Benchmarking Complications Associated with Esophagectomy.

OBJECTIVE: Utilizing a standardized dataset with specific definitions to prospectively collect international data to provide a benchmark for complications and outcomes associated with esophagectomy. SUMMARY OF BACKGROUND DATA: Outcome reporting in oncologic surgery has suffered from the lack of a standardized system for reporting operative results particularly complications. This is particularly the case for esophagectomy affecting the accuracy and relevance of international outcome assessments, clinical trial results, and quality improvement projects. METHODS: The Esophageal Complications Consensus Group (ECCG) involving 24 high-volume esophageal surgical centers in 14 countries developed a standardized platform for recording complications and quality measures associated with esophagectomy. Using a secure online database (ESODATA.org), ECCG centers prospectively recorded data on all resections according to the ECCG platform from these centers over a 2-year period. RESULTS: Between January 2015 and December 2016, 2704 resections were entered into the database. All demographic and follow-up data fields were 100% complete. The majority of operations were for cancer (95.6%) and typically located in the distal esophagus (56.2%). Some 1192 patients received neoadjuvant chemoradiation (46.1%) and 763 neoadjuvant chemotherapy (29.5%). Surgical approach involved open procedures in 52.1% and minimally invasive operations in 47.9%. Chest anastomoses were done most commonly (60.7%) and R0 resections were accomplished in 93.4% of patients. The overall incidence of complications was 59% with the most common individual complications being pneumonia (14.6%) and atrial dysrhythmia (14.5%). Anastomotic leak, conduit necrosis, chyle leaks, recurrent nerve injury occurred in 11.4%, 1.3%, 4.7%, and 4.2% of cases, respectively. Clavien-Dindo complications ≥ IIIb occurred in 17.2% of patients. Readmissions occurred in 11.2% of cases and 30- and 90-day mortality was 2.4% and 4.5%, respectively. CONCLUSION: Standardized methods provide contemporary international benchmarks for reporting outcomes after esophagectomy.

[A comparison of laparoscopic versus open repair for the surgical treatment of perforated peptic ulcers]. / Tratamiento quirúrgico de la úlcera péptica perforada: comparación entre los abordajes laparoscópico y abierto.

OBJECTIVE: To analyse the outcomes of laparoscopic versus open repair for perforated peptic ulcers (PPU). METHODS: All patients undergoing PPU repair between January 2002 and March 2012 were included in the study. Demographic characteristics, operation time, complications, and length of hospital stay were evaluated. RESULTS: Two hundred and twelve patients (median age, 49 years) were included, 60 in the laparoscopic group and 52 in the open group. Patients operated laparoscopically were significantly younger and had a higher consumption of tobacco, alcohol and cannabis. Median acute symptoms time was shorter in the laparoscopic group (6h) compared to the open group (12h; P=.025) Symptoms time was shorter in the laparoscopic group. Median operating time was significantly longer in the laparoscopic group (104.5min vs. 76min, P=.025). The percentage of conversion to open repair was 25%. There was no difference in morbidity between 2 groups, but there were 3 deaths in the open group. Median hospital stay was significantly shorter in patients treated laparoscopically when compared with the open group (6 days vs. 8 days; P=.041). CONCLUSION: Laparoscopic and open repair are equally safe in the management of PPU. A shorter hospital stay can be achieved in the laparoscopic group.

Regulation of glycosyltransferases and Lewis antigens expression by IL-1ß and IL-6 in human gastric cancer cells.

Inflammation of stomach mucosa has been postulated as initiator of gastric carcinogenesis and the presence of pro-inflammatory cytokines can regulate specific genes involved in this process. The cellular expression pattern of glycosyltransferases and Lewis antigens detected in the normal mucosa changed during the neoplassic transformation. The aim of this work was to determine the regulation of specific fucosyltransferases and sialyltransferases by IL-1ß and IL-6 pro-inflammatory cytokines in MKN45 gastric cancer cells. IL-1ß induced significant increases in the mRNA levels of FUT1, FUT2 and FUT4, and decreases of FUT3 and FUT5. In IL-6 treatments, enhanced FUT1 and lower FUT3 and FUT5 mRNA expression were detected. No substantial changes were observed in the levels of ST3GalIII and ST3GalIV. The activation of FUT1, FUT2 and FUT4 by IL-1ß is through the NF-κB pathway and the down-regulation of FUT3 and FUT5 by IL-6 is through the gp130/STAT-3 pathway, since they are inhibited specifically by panepoxydone and AG490, respectively. The levels of Lewis antigens after IL-1ß or IL-6 stimulation decreased for sialyl-Lewis x, and no significant differences were found in the rest of the Lewis antigens analyzed, as it was also observed in subcutaneous mice tumors from MKN45 cells treated with IL-1ß or IL-6. In addition, in 61 human intestinal-type gastric tumors, sialyl-Lewis x was highly detected in samples from patients that developed metastasis. These results indicate that the expression of the fucosyltransferases involved in the synthesis of Lewis antigens in gastric cancer cells can be specifically modulated by IL-1ß and IL-6 inflammatory cytokines.

Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer.

Importance: Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. Objective: To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. Design, Setting, and Participants: In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression ß coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. Exposures: Esophageal resection for cancer of the esophagus and gastroesophageal junction. Main Outcomes and Measures: All-cause postoperative 90-day mortality. Results: A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. Conclusions and Relevance: In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

The impact of body position on intra-abdominal pressure measurement: a multicenter analysis.

OBJECTIVE: Elevated intra-abdominal pressure (IAP) is a frequent cause of morbidity and mortality among the critically ill. IAP is most commonly measured using the intravesicular or "bladder" technique. The impact of changes in body position on the accuracy of IAP measurements, such as head of bed elevation to reduce the risk of ventilator-associated pneumonia, remains unclear. DESIGN: Prospective, cohort study. SETTING: Twelve international intensive care units. PATIENTS: One hundred thirty-two critically ill medical and surgical patients at risk for intra-abdominal hypertension and abdominal compartment syndrome. INTERVENTIONS: Triplicate intravesicular pressure measurements were performed at least 4 hours apart with the patient in the supine, 15 degrees , and 30 degrees head of bed elevated positions. The zero reference point was the mid-axillary line at the iliac crest. MEASUREMENTS AND MAIN RESULTS: Mean IAP values at each head of bed position were significantly different (p < 0.0001). The bias between IAPsupine and IAP15 degrees was 1.5 mm Hg (1.3-1.7). The bias between IAPsupine and IAP30 degrees was 3.7 mm Hg (3.4-4.0). CONCLUSIONS: Head of bed elevation results in clinically significant increases in measured IAP. Consistent body positioning from one IAP measurement to the next is necessary to allow consistent trending of IAP for accurate clinical decision making. Studies that involve IAP measurements should describe the patient's body position so that these values may be properly interpreted.

[Study on the improvement of trauma patient care: TRAUMACAT project]. / Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT.

UNLABELLED: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. INTERVENTION: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. MAIN OUTCOME MEASURES: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.

Effect of Roux-en-Y gastric bypass vs sleeve gastrectomy on glucose and gut hormones: a prospective randomised trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most common bariatric technique. Laparoscopic sleeve gastrectomy (LSG) is a restrictive procedure; the metabolic and endocrine effects of which remain unknown. We compared the effects of both procedures on glucose metabolism and fasting and meal-stimulated gut hormone levels. METHODS: Seven patients were randomised to LRYGB and eight to LSG. All patients were evaluated before and at 3 and 12 months postoperatively. Plasma levels of glucose, insulin, ghrelin, leptin, peptide YY (PYY), GLP-1 and pancreatic polypeptide were measured before and after 10 and 60 min of a standard test meal ingestion. RESULTS: Age, body mass index and preoperative hormone levels were similar in both groups. A significant reduction of plasma glucose and insulin levels was observed after surgery. Moreover, a normalisation of homeostatic model assessment for insulin resistance value was also seen after both procedures. The fasting and postprandial leptin levels were significantly lower in the LRYGB group. LSG was followed by a significant reduction in fasting ghrelin levels. In the LRYGB group, GLP-1 levels increased significantly after the test meal. CONCLUSIONS: LRYGB and LSG markedly improved glucose homeostasis. Only LSG decreased fasting and postprandial ghrelin levels, whereas GLP-1 and PYY levels increased similarly after both procedures.

Activation of the BMP4 pathway and early expression of CDX2 characterize non-specialized columnar metaplasia in a human model of Barrett's esophagus.

BACKGROUND: A human model of gastroesophageal reflux disease was used to examine the contribution of a non-specialized columnar type of metaplasia (NSCM) and key molecular events (BMP4 and CDX2) in the development of Barrett's esophagus. METHODS: Biopsies of the remnant esophagus from 18 patients undergoing esophagectomy with gastric preservation were taken at 6-36-month intervals postoperatively and examined for activation of the BMP pathway (BMP4/P-Smad 1/5/8) and CDX2 and CDX1 expression by imunohistochemistry, quantitative real-time PCR, Western blot, and in situ hybridization. RESULTS: A short segment (mean 15.6 mm) of NSCM was detected in 10 (56%) patients, with an increasing prevalence from 17% at 6 months to 62% at 36 months. Nuclear expression of P-Smad 1/5/8 in the squamous epithelium close to the anastomosis with strong expression in all epithelial cells of NSCM areas was found. Forty-eight (63%) biopsies with NSCM showed scattered nuclear expression of CDX2. Two cases showed isolated glands at 18, 24, and 36 months that fully expressed CDX2 and co-expressed CDX1. BMP4 mRNA and CDX2 mRNA levels were significantly greater in NSCM than in squamous epithelium. CONCLUSIONS: BMP4 activation in NSCM and early expression of CDX2 are involved in the columnar epithelial differentiation of Barrett's esophagus.

A sporadic multiple gastrointestinal stromal tumor with unique clinical and molecular features.

Most sporadic gastrointestinal stromal tumors occur as solitary lesions, whereas a multicentric appearance involving the stomach, the small intestine, or both sites is suspicious for lesions developed in the setting of hereditary or idiopathic tumor syndromes or metastatic disease. The rare occurrence of multiple sporadic gastrointestinal stromal tumors has been recently reported in the literature. Here, we report a case of multiple sporadic gastrointestinal stromal tumors affecting the small intestine in a 61-year-old man, unique with regard to the number of lesions (>30) and the molecular profile. Four different mutations of KIT involving exons 11, 13, and 17 were present among 4 of 10 excised tumors. In addition, BRAF p.V600E mutation was detected in 5 tumors and was mutually exclusive with KIT mutations. To our knowledge, this is the first time a case of a synchronic multisporadic gastrointestinal stromal tumor outstanding for the high number of lesions, which are of independent origin, is reported.

Variation in clinical, manometric and endosonographic findings in anterior chronic anal fissure: a prospective study.

Nearly all chronic anal fissures occur in the posterior midline of the anal canal. However, some of them are in the anterior midline and are rarely double or in the lateral anal walls. The aim of this study was to determine if the clinical, manometric and endosonographic characteristics in patients with chronic anal fissure varied according to topography of the fissure. The patients included in this prospective study were divided according to a fissure site in posterior midline location (Group A, n = 84) and anterior midline location (Group B, n = 30). No differences were found regarding clinical data except that anterior fissures were more common in females. Mean maximal anal resting pressure and internal anal sphincter thickness was higher in Group A. However, these differences were not statistically significant. We found correlation between mean maximal anal resting pressure and internal anal sphincter thickness in patients suffering from anterior chronic anal fissure.

Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy.

BACKGROUND AND AIMS: Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy. MATERIALS AND METHODS: All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks. RESULTS: One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures. CONCLUSION: The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.

[Impact of the availability of an external nuclear medicine service in the application of sentinel lymph node biopsy in breast cancer surgery]. / Impacto de la disponibilidad de un servicio externo de medicina nuclear en la aplicación de la biopsia del ganglio centinela en cirugía del cáncer de mama.

INTRODUCTION: To perform sentinel lymph node biopsy (SLNB), nuclear medicine services that have previously undergone a validation phase are required. The aim of the present study was to analyze the possibility of performing this technique with a previously validated, external nuclear medicine service and to study its impact on the indication for radical axillary lymphadenectomy (RAL) and on length of postoperative hospital stay. PATIENTS AND METHODS: We performed a prospective study in a cohort of patients with breast cancer starting from the introduction of SLNB in our center, which was made possible by collaboration with an external nuclear medicine service that performed lymphoscintigraphy and sentinel node detection. Intraoperative detection was performed through a portable probe. The feasibility of the project and its clinical impact were analyzed, taking a reduction in the number of lymphadenectomies and length of hospital stay as endpoints. RESULTS: A total of 196 patients with 201 breast carcinomas were treated. The most frequent interventions were tumorectomy (TC) with SLNB in 124 patients (62%), and TC with SLNB and RAL in 62 patients (31%). Sentinel node visualization on lymphoscintigraphy was achieved in 187/201 carcinomas (93.1%) and sentinel nodes were detected during the intervention in 182/187 carcinomas (97.4%). Sentinel node detection in the internal mammary chain was achieved in 23/201 carcinomas (11.4%). RAL was avoided in 131 of the 201 carcinomas (65%). Days of postoperative hospital stay with or without RAL showed a mean difference of 1.8 days (3.1 vs. 1.3; P < .001). CONCLUSION: SLNB is feasible with the collaboration of an external nuclear medicine service. This technique avoids 65% of RAL and reduces length of postoperative stay by 1.8 days.

[Endosonographic and manometric assessment of the internal anal sphincter in patients with chronic anal fissure]. / Estudio ecográfico y manométrico del esfínter anal interno en individuos con fisura anal crónica.

INTRODUCTION: High anal resting pressures have been implicated in the pathophysiology of chronic anal fissure. It is not known, however, whether altered function is associated with any morphological abnormalities of the internal anal sphincter (IAS). The aims of the present study were to determine IAS thickness in patients with chronic anal fissure and to investigate the correlation between IAS thickness and anal resting pressure. PATIENTS AND METHOD: Patients with chronic anal fissure were prospectively included between November 1999 and December 2002. Patients with a history of inflammatory bowel disease, anal surgery, and those previously treated with nitroglycerine ointment or botulinum toxin were excluded. Anal endosonography and manometry were performed. IAS thickness was considered to be increased when it was > 2.5 mm in patients < 50 years and > 3 mm in patients > or = 50 years. Anal resting pressure was considered to be increased when it was higher than 80 mmHg. RESULTS: Sixty-three patients were analyzed. An abnormally thick IAS was observed in 58 patients (92%). The mean IAS thickness was 3.7 +/- 0.7 mm. IAS hypertonia was found in 47 patients (66%). The mean anal resting pressure was 91 +/- 28 mmHg. No correlation was found between IAS thickness and anal resting pressure (r = 0.05; p < 0.68). CONCLUSIONS: Most of the patients with chronic anal fissure had an abnormally thick IAS. However, increased thickness of the IAS did not correlate with increased anal resting pressure.