Text A 78-year-old male, late fistula after Ivor-Lewis esophagectomy, communication between gastroplasty-right bronchus. Refractory to several endoscopic therapies (clips, tissue adhesive, stents). Fistula closure after combination of submucosal dissection assisted by clip-with-line traction technique of the mucosal flap (to allow deep dissection) plus over-the-scope-clip; and ablative technique (argon plasma coagulation) with single loop-and-clips technique (KING-Closure) In two consecutive endoscopic procedures. Comments: Successful treatment of a chronic persistent fistula between the digestive tract and the trachea-bronquial tree, by combination of various endoscopic closure techniques. [1]

Purpose Molecular analysis of peritoneal fluid in staging laparoscopy of gastric cancer is performed to improve the detection of free intraperitoneal tumor cells. Nevertheless, its significance is controversial, especially in patients with negative cytology but positive molecular analysis. The aim of this study was to analyze the sensitivity of molecular analysis and its prognostic value. Methods A retrospective analysis from April 2011 to October 2019 was performed. Cytology (Cyt) and molecular analysis were analyzed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) of the carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) tumor makers. Results During the study period, 138 staging laparoscopies were performed. Macroscopic carcinomatosis was found in 12.3%. Of the remaining 87.7%, 9.9% were Cyt + and 11.6% were Cyt- RT-PCR + . Of the latter, 9 responded to chemotherapy and underwent radical surgery. The sensitivity of cytology and molecular analysis was 0.70 and 0.76, respectively (p = 0.67). The 2-year overall survival (OS) of Cyt- RT-PCR + vs. Cyt + was similar (p = 0.1). The 2-year OS of Cyt-RT-PCR + subgroup who underwent radical surgery vs. Cyt-RT-PCR- patients was similar (p = 0.69), but disease-free survival was shorter in the first group (p = 0.005). Conclusion Our results show that the sensitivity of molecular analysis is similar to that of cytology. The prognostic value of positive molecular analysis was similar to positive cytology in terms of 2-year overall survival, except in the subgroup of operated patients in whom the overall survival was similar to that of those with a negative molecular analysis, albeit with a shorter disease-free survival.

Gastric and small intestine are the most common gastrointestinal stromal tumors (GISTs). There are few studies of patients who underwent surgical treatment with disparate findings. We aimed to evaluate the differences between groups and the risk factors for recurrence and mortality. A retrospective study of 96 gastric and 60 small intestine GIST was performed between 1995 and 2015. Both groups were compared in terms of clinicopathologic features, morbidity, recurrence, and mortality. Statistical analysis was performed with SPSS®. Eighty-one gastric GISTs and 56 small intestine GISTs underwent surgical treatment. Gastrointestinal bleeding was the most common cause of emergency surgery being more frequent in gastric GIST (P = 0.009); however, emergency surgery was indicated more frequently in the small intestinal GIST (P = 0.004) and was mostly due to perforation (P = 0.009). With a median follow-up of 66.9 (39.7–94.8) months, 28 (20.4%) patients had recurrence. A mitotic index > 5 (P ≤ 0.001) and the intestinal location (P = 0.012) were significantly associated to recurrence. Tumor size > 15 cm (P = 0.001) and an age of ≥ 75 years (P = 0.014) were associated to mortality. On univariate analysis, higher mean values of Ki-67 were associated to higher mortality (P = 0.0032). Small intestine GIST presented lower disease-free survival (DFS) than that of gastric GIST (65.7% vs 90.8%) with P = 0.003. The overall survival (OS) of gastric and small intestine GIST was 74.7% and 71.6%, respectively (P = 0.68). Small intestine GIST received emergency surgery more frequently showing lower DFS and same OS than that of gastric GIST. We found that Ki-67 could be a prognostic factor. Further studies are necessary to assess whether Ki-67 is a prognostic risk factor for GISTs.

Introduction: Patients (pts) with locally advanced esophageal carcinoma (LAEC) benefit from preoperative chemo-radiotherapy (NA CRT) followed by surgery. However, half of them will relapse within the first 2 years, having limited treatment options. Moreover, adenocarcinoma (ADC) and squamous cell carcinoma (SCC) are thought to represent two different diseases which might differ in terms of recurrence. Our aim is to analyze the characteristics and outcome of pts who relapse. Methods: We retrospectively reviewed pts with LAEC treated at the Gastroesophageal Tumors Functional Unit of Catalan Institute of Oncology, Bellvitge University Hospital and integrated centers who underwent NA CRT followed by surgery from 2000 to 2014. We analyzed recurrence rate (RR), median time to relapse (mTTR) and pattern of recurrence (PR): locoregional recurrence (LRR), distant recurrence (DR) or synchronic LR and DR (SR); results were stratified by histology. Clinical data and salvage therapy (ST) were also collected, including surgery, radiotherapy and palliative chemotherapy (PCT). Kaplan Meier for median overall survival (mOS) and median time to progression (mTTP) were performed. Results: 83/100(83%) pts receiving NA CRT underwent surgery: ADC 33(40%), SCC 44(53%), undifferentiated 6(7%). 88% R0, pathologic complete response (ypT0N0): 20 (24%): ADC 18,2 %, SCC 33,3%, p0,22. After a median follow-up of 26 months (m) (1-126) 1-year and 3-year RR were 36 (ADC 40,9%, SCC 27,3%) and 43% (ADC 47,7%, SCC 36,4%) respectively. mTTR 6 m (4,1-7,8), PR (%) of the 36 (43%) pts who relapse: LRR 31% (ADC 18%,SCC 55%, 37% ND) DR 50 % (ADC 72, SCC 28) SR 19 % (ADC 86, SCC 14), logRank for histology 0,032.median OS was 32 m (IC 95% 14,1-49,3): 26,8m ADC vs 45,4m SCC (p < 0,001). Median number of metastatic sites at relapse: 2. Data of 26/36 pts who relapse was available: 13/26 (50%) received ST: radical radiotherapy1 (7%), salvage surgery 1(7%). 11 (86%) receivedPCT. 90% had performance status ≤1, 100% had albumin serum levels ≥34g/l and Hemoglobin > 12g/L. PCT schedule: Docetaxel (46%), Cisplatin plus 5-fluoracyl (23%), Carboplatin plus 5-fluoracyl (15%). Median time on treatment was 10.7m (1-22). 5/13 (38%) pts received subsequent lines of PCT. Median OS was 11m (6,3-16,5): 26m (12,2-41,5) for patients who received ST versus 6,5m (1,3-11,4) for those who received best supportive care (p < 0,026). Conclusion: ADC and SCC differ significantly in their pattern of recurrence, being ADC more frequent in distant recurrence which confers a poor prognosis. A lower rate of pathologic complete response and a higher RR was observed for the group of ADC compared to SCC, although those differences were not statistical significant. Pts who relapse and maintain favorable prognostic clinical factors clearly benefit from salvage therapy if feasible and PCT.

e15111 Background: Modern management of Oesophageal and oesophagogastric junction (OGJ) cancers requires a multidisciplinary approach, which was implemented at our health centre in 2005. This study aimed to assess the impact of this change on clinical outcomes. Methods: A retrospective cohort study was conducted, covering all patients treated for oesophageal and OGJ cancer at the cancer centre established by the Bellvitge University Hospital and Catalonian Institute of Oncology, over two time periods, i.e., 2000-2004 and 2005-2008. Descriptive and multivariate analyses were performed using survival at 1 and 3 years as dependent variables. Results: Between 1 January 2000 and 31 December 2008, 586 patients were included. Number of patients with unknown stage at diagnosis was significantly reduced. Neoadjuvant strategies at the oesophageal location clearly increased in the recent period. A multidisciplinary approach resulted in a significant reduction in surgical mortality (11.8% vs. 2%) in the period 2005-2008. Analysis restricted to patients undergoing surgery with curative intent indicated a significant increase in 1- and 3-year survival in the latter period (68.4% vs. 89.8% and 38.2% vs. 57.1% respectively). Multivariate analysis showed that variables associated with improved survival were: age; tumour stage; radical intent of treatment (surgery and radical combined chemoradiotherapy); and therapeutic strategy. Conclusions: Better selection of patients for therapy together with improved staging resulted in a significant improvement in 1- and 3-year survival in cases undergoing surgery with curative intent. These changes would support the adoption of a multidisciplinary approach to clinical decision-making in cases of oesophageal and OGJ cancer.

Introduction: Neoadjuvant chemoradiotherapy (NA CRT) has shown benefit in overall survival (OS) in patients with locally advanced esophageal carcinoma. However, toxicity and postoperative morbidity are not negligible.Methods: We retrospectively reviewed patients with locally advanced esophageal carcinoma treated at Catalan Institute of Oncology and integrated centers who underwent NA CRT from 2009 to 2013. G3/4 toxicity and postoperative complications were recorded. OS and disease free survival (DFS) curves and medians were performed by using Kaplan Meier method as well as identification of prognostic factors using multivariate Cox regression.Results: 61 pts were studied: median age 61 (34-75); 90% male; 97% PS ≤ 1, 3% PS2; 20% Barrett esophagus; 51% adenocarcinoma (ADC)/ 49% squamous cell carcinoma (SCC). Location: 82% esophagus, 18% esophagogastric junction (Siewert I or II). Clinical stage included cT2N + , cT3-4a N0/+. 95% were node positive (cN+). 90% pts received 2 cycles of NA CT, being the most used regimen CDDP-5FU (87%). Total RT dose received was 45 Gy (75%) and 50,4 Gy (25%), depending on the centre protocol. G3/G4 toxicity occurred in 9% pts (5% nonhematologic, 4% hematologic). Treatment radiological response was assessed by PET: 16% complete response, 56% partial response, 20% stable disease, 8% progression. 51 pts (84%) underwent surgery, 88% R0. Pathologic complete response (ypT0N0) was achieved in 12 pts (24%): 15% of resected ADC, 30% of SCC, ypN+ 38%. Deaths due to post-operative complications (within 30 days) occurred in 2 patients (4%). Overall recurrence rate (ORR) of pts who underwent surgery was 43% (54% of resected ADC, 32% of SCC). 25% pts had distant recurrence (DR), 8% locoregional recurrence (LR), and 10% synchronic DR and LR. After a median follow-up of 18 months (m), median OS was 31,2 m (IC 95% 20,9-41,5): 22,4m ADC vs 39,7m SCC (p < .38). 1 and 2 years overall survival rate were 76,9% and 53,7%, respectively. mDFS was 17m (IC 95% 12-22): ADC 13m vs SCC 18m (p <.29). In the multivariate Cox regression, two independent factors influenced positively in OS: R0 (p< .001) and PS ≤ 1 (p< .012).Conclusion: NA CRT is a safe strategy for locally advanced esophageal carcinoma in selected pts, who have been treated with multidisciplinary approach. It improves R0 rate and tumor downstaging with similar results than previous reports. ADC and SCC represent two distinct diseases with different epidemiology and prognosis. However, no significant differences were achieved in our cohort probably due to small number of pts. Introduction: Neoadjuvant chemoradiotherapy (NA CRT) has shown benefit in overall survival (OS) in patients with locally advanced esophageal carcinoma. However, toxicity and postoperative morbidity are not negligible. Methods: We retrospectively reviewed patients with locally advanced esophageal carcinoma treated at Catalan Institute of Oncology and integrated centers who underwent NA CRT from 2009 to 2013. G3/4 toxicity and postoperative complications were recorded. OS and disease free survival (DFS) curves and medians were performed by using Kaplan Meier method as well as identification of prognostic factors using multivariate Cox regression. Results: 61 pts were studied: median age 61 (34-75); 90% male; 97% PS ≤ 1, 3% PS2; 20% Barrett esophagus; 51% adenocarcinoma (ADC)/ 49% squamous cell carcinoma (SCC). Location: 82% esophagus, 18% esophagogastric junction (Siewert I or II). Clinical stage included cT2N + , cT3-4a N0/+. 95% were node positive (cN+). 90% pts received 2 cycles of NA CT, being the most used regimen CDDP-5FU (87%). Total RT dose received was 45 Gy (75%) and 50,4 Gy (25%), depending on the centre protocol. G3/G4 toxicity occurred in 9% pts (5% nonhematologic, 4% hematologic). Treatment radiological response was assessed by PET: 16% complete response, 56% partial response, 20% stable disease, 8% progression. 51 pts (84%) underwent surgery, 88% R0. Pathologic complete response (ypT0N0) was achieved in 12 pts (24%): 15% of resected ADC, 30% of SCC, ypN+ 38%. Deaths due to post-operative complications (within 30 days) occurred in 2 patients (4%). Overall recurrence rate (ORR) of pts who underwent surgery was 43% (54% of resected ADC, 32% of SCC). 25% pts had distant recurrence (DR), 8% locoregional recurrence (LR), and 10% synchronic DR and LR. After a median follow-up of 18 months (m), median OS was 31,2 m (IC 95% 20,9-41,5): 22,4m ADC vs 39,7m SCC (p < .38). 1 and 2 years overall survival rate were 76,9% and 53,7%, respectively. mDFS was 17m (IC 95% 12-22): ADC 13m vs SCC 18m (p <.29). In the multivariate Cox regression, two independent factors influenced positively in OS: R0 (p< .001) and PS ≤ 1 (p< .012). Conclusion: NA CRT is a safe strategy for locally advanced esophageal carcinoma in selected pts, who have been treated with multidisciplinary approach. It improves R0 rate and tumor downstaging with similar results than previous reports. ADC and SCC represent two distinct diseases with different epidemiology and prognosis. However, no significant differences were achieved in our cohort probably due to small number of pts.

Introducción: el uso de las prótesis esofágicas más habitual y extendido es en la paliación de disfagia en pacientes con cáncer de esófago. Su utilización en patología esofágica benigna, estenosis o fístulas, es más reciente y con poca experiencia.

To determine if ischemic conditioning of the stomach improves the morbidity, mortality, and the anastomotic failure in gastroplasties with cervical anastomosis. Analysis of all patients with indication for cervical gastroplasty during the period of study. In all cases, ischemic conditioning was performed by selective embolization. Anastomotic failure, morbidity, and mortality rates were studied. Thirty-nine consecutive patients were included. Angiography and selective embolization of the left gastric, right gastric, and splenic arteries were performed. Surgery was performed 2 weeks later. Four patients did not have a complete embolization; median hospital stay after conditioning was 1.24 ± 0.6 days. In two patients, surgery could not be completed. Of the 33 remaining, 29 had a posterior mediastinic gastroplasty and four through the anterior mediastinum. The most common morbidity was respiratory. Five patients had a reoperation and the mortality was 6%. One case of anastomotic leak was found (3%). The mean hospital stay was 17.5 days. Preoperative embolization is a technique with acceptable morbidity and a short hospital stay. In our experience it can reduce the incidence of the morbidity, mortality, and anastomotic leak in gastroplasties with cervical anastomosis. Prospective studies will be necessary to demonstrate the validity of this approach.

Employment stability represents one of the mainstays of the Labor Law. However, in the face of a globalized economy and more open labor markets, the so called labor flexibility is being promoted in its different manners, just as it has been done in Europe and Latin America. This study examines labor flexibility theme as an option for work stability, from the experience of the Mexican case, on whose legal system, relative employment stability is enshrined as envisaged in the 1917 Constitution, specifically as provided under section 49 of the Federal Work Law of Mexico. The analysis made shows that relative stability still prevails in Mexican legal frame, even though there exists the pretention to reform labor legislation to introduce adjustable elements within work relations. Meanwhile, from the High Supreme Court, as the highest court in the country, some favorable criteria regarding flexibility have been issued, but so far, these criteria which settle jurisprudence on the sub ject have not produced evidences of a strong tendency on the particular subject yet.

La estabilidad en el empleo representa uno de los aspectos puntales del Derecho del Trabajo. Sin embargo, ante una economia globalizada y mercados de trabajo mas abiertos se promueve la llamada flexibilidad laboral en sus distintas vertientes, tal como se han dado en Europa y en paises de America Latina. El estudio examina el tema de la flexibilidad laboral como opcion a la estabilidad en el empleo, desde la experiencia del caso mexicano, en cuyo ordenamiento juridico se consagra la estabilidad en el empleo relativa, tal como se preve en la Constitucion de 1917 y de manera, muy especial, en lo previsto en el articulo 49 de la Ley Federal del Trabajo de Mexico. Se demuestra en el estudio que aun sigue prevaleciendo en el marco normativo mexicano, la estabilidad relativa, aun cuando existe la pretension de reformar la legislacion laboral para introducir elementos flexibilizadores en las relaciones de trabajo. Mientras tanto, del lado de la Suprema Corte de Justicia como maximo tribunal del pais, se han emitido criterios favorables a la flexibilidad que sientan jurisprudencia sobre el tema, sin que hasta ahora pueda evidenciarse una marcada tendencia sobre el particular

El transporte de drogas ilegales en el interior del organismo (body packer) representa un problema médico-legal en claro aumento en las últimas décadas. Los facultativos, especialmente aquellos con actividad en los servicios de urgencias, han de familiarizarse con el manejo diagnóstico y terapéutico –habitualmente conservador– de este tipo de pacientes y de sus posibles complicaciones. El presente artículo revisa los conceptos y fisiopatología generales asociados al transporte de paquetes en el tracto digestivo y describe la experiencia de un centro sanitario de referencia con un protocolo específicamente diseñado para estos enfermos.

Objective Interleukin-18 (IL-18) is a potent proinflammatory cytokine whose role in human obesity has recently been suggested. The aim of our study was to analyse in morbidly obese patients undergoing gastric bypass, the relationship of IL-18 with insulin resistance and with proinflammatory cytokines (tumour necrosis factor-alpha receptors, sTNFR), C-reactive protein (CRP) and with adiponectin.Design Observational and prospective study.Patients Sixty-five morbidly obese patients, aged 45 +/- 8.9 years, were studied before and 12 months after gastric bypass.Measurements We analysed plasma concentrations of IL-18, sTNFR, CRP and adiponectin.Results Plasma concentrations of sTNFR2, IL-18 and CRP were decreased and adiponectin significantly increased after bypass surgery. In the multiple regression analysis, preoperative values of IL-18 remained significantly associated with preoperative triglycerides (beta = 0.47, P = 0.005) and TNFR2 (beta = 0.47, P = 0.004). R-2 for the model = 0.38. Postoperative IL-18 concentrations in the multiple regression analysis were significantly associated with postoperative homeostasis model assessment of insulin resistance (HOMA-IR) (beta = 0.092, P = 0.019) and triglycerides (beta = 0.40, P = 0.036). R-2 for the model = 0.46. IL-18 did not correlate with body mass index, fat mass, fat-free mass or body fat. No relationship was either found between adiponectin and IL-18, TNFR1 and -2 and CRP.Conclusions Massive weight loss induced by gastric bypass reduces IL-18, TNFR2 and CRP. IL-18 might be a marker of the chronic inflammatory process underlying insulin resistance but its lack of association with anthropometric and body composition parameters does not support a major secretion by human adipocytes. IL-18 and sTNFR1 and -2 do not play a main role in the inhibition of the secretion of adiponectin.

PURPOSE: The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding, but it maybe possible to identify patients who have a low risk for rebleeding, and can be discharged after a short hospitalization. To examine the effect of an early discharge protocol (length of hospital stay less than or equal to 3 days), we conducted a 2-year prospective study in patients with upper gastrointestinal bleeding at low risk for rebleeding, as selected by clinical and endoscopic criteria.METHODS: During the first year of the study, patients were managed according to the standard criteria by any of six surgical teams (control period). During the second year, patients were managed by only one surgical team under the early discharge protocol guidelines (study period).RESULTS: Overall, 488 of 942 (52%) patients were considered as low risk. Early discharge was achieved in 26 of 230 (11%) patients in the control period and in 191 of 258 (74%) in the study period (P <0.001). Age and number of compensated comorbidities did not affect the rate of early discharge. Length of hospital stay was reduced from (mean +/- SD) 6 +/- 2.7 days (control period) to 3 +/- 2.3 days (study period, P <0.001). No differences were observed in rates of rebleeding, need for surgery, readmission or mortality. By contrast, no differences in lengths of stay were observed during that time period among patients admitted with coronary artery disease, colorectal cancer, or acute pancreatitis.CONCLUSION: Most patients with upper gastrointestinal bleeding who are at low risk for rebleeding can be discharged early, leading to important cost savings. (C) 1998 by Excerpta Medica, Inc.

Background. Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery.Methods. This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem.Results. No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One-and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group.Conclusions. Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.