Jing-Hai Zhou

Prevention and management of complications after colon interposition for corrosive esophageal burns

We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric-esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow-up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re-operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co-ordination needs attention. Peri-operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.

Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent

In this article, we reviewed our experience of treatment of the delayed intrathoracic nonmalignant esophageal perforation employing modified intraluminal esophageal stent. Between February 1990 and August 2006, eight patients were included in this study. Five patients experienced sepsis. The interval time between perforation and stent placement ranged from 36 h to 27 days (average, 8.6 days). Esophageal stenting and throracotomy for foreign body removal were performed in four patients. The remaining four patients underwent stent placement and thoracostomy. Nutrition was initiated through gastrostomy after 7 to 10 days after the stenting. The stent was removed after the patients resumed oral intake of food and the esophagogram showed that perforation was closed. There was no death in this group. Signs of sepsis remitted 1 week after stent placement. Complications included stress ulcer, stimulative cough, and pneumonia each. Stent removal ranged 32 to 120 days (average 66.7) after its placement. The stent was kept in place for 4 months to prevent formation of esophageal stricture in one patient with caustic esophageal burns. The follow-up was completed in all the patients. The mean follow-up period was 59 months (range 12-180). One patient with caustic esophageal burn underwent cicatricial esophagectomy and gastric transposition 3 years later due to the esophageal stricture. Barium swallow demonstrated that there was a diverticulum-like outpouching in one patient and slight esophageal stricture at T2 and T3 level in another. One patient developed reflux esophagitis 5 years after stent removal. All the patients finally had a normal intake of food. Modified esophageal stenting is an effective method to manage the delayed intrathoracic esophageal perforation. Prevention of stent migration and its convenient adjustment might be the major advantages of this method.

Functional and menometric study of side-to-side stapled anastomosis and traditional hand-sewn anastomosis in cervical esophagogastrostomy

OBJECTIVE In the study, we made the pharyngoesophageal functional assessment and menometric study on the two kinds of anastomosis (traditional hand-sewn anastomosis and side-to-side stapled anastomosis) for the further evaluation and application of cervical esophagogastrostomy. PATIENTS The study included 17 patients with esophageal squamous cancer from March 2006 to May 2008. Eight patients had undergone total esophagectomy and traditional hand-sewn technique in CEGA. The other nine patients had undergone total esophagectomy and side-to-side stapled technique in CEGA. All the 17 patients were studied for 3 months after the operations. The complete data, such as esophagogastroscopy, barium swallow and manometric studies, were obtained for each participating patient. RESULTS In the hand-sewn group of eight patients, four patients (50%) reported clinical significant symptoms of cervical dysphagia. Two patients (11.1%) reported clinical significant symptoms of cervical dysphagia in the side-to-side group of nine patients. There is a statistically significant difference between the hand-sewn group of patients (n=8) and the side-to-side group of patients (n=9) with respect to overall mean anastomotic diameters (1.688+/-0.26 cm vs 3.012+/-0.17 cm, p=2.10 x 10(-8)). In the eight patients who underwent hand-sewn technique, there were four symptomatic patients with poor menometric datum, such as anastomotic hypertensive peristaltic activity, confusing inversion of anastomotic and midcervical esophageal pressure, and consequently poor compliance of the pharyngoesophageal segment (pharyngeal shoulder pressure). By contrast, there was only one symptomatic patient with poor menometric data in the nine patients who underwent side-to-side technique. CONCLUSION The side-to-side stapled technique is conducive to decrease complications of postoperative dysphagia and is helpful for improving pharyngesophageal and anastomotic menometric function. The anastomotic technique deserves more attention and further applications.

BCAR1 Protein Plays Important Roles in Carcinogenesis and Predicts Poor Prognosis in Non-Small-Cell Lung Cancer

Objective Our previous study suggested the potential clinical implications of BCAR1 in non-small-cell lung cancer (NSCLC) (Mol Diagn Ther. 2011. 15(1): 31–40). Herein, we aim to evaluate the predictive power of BCAR1 as a marker for poor prognosis in NSCLC cases, verify the carcinogenic roles of BCAR1 in the A549 lung adenocarcinoma cell line, and testify to the BCAR1/phospho-p38 axis. Methods Between January 2006 and June 2010, there were a total of 182 patients with NSCLC (151 cases with available follow up data, and 31 cases lost to follow-up due to the invalid contact information). We inspected BCAR1, phospho-BCAR1(Tyr410), phospho-p38(Thr180/Tyr182) and p38 expression in NSCLC tissues and matched adjacent normal tissues by immunoblotting and IHC. After BCAR1 -RNA interference in A549 cells, we inspected the protein expression (BCAR1, phospho-BCAR1, phospho-p38 and p38) and performed cell biology experiments (cell growth, migration and cycle). Results BCAR1 was overexpressed in NSCLC tissues (177/182) and cell lines (A549 and Calu-3). However, it was not detected in the normal adjacent tissue in 161 of the 182 cases. Higher BCAR1 levels were strongly associated with more poorly differentiated NSCLC and predicted poorer prognosis. BCAR1 knockdown caused cell growth arrest, cell migration inhibition and cell cycle arrest of A549 cells. Overexpression of BCAR1 was associated with activation of p38 in NSCLC cases, and BCAR1 knockdown caused reduction of phospho-p38 levels in A549 cells. Conclusion Overexpression of BCAR1 is a predictor of poor prognosis in NSCLC and plays important carcinogenic roles in carcinogenesis, probably via activation of p38 MAPK. However, further investigations are required immediately.

Reconstruction of hypopharyngeal and cervical esophageal defect after resection of hypopharyngeal carcinoma: a new technique based on the use of bilateral platysma myocutaneous flaps

Commonly used procedures for reconstructing hypopharyngeal and cervical esophageal defects resulting from total laryngopharyngectomy (TL) are the gastric conduit or colon transposition as well as microvascularized free flaps. Herein we designed an alternative procedure utilizing bilateral platysma myocutaneous flaps (PMCFs) for the reconstruction of hypopharyngeal and cervical esophageal defects. This report summarizes the technical description of this procedure. TL and cervical esophagectomy were performed and bilateral PMCFs were harvested for reconstruction of hypopharyngeal and cervical esophageal defects in 25 patients aged between 46 and 73 years (mean 58.7 ± 16.2 years). All these patients had advanced-stage (IV) cancer with involvement of the cervical esophagus. Operative time ranged from 176 to 382 minutes (average 243 ± 91 minutes) and the mean intraoperative blood loss was 294 ± 119mL. There were six cases of anastomotic leak (24.0%) and two of them (8.0%) developed anastomotic stricture. Neither flap necrosis nor postoperative death was observed. The majority of our patients (68.0%) were restored to a normal unrestricted oral diet after surgery. The 3-year and 5-year actuarial survival rates were approximately 54.7% and 26.1%, respectively. We conclude that reconstruction of the cervical esophagus with bilateral PMCFs is a valuable method for treating advanced hypopharyngeal carcinoma.

Prevention of stricture development after corrosive esophageal burn with a modified esophageal stent in dogs

OBJECTIVE We sought to test the feasibility and technical ease of a newly designed nitinol-based modified esophageal stent and its effects on preventing postcaustic stricture in mongrel dogs and to try to explain the result at the molecular level. METHODS Twenty-four dogs were included in this controlled study. Stenosis index (wall thickness/intraluminal diameter), pathologic features, hydroxyproline quantities, esophageal compliance, and biomechanics were compared between the injured but unstented and stented dogs. Transforming growth factor beta1, Sma/Mad (Smad)3, and Smad7 mRNA expression and protein levels in esophageal tissue were detected by means of reverse transcriptase-polymerase chain reaction and Western blotting, respectively. RESULTS The modified esophageal stent was able to be placed and retrieved successfully and conveniently and was not only intact but there was also no macroscopic esophageal mucosal injury after the stent removal 4 months later. In comparison with the injured but unstented group, esophageal compliance, biomechanics, and the stenosis index were significantly better in the stented group. Histopathologic study revealed that collagen bundles were thinner and its orientation tended toward a regular and parallel pattern. Transforming growth factor beta1 and Smad3 mRNA expression and protein levels increased and Smad7 mRNA expression and protein levels decreased significantly in esophageal tissue in the stented group. These variables showed no statistically significant difference 2 months after stent removal. CONCLUSIONS The modified esophageal stent might be a promising stent in preventing stricture formation after corrosive esophageal burns clinically.

Circulating tumor cells in early stage lung adenocarcinoma: a case series report and literature review

Purpose The study aimed to monitor circulating tumor cells (CTCs) in early stage lung adenocarcinoma patients. Results CTCs were characterized and classified to epithelial (E-) CTCs, mesenchymal (M-) CTCs and epithelial- mesenchymal (E&M-) CTCs, as per epithelial-mesenchymal transition(EMT) biomarkers. CTCs could not be found in healthy controls. However, in cohort A, CTCs were found in 17 (17/18) cases. Detection rate of E-CTCs was lower (5/18) compared with M-CTC (10/18) or E&M-CTC (14/18). Highly abundant M-CTCs were prone to being in the tumors > 2 cm. In cohorts A and B, CTCs count increased significantly in all patients with tumor progression (7/7). Higher CTCs level or change range could be found postoperatively in the patients with tumor progression, as compared with patients with disease free survival (P < 0.01). Additionally, CTCs detected by CanPatrolTM could be validated by CytoploRare or Pep@MNPs. Materials and Methods We included four cohorts of patients and 20 healthy controls. In cohort A, CTCs were detected by a newly established approach, i.e., CanPatrolTM, prior to anesthesia and monitored after operation longitudinally. In cohort B, CTCs were not assessed prior to operation, but were longitudinally detected after operation. For validation, we detected FOLR(+)-CTCs by using CytoploRare and EPCAM(+)-CTCs by using Pep@MNPs prior to operation, in cohorts C and D, respectively. Conclusion CTCs can be detected in early stage lung adenocarcinoma, even in adenocarcinoma in situ, and CTCs detection can effectively monitor tumor progression. The distinguishing of biomarkers of highly invasive and aggressive CTCs warrants further robust study.

Clinical Value of Assaying Tumor Supplied Group of Factor/Tumor Specific Growth Factor in Patients With Solitary Pulmonary Nodule

OBJECTIVE This pilot study was designed to evaluate the clinical value of assaying tumor supplied group of factor/tumor specific growth factor (TSGF) in solitary pulmonary nodule (SPN). PATIENTS AND METHODS The study was conducted from March 2007 to September 2010 and included 33 patients with SPN and 28 healthy volunteers. TSGF was assayed in preoperative serum, intraoperative pleural lavage fluid (IPLF), and postoperative serum. RESULTS At operation, 20 patients were diagnosed with malignancy and 13 patients were diagnosed with nonmalignancy and placed in group A and group B, respectively. In group A, pathologic staging demonstrated 8 patients (group A1) with stage T1N0M0, 7 patients (group A2) with stage T1N1M0 and 53 patients (group A) with stage T1N2M0 disease. In group B, 8 patients were diagnosed with tuberculoma (group B1) and 5 patients were diagnosed with inflammatory pseudotumor (group B2). Before operation, levels of TSGF in peripheral blood were significantly higher in group A compared with group B and the control group (98.8 ± 29.9 vs. 62.1 ± 24.9 and 50.1 ± 17.9, Student-Newman-Keuls test; P < .05). The percentage of patients with positive serum TSGF results was significantly higher in group A than in group B or the control group (90.0% vs. 30.8% and 17.9%, χ(2) test; P < .05). With respect to the diagnostic value of serum TSGF in malignant SPN, we found sensitivity to be 90%, specificity to be 69.2%, positive forecast rate to be 74.5%, negative forecast rate to be 87.4%, and accurate diagnosed rate to be 79.5%. The TSGF level in IPLF in group A was significantly higher than that in group B (132.2 ± 51.9 vs. 84.6 ± 12.6, Student t test, P < .05). Additionally, TSGF in group A2 and group A3 was significantly higher compared with group A1 (162.2 ± 52.3 and 176.4 ± 17.8 vs. 100.2 ± 35.8, Student-Newman-Keuls test; P < .05). Postoperative serum TSGF in the patients diagnosed with lung cancer decreased significantly after operation. TSGF returned to a normal threshold level (71 U/mL) in the sixth month postoperatively. In addition, there was no appreciable change in the patients in group B. CONCLUSION Serum TSGF is conducive to discriminating between benign and malignant features of SPN. Additionally, investigation of IPLF TSGF can potentially offer a new approach to predict the existence of lymph node metastases.

Clinical updates of approaches for biopsy of pulmonary lesions based on systematic review

BackgroundConvenient approaches for accurate biopsy are extremely important to the diagnosis of lung cancer. We aimed to systematically review the clinical updates and development trends of approaches for biopsy, i.e., CT-guided PTNB (Percutaneous Transthoracic Needle Biopsy), ENB (Electromagnetic Navigation Bronchoscopy), EBUS-TBNA (Endobroncheal Ultrasonography-Transbronchial Needle Aspiration), mediastinoscopy and CTC (Circulating Tumor Cell).MethodsMedline and manual searches were performed. We identified the relevant studies, assessed study eligibility, evaluated methodological quality, and summarized diagnostic yields and complications regarding CT-guided PTNB (22 citations), ENB(31 citations), EBUS-TBNA(66 citations), Mediastinoscopy(15 citations) and CTC (19 citations), respectively.ResultsThe overall sensitivity and specificity of CT-guided PTNB were reported to be 92.52% ± 3.14% and 97.98% ± 3.28%, respectively. The top two complications of CT-guided PTNB was pneumothorax (946/4170:22.69%) and hemorrhage (138/1949:7.08%). The detection rate of lung cancer by ENB increased gradually to 79.79% ± 15.34% with pneumothorax as the top one complication (86/1648:5.2%). Detection rate of EBUS-TBNA was 86.06% ± 9.70% with the top three complications, i.e., hemorrhage (53/8662:0.61%), pneumothorax (46/12432:0.37%) and infection (34/11250:0.30%). The detection rate of mediastinoscopy gradually increased to 92.77% ± 3.99% with .hoarseness as the refractory complication (4/2137:0.19%). Sensitivity and specificity of CTCs detection by using PCR (Polymerase Chain Reaction) were reported to be 78.81% ± 14.72% and 90.88% ± 0.53%, respectively.ConclusionThe biopsy approaches should be chosen considering a variety of location and situation of lesions. CT-guided PTNB is effective to reach lung parenchyma, however, diagnostic accuracy and incidence of complications may be impacted by lesion size or needle path length. ENB has an advantage for biopsy of smaller and deeper lesions in lung parenchyma. ENB plus EBUS imaging can further improve the detection rate of lesion in lung parenchyma. EBUS-TBNA is relatively safer and mediastinoscopy provides more tissue acquisition and better diagnostic yield of 4R and 7th lymph node. CTC detection can be considered for adjuvant diagnosis.

Surgery combined with adenoviral p53 gene therapy for treatment of non-small cell lung cancer: a phase II study

Objective To assess the efficacy of radical surgery combined with recombinant adenoviral human p53 (rAd-p53) gene therapy in treatment of resectable non-small cell lung cancer. Method A total of 163 patients with resectable NSCLC meeting the inclusion criteria were randomly assigned to two groups: radical surgery alone (S) and radical surgery plus surgical wound surface injection of 2 x 1012 rAd-p53 units (SP). All patients were followed up for at least 3 years for efficacy and safety. Study endpoints were loco-regional recurrence or distant metastasis (Rec-Met) rate as primary endpoints, and progression free survival (PFS), overall survival (OS) and safety assessments as secondary endpoints. Results Recurrence or metastasis (Rec/Met) after surgery were 24/82 (29.27%) in SP group and 37/81 (45.68%) in S group. The difference in the Rec/Met rate was statistically significant (p = 0.0304) by chi-square test. The hazard ratios after adjusting of age and disease stage (S vs. SP) of PFS and OS are 1.772 (95% CI, 1.102 to 2.848) and 2.047 (95% CI, 1.109 to 3.377), respectively. The 3 years PFS and OS for SP vs. S were 71.9% vs. 46.9%, and 88.4% vs. 67.0%, respectively. Differences in PFS and OS between two treatment groups were significant with the p values of 0.0165 and 0.0191, respectively, using Log-Rank test. Conclusions The wound surface injection of rAd-p53 showed efficacious effects in preventing recurrence or metastasis and improving PFS and OS after a radical surgery in patients with NSCLC.