José Costa-Maia

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system

OBJECTIVE The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population. METHODS In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups. RESULTS Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS. CONCLUSIONS The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Adenoma–carcinoma sequence in intrahepatic cholangiocarcinoma

INTRODUCTION Cholangiocarcinoma is a rare tumor but recent data report a worldwide increase in incidence and mortality. There are several risk factors associated with cholangiocarcinoma, and chronic inflammation of billiary tree seems to be implied in the cholangiocarcinogenesis, but little is known about this process. PRESENTATION OF CASE We present a 56-year-old female with a bile duct adenoma incidentally discovered in the follow up of breast cancer that 18 months later progress to intrahepatic cholangiocarcinoma. DISCUSSION This is a rare presentation of intrahepatic cholangiocarcinoma that suggests the classic adenoma-carcinoma sequence in cholangiocarcinogenesis. Furthermore this case gives rise to some questions about the possible common ground on intrahepatic cholangiocarcinoma and breast cancer. CONCLUSION Cholangiocarcinogenesis is a complex multi-step mechanism and further investigations are needed to fully understand this process.

Gastric Stump Cancer: More Than Just Another Proximal Gastric Cancer and Demanding a More Suitable TNM Staging System

Background. Considerable controversy persists about the biological behavior of gastric stump cancer (GSC). The aim of this study is to clarify if this cancer is just another proximal gastric cancer or if it emerges as a distinctive clinicopathologic entity. Methods. This review of a prospectively collected gastric cancer database identified 73 patients with GSC in a single institution between January 1980 and June 2012 and compared them with 328 patients with proximal gastric cancer (PGC) and 291 patients with esophagogastric junction cancer (EGJC). Results. Patients with GSC were predominantly males. Eighty-three percent of GSC penetrated the subserosal or the serosal layers. The median number of lymph nodes retrieved in GSC patients was significantly lower than in PGC patients or in EGJC patients. Cumulative survival curves were not different between GSC, PGC, or EGJC patients. Unlike that observed in PGC and in EGJC, no significant differences in cumulative survival according to the TNM staging system were observed in GSC cases. Conclusions. The outcome of patients with GSC displayed significant differences when compared to those with other proximal gastric cancers concerning the lack of survival association with the TNM staging system. Therefore a more suitable staging system should be designed for these unique cancers.

Laparoscopic splenectomy for second-line treatment of immune thrombocytopenia – analysis of 53 patients and current perspectives

SummaryBackgroundSplenectomy is a well-established second-line treatment for immune thrombocytopenia but novel medical therapies have changed the management of this disease. The objective of this study is to analyze the current results of splenectomy as a second-line treatment.MethodsRetrospective analysis of 53 consecutive patients with chronic immune thrombocytopenia submitted to splenectomy from January 2007 through December 2014. Several parameters were analyzed including postoperative morbidity and outcomes after surgery.ResultsFifty-two (98%) patients underwent successful laparoscopic splenectomy without conversion to open procedure, with a mean operative time of 103.6 ± 38.1 minutes. The median postoperative length of stay was 3 days (range 1–36 days). There were 3 (5.7%) major postoperative complications resulting in 2 (3.8%) reoperations. No splenectomy-related mortalities occurred. Fifty (94.3%) patients presented a response 1 month after surgery (45 complete responses and 5 responses). In the follow-up (mean 24.8 ± 16.9 months) 37 (75.5%) patients had a complete and sustained response after laparoscopic splenectomy and an additional 11 (22.4%) presented platelet counts above 30×109/L (the majority of these patients eventually reaching normal platelet counts). No additional therapies were needed in 39 (79.6%) patients after surgery.ConclusionsIn our experience, laparoscopic splenectomy is an effective second-line treatment for Immune Thrombocytopenia with short and long-term response rates of 94% and 91%, respectively. Major postoperative complications occurred in 6%. Future research should aim to discover new methods to properly select patients to different second-line treatments.

Meckel’s diverticulum perforation by a fish bone: A case report

Highlights • The most commom complications of Meckel’s diverticulum are inflammation, haemorrhage, and intestinal obstruction.• The perforation of a Meckel’s diverticulum by a foreign body is a very rare complication, with few cases reported in the literature.• Definitive treatment is surgical intervention, and should not be delayed by supplementary radiographic imaging in patients with peritonitis.

The open abdomen: analysis of risk factors for mortality and delayed fascial closure in 101 patients

Introduction: The core concepts of damage control and open abdomen in trauma surgery have been expanding for emergent general surgery. Temporary closures allow ease of access to the abdominal cavity for source control. The aim of the current study was to assess the outcomes of patients who underwent open abdomen management for acute abdominal conditions and evaluate risk factors for worse outcomes and inability of fascial closure during the initial hospitalization. Methods: We conducted a retrospective analysis of 101 patients submitted to laparostomy in a single institution from January 2009 to March 2017. The evaluated outcomes were mortality, local morbidity, and rate of primary fascial closure. Results: The most common indications for open abdomen were bowel perforation, bowel ischemia, and necrotizing pancreatitis. Global in-hospital mortality rate was 62.4%. For the 37 patients discharged from the hospital, a definitive abdominal closure was attained in 28. Multivariable logistic regression analysis revealed that people older than 60 years of age and with Acute Physiology and Chronic Health Evaluation (APACHE II) scores over 18.5 had higher in-hospital mortality rates. Definitive fascial closure was statistically associated with a lower number of re-interventions and ICU stay. Conclusions: Open abdomen management may be appropriate in these critically ill patients; however, it continues to be associated with significantly high mortality, especially in elder patients and with higher APACHE II scores. Recognition of risk factors for fascia closure failure should promote the investigation for a tailored surgical approach in these patients.

Outcomes of minimally invasive versus open esophagectomy for esophageal cancer: A single-center case-control study.

171 Background: Esophagectomy is a major surgery associated with significant morbidity and mortality. There is growing evidence in literature that the minimally invasive approach in esophagectomy (MIE) may decrease morbidity. The aim of this study was the comparative analysis of the outcomes between MIE and open esophagectomy (OE) for esophageal cancer. Methods: Analysis (case-control study) of a prospective database with esophageal cancer cases submitted to curative intent surgery, between May 2006 and October 2014, in an Upper GI Surgery Unit. For this analysis, cases of non-resectional surgery were excluded. Results: From the initial population (n = 79), 65 cases (Group A: 24 MIE - 13 totally MIE and 11 hybrid MIE; Group B: 41 OE, including 5 cases of conversion from MIE) were included. Both groups were matched for gender, age, comorbidities, BMI, tumor location and histology, staging (cT and cN), neoadjuvant therapy and type of surgery. The presence of postoperative morbidity was 37,5% in MIE vs 61% i...

O-glicosylation alterations of proteins in gastric carcinoma.

62 Background: The expression of immature forms of carbohydrates could help to better understand the biological behavior of gastric cancer. METHODS From a universe of 50 patients with gastric or gastroesophageal junction carcinoma submitted to surgical treatment between January and October 2009, in our department, 36 out of 38 carcinomas ressected during this period, were selected for a tumor tissue immunohistochemical study of the simple mucin-type carbohydrate antigens (Tn, STn, T and ST) and the Lewis carbohydrate antigens (SLea and SLex). Several clinico-pathological parameters were evaluated according to the expression pattern of the antigens studied. RESULTS The ressected gastric carcinomas presented a high incidence of tissue expression of the simple mucin-type and the Lewis carbohydrate antigens, with all cases presenting expression of at least 2 of the antigens and two thirds the expression of 4 or 5. The correlation between the simple mucin-type carbohydrate antigens was high, just as the same as with the Lewis carbohydrate antigens. The analysis of the clinico-pathological profile of gastric carcinomas according to the expression of these antigens revealed the following associations: Tn with venous invasion and perineural invasion; STn with tumor location and macroscopic form; T with age, gender, tumor dimensions and location; ST with macroscopic form and WHO classification; SLea and SLex with the tumor dimensions. Staging of the tumors also revealed associations with the expressions of these antigens: Tn with serosal invasion, lymph node metastases and stage; STn with lymph node ratio; SLea with serosal invasion and lymph node metastases; SLex with depth wall invasion, lymph node metastases and stage. The antigens T e ST did not reveal differences in the expression pattern according to staging. CONCLUSIONS O-glicosylation alterations of proteins are related with gastric carcinoma, not only their incidence is high but they can also be linked with various clinico-pathological characteristics. The knowledge obtained from this study might serve as a starting point for future investigations taking into account the identification of new biomarkers based on glicosylation alterations of proteins. No significant financial relationships to disclose.