Gastric Ischemic Conditioning Prior to Esophagectomy Is Associated with Decreased Stricture Rate and Overall Anastomotic Complications

Background

Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients.

Methods

We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity.

Results

Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p =?0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p?=?0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p?=?0.03).

Conclusions

Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.

     

Sociodemographic and risk behavior characteristics associated with unprotected sex with women among black men who have sex with men and women in New York City

The objectives of this cross-sectional study were to compare sociodemographic and risk behavior characteristics between black men who have sex with both men and women (MSMW) and those who have sex with men only (MSMO) and assess factors associated with having any unprotected vaginal and/or anal intercourse (UVAI) with women in the last 3 months. Data from 326 black men who reported recent unprotected anal intercourse with a man in an HIV behavioral intervention study in New York City were analyzed. Baseline characteristics were compared between MSMW and MSMO, and factors associated with having any UVAI in the past 3 months with women among MSMW were evaluated. In total, 26.8% reported having sex with both men and women in the last 3 months. MSMW were less likely to be HIV infected, use amyl nitrates, and have unprotected receptive anal sex with most recent male partner. MSMW were more likely to be over 40 years old and use heroin. A total of 55.6% of MSMW reported having UVAI with women in the last 3 months. Compared to MSMW having only protected sex, MSMW having any UVAI with women were less likely to be HIV infected and to disclose having sex with men to female partners; they were more likely to have greater than four male sex partners in the last 3 months. In conclusion, HIV prevention interventions among black MSMW should directly address the risk of HIV transmission to both their female and male partners. Disclosure of bisexuality to female partners may be an important component of future prevention efforts.     

Risk factors associated with missing post-esophagectomy hospital milestones

Background

Our institution utilizes an esophagectomy pathway to guide postoperative management. Our aim was to identify risk factors associated with missing pathway goals.

Experimental Testing of a New Generation of Flow Diverters in Sidewall Aneurysms in Rabbits

BACKGROUND AND PURPOSE:The development of new generation flow-diverting devices will improve the result of flow diversion in challenging aneurysms. The Flow-Redirection Endoluminal Device system is a dual-layer flow-diversion device. The purpose of this study was to evaluate the effectiveness and safety of the Flow-Redirection Endoluminal Device in a sidewall aneurysm model and in the abdominal aorta in rabbits.MATERIALS AND METHODS:Single Flow-Redirection Endoluminal Devices were implanted in the right common carotid artery across sidewall, vein-pouch aneurysms and within the abdominal aorta in 22 New Zealand white rabbits and followed for 1 (n = 5), 3 (n = 5), 6 (n = 4), and 12 months (n = 8). Aneurysm occlusion was graded on a 3-point scale based on digital subtraction angiography (grade I, complete occlusion; grade II, near-complete occlusion; and grade III, incomplete occlusion). Toluidine blue and basic fuchsin staining was used for the evaluation of thrombus organization within the aneurysm and neck coverage with neointima. A scanning electron microscope was used for confirmation of the patency of branch vessels along with DSA.RESULTS:Grades I and II occlusion rates were noted in 19 (86%) and 3 (14%) aneurysms, respectively, which indicated a 100% rate of complete or near-complete occlusion. No parent artery and branch artery occlusion was shown on DSA. Histologic images indicated partial or complete intraluminal thrombus organization and neointima coverage across the aneurysm neck. A scanning electron microscope indicated that all the vessel branches along the length of the device remained patent.CONCLUSIONS:The Flow-Redirection Endoluminal Device in experimental aneurysms demonstrated high rates of progressive and complete aneurysm occlusion while preserving the patency of branch vessels.

Flow diverters have become important tools in the treatment of intracranial aneurysms as a recent disruptive technology. The Pipeline Embolization Device (Covidien, Irvine, California) is designed as a flexible microcatheter-delivered self-expanding cylindric construct composed of 48 braided strands of cobalt chromium and platinum. The Silk flow diverter (Balt Extrusion, Montmorency, France) is a retrievable device attached to a high-friction delivery system with a 200-cm steel plunger with a 15-mm-long radiopaque floppy portion that extends beyond the stent with a 45° tip. The retrievability, visibility, and flexibility remain to be improved.^1,2 Surpass (Stryker Neurovascular, Kalamazoo, Michigan) is a cobalt-chromium, low-porosity (metal surface area coverage, 30%), self-expanding tubular mesh structure with high-pore attenuation.³ The high occurrence of neurologic deficits indicates that it is necessary to keep improving the performance of current flow-diverter devices. The Flow-Redirection Endoluminal Device (FRED; MicroVention, Tustin, California) was designed to increase the visibility of the device, improve its performance in patients, and reduce the occurrence of the neurologic complications.In this study, we created a sidewall aneurysm model in rabbits and tested the FRED by combining the angiographic, histologic, and scanning electron microscope (SEM) findings at different follow-up time points.     

Correction to: Positron Emission Tomographic Imaging of Tumor Cell Death Using Zirconium-89-Labeled APOMAB® Following Cisplatin Chemotherapy in Lung and Ovarian Cancer Xenograft Models

Molecular Imaging and Biology -     

A Mixed-Methods Study of Patient–Provider E-Mail Content in a Safety-Net Setting

To explore the content of patient–provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.