Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Management of Patients with Gastric or Gastroesophageal Junction Cancer: From Theory to Integrated Clinical Path- ways Implementation in the Real World

INTRODUCTION

Best care of esophagogastric junction and gastric cancer (EGC) requires a complex, timely interaction between members of a multi-disciplinary team (MDT). An integrated clinical pathway (ICP) is necessary to achieve this goal as well as the implementation of its use in daily practice. The objective of this study was to elaborate on an integrated clinical pathway for the multi-disciplinary management of ECG. Authors also put in act an implementation program to improve adherence to guidelines thought an ICP.

METHOD

This prospective work carried out by a multi-institutional MDT in Italy identified expert panel extracted relevant recommendations and/or statements from published papers and guidelines obtaining a set of crucial interventions employed the Estimate-Talk-Estimate method. A flow-chart diagram was elaborated to elicit the process at a glance. The primary outcome measure was the elaboration of an ICP with a high consensus rate also reported as a snapshot diagram and its implementation in daily clinical practice. An accredited certification body agency validated results, and an implementation process was started in several hospitals known to treat ECG.

RESULTS

A methodologist aggregated a multi-disciplinary panel of experts from different institutions. The panel elaborated a flow-chart diagram with crucial intervention highlight and connecting lines, as well as outcome measures. An accredited certification body agency validated the entire process, representing the basis for empowerment and implementation among patients and oncological professionals in various hospitals.

CONCLUSION

The multi-disciplinary and multi-institutional expert panel successfully elaborated on a validated ICP for all stages ECG. An in-hospital implementation program has been programmed.

Interleukin-32 Contributes to Human Nonalcoholic Fatty Liver Disease and Insulin Resistance

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder due to increased accumulation of fat in the liver and in many cases to enhanced inflammation. Although the contribution of inflammation in the pathogenesis of NAFLD is well established, the cytokines that are involved and how they influence liver transformation are still poorly characterized. In addition, with other modifiers, inflammation influences NAFLD progression to liver cirrhosis and hepatocellular carcinoma, demonstrating the need to find new molecular targets with potential future therapeutic applications. We investigated gene signatures in 38 liver biopsies from patients with NAFLD and obesity who had received bariatric surgery and compared these to 10 control patients who had received a cholecystectomy, using DNA microarray technology. A subset of differentially expressed genes was then validated on a larger cohort of 103 patients who had received bariatric surgery for obesity; data were thoroughly analyzed in terms of correlations with NAFLD pathophysiological parameters. Finally, the impact of a specific cytokine, interleukin‐32 (IL32), was addressed on primary human hepatocytes (PHHs). Transcript analysis revealed an up‐regulation of proinflammatory cytokines IL32, chemokine (C‐X‐C motif) ligand 9 (CXCL9), and CXCL10 and of ubiquitin D (UBD), whereas down‐regulation of insulin‐like growth factor‐binding protein 2 (IGFBP2) and hypoxanthine phosphoribosyltransferase 1 (HPRT1) was reported in patients with NAFLD. Moreover, IL32, which is the major deregulated gene, correlated with body mass index (BMI), waist circumference, NAFLD activity score (NAS), aminotransferases (alanine aminotransferase [ALAT] and aspartate aminotransferase [ASAT]), and homeostasis model assessment of insulin resistance (HOMA‐IR) index in patients. Consistent with an instrumental role in the pathophysiology of NAFLD, treatment of control human hepatocytes with recombinant IL32 leads to insulin resistance, a hallmark metabolic deregulation in NAFLD hepatocytes. Conclusion:IL32 has a critical role in the pathogenesis of NAFLD and could be considered as a therapeutic target in patients.

The influence of preoperative psychological factors on weight loss after bariatric surgery: A preliminary report

Aim of this study was to investigate relationship between preoperative psychological factors and % total weight loss after gastric bypass. 76 adult patients scheduled for bariatric surgery were preoperatively asked to complete anxiety and depression Hamilton scales and Toronto Alexithymia Scale. At 3- and 6-month follow-up, body weight was assessed. At 6-month follow-up, alexithymic patients showed a poorer % total weight loss compared with non-alexithymic patients ( p = .017), and moderately depressed patients showed a lower % total weight loss compared with non-depressed patients ( p = .011). Focused pre- and postoperative psychological support could be useful in bariatric patients in order to improve surgical outcome.

Laparoscopic Management of a Small Bowel Recurrence of Endometrial Cancer

STUDY OBJECTIVE

We present a very rare case of focal metastasis of endometrial cancer to the small bowel entirely managed laparoscopically.

DESIGN

Case report (Canadian Task Force Classification Study design III).

SETTING

Tertiary referral centre in Rome, Italy.

PATIENTS

A 58 year-old patient with a FIGO Stage IB G2 N0 endometrial cancer was found to have a vaginal cuff recurrence and an isolated distant metastasis to the small bowel 13 months after primary treatment.

INTERVENTION

In this video we show a fully laparoscopic management mainly focusing on small bowel resection with intracorporeal anastomosis. A laparoscopic partial colpectomy was also performed. Our institutional review board approved this study.

MEASUREMENTS AND MAIN RESULTS

Operative time was 180 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathologic findings showed recurrent disease in the vaginal cuff and in the resected small bowel segment with free resection margins in both specimens and 3 mesenteric local nodes negative for metastasis. The patient was discharged on day 3 and 26 days later started adjuvant chemotherapy. After a 16-month follow-up period, the patient is still disease free and in good general conditions.

CONCLUSIONS

This case shows a successful laparoscopic management of recurrent endometrial cancer equiring complex surgical procedures.

Effects of biliopancreatic diversion on diurnal leptin, insulin and free fatty acid levels

Background

Free fatty acid (FFA) levels are raised in obesity as a consequence of increased production and reduced clearance. They may link obesity with insulin resistance. Bariatric surgery can result in considerable weight loss and reduced insulin resistance, but the mechanism of action is not well understood. Although drugs such as metformin that lower insulin resistance can contribute to weight loss, a better understanding of the links between obesity, weight loss and changes in insulin resistance might lead to new approaches to patient management.

Methods

Variations in circulating levels of leptin, insulin and FFAs over 24 h were studied in severely obese (body mass index over 40 kg/m2) women before and 6 months after biliopancreatic diversion (BPD). Body composition was measured by dual-energy X-ray absorptiometry. A euglycaemic–hyperinsulinaemic clamp was used to assess insulin sensitivity. Levels of insulin, leptin and FFAs were measured every 20 min for 24 h. Pulsatile hormone and FFA analyses were performed.

Results

Among eight patients studied, insulin sensitivity more than doubled after BPD, from mean(s.d.) 39·78(7·74) to 96·66(27·01) mmol per kg fat-free mass per min, under plasma insulin concentrations of 102·29(9·60) and 93·61(9·95) µunits/ml respectively. The secretory patterns of leptin were significantly different from random but not statistically different before and after BPD, with the exception of the pulse height which was reduced after surgery. Both plasma insulin and FFA levels were significantly higher throughout the study day before BPD. Based on Granger statistical modelling, lowering of daily FFA levels was linked to decreased circulating leptin concentrations, which in turn were related to the lowering of daily insulin excursions. Multiple regression analysis indicated that FFA level was the only predictor of leptin level.

Conclusion

Lowering of circulating levels of FFAs after BPD may be responsible for the reduction in leptin secretion, which in turn can decrease circulating insulin levels. Surgical relevanceInsulin resistance is a common feature of obesity and type II diabetes. These patients are also relatively insensitive to the biological effects of leptin, a satiety hormone produced mainly in subcutaneous fat.Biliopancreatic diversion, a malabsorptive bariatric operation that drastically reduces circulating lipid levels, improves insulin resistance independently of weight loss. The mechanism of action, however, has still to be elucidated.This study demonstrated that normalization of insulin sensitivity after bariatric surgery was associated with a reduction in 24-h free fatty acid concentrations and changes in the pattern of leptin peaks in plasma. Bariatric surgery improves the metabolic dysfunction of obesity, and this may be through a reduction in circulating free fatty acids and modification of leptin metabolism.

Vacuum Assisted Closure (VAC) therapyTM as a swiss knife multi-tool for enteric fistula closure: tips and tricks: a pilot study

OBJECTIVE

Enterocutaneous fistulas (ECFs) are an uncommon surgical problem, but they are characterized by a difficult management. Vacuum-assisted closure (VAC) therapy is a method utilized for chronic and traumatic wound healing. At first, VAC therapy had been contraindicated in the treatment of intestinal fistulas, but as time went by, VAC therapy revealed itself to be a "Swiss knife multi-tool". This paper presents some clinical cases of enterocutaneous (ECF) and enteroatmospheric fistulas (EAF) treated with VAC therapy™.

MATERIALS AND METHODS

The history of 8 patients treated for complex fistulas was revised. Four of them presented with enterocutaneous and four with enteroatmospheric fistulas. All were treated with VAC therapy with variations elaborated to help in accelerated closure of intestinal wall lesions.

RESULTS

Four out of four ECFs closed spontaneously. In the EAF group, in three cases the fistula turned slowly into an entero-cutaneous fistula, and in one out of four it closed spontaneously. The mean length of VAC therapy™ was 35.5 days and that of spontaneous closure was 36.4 days.

CONCLUSIONS

The results of our study encourage the use of VAC therapy™ for the treatment of enterocutaneous fistulas. VAC therapy™ use has a double therapeutic value: (1) it promotes the healing of the skin and allows also the management of EAFs; (2) in selected cases, those in which it is possible to create a deep fistula tract ("well") it is possible to assist to a complete healing with closure of the ECFs.

Polypoid Gallbladder Lesion in the Context of Renal Cell Carcinoma: Is Laparoscopic Cholecystectomy a Reasonable Option?

Introduction. The only curative therapeutic approach for renal cell carcinoma (RCC) is surgery. Laparoscopic surgery for RCC has become an established surgical procedure with equivalent cancer-free survival rate, following the same surgical oncological principles as open surgery. Metastatic RCC of the gallbladder is a rare phenomenon. Hence, there are few reports regarding their management. Case Presentation. We report 2 cases of gallbladder metastasis from clear cell RCC treated by laparoscopic cholecystectomy. The first case was that of a 44-year-old male patient who underwent palliative cholecystectomy, the second case was that of an 83-year-old female patient who is doing well 55 months after surgery without evidence of disease recurrence. Conclusion. The outcome allows us to demonstrate the interest of surgical resection of RCC metastases in the gallbladder by laparoscopic cholecystectomy, respecting surgical oncological principles. Laparoscopic resection of an uncommon gallbladder metastasis can provide long-term favorable outcome.

Laparoscopic extraperitoneal colostomy in elective abdominoperineal resection for cancer: a single surgeon experience

AIM

Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date.

METHODS

We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking.

RESULTS

Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group.

CONCLUSION

Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Transhepatic metallic stenting for hepaticojejunostomy stricture following laparoscopic cholecystectomy biliary injury: A case of successful 20 years follow-up

Laparoscopic cholecystectomy is still associated with a considerable rate of biliary injuries and related strictures. Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures. We report successful 20 years of follow-up of a case of trans-hepatic metallic stenting (2 Gianturco^® prostheses, 5 cm long, 2 cm in diameter) done for stenosed hepatico-jejunostomy anastomosis after laparoscopic CBD injury. Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepatico-jejunostomy or in whom re-operation involves high risk.

Protocol for a randomised clinical study comparing the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on reactive hypoglycaemia in morbidly obese subjects

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is the most performed bariatric operation. Reactive hypoglycaemia is a frequent late complication occurring in about 72% of RYGB patients, which can present with various intensities up to the serious form of neuroglycopaenia. However, it seems to occur also after sleeve gastrectomy (SG) although much more rarely.

METHODS AND ANALYSIS

A single centre, open, 1-year randomised trial to compare the incidence of hypoglycaemia after RYGB or SG. A secondary objective is the assessment of the comparative ability of the two surgical procedures in determining the improvement or normalisation of insulin sensitivity, given the established relevance of insulin resistance in the cardiometabolic syndrome of obesity.

ETHICS AND DISSEMINATION

The study will be published and presented to international meetings and, due to the safety issue, it will represent a relevant information for national healthcare systems. The protocol was approved by the Catholic University Ethical Committee (A1534/CE/2012). Clinicaltrials.gov Registration n. NCT01581801.

Single port laparoscopic cholecystectomy: which technique, which surgeon, for which patient? A study of the implementation in a teaching hospital

BACKGROUND

Single port cholecystectomy is increasingly performed. This procedure can be challenging, and we lack factors predicting the operative difficulty.

AIMS

To assess the role of surgeon experience and identify possible predictive factors of intraoperative difficulties.

PATIENTS AND METHODS

Sixty-one selected patients were prospectively enrolled between January 2008 and August 2010. Six surgeons were involved (3 seniors, 3 juniors). Anthropometrics of the patients, types of ports, exposure methods and intraoperative data were recorded. Pain was assessed with the visual analogic scale at postoperative day 1 (POD 1 VAS).

RESULTS

Fifty-eight patients with symptomatic gallstones and three with acute cholecystitis underwent single port cholecystectomy. The mean BMI, weight and height were 25.7 kg/m(2) (SD 4.45), 71.8 kg (SD 14.83) and 166 cm SD 0.07, respectively. Mean operative time was 68.4 min (SD 26.98). Anthropometrics had no influence on operative time. Senior surgeons performed more rapidly, but the difference was not significant. The overall mean POD 1 VAS was 2.26, (SD 1.81). The mean hospital stay was 2.22 days, (SD 0.9). No complications occurred. An additional exposure method was necessary in 19 procedures. This cluster presented a significantly higher operating time (81.5 min, SD 31.69 vs. 62.7, SD 22.74; p = 0.01) and POD 1 VAS (1.92 vs. 3; p = 0.031).

CONCLUSION

Single trocar cholecystectomy can be implemented safely in teaching hospitals. Anthropometrics are not predictive of operative difficulties. The need for additional exposure systems affects the operative time and pain negatively, reflecting greater technical difficulties. Research to optimize instruments may help to solve these problems.

Multimedia manuscript. Thoracoscopic management of chylothorax after esophagectomy

BACKGROUND

Chylothorax after esophagectomy is a potentially life-threatening complication, with a reported incidence rate of 1-4%. Two cases of postoperative chylothorax successfully managed thoracoscopically are reported.

METHODS

In case 1, a 61-year-old man presenting with an adenocarcinoma of the lower esophagus underwent laparoscopic transhiatal esophagectomy after neoadjuvant chemotherapy. The thoracic duct was identified, and no obvious leaks were detected. The thoracic drain was removed on postoperative day (POD) 6, and chest X-rays were normal. The patient was discharged on POD 10. On POD 20, he was readmitted for acute cardiopulmonary distress. Computed tomography scan showed a massive right collection. After insertion of a chest tube, 8 l of chylous fluid were drained. Once hemodynamic stabilization had been established, the patient was scheduled for surgery. In case 2, a 54-year-old woman presenting with esophageal stenosis after caustic injury refractory to balloon dilation and stenting underwent esophagectomy. Mediastinal dissection was difficult due to fibrotic reaction. On POD 2, the patient presented with a massive chylothorax. In both cases, three trocars were inserted in the right pleural cavity. An incomplete lateral injury of the thoracic duct was found in case 1, and a complete transection proximal to the cervical anastomosis next to the left subclavian was found in case 2. Clips and sutures were used first to seal the duct. Fibrin glue was applied to reinforce the closure. A chest tube was left in place.

RESULTS

The operative time was 60 min in case 1 and 55 min in case 2. The chylothorax did not recur, although the postoperative course was longer in case 2 due to associate comorbidities.

CONCLUSIONS

The thoracic duct is exposed to injuries during esophagectomies, especially in cases of cancer and postcaustic injuries, leading to fibrotic reaction of the surrounding tissue. Early and delayed chylothorax can be managed efficiently by a thoracoscopic approach replicating the sealing techniques used in thoracotomy.

Expanded clinical experience with 4DDome(R) composite prosthesis in elective open inguinal herniorrhaphy

Prosthetic material composition is implicated in the phenomenon of postoperative chronic groin pain that has undermined elective open inguinal herniorrhaphy. Reported herein are our 'all-comers' experiences with a novel dual component mesh (4DDome(R)). A prospective cohort (Phase II) study was performed that involved all patients undergoing elective open inguinal herniorrhaphy during a four-year period. Conventional operative technique was used except for choice of prosthesis. The 4DDome mesh comprises a molded dome-shaped composite (10% polypropylene, 90% poly-L-lactic acid) with a lightweight polypropylene mesh overlay. Short- (1 week) and intermediate-term (18 months) clinical follow-up with examination and symptom questionnaire judged outcome while surgeons rated their approval using a visual analogue scale. One hundred ninety-six patients (mean age, 65.5 years; Mean BMI, 25.5; Mean ASA, 1.8, 178 males) underwent repair of 201 inguinal hernias by six surgeons (three residents). The majority of patients had an indirect hernia (n=119) 93 being combined with a posterior wall defect [Nyhus IIIa], whereas 66 had a direct hernia [Nyhus IIIb], and 11 had a recurrent hernia.) Mean operative time was 44.6 minutes with 92 patients being operated under local anesthesia. Ten patients developed seromas and two had hematomas early postoperatively. Median intermediate-term follow-up is currently 19 (range: 3-72) months for the 147 (75%) patients still available for contact. The incidence of chronic groin pain is 8.8%, whereas there has been one hernia recurrence. Surgeon satisfaction and confidence were high. The 4DDome provides appropriate clinical results and, therefore, appears valid for use in routine practice.

Keratin 7 expression as an early marker of reflux-related columnar mucosa without intestinal metaplasia in the esophagus

BACKGROUND

The role of Barrett esophagus in carcinogenesis is widely accepted, but the significance of esophageal columnar mucosa without histological intestinal metaplasia, known as columnar-lined esophagus, is debated.

MATERIAL/METHODS

We studied 128 patients free of Helicobacter pylori with reflux-related symptoms and columnar mucosa in the esophagus at endoscopy, 106 patients with Barrett esophagus (referred to as the Barrett group) and 22 patients without intestinal metaplasia (columnar group). Samples from 20 subjects free of H. pylori were used as controls. Immunostaining for keratin 7 (KRT7), keratin 20 (KRT20), caudal type homeobox 2 (CDX2), mucin 2, oligomeric mucus/gel-forming (MUC2), and tumor protein p53 (TP53) was assessed.

RESULTS

Samples taken 1 cm above the gastroesophageal junction showed KRT7 staining in all cases in the Barrett and columnar groups and none in the control group. Immunostaining for TP53 was absent in the control group, and more frequent in the columnar group (7, 31.8%) compared with the Barrett group (14, 13.2%, P=0.033). In the columnar group, low grade dysplasia and TP53 expression was seen in 7 of 22 biopsy specimens (31.8%) at baseline and in 4 additional specimens after 2 years, for a total of 11 specimens (50.0%).

CONCLUSIONS

The expression of KRT7 might help to explain the pathological, reflux-related nature of columnar-lined esophagus, as aberrant expression in a very early stage of the multistep Barrett esophagus progression. Expression of KRT7 may occur in basal glandular cells as a result of their multipotentiality and susceptibility to immunophenotype changes induced by reflux.