Till Herbold

Prognostic relevance of nutritional status in patients with advanced esophageal cancer.

Evaluation of: Clavier JB, Antoni D, Atlani D et al. Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer. Dis. Esoph. doi:10.1111/j.1442-2050.2012.01441.x (2012) (Epub ahead of print). The influence of nutritional status of patients with esophageal cancer on the effect of chemoradiation is not well studied. In a retrospective study of 143 patients with definitive chemoradiation, the authors show that malnutrition is a negative prognostic factor. In the Western industrial world, the incidence of high BMI has greatly increased over the past few decades, together with the incidence of esophageal adenocarcinoma. Studies analyzing the influence of being overweight on the outcome after esophagectomy showed that a very high BMI has a negative impact on a patient’s survival. The interpretation of results from prognostic studies will be more complicated if several therapeutic procedures are combined, for example, neoadjuvant or adjuvant therapies combining chemoradiation or chemotherapy and esophagectomy. Prospective randomized studies including the nutritional status and immune competence for patients with advanced cancer of the esophagus are necessary.

Molecular Markers for the Prediction of Minor Response to Neoadjuvant Chemoradiation in Esophageal Cancer: Results of the Prospective Cologne Esophageal Response Prediction (CERP) Study.

Objective: The aim of this study was to evaluate the predictive value of a single or combination of biomarker(s) for histopathologic non-response to neoadjuvant chemoradiation in esophageal cancer. Summary of Background Data: Patients without response to neoadjuvant chemoradiation for esophageal cancer have no prognostic benefits, but experience time delays and risk side effects. Methods: Inclusion criteria for this prospective diagnostic study were patients with cT3,Nx,M0, esophageal squamous cell or adenocarcinoma and planned neoadjuvant chemoradiation (5- fluorouracil, cisplatin, 40Gy) followed by 2-field transthoracic esophagectomy. From pretherapeutic endoscopic tumor biopsies, ERCC1 rs11615 single-nucleotide polymorphism (ERCC1-SNP) and a combination of gene expression marker mRNA (ERCC1, DPYD, ERBB2) were analyzed. ERCC1-SNP was subdifferentiated into homozygous C-allele (CC) and T-allele (TT), and heterozygous C/T carriers. The primary endpoint was the prediction of histopathological minor response (≥10% vital tumor cells in the primary tumor) relative to marker levels. Results: From 2009 until 2013, 320 patients were screened, and 85 patients (SCC n = 29, AC n = 56) were included in the study. Forty-one patients (48%) had major response with 3-year survival rate (3-YSR) of 57% compared with 44 patients with minor response and 3-YSR of 25% (P = 0.001). Patients with ERCC1-SNP CC (n = 8) and TT (n = 37) had similar rates of minor response of 70% and 75%, and a positive predictive value (PPV) of 71% [95% confidence interval (CI 56%–84%)]. PPV increased to 89% (95% CI 73%–96%) when ERCC1-SNP was combined with mRNA markers. Conclusion: ERCC1-SNP in combination with mRNA ERCC1, DPYD, and ERBB2 from pretherapeutic endoscopic biopsies can predict minor response to chemoradiation, as a basis for individualized therapy of advanced esophageal cancer.

Effect of Laparoscopic Antireflux Surgery on Esophageal Motility

Background/Aims: The effect of laparoscopic antireflux surgery on esophageal motility is incompletely understood, and any indication for this procedure in patients with motility disorder is disputed in literature. We evaluated the influence of laparoscopic Nissen fundoplication on impaired esophageal motility. Methods: In this pathological manometric study, we divided the patients into two groups preoperatively: the hypomotility group (mean amplitude of esophageal contraction wave <40 mm Hg; HYPO group, n = 11) and the normal group (mean amplitude of esophageal contraction wave >40 mm Hg; NORM group, n = 43). The amplitudes of esophageal contraction waves 3 and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed pre- and postoperatively. Results: In total, 54 patients with GERD underwent esophageal manometry before and 6 months after Nissen fundoplication. The length and pressure of the lower esophageal sphincter were increased in both groups postoperatively (p < 0.01). Patients in the HYPO group (n = 11) showed a statistically significant increase of mean amplitude of esophageal contraction (32.8 vs. 57.3 mm Hg; p < 0.01), while no change was found in the NORM group (n = 43). A total of 72% of patients with preoperative motility disorder showed normal postoperative manometry. Conclusion: Nissen fundoplication normalizes esophageal motility, especially in patients with preoperative hypomotility. Patients with impaired esophageal motility should not per se be excluded from antireflux surgery.

Phytobezoar: Impact of Differential Diagnosis and Difficulties in Technical Diagnostics

For the diagnosis of phytobezoar, it is good to examine the stomach by endoscopy. In contrast, for the lower parts of the intestinal tract, the diagnosis can be challenging and the visible structure will frequently be impossible to distinguish from a tumor mass [2, 5] . Risk factors for the development of a phytobezoar are previous resections/reconstructions in the intestinal tract, stenosis (e.g. Crohn’s disease, tumor), disturbances of the GI motility, abnormal diet or vegetarianism [3, 4] . The localization can be in all parts of the intestinal tract. Severe complications can be an ileus or even a perforation of the intestinal wall [3] . Chemical dissolution and especially endoscopic treatment can be an appropriDear Sir, We read the article ‘Phytobezoar of the stomach’ by Park and Chae [1] with great interest. Despite the fact that the literature published on the matter is rare, with only a small number of case reports, the clinical incidence of phytobezoar seems not to be that rare in reality. I will cite here one case relevant from this point of view and which will be published shortly: we noticed a cherry pit ileus of the colon ascendens, which had been causing abdominal pain for a long period. Many previous clinical and technical examinations like endoscopy and even CT scan did not lead us to the correct diagnosis. When the patient was admitted to our hospital, we had a strong suspicion of an obstructing malignant tumor and performed a right hemicolectomy. Published online: August 3, 2010

Gastric cancer treatment in the world: Germany

Epidemiologically, around 15,500 persons per year contract gastric cancer with continuously decreasing incidence and a 5-year survival rate of only 30% to 35%. Contrary to the Asian countries, there are no prevention programs for gastric cancer in Germany, which leads to the disease frequently being diagnosed in locally advanced stages and predominantly being treated with multimodal therapy concepts. Complete (R0) resection is the therapy of choice for resectable gastric cancer. Special forms of gastric cancer that are limited to the mucosa can be endoscopically resected with a curative intent. Systematic D2 lymphadenectomy (LAD) plays a decisive role in the management of local advanced tumors because it significantly contributes to the reduction of tumor-related death and both local and regional relapse rates. Perioperative chemotherapy improves prognosis in the advanced stages, whereas palliative chemotherapy is normally indicated for metastatic diseases. Standardized resection procedures and the use of individualized multimodal therapy concepts have led to improvement in the 5-year survival rate.

Percutaneous Endoscopic Gastrostomy in Direct Puncture Technique: When, Why and How?

Background: Percutaneous endoscopic gastrostomy (PEG) placed in the pull through (PT) technique is a common procedure to restore enteral feeding in patients with swallowing disorders. Limitations of this technique are patients with obstruction of the pharynx or esophagus or with an esophageal stent. We report our experience with the direct puncture (DP) PEG device. Methods: We included 154 patients (55 women). One hundred forty patients had cancer. After passing the endoscope into the stomach, 4 gastropexies were performed with a gastropexy device and the PEG was placed with the introducer method. After 1 month, the sutures were removed and a constant gastrocutaneous fistula had been created and the new catheter could be placed safely. Results: The DP PEG was successfully placed in all patients. Overall complication rate was 11% (minor: 6%, major: 5%). The most common event was tube dislocation (40 cases). In 5 cases of dislocation, this resulted in a major complication with injuring the gastric wall and the necessity for surgical treatment. Conclusions: The DP PEG system is safe, and can be used in cases in which a standard PT PEG is not feasible. To avoid dislocation, strict adherence to a post-interventional protocol is highly recommended.

Tu1763 Esophageal Perforation - Trend Towards Endoscopic Treatment

Introduction: Despite improvement in surgical technique, morbidity and mortality is still significant after esophagectomy. Operative technique might be considered as an important factor in the outcomes of this operation. This study was intended to evaluate the perioperative outcomes of partial versus total esophagectomy for malignancy. Methods: Using the Nationwide Inpatient Sample (NIS) database, clinical data of patients who underwent esophagectomy (partial or total) with the diagnosis of esophageal malignancy including carcinoma in situ from 2006-2008 were examined. Patient characteristics, comorbidities, perioperative complications, length of stay, hospital charges and in-hospital mortality were evaluated. Results: A total of 5,851 patients underwent partial (65.60%) and total (34.30%) esophagectomy during this period. The mean age was similar between groups (partial: 63.3, total: 64.4 years; p=0.07) and the majority of patients were male (partial: 81.8%, total: 79.3%; p=0.02) and Caucasian (partial: 84.92%; total: 87.55%; p=0.02). Most of the comorbidities were similar between groups (hypertension, congestive heart failure, chronic lung disease, liver disease, renal failure, weight loss, anemia, smoking, peripheral vascular disorder and alcohol abuse). Outcome measures between groups are shown below. Conclusion: The most frequent procedure for esophageal malignancy is partial esophagectomy. Compared to the total esophagectomy, partial esophagectomy was associated with lower morbidity and lower mortality and comparable hospital stay and hospital charges. Partial esophagectomy may improve morbidity and mortality in esophageal malignancy.

Mo2073 Impact of Blood Biomarker of Neoadjuvant Treated Patients With Esophageal Carcinoma

Introduction: Anastomotic leakage is one of the causes of increased morbidity and mortality in gastrointestinal and colorectal surgery and it is also associated with elevated costs. The aim of this study was to investigate the effect of synthetic hydrogel sealant and a fibrin sealant on incompetent anastomosis in animal experimental model. Materials and methods: After obtaining approval from our Animal Ethics Committee, ten pigs were anesthetized using a standard protocol. A midline laparotomy was performed and the terminal ileum identified. Subsequently the intestine was completely sectioned 30 cm proximal to the ileocecal valve. All hand-sewn end-to-end anastomoses were performed by the same surgeon, using interrupted absorbable (3-0 polyglactine 910) sutures and leaving an orifice of 18French in the suture line (as shown in Fig 1). Animal were randomized to the application of a synthetic sealant (polyethylene glycol, group I) or fibrin sealant (group II) on the defect and the suture line. Animal were postoperatively followed for 7 days and prematurely sacrificed if sepsis developed. Otherwise, they underwent a second surgery for revision and the anastomosis was isolated and removed for subsequent histological examination. Fischers and Students t test was used for statistical analysis. P<0.05 was considered significant. Results: Preoperative data was comparable between groups, with no statistical difference. No septic complications developed in any of the study subjects. Only one animal presented a contained wound dehiscence. On the second surgery, macroscopic findings showed no difference between the 2 groups: There was no evidence of diffuse purulent peritonitis or bowel obstruction. One contained anastomotic leak was found in each group (1/5 vs. 1/5, NS). Adhesions between intestinal loops were found 4 animals: 2 in group I and 2 in group II (2/5 vs. 2/5, NS). An inflammatory mass, containing the leak appeared in 1 case (0/5 vs. 1/5, NS). Microscopically, the local inflammatory response, with granulation tissue and local peritonitis was similar in both groups. Continuity of the mucosal layer was observed in 4 of 10 samples, similar in both groups (2/5 vs. 2/5, NS). Epithelial inclusions in the anastomotic line was found in 1 case in group I and in 3 cases in group II (1/5 vs. 3/5, p=0,26). Discussion: We present a preliminary study describing a new model of incompetent anastomosis in a large animal, designed to study the effect of sealants and glues on intestinal healing. Our findings show that this is a viable model and that both synthetic and fibrin sealant may be useful in reinforcing incompetent anastomoses. Further studies are needed to understand the role of these products in the prevention of anastomotic leaks.

Intraluminale Messung des gastralen Blutflusses und der Sauerstoffsättigung mittels eines kombinierten Laser-Dopplers und Gewebespektrometer

Postoperative morbidity after esophagectomy and gastric tube formation depends on the vascularization of the gastric conduit. The aim of this experimental study was to assess a recently developed microprobe (O2C i , Fa. LEA Medizintechnik) monitoring the gastric microcirculation from the endoluminal side. Eighteen patients with no evidence of gastric pathology were included in this study. During conventional gastroscopy the microprobe was introduced via the working channel and positioned in well defined areas of the antrum, corpus and fundus. The microprobe measured the gastric blood flow (BF, in perfusion units, PU) and oxygen saturation (SO2, in %) by a combined LaserDoppler and Tissue Spectrometer. Mucosal blood flow of the fundus was significantly higher compared to the corpus (Corpus: 193 PU ± 47 SD, Fundus: 225 PU ± 41 SD; p = 0,012) whereas no significant different blood flow between antrum and fundus could be demonstrated (Antrum: 201 PU ± 40 SD, Fundus: 223 PU ± 29). Mucosal oxygen saturation of the antrum was significantly higher compared to the fundus (Antrum: 82 % ± 10 SD, Fundus: 73 % ± 10 %; p = 0,0007). This study demonstrated the feasibility of the gastric microprobe to measure parameters of gastric microcirculation from the endoluminal side.