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Minimal invasive Methoden in der Lungenresektion versprechen postoperative Vorteile durch eine geringere Beeintrachtigung der Atemmechanik, ertraglichere Schmerzen und raschere Genesung. Vor allem die Vermeidung der Aufdehnung von Rippen tragt zur postoperativen Erhaltung der physiologischen Brustwandfunktion bei. Der Einsatz der Thorakoskopie ist gerechtfertigt, wenn Mortalitats- und Morbiditatsrisiken mit herkommlichen Methoden vergleichbar sind und die Radikalitat onkologischer Eingriffe nicht beeintrachtigt wird. Zuruckhaltung besteht gegenwartig gegenuber thorakoskopischen Resektionen, die eine Kontrolle der Hilusstrukturen voraussetzen. Grunde fur diese Vorsicht sind die geringe klinische Erfahrung, das unbekannte Risiko von Blutungen und das Fehlen eines manuellen Zugangs und ublicher Nahttechnik. Wir untersuchten deshalb in einem Tiermodell die Anwendbarkeit thorakoskopischer Methoden auf die Pneumonektomie mit dem Ziel, eine Operation mit reproduzierbarer Kontrolle der Hilusgefase zu entwickeln und Aussagen uber den postoperativen Heilungsverlauf zu machen.

OBJECTIVE: Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment. SUMMARY BACKGROUND DATA: The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea. METHODS: Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis. RESULTS: There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction. CONCLUSIONS: Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.

Background Prior data indicate increased perioperative morbidity and mortality in patients receiving induction chemoradiotherapy before pneumonectomy for lung cancer. Objective We reviewed a consecutive series of pneumonectomies to determine the impact of induction therapy on operative mortality. Results Over a 15-year period, 183 patients underwent pneumonectomy for lung cancer. Forty-six received combined preoperative radiochemotherapy (25.2%), and 137 patients underwent resection only. Indications for induction therapy were stage IIB disease in 1, IIIA in 35, IIIB in 8, and IV in 2 patients. Patients receiving induction therapy were younger (mean age 58.4 vs 61.9 years; P = .033), had less heart disease (6.5 vs 26.3%; P = .0035), higher preoperative forced expiratory volume in 1 second (2.48 vs 2.13 L; P = .0018), a lower rate of endobronchial tumor (34.8 vs 67.2%; P = .0002), and underwent intrapericardial procedures more often (71.7 vs 43.1%; P = .0011). Hospital mortality was 4.3 % (2/46) after preoperative therapy and 6.6% (9/137) after resection only (P = .73); the difference in cardiopulmonary morbidity was not significant (51.1% vs 40.4%; P = .22). Induction did not predict hospital mortality after adjustment for a propensity score derived from nonoperative and operative variables correlated with neoadjuvant therapy. Conclusions A regimen of induction radiation and chemotherapy does not increase the operative mortality of pneumonectomy in carefully selected patients.

Objectives We proposed to fabricate a tissue-engineered esophagus and to use it for replacement of the abdominal esophagus. Methods Esophagus organoid units, mesenchymal cores surrounded by epithelial cells, were isolated from neonatal or adult rats and paratopically transplanted on biodegradable polymer tubes, which were implanted in syngeneic hosts. Four weeks later, the tissue-engineered esophagus was either harvested or anastomosed as an onlay patch or total interposition graft. Green Fluorescent Protein labeling by means of viral infection of the organoid units was performed before implantation. Histology and immunohistochemical detection of the antigen α-actin smooth muscle were performed. Results Tissue-engineered esophagus grows in sufficient quantity for interposition grafting. Histology reveals a complete esophageal wall, including mucosa, submucosa, and muscularis propria, which was confirmed by means of immunohistochemical staining for α-actin smooth muscle. Tissue-engineered esophagus architecture was maintained after interposition or use as a patch, and animals gained weight on a normal diet. Green Fluorescent Protein–labeled tissue-engineered esophagus preserved its fluorescent label, proving the donor origin of the tissue-engineered esophagus. Conclusions Tissue-engineered esophagus resembles the native esophagus and maintains normal histology in anastomosis, with implications for therapy of long-segment esophageal tissue loss caused by congenital absence, surgical excision, or trauma.

The augmenting effect of chronic inflammation on bladder cancer was studied in female Swiss mice treated with N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT), 0.15% by weight of diet for 20 weeks. To produce chronic inflammation one silk suture and one catgut suture were placed through the bladder wall of 63 mice to receive FANFT and 18 to receive normal diet. In remaining mice (no. = 62) the bladder was simply touched without suture insertion. Thirty-two animals treated with FANFT and 33 treated with FANFT + sutures also received supplements to their drinking water throughout the experiment of the sulfhydryl-reducing agent N-acetylcysteine (500 mg./kg. body weight/day). Seven weeks following FANFT treatment, bladder cancers developed in 12% of mice with sutures and FANFT and in 19% of those with sutures, FANFT, and N-acetylcysteine. No cancers developed in mice receiving FANFT alone or FANFT with N-acetylcysteine and none in mice treated with sutures only. Placement of silk sutures through the bladder wall of mice augments FANFT-induced bladder cancer. N-acetylcysteine at these doses does not influence the incidence.

Because ulcerative colitis predisposes to colonic cancer, for determination of the effect of colitis on experimental colon carcinogenesis, rectal instillations of peptides that attract and activate neutrophils were used to induce colitis in CD-1 (ICR) BR mice receiving 20 weekly injections of the carcinogen 1,2-dimethylhydrazine [(DMH) CAS: 540-73-8]. From week 4 through week 15 of DMH injections, twice-weekly enemas of formyl-norleucyl-leucyl-phenylalanine were given to DMH-treated mice. The effect of the antioxidant vitamin E in the diet (1,750 IU/kg diet) was studied in another group of mice treated with DMH and having colitis. Four weeks after DMH was discontinued, cancer occurred in 9 of 28 (32%) animals with DMH plus control enemas, in 22 of 29 (76%) animals with DMH plus colitis (P = .001), and in 16 of 28 (57%) animals with DMH plus colitis plus supplemental vitamin E (P = .11 compared with the group with DMH and colitis). Colitis enhances DMH-induced colonic carcinogenesis.

Background Patients with locally advanced esophageal cancer who are treated with trimodality therapy have a high recurrence rate. Preclinical evidence suggests that inhibition of cyclooxygenase 2 (COX2) increases the effectiveness of chemoradiation, and observational studies in humans suggest that COX-2 inhibition may reduce esophageal cancer risk. This trial tested the safety and efficacy of combining a COX2 inhibitor, celecoxib, with neoadjuvant irinotecan/cisplatin chemoradiation. Methods This single arm phase 2 trial combined irinotecan, cisplatin, and celecoxib with concurrent radiation therapy. Patients with stage IIA-IVA esophageal cancer received weekly cisplatin 30 mg/m2 plus irinotecan 65 mg/m2 on weeks 1, 2, 4, and 5 concurrently with 5040 cGy of radiation therapy. Celecoxib 400 mg was taken orally twice daily during chemoradiation, up to 1 week before surgery, and for 6 months following surgery. Results Forty patients were enrolled with stage IIa (30 %), stage IIb (20 %), stage III (22.5 %), and stage IVA (27.5 %) esophageal or gastroesophageal junction cancer (AJCC, 5th Edition). During chemoradiation, grade 3–4 treatment-related toxicity included dysphagia (20 %), anorexia (17.5 %), dehydration (17.5 %), nausea (15 %), neutropenia (12.5 %), diarrhea (10 %), fatigue (7.5 %), and febrile neutropenia (7.5 %). The pathological complete response rate was 32.5 %. The median progression free survival was 15.7 months and the median overall survival was 34.7 months. 15 % (n = 6) of patients treated on this study developed brain metastases. Conclusions The addition of celecoxib to neoadjuvant cisplatin-irinotecan chemoradiation was tolerable; however, overall survival appeared comparable to prior studies using neoadjuvant cisplatin-irinotecan chemoradiation alone. Further studies adding celecoxib to neoadjuvant chemoradiation in esophageal cancer are not warranted. Trial registration Clinicaltrials.gov: NCT00137852, registered August 29, 2005.

Objective Use and operative results of neoadjuvant therapy before major elective resection for primary lung cancer were examined in the Society of Thoracic Surgeons General Thoracic Surgical Database. Methods Lobectomy and pneumonectomy for primary lung cancer were identified in 12,201 patients between January 2002 and June 2008. After excluding procedures for missing clinical staging or end points; institutions with more than 10% missing data for clinical stage, discharge mortality, or length of stay; and patients treated with chemotherapy or radiation for unrelated disease, there remained 5376 resections. Study end points were discharge mortality, length of stay more than 14 days, and major morbidity. Multivariate analysis using propensity scores stratified into quintiles measured the effect of induction therapy. Results In 525 of 5376 procedures (9.8%), chemotherapy (n = 153), radiotherapy (23), or chemoradiotherapy (349) preceded resection. Compared with resection only, patients receiving induction therapy were younger and had fewer comorbidities, more reoperative surgery, and higher rates of pneumonectomy. Clinical IIIA-N2 disease was treated with induction therapy in only 203 of 397 patients (51.1%). Propensity-adjusted rates detected no difference in discharge mortality, prolonged length of stay, or a composite of major morbidity for patients receiving induction therapy. Similar results were obtained in a logistic regression model (discharge mortality P = .9883; prolonged hospital stay P = .9710; major morbidity P = .9678). Conclusion Less than 10% of all major lung resections for primary carcinoma and just more than half of all resections for clinical stage IIIA-N2 disease are preceded by neoadjuvant chemotherapy or radiation. This study does not support concerns over excessive operative risk of induction therapy.