Samuel M. Dresner

Pattern of recurrence following radical oesophagectomy with two-field lymphadenectomy

Despite increasingly radical surgery for oesophageal cancer many patients continue to represent with recurrent disease. This study aimed to evaluate the pattern of failure following attempted curative oesophagectomy with mediastinal and upper abdominal lymphadenectomy.

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: Risk factors and management

BACKGROUND Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management. STUDY DESIGN From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications. RESULTS Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n= 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications. CONCLUSIONS Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.

Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia†

Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro‐oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR.

Achalasia: management, outcome and surveillance in a specialist unit

The management and surveillance of achalasia remains controversial at the present time. The aim of this study was therefore to evaluate the results of endoscopic management and subsequent surveillance of patients with achalasia presenting to a specialist unit.

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.

Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy: risk factors and management

Benign anastomotic stricture (BAS) is a common cause of dysphagia following oesophagectomy. The aim of this study was to assess the incidence of BAS, identify risk factors for its development and evaluate the results of postoperative endoscopic dilatation.

Percutaneous endoscopic duodenostomy: the relief of obstruction in advanced gastric carcinoma.

Nausea and vomiting in patients with advanced gastric malignancy and mechanical obstruction are distressing and difficult to manage. We describe a patient with linitis plastica and gastric stasis who was treated with a percutaneous endoscopic duodenostomy as the stomach could not be used for percutaneous endoscopic gastrostomy (PEG) formation. A ConfloTM PEG tube was inserted into the second part of the duodenum using the Ponsky–Gauderer technique without complication. The patient experienced excellent symptomatic relief and tolerated enteral nutrition extremely well, regaining some weight. This manoeuvre can produce effective symptom palliation allowing the patient to be managed at home during the terminal phase of their illness.

Early outcome after laparoscopic and open floppy nissen fundoplication

There remains debate regarding the best operative procedure for gastro‐oesophageal reflux. For those who advocate a full ‘floppy’ Nissen fundoplication there is some scepticism that this can be completed effectively laparoscopically with division of all the short gastric vessels. This study therefore compared the results of patients operated on in two different hospitals in which floppy Nissen fundoplication was carried out either laparoscopically (hospital 1) or by open surgery (hospital 2).