Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11 years results from a tertiary referral centre

INTRODUCTION

Outcomes of long-term (5-10-year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12 week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery.

METHODS

Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥ 50% and ≥ 70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL ≥ 50% and ≥ 70%.

RESULTS

Three hundred thirty-nine patients (median age, 49 years; median follow-up, 7 years [0.5-11 years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL ≥ 50% and ≥ 70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both < 10.5% and > 10.5% EWL, were positively associated with EWL ≥ 50% (HR 2.23, p < 0.001) and EWL ≥ 70% (HR 3.24, p < 0.001), respectively. After a median of 6.5 years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL ≥ 50% (OR, 2.36; p = 0.013) and EWL ≥ 70% (OR, 2.03; p = 0.011) at the end of follow-up.

CONCLUSIONS

IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

TP9.2.18Are delays to diagnosis and treatment associated with reduced survival in oesophageal cancer?

Aims

Oesophageal cancer has low survival rates due to diagnosis commonly occurring in advanced stages. We performed a systematic review of delays to diagnosis and treatment in oesophageal cancer, and the impact of delay on clinical outcome.

Methods

A systematic review of Pubmed, Embase and Cochrane Library was carried out using the following search terms: (esophageal cancer) AND ((time) OR (diagnosis)) AND ((delay) OR (wait)). 821 results in English were retrieved and independently reviewed by two researchers. Studies were included if they were randomised controlled trials (RCT), meta-analyses or observational studies, and assessed delay in relation to at least one clinical outcome or TNM stage at diagnosis.

Results

15277 patients across 12 studies were included. 10/12 studies were retrospective, and there were no RCT. Heterogeneity existed amongst the studies in defining delay and outcomes (morbidity = 1/12, mortality = 2/12, disease-free = 2/12 or overall survival = 5/12, TNM stage = 6/12).

No studies demonstrated that reduced delay improved clinical outcome. Longer patient delay correlated with presence of malnutrition in one study but did not result in reduced survival.

Conclusions

Systematic review of published literature did not demonstrate a relationship between diagnosis/treatment delay and patient outcome in oesophageal cancer. Multi-centre prospective studies/RCTs are required to identify the impact of delay and the optimal timing of treatment.

A prospective audit of the 10-year outcomes from low dose-rate brachytherapy for early stage prostate cancer

AIM

New Zealand men diagnosed with early stage prostate cancer need to know what outcomes to expect from management options.

METHODS

Between 2001 and 2016, 951 men were treated with low dose-rate brachytherapy (permanent iodine-125 seed implantation) by the Wellington Prostate Brachytherapy Group based at Southern Cross Hospital, Wellington. At follow up after treatment, men had their PSA measured and were scored for urinary, bowel and sexual side effects. RESULTS: Median follow-up of men was 7.9 years (range 2.0-16.3 years). Ten-year PSA control was 95% for the 551 men with low-risk prostate cancer and 82% for the 400 men with intermediate-risk prostate cancer. Adverse effects were generally minor and short-term only. Temporary urinary obstruction developed soon after the implant in 2.6% men, and the 10-year cumulative risk of urethral stricture was 2.6%. Erectile dysfunction developed in 29% men, two-thirds of whom had a good response to a PDE5 inhibitor. Most men returned to a normal routine within four days of the implant.

CONCLUSION

LDR brachytherapy is a highly effective low-impact treatment option for New Zealand men with early stage prostate cancer.

A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy

Introduction

There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG.

Methods

A prospective study of patients undergoing LSG (2014-2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively.

Results

Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months).

Conclusion

GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.

Long-term outcomes following laparoscopic anterior and Nissen fundoplication

BACKGROUND

Limited evidence exists to which operation gives best long-term outcomes for gastro-oesophageal reflux disease. This study aimed to assess long-term symptomatic outcome and satisfaction following laparoscopic anterior (LA) or Nissen fundoplication in a specialist upper gastrointestinal unit.

METHODS

Patients who underwent primary LA or Nissen (LN) fundoplication between May 1994 and June 2010 were identified from a prospectively collected database. DeMeester, modified DeMeester, 'Gastrointestinal Symptom Rating Scale' scores and patient satisfaction were assessed by questionnaire.

RESULTS

A total of 387 patients underwent surgery and 246 patients (65%) completed questionnaires, with 181 LA patients and 65 LN patients. Median follow-up was 83 months for LA and 179 months for LN (P < 0.001). A total of 218/245 (89%) reported major improvement in symptoms and 27 (11%) reported poor outcomes. There was no differences between LA and LN for symptom scores at short (<5 years) or long-term follow-up (>5 years). Women reported significantly higher DeMeester scores and lower satisfaction (P = 0.012). One hundred and eighteen (48%) patients were taking proton pump inhibitors (PPI) at follow-up despite high satisfaction rates.

CONCLUSION

LA and LN have similar long-term results with patients reporting high satisfaction levels. Women reported more symptoms and less satisfaction than men. Despite high satisfaction rates a high percentage of patients take PPIs.

Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma

BACKGROUND

The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre.

METHODS

A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications.

RESULTS

83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients.

CONCLUSION

A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.

Patterns of failure after iodine-125 seed implantation for prostate cancer

PURPOSE

To determine the site of relapse when biochemical failure (BF) occurs after iodine-125 seed implantation for prostate cancer.

MATERIALS AND METHODS

From 2001-2009, 500 men underwent implantation in Wellington, New Zealand. Men who sustained BF were placed on relapse guidelines that delayed restaging and intervention until the prostate-specific antigen (PSA) was ⩾20 ng/mL.

RESULTS

Most implants (86%) had a prostate D90 of ⩾90%, and multivariate analysis showed that this parameter was not a variable that affected the risk of BF. Of 21 BFs that occurred, the site of failure was discovered to be local in one case and distant in nine cases. Restaging failed to identify the site of relapse in two cases. In nine cases the trigger for restaging had not been reached.

CONCLUSIONS

If post-implant dosimetry is generally within the optimal range, distant rather than local failure appears to be the main cause of BF. Hormone treatment is therefore the most commonly indicated secondary treatment intervention (STI). Delaying the start of STI prevents the unnecessary treatment of men who undergo PSA 'bounce' and have PSA dynamics initially mimicking those of BF.

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Feasibility study of sentinel lymph node biopsy in esophageal cancer with conservative lymphadenectomy

INTRODUCTION

Lymphoscintigraphy and sentinel node mapping is established in breast cancer and melanoma but not in esophageal cancer, even though many centers have shown that occult tumor deposits in lymph nodes influence prognosis. We report our initial experience with lymphoscintigraphy and sentinel lymph node biopsy in patients undergoing resection for esophageal cancer.

METHODS

Sixteen of 17 consecutive patients underwent resection for invasive esophageal cancer along with sentinel lymph node retrieval (resection rate, 94%). Peritumoral injection of (99m)Tc antimony colloid was performed by upper endoscopy prior to the operation. A two-surgeon synchronous approach via right thoracotomy and laparotomy was performed with conservative lymphadenectomy. Sentinel lymph nodes were identified using a gamma probe both in vivo and ex vivo. Sentinel lymph nodes were sent off separately for serial sections and immunohistochemistry.

RESULTS

Median patient age was 60.4 years (range, 45-75 years). Fifteen were male, and thirteen had adenocarcinoma. At least one sentinel lymph node (median, 2) was identified in 14 of 16 patients (success rate, 88%). Sentinel nodes were present in more than one nodal station in five patients (31%). In all 14 patients, the sentinel lymph node accurately predicted findings in non-sentinel nodes (accuracy, 100%). Three patients with positive sentinel lymph nodes had metastases identified in non-sentinel nodes (sensitivity, 100%).

CONCLUSIONS

Sentinel lymph node biopsy is feasible in esophageal resection with conservative lymphadenectomy, and initial results suggest it is accurate in predicting overall nodal status. Further study is needed to assess impact on patient management and prognosis.

Long-term outcomes of revisional surgery following laparoscopic fundoplication

Background

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long-term clinical outcomes.

Methods

Patients requiring late revisional surgery following laparoscopic fundoplication for gastro-oesophageal reflux were identified from a prospective database. Long-term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction.

Results

The database search found 109 patients, including 98 (5·6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow-up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62·7 per cent) or satisfied (23·5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0·004), troublesome dysphagia (16 versus 6 per cent; P = 0·118) and a lower satisfaction score (P = 0·023) than those with recurrent reflux or paraoesophageal herniation.

Conclusion

Revisional surgery following laparoscopic fundoplication can produce good long-term results, but revision for dysphagia has less satisfactory outcomes.

Laparoscopic fundoplication in patients with a hypertensive lower esophageal sphincter

BACKGROUND

A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients.

MATERIAL AND METHODS

Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP > or = 30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0-10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group.

RESULTS

Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30-55). Median follow-up after fundoplication was 99 (12-182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036).

CONCLUSION

Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.

Spontaneous rupture of the oesophagus

BACKGROUND

The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre.

METHODS

Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy.

RESULTS

The median time to diagnosis was 24 (range 4-604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Ttube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention.

CONCLUSION

Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.

Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma

BACKGROUND

About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy.

METHODS

Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. (99m)Tc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment.

RESULTS

A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9.6 per cent).

CONCLUSION

Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

Iatrogenic perforation of localized oesophageal cancer

A plea not to dilate

Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma

Background

The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma.

Methods

Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of 99mTc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld γ probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases.

Results

SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P &lt; 0·001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P &lt; 0·001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0·018), radioactive uptake (P &lt; 0·001) and malignant nodes (P = 0·004) in the mediastinum than gastric cardia tumours.

Conclusion

The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Prospective study of routine contrast radiology after total gastrectomy

BACKGROUND

The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation.

METHODS

Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy.

RESULTS

Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

CONCLUSION

There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Comparison of three different procedures for antireflux surgery

Background

No long-term comparisons of the various open and laparoscopic antireflux procedures have been undertaken. The aim of this study was to compare symptomatic outcomes of three procedures for antireflux surgery performed at three specialist units.

Methods

Patients undergoing open Nissen fundoplication, laparoscopic Nissen fundoplication and laparoscopic anterior partial fundoplication between December 1993 and February 2001 were identified. Patient outcome was assessed by means of a postal questionnaire. This was a hypothesis-generating study.

Results

Three hundred and fifty-seven patients (80·0 per cent) completed the questionnaire, with no differences in response rate between centres. Overall, a mean of only 7·6 per cent of patients reported a poor outcome. Logistic regression revealed no significant differences amongst the three procedures for any symptoms, after allowing for the effect of time. There was a general increase in the DeMeester score with increasing time from operation. The incidence of revisional reflux surgery was similar in the three groups.

Conclusion

Medium-term symptomatic outcome following all three procedures was similar. There was some recurrence of symptoms of gastro-oesophageal reflux with time for all procedures, suggesting that the effects of surgery diminish with time. The level of experience of the surgeon in a particular operation was more important than the procedure performed.

African Droughts and Dust Transport to the Caribbean: Climate Change Implications

Great quantities of African dust are carried over large areas of the Atlantic and to the Caribbean during much of the year. Measurements made from 1965 to 1998 in Barbados trade winds show large interannual changes that are highly anticorrelated with rainfall in the Soudano-Sahel, a region that has suffered varying degrees of drought since 1970. Regression estimates based on long-term rainfall data suggest that dust concentrations were sharply lower during much of the 20th century before 1970, when rainfall was more normal. Because of the great sensitivity of dust emissions to climate, future changes in climate could result in large changes in emissions from African and other arid regions that, in turn, could lead to impacts on climate over large areas.

Speeding up the diagnosis of oesophago-gastric cancer

National referral guidelines have been developed for patients with suspected oesphago-gastric cancer with the aim of reducing the delay from presentation to referral and, therefore, reducing overall delay in diagnosis. This study evaluates the impact of these guidelines and shows that they have resulted in a significant decrease in the time from referral to endoscopy for patients. Nurses can further contribute to this by increasing patient awareness of symptoms. A course is being developed to provide the necessary knowledge.

Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy: risk factors and management

Aims

Benign anastomotic stricture (BAS) is a common cause of dysphagia following oesophagectomy. The aim of this study was to assess the incidence of BAS, identify risk factors for its development and evaluate the results of postoperative endoscopic dilatation.

Methods

A consecutive series of 234 patients undergoing oesophagectomy with a stapled intrathoracic oesophagogastric anastomosis (Autosuture CEEA gun) between April 1990 and April 1999 were studied. BAS was defined as dysphagia with anastomotic narrowing (XQ200 endoscope) and no suspicion of recurrence. Statistical analysis was by the χ2 and Mann–Whitney U tests.

Results

The postoperative mortality rate was 5 per cent (12 of 234) and the anastomotic leak rate 3 per cent (six of 234). One-third of patients (70 of 222) who survived surgery re-presented with dysphagia; 5 per cent (11 of 222) were found to have proven local recurrence and 27 per cent (59 of 222) BAS. The median time to development of BAS was 92 (range 24–210) days. BAS formation was significantly related to the size of the staple gun employed: 21 mm, 80 per cent (eight of ten); 25 mm, 32 per cent (25 of 78); 28 mm, 23 per cent (19 of 81); 31 mm, 19 per cent (seven of 37) and 34 mm, 0 per cent (none of five) (χ2 = 18·3, 4 d.f., P &lt; 0·01). All patients underwent radiographically controlled endoscopic dilatation with no complications. Recurrent BAS occurred in over half of these patients (32 of 59), who had a median of 2 (range 2–17) recurrences all resolving within 532 (mean interval 68) days. Recurrent BAS formation was also significantly related to the size of the staple gun employed (χ2 = 11·6, 4 d.f., P &lt; 0·05). Following the introduction of the Autosuture ‘tilt-top’ device in July 1995 the median size of gun used rose from 25 to 28 mm with an overall decrease in the incidence of BAS from 33 to 21 per cent (χ2 = 4·0, 1 d.f., P &lt; 0·05). All patients with anastomotic leaks survived and none subsequently developed BAS. Similarly, no association was found between the development of BAS and the anastomotic site (measured from incisors), tumour subtype, resection margin length, sex, age or preoperative cardiorespiratory status.

Conclusions

Staple gun size is an important risk factor for BAS formation and ‘tilt-top’ devices enable the use of a larger head with a subsequently lower incidence of BAS. Endoscopic dilatation is an effective treatment for BAS which rarely recurs and always resolves within 18 months.

Diagnosis and management of a mediastinal leak following radical oesophagectomy

BACKGROUND

The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis.

METHODS

Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy.

RESULTS

Nineteen patients (6.5 per cent) developed a proven mediastinal leak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died.

CONCLUSION

Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.

The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction.

METHODS

The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately.

RESULTS

One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion (P =.002).

CONCLUSIONS

The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined.

Prognostic significance of peri-operative blood transfusion following radical resection for oesophageal carcinoma

INTRODUCTION

Peri-operative allogeneic blood transfusion may exert an immunomodulatory effect and has been associated with early recurrence and decreased survival following resection for several gastro-intestinal malignancies. The aim of this study was to evaluate the prognostic influence of transfusion requirements following radical oesophagectomy for cancer.

METHODS

A consecutive series of 235 patients undergoing subtotal oesophagectomy with two-field lymphadenectomy in a single centre from April 1990 to June 1999 were studied.

RESULTS

The median age was 64 years (30-79) with a male to female ratio of 3:1. The predominant histological subtype was adenocarcinoma (n = 154) compared to squamous carcinoma (n = 81). To avoid the influence of surgical complications data were excluded from the 5.5% of patients suffering in-hospital mortality. In the remaining patients, median blood loss was 900 ml (200-5500) with 46% (103/222) requiring transfusion (median 3 units, range 2-21). Median survival of non-transfused patients was 36 months compared to only 19 months for those receiving transfusion (log-rank = 4.44; 1 df, P = 0.0352). Non-transfused patients had significantly higher 2 and 5-year survival rates of 62% and 41% respectively in contrast to only 40% and 25% in those receiving blood transfusion. Even after stratification of results according to disease stage or the presence of major complications, survival was significantly worse in those receiving transfusion. Multivariate analysis demonstrated that in addition to nodal status, > 4 units transfusion was an independent prognostic indicator.

CONCLUSION

Post-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy. Meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial.