Metabolic gas exchange in critically ill surgical patients : physical, methodological, therapeutic and prognostic aspects

The aims of these studies are: - To design and to validate an automatic instrument for the measurement of oxygen consumption (Vo,), carbon dioxide production (Vco,) and respiratory quotient (R.Q.) (Appendix I). - - To assess the influence of artifacts in metabolic gas-exchange recordings due to patient-ventilator disconnections and to validate a new method for automatic detection and suppression of these artifacts (Appendix II). - To survey the disturbing influences of several clinical circumstances (especially of acetate hemodialysis) on metabolic gas-exchange measurements (Appendix III). - To quantify the stochastic and systematic errors, which are introduced when diurnal values of Vo,, Vco, and R.Q. are extrapolated from short recording periods (Chapter 5). - To analyze the systematic influence of a possible diurnal rhythm in gasexchange on such extrapolations (Chapter 5). - To determine the discrepancy between (Chapter 6): a. Basal Energy Expenditure (= BEE; i.e. the energy expenditure under basal conditions) calculated by means of the anthropometric uncorrected Harris-Benedict formula and Total Energy Expenditure (= TEE) measured by means of continuous indirect calorimetry; b. TEE calculated by means of the corrected Harris-Benedict formula and continuously measured TEE; c. intermittently measured TEE and continuously measured TEE. - To analyze to what extent a standard nutritional regimen leads to hypoor hyperalimentation and to determine whether a tailored caloric supply based on anthropometric data gives a better match to energy expenditure than a standard supply (Chapter 7). - To determine whether Vo, -indices of survivors are different from those of nonsurvivors and to analyze whether the potency of a frequently used system to predict the patient's ultimate outcome (SAPS) can be improved by addition of Vo2-index as a supplemental physiological variable (Chapter 8). - To survey the present nutritional, mechanical and pharmacological methods to reduce metabolic rate (Chapter 9)

Fixed Size of Enlarged Calcified Lymph Nodes in Esophageal Adenocarcinoma despite Complete Remission

Untreated malignant lymph nodes that are calcified are rare. Publications on such calcifications are restricted to case reports. We present a case of calcified lymph nodes in a patient with adenocarcinoma of the gastroesophageal junction that seemed to be nonresponsive to induction chemotherapy, as they did not decrease in size. However, on pathological examination of the resected lymph nodes no vital tumor cells could be detected anymore. Therefore, we hypothesize that a calcified lymph node is unable to shrink, even after adequate remission on induction chemotherapy. This should be taken into account when clinical decision-making depends on the change in size of an enlarged, calcified lymph node as a measure of treatment effect

Functional changes after pancreatoduodenectomy: Diagnosis and treatment

Relatively little is known about the gastrointestinal function after recovery of a pancreatoduodenectomy. This review focuses on the functional changes of the stomach, duodenum and pancreas that occur after pancreatoduodenectomy. Although the mortality in relation to pancreatoduodenectomy has decreased over the years, it remains associated with considerable morbidity, which occurs in 40-60% of patients. Physical complaints early after the operation are often caused by motility disorders, in particular delayed gastric emptying, which occurs in up to 40% of patients. During longer follow-up of these patients the occurrence of endocrine and exocrine pancreatic insufficiency becomes more predominant. Diabetes mellitus develops in 20-50% of patients after a pancreatic resection (pancreatogenic diabetes). The main presenting symptoms of exocrine insufficiency are weight loss and steatorrhea. Its presence is suspected on clinical ground and can be supported by fecal elastase-1 measurement. Exocrine insufficiency can be compensated with oral enteric-coated enzyme supplements. The quality of life issue will be addressed as an important outcome measurement after pancreaticoduodenectomy. Furthermore, the functional changes after pancreatoduodenectomy are described in detail with suggestions for diagnosis and treatment

Reply to Rizzatti et al.

We would like to thank Dr. Rizzatti and colleagues for their interest in our paper entitled “Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer” [...

Patients' Preferences for Surgical Management of Esophageal Cancer: A Discrete Choice Experiment

Background: Obtaining insight into patients' preferences is important to optimize cancer care. We investigated patients' preferences for surgical management of esophageal cancer. Methods: We conducted a discrete choice experiment among adult patients who had undergone esophagectomy for adenocarcinoma or squamous cell cancer of the esophagus. Patients' preferences were quantified with regression analysis using scenarios based on five aspects: risk of in-hospital mortality, risk of persistent symptoms, chance of 5-year survival, risk of surgical and non-surgical complications, and hospital volume of esophageal cancer surgery. Results: The response rate was 68 % (104/142). All aspects proved to influence patients' preferences (p < 0.05). Persisting gastrointestinal symptoms and 5-year survival were the most important attributes, but preferences varied between patients. On average, patients were willing to trade-off 9.5 % (CI 2.4-16.6 %) 5-year survival chance to obtain a surgical treatment with 30 % lower risk of gastrointestinal symptoms, or 8.1 % (CI 4.0-12.2 %) 5-year survival chance for being treated in a high instead of a low-volume hospital. Conclusions: Patients are willing to trade-off some 5-year survival chance to achieve an improvement in early outcomes. Given the preference heterogeneity among participants, the present study underlines the importance of a patient-tailored approach when discussing prognosis and treatment

Sarcopenia/Muscle Mass is not a Prognostic Factor for Short- and Long-Term Outcome After Esophagectomy for Cancer

Background: Recent studies have suggested that sarcopenia is a prognostic risk indicator of postoperative complications and predicts survival in cancer patients. The aim of this study is to investigate whether sarcopenia is associated with postoperative short-term outcome (morbidity and mortality) and long-term survival in patients undergoing esophagectomy for cancer after neoadjuvant chemoradiotherapy. Methods: All patients who underwent neoadjuvant chemoradiotherapy followed by esophagectomy for cancer, and of whom an adequate CT scan was available, were included in the current study. The presence of sarcopenia was defined by CT imaging using cut-off values of the total cross-sectional muscle tissue measured transversely at the third lumbar level. Results: A total number of 120 patients were eligible for analysis. Almost half of the patients (N = 54, 45 %) were classified as having sarcopenia; 24 sarcopenic patients (44 %) had overweight and 5 sarcopenic patients (9 %) were obese. Overall morbidity and mortality rate did not differ significantly between sarcopenic and non-sarcopenic patients, nor did long-term overall or disease-free survival. Also sarcopenic obesity was not associated with worse outcome. Conclusion: The presence of sarcopenia was not associated with a negative short- and long-term outcome in this selected group of esophageal cancer patients after neoadjuvant chemoradiotherapy followed by esophagectomy

Early onset esophageal adenocarcinoma: A distinct molecular entity?

Esophageal adenocarcinoma (EAC) is typically diagnosed in elderly with a median age of 68 years. The incidence of EAC has been rising over the last decades, also among young adults. The aim of the study was to investigate whether early onset EAC is a distinct molecular entity. To identify early onset EACs, the nationwide network and registry of histo- and cytopathology in the Netherlands (PALGA) was searched. Twenty-eight tumors of patients aged ≤40 years were selected and matched with 27 tumors of patients aged =68 years. DNA was isolated from surgically resected specimen and sequenced on the Ion Torrent Personal Genome Machine with the Ion AmpliSeq Cancer Panel. No differences in mutational load between early onset and conventional EACs were observed (P=0.196). The most frequently mutated genes were TP53 (73%) and P16 (16%). Additional mutations in early onset EACs occurred exclusively in: APC, CDH1, CTNNB1, FGFR2, and STK11. In the conventional EACs additional mutations were exclusively identified in: ABL1, FBXW7, GNA11, GNAS, KRAS, MET, SMAD4, and VHL. Additional mutations besides TP53 and P16 seem to occur in different genes related to cell fate pathways for early onset EACs, while the additional mutations in conventional EACs are related to survival pathways