Learning Curve for Laparoscopic Sleeve Gastrectomy: a Cumulative Summation (CUSUM) Analysis

PURPOSE

Bariatric surgery is currently considered the most effective and durable treatment option for morbid obesity. Laparoscopic sleeve gastrectomy (LSG) has become a popular technique and may currently be the most frequently practiced surgical operation to treat obesity. However, no objective analyses of its learning curve have been reported.

OBJECTIVE

to analyze the learning curve for LSG.

MATERIALS AND METHODS

We included all LSGs performed in our hospital (University Hospital, Spain; Public Practice) from April 2013 to February 2016. The learning curve for LSG was evaluated using cumulative sum (CUSUM) analysis. All variables among the learning curve phases were compared.

RESULTS

According to the CUSUM analysis, the learning curve was divided into three unique phases: early learning (the initial 26 patients), acquisition of skills (the middle 30 patients), and mastery of technique (the final 56 patients). The operative time and gastric stenosis significantly decreased with progression of the learning curve without differences in the 30-day postoperative complication rate, postoperative stay, or weight loss.

CONCLUSION

According to this study, the learning curve for LSG can be divided into 3 distinct phases, and about 25 patients are needed to demonstrate an improvement in surgical skill.

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option.

AIMS

the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks.

METHODS

a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018.

RESULTS

twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach.

CONCLUSIONS

endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

Role of self-expanding stents in the treatment of intrathoracic dehiscence after Ivor Lewis esophagectomy

INTRODUCTION

The role that self-expanding stents play in the treatment of dehiscence after transthoracic esophagectomy is not well defined and controversial. Our aim is to describe the experience in a tertiary care hospital using these devices for treating dehiscence after Ivor Lewis esophagectomy.

METHODS

Descriptive observational study of patients who suffered anastomotic dehiscence after a transthoracic esophagectomy, and especially those treated with stents, in the period between 2011-2016 at our hospital.

RESULTS

Ten patients (11.8%) presented anastomotic dehiscence. Eight patients received stents, one of them died due to causes unrelated to the device. Stent migration was observed in one case, and the devices were maintained an average of 47.3 days. The stent was not effective only in one patient who suffered early dehiscence due to acute ischemia of the stomach. The two patients who did not receive stents died after reoperation.

CONCLUSIONS

Stents are safe and effective devices that did not associate mortality in our series. They are especially indicated in intermediate or late-onset dehiscence and in fragile patients. The use of stents, together with mediastinal and pleural drainage, avoid reoperations with morbidity and mortality. Therefore, stents should be part of the usual therapeutic arsenal for the resolution of most suture dehiscences after Ivor Lewis esophagectomy. Randomized prospective studies would help to more precisely determine the role played by these devices in the treatment of dehiscence after transthoracic esophagectomy.

Histopathological and Immunohistochemical Analysis of the Use of Collagen Dressing as a Reinforcement of Esophagic Anastomosis in a Rat Experimental Model

INTRODUCTION

One of the most severe complications after esophaguectomy is anastomotic dehiscence. The use of collagen sponges could be an effective way to resolve this complication. Our objective was to perform an experimental model of esophageal anastomosis in rats to study these mechanisms.

METHODS

A total of 50 Sprague-Dawley rats were used divided into 2 groups, Tachosil^® group (n=25) and control group (n=25). After the section of the abdominal esophagus a single-layer esophago-gastric anastomosis was performed reinforced with 1cm of Tachosil^® wrapping the anastomosis in group 1. A functional study was performed using manometry as well as histopathological and immunohistochemical studies for angiogenic, fibrogenic and growth factors.

RESULTS

The mortality in our series was 8% in the collagen dressing group, compared to 36% in the control group. When esophageal manometry was performed, the dehiscence pressure was higher in the reinforced anastomosis, On microscopical analysis, in the collagen dressing group a profuse inflammatory reaction with abundant neutrophils and macrophages surrounded by a connective matrix with fibroblasts and blood vessels was observed, The expression of VEGF, FGF1 and FGF2 was noticeably higher in the collagen dressing group.

CONCLUSIONS

These results show that the application of collagen dressing facilitates tissue reparation phenomena, and therefore could be very useful as a reinforcement of esophago-gastric anastomosis to prevent dehiscence.

Communication between the obese patient and bariatric surgeon

Communication between the bariatric surgeon and the obese patient is very important as it influences the expectations of patients with regard to surgery, aim of the surgery and the understanding of the mechanisms of failure of surgery. Furthermore, the incidence of certain psychopathology in these patients makes it necessary for the surgeon to have the ability to communicate to the patient the need for motivation and the maintenance of healthy life habits. Although the topic is subjective, in this article we review several useful recommendations to optimize communication before and after surgery. Finally, we emphasize the need to create workshops to train the bariatric surgeon in these issues that we consider so important.

Activation of the BMP4 pathway and early expression of CDX2 characterize non-specialized columnar metaplasia in a human model of Barrett's esophagus

BACKGROUND

A human model of gastroesophageal reflux disease was used to examine the contribution of a non-specialized columnar type of metaplasia (NSCM) and key molecular events (BMP4 and CDX2) in the development of Barrett's esophagus.

METHODS

Biopsies of the remnant esophagus from 18 patients undergoing esophagectomy with gastric preservation were taken at 6-36-month intervals postoperatively and examined for activation of the BMP pathway (BMP4/P-Smad 1/5/8) and CDX2 and CDX1 expression by imunohistochemistry, quantitative real-time PCR, Western blot, and in situ hybridization.

RESULTS

A short segment (mean 15.6 mm) of NSCM was detected in 10 (56%) patients, with an increasing prevalence from 17% at 6 months to 62% at 36 months. Nuclear expression of P-Smad 1/5/8 in the squamous epithelium close to the anastomosis with strong expression in all epithelial cells of NSCM areas was found. Forty-eight (63%) biopsies with NSCM showed scattered nuclear expression of CDX2. Two cases showed isolated glands at 18, 24, and 36 months that fully expressed CDX2 and co-expressed CDX1. BMP4 mRNA and CDX2 mRNA levels were significantly greater in NSCM than in squamous epithelium.

CONCLUSIONS

BMP4 activation in NSCM and early expression of CDX2 are involved in the columnar epithelial differentiation of Barrett's esophagus.

Zenker's and epiphrenic diverticula in a patient with cutis laxa: should the surgical technique be modified?

Currently, most of esophageal diverticula arise as the result of a pulsion effect. Some esophageal motor disorders increase the intraluminal pressure and after some time, the diverticula grow through a weak point of esophageal wall. In these cases, the surgical treatment of choice is the myotomy associated with diverticulopexy or diverticulectomy. Adding a fundoplication is accepted to avoid the consequences of gastroesophageal reflux after myotomy in the epiphrenic diverticula surgery. There are other causes of esophageal diverticula that change the resistance of esophageal wall. Cutis laxa, a congenital or acquired connective disease, is a strange one. In our patient, a good result was reached modifying the standard technique accord to its ethiopathogenic mechanism.

Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy

BACKGROUND

This study assessed the feasibility of a protocol-driven written clinical pathway for multidisciplinary postoperative management after oesophagectomy for oesophageal neoplasia, and examined whether the application of such a protocol could shorten hospital stay and reduce postoperative morbidity and mortality.

METHODS

Consecutive patients undergoing transthoracic oesophagectomy for oesophageal neoplasia were divided into those treated between 2003 and 2008 to whom a clinical pathway was applied for postoperative management (group 1), and a control group treated between 1998 and 2002 when no clinical pathway was applied (group 2).

RESULTS

There were 74 patients in each group. Morbidity rates were similar in the two groups: 31 per cent in group 1 and 38 per cent in group 2. There were more pulmonary complications in group 2 (23 versus 14 per cent; P = 0.025). One patient (1 per cent) in group 1 and four (5 per cent) in group 2 died after surgery (P = 0.010). The median (range) length of hospital stay was 9 (5-98) days for group 1 and 13 (8-106) days in group 2 (P = 0.012).

CONCLUSION

Use of a written clinical pathway in patients undergoing oesophageal resection significantly reduced pulmonary complications, postoperative mortality and hospital stay.

[Outpatient monitoring of oesophageal pH with a catheter-free pH-meter (Bravo System). A Study of tolerance, safety and efficacy]

BACKGROUND AND OBJECTIVE

A new catheter-free outpatient oesophageal pH-meter system (Bravo) has recently been developed. The objective of this study is to test the tolerance, safety and efficacy of the system in the measurement of gastric-oesophageal reflux by comparing it with a conventional pH system.

PATIENTS AND METHOD

The study was performed on a control group consisting of 10 healthy volunteers (group 1) and in a group of 40 patients with symptoms of gastric-oesophageal reflux disease (groups 2 and 3). An upper digestive system endoscopy, oesophageal manometry and oesophageal pH measurements with a conventional system and/or with the Bravo catheter-free system, was performed on all patients. All patients who had both tests done (groups 1 and 2) filled in a questionnaire on any physical problems and changes in their daily activity.

RESULTS

The test tolerance was higher with the Bravo system in the 9 parameters studied. In the group of healthy volunteers (group 1), the median (range) of the total percentage of pH < 4 was 1.1% (0.5-3.1) with the conventional pH and 1.7% (0-3.4) with the Bravo. When comparing the patients with symptoms of gastric-oesophageal reflux disease (group 2) with those who had only one type of pH measurement made, the acid reflux was significantly higher in patients with Barrett's oesophagus than in the rest of the groups, with conventional pH as well as with the Bravo. If we analyse the patient group with disease due to gastric-oesophageal reflux with those on whom both techniques were used (group 3), 7 of the 10 patients had a pathological reflux that only showed up on measuring pH with the Bravo system.

CONCLUSIONS

Catheter-free pH measurements (Bravo) is better tolerated and with better satisfaction for the healthy volunteers and patients than with conventional PH, even, on occasions being more efficient for studying acid reflux due to the lower incidence of negative results.

Elevated basal calcitonin levels in a patient with a hurthle-cell carcinoma of the thyroid and neuroendocrine differentiation: report of a case

A thyroid nodule with elevated plasma levels of calcitonin is usually suggestive of a medullary thyroid carcinoma (MTC); however, thyroid and extrathyroid conditions have been reported with elevated plasma calcitonin levels in the absence of MTC. We report the case of a patient with a thyroid nodule and an elevated basal plasma calcitonin level of 315 pg/ml (normal value <100 pg/ml) who underwent a left hemithyroidectomy. Interestingly, histopathological examination revealed a Hurthle-cell carcinoma with positive neuroendocrine (NE) markers such as calcitonin and synapthophysin, but not with chromogranin staining. Thus, we discuss the phenomenon of non-NE tumors showing positivity for NE markers.

Ineffective oesophageal motility does not affect the clinical outcome of open Nissen fundoplication

BACKGROUND

Nissen fundoplication is considered the 'gold standard' in antireflux surgery but some surgeons employ a different surgical strategy when gastro-oesophageal reflux disease (GORD) is associated with motor disorders of the oesophageal body.

METHODS

Ninety-three patients undergoing surgery for GORD were divided into two groups: 52 patients (group 1) had normal oesophageal body motility and 41 (group 2) had ineffective oesophageal motility (IOM). All patients had a short Nissen fundoplication via a laparotomy. The median follow-up was 5 years in group 1 and 6.5 years in group 2.

RESULTS

The clinical outcome was satisfactory in more than 90 per cent of the patients in both groups. Only one of ten patients with IOM and dysphagia before operation still had dysphagia after surgery. One patient in each group developed postoperative dysphagia. Six of 52 patients with normal motility and eight of 41 with IOM had persistent pathological acid reflux after surgery. Significant increases in contractile wave pressure and a decrease in the percentage of non-propagated waves were found in group 2 after fundoplication.

CONCLUSION

Patients with IOM did not have an increased rate of dysphagia after total fundoplication compared with those with normal motility, but they did have a higher rate of recurrence of endoscopic and pH-proven reflux.

Primitive leiomyosarcoma of the breast: case report and review of the literature

Sarcomas of the breast account for under 1% of breast tumours. Leiomyosarcomas are less common, being a subgroup of sarcomas of the breast. Only 23 cases with immunohistochemical or electron microscopy confirmation are reported in the literature. The case of a 58-year-old woman with a leiomyosarcoma 4 cm in diameter in the upper external quadrant of the right breast is presented. Mammography and sonography were compatible with a fibroadenoma or phylloides tumour, and fine-needle aspiration (FNA) suggested medullary carcinoma. The patient underwent a Madden-type modified radical mastectomy and axillary lymphadenectomy. Adjuvant chemotherapy was implemented with Adriamycin (four cycles of 21 days). One year after surgery the patient is tumour free.

Primary eosinophilic esophagitis

Eosinophilic esophagitis is an uncommon pathology that generally affects children with a history of allergies and intrinsic asthma. We present a clinical case of eosinophilic esophagitis in a 16-year-old boy with upper dysphagia for solids since childhood. The analytical study showed only a repeat serum eosinophilia. Barium transit disclosed a reduction in caliber of the whole esophagus. Functional esophageal tests with pH monitoring and manometry were normal. Endoscopy showed a small-diameter esophagus and fibrosis with a very friable mucosa. The histological study of the esophageal biopsies revealed a full thickness major eosinophil infiltration of the esophagus. These findings suggest a differential diagnosis with a great variety of pathologies that can cause similar lesions in the esophagus, especially between primary eosinophilic esophagitis and eosinophilic esophagitis secondary to gastro-esophageal reflux disease (GERD). We implemented medical treatment with oral corticoids and total suppression of allergens from the diet, and the patient was asymptomatic.

Diagnosis and treatment of oculopharyngeal dystrophy: a report of three cases from the same family

Oculopharyngeal muscular dystrophy is a hereditary pathology transmitted in an autosomal dominant manner. The clinical symptoms are palpebral ptosis, oropharyngeal dysphagia and proximal limb weakness. Upper gastro-esophageal endoscopy is recommended to study the dysphagia, a video-radiology study with barium and an esophageal manometry to study the pharyngeo-esophageal motor disorder. Muscle biopsy reveals the presence of atrophic fibers substituted by an increase in fat and connective tissue. In 1998 Brais described the genetic alteration responsible for this pathology, a limited expansion of the triplet of GCG nucleotides in PABP2 gene on chromosome 14q11. Normal individuals have the homozygotic form (GCG)6 of this triplet, whereas patients with the described syndrome have the heterozygotic form (GCG)6-(GCG)9 or (GCG)6-(GCG)10. We present three siblings from the same family with diagnoses and genetic confirmations of oculopharyngeal dystrophy. Two of the patients underwent cricopharyngeal myotomy to relieve the dysphagia.

Immunopathology of an hDAF transgenic pig model liver xenotransplant into a primate

BACKGROUND

hDAF transgenic pigs do not display the inherent hyperacute rejection reactions of pig-to-primate xenotransplants. The purpose of this study was to determine the immunopathologic phenomena following an hDAF transgenic pig hepatic orthotopic xenotransplant into a baboon.

METHODS

Donor animals were unmodified pigs (n=4) and hDAF transgenic pigs (n=2). Recipient animals were baboons (Papio anubis). Liver biopsies were immunostained using monoclonal antibodies to C3, C5b-9, IgG, IgM, CD2, CD4, CD8, CD68, CD20, Bric 216, CD31, and fibrin, and polyclonal antibody to C4.

RESULTS

hDAF transgenic grafts showed IgG, IgM, and C4 endothelial deposits. However, no fibrin, C3, or C5b9 deposits were observed after reperfusion. hDAF xenografts displayed CD31 staining in the portal spaces, perilobular areas, and at hepatic sinuisoidal levels. The baboon that lived for 4 days displayed either CD4 or CD8 T-cells periportal infiltrate.

CONCLUSIONS

Future studies will seek to determine the physiologic role of CD31 hepatic sinusoidal expression in transgenic xenotransplants, and will also study the role of T-cell infiltrates in xenograft rejection.

Barrett's esophagus without esophageal stricture does not increase the rate of failure of Nissen fundoplication

OBJECTIVE

To assess whether the presence of Barrett's esophagus (BE) modifies the results of Nissen fundoplication.

SUMMARY BACKGROUND DATA

Some authors consider that BE, whether or not there is associated stricture, significantly increases the failure rate of standard antireflux surgery; they recommend using different and more aggressive surgical procedures in all patients with BE.

METHODS

One hundred seventy-seven patients with gastroesophageal reflux disease, without esophageal stricture, were included in a retrospective study. Patients were divided into two groups: those with BE (n = 57) and those without BE (n = 120). Nissen fundoplication was performed in all patients by the same surgical team. Clinical, endoscopic, and functional (manometry and 24-hour pH monitoring) results in the two study groups were compared.

RESULTS

After a median follow-up of 5 years (range 1-18) in the BE group and 6 years (range 1-18) in the non-BE group, the rate of clinical recurrence was 8% in the BE group and 10% in the non-BE group, with no statistically significant difference. The rate of pH-metric recurrence was the same in both groups (15%).

CONCLUSIONS

The presence of BE without esophageal stricture does not increase the rate of failure of Nissen fundoplication.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Standard antireflux operations in patients who have Barrett's esophagus. Current results

Several therapeutic options exist for patients who have BE, and treatment should be individualized (Fig. 1). The best option in patients who have a high surgical risk or who reject surgery is lifelong conservative treatment, adjusting the PPI dosage with pH-metric controls. In patients who have a low surgical risk the best option is Nissen fundoplication. Only in cases in which esophageal shortening prevents a tension-free fundoplication from being done is a Collis gastroplasty associated with a fundoplication indicated. Other options may be indicated only in exceptional circumstances: (a) duodenal switch, when, after multiple failures with previous surgery, the approach to the esophagogastric junction is extremely difficult; and (b) esophageal resection, when there is a nondilatable esophageal stenosis and in cases in which the histologic study reveals the presence of high-grade dysplasia. Whatever treatment is used, an endoscopic surveillance program is mandatory, since, with the exception of total esophagectomy, no therapeutic option completely eliminates the risk for progression to adenocarcinoma.

Factors that affect recurrence after incisional herniorrhaphy with prosthetic material

OBJECTIVE

To evaluate the risk factors for recurrence after prosthetic incisional herniorrhaphy.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre, Spain.

PATIENTS

246 patients who had incisional herniorrhaphy with a prosthetic material (polypropylene) between 1990 and 1997

INTERVENTIONS

A reinforcement mesh was inserted when the hernia was more than 5 cm. In incisional hernias less than 5 cm the reinforcement mesh was inserted when the repair was under tension or when tissues were noted to be weak during the operation.

MAIN OUTCOME MEASURES

Age, sex, obesity, the presence of bronchial disease, previous repair of the incisional hernia, type of surgery, size and site of hernia and presence of local complications during the immediate postoperative period.

RESULTS

Mean (SD) follow-up was 77 (6) months (minimum follow up two years). The hernia recurred in 43 cases (17%) (mean time of recurrence 10 (8) months). Age over 60 years, previous herniorrhaphy, size of hernia, and postoperative local complications were significant risk factors (p < 0.01) in both the univariate and multivariate analyses.

CONCLUSIONS

Patients at the greater risk of recurrence are those aged over 60 years, with large, recurrent hernias and who develop local complications during the postoperative period.

Antibiotic prophylaxis in incisional hernia repair using a prosthesis

Antibiotic prophylaxis in clean surgery with implantation of prosthetic material is widely accepted, although there are no studies on its use in abdominal incisional hernia repair. The objective was to evaluate antibiotic chemoprophylaxis in incisional herniorrhaphy with the implantation of prosthetic material. A prospective non-randomized study (1990-1998) was conducted to analyse 216 patients undergoing surgery for abdominal incisional hernia who required a prosthesis (polypropylene) in the reconstruction and who met the criteria for clean surgery. Risk factors were observed in 31.5%, the most frequent being diabetes and obesity. The incisional hernia was located mostly in the abdominal midline and in 64.4% measured over 10 cm. Antibiotic prophylaxis was administered in 140 patients (64.8%) via the systemic route, the antibiotics being first- or second-generation cephalosporins or amoxicillin-clavulanic acid. Surgical wound infection occurred in 39 patients (18.1%), 19 who had received antibiotic prophylaxis (13.6%) and 20 who had not (26.3%). In multivariate analysis using logistic regression, the variables with statistical significance for local septic infection were antibiotic prophylaxis and number of risk factors. We can conclude therefore that antibiotic chemoprophylaxis is useful in abdominal incisional herniorrhaphy surgery with implantation of prosthetic material for reducing local septic complications.

Intestinal metaplasia in patients with columnar lined esophagus is associated with high levels of duodenogastroesophageal reflux

OBJECTIVE

To evaluate the rate of duodenogastroesophageal reflux in patients with columnar lined esophagus compared with patients with gastroesophageal reflux disease without columnar lined esophagus, and to analyze whether it is related to the presence of specialized columnar epithelium in the metaplastic segment.

SUMMARY BACKGROUND DATA

The carcinomatous degeneration of columnar lined esophagus originates from a specialized columnar epithelium. The appearance of this metaplastic phenomenon is clearly related to severe prolonged gastroesophageal reflux, but only some of these patients finally develop columnar lined esophagus. For this reason other factors have been suggested, particularly the role played by the reflux of duodenal contents into the esophagus.

METHODS

The authors studied 15 healthy volunteers (control group), 10 patients with reflux symptoms but without endoscopic lesions, 20 patients with reflux esophagitis without columnar lined esophagus, and 35 patients with columnar lined esophagus (complicated with ulcers or stenosis in 8 cases), of whom 22 had intestinal metaplasia. To assess the reflux of duodenal contents into the esophagus, all the patients underwent Bilitec 2000 and 24-hour esophageal pH monitoring.

RESULTS

The presence of bilirubin in the material refluxed into the esophagus was greater in the patients with columnar lined esophagus than in the rest of the groups. Likewise, duodenogastroesophageal reflux was greater in the columnar lined esophagus patients who had intestinal metaplasia.

CONCLUSIONS

Duodenogastroesophageal reflux may play a major role in the development of columnar lined esophagus, especially in patients with intestinal metaplasia.

A case of breast cancer associated with juvenile papillomatosis of the male breast

Juvenile papillomatosis of the breast (JPB) was first described in 1980 and is occasionally associated with breast cancer. The literature reports only four cases of JPB in males; none of them associated simultaneously with breast cancer. We present a case of a male with JPB associated with a ductal carcinoma in the same gland.

Life-supporting human complement regulator decay accelerating factor transgenic pig liver xenograft maintains the metabolic function and coagulation in the nonhuman primate for up to 8 days

BACKGROUND

It is not known whether the pig liver is capable of functioning efficiently when transplanted into a primate, neither is there experience in transplanting a liver from a transgenic pigs expressing the human complement regulator human complement regulator decay accelerating factor (h-DAF) into a baboon. The objective of this study was to determine whether the porcine liver would support the metabolic functions of non-human primates and to establish the effect of hDAF expression in the prevention of hyperacute rejection of porcine livers transplanted into primates.

METHODS

Five orthotopic liver xenotransplants from pig to baboon were carried out: three from unmodified pigs and two using livers from h-DAF transgenic pigs.

FINDINGS

The three control animals transplanted with livers from unmodified pigs survived for less than 12 hr. Baboons transplanted with livers from h-DAF transgenic pigs survived for 4 and 8 days. Hyperacute rejection was not detected in the baboons transplanted with hDAF transgenic pig livers; however, it was demonstrated in the three transplants from unmodified pigs. Baboons transplanted with livers from h-DAF transgenic pigs were extubated at postoperative day 1 and were awake and able to eat and drink. In the recipients of hDAF transgenic pig livers the clotting parameters reached nearly normal levels at day 2 after transplantation and remained normal up to the end of the experiments. In these hDAF liver recipients, porcine fibrinogen was first detected in the baboon plasma 2 hr postreperfusion, and was present up to the end of the experiments. One animal was euthanized at day 8 after development of sepsis and coagulopathy, the other animal arrested at day 4, after an episode of vomiting and aspiration. The postmortem examination of the hDAF transgenic liver xenografts did not demonstrate rejection.

INTERPRETATION

The livers from h-DAF transgenic pigs did not undergo hyperacute rejection after orthotopic xenotransplantation in baboons. When HAR is abrogated, the porcine liver maintains sufficient coagulation and protein levels in the baboon up to 8 days after OLT.

24-h pH monitoring is necessary to assess acid reflux suppression in patients with Barrett's oesophagus undergoing treatment with proton pump inhibitors

BACKGROUND

Control of acid reflux is the main objective of treatment for Barrett's oesophagus. However, as these patients have a reduced sensitivity to acid reflux, disappearance of symptoms may not correlate with efficient control of acid reflux. The aim of this study was to determine in a group of patients with Barrett's oesophagus whether treatment with proton pump inhibitors suppressed pathological acid reflux once the symptoms of reflux had been controlled and the associated inflammatory lesions cured.

METHODS

Eighteen consecutive patients with Barrett's oesophagus were studied, all of whom presented with heartburn. Twenty-four-hour oesophageal pH monitoring before treatment showed pathological acid reflux in all cases: median percentage of total time with pH less than 4, 22 (range 8-52) per cent. All patients received proton pump inhibitors (dose 20-60 mg/day) until symptoms were controlled.

RESULTS

While on therapy, pH was reduced (median percentage of total time with pH less than 4, 3 versus 22 per cent; P < 0.001). However, three patients had persistent pathological rates of acid reflux.

CONCLUSION

Disappearance of symptoms is not a good indicator of control of pathological acid reflux in patients with Barrett's oesophagus. Twenty-four-hour pH monitoring should be performed for proper adjustment of the dose of medication.