Comparison between different reconstruction routes in esophageal squamous cell carcinoma

AIM:To compare postoperative complications and prognosis of esophageal squamous cell carcinoma patients treated with different routes of reconstruction. METHODS:After obtaining approval from the Medical Ethics Committee of the Sun Yat-Sen University Cancer Center, we retrospectively reviewed data from 306 consecutive patients with histologically diagnosed esophageal squamous cell carcinoma who were treated between 2001 and 2011. All patients underwent radical McKeown-type esophagectomy with at least two-field lymphadenectomy. Regular follow-up was performed in our outpatient department. Postoperative complica-tions and long-term survival were analyzed by treatment modality, baseline patient characteristics, and operative procedure. Data from patients treated via the retrosternal and posterior mediastinal routes were compared. RESULTS:The posterior mediastinal and retrosternal reconstruction routes were employed in 120 and 186 patients, respectively. Pulmonary complications were the most common complications experienced during the postoperative period (46.1% of all patients; 141/306). Compared to the retrosternal route, the posterior mediastinal reconstruction route was associated with a lower incidence of anastomotic stricture (15.8% vs 27.4%, P = 0.018) and less surgical bleeding (242.8 ± 114.2 mL vs 308.2 ± 168.4 mL, P 0.001). The median survival time was 26.8 mo (range:1.6-116.1 mo). Upon uni/multivariate analysis, a lower preoperative albumin level (P = 0.009) and a more advanced pathological stage (pT; P = 0.006; pN; P 0.001) were identified as independent factors predicting poor prognosis. The reconstruction route did not influence prognosis (P = 0.477). CONCLUSION:The posterior mediastinal route of reconstruction reduces incidence of postoperative complications but does not affect survival. This route is recommended for resectable esophageal squamous cell carcinoma.     

Anterior vs. Posterior Mediastinal Routes in Colon Interposition after Esophagectomy

Background/Aims: Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. Methodology: We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Results: Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Conclusions: Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.     

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.     

Atrial involvement and progression of sinus node dysfunction in non-senile patients: evidences from electroanatomic mapping and long-term follow-up

Purpose

Sinus node inability or conduction disorders of its surrounding atrial myocardium cause sinus node dysfunction (SND). This study aimed to characterize right atrium (RA) substrates and long-term atrial lead performance after pacemaker implantation in non-senile SND patients.

Methods

Eighteen SND patients (53.3?±?9.6 years) controlled by 18 age-matched supraventricular tachycardia patients were consecutively enrolled. The P-wave amplitude (PWA) and P-wave duration (PWD) were measured on surface electrocardiography. Electroanatomic mapping was conducted to assess the bipolar voltage, complex signals, volume, and activation time of RA. Pacemaker implantation was performed in SND patients after mapping.

Results

Compared with controls, SND patients showed significant PWA reduction (0.13?±?0.02 vs. 0.16?±?0.04 mV, p?=?0.017) and PWD prolongation (120.8?±?15.2 vs. 105.2?±?8.6 ms, p?=?0.001). The RA endocardial voltage was lower (1.56?±?0.78 vs. 2.57?±?0.55 mV, p?<?0.001) and activation time was longer (112.1?±?14.9 vs. 90.8?±?12.4 ms, p?<?0.001) in the study group. Atrial lead was anchored at the lower atrial septum in one patient and failed in another due to extensive atrial scarring. During a median follow-up of 86 (57–88) months, one patient lost atrial capturing, and overall atrial sensing was significantly decreased (2.44?±?1.16 vs. 1.87?±?1.01 mV, p?=?0.003).

Conclusions

Atrial involvement was proved and the process was progressive in non-senile SND patients, as demonstrated by diffused RA lower voltage, slower conduction, and the decrease of the atrial lead sensing.

     

3.0 T magnetic resonance imaging scanning on different body regions in patients with pacemakers

Purpose

Magnetic resonance imaging (MRI) at 3.0 T is becoming more common, but there is a lack of sufficient evidence on the safety of a 3.0 T scan in patients with pacemakers. This study aimed to investigate the safety and practical concerns of 3.0 T scans for patients with MR-conditional pacemakers.

Methods

Twenty consecutive patients were enrolled. A standardized protocol was developed by cardiologists, pacemaker engineers, and radiologists. Pacemaker interrogation was performed immediately before and after the scan. Scan-related adverse events were documented, and imaging quality was graded as level 1 to 4 by radiologists.

Results

Twenty-three MRI scans of different body regions (brain?=?13, lumbar spine?=?4, cervical spine?=?2, and heart?=?4) were performed, and the average time of a scan was 25?±?11 min. No significant changes in sensing amplitude (atrial 3.1?±?1.1 mV vs. 2.9?±?1.2 mV, P?=?0.71; ventricular 9.3?±?3.5 mV vs. 10.2?±?3.4 mV, P?=?0.46), lead impedances (atrial 647?±?146 Ω vs. 627?±?151 Ω, P?=?0.7; ventricular: 780?±?247 Ω vs.711?±?226 Ω, P?=?0.36), or pacing threshold (atrial 0.6?±?0.2 V/0.4 ms vs. 0.6?±?0.2 V/0.4 ms, P?=?0.71; ventricular 0.7?±?0.3 V/0.4 ms vs. 0.7?±?0.2 V/0.4 ms, P?=?0.85) were observed pre- and postscan. No adverse events were detected. Image quality review showed grade 1 quality in 16 patients and grade 2 quality in 4 patients with artifacts of pulse generators and leads in cardiac MRI scan and no impact on diagnostic value.

Conclusion

Our initial data indicated that 3.0 T scanning might be feasible under a standardized protocol with good diagnostic imaging quality irrespective of body region in patients with MR-conditional pacemakers.

     

Renal functions in obstructive sleep apnea patients

Purpose

The aim of this study is to investigate possible factors influencing glomerular filtration rate (GFR) in obstructive sleep apnea (OSA).

Methods

Data of OSA patients admitted to Gaziantep University sleep clinic from January 2005 to January 2010 were retrospectively evaluated. GFR is calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Patients younger than 18 years old were excluded.

Results

The mean age of OSA (n?=?634) and control group (n?=?62) were 51.13?±?11.61 and 50.69?±?13.88 years, respectively (p?=?0.81). The mean estimated GFR (eGFR) was 90.73?±?19.59 ml/min/1.73 m² in OSA patients and 94.14?±?18.81 ml/min/1.73 m² in control subjects (p?=?0.19). GFR was 84.25?±?20.87 ml/min/1.73 m² in patients with left ventricular hypertrophy (LVH) while it was 93.94?±?18.44 ml/min/1.73 m² in patients without LVH (p?=?0.00). GFR of male subjects was 92.1?±?19.23 in OSA and 95.84?±?20.08 ml/min/1.73 m² in controls (p?=?0.33). GFR of female and male patients in the OSA were 87.45?±?20.10 and 92.91?±?18.02 ml/min/1.73 m², respectively (p?=?0.13). Serum creatinine was higher in OSA patients compared to controls (p?=?0.01). GFR was 92.30?±?19.27 in male and 88.33?±?19.84 ml/min/1.73 m² in female subjects (p?=?0.01). GFR was 84.86?±?19.95 in hypertensive patients while it was 95.11?±?18.20 ml/min/1.73 m² in normotensive subjects (p?=?0.00). GFR was 89.30?±?19.96 in patients with metabolic syndrome (MetS) and it was 93.46?±?18.68 ml/min/1.73 m² in patients without MetS (p?=?0.00).

Conclusions

GFR values were lower in sleep apneic patients with MetS as well as in patients with hypertension and LVH.

     

Impact of mandibular advancement device therapy on cerebrovascular reactivity in patients with carotid atherosclerosis combined with OSAHS

Purpose

Obstructive sleep apnea-hypopnea syndrome (OSAHS) may affect cerebrovascular reactivity (CVR), representing cerebrovascular endothelial function, through complex cerebral functional changes. This study aimed to evaluate the change of CVR after 1-month and 6-month mandibular advancement device (MAD) treatment of patients with carotid atherosclerosis (CAS) combined with OSAHS.

Methods

Patients with carotid atherosclerosis combined with OSAHS who voluntarily accepted Silensor-IL MAD therapy were prospectively enrolled. All patients underwent polysomnographic (PSG) examinations and CVR evaluation by breath-holding test using transcranial Doppler ultrasound at baseline (T0), 1 month (T1), and 6 months (T2) of MAD treatment.

Results

Of 46 patients (mean age 54.4 ± 12.4 years, mean body mass index [BMI] 27.5 ± 4.5 kg/m²), 41 patients (responsive group) responded to the 1-month and 6-month treatment of MAD, an effective treatment rate of 89%. The remaining 5 patients (non-responsive group) were younger (47.4?±?13.5 years) and had a higher BMI (35.8?±?1.8 kg/m²). The responsive group had an improvement of apnea-hypopnea index (AHI) (events/h) from 33.0?±?25.0 (T0) to 12.4?±?10.4 (T1) and 8.7?±?8.8 (T2), P?<?0.001; minimum arterial oxygen saturation (minSpO₂) (%) increased from 79.8?±?9.1 (T0) to 81.8?±?9.4 (T1) and 85.2?±?5.4 (T2), P?<?0.01; longest apnea (LA) (s) decreased from 46.5?±?23.1 (T0) to 33.3?±?22.7 (T1) and 29.4?±?18.5 (T2), P?<?0.001; T90 (%) decreased from 10.3?±?14.9 (T0) to 6.1?±?11.8 (T1) and 3.3?±?7.5 (T2), P?<?0.05. Sleep architecture of these patients also improved significantly. The responsive group had a significant increase in left, right, and mean breath-holding index (BHI): left BHI(/s) from 0.52?±?0.42 (T0) to 0.94?±?0.56 (T1) and 1.04?±?0.64 (T2), P?<?0.01; right BHI(/s) from 0.60?±?0.38 (T0) to 1.01?±?0.58 (T1) and 1.11?±?0.60 (T2), P?<?0.01; mean BHI(/s) from 0.56?±?0.38 (T0) to 0.97?±?0.55 (T1) and 1.07?±?0.59 (T2), P?<?0.01), suggesting improved CVR.

Conclusion

Effective MAD therapy is beneficial for restoring cerebrovascular endothelial function in patients with CAS and OSAHS in a short period (1 month and 6 months).

Trial registration

Clinical trial registration number: NCT03665818. September 11, 2018.

     

Operator learning curve and clinical outcomes of zero fluoroscopy catheter ablation of atrial fibrillation,supraventricular tachycardia,and ventricular arrhythmias

Purpose

To investigate the learning curve for atrial fibrillation (AF), supraventricular tachycardia (SVT), and premature ventricular contraction (PVC) radiofrequency ablation (RFA) using zero fluoroscopy.

Methods

This is a retrospective, single-center study of 167 patients undergoing ablation between 2016 and 2019. Minimal fluoroscopy approach was initiated after the first 20 cases of PVI and SVT RFA. Procedures were divided consecutively into increments of 10 cases to determine operator learning curve.

Results

A total of 64 (38%) had SVT ablations, 26 (16%) had PVC ablations, and 77 (46%) had AF and underwent PVI. For SVT RFA, fluoroscopy time improved from 4.1?±?3.5 min during the first 10 cases to 0.8?±?1.2 min after 50 cases (p?=?0.0001). Sixty-two out of 64 (97%) of cases were successful. In PVC RFA, fluoroscopy time was 7.7?±?5.5 min for the first 5, 2.3?±?3.4 min after 15, and 0 min after 20 cases (p?=?0.0008). Twenty-four out of 26 (92%) of cases were acutely successful with recurrence in 2/26 (8%) of patients over 9?±?9 months. In PVI, fluoroscopy time was 9.9?±?3.3 min over the first 20 cases, 2.6?±?2.3 min after 40 cases, and 0.1 min after 50 cases (p?<?0.0001). PVI procedure time was 170?±?34 min after 60 cases from 235?±?41 min initially (p 0.001). Six out of 77 (8%) had AF recurrence at 12 months.

Conclusions

Zero fluoroscopy ablation for AF, SVT, and PVC can be safely achieved without increasing procedure time. The steepest learning curve occurs over the first 20, 15, and 40 cases for SVT, PVC, and PVI ablation respectively.

     

Long-term adherence to ambulatory initiated continuous positive airway pressure in non-syndromic OSA children

Purpose

In children, the usual indications for continuous positive airway pressure (CPAP) are residual OSA after adenotonsillectomy and/or persistent OSA due to obesity. Data concerning adherence (hours/night) following ambulatory CPAP initiation are scarce.

Methods

An observational cohort of 78 children was followed over 2 years. All exhibited sleep-disordered breathing (SDB) symptoms, were assessed by polysomnography, and prescribed CPAP. CPAP was initiated at hospital for 10 children.

Results

OSA children, mean age 10.4?±?3.2 years, were mostly males (75.6%), with a mean body mass index of 21.2?±?7.3 kg/m², and mean apnea+hypopnea index of 12.2?±?10.6 events/hour. Seventy-two children were still on CPAP at 3 months, 63 at 6 months, 55 at 1 year, and 34 at 2 years. CPAP was discontinued thanks to rehabilitation programs, dento-facial orthopedics, and/or weight loss. Mean CPAP adherence at 1, 3, 6, 12, and 24 months was respectively 6.1?±?2.8, 6.2?±?2.6, 6.2?±?2.8, 6.3?±?2.8, and 7.0?±?2.7 h/night. There was a trend towards higher CPAP adherence and younger age, primary versus middle/high school attendance, higher baseline apnea+hypopnea index, and neurocognitive disorders.

Conclusion

In our population, mean CPAP adherence defined in hours per night was high and did not decrease during the 24-month follow-up. These findings support the feasibility of ambulatory CPAP initiation in non-syndromic OSA. The high CPAP adherence is expected to be associated with improvements in neurocognition, and in metabolic and cardiovascular parameters.

     

The effects of continuous positive airway pressure and mandibular advancement therapy on metabolic outcomes of patients with mild obstructive sleep apnea: a randomized controlled study

Background

Moderate and severe obstructive sleep apnea (OSA) have been independently associated with dyslipidemia. The results of metabolic improvement with continuous positive airway pressure (CPAP) have been controversial. Less evidence exists regarding this issue in mild OSA. A current treatment for mild OSA is mandibular advancement device (MAD) therapy, but its effectiveness on the metabolic profile needs to be compared with CPAP. The purpose of this study was to compare MAD vs CPAP vs no treatment on the metabolic profile during 6 and 12 months of follow-up in patients with mild OSA.

Methods

The inclusion criteria were patients with mild OSA, both genders, ages 18 to 65 years, and body mass index (BMI) of < 35 Kg/m². Patients were randomized in 3 groups (CPAP, MAD, and control). The evaluations included physical examination, metabolic profile, and full polysomnography at baseline, 6 months, and 12 months of follow-up.

Results

Seventy-nine patients with mild OSA were randomized in three treatment groups, with mean age (± SD) of 47?±?9 years, 54% men, and AHI 9.5?±?2.9 events/h. MAD and CPAP reduced AHI at 6 and 12 months compared to the control group. MAD adherence was higher than CPAP at 6 and 12 months. Despite lower adherence compared to MAD, CPAP was more effective in reducing total cholesterol over 12 months (baseline 189.3?±?60.2 mg/dl to 173.4?±?74.3 mg/dl) and low-density lipoprotein cholesterol (LDL-c, baseline 112.8?±?54.9 mg/dl to 94.5?±?67.4 mg/dl).

Conclusions

After 1 year of treatment, CPAP was superior to MAD in reducing total cholesterol and LDL-c in patients with mild OSA.

     

The variability and burden of severe sleep apnea and the relationship with atrial fibrillation occurrence: analysis of pacemaker-detected sleep apnea

Study objectives

This was a pilot study to evaluate the long-term variability and burden of respiratory disturbance index (RDI) detected by pacemaker and to investigate the relationship between RDI and atrial fibrillation (AF) event in patients with pacemakers.

Methods

This was a prospective study enrolling patients implanted with a pacemaker that could calculate the night-to-night RDI. The mean follow-up was 348?±?34 days. The RDI variability was defined as the standard deviation of RDI (RDI-SD). RDI burden was referred to as the percentage of nights with RDI?≥?26. The patient with RDI?≥?26 in more than 75% nights was considered to have a high sleep apnea (SA) burden. An AF event was defined as a daily AF duration?>?6 h.

Results

Among 30 patients, the mean RDI of the whole follow-up period was 24.5?±?8.6. Nine (30%) patients were diagnosed with high SA burden. Patients with high SA burden had a higher BMI (26.7?±?4.8 vs 23.2?±?3.9, p?=?0.036), a higher prevalence of hypertension (86% vs 39%, p?=?0.031), and a larger left ventricular diastolic diameter (49.2 mm vs 46.7 mm, p?=?0.036). The RDI-SD in patients with a higher burden was significantly greater than that in the patients with less burden (10.7?±?4.9 vs 5.7?±?1.4, p?=?0.036). Linear regression showed that participants with a higher RDI tended to have a higher SD (R?=?0.661; p?<?0.001). The mean RDI (OR?=?1.118, 95%CI 1.008–1.244, p?=?0.044) was associated with AF occurrence.

Conclusion

Using a metric such as burden of severe SA may be more appropriate to demonstrate a patient’s true disease burden.

     

Impacts of sinus rhythm maintenance with catheter ablation on exercise tolerance in patients with paroxysmal atrial fibrillation

Background

It has been recently reported that sinus rhythm (SR) maintenance with catheter ablation therapy improves exercise tolerance (ET) in patients with persistent atrial fibrillation (AF). However, it remains to be elucidated whether this is also the case for patients with paroxysmal AF (PAF).

Methods

We enrolled consecutive 54 patients with PAF (age; 63?±?10 [SD] years old, male/female 46/8) and 26 patients with persistent AF (non-PAF) (age; 57?±?12 [SD] years old, male/female 23/3) who underwent AF ablation without recurrence. ET and cardiac function were evaluated by cardio-pulmonary exercise test and ultrasound echocardiography before and 6 months after ablation.

Results

The parameters of cardiopulmonary exercise test were comparable between the 2 groups. When PAF group was divided into 2 groups according to the time since diagnosis, peak oxygen uptake (peak VO₂) before ablation was significantly lower in patients with PAF duration of more than 1 year (n =?26), compared with those with less than 1 year (n =?28) (18.1?±?3.7 vs 21.3?±?5.8 ml/kg/min, P =?0.022). At 6 months after SR maintenance without AF burden, peak VO₂ significantly improved in both PAF (19.8?±?5.1 to 22.0?±?4.8 ml/kg/min, P =?0.0001) and non-PAF (20.6?±?3.9 to 23.4?±?5.0 ml/kg/min, P?<?0.01). Furthermore, the improvement rate of peak VO₂ after successful ablation had a highly significant inverse relationship with peak VO₂ at baseline in patients with PAF (r =???0.48, P =?0.0003).

Conclusions

These results indicate that SR maintenance with ablation improves ET in patients with PAF, especially in those with reduced ET.

     

Inner ear function in patients with obstructive sleep apnea

Objective

Because of their high metabolic activity and low-resting oxygen tension, the organs of the inner ear are vulnerable to hypoxia, a condition that occurs repetitively in obstructive sleep apnea-hypopnea syndrome (OSAHS). The present study aimed to investigate the inner ear function of patients with OSAHS.

Methods

A total of 58 patients with OSAHS (116 ears) and 20 adults without OSAHS were enrolled in the present study. The clinical features, such as air-conduction thresholds, auditory brainstem response (ABR, 11 times/s and 51 times/s stimulation rates), and distorted products otoacoustic emission (DPOAE), were evaluated and compared between these two groups.

Results

Air-conduction thresholds at 4 kHz and 8 kHz were higher in patients with OSAHS compared with controls (P?<?0.001). At the rate of 11 times per second, biauricular wave I latencies and wave V latencies in the OSAHS group were longer than those in the control group (1.51?±?0.13 vs. 1.33?±?0.07 ms, P?<?0.001; 5.65?±?0.23 vs. 5.53?±?0.23 ms, P?=?0.0016). At the rate of 51 times per second, biauricular wave I latencies and wave V latencies in the OSAHS group were longer than those in the control group (1.64?±?0.12 vs. 1.44?±?0.06 ms, P?=?0.0001; 5.92?±?0.26 vs. 5.80?±?0.18 ms, P?=?0.0077). However, there was no significant difference in the wave I and wave V interval between these two groups (P?=?0.10). DPOAE amplitude was significantly reduced in OSAHS patients, although no hearing loss was observed.

Conclusion

High-frequency hearing loss was detected in adults with severe OSAHS, and wave I latencies and wave V latencies of ABR were prolonged.

     

Temperature-guided ablation with the second-generation cryoballoon for paroxysmal atrial fibrillation: 3-year follow-up in a multicenter experience

Purpose

A strategy based on the attainment of the specific parameter of ??40 °C within the first 60 s during cryoenergy applications in the setting of cryoballoon ablation (CB-A) without the use of an inner lumen mapping catheter (ILMC) (Achieve; Medtronic, USA) for the visualization of real-time recordings (RTR) has been previously described. The latter has proven to be very effective in guaranteeing freedom from atrial arrhythmias in patients affected by paroxysmal atrial fibrillation (PAF) at 1-year follow-up. The purpose of this retrospective observational study was to evaluate the clinical outcomes of this strategy in a multicenter experience on a long-term follow-up of 3 years.

Methods

A total of 192 patients having undergone CB ablation for paroxysmal AF (PAF) starting from September 2015 to November 2016 that underwent a temperature-guided approach were included.

Results

Mean procedural time was 68.77?±?18.88. The mean number of freezes in the LSPV was 1.2?±?0.4, 1.2?±?0.4 in the LIPV, 1.1?±?0.4 in the RSPV, and 1.2?±?0.4 in the RIPV. Considering a blanking period of 3 months, freedom from AF off-AAD was achieved in 77.6% (149/192) at mean 34.5?±?5.5 months and median 35.1 months (IQR, 32.3–37.0 months) follow-up after 1 procedure.

Conclusions

A temperature-guided approach affords freedom from AF at a 3-year follow-up period in a large majority of patients affected by PAF having undergone a single CB-A procedure.

     

Lack of association between obstructive sleep apnea syndrome and specular microscopic features of the corneal endothelium

Background

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent episodes of hypoxemia and hypercapnia during sleep. The aim of this study was to determine whether OSAS causes significant changes in corneal endothelium detectable by specular microscopy.

Methods

This prospective, cross-sectional study compared the specular microscopic features of the corneal endothelium of patients with OSAS and age-and gender-matched controls. Patients diagnosed with OSAS by polysomnography in the sleep unit were classified using apnea-hypopnea indexes into two groups as mild-moderate OSAS group and severe OSAS group. All participants were divided into three age groups: 30–45, 46–60, and >?60 years. Corneal endothelial cell density (ECD), percentage of hexagonal cells (Hex), and coefficient of variation of cell area (CV) were obtained using a non-contact specular microscope. The measurements of each group were compared statistically.

Results

A total of 66 patients (51.1?±?9.4 years) and 88 controls (49.2?±?10.5 years) were examined. The mild-moderate OSAS group and the severe OSAS group had no significant differences in measures of specular microscopy compared with the controls (ECD, p?=?0.84; Hex, p?= 0.18; CV, p?=?0.41). The mean values of ECD, Hex, and CV were 2552.56?±?302.49 cells/mm², 54.13?±?8.13%, and 36.41?±?5.92, respectively, in the mild-moderate OSAS group; 2510.52?±?377.12 cells/mm², 54.85?±?8.68%, and 34.77?±?5.02, respectively, in the severe OSAS group; 2543.37?±?286.94 cells/mm², 51.89?±?9.09%, and 36.03?±?5.32, respectively, in the control group.

Conclusions

There were no significant differences in corneal endothelial features between patients and controls. Although OSAS causes systemic hypoxia, its effects do not appear to result in corneal endothelial alterations detectable by specular microscopy.

     

How important is the route of reconstruction after esophagectomy: a prospective randomized study

OBJECTIVE: A prospective randomized trial was performed to compare retrosternal and posterior mediastinal gastric tube reconstruction with regard to postoperative function and quality of life. METHODS: Twenty-six patients were randomly allocated to either retrosternal (n = 14) or posterior mediastinal (n = 12) reconstruction after gastric tube formation. Radionuclide transit studies were applied to obtain objective functional data and a standardized quality-of-life assessment was performed. RESULTS: Retrosternal reconstruction showed an increased morbidity (15 vs 13 major complications) and mortality (14.2 vs 8.3%). Radionuclide clearance in the supine position was delayed in the gastric tube in general, compared with normal controls (retention index > 40% vs < 10%). There was a significantly higher retention (p < 0.005) in the retrosternal group in the middle third of the tube and the whole tube after intake of the liquid tracer. The retention of the first solid tracer was also higher in the retrosternal group in the middle third of the tube (p = n.s.) and was significantly higher in the whole tube after 30 (p < 0.05) and 60 (p < 0.01) s. This had no significant impact on the patients' quality of life. CONCLUSIONS: The posterior mediastinal route of reconstruction is recommended but curative resection (R0) is mandatory to avoid possible complications due to local tumor relapse. After incomplete resection (R1 or R2) we recommend retrosternal reconstruction for better palliation.     

The impact of electrical connections between left ipsilateral pulmonary veins on the time-to-isolation values in cryoballoon ablation

Background

The time-to-isolation (TTI) may be a physiological predictor of durable isolations, and TTI-guided dosing strategies are widely performed in cryoballoon ablation. We sought to investigate the impact of the order of targeting the pulmonary veins (PVs) on the TTI values of left ipsilateral PVs.

Methods

This study included 144 atrial fibrillation patients who underwent PV isolations using 28-mm fourth-generation cryoballoons. In 101 patients, the left superior PV (LSPV) was targeted and followed by the left inferior PV (LIPV) (group 1), and the LIPV was targeted and followed by the LSPV in the remaining 43 (group 2).

Results

The total LSPV and LIPV freeze durations were 193?±?60 and 171?±?40 s, respectively. Real-time PV isolation monitoring was capable in 137 (95.1%) LSPVs and 119 (82.6%) LIPVs and in 112 (77.8%) patients (78 in group 1 and 34 in group 2) in both LSPVs and LIPVs. Among them, the LSPV TTI was significantly longer in group 1 than that in group 2 (54.8?±?32.1 vs. 34.1?±?17.3 s, p?<?0.0001), while the LIPV TTI was significantly shorter in group 1 than that in group 2 (23.7?±?11.8 vs. 39.2?±?19.4 s, p?<?0.0001). The ΔTTI ((TTI in LSPV)-(TTI in LIPV)) was significantly greater in group 1 than that in group 2 (31.1?±?31.4 vs.???5.0?±?25.9 s, p?<?0.0001). In 5 patients (3 in group 1 and 2 in group 2), initially targeted left PVs were not isolated despite complete vein occlusions, while they were by subsequent applications at the other ipsilateral PVs.

Conclusions

In CB ablation, the order of targeting PVs highly influenced the TTI of the left PVs owing to the presence of electrical connections between left ipsilateral PVs.

     

Relevance of sleep disturbance to the integrity and characteristics of secondary peristalsis in patients with gastroesophageal reflux disease

Objective: Sleep disturbance is common in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis is important for clearance of the refluxate from the esophagus. We aimed to test the hypothesis whether secondary peristalsis is impaired in GERD patients with sleep disturbance.

Methods: Secondary peristalsis was stimulated with slow and rapid air injections into mid-esophagus in 8 age-matched health controls and 41 patients with GERD. Sleep disturbance was assessed by the Pittsburg Sleep Quality Index (PSQI). Objective sleep measures were assessed by ambulatory actigraphy.

Results: The threshold volume for inducing secondary peristalsis during slow air injection was significantly higher in GERD patients with sleep disturbance than healthy controls (14.3?±?1.2 vs. 8.9?±?0.5?mL, p?<?.05). GERD patients with sleep disturbance had higher threshold volume of secondary peristalsis during rapid air injection than GERD patients without sleep disturbance (5.1?±?0.4 vs. 3.9?±?0.2?mL, p?<?.05) and healthy controls (5.1?±?0.4 vs. 3.6?±?0.2?mL, p?<?.05). There was a negative correlation between PSQI score and peristaltic frequency during rapid air injection (r?=??.39, p?=?.01). Secondary peristaltic amplitude during rapid air injection was negatively correlated with wake after sleep onset (r?=??.34, p?=?.04).

Conclusions: Sleep disturbance is associated with secondary peristaltic response to distension-induced esophageal stimulation in patients with GERD. Our study suggests that sleep disturbance per se may adversely influence the effectiveness of esophageal peristalsis and bolus clearance during sleep in patients with GERD.     

Reflux esophagitis and columnar‐lined esophagus after cervical esophagogastrostomy (following esophagectomy)

Reflux esophagitis (RE) and columnar‐lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow‐up is necessary for such patients irrespective of the route of esophageal reconstruction.     

Comparison between biparietal bipolar and uniparietal bipolar radio frequency ablation techniques in a simultaneous procedural setting

Purpose

To make an in vitro evaluation of the lesion size and depth produced in two different sets of radio frequency energy bipolar delivery: simultaneous biparietal bipolar (SBB) and simultaneous uniparietal bipolar (SUB).

Methods

Two separate prototypes have been built for our purpose: one to be used in SBB mode and the other to be used SUB mode. Forty left atrium samples were taken from the hearts of freshly slaughtered pigs. They were ablated into a simulator ABLABOX, where blood flow, temperature, and contact force were controlled. After being sliced into a cryotome, the samples were digitalized by a flatbed scanner, and the images were analyzed by a computer morphometric software.

Results

Transmural lesions were achieved in 18/20 samples (90%) in SBB, while SUB showed transmurality in 9/20 samples (45%). Overall maximum diameter (D_MAX) resulted larger in SUB than in SBB (2.43?±?0.30 mm, 1.62?±?0.14 mm, respectively; p?<?0.05): Moreover, maximum epicardial and endocardial diameters (D_EPI and D_ENDO, respectively) were wider in SUB group than SBB group (2.28?±?0.30 mm, 2.26?±?0.40 and 1.60?±?0.14 mm, 1.59?±?0.15 mm, respectively; p?<?0.05). We observed the same tendency in lesion depth: The total area and volume (A_TOT and V_TOT) were broader in SUB group than in SBB one (581.01?±?65.38 mm/mm², 58.10?±?6.53 mm/mm³ and 521.97?±?73.05 mm/mm², 52.19?±?7.30 mm/mm³. respectively; p?<?0.05).

Conclusions

In contrast with the smaller lesion sizes, the biparietal bipolar group showed a higher transmurality rate. These findings may suggest a better drive of the energy flow when compared with SUB lesions.