Outcomes of patients with pneumatosis intestinalis and/or portal venous gas: a study of factors associated with survival and surgical intervention.

BACKGROUNDS: This study investigated the incidence of, and mortality and management outcomes following, pneumatosis intestinalis and/or portal venous gas on computed tomography. METHODS: A retrospective study of patients identified with pneumatosis intestinalis and/or portal venous gas on computed tomography at a quaternary centre (2013-2021) was performed. Data relating to clinical presentation (including quick sequential organ failure assessment score), co-morbidities (Charlson Comorbidity Index), biochemical data (including peak lactate level), and radiological findings, were obtained. Factors associated with these were assessed by logistic regression. RESULTS: From 16 428 scans, 107 (0.65%) demonstrated pneumatosis intestinalis and/or portal venous gas (mean 65.2 years [SD 15.2]; 60 [56%] male). Overall, 37 patients (35%) had both findings present. Thirty-three deaths (31%) were recorded. Fifty-four patients (51%) underwent surgery. Death was associated with quick sequential organ failure assessment score (score 1: OR 5.71, 95% CI 1.31-24.87; score 2: OR 10.00, 95% CI 1.94-51.54), Charlson Comorbidity Index ≥5 (OR 2.86, 95% CI 1.19-6.84), peak lactate ≥2.6 mmol/L (OR 14.53, 95% CI 4.39-48.14), and concomitant pneumatosis intestinalis and portal venous gas (OR 8.25, 95% CI 3.04-22.38). The presence of free peritoneal fluid (OR 3.23, 95% CI 1.44-7.28) or perforated viscus (OR 5.10, 95% CI 1.05-24.85) were the only predictors for surgery. CONCLUSION: Pneumatosis intestinalis and portal venous gas are rare findings. Despite traditionally portending a poor prognosis, mortality occurred in only one-third of patients. There were clear indicators of mortality viz. sepsis severity, comorbidities, and concomitant pneumatosis intestinalis and portal venous gas. Factors predicting surgery warrant further investigation.

Anatomical endoscopic retrograde cholangiopancreatography simulator using moulded meshed silicone: A novel simulator pilot study.

INTRODUCTION: Endoscopic retrograde cholangio-pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient-based training in ERCP however models to date have been unconvincing. METHODS: This ERCP simulation model was constructed from moulded meshed silicone by co-designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists. RESULTS: From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009). CONCLUSIONS: The simulator showed statistically significant results in face, content, and construct validity. A follow-up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.

Clinicopathologic and survival differences between adenocarcinoma of the distal oesophagus and gastro-oesophageal junction.

BACKGROUND: The incidence of adenocarcinoma of the distal oesophagus (DO) and gastro-oesophageal junction (GOJ) are increasing. They may represent differing disease processes. This study aimed to assess clinicopathological and survival differences between patients with DO and GOJ adenocarcinomas. METHODS: Data were extracted from a prospective single-surgeon database of consecutive patients undergoing an open Ivor-Lewis oesophagectomy for oesophageal adenocarcinoma (distal oesophagus, Siewert type I and II). Differences in clinicopathological characteristics and survival were evaluated and prognostic factors examined using univariate and multivariate survival analyses. RESULTS: The data were available for 234 patients who underwent an oesophagectomy between 1992 and 2019. DO tumours had higher rates of Barrett's oesophagus (P < 0.001), presented with lower tumour stage (P = 0.02) and were more likely to be associated with fewer lymph nodes resected (P = 0.003) than GOJ tumours. The median overall survival for distal oesophageal tumours was 29.2 months, while gastro-oesophageal tumours was 38.6 months. Kaplan Meier analysis did not show a difference in overall survival between the two groups (P = 0.08). However, when adjusted for potential confounders, GOJ tumours were associated with a reduced adjusted hazard of death (adjusted HR 0.58, 95% CI 0.36-0.92, P = 0.022) compared with DO tumours. CONCLUSION: This study suggests that GOJ cancers have different clinicopathological characteristics and improved survival compared to DO tumours.