We report the case of an 80-year-old male with stage three kidney disease, who survived a primary aorto-enteric fistula (AEF) in the setting of chronic Q fever after presenting with melena and ...syncope. His initial surgical treatment included endovascular aortic repair. Type 2 endoleak was present post-operatively. Six months later, he was diagnosed with a secondary AEF after syncope and large volume hematemesis. He was definitively treated with an open explant of his stent, repair of the duodenum and bilateral axillofemoral bypass. Two years later, he remains active and independent on life-long antibiotics.
Abstract Background Neoadjuvant Chemoradiotherapy (nCRT) for locally advanced oesophageal cancer improves survival. Currently, there is equipoise in the survival benefit of nCRT versus neoadjuvant ...chemotherapy. Excessive radiotherapy to the gastric conduit prior to surgery has long been a concern. Recent studies have linked radiation doses to the gastric fundus around 30 Gy to an increased risk of anastomotic leak. This study reviews a simple process aiming to reduce radiation dose to the gastric fundus. Methods This is a single-centre, retrospective analysis of 63 adult patients treated with nCRT (CROSS protocol) then oesophagectomy with a gastric conduit reconstruction. The Gastric Fill (GF) arm were given 500 mL of water prior to radiotherapy planning and treatment. The control group were consecutive patients prior to the implementation of the GF protocol. The fundus was mapped on radiotherapy software and planned to treat it like other organs at risk. Radiation dose to the fundus was recorded and compared between the two groups. Results The GF arm included 25 patients, with 38 patients in the control arm. Patients drank 350–800 mL of water prior to planning and treatment. There were no reported aspiration events. Radiotherapy techniques included VMAT and 3DCRT. All GF patients were treated with VMAT. There was a higher proportion of mid-oesophageal tumours in the control group (21% compared with 4%). The mean volume of gastric fundus in the GF group (mean = 215 cc, SD 144) was higher than the control group (mean = 155 cc, SD 100). The proportion of gastric fundus receiving >30 Gy was lower in the GF group (mean = 10.9% SD = 16.0) compared with the control group (mean = 19.1% SD = 24.8). Conclusion Analysis did not show statistically significant difference between the groups, however, there was a trend suggesting radiation to the gastric fundus was reduced in the GF group. This study shows the feasibility of a simple and low risk intervention in reducing the radiation to the future gastric conduit. Further review with a larger cohort, and impact on anastomotic complications would be of interest for future review.
Shortages of personal protective equipment during the coronavirus disease 2019 (COVID-19) pandemic have led to the extended use or reuse of single-use respirators and surgical masks by frontline ...healthcare workers. The evidence base underpinning such practices warrants examination.
To synthesize current guidance and systematic review evidence on extended use, reuse, or reprocessing of single-use surgical masks or filtering face-piece respirators.
We used the World Health Organization, the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. We used Medline, PubMed, Epistemonikos, Cochrane Database, and preprint servers for systematic reviews.
Two reviewers conducted screening and data extraction. The quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesized.
In total, 6 guidance documents were identified. Levels of detail and consistency across documents varied. They included 4 high-quality systematic reviews: 3 focused on reprocessing (decontamination) of N95 respirators and 1 focused on reprocessing of surgical masks. Vaporized hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale.
Evidence on the impact of extended use and reuse of surgical masks and respirators is limited, and gaps and inconsistencies exist in current guidance. Where extended use or reuse is being practiced, healthcare organizations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.
In 2017 the Dutch Upper Gastrointestinal Cancer Audit Group proposed a ten-item composite measure for a ‘textbook outcome’ (TBO) following oesophago-gastric resection. Studies have shown associations ...between TBO and improved conditional and overall survival. The aim of this study was to evaluate the use of TBO to assess the outcomes from a single specialist unit in a country, with low incidence of disease, allowing comparisons with international specialist centres.
Retrospective analysis of prospectively collected oesophageal cancer surgery data at a single centre, in Australia, between 2013 and 2018. Multivariable logistical regression assessed association between baseline factors and TBO. Post-operative complications were analysed in two separate groups as Clavien-Dindo ≥2 (CD ≥ 2) and Clavien-Dindo ≥3 (CD ≥ 3). Cox-proportional hazards regression analysis determined the association between TBO and survival.
246 patients were analysed, with 50.8% (n = 125) achieving a TBO when complications were defined as CD ≥ 2 and 58.9% (n = 145) when using CD ≥ 3. Patients aged ≥75, and those with a pre-operative respiratory co-morbidity were less likely to achieve a TBO. Overall survival was not influenced by TBO when complications were defined as CD ≥ 2, however it was higher when a TBO was achieved, and complications were defined as CD ≥ 3 (HR 0.54, 95% CI, 0.35 to 0.84, P = 0.007).
TBO is a multi-parameter metric that allowed benchmarking of the quality of oesophageal cancer surgery in our unit, providing favourable outcomes compared with other published data. There was an association between TBO and improved overall survival when the definition of severe complications was CD ≥ 3.
In this paper, I suggest that the important philosophy of the future will increasingly be found neither in the “continental” nor in the “analytic” traditions but, instead, in the transcending ...sublation of (all) traditions I call “synthetic philosophy.” I mean “synthetic” both in a sense that encourages the bold combinatorial mélange of existing styles, traditions, and issues, and also in the Hegelian sense of sublating dichotomous oppositions, appropriating the distinctive insights of both sides while eliminating their errors and exaggerations, and thereby creating new syntheses in which the old oppositions are transcended.
IMPORTANCE: Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and ...surgeons in making informed decisions. OBJECTIVE: To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. EXPOSURES: Esophageal resection for cancer of the esophagus and gastroesophageal junction. MAIN OUTCOMES AND MEASURES: All-cause postoperative 90-day mortality. RESULTS: A total of 8403 patients (mean SD age, 63.6 9.0 years; 6641 79.0% male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, –1 to –2; 90-day mortality, 5.8%), high risk (score, −3 to −4: 90-day mortality, 8.9%), and very high risk (score, ≤−5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. CONCLUSIONS AND RELEVANCE: In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient’s risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
Large studies comparing totally minimally invasive oesophagectomy (TMIE) with laparoscopically assisted (hybrid) oesophagectomy are lacking. Although randomized trials have compared TMIE invasive ...with open oesophagectomy, daily clinical practice does not always resemble the results reported in such trials. The aim of the present study was to compare complications after totally minimally invasive, hybrid and open Ivor Lewis oesophagectomy in patients with oesophageal cancer.
The study was performed using data from the International Esodata Study Group registered between February 2015 and December 2019. The primary outcome was pneumonia, and secondary outcomes included the incidence and severity of anastomotic leakage, (major) complications, duration of hospital stay, escalation of care, and 90-day mortality. Data were analysed using multivariable multilevel models.
Some 8640 patients were included between 2015 and 2019. Patients undergoing TMIE had a lower incidence of pneumonia than those having hybrid (10.9 versus 16.3 per cent; odds ratio (OR) 0.56, 95 per cent c.i. 0.40 to 0.80) or open (10.9 versus 17.4 per cent; OR 0.60, 0.42 to 0.84) oesophagectomy, and had a shorter hospital stay (median 10 (i.q.r. 8-16) days versus 14 (11-19) days (P = 0.041) and 11 (9-16) days (P = 0.027) respectively). The rate of anastomotic leakage was higher after TMIE than hybrid (15.1 versus 10.7 per cent; OR 1.47, 1.01 to 2.13) or open (15.1 versus 7.3 per cent; OR 1.73, 1.26 to 2.38) procedures.
Compared with hybrid and open Ivor Lewis oesophagectomy, TMIE resulted in a lower pneumonia rate, a shorter duration of hospital stay, but higher anastomotic leakage rates. Therefore, no clear advantage was seen for either TMIE, hybrid or open Ivor Lewis oesophagectomy when performed in daily clinical practice.
This paper examines Charles Taylor's case against complete secularization in A Secular Age in the light of Nietzsche's and Heidegger's critiques of the potential for nihilism inherent in different ...kinds of philosophical appeals to "transcendence". The Heideggerian critique of metaphysics as ontotheology suggests that the theoretical pluralism Taylor rightly embraces is more consistently thought of as following from a robust ontological pluralism, and that Taylor's own commitment to ontological monism seems to follow from his own desire to leave room in his theoretical account for an ontotheological creator God who stands outside the world and ultimately unifies its meaning. The Nietzschean critique contends that any such appeal to something that transcends the limits of human finitude remains nihilistic, insofar as such valorizations of the otherworldly undermine our capacity to appreciate and experience the genuine meaningfulness of human existence in its this-worldly finitude. The paper explores Taylor's response to this Nietzschean critique, showing that Taylor "deconstructs" the crucial distinction between immanence and transcendence that any "exclusively humanist" worldview must presuppose. Taylor's response only partly resolves the problem, however, because the Nietzschean can still draw a defensible distinction between legitimate and meaningful appeals to transcendence and illegitimate and nihilistic ones. The paper concludes by suggesting that traditional appeals to a transcendent creator God, a heavenly afterlife, and so on, continue to run afoul of Nietzsche's critique of the nihilism of otherworldliness, and that we would do better to explicitly abjure such otherworldly appeals.
Purpose
Enhanced Recovery After Surgery (ERAS) protocols have been effectively expanded to various surgical specialities including oesophagectomy. Despite nutrition being a key component, actual ...nutrition outcomes and specific guidelines are lacking. This cohort comparison study aims to compare nutritional status and adherence during implementation of a standardised post-operative nutritional support protocol, as part of ERAS, compared to those who received usual care.
Methods
Two groups of patients undergoing resection of oesophageal cancer were studied. Group 1 (
n
= 17) underwent oesophagectomy between Oct 2014 and Nov 2016 during implementation of an ERAS protocol. Patients in group 2 (
n
= 16) underwent oesophagectomy between Jan 2011 and Dec 2012 prior to the implementation of ERAS. Demographic, nutritional status, dietary intake and adherence data were collected. Ordinal data was analysed using independent
t
tests, and categorical data using chi-square tests.
Results
There was no significant difference in nutrition status, dietary intake or length of stay following implementation of an ERAS protocol. Malnutrition remained prevalent in both groups at day 42 post surgery (
n
= 10, 83% usual care; and
n
= 9, 60% ERAS). A significant difference was demonstrated in adherence with earlier initiation of oral free fluids (
p
<0.008), transition to soft diet (
p
<0.004) and continuation of jejunostomy feeds on discharge (
p
<0.000) for the ERAS group.
Conclusion
A standardised post-operative nutrition protocol, within an ERAS framework, results in earlier transition to oral intake; however, malnutrition remains prevalent post surgery. Further large-scale studies are warranted to examine individualised decision-making regarding nutrition support within an ERAS protocol.
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