The development of a nucleus pulposus-derived cartilage analog scaffold for chondral repair and regeneration.

Focal chondral defects (FCDs) significantly impede quality of life for patients and impose severe economic costs on society. One of the most promising treatment options-autologous matrix-induced chondrogenesis (AMIC)-could benefit from a scaffold that contains both of the primary cartilage matrix components-sulfated glycosaminoglycans (sGAGs) and collagen type II. Here, 17 different protocols were evaluated to determine the most optimum strategy for decellularizing (decelling) the bovine nucleus pulposus (bNP) to yield a natural biomaterial with a cartilaginous constituency. The resulting scaffold was then characterized with respect to its biochemistry, biomechanics and cytocompatibility. Results indicated that the optimal decell protocol involved pre-crosslinking the tissue prior to undergoing decell with trypsin and Triton X-100. The residual DNA content of the scaffold was found to be 32.64 ± 9.26 ng/mg dry wt. of tissue with sGAG and hydroxyproline (HYP) contents of 72.53 ± 16.43. and 78.38 ± 8.46 µg/mg dry wt. respectively. The dynamic viscoelastic properties were found to be preserved (complex modulus: 17.92-16.62 kPa across a range of frequencies) while the equilibrium properties were found to have significantly decreased (aggregate modulus: 11.51 ± 9.19 kPa) compared to the non-decelled fresh bNP tissue. Furthermore, the construct was also found to be cytocompatible with bone marrow stem cells (BMSCs). While it was not permissive of cellular infiltration, the BMSCs were still found to have lined the laser drilled channels in the scaffold. Taken together, the biomaterial developed herein could be a valuable addition to the AMIC family of scaffolds or serve as an off-the-shelf standalone option for cartilage repair.

Hiatal Hernia After Esophagectomy: A Single-Center Retrospective Analysis of a Rare Postoperative Phenomenon.

Development of a post-esophagectomy hiatal hernia (PEHH) is a rare, but problematic, sequela with the current reported prevalence ranging up to 20%. To determine the incidence rate of PEHH at our institution, a retrospective review of all transhiatal esophagectomies performed from 2012 to 2020 was conducted. Demographic, operative, and oncologic data were collected, rates of PEHH were calculated, and characteristics of subsequent repair were reviewed and analyzed. A total of 160 transhiatal esophagectomies were included, of which four patients (2.5%) developed a PEHH at a mean of 12 months postoperatively (range: 3-28 months) with symptomatology driving the diagnosis for three patients. The limited size of our study does not allow for statistically significant determinations regarding risk factors or method of repair. The true prevalence of a hiatal defect is likely higher than reported, as clinically asymptomatic patients are not captured in our current literature.

Regional Anesthetic Use in Trans-Hiatal Esophagectomy. Are They Worth Consideration? A Case Series.

Background: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA. Methods: This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission. Results: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain. Conclusion: The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study's population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy. Trial Registration: This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.

The Novel Conduit: Challenges of Esophagectomy After Bariatric Surgery.

Metabolic surgery has been on the rise over the last 2 decades. As more literature has been being published regarding its efficacy in treating metabolic syndrome as well as advancements in surgical training and safety rise with it, metabolic surgery will in no doubt continue to increase in prevalence. Concomitantly, the prevalence of esophageal cancer is increasing. We present two cases of patients who are status post sleeve gastrectomy and require esophagectomy. These patients do not have the availability of a gastric conduit, and colon interposition graft was planned for their reconstructions. We here review the two unique case scenarios as well as an overview of colon interposition technique and workup considerations. The need this reconstruction technique will likely increase in the years to come and metabolic surgery and esophageal cancer both continue to rise.

Esophagectomy in octogenarians: is it at a cost?

Background: Surgical intervention in the geriatric population has a higher risk of perioperative morbidity and mortality due to frailty, comorbidities, and lack of compensatory physiologic reserve. The literature on esophagectomy in octogenarians is limited and there is concern about elderly patients being with-held surgery. The purpose of this study is to analyze the outcomes of esophagectomies for esophageal cancer in octogenarians to assess the safety of esophagectomy in this population. Methods: 145 transhiatal esophagectomies performed for esophageal cancer between 2012 and 2020 were retrospectively reviewed in this IRB approved study. Two aborted esophagectomies were excluded. Patient demographics, surgical outcomes, and oncologic outcomes were reviewed. The octogenarian group was analyzed compared to patients younger than 80 years of age. Results: Among 143 esophagectomies, 136 patients were <80 years old while 7 were ≥80 years old. Octogenarians received significantly less neoadjuvant therapy compared to younger patients (42.9% vs 80.2%, p = 0.02). No statistically significant difference was noted in complication rate, length of stay (LOS), estimated blood loss (EBL), or mortality. However, octogenarians were found to have an increase in severity of complications compared to younger patients. Conclusion: This study demonstrates that esophagectomy can be performed in carefully selected octogenarians. This comes at a cost with increased severity of complications without an increase in complication rates or mortality. This data suggests that esophagectomy can be offered selectively to older patients with clear expectations and planning for the high risk of more severe post-operative complications.

Aspiration Thrombectomy for Acute ST-Elevation Myocardial Infarction: Literature Review.

Over the years, aspiration thrombectomy for management of acute coronary syndrome was the center of discussion however due to multiple randomized control trials which did not provide sufficient evidence supporting use of this approach, this method is not routinely used. The benefit of this approach remains unknown, however, it is important to acknowledge the evolution of aspiration catheters and their potential in minimizing complications which were previously the set back of this approach. We provide a comprehensive review of the previous trials and how those catheters have since evolved significantly.

Zero leaks with minimally invasive esophagectomy: a team-based approach.

INTRODUCTION: Minimally invasive surgery has been applied in several ways to esophagectomy. Newer techniques have improved patient outcomes while maintaining oncological principles; however, mortality still exists. Most series have reported mortality rates ranging from 2% to 25%. The aim of this study was to determine the efficacy of minimally invasive esophagectomies (MIE) in a non-university tertiary care center. METHODS: MIE in the form of a combined thoracoscopic and laparoscopic technique was performed cooperatively by 2 surgeons. Records of patients who underwent MIE between September 2005 and August 2008 were retrospectively reviewed. RESULTS: Thirty-four patients underwent MIE over a 3-year period. There was a male predominance. Mean age at presentation was 62.6 years. Comorbidities were documented in 79% of the patients. Most patients (68%) presented with dysphagia. Two patients had end-stage achalasia, 1 had corrosive esophageal stricture, and 31 had esophageal malignancies. No mortalities were reported. No anastomotic leaks were observed. Eighteen (58%) patients with malignancy received preoperative chemoradiotherapy. Six (33%) patients had a pathological response (CR) on final histopathology. The mean operating time was 294 minutes. The mean blood loss was 302 mL. CONCLUSIONS: Minimally invasive esophagectomy can be performed with results that meet and exceed reported benchmarks. A team-based approach greatly impacts the outcome of the surgery. This surgical technique must be standardized to achieve this outcome.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy.

BACKGROUND AND OBJECTIVES: As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE). METHODS: Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon. RESULTS: Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention. CONCLUSIONS: Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.