Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus

The role of staging laparoscopy in complex bariatric surgery

Determining which patients will benefit from bariatric surgery is complex; however, in those who have had previous bariatric surgery or extensive abdominal surgery, this can be particularly challenging. Decisions are often made based on assumptions rather than a complete assessment of all the anatomical and physiological factors. Adopting the approach utilised in gastrointestinal surgery with a diagnostic or staging laparoscopy, it may be possible to more accurately stage disease and determine fitness bariatric surgery. Laparoscopy is relatively low risk and contributes critical information with regard to access, post-operative anatomical changes and response to anaesthetic. Additionally, it allows surgeons to accurately determine the feasibility of undertaking a procedure and facilitates a more precise discussion with patients regarding suitability for surgery. Denying patients bariatric procedures based on an incomplete assessment of risk is unfair. Scenarios in which patients have had previous surgery, particularly bariatric surgery are increasingly common with the numbers requiring revisional surgery steadily rising. Although only applicable in highly selected, very complex cases, diagnostic laparoscopy adds critical information in the preoperative assessment of patients, not only improving care but potentially widening the numbers considered eligible for bariatric surgery. Our limited experience with staging laparoscopy in patients with previous complex abdominal surgery requiring revisional surgery illustrates the potential benefit it offers in determining patient suitability for further bariatric procedures. The adoption of an established technique, applied in a novel setting offers surgeons the opportunity to more thoroughly assess potentially high risk patients as well as the ability to offer personalised care.

Minimally invasive surgery for oesophageal cancer

Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case-control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision.

Functional capillary density in ischemic conditioning: implications for esophageal resection with the gastric conduit

BACKGROUND

Ischemia may lead to leakage at the esophagogastric anastomosis after esophagectomy. The aim of this study was to investigate time dependent changes of gastric microcirculation after ischemic conditioning.

METHODS

Twenty male Lewis rats were used and analyzed in 3 study groups and 1 control group. Group 1 (n = 5) underwent ligation of the left gastric artery and intravital fluorescence microscopy (IVM) on day 0; group 2 (n = 5) underwent IVM at 28 days after ligation of the LGA; and group 3 (n = 5) underwent IVM at 56 days after ligation of the LGA. The controls (n = 5) underwent sham surgery and IVM at 28 days thereafter. IVM was used to analyze gastric microcirculation by means of functional capillary density.

RESULTS

Ligation of the LGA immediately led to significant reduction of perfusion at the lesser (100.5 +/- 3.1 microm/mm(2) vs 220.4 +/- 7.4 microm/mm(2); P <.001) and greater curvatures (195.1 +/- 7.9 microm/mm(2) vs 234.1 +/- 9.4 microm/mm(2); P = .013). During 28 days, microcirculation at the lesser curve ameliorated (164.9 +/- 12.8 microm/mm(2)) and reached normal values after 56 days (215.8 +/- 7.4 microm/mm(2)). At the greater curve, microcirculation was improved during 4 (261.3 +/- 8 microm/mm(2)P = .039) and 8 weeks (317.9 +/- 10.3 microm/mm(2); P <.001 vs control).

CONCLUSIONS

Gastric microperfusion continuously improves after partial devascularization. The results support further clinical studies to optimize gastric ischemic conditioning in patients undergoing esophagectomy.

Staginglaparoskopie in der Onkologie

The availability of more treatment options for gastrointestinal cancer requires precise and reliable pretherapeutic staging. Despite impressive technical progress in modern imaging procedures, this high level of staging quality is not yet warranted in all instances. Visual exploration of the abdominal cavity in extended diagnostic laparoscopy (EDL), including surgical dissection of areas which are primarily inaccessible, biopsy retrieval, and laparoscopic ultrasound, is superior in the diagnostic workup of early peritoneal carcinomatosis and (small) liver metastases. It is helpful to evaluate lymph node infliction and local resectability. In esophageal carcinoma, pretherapeutic EDL is valuable in case of advanced adenocarcinoma of the distal esophagus (AEG I according to Siewert), whereas the incidence of abdominal tumor manifestations in squamous cell carcinoma is too low to perform staging laparoscopy. In advanced gastric cancer, EDL yields relevant additional information in up to 20% of cases. If a multimodal therapeutic strategy is considered, EDL should be obligatory at least in prospective therapeutic studies. In carcinoma of the pancreas, EDL is in general not recommended by the majority of centers. Selective use (in particular in advanced cancer with a high probability of local irresectability) is gaining importance. In hepatobiliary malignancy including colorectal metastases, the high yield of additional information by EDL was confirmed in recent studies.