Quality of Life and Late Complications After Minimally Invasive Compared to Open Esophagectomy: Results of a Randomized Trial.

BACKGROUND: The minimally invasive esophagectomy (MIE) is widely being implemented for esophageal cancer in order to reduce morbidity and improve quality of life. Non-randomized studies investigating the mid-term quality of life after MIE show conflicting results at 1-year follow-up. Therefore, the aim of this study is to determine whether MIE has a continuing better mid-term 1-year quality of life than open esophagectomy (OE) indicating both a faster recovery and less procedure-related symptoms. METHODS: A one-year follow-up analysis of the quality of life was conducted for patients participating in the randomized trial in which MIE was compared with OE. Late complications as symptomatic stenosis of anastomosis are also reported. RESULTS: Quality of life at 1 year was better in the MIE group than in the OE group for the physical component summary SF36 [50 (6; 48-53) versus 45 (9; 42-48) p .003]; global health C30 [79 (10; 76-83) versus 67 (21; 60-75) p .004]; and pain OES18 module [6 (9; 2-8) versus 16 (16; 10-22) p .001], respectively. Twenty six patients (44%) in the MIE and 22 patients (39%) in the OE group were diagnosed and treated for symptomatic stenosis of the anastomosis. CONCLUSIONS: This first randomized trial shows that MIE is associated with a better mid-term one-year quality of life compared to OE.

Immunological changes after minimally invasive or conventional esophageal resection for cancer: a randomized trial.

BACKGROUND: This study was performed as a substudy analysis of a randomized trial comparing conventional open esophagectomy [open surgical technique (OE)] by thoracotomy and laparotomy with minimally invasive esophagectomy [minimally invasive procedure (MIE)] by thoracoscopy and laparoscopy. This additional analysis focuses on the immunological changes and surgical stress response in these two randomized groups of a single center. METHODS: Patients with a resectable esophageal cancer were randomized to OE (n = 13) or MIE (n = 14). All patients received neoadjuvant chemoradiotherapy. The immunological response was measured by means of leukocyte counts, HLA-DR expression on monocytes, the acute-phase response by means of C-reactive protein (CRP), interleukin-6 (IL-6), and interleukin-8 (IL-8), and the stress response was measured by cortisol, growth hormone, and prolactin. All parameters were determined at baseline (preoperatively) and 24, 72, 96, and 168 h postoperatively. RESULTS: Significant differences between the two groups were seen in favor of the MIE group with regard to leukocyte counts, IL-8, and prolactin at 168 h (1 week) postoperatively. For HLA-DR expression, IL-6, and CRP levels, there were no significant differences between the two groups, although there was a clear rise in levels upon operation in both groups. CONCLUSION: In this substudy of a randomized trial comparing minimally invasive and conventional open esophagectomies for cancer, significantly better preserved leukocyte counts and IL-8 levels were observed in the MIE group compared to the open group. Both findings can be related to fewer respiratory infections found postoperatively in the MIE group. Moreover, significant differences in the prolactin levels at 168 h after surgery imply that the stress response is better preserved in the MIE group. These findings indicate that less surgical trauma could lead to better preserved acute-phase and stress responses and fewer clinical manifestations of respiratory infections.

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis. METHODS: The PubMed electronic database was used for comprehensive literature search by two independent reviewers. RESULTS: Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%. CONCLUSIONS: This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-analysis.

BACKGROUND: Cervical anastomosis and thoracic anastomosis are used for gastric tube reconstruction after esophagectomy for cancer. This systematic review was conducted in order to identify randomized trials that compare cervical with thoracic anastomosis. METHODS: A literature search for randomized trials was performed in the following databases: Medline, Embase and the Cochrane Library. RESULTS: A total of 4 trials were included. All studies had a small sample size and were of moderate quality. One trial was excluded from the meta-analysis. The following outcomes were significantly associated with a cervical anastomosis: recurrent laryngeal nerve trauma (OR: 7.14; 95% CI: 1.75-29.14; p = 0.006) and anastomotic leakage (OR: 3.43; 95% CI: 1.09-10.78; p = 0.03). None of the following outcomes were associated with the location of the anastomosis: pulmonary complications (OR: 0.86; 95% CI: 0.13-5.59; p = 0.87), perioperative mortality (OR: 1.24; 95% CI: 0.35-4.41; p = 0.74), benign stricture formation (OR: 0.79; 95% CI: 0.17-3.87; p = 0.79) or tumor recurrence (OR: 2.01; 95% CI: 0.68-5.91; p = 0.21). CONCLUSION: Cervical anastomosis could be associated with a higher leak rate and recurrent nerve trauma. However, the currently available randomized evidence is limited. Further randomized trials are needed to provide sufficient evidence for the preferred location of the anastomosis after esophagectomy.

[Oesophageal endoscopic ultrasound with fine-needle aspiration biopsy in the staging of non-small-cell lung carcinoma; results from 43 patients]. / Slokdarmendo-echografie met dunnenaaldaspiratie ter stadiëring bij niet-kleincellig longcarcinoom; resultaten bij 43 patiënten.

OBJECTIVE: To calculate the number of cervical mediastinoscopies that need not be carried out ifoesophageal endoscopic ultrasound and fine-needle aspiration biopsy (EUS-FNA) are included in the staging of patients with non-small-cell lung carcinoma (NSCLC). DESIGN: Retrospective, descriptive. METHOD: Patients referred to the St. Antonius Hospital in Nieuwegein, the Netherlands, with NSCLC from January to December 2003 routinely underwent EUS-FNA during the staging process. If mediastinal or distant metastases were found to be present then cervical mediastinoscopy was not carried out as the patient was not eligible for operation. If no metastases were demonstrated then cervical mediastinoscopy was carried out. The value of EUS-FNA was calculated. RESULTS: A total of 43 patients underwent EUS-FNA: 32 men and 11 women with an average age of 64 (range: 45-77). In 22 (51%) of them, cervical mediastinoscopy was not performed as EUS-FNA demonstrated malignant cells in the lymph nodes of the mediastinum or abdomen, in the left adrenal gland or in the primary tumour which had grown into the mediastinum. In 2 of the 21 other patients malignant cells were found on mediastinoscopy showing the EUS-FNA results in 2 of 43 patients (5%) to be false-negative. No complications occurred. CONCLUSION: Based on the findings from EUS-FNA, cervical mediastinoscopy was not performed in 51% of the patient group.

Lung function changes and pulmonary complications in patients with stage III non-small cell lung cancer treated with gemcitabine/cisplatin as part of combined modality treatment.

INTRODUCTION: Lung cancer is the leading cause of cancer mortality. Chemotherapy, ideally a platinum-based regimen as part of combined modality treatment, is appropriate for selected patients with locally advanced stage III non-small cell lung cancer (NSCLC) who have a good performance status. However, chemotherapy can induce side effects including lung function changes. AIM OF THE STUDY: Retrospective analysis of lung function changes in 44 patients with stage III NSCLC treated with neoadjuvant chemotherapy (NCT) followed by surgery and/or radiotherapy. PATIENTS AND METHODS: NCT consisted of three cycles of gemcitabine/cisplatin. The following data were analysed: age, sex, the presence of chronic obstructive pulmonary disease (COPD), smoking behaviour, response, complications after surgery and/or radiotherapy, and VC, FEV(1), DL(co) and K(co) before and after chemotherapy. DL(co) values were corrected for haemoglobin concentrations. RESULTS: We found a significant decline of K(co) (-13.5% of pred; 95% CI: -16.6 to -10.4; P<0.0001), independent of tumor response or presence and severity of COPD. FEV(1) and FEV(1)/VC showed significant increases irrespective of tumor response. Significantly more pulmonary complications were recorded in the radiotherapy group after NCT (P=0.009) compared to patients who underwent surgical therapy after NCT. CONCLUSIONS: Patients diagnosed with NSCLC stadium III who were treated with NCT consisting of cisplatin and gemcitabine showed a significant decline of DL(co) and K(co), irrespective of tumor response, presence and severity of COPD, sex and number of cycles of chemotherapy. Significantly more pulmonary complications were seen in patients treated with NCT and radiotherapy compared with patients treated with NCT and surgery. Questions concering the pathophysiological mechanisms of lung function changes and long term follow-up of pulmonary toxicity due to NCT remain still unanswered and have to be subject of future studies.

Major clinical events, signs and severity assessment scores related to actual survival in patients who died from primary biliary cirrhosis. A long-term historical cohort study.

BACKGROUND/AIMS: One of the prognostic methods for survival in primary biliary cirrhosis (PBC) is the Mayo model, with a time-scale limited to 7 years. The aim of our study was to assess how major clinical events, signs, several severity assessment methods and Mayo survival probabilities fit in with actual patient survival, by using yearly observations until 0.5 years before patient death from PBC. METHODOLOGY: Data of 32 patients dying from PBC were collected prior to death at -0.5, -1, -2 etc. years (median: -5 years, range: -16 to -0.5 years). Major events registered were: first occurrence of ascites, upper gastrointestinal bleeding or manifest hepatic encephalopathy and signs, first observation of spider naevi or purpura. Severity assessment methods applied (all with scores and classes) were: Mayo (M), Child-Campbell (C), Pugh-Child (P), Pugh-Child-PBC (PP), 'Child-Pugh' (CP), and Ascites Nutritional State-Child (ANS). Fifty percent survival estimates were calculated from Mayo scores. Severity assessment method variables were: ascites (C, P, PP, CP, ANS), encephalopathy (C, P, PP, CP), nutritional state (C, ANS), edema (M), age (M), serum albumin (M, C, P, PP, CP), bilirubin (C, M, P, PP, CP), and prothrombin time (M, P, PP, CP). RESULTS: In 27 out of 32 patients a major event occurred, always between -6 and -0.5 years (median: -1 year) and, never between -16 and -7 years (p < 0.0001). A sign was first observed in 30/32 between -14 and -0.5 years (median: -2 years). Compared to the total population, a sign, and even more so, an event indicated a shorter survival (p = 0.004 and p = 0.0002, respectively). The median 50% estimated survival (predicted by the Mayo model) fitted the actual survival from -6 to -0.5 years (r = -0.7, p < 0.0001), but not from -16 to -7 years (r = -0.1, p = 0.4). All -6 to -0.5-year severity scores correlated (p < 0.0001) both with actual survival (M, C, P, PP, and CP r = 0.7; ANS r = 0.5) and with estimated M 50% survival (C, P, PP, CP r = -0.9; ANS r = -0.6; M score: -0.99), but none with actual survival from -16 to -7 years, except for M, slightly (r = -0.3, p = 0.04). A nomogram for mean C, CP, M and ANS scores related to actual survival was constructed for the -6 to -0.5-year period. The C and CP classes A, B, and C did not appear to distinguish sufficiently into actual survival, whereas the M classes did. CONCLUSIONS: The occurrence of a major event appeared to exclude survival over 6 years. In these final 6 years, Child-Campbell, Mayo and Pugh scores correlated equally well with actual survival and better than Ascites/Nutritional State score. In our PBC patients, Campbell was an excellent alternative for Pugh; for Pugh, the original Child-Turcotte variable limits were fully sufficient.

Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis.

UNLABELLED: In this study, we describe the importance of the whole-body bone scan in diagnosing the multifocality of chronic recurrent multifocal osteomyelitis (CRMO) and in distinguishing it from unifocal acute hematogenous osteomyelitis. MATERIALS: The medical records and two-phase, whole-body bone scans of 14 patients (mean age 10.5 yr) with the diagnosis of CRMO, were retrospectively reviewed. The diagnosis of CRMO was based on bone biopsy in 9 patients and clinical course/laboratory findings in 5. Bone scans were evaluated for geographic and anatomic locations of their lesions. Correlative radiographs of areas of abnormal uptake were performed to assess the radiographic appearance of the lesions. RESULTS: The presentation of the disease was localized to one painful, tender and swollen periarticular site 86% of the time. The number of lesions detected by bone scan varied from 1-18 (mean 6). Most lesions were metaphyseal, proximal or distal tibial lesions. Purely sclerotic or mixed (sclerosis and lysis) lesions were found on radiographs. Bilateral lesions were seen in 64% of patients. Biopsies were negative for organisms in all patients and exhibited subacute or chronic histologic changes in most instances. Complications of chronic hyperemia included marked overgrowth (5), diffuse demineralization (1), angular deformity (1) and length discrepancy (1). CONCLUSION: The identification of the multifocal configuration of the disease process by two-phase (soft-tissue and delayed) whole-body bone scintigraphy results in appropriate diagnosis and therapy of CRMO. Additional sites for possible bone biopsy become apparent for exclusion of other diagnoses. Supportive (nonsteroidal, anti-inflammatory medication) instead of antimicrobial therapy can be initiated with significant cost savings.

Detection of talocalcaneal coalitions by magnification bone scintigraphy.

Fibrocartilaginous talocalcaneal coalitions are very difficult to identify on plain radiography in symptomatic children and adolescents before gross ossification occurs. Computed tomography (CT) has been successful in identifying osseous and some fibro-osseous coalitions. In this series, magnification imaging of the tarsus on bone scintigraphy in the medial-lateral projection correctly identified talocalcaneal coalitions, seven of the nine bars were fibrous or fibro-osseous. Three of the fibrous lesions were equivocal or normal on conventional radiography and CT. Physiologic accumulations of activity in the growing hind foot are also presented from a control pediatric population. Magnification scintigraphy of the hind foot is offered as an adjunct to plain radiography and CT in the diagnosis of elusive nonosseous subtalar bars.