Georgios Rossidis

Bariatric Surgery: Indications, Safety and Efficacy

Obesity among adults, children and adolescents has markedly increased regardless of gender, age, ethnicity or educational level, and has become a national health threat and a major public health challenge. This obesity epidemic can be attributed to excess energy intake and decreased energy expenditure experienced in Westernized countries. Unfortunately, there is no single solution to prevent or treat obesity that will be inclusive of everyone. Often times, treatment of obesity may include a combination of diet, exercise, behavior modification, medication, and sometimes weight-loss surgeries. Hence, bariatric surgery has evolved over the last four decades and has been shown to be effective in reducing obesity related comorbidities, improve the quality of life, number of sick days, monthly medication costs, and overall mortality. With the increasing rates of weight loss surgical procedures, the quality, efficacy and surgical outcomes have improved with the creation of Bariatric Centers of Excellence designated by the American Society of Metabolic and Bariatric Surgery or American College of Surgeons. The benefits of bariatric procedures in morbidly obese patients outweigh the risks. With the advent of minimally invasive surgical procedures, bariatric surgery is a reasonable treatment option in those who strongly desire substantial weight loss and have life-threatening comorbid conditions.

Minimally invasive esophagectomy is safe in patients with previous gastric bypass

BACKGROUND The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE). METHODS Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012. RESULTS Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up. CONCLUSIONS Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barretts esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.

Discordant HER2 expression and response to neoadjuvant chemoradiotherapy in esophagogastric adenocarcinoma

BACKGROUND Targeting human epidermal growth factor receptor 2 (HER2) with trastuzumab in metastatic esophagogastric adenocarcinoma (EGA) improves survival. The impact of HER2 inhibition in combination with chemoradiotherapy (CRT) in early stage EGA is under investigation. This study analyzed the pattern of HER2 overexpression in matched-pair tumor samples of patients who underwent neoadjuvant CRT followed by surgery. METHODS All patients with EGA who underwent standard neoadjuvant CRT followed by esophagectomy at the University of Florida were included. Demographics, risk factors, tumor features, and outcome data were analyzed. Descriptive statistics, Chi-square exact test, uni- and multivariate analyses, and Kaplan Meier method were used. HER2 expression determined by immunohistochemical (IHC) was scored as negative (0, 1+), indeterminate (2+) or positive (3+). RESULTS Among 49 sequential patients (41 M/8 F) with matched-pair tumor samples, 9/49 patients (18%) had pathologic complete response (pCR), 10/49 had near pCR or not enough tumor (NET) to examine in the post- treatment samples. Patients with initial HER2 negativity demonstrated conversion to HER2 positivity after neoadjuvant CRT (7/30 cases; 23%). Baseline HER2 overexpression was more common in lower stage/node negative patients (67% in stages I, IIA vs. 33% in stages IIB, III) and did not correlate with treatment response or survival. CONCLUSIONS Although limited by a relatively small sample size, our study failed to demonstrate that baseline HER2 protein over-expression in EGA predicts response to standard CRT. However, our data suggested that HER2 was up regulated by CRT resulting in unreliable concordance between pre-treatment (pre-tx) and post-treatment (post-tx) samples. Pre-therapy HER2 expression may not reliably reflect the HER2 status of persistent or recurrent disease.

Thoracoscopic and Laparoscopic Enucleation of Esophageal Leiomyomas

Although infrequent, esophageal leiomyomas are the most common benign intramural tumors of the esophagus. As malignant potential is not a concern in these lesions, they represent ideal candidates for an organ-preserving approach. Due to their well-circumscribed growth, a minimally invasive approach should be pursued in almost all patients. We present our recent techniques and results associated with totally minimally invasive thoracoscopic and laparoscopic approaches to resection of esophageal leiomyomas. These approaches require technical expertise but can be accomplished with a short learning curve.

Laparoscopic Partial Gastrectomy

Laparoscopic partial gastrectomy, also called wedge gastrectomy, refers to resection of part of the stomach without the subsequent need for a gastrojejunostomy, in a laparoscopic fashion. It is an approach that has gained popularity for resection of lesions that are either benign (ulcers, polyps, cysts, leiomyomas, heterotopic pancreas) or malignant (gastrointestinal stromal tumors). The surgical approach to all submucosal stromal tumors is similar, and we will attempt to describe the laparoscopic approach to the resection of these lesions and the challenges associated with the size and anatomic location. The chapter will describe the surgical management of GIST, the most common submucosal lesion of the stomach.