Jonathan F. Critchlow

Impact of the Surgical Technique on Pulmonary Morbidity After Esophagectomy

BACKGROUND Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors. METHODS We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality. RESULTS A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality. CONCLUSIONS Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

High-Frequency Probe Ultrasonography Has Limited Accuracy for Detecting Invasive Adenocarcinoma in Patients with Barrett's Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma: A Case Series

AIM:To evaluate prospectively the accuracy of preoperative high-frequency (20 MHz) probe ultrasonography (HFPUS) for detecting invasive cancer in patients referred for esophagectomy because of an endoscopic biopsy diagnosis of high-grade dysplasia (HGD) or intramucosal carcinoma (ICA) in Barretts esophagus (BE).PATIENTS AND METHODS:Nine consecutive male patients (median age of 69 yr) who were referred for esophagectomy for HGD or ICA in BE agreed to participate. We performed conventional upper gastrointestinal endoscopy followed by HFPUS using a through-the-scope ultrasound probe (20 MHz), and we compared our preoperative findings with the pathologists findings in the resected esophageal specimens.RESULTS:There was complete agreement between the postoperative pathological findings and the preoperative HFPUS findings in only 4 of the 9 patients. HFPUS resulted in two false-negative diagnoses of esophageal cancer (both had T1 lesions in the resected specimens), one false-positive diagnosis of esophageal cancer, and two errors in tumor staging (1 understaged, 1 overstaged).CONCLUSIONS:HFPUS has limited accuracy for identifying invasive cancer in patients found to have HGD or IMC in BE. Pending further refinements in technology, clinical management decisions in such patients should not be based solely on the results of HFPUS.

Repeat bedside percutaneous dilational tracheostomy is a safe procedure.

ObjectivePrevious tracheostomy has been considered a relative contraindication for percutaneous dilational tracheostomy. The objective of this study was to assess the safety of percutaneous dilational tracheostomy in critically ill patients with a history of previous tracheostomy. DesignRetrospective, single-center case series of all consecutive patients requiring repeat tracheostomy for continued mechanical ventilatory support. SettingIntensive care unit of a tertiary-care referral center. SubjectsFourteen patients (eight female, six male) with a median age of 70 yrs (range, 33–94). All patients had previously undergone tracheostomy. InterventionBedside percutaneous dilational tracheostomy. Measurement and Main ResultsSubjects’ previous tracheostomies dated back between 10 days and 8 yrs. Present intubation time before percutaneous dilational tracheostomy varied between 4 and 30 days. Bedside percutaneous dilational tracheostomy was performed successfully in all 14 patients by trained pulmonologists and surgeons. Eleven patients received an 8-mm and three received a 7-mm tracheostomy tube. There were no significant periprocedural complications, and no patient required surgical revision. The only postprocedural complication was accidental decannulation in one patient, which was managed with repeat percutaneous dilational tracheostomy. ConclusionsTrained physicians can safely perform bedside percutaneous dilational tracheostomy after previous tracheostomy. Percutaneous dilational tracheostomy offers an alternative to surgical tracheostomy in this particular patient population and should not be considered contraindicated.

Outcome of early surgical complications following ileoanal pouch operation without diverting ileostomy

BACKGROUND Many surgeons use a diverting ileostomy routinely following ileoanal pouch operation because they fear that complications may lead to permanent unsatisfactory pouch function or even death. We report the outcome of early surgical complications when ileoanal pouch operation is performed without a diverting ileostomy. We performed 74 consecutive ileoanal pouch operations since ileoanal pouch operations since October 1989 using a transition-zone-sparing stapled J pouch method. RESULTS Of the 74 patients, 68 (92%) underwent the operation without a diverting ileostomy. Five of the 68 patients (7.4%) required reoperation within 30 days of operation. Pouch excision was necessary in 2 patients (3%) for reasons not resulting from omitting the diverting ileostomy, and they now have excellent pouch function. CONCLUSION Patients who required early reoperation and placement of a temporary diverting ileostomy did not suffer long-term consequences. The fear that early surgical complications following ileoanal pouch operation without diverting ileostomy are permanently detrimental is unjustified.

Isolated external iliac artery aneurysm secondary to cystic medial necrosis.

The computed tomographic and angiographic findings of an isolated external iliac artery aneurysm secondary to cystic medial necrosis in a patient without Marfans disease are demonstrated. A review of the differential diagnosis and surgical treatment of iliac artery aneurysms is presented. The dramatic surgical sequelae in this patient underscore the importance of preoperative consideration of this rare diagnosis.

Villous adenoma presenting as a vaginal polyp in a rectovaginal tract

A 72-year-old woman had a villous adenoma of endodermal derivation involving the rectovaginal septum and contiguous mucosal surfaces that presented clinically as a vaginal polypoid tumor. To explain the vaginal involvement, we postulate that the adenoma traversed a tract of developmental origin within the rectovaginal septum. This is the first report of such a unique constellation of findings.

Comparative efficacy of parenteral histamine (H2)-antagonists in acid suppression for the prevention of stress ulceration

Stress-related mucosal damage is related to a high intraluminal hydrogen ion concentration, a low intramural pH value, and a breakdown of the gastric mucosal barrier. Because the presence of gastric acid is required for stress-related mucosal damage to occur, therapy aimed at increasing intraluminal pH values has often been used as prophylaxis against complications. The amount of acid suppression required for adequate prophylaxis of gastrointestinal bleeding from stress-related mucosal damage has not been determined, but many investigators use a target gastric pH level of 3.5 to 4.0. When intravenous histamine (H2)-receptor antagonists are given in bolus dosing regimens to critically ill patients, fluctuations in gastric pH values are often observed, as might be expected. However, recent studies with primed continuous infusion of cimetidine in critically ill patients have demonstrated that consistent elevation of gastric pH to 4.0 may be attained with this regimen. Studies with continuous infusions of ranitidine are less conclusive; little information is available on famotidine.

Primary sphincter repair in anorectal trauma.

Two patients who sustained severe anorectal trauma from “fist fornication” were treated by irrigation, colostomy, drainage, antibiotics, and primary repair of the rectum and anal sphincters without complications. Both had complete return of continence. Primary sphincter repair is advocated for these and similar anorectal injuries.

Spontaneous intraperitoneal hemorrhage as the initial presentation of a gastrointestinal stromal tumor: a case report

BackgroundSpontaneous hemoperitoneum is rare. The most common etiologies are gynecologic, splenic, and hepatic. Gastrointestinal stromal tumors (GISTs) are commonly associated with intraluminal bleeding, but rarely with spontaneous hemoperitoneum. We report a case of spontaneous hemoperitoneum caused by a gastric GIST.Case reportA 54-year-old male presented with the acute onset of abdominal pain and a drop in hemoglobin. Subsequent evaluation, including a CT, MRI, and EUS, revealed a 1.2-cm mass along the greater curvature of the stomach and associated hemoperitoneum. The patient was taken electively to the operating room for laparoscopic removal of the mass. Pathology confirmed that it was a GIST.ConclusionGIST is a rare clinical entity that infrequently presents with spontaneous hemoperitoneum. Emergent treatment should be guided towards treating the spontaneous hemoperitoneum.

Ventriculoperitoneal shunting: Laparoscopically assisted versus conventional open surgical approaches.

Objectives: Ventriculoperitoneal shunting (VPS) is a mainstay of hydrocephalus therapy, but carries a significant risk of device malfunctioning. This study aims to compare the outcomes of laparoscopic ventriculoperitoneal shunting versus open ventriculoperitoneal shunting (OVPS) VPS-placement and reviews our findings in the pertinent context of the literature from 1993 to 2012. Materials and Methods: Between 2003 and 2012, a total of 232 patients underwent first time VPS placement at Beth Israel Deaconess Medical Center. Of those, 155 were laparoscopically guided and 77 were done conventionally. We analyzed independent variables (age, gender, medical history, clinical presentation, indication for surgery and surgical technique) and dependent variables (operative time, post-operative complications, length of stay in the hospital) and occurrence of shunt failure. Results: Mean operative time was 43.7 min (18.0-102.0) in the laparoscopic group versus 63.0 min (30.0-151.0) in the open group, (P < 0.05). Length of stay was similar, 5 days in the laparoscopic and in the open group, (P = 0.945). The incidence of shunt failure during the entire follow-up period was not statistically different between the two groups, occurring in 14.1% in the laparoscopic group and 16.9% in the open group, (P = 0.601). Kaplan-Meier analysis demonstrated no difference in shunt survival between the two groups (P = 0.868), with functionality in 85% at 6-months and 78.5% at 1-year. Conclusion: According to our study, LVPS-placement results compare similarly to OVPS placement in most aspects. Since laparoscopic placement is not routinely indicated, we suggest a prospective study to assess its value as an alternate technique especially suitable in obese patients and patients with previous abdominal operations.