Successful repair of acquired intrathoracic nonmalignant tracheoesophageal fistulas using thoracoacromial artery perforator flap through a midsternal incision approach: a report of three cases.

Background: Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. Surgical treatment is effective for most patients undergoing operative repair. However, in recent studies, the difficult-to-ignore early complications of surgical treatment can be as high as 62.5%. Among them, esophageal stricture occurring in 42-54% of patients, anastomosis leakage occurs at a rate of 22.7-26%, and the mortality rate can be as high as 29.4%. Here, we introduce our innovative experience repairing acquired TEFs with a thoracoacromial artery perforator flap, in which provides a clear surgical field of view, reliable reconstruction, and no serious complications during the perioperative period and no mortality or complications were observed within 180 days after the operation. Case Description: Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation. Conclusions: Repair of acquired TEFs using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.

Left-primary & right-auxiliary operation mode in mediastinoscope-assisted radical esophagectomy.

BACKGROUND: Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is the most minimally invasive esophagectomy procedure. It is a more challenging procedure and more difficult to be popularized than thoracoscopic surgery. We developed a new MATHE operation mode that provides a clearer visual field and makes the procedures simpler. METHODS: A total of 80 patients with esophageal cancer were divided into a control group (n = 29) and a study group (n = 51). The control group underwent classic MATHE, while the study group received modified MATHE. We compared the two groups on operation time; intraoperative blood loss; blood transfusion amount; incidence rate of lung infection, recurrent laryngeal nerves (RLNs) injury, chylothorax, and anastomotic leakage; and upper mediastinal lymph node dissection. RESULTS: The study group was significantly better than the control group in operation time (271.78 min vs. 322.90 min, p < 0.05), intraoperative blood loss (48.63 mL vs. 68.97 mL, p < 0.05), and left paratracheal lymph node (No. 4L) dissection rate (88.24% vs. 24.14%, p < 0.01). No significant differences were identified in the incidence rate of anastomotic leakage, lung complications, or RLNs injury between the two groups. CONCLUSION: The modified MATHE is easier to perform. Modified MATHE is significantly superior to classic MATHE in operation time, intraoperative blood loss, and upper mediastinal lymph node dissection rate.

Learning curve for inflatable mediastinoscopic and laparoscopic-assisted esophagectomy.

OBJECTIVE: To identify the morbidity that is associated with the learning curve of inflatable mediastinoscopic and laparoscopic-assisted esophagectomy (IMLE), and investigate the strategies to ride out the early period. METHODS: Our study included a retrospective series of 108 consecutive patients undergoing IMLE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at high-volume tertiary center from July 2017 to November 2020. The cumulative sum (CUSUM) method was used to analyze the learning curve. Patients were stratified into two groups in chronological order, defining the surgeon's early (Group 1: the first 27 cases) and late experience (Group 2: the next 81 cases). Intraoperative characteristics and short-term surgical outcomes were compared between the two groups. RESULTS: A total of 108 patients were included. Three patients converted into thoracoscopic surgery. The number of patients with postoperative pulmonary infection was 16 (14.8%), and vocal cord palsy had occurred in 12 patients (11.1%). One patient died within 90 days after surgery. CUSUM plots revealed decreasing total operative time, thoracic procedure time, abdominal procedure time, assistant-adjustment time after patients 27, 17, 26, and 35, respectively. CONCLUSION: IMLE is technically feasible, in terms of perioperative outcomes, for using as a radical surgery for thoracic esophageal cancer. For a surgeon experienced in minimally invasive esophageal surgery, experience of 27 cases is required to gain early proficiency of IMLE.

Antibacterial Fusion Protein BPI21/LL-37 Modification Enhances the Therapeutic Efficacy of hUC-MSCs in Sepsis.

Sepsis, which is characterized by multiple organ dysfunctions as a result of an unbalanced host-inflammatory response to pathogens, is potentially a life-threatening condition and a major cause of death in the intensive care units (ICUs). However, effective treatment or intervention to prevent sepsis-associated lethality is still lacking. Human umbilical cord mesenchymal stem cell (hUC-MSC) transplantation has been shown to have potent immunomodulatory properties and improve tissue repair yet lacks direct antibacterial and endotoxin clearance activities. In this study, we engineered hUC-MSCs to express a broad-spectrum antibacterial fusion peptide containing BPI21 and LL-37 (named BPI21/LL-37) and confirmed that the BPI21/LL-37 modification did not affect the stemness and immunoregulatory capacities of hUC-MSCs but remarkably, enhanced its antibacterial and toxin-neutralizing activities in vitro. Furthermore, we showed that administration of BPI21/LL-37-engineered hUC-MSCs significantly reduces serum levels of tumor necrosis factor α (TNF-α), interleukin 1ß (IL-1ß), and IL-6, whereas increases that of IL-10 in cecal ligation and puncture (CLP)-induced sepsis mouse model. Administration of BPI21/LL-37-engineered hUC-MSCs significantly reduced systemic endotoxin (lipopolysaccharide [LPS]) levels and organ bacterial load, ameliorated damage to multiple organs, and improved survival. Taken together, our study demonstrates that BPI21/LL-37-engineered hUC-MSCs might offer a novel therapeutic strategy to prevent or treat sepsis via enhanced antimicrobial and anti-inflammatory properties to preserve organ functions better.

Effect of habitat fragmentation on ranging behavior of white-headed langurs in limestone forests in Southwest China.

The critically endangered white-headed langur (Trachypithecus leucocephalus) is confined to fragmented karst forests of southwest Guangxi Province, China. A lack of information on the influence of habitat fragmentation on langur behavior has prevented a comprehensive understanding of their ranging behavior and the development of effective langur conservation strategies. We collected comparative data on time budgets, daily path lengths, home range and diets of four langur groups inhabiting the lightly fragmented Fusui forest (G1, G2) and the more heavily fragmented Chongzuo forest (G3, G4). The aim was to explore the effect of this fragmentation on langur ranging behavior. Our results showed that the Fusui groups spent more time on moving and less time on feeding and playing than the Chongzuo groups. Daily path lengths were 472.4-536.1 m for the Fusui groups and 449.6-480.7 m for the Chongzuo groups, indicating no marked inter-site variation. The Fusui groups occupied much larger home ranges (23.8-33.8 ha) than the Chongzuo groups (14.5-15.8 ha). However, all groups had similar monthly home ranges. Diets significantly differed among langur groups. The Fusui groups consumed more young leaves and had much lower diet diversity compared with the Chongzuo groups. Our findings indicate that habitat fragmentation is one of the crucial determinants of white-headed langur ranging behavior because fragmentation reduces and restricts the home range. Langurs in fragmented habitat adopt an energy conservation strategy characterized by devoting more time to feeding and less time to moving, with a smaller home range and consumption of more plant species. We argue that linking fragmented forests with corridors should be considered a priority in a wider and comprehensive longer term langur population conservation and habitat management strategy.

Acemannan accelerates cell proliferation and skin wound healing through AKT/mTOR signaling pathway.

BACKGROUND: Acemannan is a bioactive polysaccharides promoting tissue repair. However, the roles of acemannan in skin wound healing and the underlying molecular mechanisms are largely unclear. OBJECTIVE: The goal of this study is to investigate the positive role of acemannan in cutaneous wound healing and its mechanism. METHODS: Mouse skin wound model and skin primary fibroblasts were used to demonstrate the positive effect of acemannan on cutaneous wound healing. The expressions of cell proliferation nuclear antigen ki-67, cyclin D1 and activity of AKT/mTOR signaling were analyzed in acemannan-treated fibroblasts and mice. Rapamycin and AKT inhibitor VIII were used to determine the key role of AKT/mTOR signaling in acemannan-promoting cutaneous wound healing. RESULTS: We found that acemannan significantly accelerated skin wound closure and cell proliferation. Acemannan promoted the expression of cyclin D1 in cultured fibroblasts, which was mediated by AKT/mTOR signal pathway leading to enhanced activity of the eukaryotic translation initiation factor-4F (eIF4F) and increased translation of cyclin D1. In contrast, pharmaceutical blockade of AKT/mTOR signaling by mTOR inhibitor rapamycin or AKT inhibitor VIII abolished acemannan-induced cyclin D1 translation and cell proliferation. In vivo studies confirmed that the activation of AKT/mTOR by acemannan played a key role in wound healing, which could be reversed by rapamycin. CONCLUSION: Acemannan promoted skin wound healing partly through activating AKT/mTOR-mediated protein translation mechanism, which may represent an alternative therapy approach for cutaneous wound.