Featured Articles in Jul 2017

From Heartburn to Barrett’s Esophagus, and Beyond

 

Author list: Francisco Schlottman, Marco G. Patti, Nicholas J. Shaheen

 

Abstract: 

Background

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. About 10–15% of patients with GERD will develop Barrett’s esophagus (BE).

 

Method

The aims of this study were to review the available evidence of the pathophysiology of BE and the role of anti-reflux surgery in the treatment of this disease.

 

Results

The transformation of the squamous epithelium into columnar epithelium with goblet cells is due to the chronic injury produced by repeated reflux episodes. It involves genetic mutations that in some patients may lead to high-grade dysplasia and cancer. There is no strong evidence that anti-reflux surgery is associated with resolution or improvement in BE, and its indications should be the same as for other GERD patients without BE.

 

Conclusion

Patients with BE without dysplasia require endoscopic surveillance, while those with low- or high-grade dysplasia should have consideration of endoscopic eradication therapy followed by surveillance. New endoscopic treatment modalities are being developed, which hold the promise to improve the management of patients with BE.

 

URL: http://rdcu.be/tini


Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda

 

Author list: Christian Ngarambe, Blair J. Smart, Neeraja Nagarajan, Jennifer Rickard 

 

Abstract: 

Background

The surgical Apgar score (SAS) has demonstrated utility in predicting postoperative outcomes in a variety of surgical disciplines. However, there has not been a study validating the utility of the SAS in surgical patients in low-income countries. We conducted a prospective, observational study of patients undergoing laparotomy at a tertiary referral hospital in Rwanda and determined the ability of SAS to predict inpatient major complications and mortality.

 

Methods

All adult patients undergoing laparotomy in a tertiary referral hospital in Rwanda from October 2014 to January 2015 were included. Data were collected on patient and operative characteristics. SAS was calculated and patients were divided into four SAS categories. Primary outcomes were in-hospital mortality and major complications. Rates and odds of in-hospital mortality and major complications were examined across the four SAS categories. Logistic regression modeling and calculation of c-statistics was used to determine the discriminative ability of SAS.

 

Results

218 patients underwent laparotomy during the study period. One hundred and forty-three (65.6%) were male, and the median age was 34 years (IQR 27–51 years). The most common diagnosis was intestinal obstruction (97 [44.5%]). A high proportion of patients (170 [78%]) underwent emergency surgery. Thirty-nine (18.3%) patients died, and 61 (28.6%) patients had a major complication. In-hospital mortality occurred in 25 (50%) patients in the high-risk group, 12 (16%) in the moderate-risk group, 2 (3%) in the mild-risk group and there were no deaths in the low-risk group. Major complications occurred in 32 (64%) patients in the high-risk group, 22 (29%) in the moderate-risk group, 7 (11%) in the mild-risk group and there were no complications in the low-risk group. SAS was a good predictor of postoperative mortality (c-statistic 0.79) and major complications (c-statistic 0.75).

 

Conclusion

SAS can be used to predict in-hospital mortality and major complications after laparotomy in a Rwandan tertiary referral hospital.

 

URL: http://rdcu.be/thJ2


Clinical Prediction Rules for Appendicitis in Adults: Which Is Best?

 

Author list: Malsha Kularatna, Melanie Lauti, Cheyaanthan Haran, Wiremu MacFater, Ying Huang, John McCall, Andrew D. MacCormick

 

Abstract: 

Background

Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best.

 

Method

A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values.

 

Results

Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84–0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values.

 

Conclusion

There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.

 

URL: http://rdcu.be/tinC


Population-Based Autopsy Study of Traumatic Fatalities

 

Author list: S. Saar, A. Lomp, J. Laos, V. Mihnovits, R. Salkauskas, T. Lustenberger, M. Vali, U. Lepner, P. Talving

 

Abstract: 

Background

Injuries result in 5.8 million global fatalities annually and are the leading cause of death in younger individuals. Nevertheless, population-based autopsy investigations on traumatic deaths are scarce. We set out to study all consecutive autopsies on traumatic fatalities performed in a 5-year time segment in Estonia.

 

Method

After the ethics review board approval, all consecutive autopsies after blunt or penetrating deaths occurring in prehospital or in-hospital settings between January 1, 2009, and December 31, 2013, were retrospectively reviewed using the National Forensic Medicine Database. Fatalities due to suffocation, intoxication, burns, or freezing were excluded. Data collection included demographics, mechanism of injuries, cause of death, and a detailed injury profile. Primary outcome was cause of death. Secondary outcomes included injury patterns.

 

Results

Overall, 1344 autopsies were included. 75.7% of deaths were following blunt trauma. Mean age was 50.4 ± 18.5 years, and 77.1% were male. A total of 71.8% of deaths occurred in the prehospital setting. Accidents, assaults, and suicides constituted 64.4, 20.5, and 15.2% of deaths, respectively. A total of 51.1% of injury fatalities had a positive blood alcohol level (BAL). Mean injury severity score was 39.7 ± 23.9. Most common cause of death was due to head injuries at 50.5% followed by hemorrhage at 30.4%. Cardiac and aortic injuries were the predominant cause of hemorrhage-related fatalities.

 

Conclusions

The current population-based investigation documented brain injury as the predominant cause of death followed by cardiac and aortic injuries. High incidence of positive BAL among injury fatalities requires national initiatives for alcohol harm reduction and law enforcement efforts.

 

URL: http://rdcu.be/tinL


Window Resection for Intraluminal Cricotracheal Invasion by Papillary Thyroid Carcinoma

 

Author list: Sueyoshi Moritani

 

Abstract: 

Background

Invasion of the upper aerodigestive tract by papillary thyroid carcinoma (PTC) affects both prognosis and quality of life. We assessed the efficacy of window resection for patients with intraluminal cricotracheal invasion.

 

Methods

Clinical data were retrospectively reviewed for all patients with PTC undergoing surgery at our institution during 1981–2009. Seventy-six patients with intraluminal cricotracheal invasion were enrolled, including 34 relapsing patients.

 

Results

The 10-year disease-specific survival rate of 42 patients with intraluminal invasion who underwent initial surgery was 60.8%. The lesion was located on the laryngo-trachea in 3 (4%) of 12 patients with locoregional recurrence. No major surgical complications were associated with cricotracheal resection. Stomal closure was achieved in 30 of 76 patients (39%). Twelve patients (16%) had a permanent stoma that was directly related to cricotracheal invasion. Their stomas had been caused by large cricotracheal defects with greater than or equal to 50% circumferential resection of the trachea. Sixty-seven patients (88%) had PTC invasion into other aerodigestive structures, including the recurrent laryngeal nerve (n = 54), esophagus (n = 38), and thyroid cartilage or intraluminal invasion of the larynx (laryngeal invasion n = 23). Multivariate analysis showed that cricotracheal invasion accompanied by recurrent laryngeal nerve invasion was predictive of permanent stoma (odds ratio 0.32; 95% CI 0.107–0.945; p = 0.039).

 

Conclusions

Window resection appears to be an effective treatment option for patients with intraluminal cricotracheal invasion. However, this surgical technique may be inappropriate for the treatment of large cricotracheal defects without a supportive hard structure.

 

URL: http://rdcu.be/tinU


Solid Pseudopapillary Neoplasms of the Pancreas: A Surgical and Genetic Enigma

 

Author list: Leon Naar, Despoina-Amalia Spanomichou, Aikaterini Mastoraki, Vassilios Smyrniotis, Nikolaos Arkadopoulos

 

Abstract: 

Solid pseudopapillary neoplasms of the pancreas are rare tumors accounting for 1–2% of pancreatic exocrine neoplasms. This entity was first described by Dr. Frantz in 1959 and was defined by the World Health Organization in 1996 as “solid pseudopapillary tumor.” It is most often a benign neoplasm, but 10–15% of the cases are malignant. Over the past decades, the incidence of this tumor is increasing. However, many surgeons are still unfamiliar with this neoplasm and its unique characteristics, which can lead to pitfalls in the diagnosis and treatment. The correct diagnosis of SPNP is of utmost importance since it has a low malignant potential and with the appropriate treatment, patients have a long life expectancy. There are many genetic alterations, involving various signaling pathways that have been associated with SPNP and are very important in diagnosing the tumor. The cornerstone of SPNP treatment includes surgical excision of the tumor, preserving as much pancreatic tissue as possible. We review the information in the literature regarding more organ-preserving techniques and possible clinical features that might indicate a malignant potential, thus demanding a more radical intraoperative excision.

 

URL: http://rdcu.be/tin1


Enteral Diet Enriched with ω-3 Fatty Acid Improves Oxygenation After Thoracic Esophagectomy for Cancer: A Randomized Controlled Trial

 

Author list: P. A. Colas, E. Duchalais, Q. Duplay, V. Serra-Maudet, S. Kanane, C. Ridereau-Zins, E. Lermite, C. Aube, A. Hamy, A. Venara

 

Abstract: 

Background

Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has a success rate of 40–70%. Identifying patients with a risk of medical treatment failure would improve outcomes. The aim of this study was to identify the risk factors for failure of medical treatment in patients admitted with PDwAP.

 

Method

This multicenter retrospective observational study included all consecutive patients admitted for PDwAP and not surgically treated over a 7-year period. Peritonitis classified on the Hinchey scale was excluded. Potential clinical, biological and radiological risk factors for medical treatment failure were collected and compared between the group of patient with a failure of medical treatment (F) and the group in which treatment did not fail. Data were collected at referral.

 

Results

Ninety-one patients were included, and 29 had a failure of treatment (31.9%). The median heart rate was different between the two groups (p < 0.001), at approximately 100/min in the F group. A blood level of C-reactive protein (CRP) ≥150 mg/mL was associated with a higher rate of failure (p = 0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5 mm and intraperitoneal liquid located in the pouch of Douglas were more likely to be present in the F group (respectively, p = 0.001 and p < 0.001). A multivariate analysis showed independent risk factors as being the highest pneumoperitoneum diameter >5 mm (OR 5.193; p = 0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p = 0.036). 

  

Conclusions

The severity of sepsis (tachycardia and CRP ≥150 mg/mL) and of imaging signs (pneumoperitoneum ≥5 mm and peritoneal fluid in the pouch of Douglas) were risk factors for medical treatment failure of PDwAP requiring special supervision so as not to lose time in undertaking surgical management.

 

URL: http://rdcu.be/tin6


 

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