Gastropericardial fistula in a patient with upside-down stomach and stomach perforation: a case report.

BACKGROUND: Gastropericardial fistula is a pathological communication between the stomach and the pericardium. This case report describes a gastropericardial fistula in a patient with upside-down stomach. CASE PRESENTATION: The male patient (86) was examined for severe chest pain behind the sternum. CT revealed upside-down stomach with perforation on the lesser gastric curvature and fistulation into the pericardium with pneumopericardium. The patient was indicated for surgery. The procedure was performed from a transverse laparotomy and consisted of repositioning the stomach into the abdominal cavity, resection of the hernial sac, suture of the perforation of the lesser curvature, gastropexy and transhiatal drainage of the mediastinum and lesser sac. In the early postoperative period, the recovery was uneventful. Acute myocardial infarction with cardiorespiratory failure developed on the postoperative day (POD) 13. The patient died on POD 24 due to cardiorespiratory failure, confirmed by a sectional finding. CONCLUSIONS: Gastropericardial fistula is a rare acute complication of the diseases of the upper GIT. It is invariably a serious, life-threatening condition. Diagnosis is confirmed by thoracic CT and a contrast swallow study. The necessity of acute surgical treatment is widely accepted. The type of procedure must be selected based on the patient's individual criteria.

From Tumor Immunology to Immunotherapy in Gastric and Esophageal Cancer.

Esophageal and gastric cancers represent tumors with poor prognosis. Unfortunately, radiotherapy, chemotherapy, and targeted therapy have made only limited progress in recent years in improving the generally disappointing outcome. Immunotherapy with checkpoint inhibitors is a novel treatment approach that quickly entered clinical practice in malignant melanoma and renal cell cancer, but the role in esophageal and gastric cancer is still poorly defined. The principal prognostic/predictive biomarkers for immunotherapy efficacy currently considered are PD-L1 expression along with defects in mismatch repair genes resulting in microsatellite instability (MSI-H) phenotype. The new molecular classification of gastric cancer also takes these factors into consideration. Available reports regarding PD-1, PD-L1, PD-L2 expression and MSI status in gastric and esophageal cancer are reviewed to summarize the clinical prognostic and predictive role together with potential clinical implications. The most important recently published clinical trials evaluating checkpoint inhibitor efficacy in these tumors are also summarized.

ABC Transporters and Their Role in the Neoadjuvant Treatment of Esophageal Cancer.

The prognosis of esophageal cancer (EC) is poor, despite considerable effort of both experimental scientists and clinicians. The tri-modality treatment consisting of neoadjuvant chemoradiation followed by surgery has remained the gold standard over decades, unfortunately, without significant progress in recent years. Suitable prognostic factors indicating which patients will benefit from this tri-modality treatment are missing. Some patients rapidly progress on the neoadjuvant chemoradiotherapy, which is thus useless and sometimes even harmful. At the same time, other patients achieve complete remission on neoadjuvant chemoradiotherapy and subsequent surgery may increase their risk of morbidity and mortality. The prognosis of patients ranges from excellent to extremely poor. Considering these differences, the role of drug metabolizing enzymes and transporters, among other factors, in the EC response to chemotherapy may be more important compared, for example, with pancreatic cancer where all patients progress on chemotherapy regardless of the treatment or disease stage. This review surveys published literature describing the potential role of ATP-binding cassette transporters, the genetic polymorphisms, epigenetic regulations, and phenotypic changes in the prognosis and therapy of EC. The review provides knowledge base for further research of potential predictive biomarkers that will allow the stratification of patients into defined groups for optimal therapeutic outcome.

Early simultaneous esophagopleural and bronchopleural fistula after right pneumonectomy.

BACKGROUND: Esophagopleural and bronchopleural fistulas represent a rare, but life-threatening complication after lung resections, most often after a right pneumonectomy. CASE STUDY: A 64 years old woman was indicated for right pulmectomy for local recurrence of initially stage IIB lung cancer treated by lower lobectomy. On the postoperative day 34, an esophagopleurobronchial fistula occurred. Further course required thoracostomy with closure of the bronchial stump and vacuum-assisted closure therapy and two-phase esophagectomy with 6 weeks interval to the esophageal reconstruction. Patient represents 2 years of disease-free survival with good functional results. CONCLUSION: The therapy of esophagopleural and bronchopleural fistula is long-term and complicated, requiring a multidisciplinary approach and several basic principles must be adhered to the management including treatment of infection and prevention of sepsis, local treatment of the fistula and pleural empyema, and adequate ventilation and nutritive care.

Current status of cytoreductive surgery (CRS) and intraperitoneal hyperthermic chemotherapy (HIPEC) in the multimodal treatment of peritoneal surface malignancies.

The tumors of the peritoneal surface, both primary and secondary, are associated with a very poor prognosis and rapid progression through conventional oncology treatment including systemic chemotherapy, targeted treatment, radiotherapy, surgery, and symptomatic treatment. Until recently, most of them were considered incurable. In the 1980s, the first cytoreductive surgery ("CRS") combined with intraperitoneal hyperthermic chemotherapy ("HIPEC") became the standard of treatment for selected tumor peritoneal tumor (pseudomyxoma peritonei and primary peritoneal malignant mesothelioma). In some cases of other peritoneal carcinomatosis associated with colorectal cancer, gastric cancer and ovarian cancer in the subgroup of well selected patients, this treatment can lead to a significant prolongation of overall survival and good standard of quality of life. This method is safe in specialized centers with an acceptable rate of morbidity and mortality comparable to foreign workplaces and is also available for patients in the Czech Republic. Key words surgery, oncology, cytoreduction, intraperitoneal chemotherapy, hyperthermia.

Resilience in Rectal Cancer Treatment: Lessons from the COVID-19 Era in Czech Republic.

Introduction: The management of patients with COVID-19 infection has placed great pressure on the healthcare systems around the world. The aim of this study was to investigate the impact of the COVID-19 pandemic on the treatment outcomes of patients with rectal cancer by comparing them to those of patients with the same diagnosis in the pre-pandemic period. Methods: Retrospective data analysis of patients undergoing multimodal treatment for rectal cancer at the four university hospitals during the COVID-19 pandemic (2020-2021) and the 2-year pre-pandemic period (2018-2019). Results: A total of 693 patients (319 in the pre-pandemic period and 374 in the pandemic period) with rectal cancer were included in the study. The demographic and clinical characteristics of patients in both study periods were comparable, as was the spectrum of surgical procedures. Palliative surgery was more common in the pandemic period (18% vs 13%, p=0.084). The proportion of patients undergoing minimally invasive surgery was higher during the COVID-19 pandemic (p=0.025). There were no statistically significant differences between the study periods in the incidence/severity of post-operative complications, 30-day mortality and length of hospital stay. The number of positive resection margins was similar (5% vs 5%). Based on these results, COVID-19 had no effect on the postoperative morbidity and mortality in patients undergoing surgery for rectal cancer. Neoadjuvant treatment was more common in the pre-pandemic period (50% vs 45%). Long-course RT was predominantly offered in the pre-pandemic period, short-course RT during the pandemic. Significantly shorter "diagnosis-surgery" intervals were observed during the pandemic (23 days vs 33 days, p=0.0002). The "surgery-adjuvant therapy" interval was similar in both analysed study periods (p=0.219). Conclusion: Our study showed, that despite concerns about the COVID-19 pandemic, multimodal treatment of rectal cancer was associated with unchanged postoperative morbidity rates, increased frequency of short-course neoadjuvant RT administration and shorter "diagnosis-surgery" intervals.

The short- and long-term outcomes of pancreaticoduodenectomy for distal cholangiocarcinoma.

BACKGROUND: The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal cholangiocarcinoma (DCC) patients to identify potential prognostic factors. PATIENTS AND METHODS: A retrospective cohort study of 32 consecutive DCC patients treated with pancreaticoduodenectomy between 2009-2017. The clinicopathological and histopathological data were evaluated for prognostic factors using the univariable Cox regression analysis. The Overall Survival (OS) was estimated using the Kaplan-Meier analysis. RESULTS: The study comprised a total of 32 patients, with a mean age of 65.8 (± 9.0) years at the time of surgery. R0 resection was achieved in 25 (86.2%) patients, 19 (65.5%) patients received adjuvant oncological therapy. The OS rates at 1, 3 and 5 years were 62.5%, 37.5% and 21.9%, respectively. The 90-day mortality was 3/32 (9.4%) accounting for one-fourth of the first-year mortality rate. The median OS was 28.5 months. The only statistically significant prognostic factor was vascular resection, which was associated with worse OS in the univariable analysis (HR: 3.644; 95%-CI: 1.179-11.216, P=0.025). An age less than 65 years, ASA grade I/II, hospital stay of fewer than 15 days, R0 resection, lymph node ratio less than 0.2 and adjuvant oncological therapy tended to be associated with better OS but without statistically significant relevance. CONCLUSION: The main factor directly influencing the survival of DCC patients is surgical complications. Surgical mortality comprises a significant group of patients, who die in the first year following pancreaticoduodenectomy. Vascular resection is the most important negative prognostic factor for long-term survival.

Hybrid esophagectomy for oesophageal cancer: long-term results. A single-centre experience.

INTRODUCTION: The authors report long-term outcomes in patients who received neoadjuvant chemoradiotherapy and consequently underwent hybrid oesophagectomy for oesophageal cancer (OC). AIM: To evaluate long-term outcomes in patients suffering from OC, who underwent hybrid oesophagectomy. MATERIAL AND METHODS: Our cohort consisted of patients suffering from OC, who received neoadjuvant chemoradiotherapy. Hybrid esophagectomy was performed 8-10 weeks after oncological treatment. RESULTS: Ninety-four patients underwent surgery for OC from 2011 to 2015. Histology revealed adenocarcinoma in 60.6%, squamous cell carcinoma (SCC) in 36.2%, and other type of cancer in 3.2%. Seventy-three (77.7%) patients with advanced stage (T3-4, N0-2, M0) were indicated to receive neoadjuvant chemoradiotherapy (nCRT). Trans-hiatal hybrid oesophagectomy was performed in 83 (88.3%) patients. Transthoracic hybrid oesophagectomy was performed in 11 (11.7%) patients. Histology of the resected specimens of 18 (24.7%) patients did not reveal OC, i.e. pathological complete response (pCR). In our cohort, we proved an association between occurrence of pCR and age as well as disease-free survival (DFS). The patients who presented with pCR were significantly younger - below 60 years of age (p = 0.017). They also showed significantly higher mean DFS (p = 0.004). CONCLUSIONS: Combined oesophagectomy with neoadjuvant chemoradiotherapy results in a better long-term outcome in patients suffering from oesophageal cancer. In our set of patients who underwent hybrid esophagectomy, satisfactory short-term and especially long-term results of surgical treatment for oesophageal cancer were observed.

Prognostic factors in patients with esophageal carcinoma treated with chemoradiation: single center experience.

BACKGROUND/AIMS: The trimodality therapy including chemotherapy, external beam radiation and surgery is widely accepted as the standard of care in patients with locoregional esophageal carcinoma. METHODOLOGY: We have performed a retrospective analysis of patients with locoregional esophageal carcinoma treated with chemoradiation. RESULTS: One-hundred and fifty-two consecutive patients with non-metastatic adenocarcinoma or squamous cell esophageal carcinoma treated with chemoradiation were included in the present analysis. The median survival of the whole group was 12 months. The estimated 3- and 5-year survival rates were 24% and 19%, respectively. On multivariate analysis, female sex, weight loss and serum albumin were independent negative predictors of survival. Among 140 patients who survived more than 3 months, weight loss, female sex and therapy with paclitaxel were negatively associated with prognosis, and among 109 patients surviving more than 6 months the dose of cisplatin and surgery were independent prognostic factors. Pathologic complete response was not predictive of prognosis. CONCLUSIONS: Long-term survival is obtained in only about 20% of patients with carcinoma of the esophagus treated with chemoradiation. Female sex, weight loss and low serum albumin are independent indicators of poor prognosis. Among treatment-related factors, higher dose of cisplatin and esophagectomy were independent predictors of better prognosis, while administration of paclitaxel was associated with poor prognosis.

[Possibility of using the determination of minimal residual disease in pancreatic adenocarcinoma using real-time RT-PCR--a pilot study]. / Moznosti vyuzití stanovení minimální reziduální choroby u adenokarcinomu pankeatu pomocí metodiky real-tim RT-PCR--pilotní studie.

BACKGROUND: Minimal residual disease in patients with pancreatic cancer is defined as the presence of isolated tumor cells in the patient's body, in which the primary tumor was removed and is currently without clinical signs of disease. These isolated tumor cells may be described as precursors of micrometastases. Assessment of MRD in patients with this highly malignant disease could eliminate burdensome implementation of surgery in patients with systematic dissemination of molecular disease and provide a more precise prognosis. METHODS AND RESULTS; The study to date included 70 patients operated on with curative intent for carcinoma of the pancreas. Samples of peripheral and portal blood, bone marrow, peritoneal lavage and of the tumor itself were analyzed by real-time PCR which measured the expression of hTERT (telomerase), EGFR1 (receptor for epidermal growth factor) and CEA (carcinoembryonic antigen). The expression of these markers was correlated with clinicopathological characteristics and survival parameters. We found a statistically significant association between EGFR expression levels in the portal blood and clinical stage--patients with advanced disease have a higher expression of EGFR in the portal stream and peritoneal lavage in contrast to patients without the presence of metastases. CONCLUSIONS: The results of this pilot study demonstrated a high sensitivity and specificity of the RT-PCR method for detecting circulating tumor cells in patients with pancreatic cancer. By utilizing this methodology, we are able to provide prognostic value of minimal residual disease and its significance for the indication of radical surgery for pancreatic cancer.

Complications of the surgical treatment of esophageal cancer and microbiological analysis of the respiratory tract.

AIM: The aim of this study was to reduce the severe respiratory complications of esophageal cancer surgery often leading to death. METHODS: Two groups of patients operated on for esophageal cancer were evaluated in this retrospective analysis. The first group was operated between 2006-2011, prior to the implementation of preoperative microbiological examination while the second group had surgery between 2012-2017 after implementation of this examination. RESULTS: In total, 260 patients, 220 males and 40 females underwent esophagectomy. Between 2006-2011, 113 (87.6%) males and 16 (12.4%) females and between 2012-2017, esophagectomy was performed in 107 (81.7%) males and 24 (18.3%) females. In the first cohort, 10 patients died due to respiratory complications. The 30-day mortality was 6.9% and 90-day was 9.3%. In the second cohort, 4 patients died from respiratory complications. The 30-day mortality was 1.5% and 90-day mortality was 3.1%. With regard to the incidence of respiratory complications (P=0.014), these occurred more frequently in patients with sputum collection, however, severe respiratory complications were more often observed in patients without sputum collection. Significantly fewer patients died (P=0.036) in the group with sputum collection. The incidence of respiratory complications was very significantly higher in the patients who died (P<0.0001). CONCLUSION: The incidence of severe respiratory complications (causing death) may be reduced by identifying clinically silent respiratory tract infections.

Evaluation and management of toxicity of cytoreductive surgery/hyperthermic intraperitoneal chemotherapy: the initial experience of a single centre study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality for peritoneal surface malignancies with efficacy reported in many trials. Discrepancies, however, in the indication criteria, the extent of the surgical procedure, HIPEC regimens and toxicity evaluation represent a problem when comparing this method with other therapeutic modalities. METHODS: We describe the initial experience with CRS/HIPEC using different chemotherapy regimens (oxaliplatin, cisplatin, mitomycin C and doxorubicin) at the Comprehensive Oncology Centre Olomouc. RESULTS: A perioperative mortality of 2% and perioperative morbidity of 11%, according to Clavien-Dindo were observed. Interestingly, all these patients underwent HIPEC with oxaliplatin 460 mg/m2. The median duration of admission to hospital was 6 days in the intensive care unit (range 2-28 days) and 7 days in the surgical ward (range 1-21 days). Hospital admission did not exceed 2 weeks in 75% of patients. These results are consistent with the published results of large centres performing this treatment modality mainly due to pre-operative preparation of patients and pre-treatment and post-treatment management of HIPEC/CRS toxicity. Evaluation of the efficacy in terms of time to progression and overall survival (OS) is limited by the short follow up period. CONCLUSION: CRS/HIPEC performed is a safe method with low perioperative mortality.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system - Single centre study.

INTRODUCTION: This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. MATERIALS AND METHODS: We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. RESULTS: The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs. CONCLUSION: The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Renal cell carcinoma metastatic to the pancreas: a single center experience.

BACKGROUND/AIMS: Metastatic renal cell carcinoma (RCC) is a malignant tumor characterized by great variation in the clinical course and unusual sites of metastases. Metastases to the pancreas are, in general, rare. METHODOLOGY: A retrospective chart review of patients treated a single institution. RESULTS: Single center experience in 10 patients with this rare presentation of metastatic RCC is presented. In most cases, the course after diagnosis of RCC pancreas metastases was relatively favorable, specifically in patients treated with surgical removal of the metastases. The median survival from the diagnosis of RCC pancreas metastases was 56 months. CONCLUSIONS: The course of disease in patients with RCC pancreas metastases is often indolent. Long-term survival may be obtained after surgery even with suboptimal systemic therapy. An active therapeutic approach is warranted in these patients.

Video-assisted laparoscopic resection of the esophagus for carcinoma after neoadjuvant therapy.

BACKGROUND/AIMS: Classical operation approaches, used for decades during subtotal esophageal resection for esophageal carcinoma, have certain disadvantages. The transhiatal "blind" approach according to Orringer lacks sufficient radicality, the thoracotomic approach is burdened by serious postoperative complications, primarily respiratory. These disadvantages are eliminated to a great extent by use of the video-assisted laparoscopic transhiatal approach, which is presented in our study. METHODOLOGY: Between 2000-2006 forty-three patients with esophageal cancer underwent video-laparoscopic transhiatal esophagectomy. In all patients passage was renewed by esophagogastroplasty, constructed by placing the neoesophagus in the posterior mediastinum, anastomosis with the cervical esophagus from a laparotomy. Prior to the operation, 27 patients underwent neoadjuvant radio-chemotherapy. Chemotherapy consisted of 5 fluorouracil and cisplatinum, and radiotherapy with a total dose of 50 Gy. RESULTS: The extirpation phase was completed laparoscopically in all patients. Right-sided pneumothorax was seen in 27 patients, in six cases postoperative manifestation of left vocal chord paresis due to damage to the recurrent laryngeal nerve was observed, in 2 patients a fistula developed in the cervical anastomosis, which in all cases healed spontaneously. The operation time ranged between 225-370 minutes, the average time being 256 minutes. The mini-invasive phase took an average of 40 minutes. One patient died 57 days after the operation due to respiratory insufficiency. The average hospital stay was 12.2 days. CONCLUSIONS: The video-assisted laparoscopic transhiatal approach proved to be very useful during subtotal esophageal resection. In tumors localized in the lower portion of the esophagus, it completely replaces the transhiatal "blind" approach according to Orringer and, in comparison, eliminates operative hemorrhagic complications, which are more frequent in "blind" extirpations, especially in patients after neoadjuvant therapy. It also enables performing a lymphadenectomy, which is not possible using the "blind" approach. In tumors of the middle thoracic esophagus, which are inaccessible by the original Orringer's approach, it eliminates the need for a thoracotomy, which significantly contributes to the decrease of respiratory complications.

Necrotizing pelvic infection after rectal resection. A rare indication of endoscopic vacuum-assisted closure therapy. A case report.

INTRODUCTION: Anastomotic leak after colorectal surgery is a major problem associated with higher morbidity and mortality. In most cases of contained leaks, treatment recommendations are clear and effective. However, in rare cases like necrotizing pelvic infection, there is no clear treatment of choice, despite the mortality rate almost 21%. We present successful management with endoscopic vacuum-assisted closure therapy. THE PRESENTATION OF A CASE: A 68-year-old female patient with BMI 26, hypothyroidism and high blood pressure was indicated to low anterior rectal resection because of high-risk neoplasia of lateral spreading tumor type of the upper rectum. Four days after the primary operation, sepsis (SOFA 12) with diffuse peritonitis and unconfirmed leak according to CT led to surgical revision with loop ileostomy. On postoperative days 6-10, swelling, inflammation and subsequent necrosis of the right groin and femoral region communicating with the leak cavity developed. The endoscopy confirmed a leak of 30% of the anastomotic circumference with the indication of debridement and endoscopic vacuum-assisted closure therapy. EVAC sessions with 3-4 day intervals healed the leak cavity. Secondary healing of the skin defects required 4 months. CONCLUSION: Necrotizing pelvic infection after a leak of the colorectal anastomosis is a very rare complication with high morbidity and mortality. Endoscopic vacuum-assisted closure therapy should be implemented in the multimodal therapeutic strategy in case of major leaks, affecting up to 270° of the anastomotic circumference.

Peritoneal Carcinomatosis from Ovarian Cancer - Current Clinical Impact of Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy.

Epithelial ovarian cancer is one of the most common causes of cancer-related death in women. More than half of patients are diagnosed at an advanced stage, usually due to locoregional spread of peritoneal carcinomatosis. A combination of systemic chemotherapy and cytoreductive surgery has been the standard treatment since the mid-1990s. However, conventional chemotherapy is poorly delivered to the peritoneum due to the plasma-peritoneal barrier. Intraperitoneal chemotherapy can improve survival by eliminating residual microscopic disease. A combination of hyperthermic intravenous and intraperitoneal chemotherapy may reduce plasma toxicity and increase therapeutic effectiveness. Several experts are investigating the effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for both primary and recurrent ovarian cancer worldwide. Recent randomized studies indicate that this method prolongs overall patient survival and the disease-free interval. This approach is not yet part of standard guidelines and is the subject of several other clinical trials. However, indications should be considered in women with significant residual disease after neoadjuvant chemotherapy because these patients can benefit from comprehensive surgical resection in combination with hyperthermic intraperitoneal chemotherapy to prevent locoregional relapses.

Respiratory complications following mini-invasive laparoscopic and thoracoscopic esophagectomy for esophageal cancer. Experience in 215 patients.

INTRODUCTION: Respiratory complications (RC) including respiratory failure and adult respiratory distress syndrome (ARDS) affect the outcomes of esophagectomy substantially. In order to decrease their incidence, identification of important features of RC is necessary. AIM: To evaluate the incidence and risk factors of postoperative RC following hybrid esophagectomy. MATERIAL AND METHODS: The retrospective analysis of consecutive hybrid esophagectomies for malignancies (transhiatal laparoscopic or thoracoscopic resection and limited open reconstruction phase) assessed the incidence and outcomes of RC in relation to the patients' age, ASA score, neoadjuvant therapy, type of surgical procedure, TNM stage, the incidence of anastomotic leak and Clavien-Dindo classification. RESULTS: Transhiatal laparoscopic (176, 81.9%) or thoracoscopic hybrid esophagectomy (39, 18.1%, conversion in 7 patients) was completed in 215 patients, 187 (87%) men and 28 (13%) women. Respiratory complications developed in 86 (40%) and severe respiratory failure or ARDS occurred in 29 (13.5%) patients. The overall in-hospital mortality was 7.4%, 30-day mortality 5.6% (RC 9, myocardial infarction 1, conduit necrosis 1), and 90-day mortality a further 1.8% (multiple organ failure, ARDS). The incidence of RC correlates significantly with ASA score II and III (p = 0.0002) and Clavien-Dindo grade 4 and 5 in severe RC (p < 0.0001). Furthermore, hospital stay (p < 0.0001) and mortality (p < 0.0001) were significantly increased in RC. CONCLUSIONS: The results show a higher occurrence of RC in polymorbid patients and patients with severe complications according to the Clavien-Dindo classification. Adequate risk management including surgical technique and perioperative prophylaxis and therapy of RC should be studied and standardized.

Genetic analysis of subsequent second primary malignant neoplasms in long-term pancreatic cancer survivors suggests new potential hereditary genetic alterations.

BACKGROUND: The principal aim of this report was to study second primary malignant neoplasms (SMNs) in long-term survivors of pancreatic ductal adenocarcinoma (PDAC) with regard to the germline genetic background. PATIENTS AND METHODS: A total of 118 PDAC patients after a curative-intent surgery who were treated between 2006 and 2011 were analyzed. Of the 22 patients surviving for >5 years, six went on to develop SMNs. A genetic analysis of 219 hereditary cancer-predisposition and candidate genes was performed by targeted next-generation sequencing in germline DNA from 20 of these patients. RESULTS: Of all the radically resected PDAC patients, six patients went on to subsequently develop SMNs, which accounted for 27% of the long-term survivors. The median time to diagnosis of SMNs, which included two cases of rectal cancer, and one case each of prostate cancer, malignant melanoma, breast cancer, and urinary bladder cancer, was 52.5 months. At the time of analysis, none of these patients had died as a result of PDAC progression. We identified four carriers of germline pathogenic mutations in 20 analyzed long-term survivors. One carrier of the CHEK2 mutation was found among four analyzed patients who developed SMNs. Of the remaining 16 long-term PDAC survivors, 3 patients (19%) carried germline mutation(s) in the MLH1+ ATM, CHEK2, and RAD51D gene, respectively. CONCLUSION: This retrospective analysis indicates that SMNs in PDAC survivors are an important clinical problem and may be more common than has been acknowledged to be the case. In patients with good performance status, surgical therapy should be considered, as the SMNs often have a favorable prognosis.

Ruptured bronchial artery aneurysm: case report.

Bronchial artery aneurysm is a very rare condition. Its rupture can cause a life threatening hemorrhage. We report a case of a 50-year-old patient with a ruptured bronchial artery aneurysm who presented with epigastric pain. It is the first published case with such signs of a rupture of a bronchial artery aneurysm. CT scan confirmed the diagnosis. The patient was treated with endovascular embolization.