Detection of occult lymph node metastases in esophageal cancer by minimally invasive staging combined with molecular diagnostic techniques.
BACKGROUND AND OBJECTIVES: Lymph node metastases are the most important prognostic factor in patients with esophageal cancer. Histologic examination misses micrometastases in up to 20% of lymph nodes evaluated. In addition, non-invasive imaging modalities are not sensitive enough to detect small lymph nodes metastases. The objective of this study was to investigate the use of reverse transcriptase-polymerase chain reaction (RT-PCR) of messenger RNA (mRNA) for carcinoembryonic antigen (CEA) to increase the detection of micrometastases in lymph nodes from patients with esophageal cancer. METHODS: RT-PCR of CEA mRNA was performed in lymph nodes from patients with malignant and benign esophageal disease. Each specimen was examined histopathologically and by RT-PCR and the results were compared. RESULTS: Metastases were present in 29 of 60 (48%) lymph nodes sample by minimally invasive staging from 13 patients with esophageal cancer when examined histopathologically. RT-PCR identified nodal metastases in 46 of these 60 (77%) samples. RT-PCR detected CEA mRNA in all 29 histologically positive samples and in 17 histologically negative lymph nodes. All lymph nodes from patients with benign disease (n = 15) were negative both histopathologically and by RT-PCR. The stage of two patients was reclassified based on the RT-PCR results, which identified lymph node spread undetected histopathologically. Both of these patients developed recurrent disease after resection of the primary tumor. CONCLUSIONS: RT-PCR is more sensitive than histologic examination in the detection of lymph node metastases in esophageal cancer and can lead to diagnosis of a more advanced stage in some patients. The combination of minimally invasive surgical techniques in combination with new molecular diagnostic techniques may improve our ability to stage cancer patients. (+info)
Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution.
OBJECTIVES: To compare aortic valve replacement (AVR) using a minimally invasive approach through a transverse sternotomy with the established approach of median sternotomy. DESIGN: Retrospective, case-control study. PATIENTS: Fourteen high risk patients (median age 78, Parsonnet score of 18%) who underwent AVR performed through a minimally invasive transverse sternotomy were compared with a historical group of patients matched for age, sex, and Parsonnet score who underwent AVR performed through a median sternotomy by the same surgeon. OUTCOME MEASURES: Cross clamp time, total bypass time, intensive care stay, postoperative in-hospital stay, morbidity, and mortality. RESULTS: There were two deaths in the minimally invasive group and none in the control group (NS). The cross clamp and total bypass times were longer in the minimally invasive group (67 and 92 minutes v 46 and 66 minutes, p < 0.001). There was a higher incidence of re-exploration for bleeding (14% v 0%) and paravalvar leaks (21% v 0%) in the minimally invasive group but these differences were not significant. The minimally invasive group had a longer postoperative in-hospital stay (p = 0.025). The incidence of mortality or major morbidity was 43% (six of 14) in the minimally invasive group and 7% (one of 14) in the matched pairs (p = 0.013). CONCLUSIONS: AVR can be performed through a transverse sternotomy but the operation takes longer and there is an unacceptably high incidence of morbidity and mortality. (+info)
Video-assisted crossover iliofemoral obturator bypass grafting: a minimally invasive approach to extra-anatomic lower limb revascularization.
Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique. (+info)
Testicular sperm extraction (TESE) is often an effective method for sperm retrieval from men with non-obstructive azoospermia. However, TESE has been a blind procedure that does not identify the focal sperm-producing areas of the testicle until after tissue has been excised from the patient. Experience with a new technique of microdissection of testicular tubules is presented here that identifies sperm-containing regions before their removal. Identification of spermatogenically active regions of the testicle is possible by direct examination of the individual seminiferous tubules. The underlying concept for this technique is simple: seminiferous tubules containing many developing germ cells, rather than Sertoli cells alone, are likely to be larger and more opaque than tubules without sperm production. In a sequential series of TESE cases for men with non-obstructive azoospermia, the ability to find spermatozoa increased from 45% (10/22) to 63% (17/27) after introduction of the microdissection technique. Microdissected samples yielded an average of 160,000 spermatozoa per sample in only 9.4 mg of tissue, whereas only 64,000 spermatozoa were found in standard biopsy samples that averaged 720 mg in weight (P < 0.05 for all comparisons). For men where microdissection was attempted, successful identification of enlarged tubules was possible in 56% (15/27) of cases. However, spermatozoa were retrieved with microdissection TESE for six men in whom sperm retrieval was unsuccessful with standard TESE approaches (35% of all men with spermatozoa retrieved). These findings suggest that microdissection TESE can improve sperm retrieval for men with non-obstructive azoospermia over that achieved with previously described biopsy techniques. (+info)
Minimally invasive coronary surgery in women.
OBJECTIVE: To evaluate the minimally invasive surgery in coronary artery bypass grafting and the feasibility for revascularization of triple vessel coronary artery disease. METHODS: Nine female patients, aged 49.1 to 81.6 years (mean 64.3), were operated on for triple vessel disease through minimally invasive surgical techniques. The surgeries were performed through limited left parasternal incision under femorofemoral extracorporeal circulation. The myocardium was protected by antegrade infusion of cold blood cardioplegic solution while the aorta was cross-clamped. Under direct vision, the left saphenous vein grafts were connected sequentially to the diagonal branch, obtuse marginal branch and posterior descending branch, and the left internal thoracic arterial graft was anastomosed to the left anterior descending artery in each patient. RESULTS: The number of distal anastomoses was 3 to 4 with a mean of 3.7. The aortic crossclamp time was 52 to 130 minutes (82 +/- 25 minutes). The duration of extracorporeal circulation was 78 to 151 minutes (115 +/- 29 minutes). The postoperative course was uneventful in all patients. The postoperative length of stay was 4 to 12 days (7.2 +/- 2.0 days). Follow-up (4.2 to 8.7 months, mean 6.4) was complete in all patients and there were no late deaths or angina. Coronary angiography of 2 patients showed patent grafts. All patients were satisfied with the good cosmetic healing of the incision. CONCLUSION: Our experience demonstrates that minimally invasive surgery in coronary artery bypass grafting is technically feasible and may be an alternative approach in surgical revascularization of triple vessel coronary artery disease, especially in female patients. (+info)
Bilirubin as an anti-oxidant for surgical stress: a preliminary report of bilirubin oxidative metabolites.
BACKGROUND: Bilirubin has been recognized as an anti-oxidant. The purpose of this study was to examine whether bilirubin would act as an antioxidant for surgical stress in humans. MATERIALS AND METHODS: Serum bilirubin and urinary bilirubin oxidative metabolites (BOM) were measured in 96 patients who underwent surgery. The antioxidant activity of bilirubin was assessed using BOM measured by enzyme-linked immunosorbent assay with an anti-bilirubin monoclonal antibody. RESULTS: Serum bilirubin levels increased after surgery in all 96 patients (p < 0.01), but did not correlate with operation time or blood loss (p = 0.53 and p = 0.28, respectively). BOM increased only in patients with major surgeries (p = 0.048). Significant correlations between BOM and operation time and blood loss were found (p < 0.01). CONCLUSIONS: Bilirubin appears to act as an antioxidant for invasive surgery in humans. Urinary BOM could be a reliable marker for the degree of surgical stress. (+info)
Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach.
We report an unusual case of type IV Thoracoabdominal Aneurysm (TAA) with Superior Mesenteric Artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal Abdominal Aortic Aneurysm (AAA) ruptures. Because of the presence of the visceral artery aneurysms and the earlier operation through the retroperitoneum, standard surgical treatment via a retroperitoneal approach with an inclusion grafting technique was considered difficult. A combined surgical approach achieving retrograde perfusion of all four visceral vessels and endovascular grafting allowing exclusion of the TAA was accomplished. Complete exclusion of the aneurysm and normal perfusion of the patient's viscera was documented by means of follow-up examinations at 3 and 6 months. The repair of a type IV TAA with a Combined Endovascular and Surgical Approach (CESA) allowed us to manage both the aortic and visceral aneurysms without thoracotomy or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attractive alternative in patients with aneurysmal involvement of the visceral segment of the aorta. (+info)
Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.
BACKGROUND: Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS: Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS: Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS: Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia. (+info)