Nilanjana Banerji

Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: A case report

INTRODUCTION Gastrointestinal stromal tumors (GISTs) of the alimentary canal are malignant tumors with <1% of cases diagnosed in esophagus. These cases require special consideration given their close proximity to vital structures and propensity to be highly aggressive. Management of patients with GISTs has been transformed since the introduction of tyrosine kinase inhibitors. In this report, we present an unusual case of GIST with spontaneous esophageal perforation. PRESENTATION OF CASE A 39-year-old Caucasian male presented to our hospital with complaints of severe chest and abdominal pain. A diagnostic chest radiograph revealed a moderate right-sided pleural effusion. Subsequently, an esophagram demonstrated a perforation proximal to an elongated stricture in the distal esophagus. A left thoracotomy was performed whereby a large mediastinal mass firmly attached to the esophagus and gastroesophageal junction was encountered. The neoplasm involved proximal one-third of the stomach and perforated into the right hemithorax. Histopathological evaluation of the tumor led to a diagnosis of GIST. DISCUSSION GISTs of the gastroesophageal junction are uncommon and may rarely present with esophageal perforation. The standard of care for treating GIST at present includes tyrosine kinase inhibitors. This pharmacologic agent, along with improved surgical techniques and understanding of molecular markers for accurate diagnosis, will assuredly continue to improve overall survival of patients with GISTs. CONCLUSION When stricture or achalasia is detected on imaging, GIST should be considered in the differential diagnosis for individual patients. Additionally, chest and abdomen CT scans of may be performed to confirm presence of a tumor mass, thereby ruling out achalasia.

Robotic Operations for Gastroesophageal Reflux Disease

Hiatus hernia repair and fundoplication are currently the most prevalent surgical procedures for management of gastroesophageal reflux disease (GERD) [1, 2]. At present, the operative management for GERD has evolved into a minimally invasive approach. Such minimally invasive laparoscopic approaches have resulted in overall superior outcomes, including fewer postoperative complications and reduced hospital length of stay [3, 4]. Robotic procedures with an abdominal approach for Nissen fundoplication, hiatus hernia repair, Heller myotomy, and trans-hiatal esophagectomy without thoracoscopy or thoracotomy have been performed with encouraging outcomes [5, 6]. The da Vinci® robotic instrument (Intuitive Surgical, Palo Alto, CA) was used for all robotic surgical procedures described in this chapter for management of paraesophageal hiatus hernias, giant hernias, and recurrent hiatus hernias, as well as the more standard anatomy seen in most patients with GERD.

Using Social Network Analysis to Identify Key Players within Clinical Teams for Improving Pain Management

The use of social network analysis to understand social relationships among individuals in healthcare is a relatively recent and innovative approach. This approach has been employed to study phenomena such as disease contagion, smoking cessation, and physical collaboration. This paper presents a social network analysis conducted among clinicians in three nursing units of a large metro hospital. The aim was to examine information flow with regard to pain management in addition to explore the evolving nature of the represented network over time. For the study, social network surveys were administered to investigate characteristics of three identified nursing units. Three network questions were used to explore relationships and information flow: (a) Who do you routinely work with on pain management? (b) Who do you get new ideas or inspiration from to help your pain management efforts? (c) Who would you like to work with in the future on pain management? Two surveys were conducted to collect data over time, and standard social network measures were computed to study the interaction network and its evolving nature. Data analysis provided insights into the nature of interactions within and across these groups and thereby successfully identified key players in information flow with regard to pain management.

Incarcerated Hiatal Hernia After Robot-Assisted Esophagectomy: Transhiatal Versus Thoracoscopic Approach

To the Editor, We are grateful to Dr. Boone and colleagues for their insightful comments regarding our report on the incidence of incarcerated hiatus hernia after robotic-assisted transhiatal esophagectomy [1]. We agree with Dr. Boone and colleagues that a complication of an incarcerated hiatal hernia should not be induced by a transthoracic approach, as the integrity of the hiatus is maintained by this surgical technique. We wish to mention that our purpose in performing total esophagectomy via robotic transhiatal approach is to eliminate thoracoscopy or thoracotomy either by minimally invasive techniques, such as that utilized by Dr. Boone and coworkers, or as defined and reported by Luketich et al. [2]. Similar to the robotic thoracoscopic and minimally invasive thoracoscopic–laparoscopic approaches, the robotic-assisted transhiatal approach has minimal blood loss, NCCN guideline-recommended lymph node retrieval, acceptable operating times, and low mortality rates. A robotic-assisted transhiatal approach minimizes patient pain and discomfort compared with a thoracic approach, as well as reduces the risks of pulmonary complications that necessarily arise from entering the chest cavity. Relatively few reports of a transhiatal robotic approach for esophagectomy exist in the published literature [3–5]. Since our group is one of the few adopting this approach, the primary intent of the report was to share lessons learned from our initial experience with other surgeons who might wish to pursue this technique. We reiterate that in individuals with an already widened hiatus, a robotic transhiatal procedure poses a risk of stretching the hiatus to a point where a paragastric hiatus hernia may result. As mentioned in our publication, the technique that we suggest is a lateral repair approach by use of an onlay biologic mesh over the lateral part of the hiatus to decrease the size of the hiatus, thereby not impinging on the stomach and possibly compromising the blood supply to the gastric pull-up. Additionally, suturing the graft to the gastric pull-up prevents herniation of small bowel or colon through the hiatus. In closing, we acknowledge the fact that a thoracoscopic esophagectomy would certainly minimize the chances of an incarcerated hiatal hernia. However, since our implementation of the preventive technique (within selected patients) described in our report, we have not encountered any complications of incarcerated hiatus hernia within our practice.