745 YIELD OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN OESOPHAGEAL CANCER

The extent of lymphadenectomy in oesophageal cancer surgery is currently controversial, although current evidence shows that survival is directly related to the number of lymph nodes removed during surgery. Methods Descriptive study of patients with oesophageal cancer who underwent oesophagectomy with extended and total mediastinal lymphadenectomy using a minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our hospital for 2 years (2019 and 2020). Extended lymphadenectomy was indicated in patients with adenocarcinoma of the distal oesophagus, while total lymphadenectomy was indicated in patients with squamous tumours and adenocarcinoma of the middle oesophagus. The characteristics of the series studied and the results obtained in the 90 days postoperatively are described. Results 26 patients, mean age 65 ± 7.8 years, were operated. 21 with total mediastinal lymphadenectomy and 5 with extended lymphadenectomy. 80.7% received neoadjuvant treatment (CROSS scheme). The mean number of lymph nodes removed was 33.6 ± 14.3, with a 50% probability of being affected. As much in the lymphadenectomy of the right (106R) as in the left (106 L) recurrent groups, it was more frequently affected in the distal oesophagus adenocarcinomas. Postoperative morbidity was not negligible, with anastomotic leak rate of 7.7% (thoracic location) and 23.1% (cervical location) the majority mild, 23.1% of recurrent injury and 11.5% of chylothorax. Mortality at 90 days was 15.38%. Conclusion Based on our results, extended and total lymphadenectomy increases as much the global number of lymph nodes removed as the lymph nodes cancer-positive. In addition, it supports the performance of wide lymphadenectomies also in adenocarcinomas of the distal oesophagus. We cannot forget the greater radicalism is taxed with significant morbidity. We should remember the limitation of this study is the low number of cases, the extent of lymphadenectomy continues to be a matter of controversy.

Unusual case of malignant pleural mesothelioma

We present the case of a 65-year-old woman who presented with progressive dysphagia and was diagnosed with achalasia. She subsequently developed bilateral chylous pleural effusions, with no cause identified despite extensive investigations (including computed tomography (CT) scans, gastroscopy and medical thoracoscopy (MT)) and review at a dedicated pleural multidisciplinary team meeting.Despite optimal supportive management she deteriorated and was admitted to the intensive care unit, where she passed away due to sepsis and respiratory failure 10 months after initial presentation. A postmortem returned a diagnosis of epithelioid mesothelioma, encasing the carina, distal oesophagus and coeliac axis.Mesothelioma only very rarely presents with either chylous effusions or achalasia. Additionally while MT normally conveys excellent sensitivity for pleural malignancy, it was insufficient here. This case highlights how an unusually located mesothelioma can produce an unusual clinical picture. It also suggests a role for early video-assisted thoracoscopy to aid diagnosis.

Incarcerated paraoesophageal hernia complicated with distal oesophageal perforation: a combined laparoscopic and endoscopic approach

Paraoesophageal hernias are common, but symptoms are not always present nor pathognomonic of this condition, and patients may be suffering for many years before a diagnosis is made. Incarceration and strangulation are rare, but they are life-threatening complications, warranting an emergent surgical repair. Hiatal hernia incarceration causing distal oesophagus perforation is even rarer. To our knowledge, this is the first case report in adult patients. Despite many advances in care, a high grade of suspicion is needed to diagnose this condition, and the mortality rate for an oesophageal perforation remains high, achieving 50% in some series. We present the surgical management of a case of hiatal hernia incarceration with distal oesophagus perforation by combined laparoscopy and upper endoscopy.

Paroxysmal head drops with ataxia-like symptoms presenting as Sandifer syndrome in a 3-year old girl

We present a case of Sandifer syndrome in a 3-year-old girl who initially presented with a history of recurrent paroxysmal head drops associated with ataxia-like symptoms and recurrent falls sustaining a clavicular fracture on one occasion. She was referred to and seen by the paediatric neurologist. Physical examination, electroencephalogram, MRI brain, electromyograph single fibre study and blood tests were all normal. With the history of hiccups and choking-like episodes she was referred to the speech and language therapist (SALT). SALT assessment did not reveal indications of swallowing impairment or possible aspiration. A barium swallow later showed small amount of reflux into the distal oesophagus. This prompted a trial of lansoprazole and she was referral to the gastroenterologists. Endoscopy and oesophageal manometry were essentially normal. However, the pH impedance study revealed severe gastro-oesophageal reflux disease. She continued with lansoprazole and dairy-free diet and her symptoms resolved.

Large mediastinal haematoma after paraoesophageal hernia repair

Mediastinal haematoma is a rare complication of laparoscopic paraoesophageal hernia repair with few documented cases in the current literature. Presentation of this unique clinical problem can range from extrinsic oesophageal obstruction to life-hreatening cardiac tamponade and therefore, warrants further discussion of at-risk population aetiology, diagnosis and successful management strategies. We present the case of a 71-year-old woman who underwent laparoscopic paraoesophageal hernia repair with nissen fundoplication complicated by severe dysphagia on postoperative day 12. Further evaluation with oesophagram and CT imaging revealed a large mediastinal haematoma with near obstruction of the distal oesophagus. This was managed successfully with laparoscopic transhiatal washout and drainage.

Clinical spirocercosis in a dog in the UK

A 2-year-old female neutered crossbreed dog was presented for evaluation of a 3-day history of haematemesis, melaena and hyporexia. The dog had been imported from a rescue centre in Hungary 4 months prior to presentation. Abdominal CT revealed the presence of a 3 cm×3 cm×4 cm diameter heterogenous intraluminal mass lesion in the gastric cardia, surrounding the ostium of the cardia and continuous with the distal oesophagus. The mass lesion was subsequently surgically resected. Histopathology of the gastric mass lesion was consistent with a Spirocerca lupi granuloma. The patient unfortunately developed a pyothorax and suffered cardiopulmonary arrest resulting in death 2 days postoperatively. To the authors’ knowledge, this is the first reported case of clinical spirocercosis reported in a dog in the UK.

Primary oesophageal squamous cell carcinoma in a cat with bradycardia and ionised hypercalcaemia

An adult male domestic shorthair cat was presented for vomiting and anorexia, with a three-month history of weight loss. Bradycardia was documented during physical examination and was diagnosed as sinusal by electrocardiography. Blood electrolytes analysis revealed a marked ionised hypercalcaemia. Thoracic radiographs revealed a large soft tissue opacity at the level of the distal oesophagus. Subsequent thoracic ultrasonography and oesophagoscopy confirmed the presence of a tissue mass infiltrating distal oesophagus, oesophagogastric junction and neighbouring tissues. After biopsy and histopathological analysis, a squamous cell carcinoma (SCC) was diagnosed. Sinus bradycardia was assumed to be related to an increased vagal tone due to the close proximity of the vagal nerve with the infiltrative lesion or, less likely, severe hypercalcaemia. This case describes an atypical clinical presentation of an SCC in an uncommon location. Furthermore, to the authors’ knowledge, this is the first report of hypercalcaemia associated with oesophageal SCC in a cat.

The laparoscopic approach for epiphrenic diverticula with achalasia

IntroductionEpiphrenic diverticulum (ED) is an uncommon disease that is invariably associated with an underlying oesophageal motility disorder such as achalasia. Management of ED should always be accompanied by treatment of the underlying motility disorder to prevent recurrence of symptoms. Traditionally, ED were approached via a left thoracotomy but as laparoscopy offers better access to the distal oesophagus, its use is becoming more widespread.MethodsA total of 72 patients with oesophageal achalasia underwent laparoscopic surgery at our centre over a period of 7 years. Five (6.9%) of these had associated symptomatic ED. These patients were treated with a laparoscopic transhiatal epiphrenic diverticulectomy using intraoperative oesophagoscopy guidance, combined with a Heller myotomy and Dor fundoplication. Patients were followed up regularly and symptoms were assessed at 12 months.ResultsThe median age of the five patients with associated symptomatic ED was 56 years (range: 38–69 years). Three were male. The mean duration of surgery was 150 minutes (range: 120–180 minutes). One patient (20%) developed a postoperative oesophageal leak. The mean follow-up duration was 25 months (range: 12–36 months). At 12 months, the mean Eckardt score reduced from 6.8 to 1.6. Three patients (60%) reported an excellent outcome, one (20%) reported a good outcome and one (20%) reported a fair outcome.ConclusionsAlong with diverticulectomy, treating the underlying motility disorder with an adequate Heller myotomy and partial fundoplication is of prime importance for a good surgical outcome without symptom recurrence. Laparoscopy offers better access to the distal oesophagus than the conventional thoracic approach for ED.

Intraoesophageal migration of Teflon pledgets used for hiatal hernia repair: a serious adverse event

11 months following an elective paraoesophageal hernia repair, a female patient presents to the emergency department with severe dysphagia. A CT showed a distention of the distal oesophagus caused by a foreign body and dense material inside and outside the oesophagus wall. A gastroscopy confirmed the presence of a bezoar and secondary oesophagitis due to the intraoesophageal migration of Teflon pledgets. Even when used appropriately, only for the crus repair, the use of Teflon pledgets may result in fistulisation through the oesophagus. This complication suggests that the use of Teflon pledgets to buttress a hiatal hernia repair should be used with caution and that an alternative technique (eg, resorbable pledgets) could be preferred.