Esophageal duplication cysts: a clinical practice review.

Esophageal duplication represents one of the most common types of bronchopulmonary foregut malformations. These rare congenital anomalies occur secondary to embryological aberrations between the 4th and 8th weeks of gestation. In order to be classified as an esophageal cyst a mediastinal cyst must have a close proximity with the esophagus, be lined by alimentary (squamous epithelium) or tracheobronchial mucosa and covered by two smooth muscle layers. These rare anomalies are often asymptomatic during adulthood. However, they can cause symptoms in early childhood, generally during the first 2 years of life. Variations in location, size, presence or absence of heterotopic mucosa, will dictate the clinical presentation. Dysphagia, food impaction, persistent cough and chest pain are common clinical presentations. Imaging studies including esophagram, computed tomography (CT) and magnetic resonance imaging (MRI) can provide key findings to reach the diagnosis. Nonetheless, endoscopic evaluation, particularly endoscopic ultrasound (EUS) is the most valuable tool to determine whether this lesion is cystic versus solid and or if there are abnormal mucosal findings. Needle biopsies are controversial but can help with drainage and to rule out malignant transformation. Therapeutic options include endoluminal drainage. However, more definitive therapies include surgical excision. Open and minimally invasive (laparoscopic and thoracoscopic) techniques have been demonstrated to be safe and effective at completely removing these lesions. Recently, robotic-assisted resections have gained more attention with case reports and series reporting excellent outcomes.

Endoluminal management of benign bronchoesophageal fistula.

The ideal management of bronchoesophageal fistulas is a debated topic. While open surgical repair remains the most definitive treatment, not all patients are fit for surgery. In this communication, we present a patient who developed a bronchoesophageal fistula 1 year after an Ivor Lewis esophagectomy that involved the native oesophagus and right mainstem bronchus. Endoluminal vacuum therapy was successful at closing this benign bronchoesophageal fistula.

Collision tumors of the lung: A case report of urothelial carcinoma metastasizing to renal cell carcinoma with heterotopic ossification.

Collision tumors are rare entities that consist of at least two or more histologically and ontologically distinct tumor types within the same organ. It is still not well understood how collision tumors form; yet, three main theories have been proposed to explain the pathogenesis, including the "random collision effect," "field cancerization," and "tumor-to-tumor carcinogenesis." Collision tumors have been encountered in various body organs, including the lung. They either consist of a metastasizing tumor colliding with primary cancer or distinct primary or metastatic cancers colliding together. Here, we describe a rare case of collision tumors of the lung that consists of two metastatic carcinomas, namely renal cell carcinoma and urothelial carcinoma of the bladder. We propose that the urothelial carcinoma disseminated into several pre-existing pulmonary metastases of renal cell carcinoma with heterotopic bone formation. The possible mechanisms underlying the development of this peculiar tumor are discussed.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion.

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.

Incidence and clinical implications of upper extremity deep vein thrombosis after laparoscopic bariatric procedures.

Upper extremity deep vein thrombosis (UEDVT) represents less than 10 % of thromboembolic events, but has been associated with higher incidence of asymptomatic pulmonary embolism. Data regarding UEDVT and its treatment is limited. Our objective was to investigate UEDVT incidence, diagnosis, and treatment in our bariatric patient population. We conducted a retrospective review of patients undergoing laparoscopic bariatric surgery at our institution. Variables analyzed included patient demographics, body mass index (BMI), history of venous thromboembolic event (VTE), type of procedure, and other comorbidities. One thousand five hundred three patients were included in the study. Twenty patients developed VTE events, of which five suffered UEDVT. Although infrequent, awareness of UEDVT is necessary in order to initiate treatment in a timely fashion and to prevent major complications.

Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience.

INTRODUCTION: The risk of venous thromboembolic (VTE) events is increased in patients undergoing bariatric surgery. Population studies examining VTE rates after bariatric surgery often lack details and uniformity regarding the prophylactic regimens used. The aim of this study was to determine the incidence of VTE in patients undergoing laparoscopic bariatric surgery. METHODS: Database searches from Cleveland Clinic bariatric surgery programs in Cleveland, OH, and Weston, FL, were conducted from January 2005 to January 2013. Mechanical and chemical prophylaxes were provided for all patients as per protocol. Data on age, gender, body mass index (BMI), interval between procedure and VTE, inpatient versus outpatient status, anticoagulation prophylaxis, type of surgery and mortality were collected. RESULTS: A total of 4,293 patients underwent primary or revisional bariatric surgery during this 8-year time period. VTE events were identified in 57 patients (1.3 %). Pulmonary embolism (PE) was identified in 39 patients (0.9 %), and 15 of these patients had negative duplex studies of the lower extremities. Deep venous thrombosis only was identified in 18 patients (0.4 %). VTE rates for gastric bypass (n = 2,945), sleeve gastrectomy (n = 709), gastric banding (n = 467) and revisional procedures (n = 171) were 1.1, 2.9, 0.2 and 6.4 %, respectively. Eight patients had VTE diagnosed during their inpatient stay. The mean time to VTE diagnosis after surgery was 24 days. Seventeen patients who developed VTE had been prescribed extended prophylaxis for 2-4 weeks after discharge. There was only one VTE-related mortality from PE reported in this cohort (0.02 %). Univariate and multivariate analyses revealed age, BMI, open and revisional surgery as predictive of VTE (p < 0.05). CONCLUSION: The risk of VTE among morbidly obese patients undergoing bariatric surgery is persistent despite use of laparoscopy and aggressive prophylactic anticoagulation policy. Patients with advanced age, higher BMI and those undergoing open or revisional surgery are at higher risk of postoperative VTE.

Is the use of prosthetic mesh recommended in severely obese patients undergoing concomitant abdominal wall hernia repair and sleeve gastrectomy?

BACKGROUND: The concomitant use of nonabsorbable mesh during stapled bariatric surgery has been discouraged due to potential contamination. The aim of our study was to compare and quantify the extent of bacterial load and gross contamination of the peritoneal cavity in patients undergoing laparoscopic sleeve gastrectomy (LSG) vs those undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). STUDY DESIGN: We prospectively enrolled all patients undergoing LSG and LRYGB. Peritoneal fluid aspirate samples were collected from each subject. Sample A was obtained at the beginning of the procedure, and sample B was obtained at the end of the procedure either from the staple line wash of the LSG or the gastrojejunostomy in the LRYGB. RESULTS: A total of 77 patients (51 LSG and 26 LRYGB) and 154 samples (102 from LSG and 52 from LRYGB) were included in this study. All samples obtained at the beginning of each procedure (sample A) were culture negative. Samples of peritoneal fluid obtained at the end of the procedure (sample B) in sleeve gastrectomy procedures were all negative (0%) after a minimum of 72 hours for aerobic and anaerobic cultures. Those obtained for LRYGB (sample B) were culture positive in 4 of 26 (15%). The latter results are statistically significant (p < 0.05). CONCLUSIONS: Intraperitoneal bacterial cultures in patients undergoing LSG are negative, contrary to those in patients undergoing LRYGB. The concomitant use of prosthetic material to repair ventral hernias in patients undergoing an LSG procedure should be safe and feasible.

Fasting cycles retard growth of tumors and sensitize a range of cancer cell types to chemotherapy.

Short-term starvation (or fasting) protects normal cells, mice, and potentially humans from the harmful side effects of a variety of chemotherapy drugs. Here, we show that treatment with starvation conditions sensitized yeast cells (Saccharomyces cerevisiae) expressing the oncogene-like RAS2(val19) to oxidative stress and 15 of 17 mammalian cancer cell lines to chemotherapeutic agents. Cycles of starvation were as effective as chemotherapeutic agents in delaying progression of different tumors and increased the effectiveness of these drugs against melanoma, glioma, and breast cancer cells. In mouse models of neuroblastoma, fasting cycles plus chemotherapy drugs--but not either treatment alone--resulted in long-term cancer-free survival. In 4T1 breast cancer cells, short-term starvation resulted in increased phosphorylation of the stress-sensitizing Akt and S6 kinases, increased oxidative stress, caspase-3 cleavage, DNA damage, and apoptosis. These studies suggest that multiple cycles of fasting promote differential stress sensitization in a wide range of tumors and could potentially replace or augment the efficacy of certain chemotherapy drugs in the treatment of various cancers.

Reduced levels of IGF-I mediate differential protection of normal and cancer cells in response to fasting and improve chemotherapeutic index.

Inhibitors of the insulin-like growth factor-I (IGF-I) receptor have been widely studied for their ability to enhance the killing of a variety of malignant cells, but whether IGF-I signaling differentially protects the host and cancer cells against chemotherapy is unknown. Starvation can protect mice, but not cancer cells, against high-dose chemotherapy [differential stress resistance (DSR)]. Here, we offer evidence that IGF-I reduction mediates part of the starvation-dependent DSR. A 72-hour fast in mice reduced circulating IGF-I by 70% and increased the level of the IGF-I inhibitor IGFBP-1 by 11-fold. LID mice, with a 70% to 80% reduction in circulating IGF-I levels, were protected against three of four chemotherapy drugs tested. Restoration of IGF-I was sufficient to reverse the protective effect of fasting. Sixty percent of melanoma-bearing LID mice treated with doxorubicin achieved long-term survival whereas all control mice died of either metastases or chemotherapy toxicity. Reducing IGF-I/IGF-I signaling protected primary glia, but not glioma cells, against cyclophosphamide and protected mouse embryonic fibroblasts against doxorubicin. Further, S. cerevisiae lacking homologs of IGF-I signaling proteins were protected against chemotherapy-dependent DNA damage in a manner that could be reversed by expressing a constitutively active form of Ras. We conclude that normal cells and mice can be protected against chemotherapy-dependent damage by reducing circulating IGF-I levels and by a mechanism that involves downregulation of proto-oncogene signals.

Fasting and cancer treatment in humans: A case series report.

Short-term fasting (48 hours) was shown to be effective in protecting normal cells and mice but not cancer cells against high dose chemotherapy, termed Differential Stress Resistance (DSR), but the feasibility and effect of fasting in cancer patients undergoing chemotherapy is unknown. Here we describe 10 cases in which patients diagnosed with a variety of malignancies had voluntarily fasted prior to (48-140 hours) and/or following (5-56 hours) chemotherapy. None of these patients, who received an average of 4 cycles of various chemotherapy drugs in combination with fasting, reported significant side effects caused by the fasting itself other than hunger and lightheadedness. Chemotherapy associated toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE) of the National Cancer Institute (NCI). The six patients who underwent chemotherapy with or without fasting reported a reduction in fatigue, weakness, and gastrointestinal side effects while fasting. In those patients whose cancer progression could be assessed, fasting did not prevent the chemotherapy-induced reduction of tumor volume or tumor markers. Although the 10 cases presented here suggest that fasting in combination with chemotherapy is feasible, safe, and has the potential to ameliorate side effects caused by chemotherapies, they are not meant to establish practice guidelines for patients undergoing chemotherapy. Only controlled-randomized clinical trials will determine the effect of fasting on clinical outcomes including quality of life and therapeutic index.

Starvation-dependent differential stress resistance protects normal but not cancer cells against high-dose chemotherapy.

Strategies to treat cancer have focused primarily on the killing of tumor cells. Here, we describe a differential stress resistance (DSR) method that focuses instead on protecting the organism but not cancer cells against chemotherapy. Short-term starved S. cerevisiae or cells lacking proto-oncogene homologs were up to 1,000 times better protected against oxidative stress or chemotherapy drugs than cells expressing the oncogene homolog Ras2(val19). Low-glucose or low-serum media also protected primary glial cells but not six different rat and human glioma and neuroblastoma cancer cell lines against hydrogen peroxide or the chemotherapy drug/pro-oxidant cyclophosphamide. Finally, short-term starvation provided complete protection to mice but not to injected neuroblastoma cells against a high dose of the chemotherapy drug/pro-oxidant etoposide. These studies describe a starvation-based DSR strategy to enhance the efficacy of chemotherapy and suggest that specific agents among those that promote oxidative stress and DNA damage have the potential to maximize the differential toxicity to normal and cancer cells.