Objective: The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and ...compare it with our results with open metastasectomy. Methods: Pulmonary metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 patients: 27 open and 25 VATS over 8 years. The age and sex distribution was similar: median age was 66 for open and 69 years for VATS, p = 0.48, 70% male in open and 64% male in VATS, p = 0.31. Liver metastases were present in 37% in the open and 32% in the VATS group, p = 0.46. The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan–Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. Results: There was no in-hospital mortality. There was no difference in the incidence of missed lesions (1 in VATS, none in open, p = 0.48), pulmonary disease progression (11 in open, 9 in VATS, p = 0.47) or recurrence in the same lobe (4 in open, 3 in VATS, p = 0.54). Median follow-up was 22 (1–70) months and there was no difference to the estimated actuarial survival. Mean survival for the open group was 47 months, SE 6 with 95% CI 36–59 months and mean survival for the VATS group 35.4 months, SE 3 with 95% CI 30–41.3 months. The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 72% for VATS. Conclusions: The selective use of VATS therapeutic metastasectomy in conjunction with multi-detector CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory. Trust the radiologist’s eye.
Objectives: Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with ...microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair. Methods: A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible. Results: There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation. Conclusions: Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.
Objective: Interleukin-17 (IL-17), a potent proinflammatory cytokine, has been implicated in allograft rejection. We analyzed the efficacy of an adenoviral vector expressing an IL-17 inhibitor in ...delaying acute allograft rejection in a rat model of heart transplantation, and the biological mechanisms underlying the protective effect. Methods: We constructed an adenoviral vector expressing a soluble IL-17 receptor-immunoglobulin (IL-17R-Ig) fusion protein. IL-17R-Ig activity was assessed by inhibition of IL-17-induced IL-6 release in HeLa cells preincubated with the vector. Intracoronary vector administration was performed in F344 donor hearts that were placed as vascularized grafts into Lewis hosts. Inflammatory cells infiltrating the graft were analyzed by immunohistology. Cytokine transcripts in the graft were determined by real-time RT-PCR. Results: IL-17R-Ig gene transfer resulted in prolonged allograft survival (16.1 ± 3.1 days vs 10.3 ± 2.5 days with control virus and 10.1 ± 2.1 days with virus dilution buffer alone; p ≪ 0.001). IL-17R-Ig gene transfer reduced inflammatory cell infiltrates, especially monocytes/macrophages and CD4+ T cells (p ≪ 0.05). It also reduced intragraft cytokine transcripts for interferon-γ and transforming growth factor-β (p ≪ 0.05) and, to a lesser extent, IL-1β and tumor necrosis factor-α (p = 0.083). Conclusions: Local expression of soluble IL-17 receptor-immunoglobulin attenuates T helper type 1 (Th1) cytokine responses and leukocyte infiltration in rat cardiac allografts, thereby mediating prolonged graft survival. Intragraft IL-17 inhibition may be useful as an adjuvant therapy to systemic immunosuppression in heart transplantation.
Objective: Endoscopic saphenous vein harvesting (EVH) for coronary artery bypass grafting (CABG) has been developed to reduce leg wound morbidity and improve patient satisfaction. Choosing between ...EVH of a short vein segment from the thigh and open venous harvesting (OVH) of a short segment from the calf represents a clinical dilemma as EVH is easiest to perform from the thigh and OVH is easiest to perform from the calf. The purpose of this study was to investigate whether leg wound morbidity was reduced after EVH of a short vein segment from the thigh compared with OVH from the calf. Secondly we investigated whether EVH would reduce length of hospital stay and improve cosmetic results. Methods: From April 2004 to June 2007, 132 patients undergoing elective isolated CABG were randomized to have a short segment of saphenous vein harvested either by the EVH or OVH technique. Clinical follow-up was scheduled at day 5 and at 1 month. Primary end-points included wound morbidity. Secondary end-points included harvest time, length of hospital stay, cosmetic results and need for additional wound care after discharge. Results: The groups were preoperative similar. Three patients in the OVH group were excluded from the study as it became apparent that it was necessary to extend the incision beyond the knee. Harvest time was longer for the EVH group, but these patients suffered from significantly fewer cases of infectious and non-infective wound complications, with a substantial reduction in the need for post-discharge leg wound care. The purulent infection rates in the EVH and OVH groups were 0% and 11%, respectively. The overall leg wound morbidity rates regarding cellulitis, purulent infection, dehiscence and skin necrosis were 3% and 27% in the EVH and OVH groups, respectively (p < 0.001). The length of hospital stay was similar. The conversion rate from EVH to OVH was 14%. The EVH group experienced less pain and better cosmetic results. Conclusions: EVH of a short vein segment from the thigh results in less wound morbidity and better cosmetic results compared with OVH of a short vein segment from the calf.
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