Irfan Qureshi

An Extracellular Matrix Scaffold for Esophageal Stricture Prevention After Circumferential EMR

BACKGROUND EMR is an accepted treatment for early esophageal cancer and high-grade dysplasia. One of the limitations of this technique is that extensive mucosal resection and endoscopic submucosal dissection may be required to obtain complete removal of the neoplasm, which may result in significant stricture formation. OBJECTIVE The objective of the current study was to evaluate the efficacy of an endoscopically deployed extracellular matrix (ECM) scaffold material for prevention of esophageal stenosis after circumferential EMR. DESIGN Ten mongrel dogs were subjected to surgical plane anesthesia and circumferential esophageal EMR by the cap technique. In 5 animals, an ECM scaffold material was endoscopically placed at the resection site; the remaining 5 animals were subjected to circumferential esophageal EMR without ECM placement. Follow-up endoscopy was performed at 4 and 8 weeks; necropsy with histologic assessment was performed at 8 weeks. SETTING Animal laboratory. INTERVENTIONS Circumferential esophageal EMR by the cap technique, followed by endoscopic placement of an ECM scaffold material. MAIN OUTCOME MEASUREMENTS Degree of esophageal stricture and histologic assessment of remodeled esophageal tissue. RESULTS All 5 control dogs had endoscopic evidence of esophageal stenosis. Three required early euthanasia because of inability to tolerate oral intake. Incomplete epithelialization and inflammation persisted at the EMR site in control animals. Endoscopic placement of an ECM scaffold material prevented clinically significant esophageal stenosis in all animals. Histologic assessment showed near-normal esophageal tissue with a lack of inflammation or scar tissue at 8 weeks. CONCLUSIONS Endoscopic placement of an ECM scaffold material prevented esophageal stricture formation after circumferential EMR in this canine model during short-term observation.

Constructive remodeling of biologic scaffolds is dependent on early exposure to physiologic bladder filling in a canine partial cystectomy model.

Biologic scaffolds composed of extracellular matrix (ECM) have been used to facilitate the constructive remodeling of several tissue types. Previous studies suggest that the ECM scaffold remodeling process is dependent on microenvironmental factors, including tissue-specific biomechanical loading. The objective of the present study was to evaluate the effects of long-term catheterization (LTC), with its associated inhibition of bladder filling and physiologic biomechanical loading, on ECM scaffold remodeling following partial cystectomy in a canine model. Reconstruction of the partial cystectomy site was performed using ECM scaffolds prepared from porcine small intestinal submucosa (SIS) or porcine urinary bladder matrix (UBM). Animals were randomly assigned to either a long-term catheterization (LTC) group (n=5, catheterized 28 d) or a short-term catheterization group (STC, n=5, catheterized 24 h), and scaffold remodeling was assessed by histologic methods at 4 and 12 wk postoperatively. By 4 wk, animals in the STC group showed a well-developed and highly differentiated urothelium, a robust vascularization network, abundant smooth muscle actin (SMA), and smooth muscle myosin heavy chain (smMHC) expressing spindle-shaped cells, and many neuronal processes associated with newly formed arterioles. In contrast, at 4 wk the scaffolds in LTC animals were not epithelialized, and did not express neuronal markers. The scaffolds in the LTC group developed a dense granulation tissue containing SMA+, smMHC-, spindle-shaped cells that were morphologically and phenotypically consistent with myofibroblasts, but not smooth muscle cells. By 12 wk postoperatively, the ECM scaffolds in the STC animals showed a constructive remodeling response, with a differentiated urothelium and islands of smooth muscle cells within the remodeled scaffold. In contrast, at 12 wk the scaffolds in LTC animals had a remodeling response more consistent with fibrosis even though catheters had been removed 8 wk earlier. These findings show that early exposure of site-appropriate mechanical loading (i.e., bladder filling) mediates a constructive remodeling response after ECM repair in a canine partial cystectomy model.

Comparison of surgical techniques for early-stage thymoma: feasibility of minimally invasive thymectomy and comparison with open resection.

OBJECTIVE The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resection of the thymus is frequently practiced for benign disease; however, a VATS approach for thymoma remains controversial. The objective of the present study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with those after open resection. METHODS A retrospective review of 40 patients who underwent surgical resection of early-stage thymoma during a 12-year period was conducted. Data on patient characteristics, morbidity, recurrence, and survival were collected. The primary endpoint studied was overall survival. RESULTS Of the 40 patients, 14 underwent thymectomy for stage I and 26 for stage II thymoma; 19 were men and 21 were women (median age, 64 years; range, 35-86 years). Open thymectomy was performed in 22 patients, and VATS was performed in 18. The operative mortality rate was 0%. The tumor stage and number of patients undergoing adjuvant radiotherapy were comparable in both surgical groups. The median length of hospital stay was shorter in the VATS group (3 days) than in the open group (5 days) (P = .0001). The median follow-up was 36 months. No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (83%-100%) between the 2 groups. CONCLUSIONS VATS of early-stage thymoma appears safe and feasible and was associated with a shorter hospital stay. The oncologic outcomes were comparable in the open and VATS groups during intermediate-term follow-up. Additional follow-up is required to evaluate the long-term results of thoracoscopic thymectomy for early-stage thymoma.

Radiofrequency Ablation for the Treatment of Pulmonary Metastases

OBJECTIVES Surgical resection is the preferred treatment in selected patients with pulmonary metastases. In high-risk patients, radiofrequency ablation (RFA) may offer an alternative option. RFA may be used alone or combined with surgical resection as a lung parenchymal-sparing approach. Our objectives were to evaluate the intermediate term outcomes after RFA and to determine the prognostic variables associated with outcome in patients with pulmonary metastases. METHODS Thoracic surgeons evaluated and performed RFA under computed tomography (CT) guidance or combined with surgical resection. Patients were monitored in the thoracic surgery clinic for recurrence and survival. RESULTS Twenty-two patients (10 men, 12 women; median age, 63 years [range, 37 to 88]) underwent RFA. The primary cancer was colorectal in 9 (41%), renal in 2 (9%), sarcoma in 4 (18%), and other in 7 (32%). CT-guided RFA was the sole treatment in 17 patients (77%) and combined with surgical resection in 5 (23%). No procedurally related deaths occurred. At a mean follow-up of 27 months (range, 13.3 to 53.6 months), 9 patients are alive. The median survival was 29 months (95% confidence interval, 9.1 to 33.8). Lesion size was an important prognostic variable associated with overall and disease-free survival (p < 0.05). CONCLUSIONS RFA is safe in this group of pulmonary metastases patients, with reasonable results. Surgical resection remains the standard for resectable patients, but RFA offers an alternative in selected patients or may be used as a parenchymal-sparing approach in combination with surgical resection in selected patients.

Is minimally invasive esophagectomy indicated for cancer

Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40–60%) morbidity and 5–20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.

Surgical Palliation for Barrett's Esophagus Cancer

Adenocarcinoma arising in the setting of Barretts esophagus has the fastest increasing incidence of any malignancy in the United States. Advanced esophageal cancer carries an overall poor prognosis with most patients presenting with incurable disease. Over the past several years, new options have been introduced for the purpose of providing palliative therapy to improve quality of life. Stent placement is the most widely used palliative therapy and rapidly relieves dysphagia; however, distal migration continues to be a disadvantage. Laser therapy and brachytherapy are also administered but require repeated treatment sessions. Future options for providing effective therapy for endstage disease include improved stent designs to decrease migration and multimodality methods that combine several options in one treatment session. This article focuses primarily on palliation of unresectable tumors of the esophagus and gastroesophageal junction.

Pancreaticopleural Fistula Presenting as Right-Sided Hemothorax

Pancreaticopleural fistula represents a rare complication of pancreatitis. We report the case of a pancreaticopleural fistula presenting as recurrent right-sided hemothorax in a 43-year-old man. The patient was successfully treated with open surgical drainage and decortication, followed by octreotide, total parenteral nutrition, and stent placement in the pancreatic duct.