Tom Walsh

Are seminal fluid microorganisms of significance or merely contaminants

OBJECTIVEnTo determine the contribution of urethral and skin flora to seminal fluid cultures and the relation between bacteriospermia and seminal leukocytes.nnnDESIGNnProspective study.nnnSETTINGnIVF-ET unit at a university teaching hospital.nnnPATIENT(S)nSixty men starting an IVF-ET program.nnnINTERVENTION(S)nCulture of sequential first-catch urine, midstream urine, and semen samples with evaluation of seminal leukocytes.nnnMAIN OUTCOME MEASURE(S)nA comparison of microbes from first-catch urine, midstream urine, and semen samples and the correlations of seminal microbes, elevated leukocyte concentrations, and pregnancy.nnnRESULT(S)nMicroorganisms were detected in 37% of first-catch urine samples, 27% of midstream urine samples, and 51% of semen samples. Most microorganisms were gram-positive microbes and were common to both urine and semen samples. Mean and median leukocyte concentrations were 0.98 x 10(6)/mL and 0.10 x 10(6)/mL, respectively. There was no correlation between seminal microbes and raised leukocytes or between leukocytospermia and/or bacteriospermia and pregnancy.nnnCONCLUSION(S)nMicroorganisms are commonly found in insignificant quantities in the semen of asymptomatic men. The frequent isolation of gram-positive microbes common to both urine and semen and the absence of a correlation with raised leukocyte concentrations suggest that bacteriospermia most commonly represents contamination.

Lipoma of the cord and round ligament: an overlooked diagnosis?

Lipoma of the cord, once considered rare and insignificant, has been cast in a new light by laparoscopic pre-peritoneal surgery, with diagnostic and therapeutic implications. This study aimed to determine the incidence, significance and association of spermatic cord lipomas to inguinal hernias. A retrospective review was performed for all hernia operations carried out between January 1999 and November 2002. The incidence of cord lipomas and their relation to inguinal hernias were evaluated. There were 123 repairs performed on 111 patients, 90 of which were laparoscopic via the pre-peritoneal approach, 29 were open and 4 converted from laparoscopic to open in the early part of the series. All but two cases were male (neither female had associated lipoma of the round ligament). Twenty-six lipomas of the cord were identified with an incidence of 21%. Sixteen were associated with hernia and only 10 were pure cord lipoma, an incidence of 8%. Thirteen repairs represented recurrent hernias, two of which had pure cord lipoma, one had an associated sac. Only two lipomas were suspected clinically prior to surgery. Lipoma of the cord is a poorly recognised entity that can be present with groin symptoms and clinical findings indistinguishable from inguinal hernia. Its incidence was poorly appreciated prior to the laparoscopic era.

Targeting therapy for esophageal cancer in patients aged 70 and over

BACKGROUNDnWhile cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery.nnnOBJECTIVESnWe examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older.nnnMETHODSnA prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT)±surgery.nnnRESULTSnOf 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT±surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥3years. Mean overall survival was 28months for the entire cohort; 47months for cCRs; 61months for patients undergoing primary resection, 46months for cCRs who did not undergo resection and 29months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p=0.861).nnnCONCLUSIONncCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.

Acid suppression increases rates of Barrett’s esophagus and esophageal injury in the presence of duodenal reflux

BACKGROUNDnThe contribution of gastric acid to the toxicity of alkaline duodenal refluxate on the esophageal mucosa is unclear. This study compared the effect of duodenal refluxate when acid was present, decreased by proton pump inhibitors (PPI), or absent.nnnMETHODSnWe randomized 136 Sprague-Dawley rats into 4 groups: group 1 (n = 33) were controls; groupxa02 (n = 34) underwent esophagoduodenostomy promoting combined reflux; group 3 (n = 34) underwent esophagoduodenostomy and PPI treatment to decrease acid reflux; and group 4, the gastrectomy group (n = 35) underwent esophagoduodenostomy and total gastrectomy to eliminate acid in the refluxate. Esophaguses were examined for inflammatory, Barretts, and other histologic changes, and expression of proliferative markers Ki-67, proliferating cell nuclear antigen (PCNA), and epidermal growth factor receptor (EGFR).nnnRESULTSnIn all reflux groups, the incidence of Barretts mucosa was greater when acid was suppressed (group C, 62%; group D, 71%) than when not suppressed (group B, 27%; P = 0.004 and P < .001). Erosions were more frequent in the PPI and gastrectomy groups than in the combined reflux group. Edema (wet weight) and ulceration was more frequent in the gastrectomy than in the combined reflux group. Acute inflammatory changes were infrequent in the PPI group (8%) compared with the combined reflux (94%) or gastrectomy (100%) groups, but chronic inflammation persisted in 100% of the PPI group. EGFR levels were greater in the PPI compared with the combined reflux group (P = .04). Ki-67, PCNA, and combined marker scores were greater in the gastrectomy compared with the combined reflux group (P = .006, P = .14, and P < .001).nnnCONCLUSIONnGastric acid suppression in the presence of duodenal refluxate caused increased rates of inflammatory changes, intestinal metaplasia, and molecular proliferative activity. PPIs suppressed acute inflammatory changes only, whereas chronic inflammatory changes persisted.

Chemoradiotherapy, with adjuvant surgery for local control, confers a durable survival advantage in adenocarcinoma and squamous cell carcinoma of the oesophagus

INTRODUCTIONnOesophageal cancer usually presents with systemic disease, necessitating systemic therapy. Neo-adjuvant chemoradiotherapy improves short-term survival, but its long-term impact is disputed because of limited accrual, treatment-protocol heterogeneity and a short follow-up of randomised trials.nnnAIMSnLong-term results of two simultaneous randomised controlled trials (RCTs) comparing neo-adjuvant chemo-radiotherapy and surgery (MMT) with surgical monotherapy were examined, and the response of adenocarcinoma (AC) and squamous cell carcinoma (SCC) to identical regimens compared.nnnMETHODSnBetween 1990 and 1997, two RCTs were undertaken on 211 patients. Patients with AC (n=113) or SCC (n=98) were separately-randomised to identical protocols of MMT or surgical monotherapy.nnnRESULTSn211 patients were followed to 206 months; 104 patients were randomised to MMT (58 AC and 46 SCC, respectively) and 107 to surgery. MMT provided a significant survival-advantage over surgical monotherapy for AC (P=0.004), SCC (P=0.01). There was a 54% relative risk-reduction in lymph-node metastasis following MMT, compared with surgery (64% versus 29%, P<0.001). MMT produced a pathologic complete response (pCR) in 25% and 31% of AC and SCC, respectively. Survival advantage accrued to MMT, pCR and node-negative patients: AC pCR versus surgical monotherapy (P=0.001); residual disease following MMT versus surgical monotherapy (P=0.008); SCC pCR versus surgical monotherapy (P=0.033).nnnCONCLUSIONSnA survival advantage for MMT persisted long-term in AC and was replicated in SCC. MMT produced loco-regional tumour down-staging to extinction in 25-31% of patients, potentially permitting personalised treatment in this cohort that avoids the morbidity and mortality associated with resection. Node-negative patients with residual localised disease following MMT had a survival advantage over node-negative patients following surgery alone, supporting a systemic effect on micro-metastatic disease.

Hiccups: An Unrecognized Symptom of Esophageal Cancer?

TO THE EDITOR: The outcome for patients with esophageal carcinoma is poor. This reflects in part the aggressive nature of the disease and also the fact that the majority of patients have advanced disease at presentation. It has been previously shown that two-thirds of patients with esophageal cancer present with symptoms for 3 months or more and with at least 14 lbs weight loss (1). Furthermore, only 17% of the general population would identify difficulty swallowing as being attributable to underlying malignancy. In addition, the majority of people are not aware of “cancer of the esophagus” and only 12% are familiar with its symptoms (2). In contrast, over 90% of people are familiar with the symptoms of breast cancer. Awareness programs highlight the significance of dysphagia and weight loss, but in our experience patients frequently note persistent or distressing hiccupping. We present one such case.

Neoadjuvant antiangiogenic therapy with tamoxifen does not impair gastrointestinal anastomotic repair in the rat

Introductionu2003 Antiangiogenic therapy has the potential to moderate tumour and micrometastatic growth. Its use in the perioperative period is attractive but its potential to compromise wound and anastomotic healing is a cause for concern. Tamoxifen is antiangiogenic but also favourably modifies some aspects of wound healing. We hypothesised that tamoxifen would not adversely affect skin wound and gut anastomotic healing.

Oesophageal cancer: who needs neoadjuvant therapy?

Despite having the poorest outcomes of almost all solid tumours, not all surgeons are convinced of the need for, or the benefi t of, adjunctive treatment for oesophageal cancer. At the heart of the problem seems to lie an overinterpretation of the published work on the role of surgery. Over 30 years ago, Earlam and Cunha-Melo published the fi rst major overview of the role of surgery for oesophageal cancer, which made for grim reading. Of every 100 patients, 58 were explored, 39 underwent resection, 13 died in hospital, and only four survived for 5 years. Surgical enthusiasts insist that outcomes have improved immeasurably in the intervening years, citing up to 50% 5-year survival for surgery alone, but such results refl ect patient selection more than eff ect on outcome. Interpretation of the eff ect of surgery is impossible without a community denominator from which survival data are drawn. The report by Verhoef and colleagues in 2007 provided more startling insights. Of 1149 consecutive patients diagnosed in one region of the Netherlands, those who underwent surgery in university centres had a 5-year survival of 49% whereas patients undergoing resection in non-teaching centres had a 5-year survival of 27%. However, resection rates were only 11% for university centres compared with 21% for non-teaching centres, so both achieved similar overall outcomes. That only 8·9% of operated patients received some form of adjunctive therapy is surprising, and that only about 5% of the overall community had salvage therapy went without comment. Also, the contention that more radical surgery will result in improved overall outcome is diffi cult to sustain because of the biology of the disease. Most patients with oesophageal cancer are older, have substantial comorbidity, and have systemic disease at diagnosis. Because of their age and comorbidity, most patients are unsuitable for surgery even if curative, whether radical or conservative. Most patients classed as curable on staging will eventually develop recurrent cancer, confi rming the theory that they harbour systemic micrometastases that are undetectable by present staging methods. Systemic disease needs systemic treatment. But is it eff ective? In this issue of The Lancet Oncology, Sjoquist and colleagues have marshalled all of the evidence from randomised trials to convince all but the most obstinate that surgery alone is not enough. And this is from pooled data on eff ective and ineff ective regimens; a subgroup analysis of the most eff ective regimens would be most interesting. Some argue that if systemic treatment is needed chemotherapy should suffi ce and radiotherapy is unnecessary. Sjoquist and colleagues describe a 22% reduction in all-cause mortality for preoperative chemoradiotherapy and a 13% reduction in all-cause mortality for neoadjuvant chemotherapy. When both were directly compared there was weak evidence in favour of preoperative chemoradiotherapy. Clearly, larger randomised trials are needed that focus on patients with more advanced locoregional disease who can benefi t from tumour downstaging. When tailoring treatments the complete response rate should be a major consideration because the complete response rate for preoperative chemotherapy is only 0–4%, compared with 25–87%, depending on stage, for preoperative chemoradiotherapy. The magnitude of the complete response rate for neoadjuvant chemoradiotherapy raises a further issue: should all recipients of neoadjuvant chemoradiotherapy undergo resection? A substantial proportion will have no residual cancer but will be exposed to all of the risks of surgery. If surgery was an innocuous intervention this issue would be less problematic, but mortality from surgery varies from 5·7% in centres of excellence to 14% in the community. We cannot identify complete responders accurately but our data suggest that up to 74% of patients with a complete clinical response after chemoradiotherapy have a complete pathological response. The avoidance of surgery in complete clinical responders over a certain age or with signifi cant comorbidity might prove an acceptable balance of risks. This clarifi cation of the role of neoadjuvant therapies provides support for a more rational management approach; the default assumption should be that all resectable patients but those with the earliest stage tumours have systemic disease and should receive neoadjuvant chemoradiotherapy. Patients who cannot tolerate trimodal therapy should be off ered neoadjuvant chemotherapy. Surgery alone should Published Online June 17, 2011 DOI:10.1016/S14702045(11)70158-9

Collagenous colitis as a possible cause of toxic megacolon

Collagenous colitis is a microscopic colitis characterized by normal appearing colonic mucosa on endoscopy. It is regarded as a clinically benign disease which rarely results in serious complications. We report a case of toxic megacolon occurring in a patient with collagenous colitis. This is the first reported case of toxic megacolon occurring in this subset of patients.

Extending the reach of stapled anastomosis with a prepared OrVil™ device in laparoscopic oesophageal and gastric cancer surgery.

AbstractIntroductionnThe introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™).MethodsWe conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications.ResultsSeventy-two patients were included in the study. Patient ages ranged from 45 to 92xa0years (medianxa0±xa0SDxa0=xa069xa0±xa010xa0years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure (nxa0=xa041; 57xa0%). R0 resection was achieved in 67 patients (93xa0%). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8xa0%) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique.ConclusionDespite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction.