The need for esophagectomy in patients with Barrett's esophagus, with no endoscopically visible lesion, and a biopsy showing high-grade dysplasia or adenocarcinoma has been questioned. Recently, endoscopic techniques to ablate the neoplastic mucosa have been encouraged. The aim of this study was to determine the extent of disease present in patients with clinically occult esophageal adenocarcinoma to define the magnitude of therapy required to achieve cure.Thirty-three patients with high-grade dysplasia (23 patients) or adenocarcinoma (10 patients) and no endoscopically visible lesion underwent repeat endoscopy and systematic biopsy followed by esophagectomy. The surgical specimens were analyzed to determine the biopsy error rate in detecting occult adenocarcinoma. In those with cancer, the depth of wall penetration and the presence of lymph node metastases on conventional histology and immunohistochemistry staining was determined. The findings were compared with those in 12 patients (1 with high-grade dysplasia, 11 with adenocarcinoma) who had visible lesions on endoscopy.The biopsy error rate for detecting occult adenocarcinoma was 43%. Of 25 patients with cancer and no visible lesion, the cancer was limited to the mucosa in 22 (88%) and to the submucosa in 3 (12%). After en bloc esophagectomy, one patient without a visible lesion had a single node metastasis on conventional histology. No additional node metastases were identified on immunohistochemistry. The 5-year survival rate after esophagectomy was 90%. Patients with endoscopically visible lesions were significantly more likely to have invasion beyond the mucosa (9/12 vs. 3/25, p = 0.01) and involvement of lymph nodes (5/9 vs. 1/10, p = 0.057).Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma in Barrett's esophagus. The lack of an endoscopically visible lesion does not preclude cancer invasion beyond the muscularis mucosae, cautioning against the use of mucosal ablative procedures. The rarity of lymph node metastases in these patients encourages a more limited resection with greater emphasis on improved alimentary function (esophageal stripping with vagal nerve preservation) to provide a quality of life compatible with the excellent 5-year survival rate of 90%.
Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett's esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication.
The study was undertaken to determine the influence of various doses of aspi rin (ASA) therapy on platelet adherence to injured endothelium. Twenty-four mongrel dogs were assigned to one of four treatment groups in a randomized, blinded fashion. Each group received ASA in one of three doses: 1 mg/kg, 5 mg/kg, or 10 mg/kg or no ASA therapy (control group). After five days of ASA therapy, the dogs underwent unilateral carotid endarterectomy (CEA), in a ran domized fashion, with the contralateral carotid artery serving as control within each dog. Indium 111 oxine-labeled autologous platelets were injected into the dogs twenty minutes before the reestablishment of flow through the endarterec tomized carotid artery. Platelet scintigraphy was performed at hours 3, 24, 48 and 72 postoperatively. ASA therapy was continued postoperatively for seventy- two hours. Data were analyzed by comparing the mean platelet uptake ratios (operative to nonoperative sites) between groups. When all ASA groups were combined and compared with control values, ASA therapy significantly decreased (p < 0.05) platelet adherence up to seventy-two hours postoperatively. The same effect was observed with low- (1 mg/kg) and medium- (5 mg/kg) dose ASA, which significantly reduced (p < 0.05) platelet adherence to the endarterectomized site at hours 3, 24, 48, and 72. In contrast, there was no significant reduction in platelet uptake in the high-dose (10 mg/kg) ASA group. These results indi cate that ASA therapy given in a dosage of 1 or 5 mg/kg for at least five days preoperatively is beneficial in decreasing platelet adherence after CEA in dogs. Conversely, at a dose of 10 mg/kg, platelet uptake is not consistently inhibited. This study supports previous findings that lower doses of ASA (1-5 mg/kg) are superior to high-dose ASA (10 mg/kg) in inhibiting platelet adherence to injured endothelium in vivo.
The reason why patients with isolated supine reflux do not reflux in the upright position and patients with isolated upright reflux do not reflux in the supine position is unknown. Our objective was to determine the characteristics of the crura, lower esophageal sphincter, crura-sphincter dynamics, and esophageal body on manometry, endoscopy, and X-ray in patients with isolated upright and isolated supine reflux. Eighty consecutive patients with isolated upright reflux were compared with 82 consecutive patients with isolated supine reflux. Manometrically there was no difference in lower esophageal sphincter characteristics and esophageal contractions between the two groups. The prevalence of a hiatal hernia on manometry was similar between upright and supine refluxers (88% vs 88%). Upright refluxers had shorter hiatal hernias [median (interquartile range) 1.1 (0.65-1.8) vs 1.2 (1-2.3), P < 0.046)]. The median crural pressure, crura-sphincter pressure gradient, and crura-sphincter pressure ratio in upright refluxers was 14.96 (9.5-21.27), 3.28 (1.7-12.2), and 1.33 (0.87-2.8) mm Hg, respectively. These values were significantly higher (P < 0.001) in supine refluxers at 21.43 (16.6-29.9), 10.66 (4.3-19.7), and 2.1 (1.3-4.2) mm Hg, respectively. We conclude that the significantly higher crural pressure in patients with supine reflux acts as a mechanical ring and as a physiologic protector against the unfolding of the sphincter in the postprandial and upright periods. Higher crura-sphincter pressure gradient and larger-size hiatal hernias in patients with supine reflux results in pressurization of the hernia sac and subsequent reflux when these patients are in a supine position.
Despite the published benefits of minimally invasive video-assisted thoracoscopic surgery (VATS) for lobectomy, the majority of lobectomies in the United States continue to be performed through a thoracotomy. The low adoption rate of VATS has been attributed to its technical challenges and ergonomic inefficiencies. Robotic surgery has been proposed as an alternative minimally invasive technique that allows the replication of open lobectomy with wristed instruments and three-dimensional vision. Our aim was to analyze the transition from open to robotic lobectomy at our hospital where there had been no significant VATS lobectomy experience. We analyzed 88 open and 43 robotic lobectomies that met criteria for inclusion. Operative times were significantly longer with the robotic group but decreased with experience. The resection time of the latter half of the robotic cases decreased to within 20 minutes of the open cases. There were no conversions in the robotic cases to either VATS or open. Robotic lobectomy was associated with faster postoperative recovery with a 60 per cent decrease in length of stay. Complications were uncommon and there were no deaths in the robotic group. We conclude that the transition from open to robotic lobectomy can be achieved safely with excellent postoperative outcomes. This new technique is a viable alternative to VATS lobectomy.
