecked gastro-esophageal reflux (GER). Esophageal stents incorporating an anti-reflux valve have been introduced to address this problem. We prospectively compared an anti-reflux stent with a standard stent in the palliation of inoperable lower third esophageal tumors. Forty-nine consecutive patients with malignant dysphagia were randomized to receive a standard (n = 25, group 1) or an anti-reflux stent (n = 24, group 2). HRQoL was assessed before stenting, at 1 week and at 2 months, utilizing European Organization for Research and Treatment of Cancer questionnaires QLQ-C30, QLQ-OES24 and reflux questionnaires. Esophageal pH testing was performed within 1 week of the stent insertion. Detailed statistical analysis was employed to assess general QoL, symptoms and pH scores in both groups. Both groups reported significantly improved QoL, health and dysphagia scores at 1 week and 2 months after stenting. Group 2 patients reported significantly (P < 0.05) better DeMeester symptom, general reflux scores, and normal pH profile at 1 week. At 2 months DeMeester symptom scores were significantly (P < 0.05) better in group 2 compared with group 1. Standard and anti-reflux stents afford comparable relief from dysphagia and improved quality of life in patients with inoperable lower third esophageal cancer. Anti-reflux stents, however, controlled symptomatic and physiologically relevant reflux and should therefore be considered as optimal palliation in this cohort.

Current research and treatment for gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and have gained considerable research and treatment interest, especially in the last two decades. GISTs are driven by mutations commonly found in the KIT gene and less commonly in the platelet-derived growth factor receptor alpha gene, BRAF gene and succinate dehydrogenase gene. GISTs behave in a spectrum of malignant potential, and both the tumor size and mitotic index are the most commonly used prognostic criteria. Whilst surgical resection can offer the best cure, targeted therapy in the form of tyrosine kinase inhibitors (TKIs) has revolutionized the management options. As the first-line TKI, imatinib offers treatment for advanced and metastatic GISTs, adjuvant therapy in high-risk GISTs and as a neoadjuvant agent to downsize large tumors prior to resection. The emergence of drug resistance has altered some treatment options, including prolonging the first-line TKI from 1 to 3 years, increasing the dose of TKI or switching to second-line TKI. Other newer TKIs, such as sunitinib and regorafenib, may offer some treatment options for imatinib-resistant GISTs. New molecular targeted therapies are being evaluated, such as inhibitors of BRAF, heat shock protein 90, glutamine and mitogen-activated protein kinase signaling, as well as inhibitors of apoptosis proteins antagonist and even immunotherapy. This editorial review summarizes the recent research trials and potential treatment targets that may influence our future patient-specific management of GISTs. The current guidelines in GIST management from Europe, North America and Asia are highlighted.

Oesophagectomy in the management of end-stage achalasia - case reports and a review of the literature

Achalasia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of a hypertensive lower oesophageal sphincter. Treatment intent targets the sphincter, and either Heller's myotomy or pneumatic dilatation successfully relieves dysphagia in the majority of cases. End-stage achalasia, typified by a massively dilated and tortuous oesophagus, may occur in patients previously treated but where further dilatation or myotomy fails to relieve dysphagia or prevent nutritional deterioration, and oesophagectomy may be the only option. We describe two patients with end-stage achalasia and nutritional failure despite exhaustive conventional therapy including pneumatic dilatation and surgical myotomy. Both patients were successfully managed with transhiatal oesophagectomy and cervical gastro-esophageal anastomosis, with excellent symptomatic control and improved quality of life. These cases are discussed and the literature reviewed.

Nongenomic oestrogen signalling in oestrogen receptor negative breast cancer cells: a role for the angiotensin II receptor AT1

INTRODUCTION

Oestrogens can mediate some of their cell survival properties through a nongenomic mechanism that involves the mitogen-activated protein kinase (MAPK) pathway. The mechanism of this rapid signalling and its dependence on a membrane bound oestrogen receptor (ER), however, remains controversial. The role of G-protein-coupled receptor and epidermal growth factor (EGF) receptor in an ER-independent signalling pathway modulated by oestrogen was investigated.

METHODS

ER-positive and ER-negative breast cancer cell lines (MCF-7 and SKBR3) and primary breast cancer cell cultures were used in this study. Cell proliferation was assessed using standard MTT assays. Protein and cAMP levels were detected by Western blotting and ELISA, respectively. Antigen localization was performed by immunocytochemistry, immunohistochemistry and immunofluorescence. Protein knockdown was achieved using small interfering RNA technologies.

RESULTS

EGF and oestrogen, alone and in combination, induced cell proliferation and phosphorylation of MAPK proteins Raf and ERK (extracellular signal regulated kinase)1/2 in both ER-negative SKBR3 and ER-positive MCF-7 human breast cancer cell lines. Increased Raf phosphorylation was also observed in primary human breast cultures derived from ER-positive and ER-negative breast tumours. Oestrogen induced an increase in intracellular cAMP in ER-negative SKBR3 human breast cancer cells. Oestrogen-mediated cell growth and phosphorylation of MAPK was modified by the EGF receptor antagonist AG1478, the G-protein antagonist pertussis toxin, and the angiotensin II receptor antagonist saralasin. Knockdown of angiotensin II type 1 receptor (AT1) protein expression with small interfering RNA attenuated oestrogen-induced Raf phosphorylation in ER-negative cells. AT1 receptor was found to be expressed in the cell membrane of breast tumour epithelial cells.

CONCLUSION

These findings provide evidence that, in breast cancer cells, oestrogen can signal through AT1 to activate early cell survival mechanisms in an ER-independent manner.

Cryptorchidism: a general surgical perspective

BACKGROUND

The treatment of cryptorchidism has changed, with surgery now advocated before the age of two years. Delayed treatment affects fertility, malignant potential and psychological stress.

AIMS

To assess the pattern of referral of cryptorchid patients to a surgical clinic, management and follow-up.

METHODS

A four-year review of 114 cryptorchid patients examined age at presentation, waiting time, timing of surgery and length of follow-up.

RESULTS

The mean age at presentation to the surgical clinic was 6.7 years (neonatal to 71). The mean age at orchidopexy was 5.6 years. Seventy per cent had a surgical procedure within eight weeks of presentation to a surgeon. Seven per cent were kept under surveillance until a maximum age of three years before orchidopexy was considered. Only 29% proceeded to surgery before the age of two. Seventeen were referred to a paediatric urology unit for further management.

CONCLUSIONS

Orchidopexy seems prudent between one and two years of age. Only one-quarter of patients underwent early orchidopexy. It is vital that it is detected early, by paediatricians at birth or the general practitioners (GPs) at the six-week check up. Prompt referral to a surgeon with a paediatric interest is essential in order to permit surveillance or surgery.

Surgical treatment of gastrointestinal stromal tumors of the stomach: current status and future perspective

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, with the majority found in the stomach. Surgical resection of the primary gastric GISTs with complete resection margin has been the forefront of curative treatment. The indications for surgical resection are usually related to symptomatic gastric GISTs at presentation. Primary gastric GISTs resection performed conventionally through an open surgery can now be frequently achieved by minimal invasive surgery with similar oncological outcome. Surgeon's selection of the type of surgical techniques such as open, laparoscopic and endoscopic resections depends on the site, size and local invasion of gastric GISTs to the adjacent organ. Similarly those factors dictate the extent of gastric resections in the form of wedge, partial or total gastrectomy. All these inherent tumor factors (size and mitotic index), patient factors (older age, male) and surgical factors (incomplete resection margin, tumor rupture or spillage) play an important role in stratifying the malignant potential risk of primary gastric GISTs and their chances of recurrence. The understanding of gene mutation driving the growth of GISTs and the discovery of tyrosine kinase inhibitors (TKIs) has altered the surgical management of advanced and metastatic GISTs. Multi-modal therapy incorporating the surgical resection of GISTs and utilizing the molecular targeted therapy in the adjuvant, neoadjuvant and palliative settings can offer optimal personalized outcome and prolong patient's overall survival (OS).

An unusual presentation of Boerhaave Syndrome: a case report

We present a unique case of Boerhaave Syndrome that may highlight the spectrum of barotrauma from a Mallory-Weiss tear to full-thickness perforation. In this case, perforation only became evident following air insufflation at endoscopy.

Management of synchronous adenocarcinoma of the esophago-gastric junction and ampulla of Vater: case report of a surgically challenging condition

We report herein a case of a synchronous presentation of an adenocarcinoma of esophagago-gastric junction type II and an ampullary tumor that was treated by combined Whipple's pancreaticoduodenectomy, total gastrectomy and esophagectomy. The magnitude of this operation was safely achieved with meticulous surgical techniques and perioperative care without any major short or long term complications. Patient returned to a good quality of life at six-month follow up with no further gastrointestinal symptoms or evidence of disease recurrence.

Eosinophilic ascites with marked peripheral eosinophilia: a diagnostic challenge

Eosinophilic disease of the gastrointestinal tract is rare and is characterized by the presence of gastrointestinal symptoms in association with eosinophilic infiltration of any part of the gastrointestinal tract. Clinical presentation of eosinophilic gastroenteritis (EGE) varies not only by the part of the gastrointestinal tract involved but also with the depth of eosinophilic infiltration of the gut wall. We describe the case of a 41-year-old woman with a history of atopy who presented with severe abdominal pain and diarrhoea. Investigations showed large-volume eosinophil-rich ascites and a markedly elevated peripheral blood eosinophil count and immunoglobulin E level. Bone marrow aspirate, trephine biopsy and T-cell studies showed no evidence of underlying haematological malignancy. Vasculitic disease and parasitic infection were systematically excluded. Colonic and upper gastrointestinal biopsies confirmed a diagnosis of EGE with eosinophilic ascites. The patient was treated with systemic corticosteroids and dietary allergen elimination with dramatic therapeutic response. The diagnostic and therapeutic challenges associated with EGE in its various forms are discussed.

Endoscopic T-tube placement in the management of lye-induced esophageal perforation: Case report of a safe treatment strategy

Esophageal perforation is associated with a significant risk of morbidity and mortality. We report herein a case of lye-induced esophageal perforation managed successfully by employing endoscopic T-tube placement with a successful outcome.

The value of double balloon enteroscopy in diagnosing blue rubber bleb naevus syndrome: a case report

Blue rubber bleb naevus syndrome is a rare vascular disorder associated with multiple gastrointestinal haemangiomas that have the potential for life-threatening haemorrhage. These may be difficult to diagnose, and have classically been described using computed tomographic studies and/or mesenteric angiography. Resected surgical specimens of these lesions, especially in the small bowel, have often been extensive and poorly localized. The recent advent and progressive development of double balloon enteroscopy has allowed the direct visualization and marking of these enteric lesions and serves as a valuable adjunct not only in diagnosis but also planning prior to surgery to allow accurate estimate of the extent of resection.

Short-term outcomes of laparoscopic versus open proximal gastrectomy with double-tract reconstruction for Siewert type II and III adenocarcinoma of the esophagogastric junction: a retrospective observational study of consecutive patients

BACKGROUND

To investigate the safety and merits of laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DT) for Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

Retrospective analysis of the clinical data of 100 consecutive patients with Siewert II and III AEG treated at the Affiliated Tumor Hospital of Zhengzhou University from October 2010 to October 2019 was performed. Out of these patients, 69 underwent open proximal gastrectomy with double-tract reconstruction (OPG-DT), while 31 underwent LPG-DT. The clinicopathological characteristics, perioperative data, and short-term outcomes of the two groups were compared. A P value <0.05 was considered statistically significant.

RESULTS

Males accounted for 87% of all patients. Lymph nodes (LNs) count, time to first meal, postoperative length of stay, and postoperative complications were similar between the OPG-DT and LPG-DT group. flatus time was significantly shorter in the LPG-DT group (P<0.05), while the duration of operation was significantly shorter in the the OPG-DT group (P<0.001). Furthermore, the LPG-DT group has less blood loss, shorter flatus time, and lower postoperative-day-5 white blood cell (WBC) count and C-reactive protein (CRP) levels (P<0.05).

CONCLUSIONS

Although LPG-DT took longer to perform, its advantages of reduced blood loss and less surgical stress reflected on inflammatory markers supports an acceptable surgical option for Siewert II and III AEG.

Gun shot-101: an 8-year review of gunshot injuries in an Irish teaching hospital from a general surgical perspective

BACKGROUND

Gun-related crime offences have increased in the Republic of Ireland steadily over the past number of years. Regional trauma units are witnessing unprecedented numbers of injuries in the Republic of Ireland with limited prior experience.

AIMS

Eight-year retrospective study analysing demographic data, management and outcome of firearm-related injuries.

RESULTS

Patients who experience gunshot injuries in this region are statistically likely to be young, male and unemployed with a single shotgun injury to an extremity. Post-operative survival rates of 100% for those who undergo an exploratory laparotomy.

CONCLUSION

Ireland has comparable survival outcomes to other international centres with similar patient demographics due to timely and appropriate operative intervention. These results serve to provide a template for further patient management.

Triple-vessel mesenteric ischaemia presenting with gastric ulceration

We present an unusual presentation of chronic mesenteric ischaemia in a patient with recurrent gastric ulceration that highlights both the importance of recognition of ischaemia as a possible aetiology in those refractory to conventional treatment and the success of percutaneous transluminal mesenteric angioplasty in these cases.

Current surgical management of duodenal gastrointestinal stromal tumors

Duodenal gastrointestinal stromal tumors (D-GISTs) are uncommon mesenchymal tumors and are managed differently to common duodenal epithelial tumors. They may pose surgical challenges due to their unique but complex pancreaticoduodenal location of the gastrointestinal tract near the ampulla of Vater, pancreas, mesenteric blood vessels, biliary and pancreatic ducts. The surgical management of D-GISTs can be performed safely with good oncological outcomes provided an adequate resection margin can be achieved. The current surgical options of resectable primary D-GISTs varies with increasing complexity depending on the location, size and involvement of surrounding structures such as wedge resection with primary closure, segmental resection with small bowel anastomosis or radical pancreaticoduodenectomy. Laparoscopic approaches have been shown to be feasible and safe with good oncological outcomes in experienced hands. The minimally invasive techniques including robotic-assisted approach will likely increase in the future. D-GISTs have a prognosis comparable to gastric and other small bowel GISTs. However, the heterogeneity of different studies and the limited use of systemic tyrosine kinase inhibitor in the neoadjuvant and adjuvant settings may influence the overall survival of resected D-GISTs. The use of limited resection when condition allows is recommended due to lower surgical morbidity, less postoperative complications and better oncologic outcomes.

A randomized controlled trial of Chinese traditional medicine Dachengqi Decoction in the treatment of postoperative intestinal function recovery

BACKGROUND

Intestinal dysfunction is not conducive to the recovery of patients after surgery. It is particularly important to restore the intestinal function as soon as possible. In recent years, ultrasonic drug penetration therapy as a new type of non-invasive therapy has been used to solve this problem, but its efficacy has not been confirmed.

METHODS

Single-centre, parallel, randomized controlled clinical trial in China that included 184 patients undergoing laparoscopic gastrointestinal surgery. Ninety-one participants were randomly assigned to low-frequency ultrasound and electric pulses for transdermal drug delivery with Dachengqi Decoction (DCQD) (intervention group), and 90 were assigned to the control group after laparoscopic gastrointestinal surgery. The primary outcome was time to first flatus after surgery (by patient's subjective feeling). Secondary outcomes assessed the recovery time of bowel movement, time of the first defecation, postoperative gastrointestinal complications (e.g., nausea, vomit, and bloating), days of hospitalization and treatment costs.

RESULTS

Of 184 patients, 181 (98.4%) completed the trial. The sociodemographic characteristics and efficiency data were comparable in the two groups at baseline. The intervention group had a shorter mean time of bowel movement recovery than the control group [29.4 h (IQR, 22.0-35.0 h) vs. 33.7 h (IQR, 24.0-40.0 h; P=0.005)] and a shorter mean time to first flatus after surgery [35.8 h (IQR, 23.1-46.6 h) vs. 46.7 h (IQR, 25.9-61.3 h; P=0.012)]. Postoperative gastrointestinal reactions (e.g., nausea, vomit, and bloating) occurred in 28.6% in the intervention group and 43.3% in the control group (P=0.038). Two patients in the intervention group had electrical tingling sensations, and one patient had a skin rash during the treatment. There were no significant differences in the occurrence rates of AEs or SAE, days of hospitalization and treatment costs between the two groups.

CONCLUSIONS

Low-frequency ultrasound and electric pulses for transdermal drug delivery with DCQD can shorten the time of bowel movement recovery and accelerate first anal exhaust after laparoscopic gastrointestinal surgery.

TRAIL REGISTRATION

Chictr.org.cn Identifier: ChiCTR-IPR-17013630.

Correction to: Nongenomic oestrogen signalling in oestrogen receptor negative breast cancer cells: a role for the angiotensin II receptor AT1

After the publication of this work [1] errors were noticed in the total protein loading controls for Figs. 1C, 2B, 3B and 4B.

Start small and aim big in conducting a basic surgical skills workshop for medical students

Introduction: Medical students (MS) may lack the knowledge and experience in performing basic surgical skills (BSS) when they first commence their postgraduate surgical training. We conducted a pilot BSS workshop with specific learning outcomes for MS. Methods: Our BSS workshop program consisted of reading the pre-workshop online modules, watching the instructional videos of skills demonstration, and completing the pre-workshop multiple-choice questions (MCQ). MS attended the onsite workshop a week later, which consisted of a basic surgical theory lecture, live demonstration of the skills by the teaching faculty and, supervised skills training coupled with feedback. Surgical skills taught were knot tying, suturing techniques, laparoscopic peg transfer, precision cutting, application of endoloop ties. A standardised surgical skills rubric was used to assess the competency and safety of BSS. A post-workshop MCQ was administered to assess the knowledge learned. The criteria for successful completion of BSS were a satisfactory grade in the surgical skills assessment and a pass score in the MCQ. Results: All the participating MS achieved a satisfactory grade in the surgical skills assessment and passed the MCQ. Several pedagogical methods were used to enhance knowledge learning and practical skills competency including a flipped classroom in blended learning, technology-enhanced learning, kinesthetic learning, and providing effective feedback. Conclusion: MS taught in BSS workshop can achieve competency in knowledge, skills, safe attitude and prepare them for future postgraduate surgical training. In the current COVID-19 pandemic, our challenge is to develop similar BSS in a safe environment using technology-enhanced tools such as online instructional videos and online feedback.

Paterson-Brown Kelly Syndrome (also commonly known as Plummer-Vinson Syndrome)

The dysphagia in this condition is usually associated with iron deficiency anemia and esophageal webs. Iron supplementation and regular surveillance are required for monitoring of malignant transformation into esophageal squamous cell carcinoma.

A review of neonatal attendances out of hours in a Dublin maternity hospital

BACKGROUND All neonates have free open access to the Baby Clinic at the maternity hospitals in Dublin for assessment of neonatal health issues. Through observation, however there is an increase in number of neonates attending the hospital outside the Baby Clinic hours.

AIMS

To determine the number of neonates attending the acute neonatal service out of hours and to identify the percentage of neonates treated as true emergency.

METHODS

Retrospective chart review over a twelve-month period.

RESULTS

Seven hundred and thirty-two neonates attended the hospital out of hours. The majority were diagnosed with gastrointestinal problems (228/31%), jaundice (101/13.7%), respiratory problems (82/11.1%) and skin disorders (79/10.7%). Only 106 (14.4%) attendances warranted admissions.

CONCLUSIONS

A large number of neonatal attendances did not require acute assessment out of hours and were managed by reassurance and maternal education. A centralized phone-in-triage system was suggested to relieve the strain on the acute neonatal service.