Gastric hibernoma: a novel location and presentation of a rare tumor.

We present a case of gastric hibernoma, an unusual tumor with a location novel to the literature. A 39-year-old female presented with one year of upper gastrointestinal bleeding and dysphagia. Gastroenterology performed an esophagogastroduodenoscopy with ultrasound and identified a 6 cm mass within the muscularis propria of the antrum. Computed tomography demonstrated a 9.7 × 7.8 × 4.8 c

Assessing Survival and Grading the Severity of Complications in Octogenarians Undergoing Pulmonary Lobectomy.

Introduction. Octogenarians are at increased risk for complications after lung resection. With alternatives such as radiation, understanding the risks of surgery and associated survival are valuable. Data grading the severity of complications and long-term survival in this population is lacking. We reviewed our experience with lobectomy in octogenarians, grading complications using a validated thoracic morbidity and mortality schema. Methods. We retrospectively reviewed consecutive patients aged ≥80 undergoing lobectomy between 2004 and 2012. Demographics, clinical/pathologic stage, complications, recurrence, and mortality were collected. Complications were graded by the Seely thoracic morbidity and mortality model. Results. 45 patients (mean age 82.2 years) were analyzed. The majority of patients (28/45, 62%) were clinical stage IA/IB. 62% (28/45) of patients experienced a complication. Only 15.6% (7/45) were considered significantly morbid (≥ grade IIIB) per the Seely model. Perioperative mortality was 2% and half of patients were living at a follow-up of 53 months. Overall five-year survival was 52%. Conclusions. In carefully selected octogenarians, lobectomy carries a 15.6% rate of significantly morbid complications with encouraging overall survival. These data provide the basis for a more complete discussion with patients regarding lobectomy for lung cancer

Electronic Medical Record Inaccuracies: Multicenter Analysis of Challenges with Modified Lung Cancer Screening Criteria.

The National Comprehensive Cancer Network expanded their lung cancer screening (LCS) criteria to comprise one additional clinical risk factor, including chronic obstructive pulmonary disease (COPD). The electronic medical record (EMR) is a source of clinical information that could identify high-risk populations for LCS, including a diagnosis of COPD; however, an unsubstantiated COPD diagnosis in the EMR may lead to inappropriate LCS referrals. We aimed to detect the prevalence of unsubstantiated COPD diagnosis in the EMR for LCS referrals, to determine the efficacy of utilizing the EMR as an accurate population-based eligibility screening trigger using modified clinical criteria. We performed a multicenter review of all individuals referred to three LCS programs from 2012 to 2015. Each individual\u27s EMR was searched for COPD diagnostic terms and the presence of a diagnostic pulmonary functionality test (PFT). An unsubstantiated COPD diagnosis was defined by an individual\u27s EMR containing a COPD term with no PFTs present, or the presence of PFTs without evidence of obstruction. A total of 2834 referred individuals were identified, of which 30% (840/2834) had a COPD term present in their EMR. Of these, 68% (571/840) were considered unsubstantiated diagnoses: 86% (489/571) due to absent PFTs and 14% (82/571) due to PFTs demonstrating no evidence of postbronchodilation obstruction. A large proportion of individuals referred for LCS may have an unsubstantiated COPD diagnosis within their EMR. Thus, utilizing the EMR as a population-based eligibility screening tool, employing expanded criteria, may lead to individuals being referred, potentially, inappropriately for LCS

Paradoxical Changes: EMMPRIN Tissue and Plasma Levels in Marfan Syndrome-Related Thoracic Aortic Aneurysms

Background: Thoracic aortic aneurysms (TAAs) associated with Marfan syndrome (MFS) are unique in that extracellular matrix metalloproteinase inducer (EMMPRIN) levels do not behave the way they do in other cardiovascular pathologies. EMMPRIN is shed into the circulation through the secretion of extracellular vesicles. This has been demonstrated to be dependent upon the Membrane Type-1 MMP (MT1-MMP). We investigated this relationship in MFS TAA tissue and plasma to discern why unique profiles may exist. Methods: Protein targets were measured in aortic tissue and plasma from MFS patients with TAAs and were compared to healthy controls. The abundance and location of MT1-MMP was modified in aortic fibroblasts and secreted EMMPRIN was measured in conditioned culture media. Results: EMMPRIN levels were elevated in MFS TAA tissue but reduced in plasma, compared to the controls. Tissue EMMPRIN elevation did not induce MMP-3, MMP-8, or TIMP-1 expression, while MT1-MMP and TIMP-2 were elevated. MMP-2 and MMP-9 were reduced in TAA tissue but increased in plasma. In aortic fibroblasts, EMMPRIN secretion required the internalization of MT1-MMP. Conclusions: In MFS, impaired EMMPRIN secretion likely contributes to higher tissue levels, influenced by MT1-MMP cellular localization. Low EMMPRIN levels, in conjunction with other MMP analytes, distinguished MFS TAAs from controls, suggesting diagnostic potential

Tissue Inhibitor of Metalloproteinase-1 Deficiency Abrogates Obliterative Airway Disease after Heterotopic Tracheal Transplantation

Obliterative bronchiolitis (OB) is a major cause of allograft dysfunction after lung transplantation and is thought to result from immunologically mediated airway epithelial destruction and luminal fibrosis. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been implicated in the regulation of lung inflammation, airway epithelial repair, and extracellular matrix remodeling and therefore may participate in the pathogenesis of OB. The goals of this study were to determine the expression profiles of MMPs and TIMPs and the role of TIMP-1 in the development of airway obliteration using the murine heterotopic tracheal transplant model of OB. We demonstrate the selective induction of MMP-3, MMP-9, MMP-12, and TIMP-1 in a temporally restricted manner in tracheal allografts compared with isografts. In contrast, the expression of MMP-7, TIMP-2, and TIMP-3 was decreased in allografts relative to isografts during the period of graft rejection. TIMP-1 protein localized to epithelial, mesenchymal, and inflammatory cells in the tracheal grafts in a temporally and spatially restricted manner. Using TIMP-1–deficient mice, we demonstrate that the absence of TIMP-1 in the donor trachea or the allograft recipient reduced luminal obliteration and increased re-epithelialization in the allograft compared with wild-type control at 28 d after transplantation. Our findings provide direct evidence that TIMP-1 contributes to the development of airway fibrosis in the heterotopic tracheal transplant model, and suggest a potential role for this proteinase inhibitor in the pathogenesis of OB in patients with lung transplant

Laparoscopic Hill repair: 25-year follow-up.

BACKGROUND: The open Hill repair for gastroesophageal reflux disease and hiatal hernia is remarkably durable, with a median 10-year reoperation rate of only 3% and satisfaction of 93%. No long-term data exist for the laparoscopic Hill repair (LHR). METHODS: Patients who underwent primary LHR at Swedish Medical Center for reflux and/or hiatal hernia at least 5 years earlier (1992-2010) were identified from an IRB-approved database. There were 727 patients who met inclusion criteria, including 648 undergoing repair for reflux and 79 for paraesophageal hernia. Two questionnaires were administered via mail to evaluate long-term quality of life using validated GERD-HRQL, Swallowing score, and global satisfaction score. Outcomes were defined by GERD-HRQL score, Swallowing score, resumption of proton pump inhibitor (PPI) therapy, need for reoperation, and global satisfaction with overall results. RESULTS: Two hundred forty-two patients completed and returned the survey (226 lost to follow-up, 90 deceased, 3 denied undergoing LHR, 166 non-responders), of which 52% were male. The average age at the time of surgery was 49.5 years. Median follow-up was 18.5 years (range 6.2-24.7). The average GERD-HRQL score (7.1) and the average Swallowing score (39.9) both indicated excellent symptomatic outcomes. 30% of patients are using daily PPIs. 24 patients (9.9%) required reoperation for failure during the follow-up period, 21 in the reflux group and 3 in the paraesophageal hernia group. Overall, 85% reported good to excellent results, and 76% would recommend the operation. CONCLUSION: LHR shows excellent long-term durability and quality of life similar to the open Hill repair, with 85% good to excellent results at a median follow-up of 19 years and a reoperation rate under 10%. It is surmised that Hill suture fixation of the gastroesophageal junction to the preaortic fascia may confer unique structural integrity compared to other repairs

Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease.

BACKGROUND: A randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT. METHODS: A retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6-12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow. RESULTS: There were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% timeLNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients. CONCLUSION: Tri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure