Joerg Zehetner

Recurrence after Esophagectomy for Adenocarcinoma: Defining Optimal Follow-Up Intervals and Testing

BACKGROUND To determine the optimal follow-up strategy after esophagectomy for adenocarcinoma of the esophagus or gastroesophageal junction by evaluating the timing of recurrence and the method that first detected the recurrence. STUDY DESIGN Between 1991 and 2007, 590 patients had an esophagectomy for adenocarcinoma. Recurrence occurred in 233 (40%) and, of those, 174 had complete follow-up at our center with a protocol that consisted of an office visit with CT scans and laboratory studies every 3 months for 3 years, every 6 months for 2 years, and then annually. A subset of patients had PET annually. RESULTS Recurrence in the 174 patients with complete follow-up was systemic in 104 (60%), locoregional/nodal in 51 (30%), and both in 19 (10%). Recurrence was first suspected by symptoms and/or physical examination in 29 patients (17%), by CT scan in 105 (60%), PET in 32 (18%), and by elevated CEA in 8 (5%). Recurrence was detected at a median of 11 months (range 3 to 72 months) and occurred later after esophagectomy alone compared with patients who received neoadjuvant therapy (12 versus 8 months; p = 0.01), but the pattern of recurrence was similar. More than 90% of recurrences were detected within 2 years after neoadjuvant therapy, compared with 3 years after esophagectomy alone. Median survival after recurrence was 7 months and was significantly longer in patients treated for the recurrence (9 versus 3 months; p = 0.001). CONCLUSIONS Frequent early follow-up is appropriate after esophagectomy for adenocarcinoma because >90% of recurrences will occur by 3 years after esophagectomy alone and by 2 years following neoadjuvant therapy. Beyond these time periods, 2% to 3% of recurrences were detected each year, suggesting that annual follow-up is adequate. Survival after recurrence was improved with therapy, confirming the use of careful follow-up in these patients.

The impact of gastric distension on the lower esophageal sphincter and its exposure to acid gastric juice.

Background and Aims:The lower esophageal sphincter (LES) in patients with gastroesophageal reflux disease often has a low resting pressure and a short abdominal length. The mechanism by which this occurs is unknown. We hypothesize that gastric distension causes progressive effacement of the abdominal portion of the LES, exposing it to acid injury resulting in mucosal and sphincter damage. Our aim was to assess in normal subjects the effect of gastric distension on the LES length and pressure and its exposure to acid gastric juice. Methods:Eleven asymptomatic volunteers had their LES length and pressure measured before and during gastric distension. The location of the pH step-up point (shift from gastric pH to a pH >4) was also measured before and after distension. Results:Progressive gastric distension with air resulted in progressive shortening of LES (R2 = 0.89, P < 0.0001). After infusion of 750 cc of air there was a significant reduction in the median LES length from 4 to 2.6 cm (P = 0.001). This change occurred in the abdominal length of the LES (2.6–1.4 cm [P = 0.001]) and not in the thoracic length. At rest the pH step-up point was 0.5 cm above the lower border of the LES and with distension moved a median of 1 cm cephalad within the LES. Simultaneously with the loss of length there was a reduction in LES pressure (27.4–23.4 mm Hg, P = 0.02). Conclusions:Gastric distension causes progressive shortening of the abdominal length of the LES and a reduction in its pressure. The process exposes the effaced mucosa and sphincter to acid gastric juice.

Single-access laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials.

Background: Single-incision laparoscopic surgery has been proposed as a minimally invasive technique with the advantages of fewer scars and reduced pain. The aim of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of single-access laparoscopic cholecystectomy (SALC) versus classic laparoscopic cholecystectomy (CLC). Methods: All randomized controlled trials were identified through electronic searches (MEDLINE, PubMed, SAGES, and Cochrane Central Register of Controlled Trials) up to October 2011. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect. Results: Nine true randomized controlled trials were included in the analysis and reported a total of 695 patients, divided into the SALC group of 362 patients and the CLC group of 333 patients. Median operating time was longer with 57 minutes in SALC versus 45 minutes in CLC (P=0.00001). There was no significant difference in length of stay (SALC 1.36 d vs. CLC 1.15 d, P=0.18). Conversion to laparotomy in either group was similar; however, in 18 of 66 SALC patients an additional instrument was used, compared with 1 of 67 CLC patients (P=0.0003). Complications were not significant different [16% in SALC vs. 12% in the CLC group (P=0.74)]. Median postoperative pain with the visual analog scale score was 3.8 points in SALC versus 3.15 points in the CLC group (P=0.48). Cosmetic satisfaction was significantly more satisfying with 9 points favoring SALC versus 0 points favoring CLC (P=0.0005) in contrast to the quality-of-life questionnaire where there was no significant difference in patient overall satisfaction between SALC and CLC groups (P=0.0515). Conclusions: SALC required longer operative times than CLC without significant benefits in patient overall satisfaction, postoperative pain, and hospital stay. Only satisfaction with the cosmetic result showed a significantly higher preference towards SALC.

Proximal esophageal pH monitoring: improved definition of normal values and determination of a composite pH score.

BACKGROUND Patients with respiratory and laryngeal symptoms are commonly referred for evaluation of reflux disease as a potential cause. Dual-probe pH monitoring is often performed, although data on normal acid exposure in the proximal esophagus are limited because of the small number of normal subjects and inconsistent placement of the proximal pH sensor in relation to the upper esophageal sphincter. We measured proximal esophageal acid exposure using dual-probe pH and calculated a composite pH score in a large number of asymptomatic volunteers to better define normal values. STUDY DESIGN Eighty-one normal subjects free of reflux, laryngeal, or respiratory symptoms were recruited. All had video esophagraphy to exclude hiatal hernia. Esophageal pH monitoring was performed using 1 of 3 different dual-probe catheters with sensors spaced 10, 15, or 18 cm apart. The standard components of esophageal acid exposure were measured, excluding meal periods. A composite pH score for the proximal esophagus was calculated using these components. RESULTS The final study population consisted of 59 (49% male) subjects, with a median age of 27 years. All had normal distal esophageal acid exposure and no hiatal hernia. The 95(th) percentile values for the percent time the pH was < 4 for the total, upright, and supine periods were 0.9%, 1.2%, and 0.4%, respectively. The 95(th) percentile for the number of reflux episodes was 24 and for the calculated proximal esophageal composite pH score was 16.4. CONCLUSIONS In a large population of normal subjects, we have defined the normal values and calculated a composite pH score for proximal esophageal acid exposure. The total percent time pH < 4 was similar to previously published normal values, but the number of reflux episodes was greater.

Can ultrasound common bile duct diameter predict common bile duct stones in the setting of acute cholecystitis

BACKGROUND Our aim is assessment of ultrasound (US) common bile duct (CBD) diameter to predict the presence of CBD stones in acute cholecystitis (AC). METHODS A retrospective review from 2007 to 2011 with codes for ultrasound, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography, and AC was conducted. RESULTS The incidence of CBD stones was 1.8%. Two hundred forty eight individuals had US+MRCP+ERCP+AC, of which 48 had CBD stones and 200 did not have CBD stones. US CBD diameter range was 3.6 to 19 mm. Ninety percent of MRCPs were negative, and it delayed care by 2.9 days. Mean CBD diameter was narrower in those negative for CBD stones (5.8 vs 7.08; P = .0043). Groups based on diameter ranges <6, 6 to 9.9, and ≥10 mm demonstrated 14%, 14%, and 39% CBD stones, respectively. CONCLUSIONS US CBD diameter is not sufficient to identify patients at significant risk for CBD stones. MRCP delayed care by 2.9 days. Intraoperative cholangiography may be more effective, based on the low risk of CBD stones in AC.

Loss of Alkalization in Proximal Esophagus: a New Diagnostic Paradigm for Patients with Laryngopharyngeal Reflux

IntroductionCervical esophageal pH monitoring using a pH threshold of <4 in the diagnosis of laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of cervical esophageal exposure to gastric juice. The aim of this study was to define normal values for the percent time the cervical esophagus is exposed to a pH ≥7 and to use the inability to maintain this as an indicator for diagnosis of LPR.Material and MethodsFifty-nine asymptomatic volunteers had a complete foregut evaluation including pH monitoring of the cervical esophagus. Cervical esophageal exposure to a pH <4 was calculated, and the records were reanalyzed using the threshold pH ≥7. The sensitivity of these two pH thresholds was compared in a group of 51 patients with LPR symptoms that were completely relieved after an antireflux operation.ResultsCompared to normal subjects, patients with LPR were less able to maintain an alkaline pH in the cervical esophagus, as expressed by a lower median percent time pH ≥ 7 (10.4 vs. 38.2, p < 0.0001). In normal subjects, the fifth percentile value for percent time pH ≥ 7 in the cervical esophagus was 19.6%. In 84% of the LPR patients (43/51), the percent time pH ≥ 7 were below the threshold of 19.6%. In contrast, 69% (35/51) had an abnormal test when the pH records were analyzed using the percent time pH < 4. Of the 16 patients with a false negative test using pH < 4, 11 (69%) were identified as having an abnormal study when the threshold of pH ≥ 7 was used.ConclusionNormal subjects should have a pH ≥7 in cervical esophagus for at least 19.6% of the monitored period. Failure to maintain this alkaline environment is a more sensitive indicator in the diagnosis of the LPR and identifies two thirds of the patients with a false negative test using pH <4.

Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery

BACKGROUND Bariatric surgery is a proven tool in reducing the co-morbidities associated with morbid obesity. The aim of the present review was to assess the current data and discuss the strategies for preoperative evaluation, preoperative treatment, and intraoperative management of the obese patient with cardiac disease seeking bariatric surgery, including those who have undergone previous angiographic intervention with coronary stenting and/or antiplatelet therapy. The setting was a university hospital in the United States. METHODS A search of the English-language reports using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and antiplatelet therapy was conducted. RESULTS The methods of preoperative cardiac risk assessment found in the published studies included the use of certain criteria, stress echocardiography, and single-photon emission computed tomography. Preoperative medical treatment optimization with β-blockers and statins is recommended. Perioperative antiplatelet therapy in the form of aspirin 81 mg can be safely continued, but clopidogrel should be stopped and reinitiated with caution. CONCLUSION Preoperative assessment of morbidly obese patients with coexisting cardiac issues presents unique challenges. Safe patient care and good clinical outcomes can be achieved with adherence to evidence-based practice.

Percutaneous cholecystostomy versus laparoscopic cholecystectomy in patients with acute cholecystitis and failed conservative management: a matched-pair analysis.

Introduction: The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management. Patients and Methods: A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias. Results: There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005). Conclusion: In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

Esophageal pH exposure and epithelial cell differentiation

It is proposed that epithelial changes induced by gastroesophageal reflux disease are related to the pH environment of the esophageal lumen. We hypothesized that the various types of esophageal epithelium are associated with specific pH environments that induce their formation. The aim of this study was to compare the luminal pH environment to the histology of the distal esophageal epithelium in patients with gastroesophageal reflux disease. A total of 197 symptomatic patients with increased esophageal acid exposure on 24-hour pH monitoring were grouped according to the histology based on biopsies from the distal esophagus: 17 with squamous epithelium, 126 with cardiac epithelium (CE), and 54 with Barretts epithelium (BE). All were free of Helicobacter pylori infection and monitored off acid suppression therapy. Acid exposure was expressed as the percent of time the luminal pH was at intervals of 0-1, 1-2, 2-3, 3-4, 4-5, 5-6, and 6-7 over a 24-hour period. Patients with BE spent significantly more time at pH intervals 2-3, 3-4, and 4-5 than those with CE. This pattern switched at pH interval 5-6, where patients with cardiac mucosa spent more time than those with BE. Patients with squamous and CE had similar pH exposure at all intervals. Patients with BE have significantly longer exposure time at the pH interval of 2 to 5 compared to those with cardiac and squamous epithelium. This suggests that the exposure of stem cells to a luminal pH between 2 and 5 may trigger the differentiation of CE into intestinalized CE.

Three-dimensional Laparoscopy: Does Improved Visualization Decrease the Learning Curve among Trainees in Advanced Procedures?

Purpose: Complex laparoscopy is difficult to master because it involves 3-dimensional (3D) interpretation on a 2-dimensional (2D) viewing screen. The use of 3D technology has an uncertain effect on training surgeons. We aim to evaluate the effectiveness of 3D on learning and performing laparoscopic tasks. Methods: Medical students without laparoscopic experience (novices) were evaluated doing inanimate object transfer and laparoscopic suturing. Tasks were repeated using 2D and 3D cameras with standard instruments. Time and error rates (missed attempts, dropped objects, and failure to complete the task) were recorded. Results: Twenty-nine novice medical students experienced a 45.5% decrease in the time to complete PEG transfer using 3D (mean 207 s with 2D vs. 113 s with 3D). Error rate was reduced to 50% (2D, 4 errors vs. 3D, 2 errors) and mean drop rate was reduced to 0. Similar decreases in suture time (46.5%) were seen (mean 403 s with 2D vs. 220 s with 3D). Conclusions: Our results indicate that 3D significantly improved visualization and ability to perform complex tasks in the skills laboratory setting. This technology may be very effective in teaching advanced laparoscopic skills in the era of work-hour restrictions.