Minimally invasive esophagectomy: a teaching hospital's first year experience.

Surgical resection of the esophagus remains the mainstay of treatment for esophageal cancer. However, esophagectomy is associated with significant morbidity and mortality in the postoperative period. We have recently altered our practice pattern to include minimally invasive esophagectomy (MIE) as the approach of choice in the hope of minimizing morbidity associated with this procedure. In this retrospective analysis, we compare outcomes of our first year performing MIE to the previous 3 years of open esophagectomy (OE) at a single teaching hospital. Sixty-five patients underwent esophagectomy between June 2002 and July 2006. Among these, 22 patients underwent MIE between June 2005 and July 2006 and 43 patients underwent OE. The two groups were comparable with regards to age, comorbidities and pathologic stage. The MIE group had less operative blood loss (178 mL vs. 356 mL), decreased respiratory complications requiring mechanical ventila-tion (5% vs. 23%), increased number of lymph nodes procured per procedure (15 vs. 8), and increased number of patients discharged within 10 days (72% vs. 28%) when compared to the OE group. No difference was identified in mortality, complications, or length of stay.

Prone thoracoscopic esophageal mobilization for minimally invasive esophagectomy.

BACKGROUND: Minimally invasive esophagectomy is a complex surgical procedure. We recently began performing thoracic mobilization of the esophagus with the patient in the prone position, not the left lateral decubitus position, in the hope of minimizing the number of technical challenges. METHODS: Six consecutive minimally invasive esophagectomies were performed using prone thoracoscopic esophageal mobilization with creation of cervical anastamosis. Our esophagectomy database was evaluated for outcomes, including operative time, estimated blood loss, complications, and length of hospital stay. RESULTS: We were successful in our first six attempts, with a mean blood loss of 61 cc. Mean operative time for thoracoscopy was 80 min. Operative times were steady over the first six prone cases at 105, 85, 70, 55, 80, and 85 min. Three of the six patients had no complications. Median postoperative length of hospital stay was 11.5 days, and there were no deaths. CONCLUSIONS: This technical report and case series demonstrates that prone thoracoscopic esophageal mobilization appears to be a reasonable alternative to the same procedure performed with the patient in the decubitus position. We find the technique to simplify portions of an otherwise difficult surgical procedure. Further evaluation with larger number of patients should be performed.

The efficacy of X-rays after chest tube removal.

BACKGROUND: The insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management. MATERIALS AND METHODS: A 5-year retrospective study of 73 patients with tube thoracotomies was performed in a level II trauma center's intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected. RESULTS: Of the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patient's clinical appearance rather than on the x-ray findings. CONCLUSION: Chest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.

Artificial nutritional support in patients with gastrointestinal fistulas.

Gastrointestinal (GI) fistulas allow abnormal diversions of GI contents, digestive juices, water, electrolytes, and nutrients from one hollow viscus to another or to the skin, potentially precipitating a wide variety of pathophysiologic effects. Mortality rates have decreased significantly during the past few decades from as high as 40% to 65% to 5.3% to 21.3% largely as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques. The primary causes of death secondary to enterocutaneous fistulas have been, and continue to be, malnutrition, electrolyte imbalances, and sepsis, especially in high-output fistulas, which continue to have a mortality rate of about 35%. Priorities in the management of GI fistulas include restoration of blood volume and correction of fluid, electrolyte, and acid-base imbalances; control of infection and sepsis with appropriate antibiotics and drainage of abscesses; initiation of GI tract rest including secretory inhibition and nasogastric suction; control and collection of fistula drainage with protection of the surrounding skin; and provision of optimal nutrition by total parenteral nutrition (TPN) or enteral nutrition (EN) (or both). The role of nutrition support in the management of enterocutaneous fistulas as either TPN or EN is primarily one of supportive care to prevent malnutrition, thereby obviating further deterioration of an already debilitated patient. It has been shown in several studies that TPN has substantially improved the prognosis of GI fistula patients by increasing the rate of spontaneous closure and improving the nutritional status of patients requiring repeat operations. Moreover, other studies have shown that nutritional support decreases or modifies the composition of the GI tract secretions and is thus considered to have a primary therapeutic role in the management of fistula patients. Finally, if a fistula has not closed within 30 to 40 days, or if it is unlikely to close because of a variety of collateral or compounding pathophysiologic conditions, consideration must be given to operative resection of the fistula while continuing to maintain the previous nutritional and metabolic support. The morbidity and mortality rates in such unfortunate patients remain high despite the many recent advances in surgical and metabolic technology.

IL-3 augments adhesiveness for endothelium and CD11b expression in human basophils but not neutrophils.

A number of natural and recombinant human cytokines have been tested for their ability to activate basophil and neutrophil adhesiveness for human umbilical vein endothelial cells in vitro. Coincubation of basophils and endothelial cell monolayers for 10 min with biologically relevant concentrations of rIL-1, natural IL-2, rIL-4, rIL-5, rIL-6, rIL-8, rGM-CSF, and rIFN-gamma had no effect on basophil adhesiveness. In contrast, rIL-3 induced basophil adhesiveness for endothelial cells (optimal at 1 ng/ml: 144 +/- 18% of control adherence (mean +/- SEM); control basophil binding, 13 +/- 3%, n = 9, p less than or equal to 0.05). This increase in adhesiveness was similar in magnitude to that induced by an optimal concentration of a known potent inducer of basophil adhesiveness (1 microM FMLP, 164 +/- 15% of control adherence, n = 9). Under these experimental conditions, the effects of rIL-3 occurred at concentrations of 0.1 to 30 ng/ml, were partially dependent on calcium, and were not accompanied by histamine release. Fixation experiments demonstrated that the effect of rIL-3 was directed against the basophil rather than the endothelial cell. Neither rIL-3 nor the other cytokines tested had any effect on the adherence of 51Cr-labeled neutrophils, even when tested simultaneously on cells from the same donors. Under experimental conditions that permitted histamine release, no correlation was seen between the ability of rIL-3 (0.3 to 300 ng/ml) to induce histamine release or enhance adhesiveness (n = 8). mAb blocking experiments demonstrated a role for both CD11 and CD18 adherence glycoproteins in basophil adherence induced by rIL-3, and indirect immunofluorescence and flow cytometric analysis revealed that rIL-3 treatment led to rapid and sustained increases in cell surface expression of CD11b antigens on basophils but not neutrophils (e.g., after 10 min: 217 +/- 29 vs 91 +/- 11% of control mean fluorescence intensity, p less than 0.05). However, no correlation was seen between the magnitude of changes in CD11b expression and changes in adhesion when tested simultaneously. These results suggest that local production of IL-3 during allergic reactions in vivo may selectively promote basophil activation, adhesion to endothelium, and recruitment to extravascular sites of inflammation.

Flow cytometric methods for the analysis of human basophil surface antigens and viability.

Fluorescence and flow microfluorometric methods have been established for the detection and evaluation of IgE-bearing human leukocytes in various cell preparations including those where basophils are present at low percentages. Quantitative techniques for the determination of basophil purity, viability, and cell surface antigens including IgE are described. Use of these methods will facilitate the identification and phenotypic analysis of human IgE-bearing cells in a wide variety of biological fluids.