Jan B. F. Hulscher

Transthoracic Versus Transhiatal Resection for Carcinoma of the Esophagus: A Meta-Analysis

There is much controversy about the surgical approach to esophageal carcinoma: should an extensive resection be done to optimize long-term survival or should the extent of the operation be limited to obtain lower perioperative morbidity and mortality rates? We systematically reviewed the English-language literature published during the past decade, with emphasis on the differences between transthoracic and transhiatal resections regarding early morbidity, in-hospital mortality rates, and 3- and 5-year survival. Although transthoracic resections had significantly higher early (pulmonary) morbidity and mortality rates, 5-year survival was approximately 20% after both transthoracic and transhiatal resections.

The recurrence pattern of esophageal carcinoma after transhiatal resection

BACKGROUNDnThere is much controversy about the optimal resection for carcinoma of the esophagus. Little is known about the pattern of recurrence after transhiatal resection for esophageal carcinoma.nnnSTUDY DESIGNnWe retrospectively reviewed the charts of 149 patients who underwent transhiatal esophagectomy for carcinoma of the mid or distal esophagus or gastroesophageal junction between June 1993 and June 1997. Recurrence was classified as locoregional or distant recurrence. Nine patients with macroscopically evident tumor left after resection and three patients (2.0%) who died in the hospital were excluded from the analysis. This left 137 patients; 105 men and 32 women with a median age 65 years (range 37 to 84 years).nnnRESULTSnThere were 95 adenocarcinomas (69.3%) and 42 squamous cell carcinomas (30.7%). Overall the median followup was 24.0 months (range 1.4 to 69.2 months). For patients alive at the end offollowup without recurrence, the median followup was 36.5 months (range 23.6 to 69.2 months). Seven patients died of other causes. The median interval between operation and recurrence was 11 months (range 1.4 to 62.5 months) for patients who had recurrence, with no significant difference in interval between locoregional and systemic recurrence. Seventy-two of the 137 patients (52.6%) developed recurrent disease. Thirty-two patients (23.4%) developed locoregional recurrence only, 21 patients (15.3%) developed systemic recurrence only, and 19 patients (13.9%) had a combination of both. In only 8.0% of all patients was there recurrence in the cervical lymph nodes. The most frequent sites of distant recurrence were liver (37.5%), bone (25.0%), and lung (17.5%). Recurrence was related to postoperative lymph node status (p<0.001) and the radicality of the operation (p<0.001) in multivariate analysis. Recurrence was not associated with localization or histologic type of the tumor.nnnCONCLUSIONSnRecurrence after transhiatal resection is an early event. Almost 40% of patients developed locoregional recurrent disease. For this patient group a more extended procedure may be of benefit, especially in the patients (23.4%) with locoregional recurrence in whom this is the only site of recurrent disease. But the potential benefit of a more extended procedure has to be balanced against a possible increase in perioperative morbidity and mortality.

Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy

BACKGROUNDnBenign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications.nnnMETHODSnCharts of 6 patients with a benign tracheoneo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed.nnnRESULTSnThree men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake.nnnCONCLUSIONSnA benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.

Early postoperative hyperglycaemia is not a risk factor for infectious complications and prolonged in-hospital stay in patients undergoing oesophagectomy: a retrospective analysis of a prospective trial

IntroductionTreating hyperglycaemia in hospitalized patients has proven to be beneficial, particularly in those with obstructive vascular disease. In a cohort of patients undergoing resection for oesophageal carcinoma (a group of patients with severe surgical stress but a low prevalence of vascular disease), we investigated whether early postoperative hyperglycaemia is associated with increased incidence of infectious complications and prolonged in-hospital stay.MethodsPostoperative glucose values up to 48 hours after surgery were retrieved for 151 patients with American Society of Anesthesiologists class I or II who had been previously included in a randomized trial conducted in a tertiary referral hospital. Multivariate regression analysis was used to define the independent contribution of possible risk factors selected by univariate analysis.ResultsIn univariate regression analysis, postoperative glucose levels were associated with increased length of in-hospital stay (P < 0.001) but not with infectious complications (P = 0.21). However, postoperative glucose concentration was not found to be an independent risk factor for prolonged in-hospital stay in multivariate analysis (P = 0.20).ConclusionOur data indicate that postoperative hyperglycaemia is more likely to be a risk marker than a risk factor in patients undergoing highly invasive surgery for oesophageal cancer. We hypothesize that patients with a low prevalence of vascular disease may benefit less from intensive insulin therapy.

Transthoracic Versus Transhiatal Resection for Carcinoma of the Esophagus

There is much controversy about the surgical approach to esophageal carcinoma: should an extensive resection be done to optimize long-term survival or should the extent of the operation be limited to obtain lower perioperative morbidity and mortality rates? We systematically reviewed the English-language literature published during the past decade, with emphasis on the differences between transthoracic and transhiatal resections regarding early morbidity, in-hospital mortality rates, and 3- and 5-year survival. Although transthoracic resections had significantly higher early (pulmonary) morbidity and mortality rates, 5-year survival was approximately 20% after both transthoracic and transhiatal resections.

Stress Fracture of the Femoral Neck in a Young Female Athlete

Stress fractures have been reported to occur in association with running. They typically involve the lower extremity. Although relatively rare, unrecognized or untreated femoral neck fractures carry a much higher morbidity rate than other stress fractures. Stress fractures of the femoral neck should even be considered in young amateur athletes with hip pain. If X-ray is inconclusive, radionuclide bone imaging and MRI can be useful in diagnosing these fractures. This rare diagnosis, as well as classification and treatment options, will be discussed.

A 7-year-old Boy with an Abdominal Wall Hernia and Ischemia of the Left Leg after a Bicycle Handle Bar Injury

AbstractTraumatic abdominal wall hernia is a rare event. Wendescribe a 7-year-old boy in whom this rare injury wasncombined with a traumatic dissection of the externalniliac artery. The hernia was corrected by primary repair,nthe dissection by resection of the injured part and endto-end anastomosis.

Resection of Esophageal Carcinoma: The Role of Lymph Node Dissection

The way lymph node metastases and cancer in general are looked upon has changed significantly over the years. From the middle of the 20th century cancer was thought of more and more as a disease already disseminated at the time of presentation, and tumor positive lymph nodes were considered metastatic disease. Lymph node dissection was accordingly not considered curative anymore, but turned into a mere staging procedure. Lymph node metastases had become “indicators, but not governors of survival”1.