Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome.

BACKGROUND Boerhaave syndrome is a rare esophageal injury associated with a high mortality rate of 14.8%. Immediate diagnosis and treatment have been associated with a better outcome. Surgery remains the mainstay of treatment for those who present early with widespread septic contamination. One of the most difficult dilemmas in the treatment of Boerhaave syndrome is selection of the most appropriate management for late perforations with severe septic complications. In this situation, aggressive surgical approach with esophagectomy and immediate or postponed reconstruction is usually recommended. CASE REPORT We report a patient with spontaneous esophageal rupture successfully treated by late endoscopic stent-grafting. The patient was transferred from a rural hospital after initial non-effective conservative treatment. Endoscopic stent-grafting was performed 7 days from the onset of symptoms. A self-expanding plastic stent-graft (Polyflex) used initially very early migrated to the stomach. The plastic stent-graft was then replaced by a fully covered self-expandable metal stent-graft (EndoMAXX), which was wider and equipped with anti-migration struts. Implantation of the EndoMAXX stent-graft resulted in clinical success, with the closure of esophageal rupture confirmed 8 weeks after stent-grafting. CONCLUSIONS Our case indicates that even late after spontaneous esophageal perforation, less invasive treatment by endoscopic stent-grafting with adequate drainage of septic contamination may be an attractive option for preserving the esophagus in selected patients in stable hemodynamic condition. Our case also supports implantation of wider metallic stent-grafts to seal benign esophageal perforation above the esophago-gastric junction to prevent early migration to the stomach.

Peripheral blood T lymphocytes are downregulated by the PD-1/PD-L1 axis in advanced gastric cancer.

INTRODUCTION: Programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1) function as an immune checkpoint pathway that can be exploited by tumor cells to evade immuno-surveillance. The precise role of PD-1/PD-L1 inhibition of the immune response in GC is unknown. The study investigated PD-1 and PD-L1 expression on peripheral T-cells and its potential association with clinicopathological features in gastric cancer (GC) patients. MATERIAL AND METHODS: PD-1/PD-L1 expression on CD4(+) and CD8(+) T-cells from peripheral blood of 40 patients primarily diagnosed with advanced GC was evaluated by multicolor flow cytometry. RESULTS: The frequency of CD4(+)PD-1(+) and CD8(+)PD-1(+) cells in GC patients was higher than in the control group (p < 0.0001 and p < 0.01, respectively). Expression of PD-1 on CD8(+) cells in GC was higher than in the control group (p < 0.0001). The frequency of CD4(+)PD-L1(+) and CD8(+)PD-L1(+) cells was higher than in the control group (p < 0.0001). Expression of PD-L1 on CD4(+) and CD8(+) cells in GC was higher than in the control group (p < 0.0001). A higher frequency of CD4(+)PD-1(+) cells was found in diffuse-type compared to intestinal tumors (p < 0.029). A higher frequency of CD8(+)PD-1(+) cells was found in patients with poorly differentiated compared to well/moderately differentiated tumors (p < 0.019). CONCLUSIONS: Downregulation of peripheral blood CD4(+) and CD8(+) lymphocytes can be associated with PD-1/PD-L1 expression. This can lead to attenuation of the general immune response in GC.

E-cadherin expression as predictive marker of proximal resection line involvement for advanced carcinoma of the gastric cardia.

AIMS: Total gastrectomy for gastric cardia tumours harbours a high risk of proximal resection line (PRL) involvement. The adhesion markers CD44v6 and E-cadherin were evaluated as predictive factors for PRL involvement independent of tumour stage. METHODS: Forty-nine gastrectomy specimens for gastric cardia carcinoma (type II) were evaluated for stage, resection margins, and CD44v6 and E-cadherin immunohistochemistry. RESULTS: PRL involvement was microscopically recognized in 49% of specimens. CD44v6 expression was found in 84% of intestinal tumours, and in 56% of diffuse/mixed tumours (p=0.045). In the group of resections performed with curative intent, the proximal extension of the resection (margin) was significantly shorter in E-cadherin negative tumours than in E-cadherin positive tumours (p=0.029). Histological type and stage of the tumour, lymph node metastases, and absence of E-cadherin expression, but not the presence of CD44v6 correlated with PRL involvement. Only the absence of E-cadherin expression appeared to be a significant predictor of PRL involvement, independent of tumour stage. Survival for patients with PRL involvement was shorter than that for patients after R0 resection (p=0.07). Stage was the only independent prognostic factor emerging from multivariate survival analysis (p=0.002). CONCLUSIONS: When curative resection is intended in type II cardiac cancer patients, an oesophageal resection and gastric tube reconstruction should be considered, especially for a tumour without E-cadherin expression.