Blood flow ratio in the gastric conduit measured by laser Doppler flowmetry: A predictor of anastomotic leakage after esophagectomy.

Background: Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. Methods: A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Results: Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Conclusion: Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.

Regulation of von Willebrand factor by ADAMTS13 ameliorates lipopolysaccharide-induced lung injury in mice.

The relationship between von Willebrand factor (VWF) and inflammation has attracted considerable attention in recent years. VWF, which is stored in the Weibel-Palade bodies (WPBs) of endothelial cells (ECs), is released from WPBs in response to inflammatory stimuli and is thought to contribute to inflammation by promoting leukocyte extravasation. In this study, lung injury model mice were produced by intratracheal injection with lipopolysaccharides. The severity of lung inflammation was evaluated in mice with different genotypes (wild-type, Vwf-/-, Adamts13-/-) and mice treated with drugs that inhibit VWF function. Lung inflammation was significantly ameliorated in Vwf-/- mice compared with wild-type mice. Furthermore, inflammation was significantly suppressed in wild-type mice treated with anti-VWF A1 antibody or recombinant human ADAMTS13 compared with the untreated control group. The underlying mechanism appears to be an increased VWF/ADAMTS13 ratio at the site of inflammation and the interaction between blood cell components, such as leukocytes and platelets, and the VWF A1 domain, which promotes leukocyte infiltration into the lung. This study suggested that ADAMTS13 protein and other VWF-targeting agents may be a novel therapeutic option for treatment of pulmonary inflammatory diseases.

Generation of functional liver sinusoidal endothelial-like cells from human bone marrow-derived mesenchymal stem cells.

Introduction: Liver sinusoidal endothelial cells (LSECs) are specialized vascular endothelial cells that play an important role in the maintenance of biological homeostasis. However, the lack of versatile human LSECs has hindered research on LSECs and development of medical technologies for liver diseases including hemophilia A. In this study, we developed a technique to induce LSEC differentiation from human bone marrow-derived mesenchymal stem cells (BM-MSCs). Methods: To induce LSECs from human BM-MSCs, cytokines and chemical compounds associated with signaling implicated in LSEC differentiation and liver development were screened. Then LSEC-related genes and proteins expression in the differentiated cells were analyzed by qPCR and flow cytometry analysis, respectively. LSEC-related functions of the differentiated cells were also examined. Results: We found that the gene expression of LSEC markers, such as LYVE1, was considerably increased by culturing human BM-MSCs with bone morphogenetic protein 4, fibroblast growth factor 8b, transforming growth factor-ß signal inhibitor, and cyclic AMP. Furthermore, the differentiated cells expressed LSEC marker proteins and clearly demonstrated LSEC-specific functions, such as the uptake of hyaluronic acid. Conclusions: Our result indicate that the functional LSEC-like cells were successfully generated from human BM-MSCs using our established protocol.

Inhalation of ACE2 as a therapeutic target on sex-bias differences in SARS-CoV-2 infection and variant of concern.

Despite similar infection rates, COVID-19 has resulted in more deaths in men than women. To understand the underlying mechanisms behind this sex-biased difference in disease severity, we infected K18-human angiotensin converting enzyme 2 (ACE2) mice of both sexes with SARS-CoV-2. Our study revealed a unique protein expression profile in the lung microenvironment of female mice. As a result, they were less vulnerable to severe infection, with higher ACE2 expression and a higher estrogen receptor α (ERα)/androgen receptor (AR) ratio that led to increased antiviral factor levels. In male mice, inhaling recombinant ACE2 neutralized the virus and maintained the ERα/AR ratio, thereby protecting the lungs. Our findings suggest that inhaling recombinant ACE2 could serve as a decoy receptor against SARS-CoV-2 and protect male mice by offsetting ERα-associated protective mechanisms. Additionally, our study supports the potential effectiveness of recombinant ACE2 therapy in human lung organoids infected with the Delta variant.

Tandem Macrolactone Synthesis: Total Synthesis of (-)-Exiguolide by a Macrocyclization/Transannular Pyran Cyclization Strategy.

Tetrahydropyran-containing macrolactones were synthesized by integrating Meyer-Schuster rearrangement, macrocyclic ring-closing metathesis, and transannular oxa-Michael addition under gold and ruthenium catalysis. Single-step access to a variety of 14- to 20-membered macrolactones containing a tetrahydropyran ring was possible from readily available linear precursors in good yields and with moderate to excellent diastereoselectivity. A 13-step synthesis of (-)-exiguolide, an anticancer marine macrolide, showcased the feasibility of our tandem reaction sequence for macrolactone synthesis and also demonstrated the power of transannular reactions for rapid assembly of the tetrahydropyran rings of the target natural product.

Esophageal Carcinosarcoma with Basaloid Squamous Cell Carcinoma: A Case Report and Review of the Literature.

Esophageal carcinosarcoma is a rare tumor composed of neoplastic squamous epithelium and sarcomatous spindle cells. The origin of spindle cells remains unknown; however, the majority of sarcomatous components are currently considered to be derived from existing carcinomatous cells via epithelial-mesenchymal transition (EMT). We report a case of esophageal carcinosarcoma harboring basaloid squamous cell carcinoma successfully treated with preoperative chemotherapy. A 78-year-old man complaining dysphagia was diagnosed as esophageal carcinosarcoma. After two courses of preoperative chemotherapy with cisplatin and 5-fluorouracil, curative esophagectomy with lymph node dissection was performed thoracoscopically. Histopathological findings of the resected specimen revealed the mixture of basaloid squamous cell carcinoma and sarcomatous spindle cells. A transitional zone between both components was also detected. As fibrosis was identified around both two components, the findings indicated that both carcinomatous and sarcomatous neoplasms disappeared by preoperative chemotherapy. Final pathological diagnosis was esophageal carcinosarcoma with basaloid squamous cell carcinoma. No recurrent lesions have been detected for 25 months after the surgery. Sarcomatous spindle cells could be derived from the components of basaloid squamous cell carcinoma in our present case due to the presence of histological transition between two components. In addition, the marked immunoreactivity of vimentin (an EMT marker) detected in the tumor cells of basaloid squamous cell carcinoma could be consistent with the concept of monoclonal origin via EMT. The regimen targeting squamous cell carcinoma could also be effective in the treatment of sarcomatous components. Preoperative therapy might achieve the improvement of clinical outcome of patients with esophageal carcinosarcoma.

Reconstructed gastric conduit obstruction caused by a bezoar after esophagectomy: a case report.

BACKGROUND: Bezoars are rare but may cause gastrointestinal obstruction and ulcers. To the best of our knowledge, only two cases of bezoars in the reconstructed gastric conduit have been reported, but there has been no report on reconstructed gastric conduit obstruction due to bezoars. CASE PRESENTATION: A 60-year-old man presented to our clinic with abdominal pain and vomiting that occurred suddenly after dinner. Three years before presentation, he had undergone radical thoracoscopic esophagectomy followed by reconstruction of the gastric conduit through the posterior sternum, for esophageal cancer. Enhanced computed tomography scans showed distension of only the gastric conduit without ischemia and distension of the small intestine. According to our findings, we initially diagnosed the patient with postoperative intestinal obstruction caused by adhesions. After conservative treatment failed, the patient underwent an endoscopic study that showed a bezoar at the pylorus ring. We initially failed to remove the bezoar endoscopically because of its large size; hence, we attempted enzymatic dissolution. Three days after the first endoscopic study, the bezoar was disintegrated using a snare and extracted during a second endoscopy. The patient recovered uneventfully and presented with no complications during the 1-year follow-up interval. CONCLUSION: In cases wherein the discharge of materials in the reconstructed gastric conduit is delayed, bezoars should be considered in the differential diagnosis, and an endoscopic study should be performed to verify the cause of obstruction.

Evaluation of the impact of psoas muscle index, a parameter of sarcopenia, in patients with esophageal squamous cell carcinoma receiving neoadjuvant therapy.

BACKGROUND: The impact of sarcopenia on digestive cancer is widely known. Muscle mass, defined as the psoas muscle index (PMI), is an important parameter of sarcopenia. However, the relationship between esophageal cancer and PMI has not been fully investigated, especially in patients receiving neoadjuvant therapy. METHODS: To elucidate the influence of the PMI on patients with esophageal squamous cell carcinoma receiving neoadjuvant therapy, the progression of sarcopenia defined by the PMI, the relationship between pretherapeutic/preoperative sarcopenia and patient characteristics, and patient survival were retrospectively investigated in 82 patients with esophageal squamous cell carcinoma who underwent neoadjuvant therapy. RESULTS: The PMI decreased by more than 20 mm2/m2 between the pretherapeutic and preoperative periods in 75.6% of the patients. Pretherapeutic sarcopenia (low PMI) correlated with the pathological therapeutic response, postoperative recurrence, and pretherapeutic body mass index. Neoadjuvant chemoradiotherapy was associated with the progression of sarcopenia. The pretherapeutic sarcopenia group (low PMI) had worse disease-free survival (DFS) than the non-sarcopenia group. Furthermore, pretherapeutic sarcopenia (low PMI) was an independent prognostic risk factor of DFS according to univariate and multivariate analyses. CONCLUSIONS: The PMI may decrease during neoadjuvant therapy, especially during neoadjuvant chemoradiotherapy. Pretherapeutic sarcopenic (low PMI) patients should be followed-up more carefully postoperatively because higher risks of recurrence and poorer rates of disease-free survival are associated with these patients.

A comparative analysis of clinicopathological factors between esophageal small cell and basaloid squamous cell carcinoma.

Esophageal small cell carcinoma (E-SmCC) and basaloid squamous cell carcinomas (BSCCs) are both highly aggressive malignancies, but their detailed differences in clinical behaviors have remained virtually unknown. In addition, treatment strategies of the patients with E-SmCC have not been established. 29 cases of E-SmCC and 39 with BSCC were examined in this study to clarify the clinical features and outcome of the patients with E-SmCC and to compare the findings with those of BSCC. E-SmCCs presented a more advanced status than BSCC (TNM Stage: P = .002). Esophagectomy was performed in 15 small cell carcinoma patients and 14 were treated with non-surgical/systemic therapy. The clinical outcome of the small cell carcinoma cases was significantly worse than those with BSCC (P = .001), but results of a stage-stratified analysis revealed that the Stage I small cell carcinoma patients presented favorable prognosis (3-year survival rate 100%, n = 4). In contrast, among those with Stage II-IV, clinical outcome tended to be better in the systemic therapy group (3-year survival rate 49%, n = 13) than the surgically treated group (3-year survival rate 0%, n = 12). E-SmCC was a more aggressive neoplasm than BSCC. However, early detection could possibly improve the clinical outcome of patients with E-SmCC. Systemic therapy could also benefit the patients with advanced disease (Stage II-IV).

Thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for esophageal cancer with a right superior pulmonary vein anomaly: a case report.

BACKGROUND: Superior posterior pulmonary vein anomaly in the right upper lobe (anomalous V2), which is one of the anomalies of the right superior pulmonary vein (RSPV), runs behind the right main or intermediate bronchus. Although this rarely occurs, attention should be given to this venous anomaly during thoracoscopic esophagectomy with subcarinal lymph node dissection. Here, we report a case of thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for lower thoracic esophageal cancer with anomaly of the superior posterior pulmonary vein in the right lobe (anomalous V2). CASE PRESENTATION: A 61-year-old man was diagnosed as having lower esophageal cancer with swelling of multiple lymph nodes in the mediastinum and abdomen. His clinical diagnosis based on the eighth TNM classification system was cT3 N2 M0 stage IIIB. In addition, an anomalous V2 was recognized on preoperative computed tomography imaging before the operation. The vein ran behind the intermediate bronchus and drained into the RSPV located at the area of the subcarinal lymph node. We performed preoperative simulation by using virtual thoracoscopic imaging with the same view as that during operation to help us better dissect the lymph nodes. As a result, thoracoscopic esophagectomy and subcarinal lymph node dissection were performed in the prone position without injuring the anomalous V2. Severe complications did not occur in the postoperative course except for paralysis of the left recurrent laryngeal nerve. The patient was discharged on postoperative day 17. CONCLUSIONS: Injury to an anomalous V2 can cause severe hemorrhage during subcarinal lymph node dissection in esophagectomy. Preoperative simulation by using virtual thoracoscopic imaging is useful to avoid this complication in patients with an anatomical anomaly.

Esophageal cancer with severe funnel chest treated by simultaneous funnel chest surgery and thoracoscopic esophagectomy: a case report.

BACKGROUND: Funnel chest is the most common chest deformity, occurring in 0.06-0.3% of the general population. When it occurs concomitantly with esophageal cancer, it hinders intrathoracic surgery that is necessary for treatment. Although there are a few reports of esophagectomy performed in patients with funnel chest, simultaneous treatment of esophageal cancer and funnel chest with funnel chest surgery (Nuss method) and esophagectomy has not been reported. We report the first case of advanced esophageal cancer complicated by severe funnel chest that was treated using the Nuss method and radical thoracoscopic esophagectomy. CASE PRESENTATION: A 59-year-old man was diagnosed with advanced thoracic esophageal cancer and severe funnel chest. Because his sternum was almost attached to the vertebral bone, thereby creating a narrow space in the mediastinum, esophageal surgery was expected to be complicated. After the patient underwent neoadjuvant chemotherapy, we used the Nuss method to reconstruct the chest and widen the mediastinum. Subsequently, radical thoracoscopic esophagectomy was performed with the patient in the left decubitus position without any difficulty, and the postoperative course was uneventful. CONCLUSION: Simultaneous funnel chest surgery (Nuss method) and thoracoscopic esophagectomy with the patient in the left decubitus position are recommended for esophageal cancer patients with severe funnel chest.

Treatment of spontaneous esophageal rupture (Boerhaave syndrome) using thoracoscopic surgery and sivelestat sodium hydrate.

BACKGROUND: The mortality rate of spontaneous esophageal rupture remains 20% to 40% due to severe respiratory failure. We have performed thoracoscopic surgery for esophageal disease at our department since 1994. Sivelestat sodium hydrate reportedly improves the pulmonary outcome in the patients with acute lung injury (ALI). METHODS: We retrospectively evaluated the usefulness of thoracoscopic surgery and perioperative administration of sivelestat sodium hydrate for spontaneous esophageal rupture in 12 patients who underwent thoracoscopy at our department between 2002 and 2014. RESULTS: The patient cohort included 11 males and one female (median age, 61 years). The lower left esophageal wall was perforated in all patients. Surgical procedures consisted of thoracoscopic suture and thoracic drainage in six patients, transhiatal suture and thoracoscopic thoracic drainage in five, and thoracoscopic esophagectomy and thoracic drainage in one. The median time from onset to surgery was 8 hours with a surgical duration of 210 minutes, blood loss 260 mL, postoperative ventilator management 1 day, intensive care unit (ICU) stay 5 days, and interval to restoration of oral ingestion 13 days. Postoperative complications included respiratory failure in four patients, pyothorax in three, and leakage in one. There was no instance of perioperative mortality. Regarding perioperative administration of sivelestat sodium hydrate, the postoperative arterial oxygen partial pressure-to-fractional inspired oxygen ratio (P/F) and C-reactive protein (CRP) levels in the administration group were significantly better than those in the non-administration group on postoperative days 4 (P=0.035) and 5 (P=0.037), respectively. In contrast, there was no significant difference between the groups in median time of ventilator management, ICU stay, oral ingestion following surgery, or hospital stay. CONCLUSIONS: Thoracoscopic surgery obtained acceptable results in all patients, including two with a significant time elapse from onset to treatment. Furthermore, sivelestat sodium hydrate was suggested to help improve postoperative respiration and inflammatory response.

Definitive chemoradiotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for advanced cervical esophageal cancer.

BACKGROUND: Recently, definitive chemoradiotherapy (dCRT) has become one of the essential treatment strategies for esophageal squamous cell carcinoma (ESCC) and has been especially gaining prevalence for cervical ESCC to preserve the larynx. Our department recently introduced dCRT concomitant with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for treating advanced cervical ESCC. This study aims to assess the safety and outcomes of DCF-R in patients with advanced cervical ESCC. METHODS: We retrospectively assessed 11 patients with advanced cervical ESCC (clinical stage: II-IV, including T4b and/or M1 lymph node) who received DCF-R as the first-line treatment between December 2010 and February 2015. RESULTS: Our patient cohort comprised 8 males and 3 females (median age 68 years; range 54-76 years). The pretreatment clinical stage included stage II (1), stage III (7), and stage IV (3) cases [including 3 patients with T4b (2 trachea and 1 thyroid) and 3 patients with M1 lymph node]. We attained complete response (CR) in 10 patients and stable disease in 1 patient. Of 10 patients with CR, 5 experienced recurrence and 5 continued exhibiting CR. Furthermore, grade 3 or more adverse events included leucopenia (91%), neutropenia (91%), febrile neutropenia (45%), and pharyngeal pain (55%). While the 2-year overall survival rate was 72%, the 2-year recurrent-free survival rate was 64%, respectively. CONCLUSIONS: DCF-R treatment for advanced cervical esophageal cancer could be completed by the careful administration; although a strong blood toxicity might occur, this treatment may provide the chance to obtain favorable prognosis with larynx preservation.

Different strategy of salvage esophagectomy between residual and recurrent esophageal cancer after definitive chemoradiotherapy.

BACKGROUND: Clinical outcomes appear to differ between patients with residual or recurrent esophageal cancer after definitive chemoradiotherapy. We aimed to identify the patients most likely to benefit from this high-risk surgery, divided by the patients whose cancer was residual and recurrent groups, respectively. METHODS: We retrospectively examined 100 cases of patients who failed to respond to definitive chemoradiotherapy for thoracic esophageal squamous cell carcinoma and subsequently underwent salvage transthoracic esophagectomy. RESULTS: In-hospital morbidity was similar in both groups. T status prior to administration of chemoradiotherapy correlated with survival in the group with residual cancer (P=0.010), but this relationship was not significant in the group with recurrent cancer (P=0.635). On the other hand, pathological T status showed a significant correlation with survival in both the residual (P<0.001) and recurrent groups (P=0.001). Patients with T3 disease in the recurrent group showed better survival, similar to T0-2 patients, while worse survival was demonstrated in the residual group. In the recurrent group, N status before chemoradiotherapy did not correlate with survival (P=0.895). CONCLUSIONS: Patients with residual cancer would have good prognosis by salvage esophagectomy in cases in which the cancer had not invaded to the adventitia at the time of chemoradiotherapy and surgery. Conversely, patients whose cancer was recurrent might benefit from salvage surgery if the cancer appears to be resectable. T and N status before chemoradiotherapy are not important factors in consideration of salvage esophagectomy in cases of recurrent cancer.

Curative resection of advanced esophageal cancer with metachronous stage IV breast cancer: A case report.

INTRODUCTION: Recent studies have shown the safety and efficacy of curative resection of esophageal cancer with multiple primary cancers. However, our literature search revealed no curative surgery cases for esophageal cancer in patients with multiple primary cancers with distant metastasis. CASE PRESENTATION: A 75-year-old woman visited our hospital with dysphagia. She had a history of breast cancer with multiple bone metastasis. Esophagogastroduodenoscopy revealed a circumferential mass in the upper intrathoracic esophagus. Histopathological examination of the biopsy showed squamous cell carcinoma. Other imaging findings revealed multiple nodules in the liver. The nodules were thought to have originated from the breast, but metastasis of esophageal cancer was considered a possibility. Intraoperative frozen sections of the liver and peritoneal nodules showed adenocarcinoma. Thoracoscopic esophagectomy was then performed. Following surgery, the patient received fulvestrant therapy, followed by capecitabine therapy, and the liver tumors decreased in size. She is currently alive after 1.5 years of the surgery without local recurrence of esophageal cancer. DISCUSSION: Although the patient had metastatic breast cancer, her relapse-free interval of 20 years and good response to hormone therapy for 15 years were favorable prognostic factors. Her life expectancy was estimated to be a few years and surgery was performed. CONCLUSION: Curative resection could be considered for patients with esophageal cancer who have an additional cancer with distant metastasis when the prognosis of the additional cancer is not poor.

Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases.

INTRODUCTION: The incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position. CASE PRESENTATION: Case 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case 2: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery. CONCLUSION: Bilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.

Thoracoscopic surgery in the prone position for esophageal cancer in patients with situs inversus totalis: A report of two cases.

INTRODUCTION: Situs inversus totalis (SIT) is a rare congenital condition characterized by a complete transposition of thoracic and abdominal organs. Here, we present two successful cases of left thoracoscopic esophagectomy in the prone position for SIT-associated esophageal cancer. PRESENTATION OF CASE: Our first case was of an 82-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by hand-assisted laparoscopic gastric mobilization. Surgical duration and blood loss were 661min and 165g, respectively. His postoperative course was uneventful. The second case was of a 66-year-old man who underwent a left thoracoscopic esophagectomy in the prone position, followed by gastric mobilization via laparotomy owing to a concomitant intestinal malrotation and polysplenia. Surgical duration and blood loss were 637min and 220g, respectively. We trained for the surgical procedures preoperatively using left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy. DISCUSSION: Surgical procedures in SIT patients are challenging owing to their mirrored anatomy. Recognition　of their　variations　is　thus important to　avoid　intraoperative accidental injuries. Left-inverted and right-inverted thoracoscopic surgical videos of patients with normal anatomy were found to be useful for image training prior to the actual surgery. CONCLUSION: Thoracoscopic surgical treatment for esophageal cancer associated with SIT in the prone position can be performed safely, similar to the manner performed for thoracoscopic surgery in the right decubitus position, or surgery via an open thoracotomy. Gastric mobilization via laparotomy should be considered in patients associated other anatomic variations.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma.

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Dexmedetomidine sedation during the nighttime reduced the incidence of postoperative atrial fibrillation in cardiovascular surgery patients after tracheal extubation.

BACKGROUND: Dexmedetomidine (Dex) provides sedation and analgesia by acting on central alpha-2 receptors and is suitable for use after extubation because it has little respiratory depression. Considering the sympathoinhibitory and anxiolytic action of Dex, there is the possibility that Dex might reduce the incidence of atrial fibrillation (AF), which is recognized as a common complication after cardiovascular surgery. We investigated whether the postoperative incidence of AF decreased in patients who received Dex only during the nighttime in the intensive care unit (ICU). METHODS: We retrospectively reviewed ICU charts to determine the incidence of AF and associated factors during the 2-day period after tracheal extubation in patients who underwent cardiovascular surgery from November 2009 to November 2010. The patients were divided into a Dex group (n = 16) and a non-Dex group (n = 29). RESULTS: There were no differences in AF risk factors except for diabetes between the two groups. The average rate of Dex administration was 0.3 ± 0.2 µg/kg/h. There were also no differences between the groups in heart rate during the daytime, central venous pressure, body temperature, white blood cell count, serum level of C-reactive protein, catecholamine use, beta-blocker use, and amount of fentanyl. AF developed in one patient in the Dex group (6.3 %) and ten patients in the non-Dex group (34.5 %) during the observation period, and the difference was significant (p = 0.035). None of the risk factors for AF was significantly associated with AF in univariate analysis; however, multivariate logistic regression analysis using age, Dex use, and beta-blocker use, extracted because their p values in univariate analysis were not exceeding 0.15, showed that Dex use was the only factor associated with the development of AF (p = 0.045, odds ratio 9.75 [1.05-90.8]). CONCLUSIONS: The results suggest that adequate sedation with Dex during the nighttime can reduce the incidence of AF in cardiovascular surgery patients after extubation.

NtbZIP60, an endoplasmic reticulum-localized transcription factor, plays a role in the defense response against bacterial pathogens in Nicotiana tabacum.

A spermine-based signal transduction pathway plays a defensive role against incompatible pathogens. We identified a novel spermine-responsive cDNA from Nicotiana tabacum that encodes a basic region/leucine zipper protein with a putative transmembrane domain. Identity to Arabidopsis thaliana AtbZIP60 was sufficiently high to name the novel cDNA NtbZIP60. Expression analysis revealed that NtbZIP60 is a component of the spermine-signal pathway, and is also involved in the unfolded protein response (UPR), as demonstrated for AtbZIP60. The gene product, NtbZIP60, localizes to the endoplasmic reticulum (ER) in plant cells; once the putative transmembrane domain is eliminated from the intact protein, it targets the nucleus. The putative processed form of NtbZIP60 transactivates target genes through binding to plant-specific UPR cis-elements. Expression of NbbZIP60, an NtbZIP60 ortholog in Nicotiana benthamiana, was significantly up-regulated at 6 h and later time points upon infection with the non-host pathogen Pseudomonas cichorii, while it was unaffected by infection with the compatible pathogen Pseudomonas syringae pv. tabaci. Furthermore, NbbZIP60-silenced N. benthamiana plants allowed higher multiplication of P. cichorii compared to the control plants. Taken together, the results suggest that this ER-localized transcription factor is involved in the spermine-signal transduction pathway and plays an important role in plant innate immunity.