Thoracoscopic esophagectomy for thoracic esophageal cancer with right aortic arch and Kommerell diverticulum: a case report and literature review.

Background: Esophageal carcinoma accompanied by a right aortic arch (RAA) is very rare. When combined with Kommerell diverticulum (KD), a right aortic arch forms a vascular ring encircling both the esophagus and trachea. Due to abnormal anatomy of the upper mediastinum, it is very difficult to dissociate the esophagus and its surrounding tissues, especially the left recurrent laryngeal nerve. Herein, we report a case of successful thoracoscopic esophagectomy in an esophageal cancer patient concurrent with a RAA and KD. Case presentation: A 62-year-old male patient was diagnosed with esophageal squamous carcinoma in the middle esophagus at clinical stage I (cT1N0M0) according to UICC-TNM classification 8th edition. Further examinations revealed RAA and KD. Based on the three-dimensional CT (3D-CT) reconstruction, a Mckeown esophagectomy via a left thoracoscopic approach in semi-prone position was performed. During the operation, the left recurrent laryngeal nerve was accurately exposed and well protected. Postoperatively, severe complications, including anastomotic leakage and recurrent laryngeal nerve palsy, were not observed. The patient was discharged 12 days after the surgery. Conclusion: Preoperative 3D-CT reconstruction is useful to clarify the vascular malformation in esophageal cancer patients with RAA, and helpful to formulate a reasonable surgical approach.

Silybin alleviates hepatic lipid accumulation in methionine-choline deficient diet-induced nonalcoholic fatty liver disease in mice via peroxisome proliferator-activated receptor α.

Nonalcoholic fatty liver disease (NAFLD) is regarded as the most common liver disease with no approved therapeutic drug currently. Silymarin, an extract from the seeds of Silybum marianum, has been used for centuries for the treatment of various liver diseases. Although the hepatoprotective effect of silybin against NAFLD is widely accepted, the underlying mechanism and therapeutic target remain unclear. In this study, NAFLD mice caused by methionine-choline deficient (MCD) diet were orally administrated with silybin to explore the possible mechanism and target. To clarify the contribution of peroxisome proliferator-activated receptor α (PPARα), PPARα antagonist GW6471 was co-administrated with silybin to NAFLD mice. Since silybin was proven as a PPARα partial agonist, the combined effect of silybin with PPARα agonist, fenofibrate, was then evaluated in NAFLD mice. Serum and liver samples were collected to analyze the pharmacological efficacy and expression of PPARα and its targets. As expected, silybin significantly protected mice from MCD-induced NAFLD. Furthermore, silybin reduced lipid accumulation via activating PPARα, inducing the expression of liver cytosolic fatty acid-binding protein, carnitine palmitoyltransferase (Cpt)-1a, Cpt-2, medium chain acyl-CoA dehydrogenase and stearoyl-CoA desaturase-1, and suppressing fatty acid synthase and acetyl-CoA carboxylase α. GW6471 abolished the effect of silybin on PPARα signal and hepatoprotective effect against NAFLD. Moreover, as a partial agonist for PPARα, silybin impaired the powerful lipid-lowering effect of fenofibrate when used together. Taken together, silybin protected mice against NAFLD via activating PPARα to diminish lipid accumulation and it is not suggested to simultaneously take silybin and classical PPARα agonists for NAFLD therapy.

Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy.

BACKGROUND: In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications. AIM: To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position. METHODS: The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named "bilateral exposure method"). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018. RESULTS: There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312). CONCLUSION: This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

Discovery and Validation of a Serologic Autoantibody Panel for Early Diagnosis of Esophageal Squamous Cell Carcinoma.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) accounts for the highest incidence rate worldwide and is responsible for the fourth leading cause of cancer-related death. Currently, serologic biomarkers for early ESCC diagnosis are needed for timely treatment. METHODS: The performance of a four-autoantibody panel (i.e., anti-TP53, HRAS, CTAG1A, and NSG1) was evaluated by ELISA for the early diagnosis of ESCC with 569 retrospective serum samples. A training set comprising 129 patients with early-stage ESCC, 130 patients with esophageal benign lesion (EBL), and 150 healthy controls (HC) was used to develop an early ESCC predictive model. Data obtained from an independent validation set were used to evaluate and validate the predictive model to distinguish the early ESCC from the controls (EBL+HC). Finally, a multiplexed assay based on the Luminex xMAP technology platform was developed to enable simultaneous detection of the four-autoantibody panel using the validation set. RESULTS: The four-autoantibody panel significantly discriminated early ESCC cases from the controls with 62.8% sensitivity at 88.9% specificity in the training set and with 58.0% sensitivity at 90.0% specificity in the independent validation set. The results of the multiplexed assay using xMAP technology for early ESCC showed a significant correlation with that of the ELISA assays with 66.0% sensitivity at 90.9% specificity. CONCLUSIONS: A four-autoantibody panel showed good performance for early ESCC diagnosis with ELISA and could be further developed into a multiplex assay using the Luminex xMAP technology. IMPACT: The four-autoantibody panel could be used for serologic screening for early ESCC.

[Effects of Flooding and Drying on the Transformation of Soil Inorganic Phosphorus in the Water-Level-Fluctuating Zone of the Three Gorges Reservoir, China].

The implementation of the Three Gorges Project formed a water-level-fluctuating zone, and flooding and drying affects the soil properties and water quality of the Water-Level-Fluctuating Zone. The laboratory simulation or field sampling were conducted; however, the results cannot reflect the real conditions in practice. The effects of flooding and drying on the physical and chemical properties of soil and the transformation characteristics of inorganic phosphorus were studied in order to provide a theoretical reference for soil phosphorus loss and water eutrophication in water-level-fluctuating zone of the Three Gorges Reservoir. To investigate the conversion of soil phosphorus, plastic pots with soil were suspended at different depths (0, 2, 5, and 15 m) and submerged for 30, 60, and 180 d, and exposed for 180 d. The effects of submerged depth and time on the soil physical and chemical properties and inorganic phosphorus forms were studied. The results showed that soil pH, organic matter, total phosphorus, and available phosphorus decreased and then increased subsequently during the flooding period. After exposure for 180 d, soil pH, organic matter, and total phosphorus content decreased, while available phosphorus content increased. After flooding, the ratio of various forms of inorganic phosphorus to total phosphorus was Fe-P > Al-P > Ca8-P > Ca2-P. The content of Ca2-P and Ca8-P decreased at 0 m and 2 m and decreased at 5 m and 15 m and then increased with increased flooding time. After exposure for 180 days, the content of inorganic phosphorus increased significantly, and the content of inorganic phosphorus decreased as flooding depth increased. Al-P content increased with the flooding time, but there was no obvious change with flooding depth. The content of Fe-P did not change with the time and the depth of flooding.

MiR-504 inhibits cell proliferation and invasion by targeting LOXL2 in non small cell lung cancer.

BACKGROUND: MicroRNAs (miRNAs) play crucial roles in tumor initiation and development. The aim of the study was to explore the clinicopathological role and functional effects of miR-504 in non small cell lung cancer (NSCLC). METHODS: Quantitative reverse transcription polymerase chain reaction (QRT-PCR) was applied to detect the expression of miR-504 in 55 cases of NSCLC tissues and matched adjacent normal tissues in NSCLC patients. MTT, colony formation and transwell invasion assays were performed to evaluate the effects of miR-504 on cell proliferation and invasion, respectively. Dual luciferase reporter assay was used to verify that LOXL2 was a direct target of miR-504. QRT-PCR and western blot analysis were performed to analyze mRNA and protein expression. RESULTS: In the study, we demonstrated that miR-504 was notably downregulated in NSCLC tissues compared with adjacent normal tissues. Lower miR-504 expression positively correlated with lymph node metastasis and advanced TNM stage in patients. Furthermore, upregulation of miR-504 significantly inhibited cell proliferation, cell invasion and EMT process of NSCLC. QRT-PCR, western blot and luciferase reporter assays confirmed that miR-504 could bind to LOXL2 3'UTR region and regulate its expression. Moreover, ectopic expression of LOXL2 could rescue the inhibiting effects on cell proliferation and invasion induced by miR-504 in NSCLC cells. CONCLUSIONS: Our results indicated that miR-504 functioned as a tumor suppressor in NSCLC and may serve as a target of NSCLC treatment.

Management of Pleural Space After Lung Resection by Cryoneuroablation of Phrenic Nerve: A Randomized Study.

OBJECTIVES: Residual air space problems after pulmonary lobectomy are an important concern in thoracic surgical practice, and various procedures have been applied to manage them. This study describes a novel technique using controllable paralysis of the diaphragm by localized freezing of the phrenic nerve, and assesses the effectiveness of this procedure to reduce air space after pulmonary lobectomy. METHODS: In this prospective randomized study, 207 patients who underwent lobectomy or bilobectomy and systematic mediastinal node dissection in our department between January 2009 and November 2013 were randomly allocated to a cryoneuroablation group or a conventional group. Patients in the cryoneuroablation group (n = 104) received phrenic nerve cryoneuroablation after lung procedures, and patients in the conventional group (n = 103) did not receive cryoneuroablation after the procedure. Data regarding preoperative clinical and surgical characteristics in both groups were collected. Both groups were compared with regard to postoperative parameters such as total amount of pleural drainage, duration of chest tube placement, length of hospital stay, requirement for repeat chest drain insertion, prolonged air leak, and residual space. Perioperative lung function was also compared in both groups. Recovery of diaphragmatic movement in the cryoneuroablation group was checked by fluoroscopy on the 15th, 30th, and 60th day after surgery. RESULTS: There was no statistically significant difference in patient characteristics between the 2 groups; nor was there a difference in terms of hospital stay, new drain requirement, and incidence of empyema. In comparison with the conventional group, the cryoneuroablation group had less total drainage (1024 ± 562 vs 1520 ± 631 mL, P < .05), fewer cases of residual space (9 vs 2, P < .05), fewer cases of prolonged air leak (9 vs 1, P < .01), and shorter duration of drainage (3.2 ± 0.2 vs 4.3 + 0.3 days, P < .01). Diaphragmatic paralyses caused by cryoneuroablation reversed within 30 to 60 days. CONCLUSIONS: Cryoneuroablation of the phrenic nerve offers a reasonable option for prevention of residual air space following major pulmonary resection.

Novel diagnosis and treatment of esophageal granular cell tumor: report of 14 cases and review of the literature.

BACKGROUND: Granular cell tumors (GCT), especially in the esophagus, are rare neoplasms originating from the nervous system. There is still some controversy regarding the diagnosis and treatment of esophageal GCT. METHODS: We report 14 cases of esophageal GCT diagnosed and treated from January 2004 to March 2013. Their clinical manifestations, endoscopic image, endoscopic ultrasonography (EUS) appearance, pathology, immunohistochemistry, treatment, and prognosis were reviewed. RESULTS: The typical images of EUS were hypoechoic, homogenous, and smooth-edged tumors restricted to deep mucosal and submucosal layers. However, there were 2 cases with tumors invading muscular layer. Endoscopic ultrasonography was valuable to assess the tumor size, location, depth of invasion, and nature. According to EUS manifestation, 11 cases with lesions 3 cm or less in diameter without muscular layer invasion underwent endoscopic resection without complication and the other 3 cases underwent surgical resection. A new technique of submucosal tunnel endoscopic resection was performed in 3 submucosal cases with lesions ranging from 2 cm to 3 cm in diameter. All of these cases were benign and histology was necessary for differential diagnosis. CONCLUSIONS: Endoscopic ultrasonography plays an important guiding role in the diagnosis and treatment of esophageal GCT. Submucosal tunnel endoscopic resection is safe and effective. Further study is needed to determine whether this technique can be expanded into other applications.