Elsevier BV

Recently, simultaneous hepatectomy and pancreatoduodenectomy has been performed for the treatment of some biliary tract cancers in Japan. Postoperative hepatic failure is a common and potentially fatal complication. The aim of this study was to examine the reduction in the rate of liver regeneration after 70% hepatectomy (Hx) alone or in combination with 70% pancreatectomy (HPx). Male Sprague-Dawley rats underwent hepatectomy or simultaneous hepatectomy and pancreatectomy. The ratio of liver weight to body weight, the labeling index of hepatocytes in vivo, and DNA synthesis of the hepatocytes and/or Kupffer cells in primary culture were analyzed. The ratio of liver weight to body weight and the labeling index in HPx rat were found to be significantly lower than those values in Hx rats. There were no significant differences in plasma alanine aminotransferase levels between the two groups. The inhibitory effect on DNA synthesis was observed with coculture of hepatocytes and Kupffer cells when the portal plasma obtained 1 hour after operation was added. We further observed that the conditioned medium of Kupffer cells stimulated by the addition of the portal plasma that was obtained 1 hour after HPx inhibited DNA synthesis of hepatocytes. This effect was abolished after incubation at 56° C for 30 minutes. These results strongly suggest the existence of a growth inhibitory factor in portal plasma after HPx. This heat-labile growth inhibitory factor was released from Kupffer cells and would appear to act on hepatocytes in a paracrine manner.

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.

Data on risk factors of postoperative recurrence in patients with Crohn’s disease (CD) have shown conflicting results. The aim of this retrospective study is to identify predictors of early symptomatic recurrence of CD after surgical intestinal resection in the Chinese population. Patients diagnosed as CD who underwent intestinal resection in Jinling Hospital between May 2004 and December 2010 were included in our study. Clinical data of these patients were reviewed. Multivariable survival analysis was performed to elucidate risk factors of early postoperative symptomatic recurrence. There were a total of 141 CD patients who had at least one previous curative resection for CD under regular follow-up in our unit. Our data indicated disease behavior (95 % CI 1.01–1.70, P = 0.044), smoking habits (95 % CI 1.32–2.84, P = 0.001), indication of perforation (95 % CI 1.09–4.02, P = 0.026), and location of anastomosis (95 % CI 1.09–3.39, P = 0.023) which are, as a result, strong independent predictors of symptomatic recurrence, while the anastomosis type as side-to-side anastomosis (SSA) was significantly associated with a decreased risk of symptomatic recurrence when compared with other anastomosis type (95 % CI 0.26–0.94, P = 0.038). Medical prophylaxes also played a role in the prevention of postoperative symptomatic recurrence. A smoking habits and perforation indication for surgery at the time of resection are associated with an increased risk of symptomatic recurrence. Anastomosis type with SSA is associated with a reduced risk of symptomatic recurrence. This population-based study supports the concept that environmental factors, disease character, and surgical technique influence the risk of postoperative symptomatic recurrence of CD.

Gastric lymphomas are a relatively rare form of malignancy and controversy about their optimum treatment still exists. To date, there have been no studies directly comparing results of medical therapy alone versus a combination of surgery plus medical therapy. We reviewed our experience in the three teaching hospitals of the University of Massachusetts Medical School to determine the role of surgery in the management of early gastric lymphoma. Statistics were evaluated by means of chi-square, log-rank, and Kaplan-Meier curve analysis where appropriate. Using tumor registry data, 39 patients were treated for early disease at our medical school from 1980 to 1998. Patients treated with surgery plus chemotherapy and radiation had a 90% 5-year survival compared to patients who received chemotherapy and radiation alone (55% 5-year survival; P < 0.01). When we compared all patients on an intention-to-treat basis (patients preoperatively thought to have early-stage disease), there was still a significant survival benefit with the addition of surgery to their management. Because this is an uncommon disease, there are no large prospective studies examining treatment. Based on our retrospective experience, surgical resection should be considered an important adjunct in the treatment of gastric lymphomas in early-stage disease.

Gastric cardia cancer is currently treated with several operations. The purpose of the current study was to compare outcomes associated with three common operative approaches. The ACS-NSQIP Participant Use File was searched to identify all patients with gastric cardia malignancy who underwent total gastrectomy (TG), transhiatal esophagectomy (THE), or thoraco-abdominal esophagectomy (TAE) between 2005 and 2012. Demographic, perioperative risk factors, and outcomes were analyzed. Overall, there were 982 patients identified in the database who met inclusion criteria. The median age was 65 years (range 20–88) and 807 (82.2 %) were male. The number of patients allocated to each approach was 204 TGs (20.8 %), 271 THE (27.6 %), and 507 TAE (51.6 %). All approaches had similar major morbidity, cardiopulmonary morbidity, and 30-day mortality, however, TAE was associated with the highest overall morbidity (TAE 49.9 % vs. TG 40.7 % and THE 43.5 %, p = 0.048). The independent risk factors predicting mortality were age greater than 65 years, history of myocardial infarction, and postoperative cardiopulmonary morbidity. For patients with proximal gastric cancer, the three most common operative approaches were associated with clinically-significant rates of overall and major morbidity. Approach-associated morbidity should be considered along with tumor location and extent when choosing a technique for resection of gastric cardia malignancy.

Non-essential surgery had largely been suspended during the COVID-19 Pandemic. Enormous amounts of resources were utilized to shift surgical practices to a “disaster footing” with most elective surgeons assuming new roles to offset the anticipated burden from surgical and medical personnel delivering acute care. As the number of COVID-19-infected patients began to plateau in the state of Ohio, a four-phase “Responsible Return to Surgery” approach was adopted in concert with the Ohio Department of Health and the Ohio Hospital Association. This approach was adopted understanding that a simple return to the status quo prior to the COVID-19 pandemic might be harmful to patients, providers, and staff. The discrete phases undertaken at our quaternary care institution for a responsible return to non-essential surgery are outlined with the goal of ensuring timely care, minimizing community transmission, and preserving personal protective equipment. Operationalizing these phases relied upon the widespread use of telehealth, systematic COVID-19 testing, and real-time monitoring of hospital and personal protective equipment resources.

The impact of postoperative adjuvant chemotherapy on the oncological outcomes for stage II colorectal cancer remains controversial. The literature was searched for studies published between 1985 and 2010 in which patients with stage II colorectal cancer were randomly assigned to receive either surgery combined with postoperative adjuvant chemotherapy or surgery alone. End points included 5-year overall survival, 5-year disease-free survival, recurrence, and mortality. A significant improvement in 5-year overall survival was associated with surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.81; 95% confidence interval (CI), 0.71–0.91) and for stage II rectal cancer (hazard ratio, 0.72; 95% CI, 0.61–0.86). The 5-year disease-free survival also favored the group of surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.86; 95% CI, 0.75–0.98) and for stage II rectal cancer (hazard ratio, 0.34; 95% CI, 0.22–0.51). For stage II colon cancer, a significant reduction in risk of recurrence was found in favor of postoperative adjuvant chemotherapy (risk ratio, 0.82; 95% CI, 0.71–0.95). Postoperative adjuvant chemotherapy for stage II colorectal cancer appears to be associated with improved 5-year overall survival and 5-year disease-free survival, and reduction in risk of recurrence.

The effect on cancer-specific survival (CSS) from the number of resected nodes (node yield) and the number of nodes involved with colon cancer has not been studied with respect to age. Data from 1992 to 2006 from the Surveillance, Epidemiology and End Results (SEER) registry were analyzed for colon cancer patients undergoing curative resection, comparing younger (<40; n = 2,642) and older (≥40; n = 138,769) patients. The mean number of positive nodes and mean node yield was higher for the younger group. Younger patients were more likely to have metastatic disease and to have a nodal yield of ≥12 nodes, and were less likely to have node-negative colon cancers (all p < 0.0001). Younger age was associated with a lower risk of death from colon cancer (HR = 0.65; p < 0.0001). No CSS effect was noted with the interaction of age with either node yield or node involvement. Node yield <12 created a higher risk of cancer-specific death (HR = 1.22; p < 0.0001) regardless of stage. KM plots by stage demonstrated a CSS advantage (p < 0.0001) for younger patients. Younger patients with colon cancers do not have a worse CSS simply because of their young age, so long as proper oncologic surgical principles are adhered to.

Many surgical procedures have been developed to repair rectovaginal fistulas even if no “procedure of choice” is reported. The authors report a case of relatively uncommon, complex, medium-high post-obstetric rectovaginal fistula without sphincteral lesions and treated with a novel tailored technique. Our innovative surgical management consisted of preparing the neck of the fistula inside the vagina and folding it into the rectum so as to enclose the fistula within two semicontinuous sutures (stapled transanal rectal resection); no fecal diversion was performed. Postoperative follow-up at 9 months showed no recurrence of the fistula.