Systematic review of enhanced recovery after gastro-oesophageal cancer surgery.

INTRODUCTION: Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery. METHODS: A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria. RESULTS: From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes. In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies. CONCLUSIONS: The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.

PET-CT offers accurate assessment of tumour length in oesophageal malignancy.

INTRODUCTION: Radiotherapy is increasingly used for both curative and palliative treatment of oesophageal malignancy. Accurate treatment depends on determining tumour location and length. This study assessed the value of PET-CT versus other staging modalities in determining tumour length. MATERIALS AND METHODS: Oesophageal cancer patients who underwent staging with PET/CT and endoscopic ultrasound (EUS) in addition to their diagnostic upper GI endoscopy and subsequent surgical resection were assessed. PET/CT length was obtained retrospectively by using Hermes Hybrid Viewer™ with a 1-5 Standardised Uptake Value grey scale. An SUV of 5 was used as the cut off for determining length. Direct measurement by EUS and OGD were determined. RESULTS: 53 patients underwent PET-CT, EUS, OGD and surgical resection for oesophageal cancer. Overall the correlation between PET-CT and histopathological length was strongest (Pearson r=0.5977, 95% CI 0.390-0.747) versus EUS (Pearson R=0.5365, 95% CI 0.311-0.705) and OGD (Pearson r=0.1574, 95% CI -0.118 to 0.410). After excluding tumours with a significant chemotherapy response, PET-CT length correlated significantly with histopathological length (R=0.5651, p=0.0005). In comparison, the correlation between histological length and EUS (R=0.4637, p=0.0057) measurement was less significant and this did not correlate with OGD (R=-0.1084, p=0.5417). CONCLUSION: Tumour length estimated by PET-CT correlated most strongly with histopathological length of oesophageal malignancy and is the most accurate determinant of tumour length of all the staging modalities. This suggests a potential role for PET-CT in the planning of radiotherapy and resection, particularly when considering the practical limitations of EUS.

Sarcopenia is associated with toxicity in patients undergoing neo-adjuvant chemotherapy for oesophago-gastric cancer.

BACKGROUND: Patients with potentially curative oesophago-gastric cancer typically undergo neo-adjuvant chemotherapy prior to surgery. The majority of anti-cancer drugs have a narrow therapeutic index. The aim of this study was to determine if features of body composition, assessed using computed tomography (CT) scans, may be predictive of dose-limiting toxicity (DLT) in patients undergoing neo-adjuvant chemotherapy for oesophago-gastric cancer. The influence of sarcopenia and DLT on overall survival was also evaluated. METHODS: 89 Patients having potentially curative oesophago-gastric cancer surgery were studied. Patients studied had histologically confirmed oesophago-gastric cancer with no evidence of distant metastasis on pre-operative staging. CT scan was performed in all cases at diagnosis. DLT was defined as toxicity leading to postponement of treatment, a drug dose reduction or definitive interruption of drug administration. RESULTS: DLT occurred in 37 out of 89 patients (41.6%) undergoing chemotherapy. Sarcopenia (odds ratio, 2.95; 95% confidence interval, 1.23-7.09; p = 0.015) was associated with DLT on multivariate analysis. Median overall survival for patients who were sarcopenic was 569 days (IQ range: 357-1230 days) vs. 1013 days (IQ range: 496-1318 days) for patients who were not sarcopenic (p = 0.04). There was no significant difference in overall survival in patients who experienced DLT compared with those that did not (p = 0.665). CONCLUSIONS: Sarcopenia is a significant predictor of DLT in oesophago-gastric cancer patients undergoing neo-adjuvant chemotherapy. These results raise the potential for use of assessment of skeletal muscle mass using CT scans to predict toxicity and individualize chemotherapy dosing.

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages.

INTRODUCTION: The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes. METHODS: Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 - July 2009) and after (August 2009 - July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality. RESULTS: There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann-Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008-2009 to 6 (16.7%) in 2009-2010 (chi-squared test, p<0.0001). CONCLUSIONS: The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.

Brunner's gland hyperplasia at the ampulla of Vater.

Brunner's gland hyperplasia (BGH) is a diagnostic challenge where in the pathophysiology and natural history remain poorly understood. This Case Report describes BGH arising at the ampulla of Vater, causing abdominal pain and vomiting in a 46-year-old man. Owing to the inconclusive nature of imaging studies and suspicious intraoperative findings, a Whipple resection was performed without any complications. Histological analysis showed that the obstructing lesion was BGH, with no evidence of malignancy. This is only the second such case of its kind at the ampulla of Vater to be reported. In addition, we present the previously unreported endoscopic ultrasound findings. The subsequent literature review focuses on the pathophysiology, clinical presentation, diagnosis and management of BGH.

In situ endoluminal brushing: a safe technique for the diagnosis of catheter-related bloodstream infection.

We assessed the safety of the endoluminal brush technique for the in situ diagnosis of central-venous-catheter (CVC)-related bloodstream infection (CRBSI). The endoluminal brush was used to investigate patients with suspected CRBSI by sampling the CVC lumen to within 3-5 cm of the catheter tip (the brush was kinked to mark the length required). Quantitative peripheral blood cultures were taken 1 min pre-brushing and 1 min and 1h post-brushing. In addition, a 1 mL sample of through-catheter blood was aspirated immediately pre- and post-brushing, and aliquots were directly plated on to blood agar to determine the load of CVC-associated bacteria. After CVC removal, catheter tips were sent for culture using the Maki roll and modified Cleri flush techniques. Of 139 suspected cases, 61 (45%) had confirmed episodes of CRBSI. No patients experienced fever or rigors, or had evidence of embolic phenomena after CVC endoluminal brushing. There was no difference overall in pre-brushing and 1-min post-brushing peripheral blood bacterial counts (P < 0.702). Peripheral and CVC blood bacterial counts were significantly reduced 1h post-brushing (P < 0.03 and P < 0.001, respectively), possibly due to removal of endoluminal biomass. The endoluminal brush technique can be safely used to diagnose CRBSI without the need for CVC removal, provided that the brush is not allowed to protrude beyond the tip of the catheter.

Randomized clinical trials to determine the role of topical glyceryl trinitrate in peripheral intravenous nutrition.

BACKGROUND: The contribution of glyceryl trinitrate (GTN) to prevention of peripheral vein thrombophlebitis (PVT) during peripheral intravenous nutrition delivered by fine-bore midline intravenous catheter is unclear. The aim of this study was to establish its role. METHODS: Two consecutive randomized clinical trials were conducted. In trial 1 patients were randomized to receive standard peripheral intravenous nutrition containing heparin and hydrocortisone with or without the placement of a topical GTN patch (triple therapy or dual therapy). In trial 2 patients were randomized to receive standard peripheral intravenous nutrition with either dual therapy or topical GTN alone (monotherapy). RESULTS: Dual therapy was as effective as triple therapy in preventing PVT (incidence 10 of 37 versus 11 of 39 patients respectively). Dual therapy reduced the incidence and increased the time to onset of PVT compared with monotherapy (14 of 41 versus 22 of 35 patients respectively, P = 0.012; median 17.3 (95 per cent confidence interval (c.i.) 13.4 to 21.1) versus 8.9 (95 per cent c.i. 6.7 to 11.0) days, P = 0.007). CONCLUSION: Use of a topical GTN patch confers no benefit when peripheral intravenous nutrition is delivered via a fine-bore midline intravenous catheter.

Micropuncture cholecystectomy vs conventional laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: The aim of this study was to compare micropuncture laparoscopic cholecystectomy (MPLC), with three 3.3-mm cannulas and one 10-mm cannula with conventional laparoscopic cholecystectomy (CLC). METHODS: Patients were randomized to undergo either CLC or MPLC. The duration of each operative stage and the procedure were recorded. Interleukin-6 (IL-6), adrenocorticotropic hormone (ACTH), and vasopressin were sampled for 24 h. Visual analogue pain scores (VAPS) and analgesic consumption were recorded for 1 week. Pulmonary function and quality of life (EQ-5D) were monitored for 4 weeks. Statistical analysis was performed using the Mann-Whitney test or Fisher's exact test. Results are expressed as median (interquartile range). RESULTS: Forty-four patients entered the study, but four were excluded due to unsuspected choledocholithiasis (n = 3) or the need to reschedule surgery (n = 1). The groups were comparable in terms of age, duration of symptoms, and indications for surgery. Total operative time was similar (CLC, 63 [52-81] min vs MPLC 74 [58-95] min; p = 0.126). However, time to place the cannulas after skin incision (CLC, 5:42 [3:45-6:37] min vs MPLC, 7:38 [5:57-10:15] min; p = 0.015) and to clip the cystic duct after cholangiography (CLC, 1:05 [0:40-1:35] min vs MPLC, 3:45 [2:26-7:49] min; p <0.001) were significantly longer for MPLC. Six CLC patients and one MPLC patient required postoperative parenteral opiates (p = 0.04). Oral analgesic consumption was similar in both groups (p = 0.217). Median VAPS were lower at all time points for MPLC, but this finding was not significant (p = 0.431). There were no significant differences in postoperative stay, IL-6, ACTH or vasopressin responses, pulmonary function, or EQ-5D scores. CONCLUSIONS: The thinner instruments did not significantly increase the total duration of the procedure. MPLC reduced the use of parenteral analgesia postoperatively, which may prove beneficial for day case patients, but it did not have a significant impact on laboratory variables, lung function or quality of life.