Ali Kamran

Protective Effect of Pharmacologic Preconditioning with Pioglitazone on Random-Pattern Skin Flap in Rat is Mediated by Nitric Oxide System

BACKGROUNDnPioglitazone, a thiazolidinedione, is primarily used as an antidiabetic agent. In addition, recent reports have identified anti-ischemic and anti-inflammatory properties of pioglitazone through nitric oxide (NO) pathways.nnnOBJECTIVEnTo determine the protective effects of pioglitazone on random-pattern skin flaps in a rat model.nnnMETHODSnForty-eight male Rats were randomly assigned to eight groups. Bipedicled dorsal skin flaps (2 × 8 cm) were elevated at the midline. In pharmacologic preconditioning groups, three different doses of pioglitazone (25, 40, 80, mg/kg; doses were selected according to our pilot study) gavaged 4 h before elevating flaps. Seven days after operation, the survival of skin flap was measured. For investigating the role of NO system, in other groups the nitric oxide synthase inhibitor N-nitro-L-arginine methyl ester hydrochloride (L-NAME, 10 mg/kg) was administered alone or with an effective dose of pioglitazone. Finally, in another group, subeffective dose of nitric oxide precursor L-arginine (100 mg/kg) was coadministered with subeffective pioglitazone.nnnRESULTSnSignificant increase in flap survival was seen with pioglitazone (40 mg/kg). This protective effect was abolished by systemic administration of L-NAME (10 mg/kg). Coadministration of subeffective doses of pioglitazone with subeffetcive L-arginine significantly improved flap survival.nnnCONCLUSIONnPharmacologic preconditioning with pioglitazone improves survival of random-pattern skin flaps in rats through NO dependent mechanisms.

Risk Factors for Recurrence after Thoracoscopic Repair of Congenital Diaphragmatic Hernia (CDH)

PURPOSEnTo identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH).nnnMETHODSnAll CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses.nnnRESULTSnSixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (nu202f=u202f52) or beyond the neonatal period (>1u202fmonth) (nu202f=u202f16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36u202fmonths (IQR 9-45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, pu202f=u202f0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, pu202f=u202f0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence.nnnCONCLUSIONSnDue to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs.nnnLEVEL OF EVIDENCEnLevel III cohort study.

Slide Esophagoplasty vs End-to-End Anastomosis for Recalcitrant Esophageal Stricture after Esophageal Atresia Repair

BACKGROUNDnAnastomotic stricture is a common complication after esophageal atresia (EA) repair. Patients with a recalcitrant stricture may require surgical intervention. The technique of reanastomosis after stricture resection can affect patient outcomes.nnnSTUDY DESIGNnPatients with EA who underwent anastomotic stricture resection, from July 2010 to February 2017, were reviewed. After stricture resection, patients who had slide esophagoplasty performed were compared with those having conventional end-to-end anastomosis.nnnRESULTSnFifty patients underwent stricture repair surgery by slide esophagoplasty (nxa0= 12) or end-to-end (nxa0= 38) anastomosis technique at a median age of 14 months (interquartile range [IQR] 6 to 23 months). Significantly fewer patients required dilation therapy after slide esophagoplasty: 6 of 12 (50%) compared with 32 of 38 (84%) in the end-to-end group (pxa0= 0.02). The number of dilation sessions was significantly lower in the slide group vs the end-to-end (pxa0= 0.004) group, with a risk ratio confirming the approximately half the number of dilations for the slide approach (risk ratio 0.57, 95% CI 0.38 to 0.86). Steroid injection was combined with dilation in 3 of 12 (25%) vs 22 of 38 (58%) in the slide and end-to-end groups, respectively (pxa0= 0.10). Stent placement was used in none of slide cases vs 8 of 38 (21%) in the end-to-end group (pxa0= 0.17). Stricture incision was performed in 1 of 12 (8%) in the slide group and 11 of 38 (29%) in the end-to-end group (pxa0= 0.25). There were leak complications in fewer patients after slide esophagoplasty compared with end-to-end anastomosis: 1 of 12 (8%) vs 8 of 38 (21%) (pxa0= 0.43).nnnCONCLUSIONSnSlide esophagoplasty may be a useful technique of anastomotic configuration for selected patients with recalcitrant esophageal stricture, offering more favorable outcomes compared with end-to-end anastomosis.