Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P<0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+). CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma insitu component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis,accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned,the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management,including cholecystectomy,endoscopic retrograde cholangiopancreatography(ERCP) and sphincterotomy,or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process,usually not earlier than 6 wk after onset of acute pancreatitis,seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed,but if used for definitive treatment,they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques,if not therapeutic,can be used as a bridge to definitive operative treatment,which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.

Corticosteroid-free immunosuppression in liver transplantation: An evidence-based review

Thirty-six randomized controlled trials and two metaanalyses were reviewed. With respect to adult patients undergoing first orthotopic liver transplantation(OLT), steroid replacement resulted in fewer cases of overall acute rejection in the corticosteroid free-immunosuppression arm. Initial steroid administration for two weeks and early tacrolimus monotherapy is a feasible immunosuppression regimen without steroid replacement, although further investigations are needed in view of chronic rejections. No significant differences were noted between the treatment groups in terms of patient and graft survival independently of steroid replacement. Renal insufficiency, de novo hypertension, neurological disorders and infectious complications did not differ significantly among steroid and steroidfree groups. Diabetes mellitus, cholesterol levels and cytomegalovirus infection are more frequent in patients within the steroid group. With respect to diabetes mellitus and hypercholesterolemia, the difference was independent of steroid replacement. In relation to transplanted hepatitis C virus patients, mycophenolate mofetil does not appear to have a significant antiviral effect despite early reports. Male gender of donors and recipients, living donors, cold ischemia times, acute rejection, and early histological recurrence were related to the development of advanced hepatitis. There is sufficient scientific clinical evidence advocating avoidance of the ab initio use of steroids in OLT.

Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths?

AIM: To examine the role of coprostasis and coproliths in recurrent appendicitis. METHODS: We evaluated four hundred and twenty seven consecutive pathology reports of all appende- ctomy specimens from January 2003 to December 2004. Findings were categorised as showing acute appen- dicitis, acute recurrent appendicitis, subacute recurrent appendicitis, chronic appendicitis, or appendices without inflammation. All patients had presented with acute right lower quadrant pain. In 94 instances, there was a history of recurrent similar episodes in the past. RESULTS: Of the 427 histology reports, 294 were inter- preted as showing acute appendicitis, 56 acute recurrent appendicitis, 34 subacute recurrent appen-dicitis, 28 chronic appendicitis, and 15 non-inflamed appendices. Coprostasis was observed in 58 patients (13.58%) and the presence of coprolith in 6 (1.4%). Coprostasis, and age, were among the predictors in the final model. CONCLUSION: Coprostasis but not coproliths seems to be a contributing factor to acute exacerbations of chronic inflammatory appendicitis.

Predictors of common bile duct lithiasis in laparoscopic era

AIM: To analyze retrospectively the records of 294 conse-cutive patients operated upon for gallbladder stones, to determine the predictive factors of synchronous common bile duct (CBD) stones and validate prospectively the generated model. METHODS: The prognostic estimation of a biochemical test and ultrasonography alone to differentiate between the absence and presence of choledocholithiasis was assessed using receiver operating characteristics curve analysis. Multivariate analysis was employed using discriminant analysis for establishment of a best model. Prospective validation of the model was made.RESULTS: Discriminant forward stepwise analysis disclosed that high values (≥ 2×normal) of SGOT, ALP, conjugated bilirubin and CBD diameter on ultrasound ≥ 10 mm were all prognostic factors of CBD lithiasis in univariate and multivariate analysis, P＜0.01. History was not included in the model. Prospective validation of the model was performed by multivariate analysis using Visual General Stepwise Regression. Positive predictive value,when considering all these predictors, was 93.3%, while the negative predictive value was 88.8%. Sensitivity of the model was 96.5% and specificity 80%.CONCLUSION: The above model can be objectively applied to predict the presence of CBD stones.

Risk of venous congestion in live donors of extended right liver graft

AIM: To investigate middle hepatic vein(MHV)management in adult living donor liver transplantation and safer remnant volumes(RV).METHODS: There were 59 grafts with and 12 grafts without MHV(including 4 with MHV-5/8 reconstructions).All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnantvolumebody-weight ratios(RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume(d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes(CVindex).Small for size(SFS) and non-SFS remnant considerations were based on standard cut-off- RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV.RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30%and non-SFS-remnants with RV/TLV ≥ 30% showedno significant differences either. RV and RVBWR for non-MHV(n = 59) and MHV-containing(n = 12)remnants were 550 ± 95 ml and 0.79 ± 0.1 ml vs568 ± 97 ml and 0.79 ± 0.13, respectively(P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%.Non-MHV(n = 59) and MHV-containing(n = 12)remnants(34.1% ± 3% vs 36% ± 4% respectively,P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFSremnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4%(range: 28%-35.7%) vs non-SFS: RV/TLV 36.2%(range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30%(0.65(range: 0.6-0.7) vs 0.8(range: 0.6-1.27), P < 0.01.Two(2.8%) donors developed reversible liver failure.RVBWR and RV/TLV were concordant in 25%-33%of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n =2 remnants based on particularly risky congestive and non-congestive volume constellations.CONCLUSION: MHV procurement should consider individual remnant congestive- and non-congestive volume components and anatomy characteristics,RVBWR-RV/TLV constellation enables the identification of marginally small remnants.