Post-esophagectomy diaphragmatic hernia—a case series Summary Background Herniation of abdominal viscera through the esophageal hiatus is a rare complication following surgery for esophageal malignancies. This complication sometimes occurs suddenly and leads to a severe postoperative course. Methods We present three cases of post-esophagectomy diaphragmatic hernia operated for cancer of the lower esophagus. All patients underwent initial upper gastrointestinal (GI) endoscopy and biopsies for diagnosis. Staging was done by contrast computed tomography (CT) of the chest/abdomen/pelvis. Patients underwent neoadjuvant chemotherapy followed by surgery. Results No patients had previous hiatal hernias prior to surgery, and full crural sling dissections were carried out in all cases. The three cases vary in clinical presentation and show imaging findings of diaphragmatic hernias with variable visceral contents. Conclusion While differences in pressure between the abdominal and thoracic cavities are important, the size of the hiatal defect is something that can be influenced surgically. As with all oncological surgery, safe resection margins are essential without adversely affecting anatomical structure and function. The commonest cause is excessive widening of the esophageal hiatus during surgery and, therefore, narrowing the hiatus to fit the conduit can prevent this complication.

Systematic review and meta-analysis on the treatment of diffuse esophageal spasm Summary Background Diffuse esophageal spasm is a rare motility disorder and although diagnosis has improved over the years, optimal treatment remains controversial. The aim of this study was to determine the success rates of alternative treatments for diffuse esophageal spasm. Methods MEDLINE, EMBASE, and the Cochrane Library were searched for studies which reported treatment outcomes in patients with diffuse esophageal spasm. The primary outcome measure was success rate. Secondary outcome measures were morbidity and mortality. Results Ten observational studies involving 101 patients (35 male, 66 female, median age 61 years) with diffuse esophageal spasm treated with nifedipine (n = 24), botulinum toxin (n = 41), and surgery (n = 46) were analyzed. At a median follow-up of 8 months, the overall success rates for nifedipine, botulinum toxin, and surgery were 42.74% (95% c. i. [42.68–42.79], p < 0.00001), 74.39% (95% c. i. [74.27–74.52], p < 0.00001), and 95.74% (95% c. i. [95.69–95.80], p < 0.00001), respectively. Morbidity after surgery was 2% and no operative deaths were reported. Conclusion Surgery appears to be safe and the most successful treatment. The less invasive medical and botulinum toxin therapies provide short-term symptom relief.

Swallowing MRI for GERD—diagnosis and treatment monitoring Summary Background This study aimed to summarize a new technology for magnetic resonance imaging (MRI) of swallowing in the evaluation of esophageal function and gastroesophageal reflux disease (GERD) as well as for postoperative imaging after antireflux surgery. Methods A search was carried out in the Medline database to identify relevant publications. Results Magnetic resonance swallowing is a new, simple, nonionizing radiological method used to confirm the diagnosis of GERD or any motility disorder. The MR diagnosis of GERD was concordant with the pH-metry in 82% of patients. However, the main clinical indication is for evaluation of the cause of fundoplication failure in the postoperative patient who suffers new or recurrent symptoms. Magnetic resonance swallowing is the only method that enables a direct view of the wrap itself. In up to 93% of cases, the correct position of the fundoplication wrap could be determined; 67% of malpositions were assessed, as well as all cases of wrap. Conclusion Real-time MRI swallowing, as a noninvasive and nonionizing method, offers a new perspective for the combined anatomic and functional visualization of GERD, with the possibility of direct visualization of the surrounding structures.

Effect of fast-track surgery on inflammatory response and immune function in patients with laparoscopic distal gastrectomy Summary Introduction Enhanced recovery after surgery can reduce immunosuppression and inflammation in patients with laparoscopic distal gastrectomy Objective The aim of this study was to investigate the effect of fast-track surgery on inflammatory response and immune function in patients with laparoscopic radical gastrectomy. Methods A total of 244 patients undergoing laparoscopic radical gastrectomy for gastric cancer from January 2014 to December 2017 were collected. The patients were divided into fast-track surgery (FTS) and traditional groups. The inflammatory index, immune index, and postoperative complications were measured before and after the operation. Materials and methods There was no significant difference in immune index between the two groups on the day before operation and one day after operation, all P > 0.05. On POD3 and POD6, the expression of CD3+, CD4+, CD4+/CD8+, IgG, IgM, and IgA in the FTS group was higher than that in the traditional group and the difference was statistically significant (P < 0.05).There was no significant difference in inflammation index between the two groups on the day before operation; on POD1, POD3, and POD6, the expression of IL-6, TNF-α, and CRP in the FTS group was lower than in the traditional group and the difference was statistically significant (P < 0.05). The total postoperative complications in the FTS group were significantly lower than those in the traditional group and the difference was statistically significant (P < 0.05). Results Fast-track surgery can effectively reduce the degree of postoperative inflammatory reaction and the incidence of postoperative complications compared with the traditional group and has a smaller impact on the body’s immune function, which is worthy of promotion in clinical practice.

Amazing autumn surgery behind the light

Prognostic impact of allogenic blood transfusion following surgical treatment of esophageal cancer Summary Background Esophageal cancer (EC) surgery is associated with relatively high morbidity and mortality rates and poor overall survival (OS). The impact of allogeneic blood transfusion (aBT) on OS is still a matter of debate. We aimed to investigate the impact of aBT on OS in a homogeneous population of patients undergoing surgical treatment for EC in a single center during a 15-year period. Methods In total, 409 patients who had undergone surgical resection for EC were studied. The clinicopathological parameters and OS were compared between 170 patients (41.6%) who received perioperative aBT and 239 patients (58.4%) who did not. Results Compared with the non-transfused patients, patients who received aBT had lower preoperative hemoglobin levels, more comorbidities, and a more advanced stage of disease as reflected by tumor diameter, nodal metastases, perineural invasion, and the need for multiorgan resection. Transfused patients suffered more frequently from major postoperative complications (26/170 [21.5%] vs. 13/239 [5.7%], p < 0.001) and had a significantly longer hospital stay (17 vs. 15 days, p < 0.001). Multivariate analysis identified tumor grade (p = 0.02), perineural invasion (p = 0.001), N stage (p < 0.001), major postoperative complications (p = 0.01), and comorbidity (p = 0.04) as independent predictors of OS in patients with EC. Perioperative aBT was not found to be an independent predictor of OS in the entire cohort, neither in the stratified subanalysis. Conclusion In our study, an advanced stage of disease and comorbidities resulted in the need for blood transfusion and the occurrence of major postoperative complications, which appeared to decrease the OS in patients with EC.

Usefulness of the holistic context of frailty as a prognostic factor for the outcome of geriatric patients undergoing emergency abdominal surgery Summary Background This study aims to assess frailty in a holistic context as a prognostic factor for the outcomes of a group of geriatric patients undergoing emergency abdominal surgery, identifying the predictors that could be included in a global assessment score of preoperative frailty. Methods Four groups of predictors (physical, cognitive, functional, and social) were evaluated in a group of patients selected for abdominal surgery during the preoperative period. The outcomes for three groups of variables (mortality, morbidity, and use of health resources) were measured using multivariate logistic regression when the response variable is categorical, and the multiple linear regression model for continuous numeric response variables. Results In the period studied, 286 patients aged 65 years or older required an emergency procedure. Physical/phenotypic predictors are consequently related to outcomes of morbidity and mortality and the use of resources, while predictors of mortality and socioeconomic factors predominate in functional and cognitive outcomes. Individually, Mini Nutritional Assessment (short form), sarcopenia, Pfeiffer, Barthel, and Duke tests best predict outcomes after emergency surgery. Conclusion Frailty is a predictive factor that should be routinely used in emergency geriatric surgery in a holistic context that includes physical, cognitive, functional, and social variables. Designing scores based on a broader concept of frailty will enable a more consistent predictive evaluation. Social frailty may have an important predictive value in the postoperative hospital outcome and in other medical fields, and should be studied in more depth in the future.

Autologous aortic arch reconstruction in isolated and combined cardiac lesions Summary Objectives Various surgical strategies have been reported for the treatment of aortic coarctation with hypoplastic aortic arch, including simple resection and end-to-end anastomosis as well as various forms of patch augmentation. These techniques are limited by inadequate relief of arch obstruction and use of patch material predisposed to recurrent obstruction or aneurysm formation. We report our experience with autologous aortic arch reconstruction in isolated and combined lesions, a technique that relieves even complex forms of arch reconstruction without patch material. Methods We retrospectively analyzed our institutional experience with autologous aortic arch reconstruction in isolated and combined cardiac lesions from November 2009 to December 2016. Study endpoints were procedural success, incidence of procedure-related complications, need for re-interventions, and survival. Results In total, 54 patients underwent total autologous aortic arch reconstruction during the study period. Thereof, 13 (24%) had isolated arch obstruction and 41 (76%) had combined cardiac lesions. The majority of procedures were performed in the neonatal period (72%), median age was 8 days (range: 1 day to 4.3 years). Body weight ranged from 2.2 to 16.5 kg (median: 3.7 kg). There was one (1.9%) procedure-related early reoperation for bronchial obstruction. No repeat interventions (dilatation or re-operation) were observed. One patient with syndromic disease died on postoperative day 20 due to sepsis (1.9% in-hospital mortality rate). No late deaths were observed. Median follow-up was 23 months. Conclusion Autologous aortic arch reconstruction is a safe and effective surgical technique for the treatment of aortic arch obstruction in isolated and complex cardiac lesions. It is associated with an extremely low re-intervention rate and a low overall complication rate.

Long-term oncological outcome in thymic malignancies: videothoracoscopic versus open thymectomy Summary Background Complete resection is the standard of care for thymic malignancies. There is still a debate about the optimal surgical approach for thymic tumors, particularly regarding long-term oncological outcome. This study aimed to compare videothoracoscopic surgery (VTS) with open surgery for thymic malignancies, regarding perioperative and long-term oncological outcomes. Methods A prospective study ran from 2010 to 2019. Patients with thymoma or thymic carcinoma underwent complete thymectomy via VTS or open surgery and were followed up. The long-term oncological outcome was disease recurrence. Results There were 29 patients in the VTS group and 35 patients in the open group with an average follow-up period of 80 months. The VTS approach significantly shortened operative duration (89.7 versus 116.9 min), caused less blood loss (56.9 versus 176.3 ml), reduced pain score (4.8 versus 6.7), and shortened chest drainage duration (2.1 versus 3.1 days) as well as hospital stay (5.1 versus 7.7 days). The two groups were comparable in long-term oncological outcome (two recurrences in the VTS group and one in the open group). Conclusions Compared to open surgery, VTS leads to superior perioperative outcomes and a comparable long-term oncological outcome. The authors advocate the VTS approach as a routine option for the surgery of thymic malignancies. Main novel aspects Videothoracoscopic surgery is less traumatic and has faster recovery times than open surgery, with a comparable long-term oncological outcome.

Relationship of preoperative serum calcium and extent of neck surgery to postoperative hospital stay in patients with primary hyperparathyroidism and severe bone disease. A case series Summary Introduction After parathyroidectomy for patients with severe osteoporosis, hospital stay is likely to be prolonged because of rebound severe hypocalcemia. There is currently no method that predicts the occurrence of such an adverse effect. This study aimed to investigate preoperative serum calcium level and extent of neck surgery as predictors of the length of postoperative hospitalization. Patients and methods Fifty-five patients with primary hyperparathyroidism and severe bone disease had parathyroidectomies, 27 by a conventional bilateral exploration and 28 by focused unilateral surgery. The duration of postoperative hospitalization was tested for correlation to preoperative total serum calcium and to the extent of neck surgery. Results The median postoperative hospital stay was five days. After conventional exploration it was eight days, and after focused parathyroidectomy it was three days, a highly significant difference. Preoperative total calcium had an insignificant weak positive correlation with hospital stay. Conclusion For primary hyperparathyroidism with severe bone disease, focused unilateral parathyroidectomy is likely to reduce the duration of postoperative hospital stay. Preoperative total serum calcium is not a reliable predictor of hospital stay in this subset of patients.