The value of a follow-up programme after radical surgery for colorectal carcinoma

To evaluate the effectiveness of a follow-up programme after curative surgery for colorectal carcinoma, a 10-year series of 402 patients was surveyed for the detection rate of potentially curative recurrences and metachronous neoplasms. There were 120 recurrences (30%), and 100 of them (83%) were detected at scheduled check ups. Initial suspicion of recurrence was most often based on physical examination, carcinoembryonic antigen assay, or sigmoidoscopy. Reoperation was undertaken in 62 patients, in 26 cases (22%) for cure. The 5-year survival was 48% after curative reoperations. Metachronous adenomas and carcinomas occurred in 38 and 11 patients, respectively, giving corresponding cumulative 5-year incidences of 13% and 3.8%. Altogether, 37 patients (9.2%) had a curative reoperation for recurrent or metachronous carcinoma, and a further 38 patients (9.5%) had adenomas removed by polypectomy. It is concluded that regular follow-up is useful for the patients, and the follow-up schedule must be planned to detect both early recurrences and metachronous neoplasms.     

食管癌不同超分割方法放疗前瞻性研究

目的通过不同超分割方法放疗寻求食管癌有效的放疗技术。方法前瞻性随机将124例食管癌分为全程超分割组（30例），前程超分割组（30例），后程超分割组（34例），常规放疗组（30例）4个组进行研究，超分割放疗每日2次，每次120Gy，2次间隔6h以上，超分割剂量全程DT：68～70Gy，前、后程组超分割剂量34～36Gy。常规放疗前、后程组DT：34～36Gy，常规组剂量68～70Gy，每日1次，每次2Gy。结果放疗剂量与下咽困难症状改善，4个组基本相同，无明显差异；伴有胸背痛的病人接受放疗后症状改善4个组差异无统计学意义；肿瘤消失情况或治疗结束肿瘤残留情况全程组好于其他3个组，但差异无统计学意义。放射性食管炎全程和前程组明显高于后程和常规放疗组（P〈0．01），放疗剂量在20～50Gy发生较多。20Gy以下和50Gy以上放疗剂量发生率相对较低。放射性气管炎和肺炎发生率4个组均低。其他并发症有恶心、呕吐、白细胞下降反应，但4个组差异无统计学意义。结论本组前瞻性研究从肿瘤消失率和残留情况看全程超分割组优于其他3个组；全程和前程超分割组放射性食管炎的发生率明显高于后程超分割组与常规放疗组。     

Prospective study of the value of necropsy examination in early death after cardiac surgery.

OBJECTIVE: To assess the value of necropsy examination in patients dying soon after cardiac surgery, particularly the proportion of clinical questions answered by the necropsy, the frequency of major unexpected findings, and the limitations of the procedure. DESIGN: A three year prospective study of necropsy examinations in adult patients dying before discharge or within 30 days of cardiac surgery performed under cardiopulmonary bypass in one hospital. SETTING: Tertiary referral centre. RESULTS: 123 of 2781 patients (4.4%) died in the early postoperative period, and necropsy examination was performed in 108 of these (88%). The mortality after emergency procedures (18%) was much higher than after routine operations (2.6%). The main causes of death were cardiac failure (52%), haemorrhage (14%), cerebral disease (6%), and pulmonary emboli (5%). The necropsy changed the stated cause of death in 16 patients (15%), and answered clinical questions in 24 of 38 patients. In 15 patients necropsy examination did not provide a full explanation of death. Most of these patients died of cardiac failure soon after surgery or were sudden unexpected deaths. CONCLUSIONS: Necropsy examination in patients dying early after cardiac surgery is valuable as it answers the majority of clinical questions, and shows unexpected findings in a significant proportion of cases.     

Prognostic value of pretreatment contrast-enhanced computed tomography in esophageal neuroendocrine carcinoma: A multicenter follow-up study

BACKGROUND The rare incidence of esophageal neuroendocrine carcinoma(NEC) and limited treatment experience result in insufficient clinical observations and unsuitable guidelines for its management.AIM To investigate the prognostic value of pretreatment contrast-enhanced computed tomography(CT) characteristics in patients with esophageal NEC.METHODS Seventy-seven esophageal NEC patients who received contrast-enhanced CT at two hospitals were enrolled in this study from June 2014 to December 2019. The clinical features and image characteristics were recorded accordingly. Univariate survival analysis was performed using the Kaplan-Meier method and log-rank test, and multivariate analysis was carried out with a Cox proportional hazards model.RESULTS The multivariate analysis performed using the Cox proportional hazards model showed that N stage, adjuvant chemotherapy, and degree of enhancement were independent prognostic factors for overall survival(OS). Meanwhile, adjuvant chemotherapy was an independent prognostic factor for progression-free survival (PFS). The hazard ratios(HRs) of N stage, adjuvant chemotherapy, and degree of enhancement(mild vs moderate/marked) for OS were 0.426(P = 0.024), 3.862(P = 0.006), and 2.169/0.809(P = 0.037), respectively. The HR of adjuvant chemotherapy for PFS was 6.432(P 0.001). Adjuvant chemotherapy was significantly associated with degree of enhancement(P = 0.018).CONCLUSION Adjuvant chemotherapy is an independent prognostic factor for OS and PFS. Additionally, N stage and degree of enhancement are prognostic factors for OS in patients with esophageal NEC.     

Atrial fibrillation after surgery for esophageal carcinoma： Clinical and prognostic significance

AIM:To retrospectively evaluate the clinical relevance,perioperative risk factors,outcome of differentpharmacological prophylaxis,and short-term prognosticvalue of atrial fibrillation(AF)after surgery foresophageal carcinoma.METHODS:We retrospectively studied 63 patients withAF after surgery for esophageal carcinoma in comparisonwith 126 patients without AF after esophagectomyduring the same time.Postoperative AF incidence wasrelated to different clinical factors possibly involved in itsoccurrence and short-term survival.RESULTS:A strong relationship was observed betweenAF and postoperative hypoxia,history of chronicobstructive pulmonary disease(COPD),postoperativethoracic-gastric dilatation,age older than 65 years,malesex and history of cardiac disease.No difference wasobserved between the two groups with regard to short-term mortality and length of hospital stay.CONCLUSIONS:AF occurs more frequently afteresophagectomy in aged and male patients.Other factorscontributing to postoperative AF are history of COPD andcardiac disease,postoperative hypoxia and thoracic-gastric dilatation.     

Effect of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

AIM: To investigate the role of neoadjuvant chemoradiotherapy in prognosis and surgery for esophageal carcinoma by a meta-analysis.METHODS: PubMed and manual searches were done to identify all published randomized controlled trials (RCTs) that compared neoadjuvant chemoradiotherapy plus surgery (CRTS) with surgery alone (S) for esophageal cancer. According to the test of heterogeneity, a fixed-effect model or a random effect model was used and the odds ratio (OR) was the principal measure of effects.RESULTS: Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C (Cochrane Reviewers' Handbook 4.2.2). OR (95% CI, P value), expressed as CRTS vs S (values > 1 favor CRTS arm), was 1.19 (0.94-1.48, P = 0.28) for 1-year survival, 1.33 (1.07-1.65, P = 0.69) for 2-year survival, 1.76 (1.42-2.19, P = 0.11) for 3-year survival, 1.41 (1.06-1.87, P = 0.11) for 4-year survival, 1.64 (1.28-2.12, P = 0.40) for 5-year survival, 0.82 (0.39-1.73, P < 0.0001) for rate of resection, 1.53 (1.33-2.84, P = 0.007) for rate of complete resection, 1.78 (1.14-2.78, P = 0.79) for operative mortality, 1.12 (0.89-2.48, P = 0.503) for all treatment mortality, 1.33 (0.94-1.88, P = 0.04) for the rate of adverse treatment, 1.38 (1.23-1.63, P = 0.0002) for local-regional cancer recurrence, 1.28 (0.85-1.58, P = 0.60) for distant cancer recurrence, and 1.27 (0.86-1.65, P = 0.19) for all cancer recurrence. A complete pathological response to chemoradiotherapy occurred in 10%-45.5% of patients. The 5-year survival benefit was most pronounced when chemotherapy and radiotherapy were given concurrently (OR: 1.45, 95% CI: 1.26-1.79, P = 0.015) instead of sequentially (OR: 0.85, 95% CI: 0.64-1.35, P = 0.26).CONCLUSION: Compared with surgery alone, neoadjuvant chemoradiotherapy can improve the long-term survival and reduce local-regional cancer recurrence. Concurrent administration of neoadjuvant chemoradiotherapy was superior to sequential chemoradiotherapy.     

Increased N-terminal pro-brain natriuretic peptide level predicts atrial fibrillation after surgery for esophageal carcinoma

AIM： To evaluate the value of plasma N-terminal pro- brain natriuretic peptide （NT-proBNP） level for predicting postoperative atrial fibrillation （AF） in patients undergoing surgery for esophageal carcinoma. METHODS： NT-proBNP levels were measured in 142 patients 24 h before and 1 h after surgery for esophageal carcinoma. All patients having a preoperative cardiac diagnosis by electrocardiogram （ECG）, remained under continuous monitoring for at least 48 h after surgery, and then underwent clinical cardiac evaluation until discharge. RESULTS： Postoperative AF occurred in 11 patients （7.7%）. AF patients were significantly older （69.6 ± 12.2 years vs 63.4 ± 13.3 years, P = 0.031） than non-AF patients. There were no significant differences in history of diabetes mellitus, sex distribution, surgical approach, anastomosis site, intraoperative hypotension and postoperative fever. The preoperative plasma NT-proBNP level was significantly higher in patients who developed postoperative AF （121.3 ± 18.3 pg/mL vs 396.1 ± 42.6 pg/mL, P = 0.016）. After adjustment for age, gender, chronic obstructive pulmonary disease （COPD）, history of cardiac diseases, hypertension, postoperative hypoxia and thoracic-gastric dilation, NT-proBNP levels were found to be associated with the highest risk factor for postoperative AF （odds ratio = 4.711, 95% CI = 1.212 to 7.644, P = 0.008）.CONCLUSION： An elevated perioperative plasma BNP level is a strong and independent predictor of postoperative AF in patients undergoing surgery for esophageal carcinoma. This finding has important implications for identifying patients at higher risk of postoperative AF who should be considered for preventive antiarrhythmic therapy.     

Prospective study of surgery for left ventricular aneurysm

To assess the effects of surgery for ventricular aneurysm on left ventricular performance 18 consecutive patients referred for such surgery were Studied prospectively. The patients had the following preoperative findings: ejection fraction by Isotope ventriculogram 28± 4 percent (mean ± standard error), New York Heart Association functional class 3.6 ± 0.1 and left ventricular noncontractile area 28 ± 3 percent by the graphic integration method. Thirteen patients had both angina pectoris and congestive heart failure, two had angina alone and three had congestive heart failure alone. All patients were studied before and after operation with isotope ventriculograms at rest and during exercise and treadmill exercise tolerance tests if their clinical status permitted these studies. Five patients also had postoperative cardiac catheterization. Catheterization data were in close agreement with the results of imaging studies. In 11 patients the aneurysm was resected and in 4 H was plicated; in 3, no discrete aneurysm was found. Sixteen patients including the three with no discrete aneurysm had concomitant coronary bypass grafting. There was no operative death and one late death.After operation, all patients had significant improvement in functional class (postoperative class 2.3 ± 0.1, p < 0.005). The amount of tissue resected (percent of total left ventricular surface area) was about 50 percent of the noncontractile area visualized on contrast angiography and there was a poor correlation between these two values (r = 0.56). Only four patients (22 percent) had either an increase in ejection fraction (range 8 to 13 percent) or a greater than 10 percent reduction in end-diastolic volume. Postoperative left ventricular end-diastolic pressure was unchanged. Thus, surgery for ventricular aneurysm can be accomplished with relatively small risk. Although functional Improvement is very common, it is not related to substantial improvement in global left ventricular function.     

Prospective evaluation of laparoscopic surgery for rectosigmoidal and rectal carcinoma

PURPOSE: This study was designed to examine the shortterm results of laparoscopy in the treatment of curative cases of rectosigmoidal and rectal carcinoma. METHODS: A review was performed of a prospective registry of 70 patients who underwent curative laparoscopic resection for rectosigmoidal and rectal carcinoma between July 1993 and April 2001. Before 1997, only patients with early (Tis or T1) cancers located in the rectosigmoid and upper rectum that required bowel resection were candidates for laparoscopy. In 1997, we expanded the application of laparoscopy to include T2 cancers located anywhere in the rectum. Mesorectal transection was performed at least 5 cm below the tumor for rectosigmoidal and upper rectal lesions, and total mesorectal excision was performed for lower tumors. Primary anastomosis was performed by a double-stapling technique, or a per anum handsewn coloanal anastomosis was performed. Patient demographics and outcomes were recorded prospectively. RESULTS: The median follow-up was 23 months. An anastomosis was performed in 92.9 percent of the operations. Oral intake was started on median postoperative Day 1, and the median length of hospitalization was 8 days. Two patients needed conversion to conventional open surgery. A total of 15 postoperative complications occurred in 13 patients (18.6 percent), including anastomotic leakage in 6 (8.6 percent) and bowel obstruction in 3 (4.3 percent). Reoperation was required in six patients. Two patients developed recurrence of cancer at the anastomotic site. The expected 5-year survival and disease-free survival rates were 100 and 92.1 percent, respectively. CONCLUSION: The findings of the present study demonstrate the feasibility and safety of laparoscopic surgery for selected patients with rectal carcinoma. Morbidity and mortality rates and oncologic outcome appear to be comparable with conventional surgery.     

Prognostic value of preoperative weight loss-adjusted body mass index on survival after esophagectomy for esophageal squamous cell carcinoma

BACKGROUND The impact of body mass index(BMI)on survival in patients with esophageal squamous cell carcinoma(ESCC)undergoing surgery remains unclear.Therefore,a definition of clinically significant BMI in patients with ESCC is needed.AIM To explore the impact of preoperative weight loss(PWL)-adjusted BMI on overall survival(OS)in patients undergoing surgery for ESCC.METHODS This retrospective study consisted of 1545 patients who underwent curative resection for ESCC at West China Hospital of Sichuan University between August 2005 and December 2011.The relationship between PWL-adjusted BMI and OS was examined,and a multivariate analysis was performed and adjusted for age,sex,TNM stage and adjuvant therapy.RESULTS Trends of poor survival were observed for patients with increasing PWL and decreasing BMI.Patients with BMI≥20.0 kg/m2 and PWL<8.8%were classified into Group 1 with the longest median OS(45.3 mo).Patients with BMI<20.0 kg/m2 and PWL<8.8%were classified into Group 2 with a median OS of 29.5 mo.Patients with BMI≥20.0 kg/m2 and PWL≥8.8%(HR=1.9,95%CI:1.5-2.5),were combined into Group 3 with a median OS of 20.1 mo.Patients in the three groups were associated with significantly different OS(P<0.05).In multivariate analysis,PWL-adjusted BMI,TNM stage and adjuvant therapy were identified as independent prognostic factors.CONCLUSION PWL-adjusted BMI has an independent prognostic impact on OS in patients with ESCC undergoing surgery.BMI might be an indicator for patients with PWL<8.8%rather than≥8.8%.     

Squamous cell carcinoma in esophageal remnant after 24 years: lessons learnt from esophageal bypass surgery

Cervical esophageal carcinoma has been a vexing problem because of the multicentric nature of the disease, the common advanced stage at presentation (with invasion of important adjacent structures, especially the trachea or larynx), and difficulty in satisfactorily reconstructing pharyngogastric continuity after extensive resection. In this case report, we highlight the complexity of managing squamous cell carcinoma of the cervical esophagus, which can reappear either as a new primary or recurrence, in a retained esophageal segment 24 years after esophageal bypass surgery. We strongly recommend total esophagectomy at the time of initial surgery and not 24 years later.     

Video-assisted radical thoracoscopic and laparoscopic surgery for esophageal carcinoma

Esophageal cancer is a common malignancy, for which surgery is the most effective treatment. Compared with traditional surgery, video-assisted thoracoscopic and laparoscopy minimally invasive surgery enables less trauma, better visibility, reduced bleeding and postoperative pain, and lower incidence of surgical complications through a minimally invasive, safe, and highly cost-effective approach in favor of early rehabilitation after surgery. Therefore, the promotion and application of this surgical approach will undoubtedly benefit the majority of patients with esophageal cancer. We have performed video-assisted thoracoscopic and laparoscopy minimally invasive surgery for more than 150 patients in our hospital to date, and have carried out a series of studies in this regard. As the video shows, this approach is safe and reliable with minimal injury and bleeding.KEYWORDS : Esophageal cancer, thoracoscopy, laparoscopy     

Is CEA analysis of value in screening for recurrences after surgery for colorectal carcinoma?

The progress of 139 patients operated upon for cure of colorectal carcinoma, was followed postoperatively with a standardized protocol. A CEA test was performed for comparison with other parameters. Median observation time was four years. When an upper limit for CEA of 7.5 μg/l was allowed, sensitivity was found to be 78 per cent, specificity 91 per cent, and predictive value of an elevated CEA concentration, 83 per cent. In general, CEA measurement traced, recurrence six months before clinical diagnosis. In only a few cases was recurrence first heralded by an abnormality in other blood chemistry test results. CEA may thus be used in postoperative screening for recurrence even though most recurrences, when detected, are not curable. Read at the meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5–9, 1983 Presented in part at The World Congresses of Gastroenterology (OMGE) and Coloproctology, Stockholm, Sweden, June 14–19, 1982.     

手术治疗食管癌放疗后食管狭窄32例

目的 探讨食管癌放射治疗后食管狭窄治疗方法。方法 经上消化道钡餐透视及摄片或泛影葡胺透视及摄片、胸部CT、胃镜、ECT、腹部彩超等检查，选择无远处转移、无影像学外侵、无合并症、体质好的病人32例，采用根治性手术或食管旷置术手术方式治疗食管癌放疗后食管狭窄。结果 手术切除率87．50％，手术相关死亡率9．38％，术后吻合口瘘6．25％，乳糜胸6．25％。根治性切除病人1、3、5、8年总生存率分别为35．71％、21．43％、14．29％、7．14％。食管旷置术病人未及1年生存。结论食管癌放射治疗后食管狭窄手术治疗需严格选择病例，积极处理手术并发症。根治性切除病人疗效好。     

Esophageal dilation for endosonographic evaluation of malignant esophageal strictures is safe and effective

OBJECTIVE: Endoscopic ultrasound (EUS) is accepted as the most accurate modality for T- and N-staging of esophageal cancer, but some malignant strictures prevent passage of the echoendoscope beyond the level of the tumor. This incomplete evaluation may decrease staging accuracy. Previous studies have yielded conflicting results regarding the safety and efficacy of esophageal dilation for EUS. METHODS: We prospectively evaluated 267 consecutive patients undergoing EUS for esophageal carcinoma staging at our institution over a 66-month period to determine the number of patients requiring dilation for EUS examination, the success of dilation, safety of dilation, and clinical importance. RESULTS: Among 267 endosonographic examinations of the esophagus, 81 (30.3%) required dilation to advance the echoendoscope beyond the level of the stricture. After dilation was performed, the echoendoscope could be passed through the stricture in 69 patients (85.2%), and in 63 of 67 of the patients dilated to > or = 14 mm (94.0%). No complications have occurred secondary to the dilations performed to permit completion of the endosonographic examination. Tumor staging by EUS after dilation was T2 (14.8%), T3 (56.8%), and T4 (21.0%), nodal staging N0 (14.6%) and N1 (75.3%); and M1 (9.9%). CONCLUSIONS: We conclude that incremental, stepwise dilation of malignant strictures to 14 mm is safe and effective in permitting echoendoscope passage beyond the stenosis. The presence of a malignant stricture does not seem to diminish the utility of EUS staging of esophageal cancer.     

A symptomatic esophageal mucocele after esophageal bypass surgery

We encountered a case of esophageal mucocele with progressive respiratory symptoms which originated from an excluded thoracic esophagus that was closed at both the proximal and distal ends, and which occurred 24 years after esophageal bypass surgery for a spontaneous esophageal rupture. The patient was a 64-year-old male who was treated by a temporary external drainage for relief of his symptoms without subsequent complete resection of the mucocele via thoracotomy, because of the high surgical risks associated with such a procedure. Four-hundred and fifty milliliters of waste removed during the initial external drainage showed no signs of inflammation or malignancy, suggesting that the reason this excluded esophagus was a symptomatic mucocele was not the observed vigorous secretion, because of irritated esophageal mucosal cells or malignant cells, but instead was the result of gradual accumulation of secretions from the normal esophageal mucosa. This case suggests that an excluded esophagus without any inflammation or malignancy could form a large mucocele that can cause serious symptoms, for example respiratory difficulty, even after an extremely long interval. Although he has been both relapse-free and drainage-free for more than 5 years, further long-term follow-up in this case is mandatory.