Elevated preoperative neutrophil:lymphocyte ratio as a predictor of postoperative disease recurrence in esophageal cancer

BACKGROUND

The prognosis for patients with esophageal cancer is poor, even among those who undergo potentially curative esophagectomy. The neutrophil:lymphocyte ratio (NLR) is hypothesized to reflect the systemic inflammatory response created by a tumor and is possibly predictive of tumor aggressiveness and propensity for metastasis.

METHODS

We performed a single-center retrospective analysis of esophageal cancer patients who underwent attempted curative esophagectomy at Weill Cornell Medical Center between 1996 and 2009. We collected data on patient demographics, clinical characteristics, and receipt of neoadjuvant treatment. Preoperative blood tests were used to calculate NLR. Elevated NLR was defined a priori as ≥5.0. Logistic regression modeling was performed to analyze characteristics associated with elevated NLR. We conducted Kaplan-Meier analyses and Cox regression modeling to determine estimates and predictors of disease-free and overall survival.

RESULTS

We identified a total of 295 patients who underwent esophagectomy. The median duration of follow-up was 31 months (interquartile range [IQR] 13-61). There were 56 patients (18.9%) who had elevated NLR preoperatively. Receipt of neoadjuvant therapy was independently associated with high NLR (odds ratio [OR] 2.14, 95% confidence interval [95% CI] 1.02-4.51). In multivariable analyses, elevated NLR was associated with significantly worse disease-free (hazard ratio [HR] 2.26, 95% CI 1.43-3.55) and overall survival (HR 2.31, 95% CI 1.53-3.50).

CONCLUSIONS

Preoperative NLR is a potential prognostic marker for recurrence and death after esophagectomy. It is unclear whether NLR reflects the degree of inflammatory response to the primary tumor or other patient-specific or tumor characteristics that predispose to recurrence. Further investigation is warranted to clarify the mechanisms explaining the observed associations between elevated NLR and poor outcomes in esophageal cancer.

Correlation between serum gastrin and cellular proliferation in Barrett's esophagus

BACKGROUND

Patients with Barrett's esophagus (BE) are commonly treated with proton-pump inhibitors (PPIs) to minimize the exposure of esophageal mucosa to stomach acid. However, the use of these medications can lead to significant hypergastrinemia in a subset of patients, which is concerning due to the known tumorigenic and proliferative effects of gastrin. The present pilot study aims to investigate a potential correlation between serum gastrin and cellular proliferation in BE.

METHODS

We performed a cross-sectional analysis of patients with nondysplastic BE on PPI therapy. Fasting serum gastrin was measured on the same day as esophageal biopsies were obtained. These biopsies were then stained with Ki-67 nuclear antibody. Pearson's correlation coefficient was calculated to assess the relationship between Ki-67 index and ln(gastrin).

RESULTS

A total of 10 patients were included in the study. The mean age was 62.6 (±8.4) years and 5 patients were male. The median serum gastrin level was 45.2 pM (interquartile range [IQR] 33-113) and the median Ki-67 index was 49.6% (IQR 23-64). We found a statistically significant positive correlation between Ki-67 index and ln(gastrin) (r = 0.64; p = 0.05).

CONCLUSIONS

In nondysplastic BE patients on PPI therapy, serum gastrin levels were significantly correlated with cellular proliferation. These pilot data lend support to a potential causal effect of gastrin on neoplastic progression in BE. Longitudinal studies of patients with BE are needed to determine whether hypergastrinemia is a risk factor for the development of dysplasia and adenocarcinoma or could be used as a biomarker for disease progression.

Dating the rise of esophageal adenocarcinoma: analysis of Connecticut Tumor Registry data, 1940-2007

BACKGROUND

The timing of onset of the rise in incidence of esophageal adenocarcinoma (EAC) has not been clearly defined, and doing so may provide clues with regard to exposures associated with the changed epidemiology of this malignancy. We therefore aimed to investigate historical trends in the incidence of EAC and other upper gastrointestinal malignancies.

METHODS

We did a population-based study using Connecticut Tumor Registry (1940-2007) and Surveillance, Epidemiology, and End Results (SEER; 1973-2007) data. Age-adjusted incidence rates (per 100,000 person-years) were calculated for EAC and other upper gastrointestinal malignancies.

RESULTS

The incidence of EAC remained relatively constant until 1965-69, and then rose from 0.41 (95%CI, 0.26-0.56) to 1.31 (95%CI 1.07-1.54) in 1978-82 and 5.31 (95%CI 4.89-5.73) in 2003-07. The incidence of gastric cardia cancer began to rise in the 1950s and plateaued in the 1990s. The incidence of esophageal squamous cell carcinoma began to decrease around 1980. The trends from Connecticut Tumor Registry data closely mirrored those from SEER data.

CONCLUSIONS

The incidence of EAC began to rise in the late 1960s, predating the rise in obesity by a decade. Reduced infection rates of Helicobacter pylori, changes in microbiome, or other exposures may have contributed to the changed epidemiology of this malignancy.

IMPACT

Analysis of historical data of trends in EAC incidence implicate a change in environmental factors from the mid-20th century as primarily responsible for the initial rise in EAC incidence, predating the rise in obesity prevalence in the United States by over a decade.

Randomized comparison of 3 different-sized biopsy forceps for quality of sampling in Barrett's esophagus

BACKGROUND

Several types of forceps are available for use in sampling Barrett's esophagus (BE). Few data exist with regard to biopsy quality for histologic assessment.

OBJECTIVE

To evaluate sampling quality of 3 different forceps in patients with BE.

DESIGN

Single-center, randomized clinical trial.

PATIENTS

Consecutive patients with BE undergoing upper endoscopy.

INTERVENTIONS

Patients randomized to have biopsy specimens taken with 1 of 3 types of forceps: standard, large capacity, or jumbo.

MAIN OUTCOME MEASUREMENTS

Specimen adequacy was defined a priori as a well-oriented biopsy sample 2 mm or greater in diameter and with at least muscularis mucosa present.

RESULTS

A total of 65 patients were enrolled and analyzed (standard forceps, n = 21; large-capacity forceps, n = 21; jumbo forceps, n = 23). Compared with jumbo forceps, a significantly higher proportion of biopsy samples with large-capacity forceps were adequate (37.8% vs 25.2%, P = .002). Of the standard forceps biopsy samples, 31.9% were adequate, which was not significantly different from specimens taken with large-capacity (P = .20) or jumbo (P = .09) forceps. Biopsy specimens taken with jumbo forceps had the largest diameter (median, 3.0 mm vs 2.5 mm [standard] vs 2.8 mm [large capacity]; P = .0001). However, jumbo forceps had the lowest proportion of specimens that were well oriented (overall P = .001).

LIMITATIONS

Heterogeneous patient population precluded dysplasia detection analyses.

CONCLUSIONS

Our results challenge the requirement of jumbo forceps and therapeutic endoscopes to properly perform the Seattle protocol. We found that standard and large-capacity forceps used with standard upper endoscopes produced biopsy samples at least as adequate as those obtained with jumbo forceps and therapeutic endoscopes in patients with BE.

Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy

BACKGROUND

Few options exist for patients with localized esophageal cancer ineligible for conventional therapies. Endoscopic spray cryotherapy with low-pressure liquid nitrogen has demonstrated efficacy in this setting in early studies.

OBJECTIVE

To assess the safety and efficacy of cryotherapy in esophageal carcinoma.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Ten academic and community medical centers between 2006 and 2009.

PATIENTS

Subjects with esophageal carcinoma in whom conventional therapy failed and those who refused or were ineligible for conventional therapy.

INTERVENTIONS

Cryotherapy with follow-up biopsies. Treatment was complete when tumor eradication was confirmed by biopsy or when treatment was halted because of tumor progression, patient preference, or comorbid condition.

MAIN OUTCOME MEASUREMENTS

Complete eradication of luminal cancer and adverse events.

RESULTS

Seventy-nine subjects (median age 76 years, 81% male, 94% with adenocarcinoma) were treated. Tumor stage included T1-60, T2-16, and T3/4-3. Mean tumor length was 4.0 cm (range 1-15 cm). Previous treatment including endoscopic resection, photodynamic therapy, esophagectomy, chemotherapy, and radiation therapy failed in 53 subjects (67%). Forty-nine completed treatment. Complete response of intraluminal disease was seen in 31 of 49 subjects (61.2%), including 18 of 24 (75%) with mucosal cancer. Mean (standard deviation) length of follow-up after treatment was 10.6 (8.4) months overall and 11.5 (2.8) months for T1 disease. No serious adverse events were reported. Benign stricture developed in 10 (13%), with esophageal narrowing from previous endoscopic resection, radiotherapy, or photodynamic therapy noted in 9 of 10 subjects.

LIMITATIONS

Retrospective study design, short follow-up.

CONCLUSIONS

Spray cryotherapy is safe and well tolerated for esophageal cancer. Short-term results suggest that it is effective in those who could not receive conventional treatment, especially for those with mucosal cancer.

Safety and efficacy of endoscopic spray cryotherapy for Barrett's esophagus with high-grade dysplasia

BACKGROUND

Endoscopic ablation to treat Barrett's esophagus (BE) with high-grade dysplasia (HGD) is associated with a decreased incidence of esophageal adenocarcinoma. Endoscopic spray cryotherapy (CRYO) demonstrates promising preliminary data.

OBJECTIVE

To assess the safety and efficacy of CRYO in BE with HGD.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Nine academic and community centers; treatment period, 2007 to 2009.

PATIENTS

Subjects with HGD confirmed by 2 pathologists. Previous EMR was allowed if residual HGD remained.

INTERVENTIONS

CRYO with follow-up biopsies.

MAIN OUTCOME MEASUREMENTS

Complete eradication of HGD with persistent low-grade dysplasia, complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and complete eradication of all intestinal metaplasia.

RESULTS

Ninety-eight subjects (mean age 65.4 years, 83% male) with BE and HGD (mean length 5.3 cm) underwent 333 treatments (mean 3.4 treatments per subject). There were no esophageal perforations. Strictures developed in 3 subjects. Two subjects reported severe chest pain managed with oral narcotics. One subject was hospitalized for bright red blood per rectum. Sixty subjects had completed all planned CRYO treatments and were included in the efficacy analysis. Fifty-eight subjects (97%) had complete eradication of HGD, 52 (87%) had complete eradication of all dysplasia with persistent nondysplastic intestinal metaplasia, and 34 (57%) had complete eradication of all intestinal metaplasia. Subsquamous BE was found in 2 subjects (3%).

LIMITATIONS

Nonrandomized, retrospective study with no control group, short follow-up (10.5 months), lack of centralized pathology, and use of surrogate outcome for decreased cancer risk.

CONCLUSIONS

CRYO is a safe and well-tolerated therapy for BE and HGD. Short-term results suggest that CRYO is highly effective in eradicating HGD.

Safety, tolerability, and efficacy of endoscopic low-pressure liquid nitrogen spray cryotherapy in the esophagus

Endoscopic cryotherapy is a new technique for ablation of esophageal dysplasia and neoplasia. Preliminary studies have shown it to be safe and effective for this indication. The objective of this study is to characterize safety, tolerability, and efficacy of low-pressure liquid nitrogen endoscopic spray cryotherapy ablation in a large cohort across multiple study sites. Parallel prospective treatment studies at four tertiary care academic medical centers in the U.S. assessed spray cryotherapy in patients with Barrett's esophagus with or without dysplasia, early stage esophageal cancer, and severe squamous dysplasia who underwent cryotherapy ablation of the esophagus. All patients were contacted between 1 and 10 days after treatment to assess for side effects and complications of treatment. The main outcome measurement was the incidence of serious adverse events and side effects from treatment. Complete response for high-grade dysplasia (HGD) (CR-HGD), all dysplasia (CR-D), intestinal metaplasia (CR-IM) and cancer (CR-C) were assessed in patients completing therapy during the study period. A total of 77 patients were treated for Barrett's high-grade dysplasia (58.4%), intramucosal carcinoma (16.9%), invasive carcinoma (13%), Barrett's esophagus without dysplasia (9.1%), and severe squamous dysplasia (2.6%). Twenty-two patients (28.6%) reported no side effects throughout treatment. In 323 procedures, the most common complaint was chest pain (17.6%) followed by dysphagia (13.3%), odynophagia (12.1%), and sore throat (9.6%). The mean duration of any symptoms was 3.6 days. No side effects were reported in 48% of the procedures (155/323). Symptoms did not correlate with age, gender, diagnosis, or to treatment early versus late in the patient's or site's experience. Logit analysis showed that symptoms were greater in those with a Barrett's segment of 6 cm or longer. Gastric perforation occurred in one patient with Marfan's syndrome. Esophageal stricture developed in three, all successfully treated with dilation. In 17 HGD patients, cryotherapy produced CR-HGD, CR-D, and CR-IM of 94%, 88%, and 53%, respectively. Complete regression of cancer and HGD was seen in all seven patients with intramucosal carcinoma or stage I esophageal cancer. Endoscopic spray cryotherapy ablation using low-pressure liquid nitrogen in the esophagus is safe, well-tolerated, and efficacious.

Safety, tolerability, and efficacy of endoscopic low-pressure liquid nitrogen spray cryotherapy in the esophagus

Endoscopic cryotherapy is a new technique for ablation of esophageal dysplasia and neoplasia. Preliminary studies have shown it to be safe and effective for this indication. The objective of this study is to characterize safety, tolerability, and efficacy of low-pressure liquid nitrogen endoscopic spray cryotherapy ablation in a large cohort across multiple study sites. Parallel prospective treatment studies at four tertiary care academic medical centers in the U.S. assessed spray cryotherapy in patients with Barrett's esophagus with or without dysplasia, early stage esophageal cancer, and severe squamous dysplasia who underwent cryotherapy ablation of the esophagus. All patients were contacted between 1 and 10 days after treatment to assess for side effects and complications of treatment. The main outcome measurement was the incidence of serious adverse events and side effects from treatment. Complete response for high-grade dysplasia (HGD) (CR-HGD), all dysplasia (CR-D), intestinal metaplasia (CR-IM) and cancer (CR-C) were assessed in patients completing therapy during the study period. A total of 77 patients were treated for Barrett's high-grade dysplasia (58.4%), intramucosal carcinoma (16.9%), invasive carcinoma (13%), Barrett's esophagus without dysplasia (9.1%), and severe squamous dysplasia (2.6%). Twenty-two patients (28.6%) reported no side effects throughout treatment. In 323 procedures, the most common complaint was chest pain (17.6%) followed by dysphagia (13.3%), odynophagia (12.1%), and sore throat (9.6%). The mean duration of any symptoms was 3.6 days. No side effects were reported in 48% of the procedures (155/323). Symptoms did not correlate with age, gender, diagnosis, or to treatment early versus late in the patient's or site's experience. Logit analysis showed that symptoms were greater in those with a Barrett's segment of 6 cm or longer. Gastric perforation occurred in one patient with Marfan's syndrome. Esophageal stricture developed in three, all successfully treated with dilation. In 17 HGD patients, cryotherapy produced CR-HGD, CR-D, and CR-IM of 94%, 88%, and 53%, respectively. Complete regression of cancer and HGD was seen in all seven patients with intramucosal carcinoma or stage I esophageal cancer. Endoscopic spray cryotherapy ablation using low-pressure liquid nitrogen in the esophagus is safe, well-tolerated, and efficacious.

Esophagectomy compared with chemoradiation for early stage esophageal cancer in the elderly

BACKGROUND

: Esophagectomy has been the traditional treatment of choice for early stage esophageal cancer. However, esophagectomy is associated with high mortality and morbidity in the elderly, and these patients often receive chemoradiation instead. The authors of this report compared outcomes of esophagectomy versus chemoradiation in a population-based sample of elderly patients with early stage esophageal cancer.

METHODS

: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged > or =65 years who were diagnosed with stage I or II esophageal cancer from 1991 to 2002. The associations of treatment with esophagectomy or chemoradiation were assessed along with demographic and clinical variables. A survival analyses was performed to compare outcomes with treatment modality and was adjusted for potential confounders.

RESULTS

: Seven hundred thirty patients with stage I or II esophageal cancer were identified who underwent esophagectomy (n = 341; 46.7%) or chemoradiation (n = 389; 53.3%). Older age, squamous cell histology, and lower socioeconomic status were associated with increased odds of receiving chemoradiation. In multivariate analyses, chemoradiation was associated with worse disease-specific survival (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.64-2.64) and overall survival (HR, 1.92; 95%CI, 1.58-2.34). The receipt of chemoradiation was associated with worse survival for patients with adenocarcinoma (HR, 3.01; 95%CI, 2.24-4.04), but there was no significant difference for patients with squamous cell carcinoma (HR, 1.33; 95%CI, 0.98-1.80).

CONCLUSIONS

: Compared with chemoradiation, esophagectomy may be associated with improved survival for early stage esophageal cancer in the elderly. The current results suggest that there also may be a subset of patients with squamous cell carcinoma for whom chemoradiation is adequate therapy. A randomized trial would be useful to determine the optimal treatment for elderly patients with early stage esophageal cancer. Cancer 2009. (c) 2009 American Cancer Society.

Use of adjuvant 5-fluorouracil and radiation therapy after gastric cancer resection among the elderly and impact on survival

PURPOSE

In randomized trials patients with resected nonmetastatic gastric cancer who received adjuvant chemotherapy and radiotherapy (chemoRT) had better survival than those who did not. We investigated the effectiveness of adjuvant chemoRT after gastric cancer resection in an elderly general population and its effects by stage.

METHODS AND MATERIALS

We identified individuals in the Surveillance, Epidemiology, and End Results-Medicare database aged 65 years or older with Stage IB through Stage IV (M0) gastric cancer, from 1991 to 2002, who underwent gastric resection, using multivariate modeling to analyze predictors of chemoRT use and survival.

RESULTS

Among 1,993 patients who received combined chemoRT or no adjuvant therapy after resection, having a later year of diagnosis, having a more advanced stage, being younger, being white, being married, and having fewer comorbidities were associated with combined treatment. Among 1,476 patients aged less than 85 years who survived more than 4 months, the 313 who received combined treatment had a lower mortality rate (hazard ratio, 0.83; 95% confidence interval, 0.71-0.98) than the 1,163 who received surgery alone. Adjuvant therapy significantly reduced the mortality rate for Stages III and IV (M0), trended toward improved survival for Stage II, and showed no benefit for Stage IB. We observed trends toward improved survival in all age categories except 80 to 85 years.

CONCLUSIONS

The association of combined adjuvant chemoRT with improved survival in an overall analysis of Stage IB through Stage IV (M0) resected gastric cancer is consistent with clinical trial results and suggests that, in an elderly population, adjuvant chemoradiotherapy is effective. However, our observational data suggest that adjuvant treatment may not be effective for Stage IB cancer, is possibly appropriate for Stage II, and shows significant survival benefits for Stages III and IV (M0) for those aged less than 80 years.

Cigarette smoking and risk of lung metastasis from esophageal cancer

BACKGROUND

Whereas extensive research has explored the effect of environmental factors on the etiology of specific cancers, the influence of exposures such as smoking on risk of site-specific metastasis is unknown. We investigated the association of cigarette smoking with lung metastasis in esophageal cancer.

METHODS

We conducted a case-control study of esophageal cancer patients from two centers, comparing cases with lung metastases to controls without lung metastases. Information was gathered from medical records on smoking history, imaging results, site(s) of metastasis, and other patient and tumor characteristics. We used logistic regression to assess association.

RESULTS

We identified 354 esophageal cancer cases; smoking status was known in 289 (82%). Among patients with lung metastases, 73.6% (39 of 53) were ever smokers, versus 47.8% (144 of 301) of patients without lung metastases [P=0.001; summary odds ratio (OR), 2.52; 95% confidence interval (95% CI), 1.17-5.45; stratified by histology]. Smoking was associated with a nonsignificant increased adjusted odds of lung metastasis (OR, 1.89; 95% CI, 0.80-4.46). Upper esophageal subsite (OR, 4.71; 95% CI, 1.20-18.5), but not histology (squamous OR 0.65,95% CI 0.27-1.60), was associated with lung metastasis. Compared with the combined never/unknown smoking status group, smoking was associated with a significantly increased odds of lung metastasis (OR, 2.35; 95% CI, 1.11-4.97). There was no association between liver metastasis and smoking (OR, 0.88; 95% CI, 0.42-1.83).

CONCLUSIONS

Smoking is associated with increased odds of lung metastasis from esophageal cancer, and this relationship seems to be site specific. Future studies are needed to determine whether smoking affects the tumor cell or the site of metastasis, and whether this changes the survival outcome.

Utility in clinical practice of immunoglobulin a anti-tissue transglutaminase antibody for the diagnosis of celiac disease

BACKGROUND & AIMS

The diagnosis of celiac disease often relies on the anti-tissue transglutaminase (tTG) antibody test. The aim of this study was to evaluate its sensitivity and specificity in clinical practice with the use of commercial laboratories, in which the test characteristics might differ from research laboratories.

METHODS

We identified 122 patients with suspected celiac disease who had anti-tTG antibody serologies as well as upper endoscopy with duodenal biopsies. Those with celiac disease were classified as either classic (with diarrhea or other symptoms of malabsorption) or silent (asymptomatic). Biopsies from celiac disease patients were classified as either partial (Marsh IIIA) or total (Marsh IIIB or IIIC) villous atrophy.

RESULTS

The overall sensitivity, specificity, and positive and negative predictive values of the anti-tTG antibody test were 70.6%, 65.0%, 91.1%, and 30.2%, respectively. The sensitivity was 90.0% for patients with total villous atrophy and 42.3% for patients with partial villous atrophy (P < .0001). There were differences in both sensitivity and specificity between the 2 most commonly used commercial laboratories. The sensitivity for Lab #1 was 40.0% versus 86.4% for Lab #2 (P < .0001). The specificity for Lab #1 was 100.0%, and it was 41.7% for Lab #2 (P = .02).

CONCLUSIONS

The sensitivity of the anti-tTG antibody in clinical practice is not as high as previously reported in research laboratories. The sensitivity is significantly lower in patients with partial villous atrophy. There is also significant variability in test characteristics among major commercial laboratories in the United States. These results need to be confirmed in prospective studies.

Seronegative celiac disease: increased prevalence with lesser degrees of villous atrophy

Our aim was to assess differences in the sensitivities of serologic tests used for the diagnosis of celiac disease among patients with varying degrees of villous atrophy. Among 115 adults with biopsy-proven celiac disease who fulfilled strict criteria, including serologic testing at the time of diagnosis and response to a gluten-free diet, 71% had total villous atrophy and 29% partial villous atrophy. Endomysial antibody was positive in 77% of those with total villous atrophy, compared to 33% with partial villous atrophy (P < 0.001). There was no difference in sensitivity when the type of presentation (classical vs. silent) was compared. Endomysial antibody-positive and negative patients did not differ with respect to age at diagnosis, duration of symptoms, mode of presentation, or family history of celiac disease. All anti-tissue transglutaminase-positive patients had TVA on biopsy. Seronegative celiac disease occurs. Endomysial antibody positivity correlates with more severe villous atrophy and not mode of presentation of celiac disease. Serologic tests, in clinical practice, lack the sensitivity reported in the literature.

Neoadjuvant therapy in cancer treatment

Neoadjuvant therapy has come to play an increasingly prominent role in the treatment of cancer. Originally defined as systemic therapy given before local treatment, the concept has been extended to include radiation therapy given before surgery. Potential advantages include improved local and distant control, direct evaluation, and organ-sparing treatment. Potential disadvantages include increased toxicity and cost, potential delay in effective treatment, and obscuring of pathologic staging. Neoadjuvant therapy in cancer treatment may be viewed in three categories: tumors in which neoadjuvant treatment has been shown effective, thus becoming standard therapy; tumors in which it has been shown to facilitate organ-sparing, and tumors in which its utility has not been shown. For patients with osteogenic sarcoma, for example, preoperative chemotherapy and limb salvage therapy have become the standard of care. Response to chemotherapy, ascertained by histologic review of the surgical specimen, can be used to tailor postoperative chemotherapy. In patients with advanced laryngeal squamous cell carcinoma, neoadjuvant chemotherapy followed by radiation has permitted laryngeal preservation in a majority of patients without compromising overall survival. Phase II and III studies conducted in women with breast cancer have demonstrated promising results for neoadjuvant chemotherapy given before radiation therapy and/or surgery. Phase III studies to compare neoadjuvant therapy to standard therapy in patients with breast cancer are underway. For neoadjuvant therapy, as with other innovations in cancer treatment, it is crucial that a new strategy must be compared closely to standard therapy in terms of recurrence, survival, and impact on organ sparing, as well as quality of life and treatment costs.

Evidence of venous stasis after abdominal insufflation for laparoscopic cholecystectomy

Intraoperative venous stasis may increase the risk for perioperative deep vein thrombosis and pulmonary embolism. To determine if abdominal insufflation during laparoscopic cholecystectomy causes venous stasis, eight patients undergoing this procedure had their left common femoral veins examined by a duplex scanner before and after abdominal insufflation; the veins then were examined again before and after deflation. The right femoral veins were catheterized to measure femoral venous pressures. Abdominal insufflation to 14 millimeters of mercury pressure increased femoral venous pressures (10.2 +/- 4.1 millimeters of mercury to 18.2 +/- 5.1 millimeters of mercury; p < 0.001) and slowed peak blood velocities (24.9 +/- 8.5 centimeters per second to 18.5 +/- 4.5 centimeters per second; p < 0.05) without changing the cross-sectional areas (1.1 +/- 0.4 centimeter squared to 1.2 +/- 1.5 centimeter squared; p = NS) of the common femoral veins. Insufflation also reduced or eliminated pulsatility in the common femoral veins in 75 percent of the patients, indicating that insufflation was causing partial proximal venous obstruction. After 80 +/- 21 minutes of surgery, these changes remained significant. Deflation of the abdomen restored normal venous pulsatility in all patients, reduced femoral venous pressures (18.5 +/- 5.2 millimeters of mercury to 12.2 +/- 9.8 millimeters of mercury; p < 0.001), increased the peak blood velocities (14.2 +/- 6.8 centimeters per second to 28.1 +/- 16 centimeters per second; p < 0.05) and decreased the cross-sectional areas (1.4 +/- 0.6 centimeters squared to 0.9 +/- 0.4 centimeters squared; p < 0.05) of the common femoral veins, indicating venous decompression had occurred. The results suggest abdominal insufflation causes venous stasis during laparoscopic cholecystectomies. Measures shown to reduce intraoperative venous stasis, such as pneumatic compressive stockings, may benefit patients undergoing these procedures.