A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction.

OBJECTIVE: Palliation of malignant esophageal obstruction is an important clinical problem. Expandable metal stents are a major advance in therapy, but many stents become obstructed because of tumor ingrowth. The aim of this study was to compare a new, membrane-covered expandable metal stent to conventional prostheses in a randomized controlled trial. METHODS: Sixty-two patients with malignant inoperable esophageal obstruction at the gastroesophageal junction participated in the study. Patients were randomly assigned to covered or uncovered stents. The principal outcome measure was the need for reintervention because of recurrent dysphagia or migration. Secondary endpoints were relief of dysphagia measured by a dysphagia score (grade 0 = no dysphagia, grade 1 = able to eat solid food, grade 2 = semisolids only, grade 3 = liquids only, grade 4 = complete dysphagia) and the rate of complications and functional status. All patients were observed at monthly intervals until death or for 6 months. RESULTS: One week after stenting the dysphagia score improved significantly in both the uncovered (n = 32, 3 +/- 0.1 to 1 +/- 0.1 [means +/- SEMs], p < 0.001) and covered (n = 30, 3 +/- 0.1 to 1 +/- 0.2 [means +/- SEMs], p < 0.001) stents. Obstructing tumor ingrowth was significantly more likely in the uncovered stent group (9/30) than in the covered group (1/32) (p = 0.005). Significant stent migration occurred in 2/30 patients with uncovered stents, as compared with 4/32 patients in the covered group (p = 0.44). Reinterventions for tumor ingrowth were significantly greater in the uncovered stent group (27%), as compared with 0% in the covered group (p = 0.002). Life table analysis showed similar survival in both groups. CONCLUSION: Membrane-covered stents have significantly better palliation than conventional bare metal stents because of decreased rates of tumor ingrowth that necessitate endoscopic reintervention for dysphagia.

Liberal policy of split liver for pediatric liver transplantation. A single centre experience.

We adopted a liberal policy of extensive use of split liver in a pediatric liver transplantation (LT) program. Over a 19-month period, we have performed 64 LT in 54 patients with pediatric indications. One patient received two liver grafts as a part of a liver-small bowel transplantation and was not considered. Of the 60 LT considered, performed in 53 patients, 34 were with split grafts. The 1-year actuarial survival for the patients transplanted with a split graft was 81% and 89% when only elective cases were considered. The median time on the waiting list was 22 days with no mortality. The extensive use of split liver allowed transplantation in a large number of pediatric patients, with good results without the need for living donor liver transplantation. We envisage a trend towards systematic splitting of liver grafts.

Rejection and tacrolimus conversion therapy in paediatric liver transplantation.

Rejection and efficacy of rescue therapy with tacrolimus were evaluated in 50 children who underwent primary, ABO-compatible, liver transplantation. Six patients who died within the first week and one child who underwent retransplantation from an ABO-incompatible donor were excluded from the study. No patient or graft were lost due to rejection. We observed 48 episodes of rejection in 33 patients. Fourteen patients required conversion to tacrolimus for steroid-resistant rejection with resolution of rejection. One of these children developed PTLD. Other indications for conversion were neurotoxicity and hirsutism. One patient developed blindness of unknown origin after the conversion. Other side effects of tacrolimus were minor and resolved by lowering the dose. Five patients developed rejection after conversion; all achieved resolution with either steroid therapy or increase of tacrolimus dose. In conclusion, our study confirms that tacrolimus is an effective rescue therapy for paediatric liver transplantation.

Circulating Epstein-Barr virus DNA to monitor lymphoproliferative disease following pediatric liver transplantation.

Epstein-Barr virus (EBV) infection can induce uncontrolled lymphocyte B proliferation in immunosuppressed transplant patients. Monitoring circulating EBV-infected lymphocytes can help in identifying patients at risk of posttransplant lymphoproliferative disease (PTLD). Circulating EBV genome levels were determined in 54 liver transplant pediatric recipients. Ten patients had more than 500 EBV genome/10(5) peripheral blood lymphocytes (PBL) and exhibited clinical manifestations of EBV infection; three developed PTLD. To treat EBV infection, the level of immunosuppression was reduced and acute rejection developed in 4 patients. Three were treated with steroid and one had to be switched from cyclosporine to tacrolimus. Treatment of acute rejection was associated with increases in circulating EBV genome. None of the patients with less than 500 EBV genome/10(5) PBL developed PTLD or EBV infection. Monitoring of EBV DNA is useful in the management of EBV infection and PTLD following pediatric liver transplantation. EBV infection should be treated in ways which do not expose patients to the risk of rejection.

Extensive use of split liver for pediatric liver transplantation: a single-center experience.

The results of the extensive use of in situ liver splitting in a pediatric liver transplant program are presented. All referred donors were considered for split liver, and when the donor-recipient body weight ratio (DRWR) was greater than 2, the grafts were split. A modified split-liver technique was adopted when the DRWR was 2 or less. Eighty liver procurements were attempted and 72 (90%) were performed, enabling 65 children to receive 42 split, 22 whole, and 8 reduced-size livers. The right portions of the grafts were transplanted by other centers into adults. Median patient waiting time was 22 days, with no mortality on the waiting list. After a median follow-up of 14 months, overall patient and graft survival rates were 85% and 81%, respectively. Fifty-eight children received a single allograft, whereas 7 children required retransplantation. Two-year actuarial survival rates were 85% for split-liver recipients, 84% for whole-liver recipients, and 67% for reduced-size liver recipients. Vascular complications developed in 18% of the patients, with no difference among the 3 groups with different technique. Biliary complications developed in 25% of the children, mainly in reduced-size and split-liver recipients. Patient and graft survival rates for right split-liver grafts were 84% and 79%, respectively. Adopting a liberal policy of liver splitting provides allografts of optimal quality for pediatric transplantation, allowing a dramatic decrease in the waiting list time. The in situ split-liver technique should be considered the method of choice for expanding the cadaveric liver donor pool.

Modified splitting technique for liver transplantation in adult-sized recipients. Technique and preliminary results.

In the common split liver technique the liver is divided between the right lobe, to be transplanted to an adult, and the left lateral segment, to be transplanted to a small child. We have developed an alternative technique by which the cadaver donor liver is divided in its two anatomo-functional halves, both apt to be transplanted to adults or children of adult size. We have so far used this technique in three multi organ donors, generating, six liver grafts that we transplanted to six recipients with median age of 36.5 years (range 10-23) and a median weight of 55 kg (range 38-79). Patient survival was 83.3% and graft survival 66.6% with a median follow up of 10 months (range 8-14). These results show that the technique is effective and that it can consistently increase the number of liver grafts that can be transplanted into adult patients, with the available cadaver donor pool.

Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Endoscopic palliation of oesophageal cancer: results of a prospective comparison of Nd:YAG laser and ethanol injection.

OBJECTIVE: To evaluate the effectiveness of intratumoral alcohol injection compared with Nd:YAG laser in the treatment of unresectable fungating cancers of the oesophagus. DESIGN: Prospective, randomised clinical study. SETTING: University hospital, Italy. SUBJECTS AND INTERVENTIONS: 47 consecutive patients were randomly allocated to have endoscopic Nd:YAG laser treatment (n = 24), or intratumoural injection of 98% alcohol (n = 23). MAIN OUTCOME MEASURES: Morbidity, mortality, dysphagia score, survival. RESULTS: One patient in the laser group needed analgesic support during and after the treatment, whereas 18 (78%) of those treated with alcohol experienced mild pain and most of them required analgesics. An improvement of at least 2 points in the dysphagia score was noted in 21 patients (88%) in the laser group and in 18 in the alcohol group (78%). The mean dysphagia-free intervals between each treatment were 30 and 37 days, respectively. The median survival was 6 months in each group. There were no significant differences in the mean dysphagia scores of patients still alive. There were no complications in the laser group, but one oesophageal perforation occurred during the preliminary dilatation before the second session of alcohol injection. There were no procedure-related deaths. CONCLUSION: The two techniques allowed similar palliation of dysphagia and improvement of quality of life. Intratumoral injection of alcohol is an effective and inexpensive therapeutic option in the palliation of fungating oesophageal lesions.

Duodeno-gastro-esophageal reflux after gastric surgery: surgical therapy and outcome in 42 consecutive patients.

BACKGROUND/AIMS: Duodeno-gastro-esophageal reflux is a common event after gastric surgery and can result in severe symptoms and mucosal injury. Medical therapy is largely ineffective. The most common remedial operation consists of a long isoperistaltic Roux-en-Y limb in order to shunt duodenal contents away from the gastric pouch and the esophagus. METHODOLOGY: Between 1980 and 1996, 42 patients underwent duodenal diversion after gastric surgery. The presence of severe symptoms and/or endoscopic esophagitis unresponsive to medical therapy was considered an indication for surgery. Functional studies were performed in selected patients in an attempt to objectively document the presence of excessive duodeno-gastro-esophageal reflux. A 40-60 cm Roux-en-Y limb was constructed in all patients. RESULTS: There was no post-operative mortality. The median follow-up was 28 months (range: 5-114). Symptoms related to delayed gastric emptying persisted in 5 patients (11.9%). Overall, 32 patients (76%) had a Visick I-II score. Best results (90%) were achieved in patients with previous total gastrectomy. CONCLUSIONS: Roux-en-Y duodenal diversion should be reserved for patients with intractable symptoms and documented reflux, and is mostly effective after total gastrectomy. Patients with a residual stomach are less likely to benefit from the procedure, probably because an underlying motor disorder plays a major role in the pathogenesis of the symptoms than does the reflux of duodenal contents.

Surgical therapy in patients with failed antireflux repairs.

BACKGROUND/AIMS: Failure of antireflux surgery may be due to errors in patient selection, errors in the choice of the operation, or technical errors in the performance of the operation. The purpose of this work was to review a series of patients surgically treated for a failed antireflux procedure over the past two decades. MATERIALS AND METHODS: Seventy patients (62%) out of 113 consecutive individuals presenting with symptoms after one or more operations for gastroesophageal reflux disease underwent reoperation. Five patients had been operated on laparoscopically. The indications for reoperation were based on severity of symptoms and results of objective investigation. Surgical therapy was tailored to the individual patient based on pathophysiological abnormalities and on the results of intraoperative assessment. RESULTS: Reflux symptoms and dysphagia represented the major complaint in 62.8% and 35.7% of patients, respectively. The most common pathophysiological abnormality was an incompetent lower esophageal sphincter. Intraoperative assessment showed a disrupted or misplaced repair in 77% of the patients. The most common reoperation performed was a partial or total fundoplication (54.3%), followed by antrectomy and Roux-en-Y anastomosis (25.7%). There was no mortality. Postoperative morbidity rate was 8.5%. At a median follow-up of 48 months, 87% of patients were scored as Visick 1-2 and 90% declared themselves satisfied with the results of reoperation. CONCLUSIONS: Management of patients with failed antireflux procedures is challenging. However, detailed physiological evaluation and a surgical approach tailored to residual anatomy and function of the foregut can provide excellent results.

Disconnection of the ampulla of Vater: a new technique for reconstruction.

We report the case of a 42 year-old patient who had undergone gastric resection and Billroth I reconstruction for a duodenal ulcer 15 years earlier. The patient was admitted to our Department for a high output biliopancreatic fistula which developed after another gastric resection with Billroth II reconstruction which was performed for a peptic stricture of the gastroduodenal anastomosis. At laparotomy, a complete disconnection of the ampulla of Vater was found, with the duodenal stump oversewn 5 cm distally to the papillary area. After plasty of the biliary and pancreatic ducts, a direct anastomosis between the new ampulla and a Roux-en-Y jejunal loop was performed. The post-operative course was uneventful. The details of the surgical technique are reported.

Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients.

OBJECTIVE: To assess the effectiveness of transoral stapled diverticulum esophagostomy in relieving symptoms and decreasing outflow resistance at the pharyngoesophageal junction in patients with Zenker diverticulum. DESIGN: Cohort study. From April 1, 1992, until May 31, 1996, the operation was attempted in 95 patients. The median follow-up was 23 months (range, 13-48 months). SETTING: Tertiary care university hospital. PATIENTS: There were 74 men and 21 women, with a median age of 64 years (age range, 37-92 years). All complained of dysphagia and pharyngo-oral regurgitation, and 18 (20%) suffered from recurrent aspiration pneumonia. The median size of the pouch measured by flexible endoscopy was 4 cm (range, 2.5-8 cm). INTERVENTION: The septum between the diverticulum and the esophageal lumen was divided under general anesthesia using a linear endostapler introduced through a Weerda endoscope. In most patients, 2 applications of the endostapler with a modified anvil were used. Operative time averaged 23 minutes. MAIN OUTCOME MEASURES: Morbidity, symptom score, patient's satisfaction, videofluorographic barium transit, hypopharyngeal intrabolus pressure, upper esophageal clearance of radioisotope. RESULTS: A switch to open surgery was required in 3 patients (3.1%), due to difficult exposure of the common wall in 2 cases and a mucosal tear in the other. No postoperative morbidity or mortality was recorded. Oral feeding was started the following day and the median hospital stay was 3 days (range, 2-8 days). Five patients complained of persistent symptoms; 3 of them underwent another endosurgical operation, 1 underwent laser treatment by means of flexible endoscopy, and 1 eventually required open surgery. All patients are asymptomatic at the latest follow-up visit. Postoperative radiologic studies showed free flow of barium in all patients. Manometry showed a significant reduction of hypopharyngeal intrabolus pressure over preoperative values (P=.003). Radionuclide studies showed a significant reduction of upper esophageal residual activity at 1 minute compared with preoperative values (P=.006). CONCLUSIONS: Endosurgical approach to hypopharyngeal diverticula larger than 2 cm is safe and effective. Symptom relief, elimination of the pouch, and decreased outflow resistance at the pharyngoesophageal junction can be obtained without morbidity and with a short hospital stay.

Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty.

Redundancy of the interposed colon used as an esophageal substitute is a common finding in the long-term follow-up of these patients. When symptoms caused by food retention in the colonic loop occur, surgical correction is necessary to improve quality of life and to prevent aspiration. We report a technique to straighten the redundant colon that consists of a side-to-side colocolic anastomosis using a linear stapler. This obviates the need for a redo cologastric anastomosis. Compared with resection of the loop, the operation is quick, safe, and easy to perform, and it may decrease the risk of injury to the marginal vessels of the colon graft.