Papers From the Western Surgical Association
En Bloc vs Transhiatal Esophagectomy for Stage T3 N1 Adenocarcinoma of the Distal Esophagus
Johansson et al studied 49 patients with similar T3 N1 disease–matching criteria and concluded that en bloc esophagectomy conferred a better survival than transhiatal esophagectomy in these patients with fewer than 9 involved lymph nodes (P<.001). This argument has been long standing and this study is unlikely to put it to rest, but it does establish the limited area in which en bloc esophagectomy appears to have a favorable influence.
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Blunt Carotid Artery Injury: The Futility of Aggressive Screening and Diagnosis
Recently, we have been apprised of the need to evaluate patients carefully for blunt carotid artery injury and treat the patient with this problem aggressively. Now we present the other side of the story: blunt carotid injury is rare; of the few patients with this injury, most remain asymptomatic or develop neurologic deficits shortly after injury; and an improvement in outcome is uncertain at best and is very resource and time consuming. The lesson of this article from Mayberry et al is that before we accept an aggressive screening program for this problem, a cost-effectiveness analysis should be completed.
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Quantification of Pain and Satisfaction Following Laparoscopic and Open Hernia Repair
From Fujita et al comes a missile purporting to quantify subjective experiences by visual analog scoring. The patients who underwent laparoscopic herniorrhaphy were younger. Objective outcome was related to days prior to return to regular activities and quantity and days of analgesic use. Their findings were that pain following herniorrhaphy was age dependent. Satisfaction was similar for both approaches. We note from the discussion that the question is still open.
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Several articles this month address some of the problems related to breast cancer. Among these is one by Hansen et al, who noted that manipulation of an intact tumor by fine-needle aspiration or large-gauge core biopsy is associated with an increase in sentinel node metastases. No statement can be made, as yet, on whether these metastases would affect regional recurrence or overall survival.
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Another of these articles is from Joseph et al and involves 407 consecutive patients who underwent sentinel lymph node dissection and then completion axillary node dissection. They found that although primary tumor size and micrometastases correlate with the status of the nonsentinel nodes, extranodal extension is the most important predictor of nonsentinel lymph node metastasis.
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A third article is a study from Chagpar et al, who have collected much material regarding sentinel node biopsy. They validated that subareolar and periareolar injection techniques are accurate and support the hypothesis that the lymphatic drainage of the entire breast is to the same few sentinel nodes.
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In another article, Dowlatshahi et al report their early results with balloon brachytherapy, an alternative to conventional external beam radiation for select operable breast cancers. The 1-week treatment time allows working women and those who live at a distance from radiation centers to opt for this therapy after lumpectomy, rather than mastectomy.
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