Clinical and molecular evaluation of patients with esophageal adenocarcinoma from the United States and Japan

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Background: Esophageal adenocarcinoma (EAC) is more common than squamous cancer (ESC) in the US versus Japan (J); however, EAC in J is now more frequently recognized. We assessed features of EAC in J and US patients to determine if the cohort of EAC in Japan is similar to the US. Methods: Patients with EAC who underwent primary curative surgery were identified by reviewing all surgical cases from 1998 to the present at Johns Hopkins Hospital (n = 57) and Juntendo University Hospital (n = 20). Clinical variables included: gender, age, pathologic stage, date of surgery and of death. Methylation of APC, E-cadherin, MGMT, ER, p16, DAP-kinase and TIMP3 was determined with methylation specific-PCR for each J patient and compared to historical control US EAC patients. Logistic regression and survival analysis were used to evaluate the relationship between clinical variables and methylation status to outcome in these two patient groups. Results: Age and gender were similar in each cohort. Gender (50M/6F in US; 16M4F p = 0.29). Median age (65.5 in US; 64 in J). Path stage was lower in US patients but not significant compared to J patients. Stage distribution US: stage I (n = 30), IIA (n = 2), stage IIB (n = 6), stage III (n = 9) and stage IV (n = 4). Stage distribution in J: stage I (n = 6), IIA (n = 5), stage IIB (n = 5), stage III (n = 3) and stage IV (n = 3). Path stage unavailable in 5 US patients. Overall median survival was 4.2 years. Median survival for US was 2.9 years but not reached for J (note 15/20 J patients outcome not known). For the combined cohort, age and path stage (adjusted for clinical co-variates) correlated with worse survival. Age HR 1.05; 95% CI 1.01–1.09. Pathologic Stage HR 1.4; 95% CI 1.19–1.65. These were also predictive within each subgroup. The fraction of patients with methylation is available for three genes: APC (66% US; 70% J). p16 (39% US; 20% J). MGMT (63% US; 75% J). Conclusions: Clinical data are similar for US and J patients with EAC. Early stage in US patients may by due to induction chemoRT in the US. Predictors of survival (age and pathologic stage) are also similar. This suggests that EAC is similar in US and J patients, perhaps reflecting similar environmental and molecular causes. Methylation data for all 7 genes and their correlation with outcome will be presented at the meeting.

No significant financial relationships to disclose.

[Prevalence and causes of reflux in deep venous system of the leg in patients with insufficiency of superficial veins]

The aim of the prospective study was to find out the following: 1. What is the prevalence of deep vein reflux of the leg in patients with superficial vein reflux detected by ultrasonography? 2. What are the possible causes of deep vein insufficiency of the leg retrospectively detectable on the basis of targeted medical history? 3. Is the incidence of identified deep vein insufficiency of the leg gender specific? The sample consisted of 100 legs with superficial vein reflux detected on ultrasonography (C1 - C4 / CEAP) of 79 randomized patients (59 women aged 45 +/- 12 years and 20 men aged 52 +/- 15 years). We collected the medical history of all patients and examined them for any vascular diseases of the leg. Superficial and deep venous system of the leg was examined by routine duplex ultrasonography with 7.5 a 10 MHz linear probe in B-mode, colour flow mapping and pulse Doppler using Valsalva manoeuvre and manual compression of thigh. During the examination, patients lay both prone and on their back.

RESULTS

Prevalence of deep vein reflux in patients with superficial vein reflux detected by ultrasonography was 43 %. Prevalence of deep vein reflux in patients only with primary venous insufficiency (i.e. personal medical history without phlebothrombosis of the leg, trauma, surgery or plaster fixation) was 35.4% in our sample. The possible causes of deep vein reflux in our patients are the following: overweight and obesity (58.6%), primary valvular insufficiency (35.4%), secondary valvular insufficiency--post-thrombotic, post-traumatic (34.9%) and various combinations of these factors. Deep vein insufficiency increased with the BMI. Deep vein reflux was significantly more frequent in men (80%) as compared with women (54.2%).

[Myocardial ischaemia resulting from compression of coronary artery caused by herniation of abdominal organs into thoracic cavity]

A case of 40-year-old patient with compression of coronary artery and myocardial ischaemia is presented. Compression resulted from the herniation of abdominal organs into the thoracic cavity, which developed many years after the car accident trauma.

[Distal protection during primary coronary angioplasty in patients with acute myocardial infarction]

BACKGROUND

The aim of the study was to assess the safety, feasibility and efficacy of mechanical distal protection during primary angioplasty using FilterWire EZ (FW).

METHOD AND RESULTS

Thirty-one patients with acute myocardial infarction (AMI) were treated by primary angioplasty with distal protection using FW. The results were compared with a matched control group consisting of 33 patients with AMI treated by primary angioplasty alone. Successful FW positioning was obtained in 30 patients (97%). In these patients a lower rate of distal embolisation (3 vs. 18%, p=0.04) was found and a more effective reperfusion was assessed by ST elevation's resolution >50% immediately after the procedure (83 vs. 61%, p=0.05). A higher number of patients with corrected TIMI frame count <27 in FW group supported more effective reperfusion to but this difference did not reached statistical significance (87 vs. 73%, p=0.09). There were no differences between groups regarding average peak CK and CK-MB. However, there is a trend to lower release in FW group (32.1+/-24.5 vs. 35.3+/-31.0, p=0.33; 4.2+/-3 vs. 4.4+3.7, p=0.44).

CONCLUSIONS

The presented study confirmed that distal embolisation during primary angioplasty is a frequent phenomenon. In this setting, adjunctive use of the FW is feasible and save, and it may improve myocardial reperfusion by reducing the embolic events.

[Surgery of the low extremity varices as a part of a same-day surgery programme]

INTRODUCTION

One-day surgical methods lower the procedures costs as well the need for urgent beds in surgical clinics. The varix operation seem to be the optimal diagnosis suitable for the one-day surgical procedure.

AIM

The aim of this work is to assess a feasibility of the one-day surgery for the low extremities varix operations.

METHODOLOGY

During the period starting in January until December 2003, 98 extremities were operated for varices. The surgical procedure was the same for the hospitalized as well as for the patients assigned to the one-day surgery programme. Each patient was examined with the duplex ultrasound prior to the surgery, after the surgery a compressive bandage was indicated.

RESULTS

We operated 98 extremities in 96 patients suffering from varices during the period from January 2003 to December 2003. The trial group consisted of 67 females and 29 males aged 21-79 years of age (the average of 45.3 years). According to the CEAP classification, 57 extremities (58.2%) were assigned to the C2 category, 30 extremities (30.6%) to the C3 category, 6 extremities (6%) to the C4 category, 4 extremities (4%) to the C5 category and one extremity (1%) to the C6 category. 14 extremities in the group were operated due to the disease relapse. 62 patients (i.e. 65%) were released for the home-care on the day of the operation, 27 patients (28%) were released the following day. One patient was hospitalized for two days, three patients for three days, one patient for four days and two patients for five days. 91 out of the total 98 extremities (i.e. 93%) underwent the one-day surgery.

CONCLUSION

Although some patients require hospitalization, the varix surgery is safe and suitable for the one-day surgery. A thorough preoperative examination as well each patient's cooperation are both very important.

[Recurrence of varices in lower extremities]

Authors have done a retrospective analysis of 94 lower extremities in 88 patients examined from 1996 to 2002 for recurrence of varices in lower extremities. The goal was to find out the most frequent causes of recurrence of varices in lower extremities in patients with history of varices surgery referred to venous guidance clinic because of another onset of varices in lower extreminites or clinical signs of chronic venous insufficiency. Reflux was proved in 78 lower extremities from the total number of 94 (83%) in our sample. Isolated reflux was discovered in 59 extremities in saphenofemoral junction (39 extremities), in saphenopopliteal junction (14 extreminies), and in perforators (6 extremities). Combined reflux detected simultaneously in two or three places (SFJ, SPJ, perforators) was found in 19 extremities. In 11 cases the reflux was proved in two places and in 8 cases even in 3 places simultaneously. The main cause of recurrence of varices in lower extremities in our sample was reflux especially in saphenofemoral junction and saphenopopliteal junction. Reflux in perforators was usually accompanied with saphenofemoral and/or saphenopopliteal junctions incompetence. Isolated reflux in perforators was found very rarely (6.4%). The cause of varices recurrence was not disclosed in 17% of cases.

[Total stripping of the greater saphenous vein--an obsolete method?]

The authors discuss the surgical treatment of primary varices. The analysis is based on pathophysiological principles in the development of venous insufficiency. The attention is paid to reflux in key positions, presumably sapheno-femoral and sapheno-popliteal junctions, respectively. Dilated perforators with a reflux are considered to ensue from these refluxes. These principles enable to draw conclusions on an adequate therapeutic procedure, a limited stripping of saphena veins. A total stripping is indicated only exceptionally, when the whole stem is affected.

[Chronic venous insufficiency--outpatient study of risk factors]

The aim of the clinical study was to monitor and analyse possible causes of chronic venous insufficiency (CVI) in a randomised sample of patients with diagnosed CVI. There were 100 patients in the investigated sample, 82 women of an average age of 40.4 years and 18 men of an average age of 42.7 years. Monitoring of risk factors of development and advancement of CVI in our sample of patients showed following results: 1. frequent overweight and obesity (BMI > 25 kg/m2) in women (47.6%) and men (83%) with relatively frequent cases when a patient put on weight more than 5 kg within the last 5 years before development of CVI signs (24.4% of women and 22% of men); 2. a predominance of multiparas (68.3%) over women who have not given a birth or gave birth to 1 child (31.7%), we have found a big percentage of multiparas among both women younger than 40 (40%) and especially older women (> or = 40 years) where the percentage was 75.4%); 3. a positive family history in the majority of our patients with CVI (71%), in 88.7% in a first grade relative; 4. the major part of people in the sample were standing when working (59%), the number of people with sedentary work was high too (32%); 5. smoking admitted only minor part of the CVI patients (27%); 6. significant history of hormonal treatment in the female patients (37.8%), especially among women younger than 40 (48%); 7. other risk factors (accidents and surgeries of lower extremities, recurrent thrombophlebitis) appeared either in a very small percentage of the patients (lower limbs surgeries) or in significantly smaller percentage compared to risks in points 1 to 4 (accidents of lower extremities 20%), recurrent thrombophlebitis 22%).

Esophageal dysfunction in a female patient with diabetes mellitus and achalasia

BACKGROUND

Achalasia is an infrequent disorder of esophageal motility. Diabetes mellitus is an endocrine metabolic disease, the complication of which can afflict the motor activity of gastroenteral tract. The combination of these diseases in one patient is also very rare. In this study we introduce one patient suffering from this scarce coincidence of diseases.

CASE HISTORY

A 54-year-old diabetic patient who lost weight of 26 kg in one month with repeated hypoglycaemic collapse states and regurgitation of poorly digested food and saliva with maintained appetite and thirst. The diagnosis of esophageal achalasia II was proved. A standard surgical performance was chosen, namely the laparoscopic myotomy. The extent of myotomy was verified by preoperative manometry. Approximately 1 month after the surgery, intermittent mild dysphagia especially after the consumption of solid food and some sorts of fruit appeared. The suspicion of stricture in the site of myotomy led us to the performance of endoscopic and radiologic examinations. The balloon calibration of cardia did not reveal any residual muscular fibres. The supplementation of a prokinetic drug of itoprid three times a day resulted in a significant improvement of difficulties.

CONCLUSION

Despite the sufficient extent of surgical treatment in a patient suffering from these two diseases, the resulting effect was not fully satisfactory. It is apparent that despite the correctly indicated and performed operation in patients suffering from a metabolic disease, the complications of which afflict the motility of upper digestive tract, the ideal response to treatment cannot be expected. The supplemented prokinetic therapy is inevitable, and informing the patient on the expected result and particular residual disorders can save both the patient and surgeon from disappointment. (Fig. 3, Ref. 8.).

[CHS 100P surgical mesh in inguinal hernioplasty in adults using the Lichtenstein tension-free method]

AIMS

The authors present their initial experience with surgical grid CHS 100 P with strengthened middle strip for the intestinal hernioplasty by the method without tension according to Lichtenstein.

METHODS

In the inguinal hernioplasty by anterior transinguinal way in adult patients the authors use prolene grid and a surgical grid CHS 100 P with strengthened middle strip having been developed in collaboration with the Research Knitting Institute in Brno.

RESULTS

From November 2001 to May 2003 56 adult patients were operated on inguinal hernia by the tensionless plasty according to Lichtenstein using a surgical grid CHS 100 P. No preoperation of postoperation complication or relapse were encountered. The patients were subject to load in the first postoperation day.

CONCLUSION

Based on our first experience with flexible surgical grid with strengthened middle band CHS 100 P used for tensionless inguinal hernioplasty in adult patients according to Lichtenstein it may be concluded that the grid is well tolerated by the patients. Flexibility of the grid makes it possible to fully load inguinal area during the first postoperation day.

[Complications after laparoscopic surgery of inguinal hernias]

AIMS

The authors describe the occurrence of complications in laparoscopic approach to treat inguinal hernias in patients operated on at 2nd Surgical Clinic in Olomouc from May 1991 to the end of the year 2002.

METHODS

The occurrence of preoperation and postoperation complications and relapses in inguinal hernias treated with laparoscopy in the period of May 1991 to the end of 2002. The TAPP method was used for operation on 98% of inguinal hernias, the IPOM method for 0.9% of inguinal hernias, TEP method in 0.4% and a simple suture in operation on 0.7% of inguinal hernias.

RESULTS

Five hundred and thirty four (56% of all surgically treated inguinal hernias) were treated with laparoscopy in adult patients in the period of May 1991 to the end of 2002. Eight preoperation and postoperation complications (1.4%) were encountered. These included two cases of hematoma in the wound after port (0.3%), one hematoma of scrotum (0.2%), two artificial perforations of intestine (0.3%), one case of neuralgia of n. genitofemoralis, one artificial perforation of urinary bladder (0.2%), and one postoperation hydrocele (0.2%). There were 14 relapses (2.6%) in the 534 inguinal hernias operated on with laparoscopy.

CONCLUSION

Based on our experience in the solution of inguinal hernias with laparoscopy the method of transabdominally-preperitoneally localized grid (TAPP). In this method we have used three-point fixation--by a screw to pected ossis pubis and the upper margins of the grip with two transparietal stitches fixed permanently in subcutaneous tissue.

[Peroperative diagnostic methods during esophageal achalasia surgery. Initial experience]

AIM OF THE STUDY

The authors present their first experience with the application of esophageal manometry during the operation on achalasia of esophagus. The completeness of performed myotomy is evaluated on the basis of decreased pressure in the region of lower esophageal sphincter (LES).

METHODS

Stationary pull-through four-channel manometry was performed twice during the operation: before the application of capnoperitoneum to localize LES with evaluation of its length and tonus and after the myotomy was performed after capnoperitoneum was abolished to verify sufficient extent of myotomy. The subsequent endoscopic control was used to exclude damage of esophagus mucous membrane.

RESULTS

In the period of one year during 2002/2003 the authors operated on four patients with achalasia, when manometry was used for peroperative localization of LES and evaluation of the extent of myotomy. The peroperation manometry demonstrated decreased tonus of LES (the mean 42.06 mmHg before myotomia and the mean 20.03 mmHg after myotomia) and in one case the finding resulted in necessary extension of myotomia.

CONCLUSIONS

Based on our preliminary experience with peroperation manometry in operations on achalasia of esophagus it may be stated that it is a useful method for objectivization of the completeness of myotomy, which does not significantly prolong the period of operation. It contrast, it makes it possible to respond to lasting hypertonic area in LES subjected to myotomy, which may be the cause of lasting complaints of patients after the operation.

Open versus laparoscopic appendectomy

BACKGROUND/AIMS

To asses the role of laparoscopic appendectomy in the treatment of acute as well as chronic appendicitis on the basis of our own experiences.

METHODOLOGY

From the set of 849 patients treated with appendectomy (from January 1993 to December 2000) 331 were singled out, i.e.; those unable to work for some time and thus being on sickness benefit who asked for a medical certificate. They were operated on for either acute or chronic appendicitis.

RESULTS

In our set of 331 patients (158 males, 173 females, the average age 29.4) open appendectomy was performed on 179 patients and laparoscopic appendectomy on 152. Laparoscopic appendectomy was performed in 43 males (28%) and 109 females (72%); open appendectomy in 115 males (64%) and 64 females (36%). Laparoscopic appendectomy took 53.7 +/- 18.1 minutes, open appendectomy took 43.6 +/- 8.99 minutes. The time of work disablement is longer in open appendectomy (open appendectomy: 41.2 +/- 9.91 days; laparoscopic appendectomy; 29.1 +/- 15.11 days). A significant difference (p < 0.00001) can be seen in the length of hospitalization (laparoscopic appendectomy: 5.0 +/- 2.75 days, open appendectomy: 8.3 +/- 2.83 days).

CONCLUSIONS

Patients who undergo laparoscopic appendectomy spent less time in hospital, and they can return to work rather earlier. On the other hand the time of surgery is longer. Higher cost is compensated for with shorter hospitalization and early return to work.

[Anatomic and hemodynamic changes in the venous vascular bed in the lower extremities with chronic venous insufficiency]

The authors paid attention to revealing as precisely as possible anatomical and haemodynamic conditions in venous vascular bed in the course of ultrasonographic examination of 309 lower extremities with clinical manifestations of chronic venous insufficiency (CVI). A combined reflux in the superficial and deep venous system (53.7%) or isolated reflux in superficial veins (25.9%) proved to be the most frequent pathogenic bases of CVI. Pathophysiology of varices was mostly based on the venous reflux and the primary idiopathic CVI was mostly present (98.1%). The post-thrombotic partial obstruction of the deep venous system (post-thrombotic venous changes on the walls) was demonstrated exceptionally (1.9%). A high coincidence of reflux in the deep and superficial venous system points out to s.c. secondary reflux in the deep veins originating on the basis of primary reflux in the large or small saphena. An attempt was made to clarify, whether the development and frequency of incompetent perforators is directly connected with the presence and seriousness of reflux in the large and small saphena. The presence and severity of large saphena insufficiency does not univocally indicate the presence of dilated or insufficient perforators on the medical side of the crus, where these anastomoses are present most frequently. The large saphena is a long vein typically suffering from segmental insufficiency, i.e. reflux affecting a certain portion, whereas other parts of the vein may be fully competent. Anatomical venous variability and abnormalities on lower extremities were demonstrated in every fifth extremity (62 extremities, 20.1%). Most of them concerned large saphena (39 extremities, 62.8%), small saphena being second (15 extremities, 25.2%). Other anatomical deviations occurred sporadically as solitary findings. In the large saphena, duplication was present most frequently (54.8%). Insufficient variable superficial veins and anatomical venous anomalies were mostly not the only pathogenic basis of CVI, but were predominantly associated with insufficiently in the area of deep veins and perforators (84%). In our cohort there were altogether 55 extremities (17.8%) after the operation on superficial venous system, where relapses of varices were found. The causes of post-operation relapse of varices may be divided into three groups: 1. insufficiency of the large saphena, 2. insufficiency of the small saphena and 3. insufficiency of the deep veins. A combined simultaneous insufficiency in several venous systems was found most frequently (27 extremities, 49.1%). Even though the reflux in the deep veins was demonstrated in 50.9% of these extremities, a combination with the reflux in superficial veins and perforators (49.1%) was present with the exception of one case of isolated insufficiency. The insufficiency of the large and small saphena was clearly the leading single causes (15 extremities, 27.3%) of varix relapses. The patients should never be operated on the venous system of lower extremities without previous detailed ultrasonographic examination. It is the only way to increase probability of the operation success and to decrease the risk of relapses of CVI manifestations.

Limited versus total stripping of vena saphena magna

BACKGROUND

There are two different ways to operate on patients with varicose veins.

OBJECTIVES

Prospective evaluation of two groups of patients operated on in two different ways to find out more convenient procedure for varicose veins surgery.

METHODS

The results of 577 patients operated on for lower limbs varicose veins were evaluated. The patients were divided into two groups. The first group comprised of 125 patients in whom limited stripping of vena saphena magna was performed. The second group comprised of 397 patients in whom total stripping of vena saphena magna was applied. In the remaining 55 patients an operation other than VSM was performed in the venous system of lower limbs. During the follow-up three months after the operation the main attention was paid to a possible neurological disturbance.

RESULTS

Much better results were observed in the group of patients treated with the method of limited stripping. Neurological disturbances occurred in two patients only (i.e. 1.6%). Within the other group disturbances were encountered in 28 patients (i.e. 7%).

CONCLUSIONS

Limited stripping of vena saphena magna results in lower number of neurological disturbances. (Tab. 1, Ref. 10.).

[Severing perforators in advanced stages of chronic venous insufficiency]

OBJECTIVE

To evaluate the importance of anastomozing veins in the development of chronic venous insufficiency (CVI).

METHOD

Perspective analysis of a group of 82 extremities where the perforators were severed by the endoscopic or open method.

RESULTS

Surgery of the perforators was associated with a decline of the total number of perforators detectable on DUS, with a marked reduction of extremities with insufficient perforators and improved total CEAP score. In 98% extremities at the same time surgery of the epifascial venous system was performed.

CONCLUSIONS

The role of perforators in the development of CVI is not unequivocal and its assessment is more difficult due to concurrent operations of the epifascial system. Dissection of the perforators is indicated in cca one tenth of patients with CVI.

[Endoscopic subfascial dissection of perforators (ESDP) vs open ligation of perforators]

OBJECTIVE

Comparison of two surgical procedures in discontinuation of the venae perforantes.

METHOD

The authors evaluated perspectively a group of 78 patients subjected to 82 operations with severing of the venae perforantes on the lower extremities. They defined the indications for both surgical procedures.

RESULTS

The open procedure (Cockett's segmental operation) was indicated in 10 extremities, ESDP in 72. The endoscopic operation lasted on average 59 minutes, the open one 50 minutes. The hospitalization period in the endoscopic variant was shorter (6.1 days vs. 8.5 days after the open operation). preoperative complications such as haemorrhage from the severed perforator occurred in ESDP. In Cockett's operation there were no preoperative complications, but there were two cases of healing per secundam during the postoperative period. Healing of crural ulcers within 12 weeks was recorded in both types of operations. The open procedure is indicated where there are major nodes on the leg and there are no extensive trophic changes, in particular in patients in stages C3 and C4. ESDP is indicated in patients in advanced stages of CVI, i.e. C5 and C6 according to CEAP.

CONCLUSIONS

Every method has its indications whereby a higher incidence of complications may be foreseen after the open operation as compared with the endoscopic one.

Consensus statements from the Second International Lung Cancer Molecular Biomarkers Workshop: a European strategy for developing lung cancer molecular diagnostics in high risk populations

The Second Molecular Biomarkers Workshop was held at the Roy Castle International Centre for Lung Cancer Research in Liverpool, in June 2001 and it brought together experts in the clinical, epidemiological and molecular-pathology of lung cancer from Europe and the USA, to address issues surrounding the development of a European strategy for early lung cancer detection. The 2001 Workshop Breakout Groups concentrated on the current challenges in the early detection of lung cancer which need to be addressed in the light of the recent surge in interest in many countries for mounting new clinical trials to evaluate the utility of Spiral CT in early lung cancer detection. If population-based trials of CT screening are mounted it will also be a favorable clinical environment in which to evaluate efficiently recent advances in molecular screening and genotyping. The Workshop focused specifically on: a) clinical and molecular biomarkers, b) sputum as an early detection and diagnostic tool, c) validation of molecular markers prior to their use in early detection trials and d) ethical issues that have to be considered in early lung cancer detection trials. A distillation of the Workshop discussions is given in this article.

Primary malignant melanoma of the esophagus treated by endoscopic ablation and interferon therapy

Primary malignant melanoma of the esophagus is a rare illness accounting for 0.1-0.2% of malignant diseases of the esophagus; however, the incidence of the disease appears to be rising. The average survival time is between 10 and 15 months. The authors describe the 25 month follow up of a patient with primary malignant melanoma of the esophagus which was treated with endoscopic ablation followed by interferon therapy. No other focus was found and the patient is undergoing regular endoscopic check-ups, currently without any problems.