George Karimundackal

Effect of Short-term vs Prolonged Nasogastric Decompression on Major Postesophagectomy Complications: A Parallel-Group, Randomized Trial

HYPOTHESIS Controversy exists over the need for prolonged nasogastric decompression after esophagectomy. We hypothesized that early removal of the nasogastric tube would not adversely affect major pulmonary complications and anastomotic leak rates. DESIGN Single-center, parallel-group, open-label, randomized (1:1) trial. SETTING A tertiary referral cancer center with high esophagectomy volume. PATIENTS One hundred fifty patients undergoing esophagectomy with gastric tube reconstruction. INTERVENTIONS Either conventional nasogastric decompression for 6 to 10 days (75 patients) or early removal (48 hours) of nasogastric tube (75 patients) with stratification for pyloric drainage and anastomotic technique. MAIN OUTCOME MEASURES The primary (composite) end point was the occurrence of major pulmonary complications and anastomotic leaks. Secondary end points were the need for nasogastric tube reinsertion and patient discomfort scores. Analysis was performed on an intent-to-treat basis. RESULTS No significant differences were seen in the occurrence of the composite primary end point of major pulmonary and anastomotic complications between the delayed (14 of 75 patients [18.7%]) and early (16 of 75 patients [21.3%]) removal groups, respectively (P = .84). Nasogastric tube reinsertion was required more often (23 of 75 patients [30.7%] vs 7 of 75 patients [9.3%]) in the early group (P = .001). Mean patient discomfort scores were significantly higher in the delayed (+1.3; 95% CI, 0.4-2.2; P = .006) than in the early removal group. Significantly more patients in the delayed removal group (26 of 75 patients [34.7%] vs 10 of 75 patients [13.3%] in the early removal group; P = .002) identified the nasogastric tube as the tube causing the most discomfort. CONCLUSIONS Early removal of nasogastric tubes does not increase pulmonary or anastomotic complications after esophagectomy. Patient discomfort can be significantly reduced by early removal of the nasogastric tube. TRIAL REGISTRATION Clinical Trials Registry of India Identifier: CTRI/2010/091/003023.

Novel cost-effective method of laparoscopic feeding- jejunostomy

A feeding jejunostomy tube placement is required for entral feeding in a variety of clinical scenarios. It offers an advantage over gastrostomies by eliminating the risk of aspiration. Standard described laparoscopic methods require special instrumentation and expensive custom-made tubes. We describe a simple cost-effective method of feeding jejunostomy using regular laparoscopic instruments and an inexpensive readily available tube. The average operating time was 35 min. We had no intra-operative complications and only one post-operative complication in the form of extra-peritoneal leakage of feeds due to a damaged tube. No complications were encountered while pulling out the tubes after an average period of 5–6 weeks.

Lymphadenectomy in Esophageal Cancer: The Real Issues

We thank Mineo and colleagues [1] for their interest in our article [2]. The authors have pioneered nonintubated video-assisted thoracoscopic surgery (VATS) for years. We are encouraged and supported by many of their works while exploring the feasibility and safety of nonintubated VATS in major pulmonary resections [2–4]. Undoubtedly, patients with undetermined lung nodules are increasing and either a diagnostic or a curative VATS is their treatment of choice. Although intubated general anesthesia is the standard for VATS with negligible and manageable risks, postoperative nausea, vomiting, and gagging on the endotracheal tube are still the most undesirable clinical anesthesia outcomes in surgical patients [5]. We agree with Mineo and colleagues that high-risk patients for intubated general anesthesia would benefit from nonintubated VATS mostly, as our geriatric patients did [3]. However, if a nonintubated technique is also safely feasible, we believe that most patients would prefer a nonintubated technique first, similar to their preference for a minimally invasive approach using VATS instead of open thoracotomy. In this regard, the speculation of “when-and-for-who” may be interpreted from another side as “when-and-for-who-not-to” do a nonintubated VATS. Selection criteria for nonintubated VATS have been described previously [2–4]. As a rule, the safety of the VATS approach and airway management should be carefully and individually evaluated before surgery. Patients are considered to have a nonintubated VATS only when the caring thoracic surgeon and anesthesiologist are both confident with the technique. Conversion to either a thoracotomy or intubated general anesthesia should be performed decisively in a timely manner. With the guidance of a bronchoscope and the use of bronchial blocker for one-lung ventilation, airway injury can be minimized under the practice of an experienced thoracic anesthesiologist. We thank Mineo and colleagues for highlighting this important safety issue with nonintubated VATS, and we truly believe in the future application of this method to complement the modern era of minimally invasive and enhanced recovery practice.

Early removal of chest tubes after lung resection---VATS the reason?

diagnose whether it was aorto-iliac occlusive disease (Leriche syndrome) with significant collateralization or results from cardiac thrombus. However, the development of such a bypassing collateral vascular network obviously indicates it was not an acute aortic occlusion (AAO). The patient did not have a previous peripheral arterial reconstruction and atherosclerotic cardiac disease but suffered from rheumatic heart disease. Severe mitral valve stenosis was believed to be the cause of atrial fibrillation and thrombus in the left atrium. It must be pointed that the patient had cerebral embolism and acute left lower extremity which recovered after treatment 5 years ago, but no traumatic history, abdominal aortic aneurysms, and dyscinesia of both lower extremities. No anticoagulants were administrated during the past several years before being admitted to our hospital for cardiac surgery. We had no sufficient evidences to conclude that chronic atrial fibrillation is not associated with the infrarenal aortic occlusion. Perhaps we should objectively describe Fig. 2 as ‘occlusion of the infrarenal aorta and abundant collateral bypassing arteries between abdominal aorta and bilateral femoral artery.’ Luckily, the patient recovered well and remains healthy.

Pulmonary hemangioendothelioma with osteoclast-like giant cells: A rare observation.

Pulmonary epithelioid hemangioendothelioma (PEH) is a rare vascular neoplasm, predominantly encountered in women, more often in the age group of 40 years and below. It is a tumor of borderline malignant potential with a clinical course intermediate between hemangioma and angiosarcoma. The tumor has variable prognosis, and treatment options include surgical excision in operable cases and chemotherapy in disseminated ones. The present report describes complete clinical, radiological, and histopathological features of PEH with osteoclast-like giant cells and metaplastic ossification in a 20-year-old boy who presented with dyspnea and episodes of hemoptysis with review of literature.

Giant mediastinal carcinoid

© 2015 Indian Journal of Medical and Paediatric Oncology | Published by Wolters Kluwer Medknow A 25-year-old male was presented with cough. Computed tomography (CT) scan showed anterior mediastinal mass [Figure 1] encasing the aortic arch and left brachiocephalic vein with compression of the superior vena cava. CT-guided biopsy showed neuroendocrine tumor staining with chromogranin, synaptophysin, and neuron specifi c enolase. Postchemoradiotherapy positron emission tomography-CT scan revealed static disease [Figure 2]. At surgery, the mass could be dissected off the major vessels; the thrombosed left brachiocephalic vein was resected. Good collaterals obviated the need for vascular reconstruction. The patient recovered after a stormy postoperative course. Histopathology report showed neuroendocrine carcinoma, mitotic rate of 10/10 HPF, and MIB-1 proliferation index of 8-10%. On 5-year follow-up, the patient is asymptomatic and disease-free on CT scan.

Management of T2N0 Esophageal Cancer

We read with interest the article by Ahmad and associates [1] regarding the utility of lung transplantation for lung cancer, which concluded that lung transplantation was a reasonable option for patients who did not benefit from medical or surgical therapies to control their cancers. However, we would like to raise some questions that require further clarifications. Lung cancer was earlier considered an absolute contraindication for lung transplantation, but study has begun to focus on the benefits for long-term survival after lung transplantation for bronchoalveolar carcinoma (BAC) [2, 3]. However, lung transplantation is not supported for patients with other types of bronchogenic carcinoma owing to high risk of cancer recurrence [2]. Ahmad and colleagues [1] comment that “lymph node metastases did not preclude survival.” Despite this, does N1 or N2 disease as a marker of tumor metastasis actually not predict the outcome of transplanted patients? Perrot and coworkers [3] have demonstrated that patients with stage II or III bronchogenic carcinoma had worse prognosis than patients with stage I, and usually succumb to cancers due to extensive tumor recurrence. Thus, lymph node invasion in these patients causes a clinical dilemma of recipient selection and greatly affects actual survival. Patients with suspicious N2 nodes should be investigated by mediastinoscopy as discussed by Ahmad and colleagues [1]; N2positive lung cancer is generally considered a contraindication to surgical therapy, even though surprisingly reasonable survival was achieved in this study. Endobronchial ultrasound–fine-needle aspiration in addition tomediastinoscopycan facilitate thedetection of N1 disease; N1 disease rather than N2 disease as the cutoff for exclusion of lung transplantation may turn to optimal selection of patients. Thus, N2 disease as the cutoff is not convincing. Whether patients with bronchogenic carcinoma benefit from lung transplant should be confirmed by a large prospective trial. However, several ethical issues related to lung transplant should be resolved. Patients with bronchogenic carcinoma receiving lung transplants only accounted for 0.1% of the total number, and waiting-list mortality is commonly ascribed to donor scarcity; therefore, how to allocate the limited donors will be discussed before the trial is launched. Should patients not amenable to surgical resection (no N2 disease) receive lung transplant or chemotherapy-based treatment? Transplant is inadequate for some patients who can benefit largely from chemotherapy. Furthermore, whether chemotherapy should be performed after lung transplant remains undecided. In addition, it is still unknown whether postoperative immunosuppressive regimens can increase the risk of cancer relapse, and that requires the proof of further research.

Route of reconstruction after total oesophagectomy.

We read with interest the small but elegant cadaveric anatomy study by Hu et al. [1] comparing the lengths of the anterior with the posterior mediastinal routes for oesophageal reconstruction. The ideal route of reconstruction has been a longstanding controversy in oesophageal surgery, with several randomized trials and even a meta-analysis [2] on the subject. The meta-analysis did not show statistically significant differences in complication rates and outcomes between the anterior and posterior mediastinal routes but admitted that there was a need for more data. Hu et al. conclude that, contrary to the popular belief, the anterior mediastinal route is significantly shorter than the posterior route. This cadaveric study supports the results of the same group’s intraoperative study [3] published earlier but contradicts other cadaveric studies [4, 5]. The authors base their measurements on different distal points than those used routinely in previous studies. We agree with the authors that the distal reference points they used are certainly more clinically relevant than the coeliac axis. The choice of reconstruction route for most of the surgeons would depend on various factors, namely the anticipated risk of local recurrence, potential need for postoperative radiotherapy for a R+ resection, whether the surgery was done after oesophagectomy or just as a bypass procedure with the oesophagus in situ, past history of sternotomy, personal choice and importantly, the length to be traversed by the gastric substitute. Our standard preference so far has been to use the posterior mediastinal route in all cases unless we anticipated a high risk of local recurrence or planned postoperative radiotherapy ( 10% of patients). Major postoperative complication rates in 820 patients who underwent posterior mediastinal reconstruction were similar to 97 patients who underwent an anterior reconstruction (25.5 versus 27.1%, P > 0.05) over the past eight years. One of the potential advantages of using the anterior mediastinal route could be a lower incidence of septic mediastinitis in the case of anastomotic leaks. This has been an unconfirmed observation in our series and we are interested to know the experiences of the authors and other oesophageal surgeons in this area. If that were so, the authors’ results could then provide a powerful argument for routinely using the anterior mediastinal route for oesophageal reconstruction. We intend to measure the required length through both routes intraoperatively in our patients and urge other oesophageal surgeons to generate unequivocal data on this issue.

Lymph nodal staging for non-small-cell lung cancer

We read with interest Matsuguma et al.’s recent paper in the journal [1] on the optimum method of lymph node (LN) staging for non-small-cell lung cancer (NSCLC). We congratulate the authors on their elegant analysis of the data to conclude that the LN ratio had the best discriminatory power, followed by the LN number, both of which were superior to the current nodal staging system. Several other authors [2–5] have come up with similar results and have espoused the use of either the LN ratio or positive LN number for the pathological staging of NSCLC. In an ideal world, with uniform standards of surgery, pathology grossing and reporting, there is no doubt that these methods would be superior to the conventional lymph nodal staging system. We, however, believe that there are several points to be considered before recommending that these be used to modify the existing tumour node metastases (TNM) staging system. First, it is often difficult to get an accurate count of the number of LNs harvested in the mediastinum. Frequently, this depends not only on the expertise of the operating surgeon, but also the diligence of the pathologist grossing the specimen. Moreover, anthracotic LNs in the mediastinum often fragment, thereby giving an erroneous count. Secondly, the ratio of metastatic LNs would be widely variant between surgeons, thoracic units and institutions depending on their surgical philosophy, expertise and again, the pathologist. Surgeons performing mediastinal LN sampling would have very different LN ratios from those who perform a radical systematic mediastinal LN dissection. Paradoxical results could appear due to an inordinately high pick-up of normal LNs, reducing the LN ratio. Thirdly, preoperative LN staging, already inaccurate, would become even more inaccurate as it would be virtually impossible to get a metastatic LN ratio or even an LN number based on radiological investigations or even a mediastinoscopy. Finally, these methods would increase the complexity of staging, making them less likely to be complied with by routine pathology reporting. While we agree wholeheartedly with the authors that the LN ratio or number would be superior to the existing TNM staging system, we would be reluctant to advocate the adoption of these methods in the TNM staging system.

The philosophy of a nerve-sparing thoracotomy closure

We read with interest Bayram and colleagues’ recent article [1] on the randomized trial evaluating a modified thoracotomy closure technique to reduce compression of the intercostal nerve and thereby reduce post-thoracotomy pain. The authors’ report a statistically significant reduction in postoperative pain using this technique. The described procedure is a modification of a technique proposed by Cerfolio and colleagues [2, 3], who harvest the intercostal muscle flap at the beginning of surgery, retract the flap outside the thoracotomy field using a soft Penrose drain, and, at closure, drill holes in the lower rib to avoid compressing the nerve. This approach is theoretically a more attractive concept as it avoids nerve entrapment both by the chest retractor during surgery and the pericostal sutures after closure. Bayram’s technique, on the other hand, does not avoid nerve compression intraoperatively by the chest retractor, and nerve compression at this stage could still cause postoperative neuropathic pain. We have seen Cerfolio’s group perform their procedure with impressive results and are halfway through a randomized trial to evaluate the technique in our unit. Similar to Cerfolio’s group, we retract the harvested flap with a soft drain and this gives unrestricted intrathoracic access.