Jonathan Shenfine

Spontaneous rupture of the oesophagus

The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre.

A randomized controlled clinical trial of palliative therapies for patients with inoperable esophageal cancer.

OBJECTIVES:A dramatic rise in incidence, an aging population, and expensive palliative treatments have led to an escalating burden on clinicians managing inoperable esophageal cancer with only limited evidence of effectiveness. This study compares the clinical effectiveness and cost-effectiveness of self-expanding metal stents (SEMSs) with other palliative therapies to aid clinicians in making an evidence-based treatment choice.METHODS:We conducted a prospective, multicenter, randomized, controlled, clinical trial with 215 patients followed until death or study closure. The primary outcome measures were dysphagia, quality of life (QL) 6 weeks following treatment, and total cost of treatment. Secondary outcome measures included treatment-associated morbidity, mortality, survival, and cost-effectiveness. An intention-to-treat analysis was carried out.RESULTS:There was a significant difference in mean dysphagia grade between treatment arms 6 weeks following treatment (P=0.046), with worse swallowing reported by rigid stent–treated patients (mean dysphagia score difference=−0.49; 95% confidence interval (CI) −0.10 to −0.89, P=0.014). Global QL scores were lower at both 1 and 6 weeks following treatment for patients treated by SEMSs (mean difference QL index week 1=−0.66; 95% CI: −0.02 to −1.30, P=0.04; mean difference QL index week 6=−1.01; 95% CI −0.30 to −1.72, P=0.006). These findings were associated with higher post-procedure pain scores in the SEMS patient group (mean difference of the European Organisation for Research and Treatment of Cancer QLQ C-30 pain symptom score at week 1=11.13; 95% CI: 2.89–19.4; P=0.01). Although mean EQ-5D QL values differed between the treatments (P<0.001), this difference dissipated following generation of quality-adjusted life year values. Total costs varied between treatment arms but these findings canceled out when SEMSs were compared with non-SEMS therapies (95% CI −845.15–1,332.62). These results were robust to sensitivity analysis. There were no differences in the in-hospital mortality or early complication rates, but late complications were more frequent after rigid stenting (risk ratio=2.47; 95% CI 1.88–3.04). There was a survival advantage for non-stent-treated patients (log-rank statistic=4.21, P=0.04).CONCLUSIONS:The treatment choice for patients with inoperable esophageal cancer should be between a SEMS or a non-stent treatment after consideration has been given to both patient and tumor characteristics and clinician and patient preferences.

Anti-reflux surgery in lung transplant recipients: outcomes and effects on quality of life

Fundoplication may improve survival after lung transplantation. Little is known about the effects of fundoplication on quality of life in these patients. The aim of this study was to assess the safety of fundoplication in lung transplant recipients and its effects on quality of life. Between June 1, 2008 and December 31, 2010, a prospective study of lung transplant recipients undergoing fundoplication was undertaken. Quality of life was assessed before and after surgery. Body mass index (BMI) and pulmonary function were followed up. 16 patients, mean±sd age 38±11.9 yrs, underwent laparoscopic Nissen fundoplication. There was no peri-operative mortality or major complications. Mean±sd hospital stay was 2.6±0.9 days. 15 out of 16 patients were satisfied with the results of surgery post fundoplication. There was a significant improvement in reflux symptom index and DeMeester questionnaires and gastrointestinal quality of life index scores at 6 months. Mean BMI decreased significantly after fundoplication (p=0.01). Patients operated on for deteriorating lung function had a statistically significant decrease in the rate of lung function decline after fundoplication (p=0.008). Laparoscopic fundoplication is safe in selected lung transplant recipients. Patient benefit is suggested by improved symptoms and satisfaction. This procedure is acceptable, improves quality of life and may reduce deterioration of lung function.

Chained time trade-off and standard gamble methods

It may be difficult to value palliative health states using health state valuation methods such as the time trade-off (TTO) and standard gamble (SG) where health states are traditionally valued relative to perfect/good health and death. Chained methods have been developed to help in this context. However, few studies have compared the values produced by chained TTO and SG methods. To address this issue, a study was conducted to measure the health state values associated with oesophageal cancer using chained TTO and SG techniques. The methods were found to be acceptable amongst the sample respondents, who had previously been treated for oesophageal cancer. There were no significant differences between the health state values produced by the TTO and the SG methods. Within each method, however, there were significant differences between the health states valued. It is concluded that the use of health state valuation techniques such as the TTO and SG is feasible amongst people with a history of oesophageal cancer.

Management of spontaneous rupture of the oesophagus

Spontaneous rupture of the oesophagus (SRO) is a rare and often fatal event. The aim of this study was to evaluate the presentation, management and outcome of SRO in a single unit.

A Call for Standardization of Antireflux Surgery in the Lung Transplantation Population

Long-term survival post lung transplant is reduced significantly by Bronchiolitis Obliterans Syndrome. It is suggested that extra-esophageal reflux disease is a risk factor for Bronchiolitis Obliterans Syndrome and that antireflux surgery may be beneficial. However, practice between centers varies greatly. We suggest a need for improved evidence and standardization.

Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry (Br J Surg 2008; 95: 57–63)

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Measuring quality of life and utilities in esophageal cancer

For many years indicators such as mortality rates, levels of morbidity and cure measured the success of treatments for esophageal cancer. However, it is now recognised that quality of life (QOL) is an important measure of outcome. This is especially so for esophageal cancer, where the therapeutic options include curative treatments or palliative care. A number of measures have been developed but few QOL studies have been conducted in esophageal cancer. A health economics approach to outcome measurement, that seeks to quantify individual preferences (or utilities), offers a number of advantages. However, it is important to recognize that these methods are still under development. Nevertheless, by seeking to measure the strength of individual preferences, utilities provide additional information for decisions regarding which treatments provide the most optimal outcomes.

Authors' reply: Spontaneous rupture of the oesophagus (Br J Surg 2008; 95: 1115–1120)

Sir We read with great interest the article highlighting the heterogeneity of spontaneous oesophageal rupture. The authors conclude that non-operative treatment is suitable for selected patients with contained contamination, and in-hospital mortality rate is higher in those undergoing thoracotomy. Diagnosis of spontaneous oesophageal rupture is a challenge due to a variety of non-specific symptoms. Delay in diagnosis of more than 24 hours has been reported to be associated with poor outcome1 – 3. Griffin and colleagues have demonstrated that delay in diagnosis of more than 24 hours had no effect on mortality rate. In their report, there was no difference in delay to diagnosis between non-operative and surgical groups. Since the patients in the nonoperative group had been stratified as contained contamination and had less risk of mortality, delay to diagnosis may have minor impact on their survival. However, patients in the surgical group had extensive disease and higher percentage of systemic inflammatory response syndrome. We wonder if delay to diagnosis has no effect on mortality rate in these patients. The authors have emphasized the utility and importance of endoscopy for diagnosis and management of spontaneous oesophageal rupture. Although 27 of 51 patients were not diagnosed by chest radiograph owing to failure to identify mediastinal, thoracic or subcutaneous air at the emergency department, a majority of patients were diagnosed by contrast esophagogram or contrast-enhanced computed tomography. Only eight of 18 patients diagnosed by endoscopy had undergone previous radiological investigations (contrast swallow in six, computed tomography in two) that had failed to identify a perforation. Although the authors argue that no evidence showed possible further damage by endoscopy, the risks have not been well studied and documented. How could the authors exclude the possibility that the esophageal rupture might be caused by endoscopy in these eight patients? Furthermore, we wonder how many of the eight patients diagnosed by endoscopy were treated by thoracotomy. If most of them had contained contamination and could be treated successfully without surgery, the necessity of endoscopy for diagnosis is in doubt. Jung-Jyh Hung Cathay General Hospital, 280 Renai Rd, Sec.4, Taipei, Taiwan DOI: 10.1002/bjs.6757