A rare cause of tracheopleural fistula following minimally invasive oesophagectomy.

Totally minimally invasive oesophagectomy (TMIE) has been utilised to reduce respiratory and cardiac complications, offering favourable clinical and oncological outcomes. A 62-year-old male patient underwent two-stage TMIE for a Siewert type I tumour. During thoracoscopic oesophageal mobilisation and lymphadenectomy, a 10-mm bone-like mass was recognised and dissected along the subcarinal nodes, revealing a 2-3mm opening on the inferomedial aspect of the right main bronchus. The airway opening was repaired after conversion. This is the first report of an accessory cardiac bronchus encountered during oesophagectomy. Recognition of its characteristic position and features may result in early diagnosis and avoidance of a potentially lethal injury.

Primary adenocarcinoma of the esophagogastric junction, combined with an obscure hepatoid adenocarcinoma component, as discovered after the development of a metachronous liver metastasis.

BACKGROUND: Esophageal hepatoid adenocarcinomas (HACs) belong to alpha fetoprotein (AFP)-producing adenocarcinomas and are relatively sparse. CASE PRESENTATION: A 35-year-old man suffering from adenocarcinoma of the esophagogastric junction (EGJ), with negative preoperative studies for metastatic disease, underwent Ivor Lewis esophagectomy. The histologic examination demonstrated a poorly differentiated, IIA (T3N0M0) staged EGJ adenocarcinoma. The patient had been advised not to receive any adjuvant therapy, with the follow-up studies at six months being negative for recurrence. Eleven months postoperatively, he was diagnosed with a bulky mass in the liver's right lobe, accompanied by elevated AFP serum levels. The percutaneous biopsy revealed the presence of HAC, immunohistochemically positive for AFP. The surgical specimen was re-evaluated and was also found immunohistochemically positive for AFP, re-defining the tumor as combined adenocarcinoma and HAC of the EGJ. The patient received two sessions of transarterial chemoembolization (TACE) of the liver mass. However, following the 2nd TACE session, he developed signs of hepatic insufficiency and expired twenty days later. CONCLUSIONS: It is crucial to identify the presence of a HAC, as HAC seems to have an aggressive course, with limited therapeutic options as well as therapeutic response. HIPPOKRATIA 2020, 24(3): 138-142.

Sarcopenia does not affect postoperative complication rates in oesophageal cancer surgery: a systematic review and meta-analysis.

INTRODUCTION: The high morbidity and mortality rates after oesophagectomy indicate the need for rigorous patient selection and preoperative risk assessment. Although muscle mass depletion has been proposed as a potential prognostic factor for postoperative complications and decreased survival in gastrointestinal cancer patients, available data are conflicting. The purpose of the present meta-analysis is to determine whether sarcopenia predicts postoperative outcomes in patients undergoing oesophagectomy. METHODS: The databases MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on the effect of sarcopenia on postoperative outcomes following oesophageal cancer surgery. Outcomes included surgical complications, anastomotic leakage, respiratory complications, cardiovascular complications, postoperative infections, major complications and overall complications. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. FINDINGS: A total of eight studies involving 1488 patients diagnosed with oesophageal cancer and who underwent oesophagectomy were included in the meta-analysis. The presence of sarcopenia did not significantly increase the rate of surgical complications (odds ratio, OR, 0.86, 95% confidence interval, CI, 0.40-1.85), anastomotic leakage (OR 0.75, 95% CI 0.42-1.35), respiratory complications (OR 0.56, 95% CI 0.21-1.48), cardiovascular complications (OR 0.94, 95% CI 0.31-2.83), postoperative infection (OR 1.14, 95% CI 0.52-2.50), major complications (OR 0.81, 95% CI 0.23-2.82) or overall postoperative complications (OR 0.80, 95% 0.32-1.99). CONCLUSION: Sarcopenia does not seem to affect postoperative complication rates of patients undergoing oesophagectomy for oesophageal cancer. Future research should focus on determining whether prognosis differs according to muscle mass in this patient population.

Esophageal melanoma: a systematic review and exploratory recurrence and survival analysis.

Esophageal melanoma is a rare and poorly described malignancy. We sought to review all available data on the clinicopathological features, management options, and outcomes of patients with esophageal melanoma to guide clinicians working to treat these uncommon tumors. A systematic literature search of the PubMed, Embase, and Cochrane databases was performed. Exploratory recurrence and survival analyses were performed using previously-validated pooled Cox and logistic regression techniques for case reports and case series. Quality assessment of included studies was performed using the tools developed by the Joanna Briggs and the National Heart, Lung, and Blood Institutes. Fifty-nine studies were reviewed. A total of 93 patients with esophageal melanoma were identified. The mean patient age was 61.2 ± 10.6 years. Esophageal melanoma usually developed at the lower esophagus (48.4%). 90.3% of the patients were symptomatic at presentation, with dysphagia being the most common symptom (72%). Esophagectomy was performed in 91.4% of the patients. Postoperatively, 14 patients (15.1%) received adjuvant chemotherapy. Tumor recurrence was seen in 37 patients (39.8%). The median time to recurrence was 6 months. Disease-specific mortality was 43%. All-cause mortality was 46.1%. On multivariable Cox regression, older patient age (hazard ratio [HR] = 0.91, P = 0.008) and higher Melan-A expression (HR = 0.21; P = 0.029) were associated with a significantly lower risk of mortality. Higher S100 levels (HR = 37.4; P = 0.001) were predictive of poor survival. On logistic regression, large, ulcerated, lower esophageal tumors were significantly more likely to recur (P = 0.018, P = 0.013, and P = 0.027 respectively). Esophageal melanoma is a rare malignancy that tends to present with dysphagia. Most surgically-treated patients undergo esophagectomy. Large, ulcerated, lower esophageal lesions recur more frequently. Immunohistochemistry provides prognostic information regarding survival.

Meta-analysis of risk factors and complications associated with atrial fibrillation after oesophagectomy.

BACKGROUND: Oesophagectomy is associated with high morbidity and mortality rates. New-onset atrial fibrillation (AF) is a frequent complication following oesophagectomy. Several studies have explored whether new-onset AF is associated with adverse events after oesophagectomy. METHODS: This review was performed according to PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 25 November 2018. A meta-analysis was conducted with the use of random-effects modelling. The I2 statistic was used to assess for heterogeneity. RESULTS: In total, 53 studies including 9087 patients were eligible for analysis. The overall incidence of postoperative AF was 16·5 per cent. Coronary artery disease and hypertension were associated with AF, whereas diabetes, smoking and chronic obstructive pulmonary disease were not. Patients with AF had a significantly higher risk of overall postoperative adverse events than those without fibrillation (odds ratio (OR) 5·50, 95 per cent c.i. 3·51 to 8·30), including 30-day mortality (OR 2·49, 1·70 to 3·64), anastomotic leak (OR 2·65, 1·53 to 4·59) and pneumonia (OR 3·42, 2·39 to 4·90). CONCLUSION: Postoperative AF is frequently observed in patients undergoing oesophagectomy for cancer. It is associated with an increased risk of death and postoperative complications.

Gastric tube volvulus following an Ivor-Lewis esophagectomy.

Gastric tube conduit is the method of choice for restoring continuity of the digestive track after a partial or total esophagectomy. Redundant gastric conduit (i.e. an elongated, floppy conduit) is a rare cause of dysphagia in patients with long survival. Gastric tube volvulus is exceedingly rare with only three cases described in the literature. We present the diagnostic and therapeutic course of a 57-year-old man who presented to our department with gastric tube volvulus 32 months after an Ivor-Lewis esophagectomy. Diagnosis was made with computed tomography and volvulus was reduced endoscopically. To the best of our knowledge, this is only the fourth case of gastric tube volvulus described in the English literature. This rare situation might be a consequence of a redundant gastric tube. Endoscopic volvulus decompression was successful in our case.

Animal models in the research of abdominal aortic aneurysms development.

Abdominal aortic aneurysm (AAA) is a prevalent and potentially life threatening disease. Many animal models have been developed to simulate the natural history of the disease or test preclinical endovascular devices and surgical procedures. The aim of this review is to describe different methods of AAA induction in animal models and report on the effectiveness of the methods described in inducing an analogue of a human AAA. The PubMed database was searched for publications with titles containing the following terms "animal" or "animal model(s)" and keywords "research", "aneurysm(s)", "aorta", "pancreatic elastase", "Angiotensin", "AngII" "calcium chloride" or "CaCl(2)". Starting date for this search was set to 2004, since previously bibliography was already covered by the review of Daugherty and Cassis (2004). We focused on animal studies that reported a model of aneurysm development and progression. A number of different approaches of AAA induction in animal models has been developed, used and combined since the first report in the 1960's. Although specific methods are successful in AAA induction in animal models, it is necessary that these methods and their respective results are in line with the pathophysiology and the mechanisms involved in human AAA development. A researcher should know the advantages/disadvantages of each animal model and choose the appropriate model.

Single-Incision Laparoscopic Right Hemi-Colectomy: a Systematic Review.

As surgeons became more adept with laparoscopic colon surgery, other less invasive procedures, such as single-incision laparoscopic right hemi-colectomy (SIL-RH), have been applied. The objective of this study was to evaluate the safety of SIL-RH as well as its intraoperative and postoperative outcomes for right-sided colon diseases. A detailed search in PubMed for citations that included SIL-RH from 2000 to 2014 revealed 21 studies fulfilling the criteria of the present review. A total of 684 patients were analyzed. Of the patients, 50.2 % were men. Mean patient age was 64.8 years. Of the patients, 36.1 % had already undergone an abdominal operation before the performance of SIL-RH, while 69 % of the patients underwent SIL-RH for colon cancer. Relatively low rates of overall morbidity (15 %) and mortality (0.75 %) were reported in the included studies. Mean length of postoperative hospital stay (LOS) was 5.5 days. Bowel motility return had a mean value of 2.8 days. Mean number of harvested lymph nodes (LN) was 19.2 LN. All resection margins were tumor-free. SIL-RH was a safe alternative to multiport laparoscopic right hemi-colectomy (ML-RH) in terms of morbidity and mortality, postoperative gastrointestinal function recovery, LOS, as well as oncological radicalness.

Minimally invasive esophagectomy for esophageal cancer: techniques and outcomes.

Despite recent improvements in diagnosis, surgical treatment and neo-adjuvant therapy, patients with esophageal cancer have poor prognosis with overall 5-year survival rates of 5-15%.Esophagectomy is the standard treatment for resectable esophageal cancer, but only one third of patients are considered candidates for cure. Minimally invasive techniques have been attempted to improve the postoperative outcomes in such a surgical procedure with high postoperative morbidity and mortality. The purpose of this review is to analyze the minimally invasive esophagectomy (MIE) techniques in the early-stage esophageal carcinoma. MIE is still crowed with heterogeneous studies with several different techniques. MIE comparing to open esophagectomy procedures have less morbidity with less overall in-hospital incidence of pulmonary infections and shorter duration of ICU admission. In addition,MIE techniques preserve the quality of life better than the open procedures, with faster postoperative recovery.

Expression of tissue IGF 1, TGFbeta and EGFR in the sequential steps of intestinal adaptation in a rat model of short bowel syndrome.

BACKGROUND: The long-term morphological changes and the expression of tissue growth factors IGF 1, TGFbeta and EGFR in the gut mucosa, during the process of intestinal adaptation were examined. METHODS: Four groups of rats were used: a. Sham rats (n = 10) underwent bowel transection and reanastomosis, b. SBS rats underwent an 80% small bowel resection: group A rats (n = 10) were sacrificed 15 days after surgery, group B (n = 10), 30 days after surgery, and group C (n = 10), 60 days after surgery. Morphological small bowel parameters (villus height, lumen diameter and others) of adaptation were examined sequentially. Tissue samples were studied immunohistochemically for the detection of IGF 1, TGFbeta, and EGFR. RESULTS: There was a significant increase in all morphological parameters at day 15, in the intestinal samples; a further increase followed at day 30 and day 60 (p < 0.0001). Accordingly, an increase in the expression of IGF 1, TGFbeta and EGFR was noted at day 15 (p < 0.05), and at day 30 (NS). CONCLUSION: Intestinal adaptation is an ongoing process lasting more than 2 months after massive small bowel resection. Peptide growth factors are expressed in the intestine continuously during this period, but the first two weeks are the most critical for the mucosal growth.

[Sexual mutilations through ages]. / Les mutilations sexuelles à travers les âges.

Among the ethnic mutilations (volunteer mutilations performed for religious, aesthetic, moral or hygienic purposes), genital mutilation (circumcision, castration, total emasculation, infibulation, excision, etc.) have always fascinated the human mind and are the subject of our historical overview.

Gastric cancer and adjuvant chemoradiotherapy: when and where, that's the question.

PURPOSE: Although the incidence of gastric cancer is decreasing, there were still 159,900 new cases and 118,200 deaths in Europe in 2006 representing the 5th highest incidence and 4th highest cause of cancer-related deaths. Postoperative adjuvant chemoradiotherapy has been demonstrated to result in a significant improvement in overall and disease-free survival. We studied the current role of adjuvant chemoradiotherapy in gastric cancer. METHODS: Randomized phase III studies and selected phase II studies for adjuvant chemoradiotherapy in gastric cancer were searched in PUBMED using key words. Also, international treatment guidelines as well as review papers were searched and analysed. RESULTS: Based on the published literature, treatment guidelines and reports from international meetings it is obvious that adjuvant chemoradiotherapy in gastric cancer contributes in improved treatment results. CONCLUSION: Surgical resection remains the cornerstone of curative treatment for gastric cancer. The combination of modern radiotherapy techniques with chemotherapy is feasible, safe and improves overall survival of patients with gastric cancer.

Baron Dominique-Jean Larrey (1766-1842): founder of military surgery and trauma care.

Dominique-Jean Larrey was a distinguished surgeon in chief of Napoleon's army and a faithful servant of the Empire. His surgical skills and inventions, his absolute attachment and devotion to his profession, his humanitarian spirit and courage entitled him as one of history's greatest military surgeons.