The impact of fatal complications on surgical esophagocoloplasty outcome in cancer patients

Relevance: The impact of esophageal cancer surgery complications on survival rate remains a challenge due to the complications and mortality associated with surgical esophagocoloplasty. The purpose of this study was to assess the impact of fatal complications (colonic graft necrosis and pneumonia) on surgical esophagocoloplasty outcomes in cancer patients. Results: The analysis included 110 patients treated by colonic esophagoplasty for esophageal carcinomas and gastroesophageal junction carcinomas. The frequency of postoperative complications of degree III-IV according to Clavien-Dindo was 36.4% (40/110). Pneumonia developed in 15% (16/110), colonic graft necrosis – in 5% (6/110). Out of all causes of death (pneumonia, graft necrosis, bleeding, pulmonary thromboembolism), only graft necrosis (odds ratio (OR) 21.112 [95% CI 2.751-162.013] p=0.003) and pneumonia (OR 15.141 [95% CI 3.225-71.089] p=0.001) were the predictors for 90-days’ mortality. Mortality from pneumonia amounted to 37.5% (6/16), from necrosis – 50% (3/6). Median overall survival without pneumonia (n=94) and with pneumonia (n=16) was 26.6 and 8.0 months, respectively (plogrank=0.030; pcox=0.034). Median overall survival without graft necrosis (n=104) and with necrosis (n=6) was 26.6 and 3.7 months, respectively (plogrank=0.0001; pcox=0.001). The patients subjected to colonic esophagoplasty with planning (n=55) had fewer postoperative complications (56.4% [31/55] vs. 16.4% [9/55], p<0.0001), lower risk of their development (OR 0.151, 95% CI 0.0620.369, p<0.0001), higher overall 10-year survival (26.0% vs. 17.7%) and median survival (49.8 vs. 17.4 months, plogrank=0.038, pcox=0.041). Conclusions: Postoperative development of pneumonia or colonic graft necrosis is associated with a significant deterioration in treatment outcomes. Improving the surgical management of cancer patients who require esophagocoloplasty has the potential to improve long-term survival.

Double Pedicle Artery Rotation Sigmoid Vaginoplasty for Vaginal Aplasia Management

Sigmoid vaginoplasty has been popular for neovagina reconstruction in vaginal aplasia. The most common surgical complication was vaginal stenosis caused by inadequate vascularization and tension because of graft length. Therefore, ischemia ensued and disrupted wound healing. The selection of double pedicle artery rotation sigmoid vaginoplasty is expected to reduce this problem. Five patients from April to December 2016 were diagnosed with vaginal aplasia; 4 had history of neovagina stenosis. These patients underwent sigmoid vaginoplasty with double pedicle artery rotation. No complications occurred during or after the procedure. Assessment postsurgery was conducted at 1 year. These results suggest that double pedicle artery rotation sigmoid vaginoplasty is a safe and acceptable technique for management of vaginal aplasia. The procedure decreased tension inside vascular pedicles as a result of maintaining abundant vascularization supply. Consequently, this procedure could avert graft necrosis, leakage, and severe stenosis. All of the patients exhibited regular menstrual cycle and satisfactory sexual activity. The outcomes were excellent with remarkable anatomical and functional results.

Colonic esophagoplasty with planning in esophageal and gastroesophageal junction carcinomas surgical treatment

The effectiveness of the colonic esophagoplasty planning method for surgical treatment of esophageal and gastroesophageal junction carcinomas is evaluated by analyzing factors that affect the mortality risk from respiratory complications and other causes.Colonic esophagoplasty in cases of non-transplanted stomach was performed in 109 patients with esophageal carcinomas – 66.1 % (72/109) and gastroesophageal junction carcinomas – 33.9 % (37/109). Esophagoplasty was performed using the planning method (selective angiography and trial clamping of vessels) which was applied in 40.4 % (44/109) patients. The method effectiveness was evaluated by determining the effect of mortality risks (hazard ratio – HR) from respiratory complications (aspiration pneumonia and adult respiratory distress syndrome) and other causes.Postoperative morbidity was determined in 66.8 % (73/109) observations. Graft necrosis was diagnosed in 7.3 % patients (8/109), esophageal anastomosis leakage without graft necrosis – in 5.5 % patients (6/109), pneumonia – 14.7 % patients (16/109) patients, pulmonary and heart failure – in 5.5 % patients (6/109), pulmonary artery thromboembolism – in 0.9 % patients (1/109). The use of the planning method reduced the mortality risk from respiratory complications and from other causes (HR 0.46 [95 % CI 0.24–0.89], pCox = 0.021 and HR 0.52 [95 % CI 0.29–0.95], pCox = 0.034, respectively).The planning method allows selecting the most suitable colonic segment, planning in advance the levels of feeding vessels intersection and forming a graft by subtotal colon mobilization. Adverse factors in relation to the mortality risk from respiratory complications and from other causes are the fact of graft necrosis development, the presence of long-existing cervical fistula in conditions of wound infection and the presence of bile reflux, stage III and IV of malignant tumors.

Concurrent Hepatic Artery and Portal Vein Thrombosis after Orthotopic Liver Transplantation with Preserved Allografts

In contrast to early HAT, late HAT has an insidious clinical presentation. Nevertheless, biliary and vascular reconstructions in this late setting are unlikely to improve outcome. Patent portal flow makes an important contribution to the viability of liver in case of late HAT while the allograft reconstitutes intrahepatic arterial flow through neovascularization. Concurrent HAT with PVT without immediate graft necrosis is extremely rare, and allograft and patient survival are seemingly impossible without retransplantation. In fact, hepatopetal arterial and portal venous neovascularization are known albeit obscure phenomena that can preserve posttransplant hepatic function under the extenuating circumstances of complete interruption of blood flow to the graft. We describe two such cases that developed combined HAT and PVT more than six months after OLT with perfect preservation of graft function. The survival of allografts in our cases was due to extensive hepatopetal arterial and portal venous collateralization. Simultaneous HAT and PVT after OLT are rare events and almost uniformly fatal, if they occur early. Due to paucity of such cases, however, underlying mechanisms and etiology remain elusive, and despite radiological diagnosis of these complications, there is no way to predict these events in the wake of stable graft function.

Μελέτη της επίπτωσης της χορήγησης βλαστοκυττάρων από λιπώδη ιστό στην βιωσιμότητα ολικού πάχους μοσχευμάτων δέρματος σε διαβητικούς και μη διαβητικούς επίμυες και ο συσχετισμός της όποιας επιδράσεως με την έκφραση των παραγόντων VEFG και TGFb3

Background: Skin grafts are frequently used for a variety of indications in plastic andreconstructive surgery. heir necrosis is a common complication while differenttherapies have been proposed. Currently, adipose-derived stem cells (ASCs) holdgreat promise for their angiogenic potential and role during tissue repair. In this study,autologous transplantation of ASCs was usedin skin grafts in diabetic and nondiabeticrats to determine if it increases angiogenesis, skin graft survival and woundhealing.Methods: ASCs were isolated, cultured, labeled with fluorescent dye and injectedunder full thickness skin grafts in twenty rats (group 1 and group 3, non-diabetic anddiabetic respectively, ten rats in each group), while twenty others served as controls(group 2 and group 4, non-diabetic and diabetic respectively, ten rats in each group).immunohistochemistry. Additionally, immunohistochemical staining intensity ofvascular endothelial growth factor (VEGF) and transforming growth factor b3(TGFb3) was assessed in all grafts.Results: Mean area of graft necrosis was significantly less in group 1 than group 2(6.12% vs. 32.62%, p<0.01). Statistically significant increase of microvessel density,collagen density, VEGF and TGFb3 expression was noted in group 1 compared withgroup 2 (all: p<0.01). Additionally, mean area of graft necrosis was significantly lessin group 3 than group 4 (7.49% vs. 39.67%, p<0.001). Statistically significant30increase of capillary density, collagen intensity, VEGF and TGFb3 expression wasnoted in group 3 compared with group 4.Conclusions: These findings suggest that autologous ASCs transplantation increasesfull-thickness skin graft survival and shows promise for use in skin graft surgery. Thismight be both due to in situ differentiation of ASCs into endothelial cells and ASCsincreased secretion of growth factors such as VEGF and TGFb3 that enhanceangiogenesis and wound healing. This might represent a novel therapeutic approach inskin graft surgery which is particularly useful for diabetic wounds.