Staging and surgical approaches in gastric cancer: a clinical practice guideline.

BACKGROUND: Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer. METHODS: Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed. RESULTS: One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented. CONCLUSIONS: All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

Management and outcomes of localized esophageal and gastroesophageal junction cancer in older patients.

BACKGROUND: Older patients are commonly excluded from clinical trials in esophageal and gastroesophageal junction (gej) cancer. High-level evidence to guide management in this group is lacking. In the present study, we compared outcomes and described tolerance for curative- and noncurative-intent treatments among patients 70 years of age and older. METHODS: We retrospectively reviewed all patients 70 years of age and older diagnosed with localized esophageal and gej cancer at our centre between 2005 and 2012. RESULTS: The 74 patients identified had a median age of 77 years. Of those patients, 62% received curative-intent treatment, consisting mostly of concomitant chemoradiation therapy (n = 43, 93%). Median overall survival for patients receiving curative-intent treatment was 18.6 months [95% confidence interval (ci): 13.0 to 28.0 months], with 23% being long-term survivors (95% ci: 11.3% to 36.7%). In contrast, patients receiving noncurative-intent treatment had a median overall survival of 8.8 months (95% ci: 6.7 to 11.9 months), with none being long-term survivors (p < 0.0001). Improvement of dysphagia was seen after curative (81%) or palliative radiotherapy (78%) in symptomatic patients, and toxicities were manageable. The odds of not receiving curative treatment was higher by a factor of 8.5 among patients 80 years of age or older compared with those 70-79 years of age (95% ci: 2.5 to 28.7). CONCLUSIONS: In managing older patients with esophageal and gej cancer, curative-intent treatment (compared with noncurative-intent treatment) leads to a significant survival benefit with a reasonable toxicity profile. Informed counselling of patients and their families about a curative treatment approach and efforts to increase awareness among oncology care providers are suggested.

National trends in gastroesophageal reflux surgery.

OBJECTIVES: To assess the surgical technique and the frequency of different types of antireflux surgery used in Canada after the introduction of laparoscopic antireflux surgery. DESIGN: Gastroesophageal reflux (GER) surgery and population data in fiscal years 1992 through 1996. were accessed through the Canadian Institute of Health Information, provincial health ministries, MED ECHO and Statistics Canada databases. Data were also analysed by province and nationally for type of surgery (e.g., open abdominal, thoracic, thoracoscopic and laparoscopic). RESULTS: National data showed a slight increase in GER surgery in the last 5 years. Laparoscopic surgery increased 2.8 fold in 1993 and 1.6 fold in 1995 over the previous years. Open abdominal cases decreased 1.1 fold from 1992 to 1996. Thoracic cases remained essentially unchanged. Provincial and regional disparities in procedures per 100,000 population exist (Ontario 7.1 versus Nova Scotia 20.7). Areas in which little or no laparoscopic surgery was done had an average increase of 3%, whereas areas in which laparoscopic surgery was done had an average increase of 16% in GER surgery during the course of the study. In provinces west of Quebec (with the exception of Manitoba) more than 50% of GER surgery is laparoscopic; in areas east of Ontario less than 25% of GER surgery is performed laparoscopically. Five provinces (Manitoba, Quebec, Nova Scotia, Prince Edward Island and Newfoundland) performed significantly fewer laparoscopic procedures than the national average. CONCLUSIONS: The frequency of GER surgery is increasing modestly in Canada and is performed most often by the open abdominal route. Regional disparities in open and laparoscopic techniques are apparent. Laparoscopic surgery for GER is increasing rapidly and accounts for the decrease in open GER surgery.

Radiation-induced esophageal squamous cell carcinoma in situ.

A report of radiation-induced squamous cell carcinoma in situ of the esophagus is presented. This report indicates that the patient developed the carcinoma in situ many years after chest wall irradiation for breast cancer treatment. A review of the literature with respect to carcinogenesis after radiotherapy is included and recommendations for the follow-up of patients having mediastinal radiation are suggested.

Grooved director aids fascial enlargement and closure.

Gallbladder retrieval following laparoscopic cholecystectomy through the umbilical or epigastric port site is at times tedious, may result in gallbladder perforation from excessive tearing forces applied to the gallbladder or from instrumental perforation while attempting to enlarge the fascia and is very "low tech" compared to the laparoscopic procedure. Port-site herniae develop when the fascia at either site is not closed adequately with sutures because of inadequate vision through the small incision and the concern for inadvertent injury to the tissues underlying the fascia. This study reports the use of a simple instrument, a spoon-shaped grooved director, to aid both the fascial enlargement and the fascial closure. The instrument has been used in more than 30 laparoscopic cholecystectomies and has been found to be simple, safe and effective for fascial enlargement and closure. This reusable instrument should be used routinely for laparoscopic cholecystectomy but offers significant advantages in the obese individual.

Anastomotic and regional blood flow following esophagogastrectomy in an opossum model.

Adenocarcinoma of the esophagus is increasing in incidence. The primary treatment is surgical resection, which is associated with considerable risk of anastomotic dehiscence and stricture. Decreased blood flow has been suggested as one of the factors contributing to these anastomotic failures. Our hypothesis was that anastomotic blood flow was decreased secondary to gastric and esophageal mobilization and would be increased by endogenous nitric oxide. Five opossums underwent esophagogastrectomy. Gastric and esophageal blood flow was measured following laparotomy, esophageal and gastric mobilization, esophagogastric resection and anastomosis, and L-arginine infusion. Radioactive microspheres were used to measure blood flow in the mucosa and muscularis of the esophagogastric anastomosis, esophagus, and stomach. Contrary to our hypothesis, blood flow in the anastomosis was maintained if not increased following esophagogastrectomy. However, the blood flow to the gastric mucosa adjacent to the anastomosis may be decreased. This suggests a possible redistribution of gastric blood flow to supply the anastomosis. If prolonged, this may contribute to poor anastomotic healing. L-Arginine infusion had no effect on blood flow at the anastomosis.

Treatment of extraesophageal manifestations of gastroesophageal reflux disease.

Extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, asthma and 'acid' laryngitis. The response to medical and/or surgical therapy of these conditions is highly variable and often delayed. Of patients with GERD-related symptoms, those with extraesophageal manifestations are some of the most difficult to treat. Histamine antagonists, proton pump inhibitors and antireflux surgery have all been used to treat GERD-related asthma with variable results. Asthma patients who do not respond to high-dose acid suppression may be refractory to all forms of therapy. GERD is the third most common cause of chronic cough, and therapeutic results with acid suppression and antireflux surgery are variable. Posterior laryngitis presents as chronic hoarseness and has been shown to resolve clinically and histologically with acid suppression therapy or antireflux surgery. Results are variable, and controlled trials are lacking.

Educational aspects of mathematics disabilities.

Research suggests that students with learning disabilities have significant difficulty acquiring and retaining math skills. A variety of factors seem to be contributing to the poor math performance of these individuals. The purpose of this article is to discuss these factors and make recommendations that will enhance the likelihood of better math performance. The article begins with a discussion of national reform movements that have influenced math instruction (i.e., National Council of Teachers of Mathematics Standards, minimum competency testing, graduation requirements, inclusion). Next, learner characteristics are reviewed, then issues related to math instruction are described. Finally, ways to improve current practices in math education are discussed.

The gastroesophageal flap valve: in vitro and in vivo observations.

BACKGROUND: This study was performed to confirm the presence and significance of a gastroesophageal flap valve. METHODS: The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope. RESULTS: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed. CONCLUSIONS: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.

Enteral feeding in esophageal surgery.

Malnutrition is frequently associated with esophageal cancer. To maintain and improve nutrition during the stress of esophagectomy early postoperative enteral feeding was used in surgical patients. Minor complications such as jejunal tube dislodgment, metabolic derangements, and feeding-related gastrointestinal complications occurred, all of which were easily corrected. Nutritional status was maintained or improved in most patients and the actual cost compared to a calculated cost of an equinitrogenous, equicaloric parenteral solution was much less.

Intraoperative whole-lung torsion producing pulmonary venous infarction.

Pulmonary venous infarction and whole-lung torsion are both rare, life-threatening complications of thoracic operations. A case of whole-lung torsion with resultant pulmonary venous infarction of the entire lung after a nonpulmonary thoracic operation is reported.

The use of oximetry in determining intestinal blood flow.

The intraoperative evaluation of intestinal ischemia and viability is often subjective and unreliable. The results of recent reports of pulse and surface oximetry have suggested that these techniques may be useful in assessing intestinal blood flow. In the current study, we evaluated and compared the ability of intestinal tissue oxygen saturation (as measured by pulse oximetry) and intestinal surface oxygen tension (as measured by surface oximetry) to determine the actual intestinal tissue blood flow (as measured with a radiolabeled microsphere technique). In five dogs, tissue oxygen saturation, surface oxygen tension and blood flow of the proximal and distal parts of the small intestine were measured under basal conditions. A clamp placed around the root of the superior mesenteric artery was then tightened to decrease the blood flow through this artery (as measured by an ultrasonic flow probe) by 50 percent and then by 75 percent, repeating all measurements after each reduction. The two consecutive reductions in superior mesenteric artery blood flow resulted in an average 54 and 76 percent reduction in tissue blood flow, respectively. As a result of these reductions in tissue blood flow, the average intestinal tissue oxygen saturation (percentage), as determined by pulse oximetry, decreased significantly from a basal value of 93 +/- 1 to 83 +/- 1 (p < 0.05) and then to 76 +/- 1 (p < 0.05) with the two progressive blood flow reductions. Intestinal surface oxygen tension decreased more steeply, from a basal value of 97 +/- 1 to 80 +/- 6 (p < 0.05) and then to 64 +/- 7 millimeters of mercury (p < 0.05) with the same two reductions in tissue blood flow. Both techniques were capable of estimating tissue blood flow, but pulse oximetry was quicker and simpler to use. We conclude that the pulse oximeter has the potential to be of value in the intraoperative assessment of intestinal blood flow.

Laser fulguration for palliation of rectal tumours.

Palliative therapy for rectal carcinoma includes control of bleeding, tenesmus, mucous discharge, obstruction and pain. These local symptoms can cause serious morbidity for patients with locally advanced or metastatic rectal cancer. As an alternative to surgical resection for palliation, the authors applied endoscopic laser fulguration in 15 patients with rectal tumours; 14 experienced immediate relief of symptoms. At 6.4 months' follow-up, two patients had recurrent tenesmus and two required a colostomy. A high degree of patient acceptance makes laser fulguration for rectal tumours an important modality, for palliation; however, control of tenesmus may be temporary.

Neodymium:yttrium-aluminum-garnet laser vaporization for palliation of obstructing esophageal carcinoma.

Palliative therapy for obstructing esophageal carcinoma is more often necessary than curative surgery. The neodymium:yttrium-aluminum-garnet laser was used for vaporization of obstructing esophageal carcinoma in 18 patients requiring 24 treatments. Three women and 15 men (age range 42 to 87 years) had esophageal carcinoma (seven squamous cell and nine adenocarcinoma). Twelve tumors were at the esophagogastric junction, four at the midesophagus, and two in the cervical esophagus. Lengths varied from 3 to 7 cm. Inoperability was due to diffuse metastases in eight patients, local invasion in five, poor operative risk in one patient, and patient refusal for operative treatment in four patients. Energy use was 1000 to 22,600 J per session (mean 6120 J). Good results were achieved in 16 patients (88.9%): Seven returned to full diet, five to soft diet, and four to full fluids without dysphagia. Four patients required retreatment 1 to 3 months later because of recurrent dysphagia. One patient was not benefited by the treatment and died of carcinomatosis 1 week later. No intraoperative complications occurred. Postoperatively, one patient had laryngeal edema and another had a bronchoesophageal fistula 3 weeks later. The mean survival time is 3 1/2 months. Neodymium:yttrium-aluminum-garnet laser vaporization for obstructing esophageal carcinoma is effective palliation regardless of histologic tumor type. It can be performed under direct vision with a low frequency of postoperative complications.

Post Nissen syndrome.

The Nissen fundoplication is the most common anti-reflux operation performed. Gas bloat and inability to vomit after repair may be severe, but infrequently require reoperation; in contrast, other complications can be very debilitating or life-threatening. One hundred and sixteen patients who required reoperation for serious complications after Nissen repair are presented and classified according to the cause of the failed repair. Nissen complications resulted in recurrent reflux (86 per cent), severe dysphagia (60 per cent), esophageal dysmotility (48 per cent) and gastric perforation and fistualization (5 per cent). The "classic" Nissen fundoplication involves a blind 360 degree wrap, which includes the acid-producing parietal cell mass. The resulting pouch drains poorly and is, therefore, subject to gastric ulceration. Reoperation at our institution, using principally the Hill antireflux procedure, gave excellent or good results in 86 per cent, fair in 9 per cent and poor in 5 per cent. Three operative deaths (2.6 per cent) and one late death (0.9 per cent) occurred.

A method for recovering a lost retrieval line under direct vision in children with esophageal strictures.

Loss of a retrieval line for repeated esophageal dilations for caustic esophageal stricture may result in inability to dilate these strictures. We describe a simple means for retrieving such a line once it has been removed.

Lower esophageal sphincter pressure and gastroesophageal pressure gradients in excessively obese patients.

The purpose of the present study was to investigate the relationship of the gastroesophageal pressure gradient (GEPG) to lower esophageal sphincter pressure (LESP) in normal and in severely obese subjects. Eight lean volunteers with no clinical evidence of gastroesophageal reflux and eight asymptomatic severely obese patients (at least 80% over their ideal weight) underwent esophageal manometric studies with measurements of the LESP and GEPG in both inspiration and expiration. The LESP/GEPG ratio was also calculated in both inspiration and expiration. Acid sensitivity was assessed by means of infusion of 0.1 N HCl subsequent to the baseline motility study. There was no significant difference between the LESP in obese patients (O.P.) and normal subjects (N.Sb.) in either inspiration (mean +/- SEM in mm Hg: N.Sb. = 16.4 +/- 1.6, O.P. = 18.7 +/- 2.5), or expiration (N.Sb. = 16.6 +/- 1.5, O.P. = 20.6 +/- 2.6). However, the GEPG in both inspiration (N.Sb. = 13.3 +/- 1.6, O.P. = 23.1 +/- 2.0; p less than 0.001) and in expiration (N.Sb. = 2.1 +/- 0.5, O.P. = 8.1 +/- 1.1; p less than 0.001) was significantly higher in obese patients than in controls. As a result, the GEPG/LESP ratios were also higher (expiration N.Sb. = 0.15 +/- 0.03, O.P. = 0.46 +/- 0.10; p less than 0.01) in obese patients; and for inspiration (N.Sb. = 0.86 +/- 0.13, O.P. = 1.33 +/- 0.12; p less than 0.01) in the obese patients the ratio was greater than 1. None of the normal subjects exhibited acid sensitivity, but 6 of the 7 obese patients tested developed heartburn during acid infusion. In conclusion, the GEPG/LESP ratio in inspiration was greater than unity for obese patients inspite of normal LESP. Such a change in the ratio could facilitate reflux in obese patients.

Sutureless bowel anastomosis using Nd:YAG laser.

Small bowel anastomoses were performed without sutures by using the Nd:YAG laser to produce welded enterotomies. Optimal energy levels for contact and noncontact laser were determined. Anastomoses produced using five target energy levels between 100 and 500 J were examined. Short-term anastomotic strength of these enterotomies was measured 1 min after the welding. Bursting pressure of the laser welded enterotomies was compared to the bursting pressure of traditional two-layer, inverting, interrupted sutured bowel anastomoses. The overall mean bursting pressure of non-contact-welded enterotomies was 50.6 mmHg. Optimal laser settings determined in this initial phase were then used to produce anastomoses in rabbits which are recovered postoperatively for 1 or 2 weeks in order to examine long-term viability and integrity of the anastomoses. All chronic rabbit preparations recovered without complication. The mean bursting pressure was 200 mmHg, not significantly different from that of uncut bowel or two-layer sutured anastomosis.

Reoperation after failed esophagomyotomy for achalasia.

Of 49 patients with achalasia treated surgically between 1975 and 1985, 12 (8 women, 4 men) had undergone transthoracic esophagomyotomy previously. Four had had concomitant upper gastrointestinal surgery. All 12 patients complained of dysphagia; other symptoms included regurgitation, nocturnal aspiration, heartburn, chest pain, vomiting, upper gastrointestinal bleeding and weight loss. The average time from initial operation to onset of symptoms was 9 months. Preoperative investigations and operative findings identified the cause of dysphagia as inadequate or healed esophagomyotomy with persistent or recurrent achalasia (eight patients--two had partially disrupted fundoplications contributing to their dysphagia), hiatus hernia with reflux esophagitis causing esophageal spasm or peptic esophageal stricture (two patients) and incorrect initial diagnosis and treatment (two patients). Treatment, with the aid of intraoperative manometry, included repeat Heller myotomy (five patients), Hill antireflux repair (four patients), takedown of Nissen fundoplication and extension of myotomy (two patients). The average follow-up was 16 months. Eight patients had good results, two required further operation and one underwent multiple dilatations postoperatively. The causes of recurrent dysphagia following surgery for achalasia are diverse and patients require individualized investigation and treatment. Remedial surgery for achalasia can correct postoperative dysphagia but results are less successful than those following an adequate initial operation.

Surgical management of peptic esophageal stricture. Twenty-year experience.

The consensus in the conflict about surgical management of peptic esophageal stricture presently favors conservative antireflux procedures with dilatation rather than resection. However, emphasis is now shifting to the controversy of conservative surgical treatment versus medical management with dilatation alone. We analyzed the influence of seven variables on the postoperative result in 160 patients undergoing antireflux operations with dilatation for peptic esophageal stricture. The mean follow-up is 47 months (range 6 to 240) and the mean age is 57 years (range 13 to 83). One hundred seven patients operated on early in the course of the disease have better results (90% good, 9% fair, 1% poor) than 31 patients having a previous failed operation (52% good, 23% fair, 26% poor) and 22 patients having multiple dilatations (45% good, 23% fair, 32% poor) (p less than 0.05). Intraoperative manometry improves results (p less than 0.05), and postoperative reflux has a negative influence on results (p less than 0.05). The postoperative lower esophageal sphincter pressure in patients without reflux (17.7 +/- 1.3 mm Hg) is higher than in those with reflux (8.9 +/- 0.8 mm Hg, p less than 0.05) and is an accurate predictor of the risk of reflux (p less than 0.001). Intraoperative and postoperative sphincter pressures are objective indicators of outcome but because of variability are not predictive (p less than 0.05). The presence of Barrett's esophagus and the age and sex of patients do not alter outcome. Adenocarcinoma did not develop in patients with Barrett's esophagus once reflux was eliminated. This information indicates that conservative antireflux operation with dilatation is the treatment of choice in patients with peptic esophageal stricture.