Ideal Anatomical Landmark Points for Thoracic Esophagus Segmentation in the Chinese Population

Introduction: The standards of esophagus segmentation remain different between the Japan Esophageal Society (JES) guideline and the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) guideline. This study aimed to present variations in the location of intrathoracic esophageal adjacent anatomical landmarks (EAALs) and determine an appropriate method for segmenting the thoracic esophagus based on the relatively fixed EAALs.Patients and Methods: The distances from the upper incisors to the upper border of the esophageal hiatus, lower border of the inferior pulmonary vein (LPV), tracheal bifurcation, lower border of the azygous vein (LAV), and thoracic inlet were measured in the patients undergoing thoracic surgery. The median distances between the EAALs and the specified starting points, as well as reference value ranges and ratios, were obtained. The variation coefficients of distances and ratios from certain starting points to different EAALs were calculated and compared to determine the relatively fixed landmarks.Results: This study included 305 patients. The average distance from the upper incisors to the upper border of the cardia, the midpoint between the tracheal bifurcation and esophageal hiatus (MTBEH), LPV, LAV, tracheal bifurcation, and thoracic inlet were 41.6, 35.3, 34.8, 29.4, 29.5, and 20.3 cm, respectively. The distances from the upper incisors or thoracic inlet to any intrathoracic EAALs in men were higher than in women. In addition, the height, weight, and body mass index (BMI) were correlated with the distances. The ratio of the distance between the upper incisors and tracheal bifurcation to the distance between the upper incisors and upper border of the cardia and the ratio of the distance between the thoracic inlet and tracheal bifurcation to the distance between the thoracic inlet and upper border of the cardia possessed relatively smaller coefficients of variation.Conclusion: The distances from the EAALs to the upper incisors vary with height, weight, BMI, and gender. Compared with distance, the ratios are more suitable for esophagus segmentation. Tracheal bifurcation and MTBEH are ideal EAALs for thoracic esophagus segmentation, and this is consistent with the JES guideline recommendation.

Mediastinal Extension of a Pancreatic Pseudocyst: A Rare Intrathoracic Complication of Pancreatitis

Pancreatic pseudocysts are a common complication of pancreatitis. However, mediastinal extension of a pseudocyst is rare and often presents with atypical symptoms. We present a case of mediastinal extension of a pancreatic pseudocyst in a 56-year-old woman with a history of alcohol-related chronic pancreatitis, who presented with acute on chronic epigastric abdominal pain and atypical chest pain. Serum lipase was elevated, and imaging by contrast-enhanced computed tomography (CT) demonstrated a paraesophageal fluid collection. This collection was continuous with a peripancreatic pseudocyst and extended into the posterior mediastinum via the esophageal hiatus. Mediastinal extension of a pancreatic pseudocyst was confirmed by magnetic resonance imaging (MRI). The patient was managed conservatively in the hospital with parenteral nutrition therapy, pain control, and close imaging observation. The patient was discharged home to continue conservative management and close imaging follow-up. An initial follow-up CT examination 8 weeks after discharge revealed interval decrease in the posterior mediastinal collection but also interval development of loculated left pleural and pericardial effusions.

Laparoscopic plasty of giant diaphragmatic hernia using a biocarbonic implant

This article discusses the results of a prospective randomized study of laparoscopic plasty of giant hiatal hernias with a hernial defect area of 1020 cm2. A total of 92 patients underwent surgery from 2014 to 2020. The patients were divided into two study groups. Group 1 included 46 patients who underwent laparoscopic plasty of the esophageal hiatus by posterior cruroraphy. Group 2 consisted of 46 patients who underwent laparoscopic plasty of the esophageal hiatus using a two-layer Ultrapro (Ethicon) mesh biocarbonic implant according to the developed technique.

The impact of the nucleotide-binding oligomerization domain 1 (NOD 1) gene polymorphism on Helicobacter Pylori induced chronic gastritis in hepatic patients.

Background: Chronic infection with Helicobacter pylori (H.pylori ) causes atrophic and even gastric metaplastic changes, and it has a well-known link to peptic ulceration. Nucleotide-binding oligomerization domain-containing protein 1 (NOD1) is a protein receptor that is presented by the NOD1 gene. It distinguishes H.pylori bacterial molecules and enhances an immune response Objectives: to describe the relation between the NOD1 gene (rs2075820) polymorphism and H.pylori infection in hepatic and non hepatic patients with chronic gastritis, study its impact on the degree of chronic gastritis in H.pylori positive individuals, and to examine the effect of H. pylori on clinical, endoscopic and histopathological findings and child paugh scoring in hepatic patients. Methodology: Gastric tissue samples were taken from selected 200 patients with chronic gastritis, either hepatic or non hepatic. Rapid urease test and pathological findings classified them into H.pylori infected and non infected patients. Genotyping of NOD 1 was studied using polymerase chain reaction /restriction fragment length polymorphism (PCR–RFLP) method. Results: A significant higher frequency of AA genotype, and the A allele of NOD1 gene in H.pylori +ve patients, either hepatic; (58%)-(73%) or non hepatic;(62%)-(78%) as compared to H.pylori –ve patients,(P <0.001). A highly significant relation between NOD1 genotypes and endoscopic findings, where most of H.pylori infected patients with AA genotype had more peptic ulcer, antral erosion, gastric prolapse, esophageal varices and esophageal hiatus hernia compared to patients with GA and GG genotypes, (P<0.001). No significant impact of H.pylori on signs of liver affection and child paugh scoring in hepatic patients. Conclusions: In NOD1 gene polymorphism, AA genotype and A allele have significantly implicated in H.pylori infection susceptibility and progression. While GG genotype and G allele have a protective effect against H.pylori infection.

Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis

Introduction The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer. Materials and methods Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted. Results Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0–22.0%), 1.4% (95% CI = 0.8–2.2%), 35% (95% CI = 20.0–54.0%), and 5.0% (95% CI = 3.0–8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0–21.6%). Conclusions Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.

Safety and feasibility of total laparoscopic radical resection of Siewert type II gastroesophageal junction adenocarcinoma through the left diaphragm and left thoracic auxiliary hole

Background The incidence of adenocarcinoma of the esophagogastric junction (AEG) is rising every year; however, the mode of operation for Siewert II AEG is still controversial. Accumulating evidence has shown that transabdominal surgery is better than transthoracic surgery for Siewert II AEG with esophageal invasion < 3 cm. In patients with obesity, a large tumor size, and high transection of the esophagus, the transabdominal esophageal hiatus approach for lower mediastinal lymph node dissection and posterior mediastinal anastomosis is difficult. Thus, total laparoscopic radical resection of Siewert II AEG is carried out through the left diaphragm and left chest auxiliary hole for the optimal surgical field of vision and space. In this prospective study, we assessed the feasibility of carrying out the procedure abdominally through the left diaphragm and auxiliary hole. Methods Ten patients with Siewert II AEG were recruited between April and June 2019. Siewert II AEG was treated by total laparoscopy through the left diaphragm and left chest auxiliary hole. Clinicopathological features, surgical data, and adverse events were collected and analyzed in this prospective study. Results The average duration of the operation was 348 ± 37.52 min, lower mediastinal dissection took 20.6 min, the OrVil anastomosis time was 29.8 min, the time necessary to suture the seromuscular layer through the left thoracic auxiliary hole was 11 min, the safety margin was 3.2 cm, and the total number of lymph nodes dissected was 40.6. The number of lower mediastinal lymph nodes dissected was 6.2. The rate of lymph node metastasis in the N110 group was 9 ± 12.45%, and the average intraoperative blood loss was 170 ± 57.47 mL. No anastomotic leakage or anastomotic stricture occurred after the operation. The time of intestinal function recovery was 2 days, and the first time of enteral nutrition through a jejunal nutrition tube was 2.4 days. No tumor recurrence was found in 10 patients at 1 year postoperatively. Conclusion Total laparoscopic radical resection through the left diaphragm and left thoracic auxiliary hole for Siewert II AEG patients is feasible and safe. Thus, it may be a good surgical alternative for patients with esophageal tumors invading less than 3 cm. Trial registration ChiCTR, ChiCTR2000034286. Registered 8 July 2020, http://www.chictr.org.cn/showproj.aspx?proj=55866.

Esophageal Hiatus Hernia

A 83-year-old women presented to the emergency department with epigastric pain and vomiting that had progressively worsened over a period of 1 year. Her medical history was notable for type 2 diabetes and hypertension. A physical examination revealed that breath sounds were weakened. Her abdomen was soft, with moderate epigastric tenderness and normal bowel sounds. The rest of the physical examination was unremarkable. A radiograph of the chest confirmed compression of both lungs for unknown reasons (Figure 1A). Computed tomography (CT) of the chest revealed a large hiatus hernia containing almost the entire stomach (Figure 1B). A diagnosis of esophageal hiatus hernia was made. Hiatus hernia refers to a disease status involving herniation of the contents of the abdominal cavity, especially the stomach, through esophageal hiatus of the diaphragm into the mediastinum. It is accepted that the prevalence of hiatus hernia increases with age and body mass index. The typical symptom of hiatus hernia is gastroesophageal reflux and less common symptoms are epigastric or chest pain and dysphagia. It is necessary to make a critical risk-benefit assessment mandatory before complicated and surgical treatment of hiatus hernia, usually coupled with an antireflux procedure.8,9 After a well-informed discussion of treatment options with the patient and her family, the decision was made to pursue surgery. After the procedure, she clinically improved and was discharged home with outpatient follow-up.

569 LAPAROSCOPIC REPAIR OF A VOLUMINOUS SYMPTOMATIC HIATAL HERNIA USING AN ABSORBABLE SYNTHETIC MESH

In symptomatic voluminous paraesophageal hiatal hernias not only a laparoscopic surgical approach, but also the use of mesh can be considered too. The use of surgical protesis in hiatal henia repair was a debated surgical topic in the last years A laparoscopic repair of a symptomatic type III hiatal hernia by plastic of the hiatus, fundoplicatio and use of an absorbable glycolic acid/trimethylene carbonate synthetic mesh is showed. Methods The patient was a 59 years old male suffering from recurrent aspiration pneumonias. Surgery was performed by a standardized tecnique in a high volume laparoscopic surgical centre. The hernia sac was removed and the plastic of the esophageal hiatus was performed. After the mesh placement a Nissen fundoplicatio was performed. No drain was placed. Results In the postoperative period a contrat-soluble swallow was performed and it resulted in a good transit witout any sign of recurrence. The patient was discharged with an appropiate oral intake. One year after surgery the patient is asymptomatic and in good conditions. Conclusion A voluminous symptomatic hiatal hernia can be successfully treated in a high-volume and long-term experienced laparoscopic surgical. The use of an absorbable, handily positionable and synthetic mesh can help to gain a lower rate of recurrence without any risk for the patients. The technical skill and all the surgical steps never are renounceable because of the presence of the mesh. Further studies with a longer-term follow-up and a international live debate are necessary. Video https://www.dropbox.com/s/384ujzm3rnoqe0a/Hiatal%20Hernia%20Dr.%20Cocozza%20ISDE%202020.mp4?dl=0