More recently a large randomized

trial published by Macdonald but including mostly gastric cancer patients and only a small proportion of patients with GE junction tumors demonstrated a substantial survival benefit to postoperative therapy (2). Data that might support specific conclusions about GE junction esophageal tumors was not provided, likely because an insufficient number of patients were in this category. Discussion as to why it is difficult to develop definitive conclusions about these different approaches may be appropriate. Certainly, the bias of treating physicians and patients related to use of these very different approaches has limited randomization. The large size of a trial that designed to properly Inhibitors,research,lifescience,medical establish differences in survival that are likely to be modest (i.e.

the range of 10-15% in long term survival), is difficult to do in esophageal cancer, a relatively uncommon tumor. While it would certainly appropriate Inhibitors,research,lifescience,medical to close this article with a routine statement that definitive randomized data is needed, such information is unlikely in the near future and this review article actually provides information Inhibitors,research,lifescience,medical important to guiding therapy for patients here and now while studies are done around the world. Footnotes No potential conflict of interest.
A 57-year-old man with no relevant past medical history was referred to our digestive tract endoscopy unit because of a clinically silent rectovesical fistula (Fig 1), which was diagnosed Inhibitors,research,lifescience,medical by a radiological contrast examination 10 days after laparotomic resection of the sigmoid colon. The resection had been performed 10 days following the detection of a distal sigmoid adenocarcinoma, diagnosed in our centre by colonoscopy plus biopsies. Endoscopy of the lower gastrointestinal tract confirmed the presence of a rectovesical fistula of 6 mm diameter,

with an orifice at the colorectal anastomosis, Inhibitors,research,lifescience,medical located 9 cm from the anal margin. The patency of the fistula was verified by instillation of methylene blue through the bladder catheter. Figure 1 Endoscopic image of the rectovesical fistula The day after the diagnostic endoscopy we placed an OVESCO® clip (OVESCO® Endoscopy GmbH, Tuebingen, Germany) to close the fistula endoscopically (Fig 2). Metalloexopeptidase This intervention took about 15 minutes and was performed with the patient sedated, but conscious. Figure 2 Rectovesical fistula closed with the OVESCO clip Three weeks after placement of the OVESCO® clip the patient signaling pathway started chemotherapy with FOLFOX (4 cycles) and 3 months later underwent resection of two hepatic segments (segments 1 and 8) because of residual metastases. Six days after surgery the patient complained of “liquid in the rectum” and a computed tomography scan showed a residual fistula between the bladder and the colorectal anastomosis (Fig 3). Two days later a lower gastrointestinal tract endoscopy was performed showing the absence of the OVESCO® clip and a 3-mm orifice of the residual fistula.