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.

Current position of ALPPS in the surgical landscape of CRLM treatment proposals

The Authors summarize problems,criticisms but also advantages and indications regarding the recent surgical proposal of associating liver partition and portal vein ligation(PVL)for staged hepatectomy(ALPPS)for the surgical management of colorectal liver metastases.Looking at published data,the technique,when compared with other traditional and well established methods such as PVL/portal vein embolisation(PVE),seems to give real advantages in terms of volumetric gain of future liver remnant.However,major concerns are raised in the literature and some questions remain unanswered,preliminary experiences seem to be promising.The method has been adopted all over the world over the last 2 years,even if oncological long-term results remain unknown,and benefit for patients is questionable.No prospective studies comparing traditional methods(PVE,PVL or classical 2 staged hepatectomy)with ALPPS are available to date.Technical reinterpretations of the original method were also proposed in order to enhance feasability and increase safety of the technique.More data about morbidity and mortality are also expected.The real role of ALPPS is,to date,still to be established.Large clinical studies,even if,for ethical reasons,in well selected cohorts of patients,are expected to better define the indications for this new surgical strategy.

Significance of preoperative C-reactive protein as a parameter of the perioperative course and long-term prognosis in squamous cell carcinoma and adenocarcinoma of the oesophagus

瞄准：C 反应的蛋白质(CRP ) 是尖锐阶段的反应物和瘤的恶意的潜力的已知的指示物。这研究的目的是作为起作用的仙子的一个参数调查外科手术前的 CRP 的意义在有有鳞的房间癌和食道的腺癌的病人的路线和长期的预后。方法：浆液 CRP 在从 1989 年 12 月为癌症经历 oesophagectomy 到 2004 年 3 月的 371 个病人中的 291 个外科手术前地被决定。中部的耐心的年龄是 59 (28-79 ) 年， 82.5% 病人是男性。有鳞的房间癌在 151 被诊断(51.9%) 并且在 122 个病人的腺癌。Transhiatal oesophagectomy 在 151 被做(51.9%) 病人并且 134 (46.0%) 病人们经历了腹胸的过程。结果：(43.6%) 在 127，外科手术前的浆液 CRP 集中在正常以内的病人变化(【 5 mg/dL ) ，提高的 CRP 层次在 164 被测量(56.4%) 病人。瘤扩展(P 【 0.0005 ) 并且淋巴节点的数字由变形传播影响了(P = 0.015 ) 显著地与提高的 CRP 层次在这个组被增加。在起作用的仙子之中参数两输血的数字(P = 0.006 ) 并且一般复杂并发症率(P = 0.002 ) 在有提高的外科手术前的 CRP 层次的病人是更高的。13.6 的长期的幸存率(0-109.8 ) 瞬间在有与 18.9 相比的提高的 CRP 层次的组是更差的(0-155.4 ) 在有正常 CRP 的组的瞬间铺平(木头等级测试：P = 0.107 ) 。有向后的变量选择的 Multivariate 分析与食道的癌在病人作为长期的预后的一个独立预示的因素识别了外科手术前的 CRP，与 1.182 的危险比率(95% 信心间隔：1.030-1.356 ) 。结论：外科手术前的浆液 CRP 水平是在有有鳞的房间癌和食道的腺癌的病人的一个容易坚定的独立预示的标记。

Protective effects of ischemic preconditioning and application of lipoic acid prior to 90 min of hepatic ischemia in a rat model

AIM: To compare different preconditioning strategies to protect the liver from ischemia/reperfusion injury focusing on the expression of pro- and anti-apoptotic proteins. Interventions comprised different modes of ischemic preconditioning (IP) as well as pharmacologic pretreatment by α-lipoic acid (LA). METHODS: Several groups of rats were compared: sham operated animals, non-pretreated animals (nt), animals receiving IP (10 min of ischemia by clamping of the portal triad and 10 min of reperfusion) prior to sustained ischemia, animals receiving selective ischemic preconditioning (IPsel, 10 min of ischemia by selective clamping of the ischemic lobe and 10 min of reperfusion) prior to sustained ichemia, and animals receiving 500 μmol α-LA injected i.v. 15 min prior to the induction of 90 min of selective ischemia. RESULTS: Cellular damage was decreased only in the LA group. TUNEL-positive hepatocytes as well as necrotic hepatocyte injury were also decreased only by LA (19 ± 2 vs 10 ± 1, P < 0.05 and 29 ± 5 vs 12 ± 1, P < 0.05). Whereas caspase 3- activities in liver tissue were unchanged, caspase 9- activity in liver tissue was decreased only by LA pretreatment (3.1 ± 0.3 vs 1.8 ± 0.2, P < 0.05). Survival rate as the endpoint of liver function was increased after IP and LA pretreatment but not after IPsel. Levels of lipid peroxidation (LPO) in liver tissue were decreased in the IP as well as in the LA group compared to the nt group. Determination of pro- and anti-apoptotic proteins showed a shift towardsanti-apoptotic proteins by LA. In contrast, both our IP strategies failed to influence apototic cell death. CONCLUSION: IP, consisting of 10 min of ischemia and 10 min of reperfusion, protects only partly against ischemia/reperfusion injury of the liver prior to 90 min of selective ischemia. IPsel did not influence ischemic tolerance of the liver. LA improved tolerance to ischemia, possibly by downregulation of pro-apoptotic Bax.

Reduction of ischemia reperfusion injury after liver resection and hepatic inflow occlusion by α-lipoic acid in humans

AIM: To evaluate the protective effects of precondition- ing by α-lipoic acid (LA) in patients undergoing hepatic resection under inflow occlusion of the liver. METHODS: Twenty-four patients undergoing liver re- section for various reasons either received 600 mg LA or NaCl 15 min before transection performed under inflow occlusion of the liver. Blood samples and liver wedge bi- opsy samples were obtained after opening of the abdo- men immediately after inflow occlusion of the liver, and 30 min after the end of inflow occlusion of the liver. RESULTS: Serum levels of aspartate transferase and alanine transferase were reduced at all time points in patients who received LA in comparison to those who received NaCL. This was accompanied by reduced histo- morphological features of oncosis. We observed TUNEL- positive hepatocytes in the livers of the untreated patients, especially after 30 min of ischemia. LA attenu- ated this increase of TUNEL-positive hepatocytes. Under preconditioning with LA, ATP content was significantly enhanced after 30 min of ischemia and after 30 min of reperfusion. CONCLUSION: This is the first report on the poten- tial for LA reducing ischemia/reperfusion injury (IRI) of the liver in humans who were undergoing liver surgery. Beside its simple and rapid application, side effects did not occur. LA might therefore represent a new strategy against hepatic IRI in humans.

Emergency robotic colorectal surgery during the COVID-19 pandemic: A retrospective case series study

Objective: While interest in elective robotic surgery is growing, use in emergency setting remainslimited due to challenges posed by sicker patients, advanced pathology and logistical issues. During theCOVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from thebedside and reducing the number of directly exposed medical staff. The objective of this study was toreport patient outcomes and initial learning experience of emergency robotic colorectal surgery duringthe COVID-19 pandemic.Methods: A case series study was conducted, including patients undergoing emergency robotic colorectalsurgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK.Patient data were collected from an ethics approved prospective database. Patient demographics,operative time, conversions and postoperative complications were recorded. In addition, readmissions,length of stay and short-term oncological outcomes were analyzed.Results: Ten patients with median age 64 y (range, 36-83 y) were included. Four patients had roboticcomplete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease inemergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was249 ± 117 min, the median length of stay was 9.4 d (range, 5-22 d). Only one patient was given atemporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality.Conclusions: Provided an experienced team and peri-operative planning, emergency robotic colorectalsurgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncologicalcases and avoidance of diverting stoma.

High miR-196a levels promote the oncogenic phenotype of colorectal cancer cells

AIM: To analyze the relevance of the microRNA miR-196a for colorectal oncogenesis. METHODS: The impact of miR-196a on the restriction targets HoxA7, HoxB8, HoxC8 and HoxD8 was analyzed by reverse transcription polymerase chain reaction (RT-PCR) after transient transfection of SW480 cancer cells. The miR-196a transcription profile in colorectal cancer samples, mucosa samples and diverse cancer cell lines was quantifi ed by RT-PCR. Transiently miR-196a-transfected colorectal cancer cells were used for diverse functional assays in vitro and for a xenograft lung metastasis model in vivo. RESULTS: HoxA7, HoxB8, HoxC8 and HoxD8 were restricted by miR-196a in a dose-dependent and gene-specific manner. High levels of miR-196a activated the AKT signaling pathway as indicated by increased phosphorylation of AKT. In addition, high levels of miR-196a promoted cancer cell detachment,migration, invasion and chemosensitivity towards platin derivatives but did not impact on proliferation or apoptosis. Furthermore, miR-196a increased the development of lung metastases in mice after tail vein injection. CONCLUSION: miR-196a exerts a pro-oncogenic influence in colorectal cancer.

VEGF-D expression correlates with colorectal cancer aggressiveness and is downregulated by cetuximab

AIM:To gain mechanistic insights into the role played by epidermal growth factor receptor (EGFR) in the regulation of vascular endothelial growth factors (VEGFs) in colorectal cancer (CRC). METHODS:The impact of high-level expression of the growth factor receptors EGFR and VEGF receptor (VEGFR)3 and the VEGFR3 ligands VEGF-C and VEGF-D on disease progression and prognosis in human CRC was investigated in 108 patients using immunohistochemistry. Furthermore, the expression of the lymphangiogenic factors in response to the modulation of EGFR signalling by the EGFR-targeted monoclonal antibody cetuximab was investigated at the mRNA and protein level in human SW480 and SW620 CRC cell lines and a mouse xenograft model. RESULTS: Human CRC specimens and cell lines displayed EGFR, VEGF-C and VEGF-D expression with varying intensities. VEGF-C expression was associated with histological grade. Strong expression of VEGF-D was significantly associated with lymph node metastases and linked to a trend for decreased survival in lymph node-positive patients. EGFR blockade with cetuximab resulted in a significant decrease of VEGF-D expression in vitro and in vivo. CONCLUSION:In conclusion, the expression of VEGF-D in colorectal tumours is significantly associated with lymphatic involvement in CRC patients and such expression might be blocked effectively by cetuximab.

Endoscopic mucosal resection of colorectal adenomas > 20 mm: Risk factors for recurrence

AIM: To evaluate risk factors for local recurrence after endoscopic mucosal resection of colorectal adenomas > 20 mm.METHODS: Retrospective data analysis of 216 endoscopic mucosal resections for colorectal adenomas > 20 mm in 179 patients(40.3% female; median age 68 years; range 35-91 years). All patients had at least 1 follow-up endoscopy with a minimum control interval of 2 mo(mean follow-up 6 mo/2.0-43.4 mo). Possible factors associated with local recurrence were analyzed by univariate and multivariate analysis. RESULTS: Median size of the lesions was 30 mm(20-70 mm),69.0% were localized in the right-sided(cecum,ascending and transverse) colon. Most of the lesions(85.6%) showed a non-pedunculated morphology and the majority of resections was in piecemeal technique(78.7%). Histology showed carcinoma or high-grade intraepithelial neoplasia in 51/216(23.6%) lesions including 4 low risk carcinomas(pT1 a,L0,V0,R0- G1/G2). Histologically proven recurrence was observed in 33/216 patients(15.3%). Patient age>65 years,polyp size>30 mm,non-pedunculated morphology,localization in the right-sided colon,piecemeal resection and tubular-villous histology were found as associated factors in univariate analysis. On multivariate analysis,only localization in the rightsided colon(HR = 6.842/95%CI:1.540-30.394; P=0.011),tubular-villous histology(HR = 3.713/95%CI: 1.617-8.528;P=0.002) and polyp size>30 mm(HR=2.563/95%CI:1.179-5.570; P=0.017) were significantly associated risk factors for adenoma recurrence. CONCLUSION: Meticulous endoscopic follow-up is warranted after endoscopic mucosal resection of adenomas localized in the right-sided colon larger than > 30 mm,with tubular-villous histology.

Coexpression of receptor-tyrosine-kinases in gastric adenocarcinoma-a rationale for a molecular targeting strategy?

AIM: To define the (co-)expression pattern of target receptor-tyrosine-kinases (RTK) in human gastric adenocarcinoma. METHODS: The (co-)expression pattern of VEGFR1-3,PDGFRα/b and EGFR1 was analyzed by RT-PCR in 51 human gastric adenocarcinomas. In addition,IHC staining was applied for confirmation of expression and analysis of RTK localisation. RESULTS: The majority of samples revealed a VEGFR1 (98%),VEGFR2 (80%),VEGFR3 (67%),PDGFRα (82%) and PDGFRβ(82%) expression,whereas only 62% exhibited an EGFR1 expression. 78% of cancers expressed at least four out of six RTKs. While VEGFR1-3 and PDGFRα revealed a predominantly cytoplasmatic staining in tumor cells,accompanied by an additional nuclear staining for VEGFR3 ,EGFR1 was almost exclusively detected on the membrane of tumor cells. PDGFRβ was restricted to stromal pericytes,which also depicted a PDGFRα expression.receptor-tyrosine-kinases coexpression in gastric adenocarcinoma and might therefore encourage an application of multiple-target RTK-inhibitors within a combination therapy.

Paraesophageal hernia and iron deficiency anemia:Mechanisms,diagnostics and therapy

There is ample clinical evidence suggesting that the presence of large axial or paraesophageal hernias may lead to iron deficiency anemia.So-called Cameron lesions,as well as other small mucosa erosions,in the sliding area of these diaphragmatic hernias lead to invisible chronic blood loss and consequently to iron depletion.While the spectrum of symptoms in these patients is large,anemia is often not the only indication and typically not the primary indication for surgical correction of diaphragmatic hernias.Drug treatment with proton pump inhibitors and iron substitution can alleviate anemia,but this is not always successful.To exclude other possible bleeding sources in the gastrointestinal tract,a comprehensive diagnostic program is necessary and reviewed in this manuscript.Additionally,we discuss controversies in the surgical management of paraesophageal hernias.

Laparoscopic step 1 ALPPS with microwave transection of theliver for Klatskin tumors:Is it worthwhile?

To the Editor：Associating liver partition and portal vein ligation for stagedhepatectomy （ALPPS） was introduced in 2007 [1]. This techniqueis now used worldwide and has a wide spectrum of indications.However, scientific debate and un-regulated surgical experimentationconcerning the application of this technique led the surgeons to organize the first Consensus Meeting [2] to build a scientificconsensus. One of the most controversial indications to ALPPS isits application for Klatskin tumors. The aim of this letter is to analyzethe critical aspects of laparoscopic microwave ALPPS for radicalsurgical treatment of Klatskin tumors.

Image cytometric DNA analysis of mucosal biopsies in patients with primary achalasia

瞄准：为随后的快速的诊断在弛缓不能病人的粘膜活体检视决定 DNA 非整倍性。方法：从中间的活体检视第三根食管与弛缓不能在 15 个病人被获得。染色的 Immunohistochemical 为 p53 为 Ki67 和 PAb 1801 与单音的同种细胞的抗体 MIB-1 被执行，除了为发育异常的常规 histologic 考试。新鲜活体检视材料的原子核是酶的联盟者并且机械地孤立，并且 DNA 内容在福尔根的染色以后与图象血细胞计数被决定。恶意分级的 DNA 根据 Boecking 被估计决定在正常双山峰附近注意的 DNA 价值的可变性。测量的进一步的索引包括了整倍体的率，和 5c- ， 7c-exceeding 和 9c-exceeding 评价。结果：组织学的考试没表明发育异常；当时 MIB-1 (基础) 在 8/15 弛缓不能标本显示出阳性反应， p53 在所有标本是否定的。图象 cytometric DNA 分析在 4/15 (26.7%) 检测了非整倍性标本。从有象标本一样的有鳞的房间癌的 15 个病人的样品只获得了 2 对作为参考测试服务的肿瘤厘米近似。象 9 件 peritumoral 样品(9/15 ) 一样的所有癌(15/15 ) 是一整倍体。从有 peritumoral 和癌标本的弛缓不能病人的活体检视的比较统计上揭示了有效差量考虑整倍体的率(双：P 【 0.0001；四倍的：P = 0.001 ) ，根据 Boecking 恶意分级(P 【 0.0001 ) 并且 5c-(P 【 0.0001 ) ， 7c-(P 【 0.0001 ) ，并且 9c-(P = 0.0001 ) 在各自的顺序与 progredient DNA 改变超过率。结论：发现那 DNA 非整倍性被图象血细胞计数与弛缓不能在病人的食道的标本识别，它可能由于在 27% 病人作为癌前期损害介绍的特定的染色体改变，导致我们断定图象血细胞计数代表一个珍贵屏蔽工具。

Soluble Triggering Receptor Expressed on Myeloid Cells-1 and Inflammatory Markers in Colorectal Cancer Surgery： A Prospective Cohort Study

Background： Major abdominal surgery, including colorectal cancer （CRC） surgery, leads to systemic inflammatory response syndrome that can be detected and monitored with inflammatory markers testing. The aims of the study were to evaluate the usefulness of soluble triggering receptor expressed on myeloid cells-l （sTREM-1 ）, interleukin-6 （IL-6）, procalcitonin （PCT）, and C-reactive protein （CRP） in following the inflammatory response in CRC surgery and postoperative period, as well as to determine if duration of the surgery and the time that the colon has been opened during the surgery （open colon time [OCT]） refect a larger surgical stress through inflammatory markers rise. Methods： The study included 20 patients who underwent CRC surgery and 19 healthy volunteers from June 2011 to September 2012. We determined inflammatory markers 1 day before surgery （T0）, 24 h （T1）, 48 h （T2）, and 7 days after the surgery （T3）. All statistical analyses were calculated using MedCalc Statistical Software version 14.8.1 （MedCalc Software bvba, Ostend, Belgium）. Results： Concentrations ofCRP, PCT, and I L-6 in all measurement times were statistically different and sTREM- 1 did not yield statistical significance. A weak positive correlation was/bund between l L-6 in T 1 and T2 with the duration of the surgery （T 1 ： r= 0.4060, P 〈 0.0001 ; T2：r =0.3430, P〈0.0001）andOCT（T1：r= 0.3640, P〈0.0001,T2：r=0.3430, P〈0.0001）.AweakpositivecorrelationbetweenCRP in T2 and OCT （r = 0.4210, P 〈 0.0001 ） was also found. The interconnectivity of tested parameters showed a weak positive correlation between CRP and IL-6 in T1 （r= 0.3680; P 〈 0.0001 ）, moderate positive correlation in T2 （r = 0.6770; P 〈 0.0001）, and a strong positive correlation in T3 （r = 0.8651; P 〈 0.0001）. Conclusions： CRP, IL-6, and PCT were shown to be reliable for postoperative monitoring. Simultaneous determination of CRP and IL-6 might not be useful as they follow similar kinetics, sTREM- 1 might not be useful in CRC postoperative monitoring.

Laparoscopic staging in hilar cholangiocarcinoma:Is it still justified?

Radical resection remains the only potential curative therapy for hilar cholangiocarcinoma(HCCA).The aim of staging laparoscopic(SL) is to identify patients with previously undetected advanced disease who will not benefit from surgical palliation and therefore avoid unnecessary laparotomies.The accuracy of non-invasive imaging techniques has significantly improved during the last years.As a consequence,the diagnostic yield of SL of biliary tract malignancy should have decreased proportionally.At the same time,some authors have recently questioned the value of laparoscopic ultrasound(LUS) as a complement of SL.In this setting,the precise role of SL and LUS in the preoperative workup of HCCA remains unclear.As it seems undoubtedly clear that its efficacy has decreased in the last decades,there is a general consensus that the universal use of SL shouldn't be recommended anymore;SL should be performed only in selected patients with higher risk of holding unresectable disease(T2/T3 or Bismuth type 3/4 and patients with suspicion of metastases).It would also be recommended in patients with potentially resectable disease who would need preoperative invasive procedures.Finally,SL should be performed preceding laparotomy in one session.Further studies on the benefit of SL and LUS in this subset of HCCA patients are warranted.

Endoscopic findings in patients with Schatzki rings:Evidence for an association with eosinophilic esophagitis

AIM:To investigate endoscopic findings in patients with Schatzki rings(SRs) with a focus on evidence for eosinophilic esophagitis(EoE).METHODS:We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic,Wiesbaden,Germany between July 2007 and July 2010.All patients with endoscopically diagnosed SRs,defined as thin,symmetrical,mucosal structures located at the esophagogastric junction,were prospectively registered.Additional endoscopic findings,clinical information and histopathological findings with a focus on esophageal eosinophilia(≥ 20 eosinophils/high power field) were recorded.The criteria for active EoE were defined as:(1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf;(2) symptoms of esophageal dysfunction;and(3) exclusion of other causes of esophageal eosinophilia.Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy.The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.RESULTS:A SR was diagnosed in 171(3.3%;128 males,43 females,mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinalendoscopy.Twenty of the 116 patients(17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia(≥ 20 eosinophils/hpf).Nine of these patients(8 males,1 female,mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE,whereas in 11(9%) patients with ≥ 20 eosinophils/hpf,a definite diagnosis of EoE was made.Three of the 11 patients(27%) with definite EoE had no suspicious endoscopic features of EoE.In contrast,in the 25 patients in whom EoE was suspected by endoscopic features,EoE was only confirmed in 7(28%) patients.Patients with EoE were younger(mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years,P = 0.012),were more likely to have a history of allergies(73% vs 29%,P = 0.007) and complained more often of dysphagia(91% vs 34%,P = 0.004) and food impaction(36% vs 6%,P = 0.007) than patients without EoE.Endoscopically,additional webs were found significantly more often in patients with EoE than in patients without EoE(36% vs 11%,P = 0.04).Furthermore,the SR had a tendency to be narrower in patients with EoE than in those without EoE(36% vs 18%,P = 0.22).The percentage of males(73% vs 72%,P = 1.0) and frequency of heartburn(27% vs 27%,P = 1.0) were not significantly different in both groups.The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger(mean age 49 ± 10 years vs 58 ± 6 years,P = 0.0008) and were more likely to have a history of allergies(78% vs 24%,P = 0.003) than patients with < 20 eosinophils/hpf.Predictors of EoE were younger age,presence of dysphagia or food impaction and a history of allergies.CONCLUSION:A significant proportion of patients with SRs also have EoE,which may not always be suspected according to other endoscopic features.

Is the schatzki ring a unique esophageal entity?

AIM:To study,whether the association of Schatzki rings with other esophageal disorders support one of the theories about its etiology.METHODS:From 1987 until 2007,all patients with newly diagnosed symptomatic Schatzki rings (SRs) were prospectively registered and followed.All of them underwent structured interviews with regards to clinical symptoms,as well as endoscopic and/or radiographic examinations.Endoscopic and radiographic studies determined the presence of an SR and additional morphological abnormalities.RESULTS:One hundred and sixty-seven patients (125 male,42 female) with a mean age of 57.1±14.6 years were studied.All patients complained of intermittent dysphagia for solid food and 113 (79.6%) patients had a history of food impaction.Patients experienced symptoms for a mean of 4.7±5.2 years before diagnosis.Only in 23.4% of the 64 patients who had endoscopic and/or radiological examinations before their first presentation to our clinic,was the SR previously diagnosed.At presentation,the mean ring diameter was 13.9±4.97 mm.One hundred and sixty-two (97%) patients showed a sliding hiatal hernia.Erosive reflux esophagitis was found in 47 (28.1%) patients.Twenty-six (15.6%) of 167 patients showed single or multiple esophageal webs;five (3.0%) patients exhibited eosinophilic esophagitis;and four (2.4%) had esophageal diverticula.Four (7%) of 57 patients undergoing esophageal manometry had nonspecific esophageal motility disorders.CONCLUSION:Schatzki rings are frequently associated with additional esophageal disorders,which support the assumption of a multifactorial etiology.Despite typical symptoms,SRs might be overlooked.

Development and internal validation of the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score:is the patient suitable for Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)?

Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.