Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak

Introduction

Morbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy.

Aim

To quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD).

Material and methods

We identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days.

Results

Eleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation.

Conclusions

Laparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.

Myocardial ischaemia reperfusion injury: the challenge of translating ischaemic and anaesthetic protection from animal models to humans

Myocardial ischaemia reperfusion injury is the leading cause of death in patients with cardiovascular disease. Interventions such as ischaemic pre and postconditioning protect against myocardial ischaemia reperfusion injury. Certain anaesthesia drugs and opioids can produce the same effects, which led to an initial flurry of excitement given the extensive use of these drugs in surgery. The underlying mechanisms have since been extensively studied in experimental animal models but attempts to translate these findings to clinical settings have resulted in contradictory results. There are a number of reasons for this such as dose response, the intensity of the ischaemic stimulus applied, the duration of ischaemia and lost or diminished cardioprotection in common co-morbidities such as diabetes and senescence. This review focuses on current knowledge regarding myocardial ischaemia reperfusion injury and cardioprotective interventions both in experimental animal studies and in clinical trials.

Implications of the calcium-sensing receptor in ischemia/reperfusion

The calcium-sensing receptor (CaSR) is a G protein-coupled receptor (GPCR) which was first isolated from bovine parathyroid glands. Its complex structure has been well characterized, which helped to better understand its function. The CaSR activity can be modulated by various ligands, either activators (also called "calcimimetics") or inhibitors (or "calcilytics"). The main role of the CaSR concerns Ca²⁺ homeostasis. In bone, intestine and kidney, the CaSR acts as a sensor for extracellular ionized Ca²⁺ concentration ([Ca²⁺]_e) to keep it stable. Such a homeostatic function is well illustrated by human inherited diseases caused by mutations in CASR gene, characterized by Ca²⁺ balance disturbances. Interestingly, the CaSR is also expressed in numerous tissues which are not directly involved in Ca²⁺ regulation. There, the CaSR has been implicated in regulatory pathways, including cell proliferation, differentiation and apoptosis. Moreover, recent observations suggest that the CaSR may be involved in ischaemia/reperfusion (I/R) cascades. In cardiomyocytes, the expression and activation of the CaSR are significantly induced at the time of I/R, which induces apoptotic pathways. Likewise, the activation of the CaSR in I/R in brain, liver and kidney has been associated with increased cell death and aggravated structural and functional damage. The present review summarizes these observations and hypothesizes a novel therapeutic option targeting the CaSR in I/R.

Mesenchymal stromal cell therapy in conditions of renal ischaemia/reperfusion

Acute kidney injury (AKI) represents a worldwide public health issue of increasing incidence, with a significant morbi-mortality. AKI treatment mostly relies on supportive manoeuvres in the absence of specific target-oriented therapy. The pathophysiology of AKI commonly involves ischaemia/reperfusion (I/R) events, which cause both immune and metabolic consequences in renal tissue. Similarly, at the time of kidney transplantation (KT), I/R is an unavoidable event which contributes to early graft dysfunction and enhanced graft immunogenicity. Mesenchymal stromal cells (MSCs) represent a heterogeneous population of adult, fibroblast-like multi-potent cells characterized by their ability to differentiate into tissues of mesodermal lineages. Because MSC have demonstrated immunomodulatory, anti-inflammatory and tissue repair properties, MSC administration at the time of I/R and/or at later times has been hypothesized to attenuate AKI severity and to accelerate the regeneration process. Furthermore, MSC in KT could help prevent both I/R injury and acute rejection, thereby increasing graft function and survival. In this review, summarizing the encouraging observations in animal models and in pilot clinical trials, we outline the benefit of MSC therapy in AKI and KT, and envisage their putative role in renal ischaemic conditioning.

Risk of acute coronary events associated with glyburide compared with gliclazide use in patients with type 2 diabetes: a nested case-control study

AIM

Sulfonylureas might increase the risk of adverse cardiovascular events; however, emerging evidence suggests there may be important differences amongst these drugs. Some, like glyburide, inhibit KATP channels in the heart and pancreas, while others, like gliclazide, are more likely to selectively inhibit KATP channels in the pancreas. We hypothesized that the risk of acute coronary syndrome (ACS) events would be higher in patients using glyburide compared with gliclazide.

METHODS

This nested case-control study used administrative health data from Alberta, Canada. New users of glyburide or gliclazide aged ≥66 years between 1998 and 2010 were included. Cases were individuals with an ACS-related hospitalization or death. Up to four controls were matched based on birth year, sex, cohort-entry year and follow-up time. Multivariable conditional logistic regression was used to estimate adjusted odds ratios (OR), controlling for baseline drug use and co-morbidities.

RESULTS

Our cohort included 7441 gliclazide and 13 884 glyburide users; 51.4% men, mean (s.d.) age 75.5 (6.6) years and mean (s.d.) duration of follow-up 5.5 (4.0) years. A total of 4239 patients had an ACS-related hospitalization or death and were matched to 16 723 controls. Compared with gliclazide use, glyburide use was associated with a higher risk (adjusted OR 1.14; 95% CI 1.06-1.23) of ACS-related hospitalization or death over 5.5 years (number needed to harm: 50).

CONCLUSION

In this observational study, glyburide use was associated with a 14% higher risk of ACS events compared with gliclazide use. Although the difference is small and probably to have implications at the population level rather than the individual patient or clinician, any causal inferences regarding sulfonylurea use and adverse cardiovascular risk should be tested in a large-scale randomized controlled trial.