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Interactive CardioVascular and Thoracic Surgery Advance Access





Published: Wed, 22 Nov 2017 00:00:00 GMT

Last Build Date: Wed, 22 Nov 2017 08:48:38 GMT

 



Off-label use of thoracic aortic endovascular stent grafts to simplify difficult resections and procedures in general thoracic surgery

2017-11-22

Abstract
OBJECTIVES
Tumour infiltration, or gross infectious involvement of the thoracic aortic wall, poses a significant intraoperative risk for fatal bleeding and therefore could compromise adequate resection or efficient surgical management of pleural infection in a considerable amount of cases. We present 3 successful cases of off-label thoracic aortic endografting to safeguard thoracic aortic wall integrity.
METHODS
After all patients received thoracic stent grafts through femoral access into the descending aorta, the first patient underwent a resection of a locally advanced squamous cell carcinoma of the left inferior lobe cT4cN0–1cM0 after neoadjuvant chemoradiation, which had infiltrated the descending aortic wall. The second case was video-assisted thoracoscopic bilateral pleural decortication for empyema with aortic ulcers of the distal thoracic aorta in a patient with pancreatic intrathoracic fistula in a necrotizing pancreatitis. The third patient was operated for a locally advanced squamous cell carcinoma of the left inferior lobe initial stage cT4 cN1–2 cM0 after neoadjuvant chemoradiation, which had broad contact to the descending aorta at the level of thoracic vertebrae 7 and 8 on a circumference of circa 180°. Regional ethics committee approval according the Swiss Federal Human Research Act was obtained according to regulations.
RESULTS
Preventive stent graft placement resulted in complication-free resection and significantly minimized the risk of fatal intraoperative bleeding. Patients were thus not exposed to complications associated with aortic cross-clamping, possible prosthetic replacement and extracorporeal circulation techniques.
CONCLUSIONS
In carefully selected patient populations, the resection of locally advanced tumours or infectious processes involving the aortic wall can be facilitated by thoracic endovascular aortic repair prior to resection.



Prognostic value of lymph node count on survival in pathologically node-negative oesophageal squamous cell cancer

2017-11-21

Abstract
OBJECTIVES
This study aims to determine whether lymph node (LN) count is an independent predictor of survival in patients with pathologically node-negative (pN0) oesophageal squamous cell carcinoma (OSCC).
METHODS
Retrospective analysis was performed on 194 pN0 OSCC patients undergoing radical oesophagectomy between January 2004 and December 2008. The association between the LN count and survival was assessed using the Cox proportional hazard model. The optimal LN count cut-off values were determined using the X-tile program.
RESULTS
A total of 10 and 29 nodes were used as the cut-off values determined by X-tile program. Subsequently, all patients were divided into the high-, middle- and low-risk subsets in terms of 5-year overall survival rates, which were 36.7%, 56.9% and 81.8%, respectively (P <0.001). LN count was also validated as an independent prognostic factor in multivariate Cox analysis (P <0.001; hazard ratio 0.45; 95% confidence interval 0.29–0.69). Further analysis showed that patients with 14 or more LN count showed a reduced death from OSCC compared with those with less than 14 LN count (P =0.002, 5-year overall survival 66% vs 46.5%).
CONCLUSIONS
LN count exhibits prognostic significance in pN0 OSCC. In addition, the minimum number of LNs that should be removed in pN0 OSCC is probably 14.



Endothelin-1 may play an important role in the Fontan circulation

2017-11-21

Abstract
OBJECTIVES
Our goal was to evaluate whether endothlin-1 (ET-1) plays an important role in the Fontan circulation.
METHODS
Thirteen patients with single-ventricle physiology (Glenn circulation, n = 7; Fontan circulation, n = 6) were evaluated using lung histopathological and immunohistochemical studies and then compared with the normal autopsied controls without congenital heart disease (n = 13). We evaluated the medial thickness of the small pulmonary arteries. For 10 of these patients, quantitative real-time polymerase chain reaction analyses of ET-1, endothelin receptors Type A and Type B, endothelin-converting enzyme-1 and endothelial nitric oxide synthase were performed.
RESULTS
The medial thickness of the small pulmonary arteries in patients with single-ventricle physiology was greater than that of those in the control group (P = 0.0341). Severe medial hypertrophy of the pulmonary arteries was observed in patients who had poor outcomes. Immunohistochemical studies revealed that the marked expression of ET-1 was observed in the endothelium and media of their pulmonary arteries. In these patients, the messenger RNA expression of ET-1 was also increased. Two patients showed high levels of expression of ETAR and ETBR, although these 2 cases maintain good Fontan circulation.
CONCLUSIONS
Medial hypertrophy and the overexpression of ET-1 in the pulmonary arteries were observed in some patients in whom the Fontan circulation failed. Our data suggest that ET-1 may play an important role in maintaining the Fontan circulation.