A preoperative predictive tool to assess the need for staging laparoscopy in oesophagogastric cancer patients

INTRODUCTION

Staging laparoscopy (SL) has become commonplace in the preoperative staging pathway for oesophagogastric (OG) cancer. SL is often performed before curative treatment to examine for macroscopic peritoneal metastases (PM) or positive peritoneal cytology (PPC). The aim of this study was to develop an objective risk scoring system to predict both PM and PPC at SL.

METHODS

A prospectively collected and maintained database of all OG cancer patients treated between 2006 and 2020 was reviewed. Univariate and multivariate analyses were performed to identify risk factors for both PM and PPC at SL. A risk score was produced for both PM and PPC, and then validated internally.

RESULTS

Among 968 patients who underwent SL, 96 (9.9%) had PM and 81 (8.4%) had PPC at SL. Tumour site (p < 0.001), computed tomography (CT) T stage (p < 0.001) and N stage (p = 0.029) were significantly associated with PM at SL (p < 0.001). Tumour site (p < 0.001), biopsy histology (p = 0.041), CT T stage (p < 0.001) and N stage (p < 0.001) were significantly associated with PPC. The risk scoring model for PM included cancer site and CT T stage. This was successfully tested on the validation set (area under the receiver operating characteristic [AUROC] = 0.730). The risk scoring model for PPC included cancer site, CT T and N stage. This was successfully tested on the validation set (AUROC = 0.773).

CONCLUSIONS

The current risk scores are valid tools with which to predict the risk PM and PPC in patients undergoing SL for OG cancer and may help to avoid subjecting patients to unnecessary SL.

The Birmingham Standardized Idiopathic Intracranial Hypertension Shunt Protocol: Technical Note

BACKGROUND

Insertion of cerebrospinal fluid (CSF) shunts in patients with idiopathic intracranial hypertension (IIH) is challenging mainly due to the small ventricles and phenotypical body habitus. In this report the authors present their surgical protocol for insertion of a ventriculoperitoneal shunt (VPS) in patients with IIH and the associated revision rates.

METHODS

The protocol comprises the following: shunt surgery by neurosurgeons with expertise in CSF disorders; a frontal VPS usually right sided but left sided if the left ventricle is bigger; use of the proGAV 2.0 valve with gravitational unit, set at 10 and the M.scio telemetric sensor; cannulation of the ventricle with StealthStation EM navigation system; and laparoscopic insertion of the peritoneal catheter. The authors describe the protocol and rationale and evidence behind each component and present the results of a prospective analysis on revision rates.

RESULTS

The protocol has been implemented since 1 July, 2019, and by 28 February, 2022, sixty-two patients with IIH had undergone primary VPS insertion. The 30-day revision rate was 6.5%, and overall 11.3% of patients underwent revision during the study period, which compares favorably with the literature. The etiology for early failures was related to the surgical technique.

CONCLUSIONS

The components of the Birmingham standardized IIH shunt protocol are evidence based and address the technical challenges of CSF diversion in patients with IIH. This protocol is associated with a low revision rate, and the authors recommend standardization for CSF shunting in IIH.

Impact of postoperative complications on survival after oesophagectomy for oesophageal cancer

BACKGROUND

Recent evidence suggests that complications after oesophagectomy may decrease short- and long-term survival of patients with oesophageal cancer. This study aimed to analyse the impact of complications on survival in a Western cohort.

METHODS

Complications after oesophagectomy were recorded for all patients operated on between January 2006 and February 2017, with severity defined using the Clavien-Dindo classification. Associations between complications and overall and recurrence-free survival were assessed using univariable and multivariable Cox regression models.

RESULTS

Of 430 patients, 292 (67·9 per cent) developed postoperative complications, with 128 (39·8 per cent) classified as Clavien-Dindo grade III or IV. No significant associations were detected between Clavien-Dindo grade and either tumour (T) (P = 0·071) or nodal (N) status (P = 0·882). There was a significant correlation between Clavien-Dindo grade and ASA fitness grade (P = 0·032). In multivariable analysis, overall survival in patients with Clavien-Dindo grade I complications was similar to that in patients with no complications (hazard ratio (HR) 0·97, P = 0·915). However, patients with grade II and IV complications had significantly shorter overall survival than those with no complications: HR 1·64 (P = 0·007) and 1·74 (P = 0·013) respectively.

CONCLUSION

Increasing severity of complications after oesophagectomy was associated with decreased overall survival. Prevention of complications should improve survival.

Validation of the NUn score as a predictor of anastomotic leak and major complications after Esophagectomy

Predicting major anastomotic leak (AL) and major complications (Clavien-Dindo 3-5) following esophagectomy improves postoperative management of patients. The role of the NUn score in their prediction is controversial. This study aims to evaluate the predictive ability of this simple score. Data were retrospectively collected for consecutive esophagectomies over a 10-year period, and NUn scores were retrospectively calculated for each patient from informatics data. A standardized definition of major AL was used, excluding minor asymptomatic, radiologically detected leaks. The predictive accuracy of the NUn score and its constituent parts, for major AL and major complications, was assessed using area under receiver operating characteristics curves (AUROCs). Of 382 patients, 48 (13%) developed major AL and 123 (32%) developed major complications. The NUn score calculated on postoperative day 4 was significantly predictive of both outcomes, with AUROCs of 0.77 and 0.71, respectively (both P < 0.001). A NUn score cut-off of 10 had a negative predictive value of 95% for major AL. The NUn score was predictive of major complications on multivariable analysis. The NUn score was found to be a significant predictor of major AL, suggesting that this is a useful early warning score for major AL. The score may also be useful in identifying patients that are the most likely to benefit from enhanced recovery protocols.

Vascular calcification does not predict anastomotic leak or conduit necrosis following oesophagectomy

BACKGROUND

Anastomotic leaks (AL) and gastric conduit necrosis (CN) are serious complications following oesophagectomy. Some studies have suggested that vascular calcification may be associated with an increased AL rate, but this has not been validated in a United Kingdom population.

AIM

To investigate whether vascular calcification identified on the pre-operative computed tomography (CT) scan is predictive of AL or CN.

METHODS

Routine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed. Calcification of the proximal aorta, distal aorta, coeliac trunk and branches of the coeliac trunk was scored by two reviewers. The relationship between these calcification scores and occurrence of AL and CN was then analysed. The Esophagectomy Complications Consensus Group definition of AL and CN was used.

RESULTS

Complication data were available in n = 411 patients, of whom 16.7% developed either AL (15.8%) or CN (3.4%). Rates of AL were significantly higher in female patients, at 23.0%, compared to 13.9% in males (P = 0.047). CN was significantly more common in females, (8.0% vs 2.2%, P = 0.014), patients with diabetes (10.6% vs 2.5%, P = 0.014), a history of smoking (10.3% vs 2.3%, P = 0.008), and a higher American Society of Anaesthesiologists grade (P = 0.024). Out of the 14 conduit necroses, only 4 occurred without a concomitant AL. No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes. Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes. However, the stepwise approach did not select any factors for inclusion in the final models. The analysis was repeated for composite outcomes of those patients with either AL or CN (n = 69, 16.7%) and for those with both AL and CN (n = 10, 2.4%) and again, no significant associations were detected. In the subset of patients that developed these outcomes, no significant associations were detected between calcification and the severity of the complication.

CONCLUSION

Calcification scoring was not significantly associated with Anastomotic Leak or CN in our study, therefore should not be used to identify patients who are high risk for these complications.

Prognostic significance of circumferential resection margin involvement in patients receiving potentially curative treatment for oesophageal cancer

INTRODUCTION

The utility of Circumferential Resection Margin (CRM) status in predicting prognosis in oesophageal cancer is controversial, with different definitions used by the College of American Pathologists and the Royal College of Pathologists. We aimed to determine prognostic significance of CRM involvement and evaluate which system is the best predictor of prognosis.

METHODS

A cohort of 390 patients who had potentially curative oesophagectomy (- + neoadjuvant chemotherapy) were analysed. Associations between CRM involvement and patient outcome were assessed for the whole cohort, and for pre-specified subgroups of T3 tumours and those who received neo-adjuvant chemotherapy.

RESULTS

CRM-involvement was associated with higher T and N stage, tumour differentiation, increased tumour length and both lymphovascular and perineural invasion. Overall Survival (OS) and Recurrence Free Survival (RFS) significantly worsened with CRM-involvement (p = 0.001, p < 0.001). R1a (<1 mm but no macroscopic involvement) resulted in significantly improved OS (p = 0.037) and RFS (P = 0.026) compared to R1b (macroscopic involvement), but did not differ significantly from R0 (≥1 mm). The association between CRM-involvement and both OS and RFS remained significant regardless of whether neoadjuvant chemotherapy was given. However, CRM-involvement was not a significant prognostic marker in T3 patients (p = 0.148). Multivariable analysis found N stage, lymphovascular invasion, patient age and neoadjuvant chemotherapy to be significantly predictive of patient outcome. CRM-involvement was not a significant independent prognostic marker.

CONCLUSIONS

CRM-involvement was not found to be independently predictive of prognosis, after accounting for other prognostic markers. As such, CRM should not be considered a major prognostic factor in patients with oesophageal cancer.

Prognostic significance of tumor length in patients receiving esophagectomy for esophageal cancer

AIMS

We investigated the prognostic value of tumor length measurements acquired both from pre-operative imaging and post-operative pathology in esophageal cancer.

METHODS

Tumor lengths were examined retrospectively for 389 esophagectomy patients with respect to Endoscopy, EUS (Endoscopic Ultrasound), CT and PET-CT, and pathology. Correlations between the measurements on the different approaches were assessed, and associations between tumor length and survival were analyzed.

RESULTS

Only the tumor lengths assessed on pathology were found to be significantly associated with overall (P = 0.001) and recurrence free (P < 0.001) survival on univariable analysis. The median overall survival was 47.1 months in those patients with tumor lengths <3.0 cm, falling to 19.6 and 18.0 months in those with 3.0-4.4 and 4.5+ cm tumors, respectively, demonstrating a reduction in patient survival at a tumor length of around 3 cm. Tumor length on pathology was significantly correlated with tumor differentiation and both T- and N-categories. After accounting for these factors, tumor length on pathology was a significant independent predictor of recurrence-free (P = 0.016), but not overall (P = 0.128) survival.

CONCLUSIONS

Tumor lengths on pathology were found to be the most predictive of patient outcome. However, after accounting for other tumor-related factors, tumor length only resulted in a marginal improvement in predictive accuracy.

The long term results of endoscopic surveillance of premalignant gastric lesions

BACKGROUND

A large proportion of patients attending open access endoscopy have histological and gross pathological findings that are potentially premalignant. The proportion of these patients who go on to develop malignancies and the timescale over which this occurs are uncertain.

AIMS

This study aims to discover the incidence of gastric cancers in this "high risk" group and to examine the potential for their early diagnosis and treatment.

PATIENTS

A total of 1753 patients attended open access endoscopy. From these, 166 patients with dysplasia, intestinal metaplasia, atrophic gastritis, foveolar hyperplasia, regenerative changes, polyps, or ulcers who agreed to undergo annual surveillance endoscopy were studied.

METHODS

Patients were endoscoped annually. Additionally, patients with ulcers were re-examined at two monthly intervals until ulcer healing. Cancers detected were treated by gastrectomy.

RESULTS

Twenty two of 1753 patients attending open access endoscopy had gastric cancer (1.3%). In the study population, 14 cancers were detected over 10 years (8.4 %). These were of an earlier stage than those detected at open access (stage I and II 67% v 23%; p<0.05) and five year survival was significantly higher (50% v 10%; p=0.006). In atrophic gastritis and intestinal metaplasia the risk of malignancy was 11%.

CONCLUSIONS

In patients with atrophic gastritis or intestinal metaplasia, annual surveillance can detect most new tumours at an early stage with a major improvement in survival. Potential benefits of such a surveillance programme are large and warrant further investigation in a multicentre randomised controlled trial.

Prospective, double-blind, placebo-controlled randomized trial of cimetidine in gastric cancer. British Stomach Cancer Group

Cimetidine is thought to inhibit suppressor T-lymphocyte function and preliminary evidence from a randomized trial indicated that it might prolong survival for patients with operable and inoperable gastric cancer. The British Stomach Cancer Group conducted a randomized, double-blind, placebo-controlled trial examining the effects of cimetidine (400 mg or 800 mg twice a day) on the survival of patients with early (stages I, II and III: n = 229) and advanced (stages IVa and IVb: n = 201) gastric cancer. The primary end point was death. A total of 442 patients were randomized by 59 consultants in 39 hospitals between February 1990 and March 1995. Log-rank survival analysis was used to assess differences between the groups. Three hundred and forty patients died during the study: 166 (49%) in the cimetidine treatment groups and 174 (51%) in the placebo groups. Median survival for patients receiving cimetidine was 13 months (95% confidence interval (CI) 9-16 months) and 11 months in the placebo arm (95% CI 9-14 months). There was no significant difference in survival between the two treatment groups (P = 0.42) or between different doses of cimetidine tablets (P = 0.46). Five-year survival of those patients randomized to cimetidine was 21% compared to 18% for those patients randomized to placebo. Cimetidine at a dose of 400 mg or 800 mg twice a day does not have a significant influence on the survival of patients with gastric cancer compared to placebo.

Radical surgery for early gastric cancer

The role of radical surgery for early gastric cancer has become a topic of considerable debate. Despite excellent results from Japan and several retrospective and uncontrolled trials, results from two large prospective randomized trials appear to demonstrate no benefit from D2 compared to the D1 resections. These trials have prompted a move away from radical lymph-node dissection. We argue that this reasoning is flawed and based not on the lack of efficacy of the D2 resection but in an attempt to reduce post-operative mortality and morbidity. Post-operative complications are largely a result of distal pancreatectomy and splenectomy and the relative inexperience of surgeons performing the operations. By preserving these organs and concentrating surgery to specialized centres the complication rate of radical surgery can be significantly reduced to approximate that of non-radical surgery. Lymph-node metastasis to the N2 nodes in early gastric cancer has been shown to be as high as 23%. Non-radical surgery poses significant risks of leaving residual disease. Radical surgery must remain the operation of choice if non-curative surgery for a curable condition is to be avoided.

Screening for gastric cancer by Helicobacter pylori serology: a retrospective study

BACKGROUND

Screening by serology for Helicobacter pylori in young dyspeptic patients has been shown to be effective in reducing demand for endoscopy. H. pylori has been implicated in the causation of gastric cancer and the reported seropositivity rate in patients with gastric cancer ranges from 69 to 94 per cent. The aim of this study was to assess the potential value of Helicobacter antibodies as a method of selecting dyspeptic patients over the age of 45 years for endoscopy.

METHODS

A retrospective comparison of the antibody status to H. pylori was made between 154 patients with gastric cancer and a sex- and date of birth-matched dyspeptic control group. Results from the former group were correlated with demographic data and tumour characteristics.

RESULTS

Significantly more patients with gastric cancer were seropositive than controls (77 versus 66 per cent). H. pylori was not related to the Laurén classification of the tumour. Tumour site was significant: body and antrum tumours were associated with Helicobacter whereas cardial tumours appeared to be unrelated.

CONCLUSION

Screening by antibody assays to H. pylori would miss more than 30 per cent of current gastric cancers. The increasing incidence of cardial cancer would cause this percentage to rise in the future.

Determination by western blot (immunoblot) of seroconversions to toxic shock syndrome (TSS) toxin 1 and enterotoxin A, B, or C during infection with TSS- and non-TSS-associated Staphylococcus aureus

Serum antibody responses to toxic shock syndrome (TSS) toxin 1 (TSST-1) and staphylococcal enterotoxins A, B, and C were determined by western blot (immunoblot) analysis of acute- and convalescent-phase paired sera from 18 TSS- and 31 non-TSS-associated Staphylococcus aureus infections. Compared with non-TSS cases, seroconversion to TSST-1 was significantly more frequent among both menstrual (5 of 8 versus 1 of 31; P less than 0.001) and nonmenstrual (3 of 10; P less than 0.05) patients. Seroconversion to staphylococcal enterotoxin A was also more frequent among both menstrual (2 of 8 versus 0 of 31; P less than 0.05) and nonmenstrual (2 of 9; P less than 0.05) TSS patients. In general, patients with TSS associated with TSST-1-positive S. aureus were more likely to seroconvert exclusively to TSST-1 (4 of 12 versus 0 of 6; P = 0.16), whereas those associated with TSST-1-negative S. aureus were more likely to seroconvert exclusively to enterotoxins (3 of 6 versus 0 of 11; P less than 0.05). Concurrent seroconversions to multiple exoproteins were more frequent among both menstrual (3 of 8; P less than 0.05) and nonmenstrual (2 of 9; P less than 0.05) TSS patients compared with persons without TSS (0 of 31). These data suggest but do not prove that enterotoxins (especially staphylococcal enterotoxin A) in addition to TSST-1 may be involved in both menstrual and nonmenstrual TSS. Furthermore, since exposure to multiple exoproteins is more likely to occur during TSS-associated than non-TSS-associated S. aureus infections, the possibility of additive or synergistic effects of these putative toxins in the pathogenesis of TSS should be further explored.

Interactions of ciprofloxacin with clindamycin, metronidazole, cefoxitin, cefotaxime, and mezlocillin against gram-positive and gram-negative anaerobic bacteria

A total of 598 clinical isolates of anaerobic bacteria were tested against ciprofloxacin by the agar dilution technique with 10(5) CFU on Wilkins-Chalgren medium. Selected strains representative of the six major genera of anaerobes relatively resistant to the quinolones were tested for interactions with ciprofloxacin in combination with clindamycin, metronidazole, cefoxitin, cefotaxime, or mezlocillin by using a checkerboard agar dilution technique. Cefotaxime-ciprofloxacin and clindamycin-ciprofloxacin were the most effective combinations, with 16% of all isolates and 44% of the Bacteroides fragilis group isolates responding synergistically to the former combination and 9% of all isolates and 37% of Peptostreptococcus isolates responding synergistically to the latter. Occasional synergy was seen with all other antibiotic combinations except for metronidazole-ciprofloxacin. Likewise, synergism was seen with all groups of anaerobes except for Fusobacterium species. Antagonistic interactions were observed only with a Peptostreptococcus intermedius strain tested against clindamycin-ciprofloxacin. These data suggest that combinations of ciprofloxacin with these agents may be useful for certain resistant anaerobic infections.