Sabrina Rampado

Effects of Neoadjuvant Therapy on Perioperative Morbidity in Elderly Patients Undergoing Esophagectomy for Esophageal Cancer

BackgroundThe use of cytoreductive therapy followed by surgery is preferred by many centers dealing with locally advanced esophageal cancer. However, the potential for increase in mortality and morbidity rates has raised concerns on the use of chemoradiation therapy, especially in elderly patients. The aim of this study was to assess the effects of induction therapy on postoperative mortality and morbidity in elderly patients undergoing esophagectomy for locally advanced esophageal cancer at a single institution.MethodsPostoperative mortality and morbidity of patients ≥70 years old undergoing esophagectomy after neoadjuvant therapy, between January 1992 and October 2005 for cancer of the esophagus or esophagogastric junction, were compared with findings in younger patients also receiving preoperative cytoreductive treatments.Results818 patients underwent esophagectomy during the study period. The study population included 238 patients <70 years and 31 ≥70 years old undergoing esophageal resection after neoadjuvant treatment. Despite a significant difference in comorbidities (pulmonary, cardiological and vascular), postoperative mortality and morbidity were similar irrespective of age.ConclusionsElderly patients receiving neoadjuvant therapies for cancer of the esophagus or esophagogastric junction do not have a significantly increased prevalence of mortality and major postoperative complications, although cardiovascular complications are more likely to occur. Advanced age should no longer be considered a contraindication to preoperative chemoradiation therapy preceding esophageal resection in carefully selected fit patients.

Minimally invasive enucleation of esophageal leiomyoma

BackgroundLeiomyoma accounts for 70% of all benign tumors of the esophagus. Open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have recently emerged as interesting alternatives. To date, only case reports or very small series of such techniques have been reported. The authors report their experience over the past decade.MethodsBetween January 1999 and August 2005, 11 patients (6 men and 5 women; median age, 44 years) underwent surgery after presenting with dysphagia, chest pain, or heartburn. The surgical approaches included right video-assisted thoracoscopy (n = 7) for tumors of the middle lower third of the esophagus and laparoscopy (n = 4) for tumors within 4 to 5 cm of the lower esophageal sphincter or located at the gastroesophageal junction (GEJ). Intraoperative endoscopy with air insufflation during enucleation was used to confirm mucosal integrity and safeguard against esophageal perforation. Reapproximation of the muscle layers was performed after tumor enucleation to prevent the development of a pseudodiverticulum. A Nissen or Toupet fundoplication was added for patients undergoing laparoscopic enucleation of the leiomyoma.ResultsThe median operative time was 150 min. All tumors were benign leiomyomas (median size, 4.5 cm). One leiomyoma located at the gastroesophageal junction required intraoperative mucosal repair with three stitches for an esophageal perforation (preoperative biopsies had been taken). There were no major morbidities, including deaths or postoperative leaks. The median postoperative hospital stay was 6 days. All the patients were free of dysphagia during a median follow-up period of 27 months. One patient had a small (<2 cm) asymptomatic pseudodiverticulum at the 6-month follow-up endoscopy.ConclusionsVideo-assisted enucleation of esophageal leiomyoma can be performed effectively and safely with no mortality and low morbidity. Thoracoscopic and laparoscopic techniques for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with minimally invasive surgery.

Esophageal GIST: case report of surgical enucleation and update on current diagnostic and therapeutic options.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, but they have been rarely reported in the esophagus. The authors present the case of an esophageal GIST and discuss the diagnostic course and therapeutic options, as currently reported in the literature.

Single-band mucosectomy for granular cell tumor of the esophagus: safe and easy technique

BackgroundMucosectomy involves resection of a digestive wall fragment that frequently removes a part or even all of the submucosal mass. The single-band mucosectomy technique was used to remove a granular cell tumor (GCT) of the esophagus. Only 3% of GCTs, which are relatively uncommon neoplasms, arise in the esophagus. Ultrasonography has allowed for more frequent recognition and better definition of this disease. Until recently, surgical resection of the esophagus has been the only treatment alternative to endoscopic surveillance. Endoscopic techniques such as mucosal resection (EMR), laser, and argon plasma have been proposed as safe and effective alternatives to surgery. However, to date, only a few reports of these endoscopic techniques have been published. This study aimed to evaluate the safety and feasibility of single-band mucosectomy for removing a GCT of the esophagus.MethodsSix patients (1 man and 5 women; mean age, 45 years) with a GCT were studied between January 2000 and May 2004. They underwent EMR after endoscopic ultrasonography.ResultsThe EMR was performed with a diathermic loop after injection of saline solution into the esophageal wall. Only one session was necessary for removal of the tumor from all 6 patients, and no complication was observed. During a mean clinical endoscopic follow-up period of 36 months, no recurrences, scars, or stenoses were observed.ConclusionsThese findings show EMR to be a safe and effective technique that allows complete removal of GCTs. Furthermore, this technique provides tissue for a definitive pathologic diagnosis, which laser and argon plasma do not provide. We recommend EMR as the treatment of choice for GCTs after an accurate ultrasonographic evaluation.

Mediastinal carcinosis involving the esophagus in breast cancer: The breast-esophagus syndrome : Report on 25 cases and guidelines for diagnosis and treatment

Introduction:Breast metastases of mucosal/submucosal layers of the esophagus are extremely rare: esophageal involvement is usually part of a mediastinal carcinosis. Aim:We report the largest series to date of 25 cases of metastatic esophageal involvement from breast cancer, discussing both diagnostic techniques and treatment options. Materials and Methods:Twenty-five female patients with a history of breast cancer referred for secondary esophageal involvement (1980–2006) were studied. Results:All patients presented with worsening dysphagia. Twenty-four had undergone surgery for breast cancer a median of 10 years earlier: 1 had received chemoradiotherapy, and 17 had adjuvant radiotherapy/telecobalt therapy following breast surgery. Endoscopic biopsy/cytology were negative for cancer in 17 of 19 patients; in 9 patients, the diagnosis was made with thoracoscopy/laparoscopy. Immunohistochemical staining was done in 10 patients (ER and/or PrR positive). Fifteen patients presented with distant metastatic involvement. Therapy was directed toward dysphagia relief, mostly with endoscopic dilations/prostheses. Complications (4 perforations) occurred only in those 15 patients who had endoscopic dilations/prostheses. Fifteen patients had cytoreductive therapy. Nine of 25 patients are still alive. The median overall survival was 7 months; 1-, 3-, and 5-year survival rates were 44%, 16%, and 8%, respectively. Conclusions:A “breast-esophagus” syndrome can be defined: it is often diagnosed only after excluding other diseases or after relief of dysphagia with adequate therapy. The presence of distant metastases helps the diagnosis of esophageal involvement from mediastinal carcinosis, while diagnosis is a problem in case of mediastinal/pleural disease only: in this case, exploratory thoracoscopy is mandatory for a final diagnosis. Given the high related risk of perforation from endoscopic procedures (dilations/prostheses), the treatments of choice are currently hormone therapy or chemotherapy/radiotherapy.

Caustic ingestion and oesophageal cancer: intra- and peri-tumoral fibrosis is associated with a better prognosis

OBJECTIVE Oesophageal carcinoma is a well-known late complication of caustic ingestion, occurring in up to 7% of cases. We report a large series of patients with oesophageal scar cancer (SC), investigating the association between fibrosis and survival. METHODS A total of 25 patients with a history of oesophageal SC (1979-2005) were retrospectively studied. The amount of intra- and peri-tumoral fibrotic tissue was measured with Azan-Mallory staining. A control group of patients with non-SC was used for comparison. RESULTS Twenty-five patients (16 males:9 females, median age 59 years), presented with SC. The histotype was squamous cell carcinoma (SCC) in 20 (80%) patients, adenocarcinoma (AC) in three (12%) and verrucous carcinoma in two (8%). Oesophageal resection was performed in 17 of 25 (68%) patients; in eight (32%), only a palliative treatment (endoscopic/surgical) was possible. Mortality and morbidity rates were 4% and 40%, respectively. One-, 3- and 5-year overall actuarial survival rates for SC patients were 72%, 56% and 52%, respectively. The amount of fibrotic tissue around/within the tumour was significantly higher in SC patients (34.5% vs 5.9% non-SC, p=0.01); these patients had also a higher prevalence of tumours limited to the muscular wall (pT1-T2) (76% vs 28% non-SC, p<0.0001) and less lymph node metastases in T1-T2 cases (8% vs 34% non-SC, p=0.07). The 5-year survival was significantly better in SC patients: 71% versus 24% for resected cancers (p<0.0001), and 52% versus 15% for all observed patients (p=0.0001). CONCLUSIONS The presence of fibrotic tissue around/within the tumour is associated with a better prognosis in SC. Fibrosis might offer a protection against both local spread and nodal dissemination.

Long-term health-related quality of life after minimally invasive surgery for diverticular disease

Background and aimsThe aim of this multicentric study was to evaluate the disease specific and the generic quality of life in patients affected by colonic diverticular disease (DD) who had undergone minimally invasive or open colonic resection or who had been treated with medical therapy in the long-term follow-up.Patients and methodsSeventy-one consecutive patients admitted to the departments of surgery of Padova and Arzignano Hospitals for DD were interviewed: 22 underwent minimally invasive colonic resection, 24 had open resection, and 25 had only medical therapy. The interview focused on disease specific and generic quality of life, body image, and disease activity.ResultsPadova Inflammatory Bowel Disease Quality of Life (PIBDQL) was validated for the use in DD patients. PIBDQL scores were significantly worse in all patients with DD than those obtained by healthy subjects and it correlated with the symptoms score. The generic quality of life seemed similar in patients who had minimally invasive colonic resection compared with healthy subjects. Body Image Questionnaire scores correlated inversely with the presence of a stoma.ConclusionsDisease activity resulted as the only independent predictor of the disease-specific quality of life. In fact, DD affected bowel function and quality of life of patients in the long-term follow-up regardless of the type of therapy adopted. The presence of a stoma affected the patients’ body image.

A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patients hypopharynx. Using transillumination from the optical device, the patients neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Les aspects endoscopiques de l’hypertension portale: diagnostic et classification

RésuméQuand s’instaure un état d’hypertension portale, des circulations collatérales entre le système porte et le système cave se forment ou s’ouvrent.Du point de vue clinique, les plus importantes sont celles qui impliquent le secteur gastro-intestinal, parce qu’elles peuvent provoquer la dilatation du plexus sous-muqueux avec formation de varices endoluminales.Les varices peuvent se trouver sur tous secteurs du tractus gastro-intestinal (oesophage, estomac, duodénum, iléon, côlon, rectum), mais les varices gastro-oesophagiennes s’observent plus fréquemment et en cas de rupture, elles peuvent provoquer de graves hémorragies. L’hémorragie de varices oesophagiennes représente encore aujourd’hui une des plus graves complications de la cirrhose hépatique et un défi toujour renouvelé pour l’endoscopiste.Malgré l’introduction de nouveaux moyens diagnostiques et de nouvelles thérapies, la mortalité au premier épisode de saignement reste encore très ⫑evée (30%–40%).Ceci est lié non seulement à l’entité de l’hémorragie et à la vitesse de son contrôle mais également au stade d’insuffisance hépatique et à l’apparition de complications cardio-pulmonaire, rénales, infectieuses et surtout hémorragiques.L’examen endoscopique, s’il est conduit de manière correcte, représente la meilleure technique pour le diagnostic, la classification et la thérapie aussi bien en première intention qu’en urgence.SummaryDuring portal hypertension occurs the formation and/or opening of collateral circulations between the portal and caval systems.One of the most significant clinical consequences is the formation of endoluminal varices at the intestinal level. There is also congestion of the mucosa, termed portal congestive gastropathy or portal congestive colonopathy, depending on the area affected.Varices could be present in the entire gastro-intestinal tract (esophagus, stomach, duodenum, ileum, colon, rectum). However the most frequently observed are the esophageal varices and in case of rupture they cause severe haemorrhage.Bleeding from esophageal varices is one of the most important complications of liver cirrhosis and represent a critical moment for the endoscopist.Although the use of modern diagnostic and therapeutic technique, mortality during the first episode of bleeding still remains very high (30–40%).This is related not only to the entity of the haemorrhagic fact and the endoscopic ability to control it, but also to the degree of the liver disease, cardiopulmonary, kidney, infective and haemorrhagic complications.Endoscopic examination, if correctly performed, represents the best technique for the diagnosis, the classification and the therapeutic approach both in election and emergency.

Cost analysis of incisional hernia repair with synthetic mesh and biological mesh: an Italian study

Repair of an incisional hernia (IH) generates costs on several levels and domains of society. The aim of this study was to make a complete cost analysis of incisional hernia repair (IHR) with synthetic and biological mesh and to compare it with financial reimbursement. Patients were grouped into three levels to determine the complexity of their care, and hence, the costs involved. Group 1 included patients without comorbidities, who underwent a “standard” incisional hernia repair (SIHR), with synthetic mesh. Group 2 included patients with comorbidities, who underwent the same surgical procedure. Group 3 included all patients who underwent a “complex” IHR (CIHR) with biological mesh. Total costs were divided into direct (including preoperative and operative phases) and indirect costs (medications and working days loss). Reimbursement was calculated according to Diagnosis-Related Group (DRG). From 2012 to 2014, 76 patients underwent prosthetic IHR: group 1 (35 pts); group 2 (30 pts); and group 3 (11 pts). The direct costs of preoperative and operative phases for groups 1 and 2 were €5544.25 and €5020.65, respectively, and €16,397.17 in group 3. The total reimbursement in the three groups was €68,292.37 for group 1, €80,014.14 for group 2, and €72,173.79 for group 3, with a total loss of €124,658.43, €69,675.36, and €100,620.04, respectively. All DRGs underestimate the costs related to IHR and CIHR, thus resulting in an important economic loss for the hospital. The cost analysis shows that patient-related risk factors do not alter the overall costs. To provide a correct “cost-based” reimbursement, different DRGs should be created for different types of hernias and prostheses.