Sarah M. Cowgill

Preoperative carbohydrate antigen 19-9 is most predictive of malignancy in older jaundiced patients undergoing pancreatic resection.

Objectives: Given the increased detection of occult pancreatic neoplasms with modern imaging modalities, it is often difficult to determine the risk of malignancy before curative pancreatectomy. We reviewed patients who underwent pancreatectomy to determine factors predictive of malignancy with particular attention to the serum marker carbohydrate antigen 19-9 (CA19-9). Methods: One hundred eighteen patients underwent radical pancreatectomy for malignant (n = 59) or benign (n = 59) pancreatic lesions. Demographic data, preoperative CA19-9 levels (normal, <37 U/mL), and follow-up were obtained from patient charts. Logistic regression analysis was used to determine univariate and multivariate predictors of malignancy. Results: Significant multivariate predictors of malignancy were increased CA19-9, age older than 50 years, and preoperative jaundice. The sensitivity and specificity of increased preoperative CA19-9 alone were 71% and 83%, respectively. The combination of age older than 50 years and jaundice was a more accurate predictor than CA19-9 (sensitivity, 76%; specificity, 92%). Increased CA19-9 was highly specific (97%) for malignancy in older jaundiced patients or when the preoperative level was greater than 150 U/mL. Conclusions: Age and preoperative jaundice are more predictive of malignancy than CA19-9 alone unless levels are greater than 150 U/mL. Preoperative CA19-9 levels should be interpreted within the context of these other clinical factors.

Upright, supine, or bipositional reflux : Patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication

IntroductionThis study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication—i.e., pattern of reflux—affects symptoms before or after laparoscopic Nissen fundoplication.MethodsA total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test.ResultsBefore fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved.ConclusionsPreoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.