Fate of the esophagogastric anastomosis

ObjectiveThe study objective was to evaluate histopathology of the esophagogastric anastomosis after esophagectomy, determine time trends of histologic changes, and identify factors influencing those findings.MethodsA total of 231 patients underwent 468 upper gastrointestinal endoscopies with anastomotic biopsy a median of 3.5 years after esophagectomy. Mean age was 59 ± 12 years, 74% (171) were male, and 96% (222) were white. Seventy-eight percent (179) had esophagectomy for cancer, 13% (30) had chemoradiotherapy, and 13% (30) had prior esophageal surgery. The anastomosis was 20 ± 2.0 cm from the incisors. Anti-reflux medications were used in 59% of patients (276/468) at esophagoscopy. Histopathology was graded as normal (0), consistent with reflux (1), cardia mucosa (2), intestinal metaplasia (3), and dysplasia (4). Repeated-measures nonlinear time-trend analysis and multivariable analyses were used.ResultsGrades 0 and 1 were constant, 5% and 92% at 10 years, respectively. Anti-reflux medication, induction therapy, and higher anastomosis were predictive of less grade 1 histopathology. Grades 2 and 3 increased with time: 12% and 33% at 5 years and 4% and 16% at 10 years, respectively. No variable was predictive of grade 2 or 3 (P > .15) except passage of time. No patient’s condition progressed to dysplasia or cancer.ConclusionsThe esophagogastric anastomosis is subject to gastroesophageal reflux. To minimize histopathologic changes of reflux, the anastomosis should be constructed as high as possible (closer to incisors) and anti-reflux medications prescribed. Surveillance endoscopy, if performed, will document a time-related progression of reflux-related histopathologic changes. However, during surveillance, intestinal metaplasia is uncommon and progression to cancer rare

Two-Person Technique of Peroral Endoscopic Myotomy for Achalasia with an Advanced Endoscopist and a Thoracic Surgeon: Initial Experience

Background and Aims. We initiated peroral endoscopic myotomy (POEM) utilizing a two-person technique with combination of an advanced endoscopist and a thoracic surgeon with complementary skills. Our aim was to determine the feasibility and outcomes in initial 20 patients. Methods. In this observational study, main outcomes measured were therapeutic success in relieving symptoms (Eckardt score < 3), decrease in lower esophageal sphincter (LES) pressures, improvement in emptying on timed barium esophagogram (TBE), and complications. Results. POEM was successful in all 20 patients with a mean operative time of 140.1+32.9 minutes. Eckardt symptom scores decreased significantly at two-month follow-up (6.4+2.9 versus 0.25+0.45, p<0.001). Both basal and residual LES pressures decreased significantly (28.2+14.1 mmHg versus 12.8+6.3 and 22.4+11.3 versus 6.3+3.4 mmHg, p=0.025 and <0.001, resp.). Barium column height at 5 minutes on TBE reduced from 6.8+4.9 cm to 2.3+2.9 cm (p=0.05). Two patients (10%) had mucosal perforations and one had delayed bleeding (5%). Conclusions. Two-person technique of POEM with combination of an advanced endoscopist and a thoracic surgeon is highly successful with low risk of complications

Optimal planning and management strategies for minimally invasive lung segmentectomies : an international delphi consensus report

CALGB140503/JCOG0802 RCTs comparing lobectomy with sublobar resection in stage IA NSCLC have confirmed the non-inferiority of segmentectomy. Additional insight is needed to improve preoperative work-up and intraoperative strategies to increase safety and promote the dissemination of minimally invasive segmentectomy (MIS). A Delphi panel study assessed the level of consensus among surgeons for the planning and management of MIS.Twenty-one expert lung surgeons represented academic institutions, major teaching hospitals, and community hospitals from Europe, North America, and Asia. A three-round Delphi methodology was employed to analyse the answers of each panellist. Recognising that questions with fewer response options have a higher consensus probability due to limited variability, weighted consensus thresholds were modified based on the number of response options.The 21 panellists responded to all three rounds of questions. Based on the most robust consensus (94.4%), 3-D chest CT reconstructions are recommended only when planning complex segmentectomies. Surgeons should perform 3-D reconstructions chest CT scans (consensus = 83.3%). The most effective and safest technique is image-guided VATS in a hybrid operating room (consensus = 83.3%). Dyes with intravenous administration are the safest technique for identifying the intersegmental plane during MIS (consensus = 72.2%). Augmented/mixed reality will probably not immediately help reduce perioperative complications (consensus = 72.2%).This Delphi Consensus supports 3-D reconstructions and preoperative pulmonary nodule localisation before complex MIS. These recommendations should be considered when allocating resources to improve MIS's safety and oncologic efficacy for patients with small, early-stage lung cancers

An examination of in vitro erythropoiesis by utilizing agents that mimic the in vitro activity of erythropoietin

The major in vivo hormonal regulator of terminal erythropoiesis is erythropoietin (Ep). This 38,000 dalton acidic glycoprotein has been shown to stimulate the formation of hemoglobinizing erythroblasts. Two in vitro assays designed to measure Ep bioactivity were utilized to determine if other agents could mimic Ep activity in vitro. It was hoped that this approach might yield insights into the mechanism of action of Ep. Several agents have now been identified, and two, dimethyl sulfoxide (DMSO) and sodium orthovanadate had previously been shown (in other systems) to stimulate membrane phosphorylation changes. Accordingly, Ep, DMSO and sodium orthovanadate were assayed with Ƴ-³²P-ATP and plasma membranes purified from Ep-responsive cells to determine if each could induce significant phosphorylation changes as assessed by sodium dodecyl sulfate polyacrylamide gel electrophoresis and autoradiography. It was found that while both sodium orthovanadate and DMSO effected profound phosphorylation alterations, Ep did not elicit any detectable phosphorylation changes. Specifically, vanadate caused a generalized increase in membrane base-stable phosphoproteins, and DMSO reproducibly stimulated the base resistant phosphorylation of a 35 Kd membrane-associated protein. It is reasonable to postulate that the latter phosphorylation event might be responsible for the stimulatory activity of DMSO on terminally differentiating erythroid cells. To understand whether Ep and Ep-mimicking agents were operative on the same target cell population, homogeneous, virally-infected, erythroblasts were cultured in vitro and assayed for ³H-thymidine incorporation in the presence of each agent at various intervals during erythroid cell differentiation. It was found that Ep greatly stimulated very early, as well as differentiated, erythroblasts to proliferate, while four different Ep-mimicking agents could only effect thymidine incorporation into a more mature erythroid population. From this work it is conceivable that Ep-mimicking agents stimulate in vitro erythropoiesis through specific membrane phosphorylation changes and function primarily on late erythroblasts, while the mechanism of action of Ep on primitive and late erythroblasts remains unresolved.Medicine, Faculty ofPathology and Laboratory Medicine, Department ofGraduat