Shaun R. Preston

Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer

Defined clinical pathways can contribute to improved outcomes in patients undergoing oesophageal cancer surgery. A standardized oesophagectomy clinical pathway (SOCP) established at the Virginia Mason Medical Center (VMMC) in Seattle, Washington, USA was introduced into the Royal Surrey County Hospital (RSCH), Guildford, UK in 2011. The aim of this study was to see whether transfer and implementation of an oesophagectomy care pathway could change postoperative outcomes significantly.

Exocrine pancreatic insufficiency following esophagectomy

Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase-1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase-1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow-up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase-1 measured. PERT was then offered to patients with fecal elastase-1 less than 200 μg/g (EPI) as well as those in the 200-500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase-1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1-42) following surgery. Ten patients had fecal elastase-1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty-nine patients had a fecal elastase-1 in the 200-500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase-1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high‐grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long‐term quality of life in patients following esophagectomy.

A Literature Review on the Role of Totally Extraperitoneal Repairs for Groin Pain in Athletes

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%-100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.

Updates on Surgical Management of Advanced Gastric Cancer: New Evidence and Trends. Insights from the First International Course on Upper Gastrointestinal Surgery—Varese (Italy), December 2, 2011

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon’s role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC.

Thoracoscopic-assisted four-phase esophagectomy with four-field lymph node dissection for esophageal cancer: case report and description of a new technique.

Complete (R0) resection and extent of lymphadenectomy are important prognostic factors for survival in patients undergoing surgery for esophageal carcinoma. We describe the first case of combined open and thoracoscopic esophagectomy with extended lymphadenectomy including abdominal, cervical, right, and left mediastinal (four-field, four-phase) nodal clearance in a 37-year-old woman with squamous cell carcinoma of the esophagus. This report provides a tailored strategy to achieve a high level of tumor clearance and complete resection. The approach described challenges the limitations of standard radical nodal clearance and may encourage surgeons to consider more extensive resections.

Iatrogenic gastric ulceration

Dear Editor, Selective internal radiation therapy (SIRT) with yttrium-90 (Y-90)-emitting microspheres, wherein intra-arterial infusion of Y-90 microspheres is performed, is increasingly recognised as an effective therapy of both primary and secondary hepatic malignancies [1]. This is commonly used as a loco-regional radiation therapy for unresectable hepatic neoplasms. Gastrointestinal complications of this novel therapy are sparse and the incidence varies from 3–24 % [2]. These include radiation ulcers mostly in the gastric antrum, pylorus and duodenum [1, 2]. We present the case of a 39-year-old man who was diagnosed with a T3 N0 M1 adenocarcinoma of the rectosigmoid in January 2010. The tumour was inoperable at the time of diagnosis due to widespread hepatic metastasis. He was KRas mutant and was started on FOXFIRE trial (FOLFOX chemotherapeutic regimen with SIRT). But after his first dose of chemotherapy in February 2010, he developed hypersensitivity reaction to oxaliplatin and hence continued chemotherapy with 5FU alone. After his fifth course of 5FU in May 2010, he developed symptoms of gastritis and was put on proton pump inhibitors. He had no relief of symptoms and an endoscopy done on 8th July 2010 revealed a large pre-pyloric ulcer which was biopsied (Fig. 1). The biopsy showed nonspecialised gastric mucosa admixed with ulcer slough and granulation tissue. The lamina propria showed mixed inflammatory infiltrate, increase in vascularity and scattered round dense eosinophilic radiation microspheres embedded in the submucosa (Fig. 2). Diagnosis of this pre-pyloric ulceration due to SIRT required a high degree of clinical suspicion along with characteristic endoscopic findings and pathognomonic radiation microspheres in the biopsy. The patient showed further disease progression on chemotherapy in later months and finally succumbed to unresponsive metastatic disease in 2011. The current evidence suggests that radio embolizationassociated gastroduodenal ulceration results either as a consequence of indirect irradiation or from direct deposition of Y-90 microspheres and biopsy can help differentiate between the two pathologies. The presence of perfectly round, purple microspheres on histological examination of the biopsy specimen is diagnostic of this type of injury [1, 3]. Awareness and knowledge of this type of injury amongst general histopathologists is very much essential for accurate identification and diagnosis of this condition. The lack of

Enhanced Recovery After Surgery (ERAS) and Nutritional Aspects

Esophagectomy combined with one or more treatment modalities in the neoadjuvant or perioperative period is the primary curative treatment for esophageal and junctional adenocarcinoma. Improvements in surgical practice and perioperative care, combined with centralisation of specialist cancer care, have improved outcomes. Despite this esophagectomy is still associated with significant morbidity and mortality.