The efficacy of inhaled nanoparticle tacrolimus in preventing rejection in an orthotopic rat lung transplant model.

OBJECTIVE: The immunosuppressive efficacy of inhaled nanoparticle tacrolimus was compared with systemic tacrolimus in a rodent allogeneic lung transplant model. METHODS: Sixteen rats underwent allogeneic left orthotopic lung transplantation and were divided into 3 treatment groups: (1) inhaled nanoparticle tacrolimus: 6.4 mg tacrolimus/6.4 mg lactose twice per day; (2) intramuscular tacrolimus: 1 mg/kg tacrolimus once per day; and (3) inhaled lactose: 6.4 mg of lactose twice per day. Five days after transplant, the rats were necropsied and underwent histologic rejection grading and cytokine analysis. Trough levels of tacrolimus were measured in allograft, blood, and kidney. RESULTS: Both intramuscular (n = 6) and nanoparticle tacrolimus (n = 6) rats displayed lower histologic grades of rejection (mean scores 3.4 ± 0.6 and 4.6 ± 0.9, respectively) when compared with lactose rats (n = 4) (mean score 11.38 ± 0.5, P = .07). Systemic tacrolimus trough levels (median) were lower in nanoparticle tacrolimus-treated rats versus intramuscular-treated rats (29.2 vs 118.6 ng/g; P < .001 in kidney, and 1.5 vs 4.8 ng/mL; P = .01 in blood). CONCLUSIONS: Inhaled nanoparticle tacrolimus provided similar efficacy in preventing acute rejection when compared with systemic tacrolimus while maintaining lower systemic levels.

Immediate postoperative parastomal end sigmoid hernia resulting in evisceration and strangulation.

Parastomal evisceration is a very rare complication occurring after stoma formation. We report the case of this complication which occurred within 3 days status post end sigmoid colostomy in a 69-year-old male who initially presented with perianal infection-severe necrotizing fasciitis. This case highlights the significance of the size of a stomatal aperture and should remind general surgeons of the one of dangerous complications indicated by a stomatal aperture that is just a centimeter larger than the accepted ideal size.

Diagnosis of anastomotic leak: electrolyte detection versus barium fluoroscopy.

BACKGROUND: We recently described a new method of diagnosing anastomotic leak using the detection of electrical changes induced by electrolyte extravasation from a surgically created gastric leak site in experimental rats. We sought to compare the sensitivity and specificity of anastomotic leak detection for this method to that of upper gastrointestinal (GI) barium fluoroscopy. METHODS: Experimental rats with a surgically created gastric leak site and controls were interrogated as to the presence of leak using either the electrolyte-gated leak detection method or upper GI barium fluoroscopy. The sensitivity and specificity of leak detection for the two methods were compared. RESULTS: The sensitivity and specificity of electrolyte-gated leak detection were both 100% (95% confidence interval 69-100%). Barium upper GI fluoroscopy misidentified one leak as a control and one control as a leak, for a sensitivity and specificity of 80% each (95% confidence interval 37-97%). No statistically significant difference was seen between electrolyte-gated leak detection and barium upper GI fluoroscopy in terms of the sensitivity and specificity of anastomotic leak detection. CONCLUSIONS: Electrolyte-gated leak detection was similarly sensitive and specific for anastomotic leak detection as upper GI barium fluoroscopy, the current standard. The electrolyte-gated method has the advantages of an inert contrast agent (normal saline) and the possibility of performing leak interrogation at the bedside. Electrolyte-gated leak detection might represent a plausible alternative to upper GI barium fluoroscopy for routine postoperative anastomotic leak surveillance after esophagectomy or other foregut surgery.

Feasibility of video-assisted thoracoscopic surgery lobectomy in Veterans Administration patients.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) pulmonary lobectomy has been associated with decreased complication rates and length of stay compared with lobectomy by thoracotomy. No studies have addressed VATS lobectomy in Veterans Administration (VA) patients. METHODS: A retrospective review was undertaken of 50 VATS lobectomies performed between August 2007 and June 2009 by one surgeon in a VA hospital, a university-affiliated county hospital, and a private community hospital. RESULTS: VA patients had more medical comorbidities, poorer lung function, greater current smoker status, and fewer preoperative biopsies. Pleural adhesions or hilar lymphadenopathy were encountered more commonly in VA than nonfederal patients. Surgical times and number of procedures performed were greater in VA patients. There was no statistically significant difference in the risk of postoperative complications or chest tube duration although length of stay was longer for VA patients. CONCLUSIONS: VATS lobectomy is feasible in a VA setting. The evidence strongly suggests that veterans can benefit from VATS lobectomy in terms of improved outcomes and diminished length of stay compared with thoracotomy.