Major Intraoperative Complications During Minimally Invasive Esophagectomy.

BACKGROUND: Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer. METHODS: Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction. RESULTS: Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%. CONCLUSIONS: This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Effect of thoracic cage width on surgery time and postoperative outcome in minimally invasive esophagectomy.

INTRODUCTION: Minimally invasive esophagectomy (MIE) for esophageal cancer is a complex procedure that reduces postoperative morbidity in comparison to open approach. In this study, thoracic cage width as a factor to predict surgical difficulty in MIE was evaluated. METHODS: All patients of our institution receiving either total MIE or robotic-assisted MIE (RAMIE) with intrathoracic anastomosis between February 2016 and April 2021 for esophageal cancer were included in this study. Right unilateral thoracic cage width on the level of vena azygos crossing the esophagus was measured by the horizontal distance between the esophagus and parietal pleura on preoperative computer tomography. Patients' data as well as operative and postoperative details were collected in a prospective database. Correlation between thoracic cage width with duration of the thoracic procedure and postoperative complication rates was analyzed. RESULTS: Overall, 313 patients were eligible for this study. Thoracic width on vena azygos level ranged from 85 to 149 mm with a mean of 116.5 mm. In univariate analysis, a small thoracic width significantly correlated with longer duration of the thoracic procedure (p = 0.014). In multivariate analysis, small thoracic width and neoadjuvant therapy were identified as independent factors for long duration of the thoracic procedure (p = 0.006). Regarding postoperative complications, thoracic cage width was a significant risk factor for occurrence of postoperative pneumonia in the multivariate analysis (p = 0.045). Dividing the cohort into two groups of patients with narrow (≤ 107 mm, 19.5%) and wide thoraces (≥ 108 mm, 80.5%), the thoracic procedure was significantly prolonged by 17 min (204 min vs. 221 min, p = 0.014). CONCLUSION: A small thoracic cage width is significantly correlated with longer operation time during thoracic phase of a MIE in Europe, which suggests increased surgical difficulty. Patients with small thoracic cage width may preferably be operated by MIE-experienced surgeons.

Extended lower paratracheal lymph node resection during esophagectomy for cancer - safety and necessity.

BACKGROUND: The ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance. METHODS: Retrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 - December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. RESULTS: 103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively). CONCLUSION: The resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.

Analysis of orthostatic intolerance symptoms in patients with premature ejaculation.

OBJECTIVE: The autonomic nervous system (ANS) plays an important role in maintaining physiological regulation. It regulates the body's response to many variable situations. Orthostatic intolerance (OI) is one of the most important signs of autonomic dysfunction. Autonomic dysfunction is known to cause premature ejaculation (PE) by disturbing the balance in erection and ejaculation cycles. Considering that OI may develop due to autonomic dysfunction in patients with PE, we hypothesized that OI symptoms would increase in these patients. The aim of our study was to investigate the relationship between orthostatic intolerance and PE. PATIENTS AND METHODS: This case-control study included a total of 39 patients with PE and 47 volunteers without PE. All subjects were assessed using the self-reported Orthostatic Grading Scale (OGS). In addition, the validated five-item Turkish version of the Premature Ejaculation Diagnostic Tool (PEDT) was used to evaluate PE. The PE group included patients with a PEDT score ≥ 11. RESULTS: The mean ages of the PE and control groups were 38.2 ± 7.8 and 40.5 ± 9.1 years, respectively (p = 0.137). The mean PEDT scores of the PE and control groups were 13.9 ± 3.6 and 6.6 ± 2.9, respectively (p < 0.0001), and their mean OGS scores were 5.6 ± 2.4 and 1.6 ± 1.3, respectively (p < 0.0001). A statistically significant correlation was found between the PEDT and OGS scores (r: 0.686, p < 0.0001). CONCLUSIONS: The orthostatic intolerance symptoms of patients with PE were higher than those of the control group. There was a correlation between the severity of PE and the severity of orthostatic intolerance. This is the first study in the literature to reveal a relationship between orthostatic intolerance and PE.

Low psoas muscle index has a negative impact on survival after minimal invasive esophagectomy for cancer in European men.

INTRODUCTION: Sarcopenia, a key component of frailty in cancer patients, is associated with complicated procedures and worse survival after esophageal resection. The psoas muscle index (PMI) has been implicated as a possible sarcopenia imaging marker. This retrospective study aims to elucidate the effect of PMI and BMI in a cohort in Europe after totally minimally invasive esophagectomy for cancer. METHODS: The study included 318 consecutive adult patients (261 men and 57 women) who underwent minimally invasive esophagectomy for cancer between January 2016 and April 2021 in a German University Hospital. The PMI was measured at the third lumbar vertebra in the preoperative CT scan. The endpoints postoperative complication rates and survival rates were analysed and correlated with PMI and BMI according to gender. RESULTS: Male patients with low PMI (< 5.3 cm2/ m2) had a significantly higher rate of postoperative pulmonary and cardiac complications (p = 0.016, respectively p = 0.018). Low PMI and low BMI (<25 kg/m2) were associated with decreased survival rates in the univariate (p < 0.001) and multivariate analysis in male patients (p = 0.024, respectively 0.004). Having a low PMI (< 5.3 cm2/ m2) was significantly associated with worse overall survival in normal and underweight men (p < 0.001), but not in obese men with a BMI ≥ 25kg/m2 (p = 0.476). CONCLUSION: Preoperative PMI and BMI are valid risk factors regarding postoperative survival after minimal invasive esophagectomy for cancer especially in a male European cohort.

Antibody response of sheep to simultaneous vaccination of foot-and-mouth disease, peste des petits ruminants, sheep pox and goat pox, and bluetongue vaccines.

There are many infectious animal diseases in T urkey and generally, vaccination is the primarly control strategy to combat them. However, it is difficult to apply all vaccines in a definite period in the field due to limitations of the labor and finance. Rapid vaccination and effective use of labor can be possible with the help of simultaneous vaccine administrations. The study aims to show the effects of simultaneous foot-and-mouth disease (FMD), peste des petits ruminants (PPR), sheep pox and goat pox (SGP), and bluetongue (BT) vaccine administration on the antibody response of sheep. For this aim, 30 sheep were divided into one experiment and 5 control groups. Blood samples were collected in each group at 0, 30 and 60 days post-vaccination (DPV). Immune response was measured with virus neutralization test (VNT) and, liquid phase blocking ELISA (LPBE) for FMDV; VNT for BTV and PPR. A live virus challenge study was performed to determine the immune response of SGP vaccine. As a result, antibody titers for each vaccine agent decreased on 60 DPV with the simultaneous vaccination except FMD. The difference between means of antibody titer decrease with single and simultaneous vaccinations is significant especially for BTV and PPR vaccines at 60DPV (p<0.05). Briefly, this decreasing immune response of three live vaccines can be explained with the development of the interference, administration of these vaccines from the same injection site, the effect of cytokines, especially IL-10 effect of SGP vaccine. It was concluded that four vaccines can not be used simultaneously in sheep.

The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler.

BACKGROUND: For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. METHODS: Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. RESULTS: In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). CONCLUSION: There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

Evaluation of antibody response of sheep to foot-and-mouth disease vaccine prepared by using different MontanideTM oil adjuvants.

Despite the widespread use of the conventional inactivated foot-and-mouth disease (FMD) vaccine, its immunogenicity is poor and the duration of its protection is short. In this study, humoral response to commercial ready-to-use MontanideTM ISA 201 VG and MontanideTM ISA 61 VG oil adjuvants and a common adjuvant MontanideTM ISA 206 VG developed by Seppic Inc., were evaluated for FMD antigens in sheep and double oil emulsion (w/o/w) formulations of MontanideTM ISA 201 and 206 and single oil emulsion (w/o) of MontanideTM ISA 61 have been prepared by using current FMDV antigens (O/TUR/07, A/ASIA/G-VII, A/TUR/16 and ASIA/ TUR/15). The animals (n=48) were vaccinated subcutaneously with formulations and five sheep were maintained as an unvaccinated control group. Blood samples were taken at day 0, 7, 14, 21, 28, 60, 90, 120 and 150. Virus neutralization and liquid phase blocking ELISA tests were used to compare antibody response to vaccines prepared by using different MontanideTM mineral oils. The results showed that vaccines prepared by using MontanideTM ISA 61 and 201 gave better antibody response to FMD antigens than MontanideTM ISA 206 formulation, although results were not statistically significant for certain days of sampling. Moreover, the overall type O antibody response of MontanideTM ISA 201 was found to be superior to MontanideTM ISA 61.

Relationship of condylar position to disc position and morphology.

INTRODUCTION/OBJECTIVE: The purpose of this study was to assess whether condylar position, as depicted by magnetic resonance imaging, was an indicator of disc morphology and position. METHODS AND MATERIAL: One hundred and twenty two TMJs of 61 patients with temporomandibular joint disorder were examined. Condylar position, disc deformity and degree of anterior disc displacement were evaluated by using magnetic resonance imaging. RESULTS AND DISCUSSION: Posterior condyle position was found to be the main feature of temporomandibular joints with slight and moderate anterior disc displacement. No statistical significance was found between the condylar position, and reducing and nonreducing disc positions. On the other hand, superior disc position was found to be statistically significant for centric condylar position. CONCLUSION: It was concluded that posterior condyle position could indicate anterior disc displacement whereas there was no relation between the position of condyle and the disc deformity.

Antibody response of sheep to simultaneous vaccination of foot-and-mouth disease, peste des petits ruminants, sheep pox and goat pox, and bluetongue vaccines

@#There are many infectious animal diseases in Turkey and generally, vaccination is the primarly control strategy to combat them. However, it is difficult to apply all vaccines in a definite period in the field due to limitations of the labor and finance. Rapid vaccination and effective use of labor can be possible with the help of simultaneous vaccine administrations. The study aims to show the effects of simultaneous foot-and-mouth disease (FMD), peste des petits ruminants (PPR), sheep pox and goat pox (SGP), and bluetongue (BT) vaccine administration on the antibody response of sheep. For this aim, 30 sheep were divided into one experiment and 5 control groups. Blood samples were collected in each group at 0, 30 and 60 days post-vaccination (DPV). Immune response was measured with virus neutralization test (VNT) and, liquid phase blocking ELISA (LPBE) for FMDV; VNT for BTV and PPR. A live virus challenge study was performed to determine the immune response of SGP vaccine. As a result, antibody titers for each vaccine agent decreased on 60 DPV with the simultaneous vaccination except FMD. The difference between means of antibody titer decrease with single and simultaneous vaccinations is significant especially for BTV and PPR vaccines at 60DPV (p<0.05). Briefly, this decreasing immune response of three live vaccines can be explained with the development of the interference, administration of these vaccines from the same injection site, the effect of cytokines, especially IL-10 effect of SGP vaccine. It was concluded that four vaccines can not be used simultaneously in sheep.

Evaluation of antibody response of sheep to foot-and-mouth disease vaccine prepared by using different MontanideTM oil adjuvants

@#Despite the widespread use of the conventional inactivated foot-and-mouth disease (FMD) vaccine, its immunogenicity is poor and the duration of its protection is short. In this study, humoral response to commercial ready-to-use MontanideTM ISA 201 VG and MontanideTM ISA 61 VG oil adjuvants and a common adjuvant MontanideTM ISA 206 VG developed by Seppic Inc., were evaluated for FMD antigens in sheep and double oil emulsion (w/o/w) formulations of MontanideTM ISA 201 and 206 and single oil emulsion (w/o) of MontanideTM ISA 61 have been prepared by using current FMDV antigens (O/TUR/07, A/ASIA/G-VII, A/TUR/16 and ASIA/ TUR/15). The animals (n=48) were vaccinated subcutaneously with formulations and five sheep were maintained as an unvaccinated control group. Blood samples were taken at day 0, 7, 14, 21, 28, 60, 90, 120 and 150. Virus neutralization and liquid phase blocking ELISA tests were used to compare antibody response to vaccines prepared by using different MontanideTM mineral oils. The results showed that vaccines prepared by using MontanideTM ISA 61 and 201 gave better antibody response to FMD antigens than MontanideTM ISA 206 formulation, although results were not statistically significant for certain days of sampling. Moreover, the overall type O antibody response of MontanideTM ISA 201 was found to be superior to MontanideTM ISA 61.

Quality of life of primary caregivers of spinal cord injury survivors living in the community: controlled study with short form-36 questionnaire.

OBJECTIVE: To compare the quality of life scores of primary caregivers of spinal cord injury survivors living in the community with healthy age matched-population based controls and to determine the relationship between some severity parameters related with spinal cord injury and the quality of life scores of primary caregivers. SETTING: University hospital, rehabilitation centre. METHODS: Fifty primary caregivers of spinal cord injured patients living in the community and 40 healthy age-matched controls completed SF-36 (short form-36) questionnaire forms. Questionnaires were administered by interviewers who were physiatrists and the authors of the present study. All the patients were rehabilitated by the authors and data about the duration of injury, lesion levels, ASIA scores, degree of spasticity, presence of bladder and bowel incontinence and pressure sores were gathered from the hospital recordings and/or by physical examinations during control visits when the primary caregivers were administered the questionnaires. RESULTS: Quality of life scores measured by SF-36 were significantly low in the primary caregivers group compared to age-matched healthy population based controls. No significant relation was demonstrated between the quality of life scores of primary caregivers and parameters such as the duration of injury, lesion levels, ASIA scores, degree of spasticity, bladder and/or bowel incontinence and pressure sores respectively. CONCLUSION: According to the results of the present study, being a primary caregiver of a spinal cord injured victim significantly interferes with quality of life; some severity parameters related to the injury however do not seem to have an additional impact on the primary caregiver's life quality.