Cytokine Response in the Pleural Fluid and Blood in Minimally Invasive and Open Esophagectomy.

BACKGROUND: Transthoracic esophagectomy for cancer triggers a massive inflammatory reaction. The data whether a minimally invasive esophagectomy (MIE) leads to less pronounced inflammatory response compared to open right-sided transthoracic esophagectomy (OE) are scarce. The aim of this study was to evaluate the extent of the inflammatory reaction, represented by levels of the pro-inflammatory interleukins IL-6 and IL-8, the anti-inflammatory IL-1 RA and the chemokines CINC-1 and MCP-1 in the right pleural fluid and the blood from patients undergoing standard OE or MIE. METHODS: Pleural drainage fluid and blood was collected at five different time points during the first 72 h following surgery, and the concentrations of IL-6, IL-8, IL-1 RA, CINC-1 and MCP-1 were analyzed using enzyme-linked immune-sorbent assays in 24 patients undergoing MIE or OE. RESULTS: The groups were matched for cancer stage and comorbidities. Pro- and anti-inflammatory mediator levels in the pleural fluid were markedly increased at the end of surgery and on postoperative days 1-3. The pleural inflammatory response of all cyto- and chemokines was lower in the MIE group, reaching significance at some time points. Cyto- and chemokine response levels measured in the blood were overall lower compared to those in the pleural fluid. The chemokines CINC-1 and MCP-1 reacted less pronounced or not at all. Preoperative pulmonary comorbidity, postoperative pulmonary morbidity and length of surgery were associated with an increased reaction in selected mediators. CONCLUSIONS: The minimally invasive technique attenuates the inflammatory response, especially locally in the thoracic compartment. Length of procedure, preoperative pulmonary comorbidity and postoperative pulmonary complications are mirrored in an increase in individual inflammatory markers in the pleural fluid. The value of the chemokines CINC-1 and MCP-1 as markers of inflammation in the setting of esophagectomy is unclear.

Results of directly applied activated carbon cloth in chronic wounds: a preliminary study.

OBJECTIVE: Activated carbon (AC) has been used in wound therapy as an active substance inside dressings. Applying AC directly on a wound is a new concept. The aim of this study was to analyse the outcomes of chronic wounds which were managed with directly applied activated carbon knitted cloth (ACC, Zorflex) in Swiss patients. METHOD: A retrospective analysis of the records of all patients with chronic wounds treated with ACC between 1 October 2013 and 31 December 2015 in an outpatient wound clinic. Chronic was defined as a wound being present for >3 weeks. Malignant wounds were excluded. The main outcome was the time to complete closure or readiness for spilt-thickness skin grafting (STSG). Descriptive data, including nutritional status and angiology results were obtained. RESULTS: There were 36 women and 34 men, median age 68 years old. The median body mass index (BMI) 28.1kg/m2 and 76% (n=53) of patients had comorbidities. Angiology exam results showed signs of reduced arterial perfusion in 13% (n=9) of patients and malnutrition in 11% (n=8). Of the wounds included 34% (n=24) were on the trunk and 66% (n=46) on the extremities. The median wound size was 6.9cm2 (range: 0.1-300cm2). The wounds on the trunk were larger than wounds on extremities (10 versus 2cm2). Overall, median time to wound closure was 51 days. In 94% (n=66) of patients, wounds closed without further intervention and 6% (n=4) underwent STSG. Patients with comorbidities showed longer wound healing times compared with those without. No adverse events such as allergies or skin irritation occurred. Cost analysis, including personnel and material and stratified according known wound closure times, showed ACC (US$ 1252) to be like hydrocolloids (US$ 1128), but substantially lower than white gauze (US$ 3026) and negative pressure wound therapy (NPWT) (US$ 2578). CONCLUSION: ACC applied directly on chronic wounds of different aetiology is safe with short closure times. The cost efficiency is high. It combines the positive features of other wound dressings, such as hydrocolloids and NPWT, without their disadvantages. The dressing change of ACC is easy and non-specialised nurses or even patients themselves can be taught to perform it.

A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study.

BACKGROUND: Parastomal hernias (PSH) are one of the most frequent complications of enterostomies with a non-negligible complication rate and a significant socioeconomic effect. Therefore, preventing PSH by placing a mesh at the time of primary surgery has been advocated. The aim of our study was to evaluate the safety and feasibility of the new stomaplasty ring [Koring™, (Koring GmbH, Basel, Switzerland)] and investigate the reason why surgeons are reluctant to take preventive measures. METHODS: A multicenter observational study was conducted on 30 patients between December 2013 and January 2015. In permanent end colostomies and end ileostomies, the Koring™ was implanted. The primary outcome was the 30-day morbidity (infection and other stoma-related complications). Secondary endpoints were the technical feasibility and the time needed to fix the ring. In addition, an online survey of 107 surgeons was performed. RESULTS: Twenty-seven patients received permanent end colostomies, and three received end ileostomies. No stoma-related complication was detected within the first 30 days post-operatively. The Koring™ ring was evaluated by the surgeons as easy and very easy to implant in more than half of the patients. Average additional operating time for ring implantation was 19 min. CONCLUSIONS: Koring™ implantation at the time of creating the stoma is safe, easy and only adds minimally operating time. A long-term follow-up as well as a randomized controlled study is needed to evaluate the impact of the Koring™ on PSH prevention. The ease and rapidity with which Koring™ can be implanted may help surgeons to overcome their apprehension of using a preventative device.

Influence of type of mesh fixation in endoscopic totally extraperitoneal hernia repair (TEP) on long-term quality of life.

INTRODUCTION: Laparoscopic total extraperitoneal mesh repair (TEP) of inguinal hernia has become well accepted with low recurrence and high patient satisfaction rates. However, inguinal pain has also been reported. Source of this pain has been suggested to be the fixation method, especially the use of tacks. Introduction of fibrin glue and absorbable tacks were suggested to lower chronic pain and inguinal discomfort rates. This study analyses the different methods of fixation. PATIENTS AND METHODS: 201 patients were analysed. Primary end-points were patients' satisfaction, health-related quality of life, and specific inguinal conditions (e.g. pulling, swelling, troubles at coughing). Secondary endpoints were duration of operation, length of hospital stay, and material costs. RESULTS: Fibrin glue was used in 101 patients and tacks in 100 patients, in 21 of those absorbable tacks. Patients were fully satisfied with the results in more than 90%, irrespective of the fixation method. Health-related quality of life along the SF-12(®) questionnaire attested no differences. Inguinal pulling occurred significantly more often after fibrin glue (25.7 %) than after tack fixation (11 %; p = 0.026), whereas no differences in the other specific inguinal sensations occurred. CONCLUSION: Mesh fixation in TEP can be performed either by tacks or by fibrin glue with similar long-term results concerning satisfaction, health-related quality of life, and pain. No advantage of fibrin glue could be found, in fact, a higher percentage of patients had inguinal pulling and burning sensations after the use of fibrin glue. The use of absorbable tacks showed no advantage.

Unusual total knee immobilization in an elderly patient due to inferior patella dislocation: Case report and review of the literature.

Inferior dislocation of the patella is a rare cause of a blocked knee and occurs typically in elderly patients. In most cases the mechanism is an osteophyte on the superior pole of the patella that becomes entrapped into the femoral trochlea, keeping the patella horizontally rotated and inferior localized. Advanced age and osteoarthritic changes of the knee are the main risk factors. Reduction should be performed under general anesthesia. We describe a case of an elderly lady with a type II inferior patella dislocation after direct blunt trauma. The therapy entailed reduction, knee arthroscopy, arthroscopic resection of osteophytes and smoothening of the articular surface. No recurrence occurred and range of motion was satisfactory at time of follow-up.

Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis.

OBJECTIVE: Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model. METHOD: Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score. RESULTS: Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients. CONCLUSION: The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.

Population-based trend analysis of laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease.

BACKGROUND: The Nissen and Toupet fundoplications are the most commonly used techniques for surgical treatment of gastroesophageal reflux disease. To date, no population-based trend analysis has been reported examining the choice of procedure and short-term outcomes. This study was designed to analyze trends in the use of Nissen versus Toupet fundoplications, and corresponding short-term outcomes during a 10-year period between 1995 and 2004. METHODS: A trend analysis was performed of 873 patients (Toupet: 254 patients, Nissen: 619 patients) prospectively enrolled in the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery. RESULTS: The frequency of the performed techniques remained stable during the observation period (p value for trend 0.206). The average postoperative and total length of hospital stay both significantly decreased during the 10-year period from 5.6 to 4.0 days and 6.8 to 4.8 days, respectively (both p values for trend <0.001). The average duration of surgery decreased significantly from 141 minutes to 121 minutes (p value for trend <0.001). There was a trend towards less complications in later years (2000-2004) compared to early years (1995-1999, p = 0.058). Conversion rates were significantly lower in later years compared with early years (p = 0.004). CONCLUSIONS: This is the first trend analysis in the literature reporting clinical outcomes of 873 prospectively enrolled patients undergoing Nissen and Toupet fundoplications during a 10-year period. The proportion of laparoscopic Nissen versus Toupet fundoplications remained stable over time, indicating that literature reports of the advantages of one procedure over the other had minimal influence on surgeons' choice of technique. Length of hospital stay, duration of surgery, morbidity, and conversion rate decreased over time, reflecting the learning curve. Clearly, patient outcomes have much improved during the 10-year observation period.

Evaluation of critical incidents in general surgery.

BACKGROUND: The analysis of adverse events is a central step in critical incident reporting, but has not been described in a surgical setting. The aim of this study was to develop an evaluation protocol and assess its feasibility. METHODS: All incidents were analysed by a multidisciplinary team. A coding system based on three published theories was used to assess all incidents and their underlying causes. A risk analysis was also conducted. RESULTS: Between July 2004 and December 2005, 9785 inpatients were treated and 139 critical incidents reported. Classification of active errors revealed 47.7 per cent to be execution failures and 45.9 per cent knowledge-based errors. The distribution of medical errors was 12.9 per cent diagnostic, 46.0 per cent treatment, 17.3 per cent preventive and 23.7 per cent other. Some 282 latent failures were identified among the 139 incidents. Risk analysis revealed a severe incident rate of 21.6 per cent. CONCLUSION: This study has shown the feasibility of an evaluation protocol based on a combination of three classification systems and a risk analysis. It allows a thorough assessment of critical incidents, identification of priorities and tailored countermeasures.

Randomized controlled trial investigating the effect of music on the virtual reality laparoscopic learning performance of novice surgeons.

BACKGROUND: Findings have shown that music affects cognitive performance, but little is known about its influence on surgical performance. The hypothesis of this randomized controlled trial was that arousing (activating) music has a beneficial effect on the surgical performance of novice surgeons in the setting of a laparoscopic virtual reality task. METHODS: For this study, 45 junior surgeons with no previous laparoscopic experience were randomly assigned to three equal groups. Group 1 listened to activating music; group 2 listened to deactivating music; and group 3 had no music (control) while each participant solved a surgical task five times on a virtual laparoscopic simulator. The assessed global task score, the total task time, the instrument travel distances, and the surgeons' heart rate were assessed. RESULTS: All surgical performance parameters improved significantly with experience (task repetition). The global score showed a trend for a between-groups difference, suggesting that the group listening to activating music had the worst performance. This observation was supported by a significant between-groups difference for the first trial but not subsequent trials (activating music, 35 points; deactivating music, 66 points; no music, 91 points; p = 0.002). The global score (p = 0.056) and total task time (p = 0.065) showed a trend toward improvement when participants considered the music pleasant rather than unpleasant. CONCLUSIONS: Music in the operating theater may have a distracting effect on novice surgeons performing new tasks. Surgical trainers should consider categorically switching off music during teaching procedures.

[Complex fracture of the proximal humerus in the elderly. Locking plate osteosynthesis vs hemiarthroplasty]. / Komplexe proximale Humerusfraktur beim alten Menschen. Winkelstabile Plattenosteosynthese vs. Hemiarthroplastik.

BACKGROUND: The purpose of the present study was a direct comparison of fixed-angle plate fixation (FAPF) and shoulder hemiarthroplasty (SHA) for complex fractures of the proximal humerus in the elderly. PATIENTS AND METHODS: A single-institution case series of 52 consecutive geriatric patients (age > or =70 years) treated with FAPF for three- and four-part fractures of the proximal humerus between 2003 and 2005 was analysed 1 year after surgery. The analysis included Constant Score (CS), Oxford Shoulder Score (OSS), and radiological evaluation. Outcome was compared with a similar historic group of patients (n=59) who received SHA in an earlier period (1995--1997). RESULTS: The patient groups showed no differences in age, gender, or fracture type. Median CS was significantly better for FAPF (71 vs 41). Evaluation of pain demonstrated no differences between the two treatment modalities in the OSS. Revision surgery was performed more often in the FAPF group (25% vs 2%). CONCLUSION: Compared to SHA, functional outcome was superior with FAPF. However, this was associated with a higher rate of revision surgery. Most patients were still able to live independently in their original environment, regardless of the type of surgery.

Early in vivo experience with the Hemodynamic Plus St. Jude Medical heart valves in patients with narrowed aortic annulus.

BACKGROUND: Small aortic orifice primarily resulted in heart prosthesis mismatch in a significant number of patients. The Hemodynamic Plus (HP) series of St. Jude Medical heart valves represents an interesting innovation, allowing a larger valve orifice area with an equivalent tissue annulus diameter. METHODS: Hemodynamic characteristics of the 21-mm HP St. Jude Medical valve were prospectively compared with those of the standard 21-mm and 23-mm St. Jude Medical valves in three groups of 22 patients. Patients were selected from a database to be rigorously matched for age, sex, body surface area, functional class, underlying lesion, native valve opening area, left ventricular function, and preoperative peak and mean valve gradients. Postoperative evaluation (follow-up ranging from 3 to 24 months; mean, 11.5 months) included clinical examination and echocardiographic studies. RESULTS: There was no operative mortality or significant perioperative complications. Short-term clinical follow-up was marked by a complete absence of valve-related complications. Presently, all but 1 patient in the 21-mm HP group and 2 in the 21-mm standard group are in New York Heart Association functional class I. Doppler echocardiography-derived mean and maximal pressure gradients were significantly lower in the 21-mm HP group (8.1 +/- 1.9 and 16.4 +/- 3.4 mm Hg) than in the 21-mm standard group (13.4 +/- 3.9 and 21.2 +/- 4.3 mm Hg; p = 0.002 and p = 0.0004, respectively), confirming the better hemodynamic performance already described in in vitro studies. Pressure gradients did not differ significantly between the 21-mm HP and the 23-mm standard groups. The 21-mm HP valve demonstrated the highest performance index; 0.66 +/- 0.08, compared with 0.49 +/- 0.09 for the 21-mm standard valve (p < 0.001) and 0.59 +/- 0.07 for the 23-mm standard valve (p < 0.001). CONCLUSIONS: In vivo hemodynamic performance of the 21-mm HP valve corresponds closely to that of the 23-mm standard valve and is substantially better than that of the 21-mm standard valve. The 21-mm HP St. Jude Medical valve demonstrates excellent hemodynamic characteristics and can be recommended in normal-sized adult patients with narrow aortic root. This valve will minimize the need for aortic annulus enlargement.

Early experience with the new Masters series of St. Jude Medical heart valve: in vivo hemodynamic and clinical results in patients with narrowed aortic annulus.

BACKGROUND AND AIMS OF THE STUDY: Aortic valve replacement in the small aortic root results in a heart-prosthesis mismatch in a significant number of patients. The new Masters series of St. Jude Medical (SJM) valves represents the company's most recent innovation, combining the beneficial Hemodynamic Plus (HP) characteristics with rotatability. Thus, this valve allows for a larger valve orifice area with an equivalent tissue annulus diameter and reduces the potential interferences of subannular tissue with leaflet mobility. METHODS: We compared prospectively the hemodynamic characteristics and the early clinical results in four groups of 25 patients each who received either the 21 Masters-HP, the 21 Standard, the 21 HP or the 23 Standard SJM valves. Patients were selected from our database and matched rigorously for age, gender, body surface area, NYHA functional class, underlying lesion, native valve opening area and left ventricular function, as well as preoperative peak and mean valve gradients. Postoperative evaluation included clinical examination and echocardiographic studies before hospital discharge and at six months. RESULTS: Short-term clinical follow up was marked by a complete absence of valve-related complications in all groups. Doppler-derived mean and maximal pressure gradients were significantly lower in the 21 HP (8.7 +/- 3.1 mmHg and 15.1 +/- 4.0 mmHg, respectively) and 21 Masters-HP groups (8.9 +/- 2.6 mm +/- Hg and 14.5 +/- 3.8 mmHg) than those in the 21 Standard group (15.1 +/- 3.2 mmHg and 22.5 +/- 6.1 mmHg; p = 0.002 and p = 0.004, respectively). These results confirm that the superior hemodynamic performance of the HP series is maintained in the Masters-HP valve, despite the introduction of a new cuff design allowing rotatability. Pressure gradients did not differ significantly between the 21 HP, the 21 Masters-HP and the 23 Standard groups. CONCLUSIONS: The hemodynamic performance of the 21 Masters-HP SJM valve corresponds closely with that of the 21 HP and 23 Standard valves and is substantially better than that of the 21 Standard valve. The Masters-HP valve will continue to reduce cardiac-prosthesis mismatch in normal-sized patients with a narrowed aortic root; its performance index is equal to that of the 21 HP valve and significantly higher than that of the 21 Standard valves. The valve will also further reduce the need for aortic annulus enlargement.

[Perforation of Meckel's diverticulum by a toothpick]. / Zahnstocherperforation eines Meckel-Divertikels.

We report the case of a 31-year-old man with lower abdominal pain, leucocytosis and normal sonographic findings. When performing laparoscopy we found a Meckel's diverticulum perforated by a toothpick. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Symptoms normally occur only when there are complications, when bleeding, obstruction and inflammation are most frequent. Despite modern imaging techniques the diagnosis is difficult and often made intraoperatively. Resection should be performed in any case, because the risk of future complications of the diverticulum outweigh the morbidity after simple diverticulectomy.

Influence of additional resection of the gastric fundus on excessive weight loss in laparoscopic very very long limb Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. The effect of the procedure is based on restriction, malabsorption and changes in hormonal axis. Ghrelin is an important appetite hormone which is produced mainly in the gastric fundus. By adding a resection of the gastric fundus, we hypothesized that excessive weight loss will be more prominent and the satiety feelings less pronounced compared to standard RYGB. A total of 73 patients with standard very very long limb (VVLL) RYGB (group A) were compared with 44 patients with VVLL RYGB with resection of the fundus (group B). Outcome measures were excessive weight loss (EWL), body mass index (BMI), early postoperative morbidity, change of co-morbidities, and appetite reduction as assessed by an appetite questionnaire over a postoperative period of 24 months. Groups were comparable in basic preoperative descriptions. Additional fundus resection did not influence EWL (group A 66.1 % vs. group B 70.6 %, p = 0.383) or BMI (group A 29 kg/m(2) vs. group B 27 kg/m(2), p = 0.199). No significant difference in morbidity or change of co-morbidities occurred. The appetite and satiety questionnaire showed no difference between group A and group B, respectively. Adding a resection of the gastric fundus in RYGB did not alter the clinical results, i.e., increased excessive weight loss, decrease of appetite, or increase of satiety. The value of removing a part of the ghrelin-producing cells might be overestimated.

Tumour-infiltrating lymphocytes and survival in patients with adenocarcinoma of the oesophagus.

INTRODUCTION: Tumor-infiltrating lymphocytes (TILs) and forkhead box transcription factor positive (FoxP3(+)) regulatory T-lymphocytes (TREGs) have been analyzed in a variety of tumors but not in oesophageal adenocarcinoma. PATIENTS AND METHODS: Tissue from 130 adenocarcinomas of the oesophagus was re-evaluated in the centre and periphery of tumour, respectively, using immunohistochemical staining with anti-CD3, anti-CD4, anti-CD8, anti-CD25 and anti-FoxP3 antibodies. Patients were stratified according neoadjuvant treatment. 106 patients proceeded directly to surgery and 24 underwent pre-operative radio-chemotherapy (RCT). RESULTS: In patients without RCT, TILs were found significantly more frequently in the periphery with the exception of CD25(+) cells. Patients with centrally low counts of FoxP3(+) TREGs had higher tumour stages than patients with high counts (p < 0.011). The number of FoxP3(+) TREGs was significantly associated with the number of CD8(+) cells (centre: p < 0.001, periphery: p = 0.002). The multivariate regression analysis identified UICC stage (IIB/III vs. I/IIA, hazard ratio 2.6, p = 0.011) and completeness of resection (no vs. yes, hazard ratio 2.3, p = 0.015) as independent predictors of survival. RCT significantly reduced the number of TREGs in the centre (p = 0.016) but not the number of the other TILs. CONCLUSION: UICC stage and completeness of resection but none of the TILs were prognostic markers for long-term survival. We found no morphologic evidence that TREGs suppress immunological response, represented by the infiltration of CD8(+) cells. Preoperative RCT affected the centre of tumours more than the periphery, which may indicate that it does not inhibit the host-to-tumour reaction. RCT affects TREGs more than the other TILs.

Prognostic influence of immunohistochemically detected lymph node micrometastasis and histological subtype in pN0 oesophageal cancer.

INTRODUCTION: Differences in frequency and clinical impact of lymph node micrometastasis between histological subtypes of oesophageal cancer have not been determined. METHODS: 1204 lymph nodes from 32 squamous cell carcinomas and 54 adenocarcinomas with complete resection and pN0 status were re-evaluated using a serial sectioning protocol including immunohistochemistry. Intra-nodal tumour cells were classified as micrometastases (0.2-2 mm) or isolated tumour cells (<0.2 mm). RESULTS: There was no significant difference in the frequency of micrometastases between adenocarcinoma and squamous cell carcinoma (11.3% vs. 3.1%, p=n.s.). In the squamous cell carcinoma group, Kaplan-Meier curves showed a significantly prolonged 5-year survival (p=0.02) and disease free interval (p<0.01) for immunohistochemically node negative versus node positive patients. In patients with adenocarcinoma, no such difference (p=n.s. and p=n.s., respectively) was seen. In patients who did not undergo pre-treatment, those with adenocarcinoma had a significant 5-year survival (65% vs. 53%; p=0.03) and disease free interval (83% vs. 58%; p<0.05) advantage over those with squamous cell carcinoma. After pre-treatment, no difference between the histological subtypes was detected. Regression analysis did not reveal any factors that significantly affected overall survival in node negative patients. However, four factors did significantly influence disease free interval: pre-treatment (HR 3.3 [95% CI 1.2-9.1], p=0.02); micrometastasis (HR 5.3 [95% CI 1.4-19.7], p=0.01); UICC stage II vs. 0/I (HR 2.2 [95% CI 1.1-4.4], p=0.03); and adenocarcinoma (HR 0.3 [95% CI 0.1-0.9], p=0.03). CONCLUSION: The difference in frequency and clinical impact of immunohistochemically detected micrometastasis may indicate that adenocarcinoma and squamous cell carcinoma should not be treated as one entity.

Influence of neoadjuvant radio-chemotherapy on tumor-infiltrating lymphocytes in squamous esophageal cancer.

INTRODUCTION: Data on influence of radio-chemotherapy (RCT) on tumor-infiltrating lymphocytes (TILs) is scarce and no study addressed this issue in esophageal squamous cell cancer (SCC) so far. METHODS: Tumor specimens of 49 patients with SCC were re-evaluated with immunohistochemical staining with anti-CD3, anti-CD4, anti-CD8, anti-CD25 and anti-FOXP3 antibodies. Lymphocytes were counted in one high power field (0.189 mm(2)) at the periphery and in the centre of tumors. RESULTS: 21 patients received preoperative RCT, 28 proceeded directly to surgery. There was no significant difference in survival between the two groups (median survival 23.2 months vs. 22.1 months, log rank test p=n.s.). Cox regression analysis showed that no variable had a significant effect on survival. The infiltrating pattern of TILs revealed higher numbers peripherally independent of the administration of RCT. There was a significant decrease in all cell numbers except CD4(+) cells in the centre of the tumors after RCT (CD3(+)p=0.005; CD8(+)p=0.02; CD25(+)p=0.01; FoxP3(+)p=0.01). There were fewer TILs in the periphery after RCT; however, this difference only reached significance in FoxP3(+) cells (p=0.01). CONCLUSION: Neoadjuvant RCT reduced the number of TILs in esophageal SCC. This was primarily seen in the centre of tumors and suggests that the effect of RCT on immunological response is located in the centre of tumors.

Risk prediction scores for postoperative mortality after esophagectomy: validation of different models.

BACKGROUND: Different prediction models for operative mortality after esophagectomy have been developed. The aim of this study is to independently validate prediction models from Philadelphia, Rotterdam, Munich, and the ASA. METHODS: The scores were validated using logistic regression models in two cohorts of patients undergoing esophagectomy for cancer from Switzerland (n = 170) and Australia (n = 176). RESULTS: All scores except ASA were significantly higher in the Australian cohort. There was no significant difference in 30-day mortality or in-hospital death between groups. The Philadelphia and Rotterdam scores had a significant predictive value for 30-day mortality (p = 0.001) and in-hospital death (p = 0.003) in the pooled cohort, but only the Philadelphia score had a significant prediction value for 30-day mortality in both cohorts. Neither score showed any predictive value for in-hospital death in Australians but were highly significant in the Swiss cohort. ASA showed only a significant predictive value for 30-day mortality in the Swiss. For in-hospital death, ASA was a significant predictor in the pooled and Swiss cohorts. The Munich score did not have any significant predictive value whatsoever. CONCLUSION: None of the scores can be applied generally. A better overall predictive score or specific prediction scores for each country should be developed.

Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: low primary closure rate.

BACKGROUND: Abdominal Vacuum-Assisted Closure (V.A.C.) systems for treatment of open abdomens have been predominantly used for trauma patients with a high primary fascial closure rate. Use of the V.A.C. technique in abdominal sepsis is less well established. METHODS: All patients with abdominal sepsis and treatment with the abdominal V.A.C. system between 2004 and 2007 were prospectively assessed. End points were fascial closure, V.A.C.-related morbidity, and quality of life score (SF-36) at follow-up. RESULTS: Thirty patients with abdominal sepsis were included in the study. Primary fascial closure was feasible in 10, partial closure in 4, and no closure in 16 patients. Median number of V.A.C. changes was 3 (range, 1-10). Nine patients died. V.A.C.-related morbidity was as follows: two fistulas, three fascial edge necroses, one skin blister, and four prolapses of small bowel between the fascia and foam. Univariate analysis showed no variables influencing primary closure rate or V.A.C.-related morbidity. Mortality was significantly influenced by age (P < 0.001), respiratory failure (P = 0.01), and pneumonia (P = 0.03). At follow-up, V.A.C. patients scored lower in the physical health scores and similar in the mental health scores compared with the normal population. CONCLUSIONS: Treatment of the open abdomen in patients with abdominal sepsis with the abdominal V.A.C. system is safe with good long-term quality of life. Primary closure rate in these patients is substantially lower than in trauma patients. Stepwise closure of the fascia during V.A.C. changes should be attempted to avoid additional lateral retraction of fascial edges. V.A.C.-related complications may be avoided with careful surgical technique.

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial.

BACKGROUND: Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections. MATERIALS AND METHODS: Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea. RESULTS: One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups. CONCLUSION: Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.