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Background A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller–Dor myotomy. Methods We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). Results Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p  = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. Conclusion This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller–Dor myotomy.

Introduction National Comprehensive Cancer Network (NCCN) guidelines recommend hepatic resection and lymphadenectomy (LND) for gallbladder adenocarcinoma (GBA). We sought to evaluate compliance with these recommendations and to assess trends in the management and survival of patients with GBA. Methods Using Surveillance, Epidemiology and End Results (SEER)-Medicare-linked data, we identified 2,955 patients with GBA who underwent cancer-directed surgery from 1991 to 2005. We assessed clinicopathologic data, trends in surgical management, and survival. Results From 1991 to 2005, preoperative evaluation included CT (62%), MRI (6%), and PET (2%). Only 383 (13%) patients underwent radical resection/hepatectomy with a temporal increase over the study period (1991–1995, 12%; 1996–1999, 10%; 2000–2002, 12.0%; 2003–2005, 16%; P  < 0.001). For patients undergoing radical resection/hepatectomy, LND ≥ 3 nodes was performed in 96 (3%) patients. Among patients who had LND, 47% had nodal metastasis. The overall 1-, 3-, and 5-year survival was 56%, 30%, and 21%. On multivariate analysis, radical resection/hepatectomy (hazard ratio (HR) = 0.71) and LND ≥ 3 nodes (HR = 0.56) were independently associated with increased survival. There was no significant improvement in survival over time ( P  = 0.60). Conclusions Compliance with NCCN guidelines for GBA remains poor. Survival of patients with surgically managed GBA has not improved over time.

Background With increasing efficacy of preoperative chemotherapy for colorectal cancer, more patients will present with one or more disappearing liver metastases (DLM) on preoperative cross-sectional imaging. Patients and Methods A retrospective review was conducted evaluating the radiological response to preoperative chemotherapy for 168 patients undergoing surgical therapy for colorectal liver metastases at Johns Hopkins Hospital between 2000 and 2008. Results Forty patients (23.8%) had one or more DLM, accounting for a total of 127 lesions. In 22 patients (55%), all DLM sites were treated during surgery. Of the 17 patients with unidentified, untreated DLM, ten patients (59%) developed a local recurrence at the initial site, half of which also developed recurrences in other sites. While the intrahepatic recurrence rate was higher for patients with DLM left in situ ( p  = 0.04), the 1-, 3-, and 5-year overall survival rate was not significantly different for patients with DLM left in situ (93.8%, 63.5%, and 63.5%, respectively) when compared to patients with a radiological chemotherapy response in whom all original disease sites were surgically treated (92.3%, 70.8%, and 46.2%, respectively; p  = 0.66). Conclusions DLM were frequently observed in patients undergoing preoperative chemotherapy for liver metastases. Survival was comparable in patients with untreated DLM, in spite of high intrahepatic recurrence rates seen in these patients. Therefore, aggressive surgical therapy should be considered in patients with marked response to chemotherapy, even when all DLM sites cannot be identified.

Purpose Our aim was to determine what specific patient and peri-operative factors contribute to major complications after esophagectomy. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, data for esophagectomies between the years 2005 and 2008 were extracted and analyzed. Thirty-day post-operative complications were classified into seven major groups: (1) wound infections, (2) respiratory complications (pneumonia, intubation), (3) cardiac complications, (4) deep venous thrombosis, (5) sepsis/septic shock, (6) re-operation, and (7) death. Univariate analysis and logistic regression modeling were performed to determine if a significant association existed between patient factors or peri-operative factors and these post-operative complications. Results One thousand thirty-two patients who underwent esophagectomy were identified. Diabetes was the strongest pre-operative independent predictor of death (odds ratio (OR) 10.98; 95% confidence interval (CI) 1.37–1.15, p  < 0.1) or respiratory (OR 1.86; 95% CI 1.03–3.29, p  = 0.04) or cardiac (OR 5.14; 95% CI 1.93–13.20, p  < 0.01) complications following esophagectomy. Thoracotomy performed during the operation was not associated with an increased risk of respiratory or cardiac complications. Conclusions The major predictors of morbidity after an esophagectomy are the patient factors of diabetes, dyspnea, peripheral vascular disease, and cerebrovascular accident while the peri-operative factors are pre-operative international normalized ratio, contaminated wound classification, and American Society of Anesthesiologists class. Similarly, the major predictors of mortality are diabetes, dyspnea, and age for patient factors and contaminated wound classification for peri-operative factors.

Background Locally advanced unresectable pancreatic adenocarcinoma is characterized by poor survival despite chemotherapy and conventional radiation therapy (RT). Recent advances in real-time image-guided stereotactic radiosurgery (SRS) have made it possible to treat these cancers in two to four fractions followed by systemic chemotherapy. Aims The aims of this study includes the following: (1) obtain local control of the disease; (2) improve the survival of these unresectable patients; (3) evaluate the toxicity of SRS; and (4) report results of the largest series from a single center. Methods Pancreatic SRS involves delivery of high doses of accurately targeted radiation given non-invasively in two to four fractions. We treated 85 consecutive patients with locally advanced and recurrent pancreatic adenocarcinoma from February 2004 to November 2009. Age range: 36–88 years, median 66 years; sex: 50 males, 35 females; race: 79 Caucasian, five African American, one Asian; histology: 80 adenocarcinoma, three islet cell, two other. Pre-SRS staging: T 3–4 85; N + 16, N x 57, N 0 12; M 0 64, M 1 21. All patients were unresectable at the time of SRS. Seventy-one had no prior surgical resection, and 14 had local recurrence after prior surgical resection. Twenty-nine patients had progression of disease after prior conventional RT. Location of the tumor: head, 57; body and tail, 28. Pre-SRS chemotherapy was given in 48 patients. All patients received gemcitabine-based chemotherapy regimen after SRS. Median tumor volume was 60 cm 3 . PET/CT scans done in 55 patients were positive in 52 and negative in three patients. Average maximum standard uptake value was 6.9. Pain score on a scale of 1–10 was: 0–3 in 54, 4–7 in 18, and 8–10 in 13 patients. SRS doses ranged from 15 to 30 Gy with a mean dose of 25.5 Gy delivered in 3 days divided in equal fractions. Mean conformality index was 1.6, and mean isodose line was 80%. Results Tumor control: complete, partial, and stable disease were observed in 78 patients for the duration of 3–36 months with median of 8 months. Pain relief was noted in majority of patients lasting for 18–24 weeks. Most of the patients died of distant disease progression while their primary tumor was controlled. Overall median survival from diagnosis was 18.6 months and from SRS it was 8.65 months. For the group of 35 patients with adenocarcinoma without prior surgical resection or RT and no distant metastases, the average and 1-year survival from diagnosis was 15 months and 50%, respectively, and from SRS it was 11.15 months and 30.5%, respectively. Toxicity A total of 19 (22.37%) patients developed grades III/IV GI toxicity including duodenitis, 12 (14.1%); gastritis, 11 (12.9%); diarrhea, three (3.5%); and renal failure was noted in one (1.2%). Three patient had both gastritis and duodenitis. Toxicity was significantly more prevalent in the first 40 patients compared with the last 45 patients (32.5 vs 13.9%). Conclusions SRS for unresectable pancreatic carcinoma can be delivered in three fractions with minimal morbidity and a local tumor control rate of 91.7%. The survival is comparable or better than the reported results for advanced pancreatic cancer, specifically for the group of previously untreated patients with unresectable tumors. Development of distant metastases remains a significant factor.

Introduction Considerable controversy exists over whether the preoperative use of infliximab (IFX) for refractory ulcerative colitis (UC) increases the risk for surgical complications after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to assess the association between preoperative IFX use and short-term surgical complications in a single-surgeon cohort at a tertiary care academic center. Methods UC patients who underwent IPAA from September 2005 through May 2009 were retrospectively identified. Twenty-nine patients treated with IFX within 12 weeks of surgery and 52 non-IFX control subjects were identified. Short-term postoperative outcomes were compared between groups occurring within 30 days of loop ileostomy closure. Results Patients were similar with respect to demographics, co-morbidities, rate of emergency surgery, hand-sewn anastomosis, and preoperative use of cyclosporine, azathioprine, and high-dose steroids. IFX patients were more likely to have received a laparoscopic hand-assisted IPAA, low-, medium-, and any-dose steroids, 6-mercaptopurine (6-MP), methotrexate, and to have failed medical therapy. There was no short-term mortality. Overall postoperative and infectious complications were similar between IFX and non-IFX groups. Multivariate regression models revealed no independent predictors for postoperative complications when including IFX [odds ratio (OR) 0.78, p  = 0.67], laparoscopic hand-assisted IPAA, 6-MP, methotrexate, steroids, failure of medical therapy, and body mass index. Conclusions Preoperative IFX use was not associated with an increased risk of short-term postoperative complications after IPAA.

Background Evaluation of risk factors for adverse outcomes following distal pancreatectomy (DP) has been limited to data collected from retrospective, primarily single-institution studies. Using a large, multi-institutional prospectively collected dataset, we sought to define the incidence of complications after DP, identify the preoperative and operative risk factors for the development of complications, and develop a risk score that can be utilized preoperatively. Methods The American College of Surgeons National Surgical Quality Improvement Program participant use file was utilized to identify patients who underwent DP from 2005 to 2008 by Current Procedural Terminology codes. Multivariate logistic regression analysis was performed to identify variables associated with 30-day morbidity and mortality. A scoring system was developed to allow for preoperative risk stratification. Results In 2,322 patients who underwent DP, overall 30-day complication and mortality were 28.1% and 1.2%, respectively. Serious complication occurred in 22.2%, and the most common complications included sepsis (8.7%), surgical site infection (5.9%), and pneumonia (4.7%). On multivariate analysis, preoperative variables associated with morbidity included male gender, high BMI, smoking, steroid use, neurologic disease, preoperative SIRS/sepsis, hypoalbuminemia, elevated creatinine, and abnormal platelet count. Preoperative variables associated with 30-day mortality included esophageal varices, neurologic disease, dependent functional status, recent weight loss, elevated alkaline phosphatase, and elevated blood urea nitrogen. Operative variables associated with both morbidity and mortality included high intraoperative transfusion requirement (≥3 U) and prolonged operation time (>360 min). Weighted risk scores were created based on the preoperatively determined factors that predicted both morbidity ( p  < 0.001) and mortality ( p  < 0.001) after DP. Discussion The rate of serious complication after DP is 22%. The DP-specific preoperative risk scoring system described in this paper may be utilized for patient counseling and informed consent discussions, identifying high-risk patients who would benefit from disease optimization, and risk adjustment when comparing outcomes between institutions.

Background There have been numerous studies with conflicting results regarding the use of anti-tumor necrosis factor (TNF) therapy and its relationship to postoperative outcome in Crohn disease. The aim of our study was to examine the rate of postoperative morbidity in patients receiving anti TNF therapy in the perioperative period. Methods All patients undergoing surgery for Crohn disease from 2005 till 2008 were abstracted from a prospective database. Patients undergoing surgery which included a suture or staple line at risk for leaking were selected for the study. A retrospective review of medical records was performed. The study group comprised patients treated with perioperative anti TNF therapy (defined as treatment within 8 weeks preoperatively or up to 30 days postoperatively). The remainder of the patients did not receive perioperative anti TNF therapy. Patient characteristics, disease severity, medication use, operative intervention and 30-day complication were compared between the two groups. Results Three hundred and seventy patients were selected for analysis in this study, of which 119 received perioperative anti TNF therapy and 251 did not. The groups were similar in baseline characteristics, perioperative risk factors and procedures. The group who received perioperative anti TNF therapy had a more severe disease overall as measured by the American College of Gastroenterology (ACG) categories of disease (50% severe fulminant disease in the perioperative anti-TNF therapy group versus 18% in the group that did not receive perioperative anti-TNF therapy, p < 0.001). There was no significant association of perioperative anti TNF therapy and any postoperative complications (27.9% in anti-TNF group versus 30.1% in no anti-TNF group, p = 0.63) nor intra-abdominal infectious complications (5.0% in anti-TNF group versus 7.2% in no anti-TNF group, p = 0.44). Univariate analysis showed that the only factors associated with an increase in postoperative intra-abdominal infections were age and penetrating disease. Conclusions The use of anti-TNF therapy in the perioperative period is safe and is not associated with an increase in overall or infectious complications in Crohn disease patients undergoing surgery.

Background Elevated microsatellite instability at selected tetranucleotide repeats (EMAST) is a genetic signature identified in 60% of sporadic colon cancers and may be linked with heterogeneous expression of the DNA mismatch repair (MMR) protein hMSH3. Unlike microsatellite instability-high (MSI-H) in which hypermethylation of hMLH1 occurs followed by multiple susceptible gene mutations, EMAST may be associated with inflammation and subsequent relaxation of MMR function with the biological consequences not known. We evaluated the prevalence of EMAST and MSI in a population-based cohort of rectal cancers, as EMAST has not been previously determined in rectal cancers. Methods We analyzed 147 sporadic cases of rectal cancer using five tetranucleotide microsatellite markers and National-Cancer-Institute-recommended MSI (mononucleotide and dinucleotide) markers. EMAST and MSI determinations were made on analysis of DNA sequences of the polymerase chain reaction products and determined positive if at least two loci were found to have frame-shifted repeats upon comparison between normal and cancer samples from the same patient. We correlated EMAST data with race, gender, and tumor stage and examined the samples for lymphocyte infiltration. Results Among this cohort of patients with rectal cancer (mean age 62.2 ± 10.3 years, 36% female, 24% African American), 3/147 (2%) showed MSI (three males, two African American) and 49/147 (33%) demonstrated EMAST. Rectal tumors from African Americans were more likely to show EMAST than Caucasians (18/37, 49% vs. 27/104, 26%, p  = 0.014) and were associated with advanced stage (18/29, 62% EMAST vs. 18/53, 37%, non-EMAST p  = 0.02). There was no association between EMAST and gender. EMAST was more prevalent in rectal tumors that showed peri-tumoral infiltration compared to those without (30/49, 60% EMAST vs. 24/98, 25% non-EMAST, p  = 0.0001). Conclusions EMAST in rectal cancer is common and MSI is rare. EMAST is associated with African-American race and may be more commonly seen with metastatic disease. The etiology and consequences of EMAST are under investigation, but its association with immune cell infiltration suggests that inflammation may play a role for its development.

Introduction The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CR-POSSUM) modifications are used extensively to predict and audit post-operative mortality and morbidity. This aim of this systematic review was to assess the predictive value of the POSSUM models in colorectal cancer surgery. Methods Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched for original studies published between 1991 and 2010. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data was specific to colorectal cancer surgery. Predictive value was assessed by calculating observed to expected (O/E) ratios. Results Nineteen studies were included in final review. The mortality analysis included ten studies (4,799 patients) on POSSUM, 17 studies (6,576 patients) on P-POSSUM and 14 studies (5,230 patients) on CR-POSSUM. Weighted O/E ratios for mortality were 0.31 (CI 0.31–0.32) for POSSUM, 0.90 (CI 0.88–0.92) for P-POSSUM and 0.64 (CI 0.63–0.65) for CR-POSSUM. The morbidity analysis included four studies (768 patients) on POSSUM with a weighted O/E ratio of 0.96 (CI 0.94–0.98). Conclusions P-POSSUM was the most accurate model for predicting post-operative mortality after colorectal cancer surgery. The original POSSUM model was accurate in predicting post-operative complications.