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INTRODUCTION: Pneumatosis of the small bowel mesentery is rare and the preserve of case reports. This case report describes the importance of a multi-disciplinary team (MDT) approach to rare pathologies. CASE REPORT: A 78-year-old man presented to our unit with a two-day history of upper abdominal pain associated with nausea and intermittent vomiting. An urgent computed tomography (CT) scan was organised. The scan was grossly abnormal and difficult to interpret; it was reported as widespread intra-mural gas within the small bowel wall most likely secondary to extensive small bowel ischaemia. Although surgical intervention was very high risk (predicted P-possum mortality of over 60%) and there was a strong possibility that the patient would not recover from surgery, the disparity between clinical and radiological findings meant that a diagnostic laparoscopy was indicated. A diagnostic laparoscopy showed that the small bowel itself was normal but there was extensive gas within the mesentery, caused by a band adhesion which had eroded into the peritoneal layer of the small bowel mesentery. DISCUSSION: Pneumatosis of the small bowel mesentery is a pathological sign rather than a diagnosis and is characterised by gas within the mesenteric sleeves. It is likely associated with significant morbidity and therefore rarely observed as the majority with this sign would not be deemed suitable for surgical intervention. CONCLUSION: The case highlights an unusual pathology, rare imaging findings, the importance of a multi-disciplinary approach and the value of clear communication and informed consent when considering major intervention or surgery.
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OBJECTIVES: The prognostic significance of the circumferential resection margin (CRM) status in oesophageal cancer patients treated with neo-adjuvant chemotherapy and radical resection is controversial. Furthermore, it is currently unclear whether patients with cancer located at the CRM have a prognosis different from that of those with cancer within 1 mm of the CRM. This is the first study aiming to establish the optimal tumour-free distance from the CRM of an oesophagectomy in patients who have undergone neo-adjuvant chemotherapy. METHODS: The clinicopathological data of 232 oesophageal cancer patients from two UK centres were analysed. The CRM status was classified as Group A (cancer at the CRM), Group B (cancer within 1 mm but not at the CRM) and Group C (no cancer within 1 mm from the CRM). The relationship between the CRM status and patient survival was investigated. RESULTS: Thirty-eight specimens were classified as Group A, 89 as Group B and 105 as Group C. CRM status was related to the depth of tumour invasion (P < 0.001) and lymph node status (P < 0.001). The prognoses of the Group A and the Group B patients were similar. Both were poorer than that of the Group C patients (P = 0.008). Lymph node status was the only independent prognostic marker in multivariate analysis. CONCLUSIONS: Oesophageal cancer patients treated with preoperative chemotherapy with cancer cells at the CRM or within 1 mm of the CRM of the resected specimen have a significantly worse survival than patients with no cancer cells within 1 mm of the margin. However, this study suggests that the overall prognostic significance of the CRM status is limited in this cohort and the postoperative lymph node status is the most important prognostic factor in oesophageal cancer patients treated with neo-adjuvant chemotherapy and surgery.
