Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

OBJECTIVE

To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy.

METHODS

Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality.

RESULTS

During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts.

CONCLUSIONS

Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Lung cancer outcomes in the elderly: potential disparity in screening

OBJECTIVES

The aim of this study was to analyse outcomes of lung cancer in the elderly.

METHODS

A retrospective analysis was performed of patients in the National Cancer Database with NSCLC from 2004 to 2017 grouped into 2 categories: 70-79 years (A) and 80-90 years (B). Patients with multiple malignancies were excluded. Kaplan-Meier curves estimated the overall survival for each age group based on stage.

RESULTS

In total, 466 051 patients were included. Less-invasive techniques (imaging and cytology) diagnosed cancer as a function of age: 14.6% in A vs 21.3% in B [P < 0.001, standardized mean difference (SMD) 0.175]. Clinical stage IA was least common in B (15%) compared to 17.3% in A (P < 0.001, SMD 0.079). Approximately 83.0% in B did not receive surgery compared to 70.0% in A (P < 0.001, SMD 0.299). Of the 83.0%, 8.0% were considered poor surgical candidates because of age or comorbidities compared with 6.2% in A (P < 0.001, SMD 0.299) For 71.0% in B, surgery was not the first treatment plan compared to 62.0% in A (P < 0.001, SMD 0.299). Survival curves showed worse prognosis for each clinical and pathologic stage for B compared to A.

CONCLUSIONS

Patients older than 80 years present less frequently as clinical stage IA, are less commonly offered surgical intervention and are more frequently diagnosed using less accurate measures. They also have worse outcomes for each stage compared to younger patients.

Association of conduit dimensions with perioperative outcomes and long-term quality of life after esophagectomy for malignancy

Objective

The impact of conduit dimensions and location of esophagogastric anastomosis on long-term quality of life after esophagectomy remains unexplored. We investigated the association of these parameters with surgical outcomes and patient-reported quality of life at least 18 months after esophagectomy.

Methods

We identified all patients who underwent esophagectomy for cancer from 2018 to 2020 in our institution. We reviewed each patient's initial postoperative computed tomography scan measuring the gastric conduit's greatest width (centimeters), linear staple line length (centimeters), and relative location of esophagogastric anastomosis (vertebra). Quality of life was ascertained using patient-reported outcome measures. Perioperative complications, length of stay, and mortality were collected. Multivariate regressions were performed.

Results

Our study revealed that a more proximal anastomosis was linked to an increased risk of pulmonary complications, a lower recurrence rate, and greater long-term insomnia. Increased maximum intrathoracic conduit width was significantly associated with trouble enjoying meals and reflux long term after esophagectomy. A longer conduit stapled line correlated with fewer issues related to insomnia, improved appetite, less dysphagia, and significantly enhanced "social," "role," and "physical'" aspects of the patient's long-term quality of life.

Conclusions

The dimensions of the gastric conduit and the height of the anastomosis may be independently associated with outcomes and long-term quality of life after esophagectomy for cancer.

Thymic en-bloc resection with veins: case demonstrations and review of the literature

Locally invasive thymic neoplasms are challenging clinical scenarios and typically require a multidisciplinary approach. The involvement of major mediastinal veins such as the superior vena cava (SVC) used to be a contraindication to surgery, but with improved surgical technique and outcomes, this paradigm has shifted. In some situations, complex resections and reconstructions may be indicated and required to improve the long-term outcome of these patients. We report two of our cases along with a current review of literature. We also describe the preoperative workup, operative techniques, postoperative management, complications, and outcomes of patients with invasive thymic neoplasms that involve the mediastinal veins. Our first case describes a patient who was diagnosed with a thymoma extending from the diaphragm to the base of the neck that was also encasing major vascular structures including the SVC and left innominate vein. Our second case describes a patient who was also diagnosed with a large anterior mediastinal mass encasing the great veins and invading the chest wall. We describe the management of these patients and then delve deeper into operative techniques including SVC resection and reconstruction. We describe the types of conduits that can be used and complications to be mindful of when clamping the great veins, such as the SVC. Improvements in conduit materials and neoadjuvant and adjuvant therapies over the years have made it more feasible for patients with invasive thymic neoplasms to undergo surgery.

Gender trends in cardiothoracic surgery authorship

OBJECTIVE

In recent years, the historically low proportion of women cardiothoracic surgeons and trainees has been a subject of intense focus. Publications remain a key metric of academic success and career advancement. We sought to identify trends in the gender of first and last author publications in cardiothoracic surgery.

METHODS

We searched for publications between 2011 and 2020 in 2 US cardiothoracic surgery journals, identifying those with Medical Subject Heading publication types of clinical trials, observational studies, meta-analyses, commentary, reviews, and case reports. A commercially available, validated software (Gender-API) was used to associate gender with author names. Association of American Medical Colleges Physician Specialty Data Reports were used to identify concurrent changes in the proportion of active women in cardiothoracic surgery.

RESULTS

We identified 6934 (57.1%) pieces of commentary; 3694 (30.4%) case reports; 1030 (8.5%) reviews, systematic analyses, meta-analyses, or observational studies; and 484 (4%) clinical trials. In total, 15,189 total names were included in analysis. Over the 10-year study period, first authorship by women rose from 8.5% to 16% (0.42% per year, on average), whereas the percentage of active US women cardiothoracic physicians rose from 4.6% to 8% (0.42% per year). Last authorship was generally flat over the decade, going from 8.9% in 2011% to 7.8% in 2020 and on average, increased at just 0.06% per year (P = .79).

CONCLUSIONS

Over the past decade, authorship by women has steadily increased, more so at the first author position. Author-volunteered gender identification at the time of manuscript acceptance may be useful to more accurately follow trends in publication.

Rapid Prototyping Techniques for the Development of a Take-Home Surgical Anastomosis Simulation Model

OBJECTIVE

The objective of this paper is to describe the techniques and process of developing and testing a take-home surgical anastomosis simulation model.

DESIGN

Through an iterative process, a simulation model was customized and designed to target specific skill development and performance objectives that focused on anastomotic techniques in thoracic surgery and consist of 3D printed and silicone molded components. Various manufacturing techniques such as silicone dip spin coating and injection molding have been described in this paper and explored as part of the research and development process. The final prototype is a low-cost, take-home model with reusable and replaceable components.

SETTING

The study took place at a single-center quaternary care university-affiliated hospital.

PARTICIPANTS

The participants included in the model testing were 10 senior thoracic surgery trainees who completed an in-person training session held during an annual hands- on thoracic surgery simulation course. Feedback was then collected in the form of an evaluation of the model from participants.

RESULTS

All 10 participants had an opportunity to test the model and complete at least 1 pulmonary artery and bronchial anastomosis. The overall experience was rated highly, with minor feedback provided regarding the set- up and fidelity of the materials used for the anastomoses. Overall, the trainees agreed that the model was suitable for teaching advanced anastomotic techniques and expressed an interest in being able to use this model to practice skill development.

CONCLUSIONS

Developed simulation model can be easily reduced, with customized components that accurately simulate real-life vascular and bronchial components suitable for training of anastomoses technique amongst senior thoracic surgery trainees.

Gender differences in Medicare payments to cardiothoracic surgeons in 2019

OBJECTIVES

The STS Thoracic Surgery Practice and Access Task Force - 2019 Workforce Report noted gender-based differences in the income of cardiothoracic surgeons in the United States. We analysed the 2019 Medicare payment data for thoracic and cardiac surgeons to investigate the gender-based payment gap among cardiothoracic surgeons.

METHODS

The 2019 Medicare Physician and Other Practitioners by Provider and Services data set merged with the Doctors and Clinicians National Downloadable File was utilized to conduct a cross-sectional analysis of gender differences in Medicare payments, numbers of services, unique billing codes, years in practice, Medicare beneficiary age, regional population density (rural-urban commuting area code) and patient panel complexity (hierarchical condition category) for providers. The providers' self-reported gender (women or men) and provider type (thoracic surgery or cardiac surgery) were binarily set according to the Center for Medicare and Medicaid Services standards. Independent analyses were performed with thoracic and cardiac surgeons. We also used the 2013 and 2016 Medicare Physician and Other Practitioners by Provider and Services data sets to analyse the trends in adjusted gender-based payment differences across 2013, 2016 and 2019.

RESULTS

After controlling for the covariates, women thoracic surgeons received $25,183.50 [95% confidence interval (CI) $16,307.60, $34,059.40] less than the mean Medicare payment than men thoracic surgeons. Likewise, women cardiac surgeons received $20,960 [95% confidence interval (CI) $1,014.80, $40,902.80] less than the mean adjusted Medicare payment than their men counterparts.

CONCLUSIONS

In 2019, women cardiothoracic surgeons received a significantly lower mean Medicare payment than men cardiothoracic surgeons after controlling for the number of services, unique billing codes, the complexity of the patient panel, years in practice and regional population density. The payment gap between women and men exhibited no statistically significant change over 2013, 2016 and 2019. Future studies are warranted to understand the association between gender representation and the pay gap.

Three-dimensional technologies in chest wall resection and reconstruction

Resection and reconstruction of the chest wall can pose unique challenges given its vital role in the protection of the thoracic viscera and the dynamic part it plays in respiration. A number of new three-dimensional (3D) technologies may be invaluable in tackling these challenges. Herein we review the use of 3D technologies in preoperative imaging with virtual 3D models, printing of 3D models for preoperative planning, and printing of 3D prostheses when approaching complex chest wall reconstruction.

Bilateral Bronchoscopic Lung Volume Reduction After Surgical Fissure Completion

Although bilateral lung volume reduction surgery has been shown to be safe and effective in carefully selected patients with upper lobe-predominant emphysema and hyperinflation, bronchoscopic lung volume reduction via placement of endobronchial valves is conventionally performed only unilaterally. Furthermore, it is not offered to patients with interlobar collateral ventilation because of the lack of clinical efficacy. We describe two novel management approaches including (1) bilateral bronchoscopic lung volume reduction, and (2) a combined thoracic surgical and interventional pulmonary procedure involving surgical fissure completion followed by endobronchial valve placement, which culminated in safe and effective lung volume reduction of both lungs along with an excellent patient outcome.

Nonsurgical management of Fusobacterium necrophorum sternoclavicular septic arthritis: a case report

BACKGROUND

To date, the gold-standard treatment for sternoclavicular septic arthritis has been surgery due to the high failure and complication rates of medical treatment. In particular, presentation of Fusobacterium sternoclavicular septic arthritis has been rarely reported and very sparsely investigated, and only one other case report of septic arthritis caused by this pathogen exists in literature.

CASE PRESENTATION

We report a case of an otherwise healthy 38-year-old Caucasian woman who presented with sternoclavicular septic arthritis as a complication of Fusobacterium necrophorum mediastinitis. Our patient underwent successful management through nonstandard, conservative treatment of 7 weeks of intravenous piperacillin + tazobactam followed by 6 weeks of oral amoxicillin + clavulanic acid.

CONCLUSION

We highlight a case of the rare presentation of Fusobacterium necrophorum sternoclavicular septic arthritis that did not require surgical intervention for successful management. Though infection of the sternoclavicular joint is unusual, it continues to be seen in thoracic surgery, and there are increasing numbers of antibiotic-resistant organisms. This case broadens insight into the clinical course and treatment of such conditions. The success of conservative management in this case aligns with the similar nonsurgical course of the one previous report of Fusobacterium sternoclavicular septic arthritis occurrence. Thus, further discussion and thought for reevaluating the current standard practice of surgery for sternoclavicular joint infection is suggested. Our case supports assessing a patient's overall health, causative organism, and extent of infection in interventional course and taking the feasibility of conservative management into more weighted consideration.

Risk factors for prolonged air leak and need for intervention following lung resection

OBJECTIVES

Prolonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention.

METHODS

Retrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated.

RESULTS

In total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050).

CONCLUSIONS

Age, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.

OUP accepted manuscript

Severe coronavirus disease of 2019 (COVID-19) disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes substantial parenchymal damage in some patients. There is a paucity of literature describing the surgical management COVID-19 associated bronchopleural fistula after failure of medical therapy. We present the case of a 59-year-old woman with SARS-CoV-2 pneumonia, secondary bacterial pneumonia with bronchopleural fistula and radiographic and clinical evidence of disease refractory to medical therapy. After a course of culture-driven antimicrobial therapy and failure to improve following drainage with tube thoracostomy, she was treated successfully with Clagett open thoracostomy. After resolution of the bronchopleural fistula, the thoracostomy was closed and she was discharged home. In cases of severe COVID-19 complicated by bronchopleural fistula with parenchymal destruction, a tailored approach involving surgical management when indicated can lead to acceptable outcomes without significant morbidity.

Routine Chest X-ray After Chest Tube Removal Is Not Indicated for Minimally Invasive Lung Resection

BACKGROUND

Chest x-rays after chest tube removal are common practice in post-operative thoracic surgery patients. Whether these x-rays change clinical management is debatable. We investigated prevalence and management of post-pull pneumothoraces following lung resection.

METHODS

Retrospective review of minimally-invasive wedge-resections, segmentectomies, and lobectomies between March 2018 and September 2018. Baseline factors, operative technique, chest tube management, and outcomes following post-pull chest x-ray and factors associated with post-pull pneumothoraces were analyzed.

RESULTS

200 consecutive patients were analyzed: 117 wedge-resections (59%), 24 segmentectomies (12%), and 59 lobectomies (30%). Wedge-resections compared to segmentectomy or lobectomy had lower rates of chest tube usage, drain duration, air-leaks, and need for clamp-trial, with Blake drains most often removed last compared to segmentectomy or lobectomy (all <0.001). 110 patients (55%) experienced a post-pull pneumothorax, which were largely small/tiny/trace (96%). 5 patients experienced symptoms and no patients required intervention. Resection type was associated with pneumothorax rate, need for additional imaging, and discharge timing (all p<0.05). Those with pneumothoraces compared to those without differed in type of resection and chest drain, presence of air-leak within 24 hours of removal, need for clamp trial, order of tube removal, and hospital length of stay (all p<0.05). Multivariable regression showed only clamp trial was associated with post-pull pneumothorax development (OR 2.48 95% CI 1.13-5.45; p=0.024).

CONCLUSIONS

While routine use of post-pull chest x-ray identified a high prevalence of pneumothorax, no intervention was required. Our study demonstrates post-pull imaging may not be indicated in asymptomatic patients without prior air leak or clamp trial.

Definition and assessment of high risk in patients considered for lobectomy for stage I non-small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document

OBJECTIVE

Lobectomy is a standard treatment for stage I non-small cell lung cancer, but a significant proportion of patients are considered at high risk for complications, including mortality, after lobectomy and might not be candidates. Identifying who is at risk is important and in evolution. The objective of The American Association for Thoracic Surgery Clinical Practice Standards Committee expert panel was to review important considerations and factors in assessing who is at high risk among patients considered for lobectomy.

METHODS

The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an expert panel that developed an expert consensus document after systematic review of the literature. The expert panel generated a priori a list of important risk factors in the determination of high risk for lobectomy. A survey was administered, and the expert panel was asked to grade the relative importance of each risk factor. Recommendations were developed using discussion and a modified Delphi method.

RESULTS

The expert panel survey identified the most important factors in the determination of high risk, which included the need for supplemental oxygen because of severe underlying lung disease, low diffusion capacity, the presence of frailty, and the overall assessment of daily activity and functional status. The panel determined that factors, such as age (as a sole factor), were less important in risk assessment.

CONCLUSIONS

Defining who is at high risk for lobectomy for stage I non-small cell lung cancer is challenging, but remains critical. There was impressive strong consensus on identification of important factors and their hierarchical ranking of perceived risk. The panel identified several key factors that can be incorporated in risk assessment. The factors are evolving and as the population ages, factors such as neurocognitive function and frailty become more important. A minimally invasive approach becomes even more critical in this older population to mitigate risk. The determination of risk is a clinical decision and judgement, which should also take into consideration patient perspectives, values, preferences, and quality of life.

Chemoradiation Therapy as Definitive Treatment of Esophageal Cancer

Definitive chemoradiation therapy avoids the perioperative and long-term morbidity of esophagectomy and is the standard of care for cervical esophageal cancer. There are significant differences in tumor response to chemoradiation and recurrence patterns between squamous cell cancer and adenocarcinoma of the esophagus. Multimodality therapy for esophageal cancer continues to progress, now with the widespread use of PET scanning and possible active surveillance in patients with complete clinical response to chemoradiation. As drug development and targeted therapy trials continue to expand, our understanding of tumor biology and precision medicine will continue to refine the treatment of esophageal cancer.

Robotic-assisted tracheobronchial surgery

Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.

Optimal Approach to Lobectomy for Non-Small Cell Lung Cancer: Systemic Review and Meta-Analysis

Objective

Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer.

Methods

Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations.

Results and recommendations

One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb).

Conclusions

This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.

Thoracoscopic Resection of a Nonseminomatous Primary Mediastinal Germ Cell Tumor

PMNGCT is an independent predictor of poor prognosis despite advances in multidisciplinary management. Multidrug chemotherapy followed by aggressive surgical resection remains the mainstay of treatment. Although associated with significant morbidity, an open surgical approach is traditionally used. We describe the first reported case, to our knowledge, of a patient who underwent resection of a PMNGCT via a minimally invasive approach following induction chemotherapy.

Outcomes of minimally invasive sleeve resection

Background

Sleeve resection allows for preservation of lung parenchyma and improved long-term outcomes when compared with pneumonectomy. Little is known about minimally invasive sleeve resection, especially indications, feasibility, technical aspects, complications, and outcomes. We reviewed our institutional experience with sleeve resections via a minimally invasive approach.

Methods

We performed a retrospective review of a prospectively maintained database from 01/01/2010 to 11/01/2017. Indications, operative details, pathology, postoperative complications were reviewed and longer-term follow-up was reviewed.

Results

Fifteen patients were identified (5 males, 10 females). Details are presented in Table 1. Patients ranged in age from 7 to 82 years (median, 57 years). Approaches included video-assisted thoracoscopic surgery (VATS) and robotic. Airway sleeve resection was performed in all patients with an additional arterioplasty in 4, one patient having a double sleeve. Length of stay ranged from 3 to 10 days (median, 5 days). Indication for surgery included carcinoid in 5 (1 atypical), NSCLC in 6, and 4 additional pathologies. Complications occurred in 6 patients: air leak [2], pericardial effusion [1], transient brachial plexopathy [1], and atrial fibrillation [2]. There were no anastomotic complications. Median follow-up was 4.2 years. There were no anastomotic strictures.

Conclusions

In experienced centers, sleeve resection via a minimally invasive approach is feasible with acceptable morbidity and mortality. Results in this small series appear comparable with the open approach.

Minimally Invasive Intragastric Approach to Gastroesophageal Junction Disease

BACKGROUND

A minimally invasive intragastric approach to the gastroesophageal junction (GEJ) allows resection of intramural disease while avoiding disruption of the lower esophageal sphincter and vagus nerves. Few surgeons use this approach; thus little is known regarding its indications, feasibility, technical aspects, complication profile, and long-term outcomes. This study reviewed the experience with this technique.

METHODS

A retrospective review was performed of a prospectively maintained, Institutional Review Board-approved database covering the period from January 1, 2005 to August 1, 2017. Indications, operative details, postoperative complications, and outcomes were assessed.

RESULTS

There were 12 patients identified. The mean age of these patients was 51.9 years. The indications for resection included 10 symptomatic leiomyomas, one gastrointestinal stromal tumor, and three cancers of the GEJ. Mean and median length of stay were 4.9 and 2.5 days, respectively. There were two postoperative esophageal leaks managed with laparoscopic repair. Of the 3 patients with cancer, 2 underwent an R0 resection, whereas 1 patient underwent an R1 resection. There were no other complications or recurrences. Mean follow-up was 6.0 years (range, 0.5 to 12.6 years); no patients had stricture or symptomatic gastroesophageal reflux on long term follow-up.

CONCLUSIONS

Resection of selected intramural GEJ disorders through a minimally invasive transgastric approach can be performed safely with acceptable morbidity and good long-term results. The approach allows preservation of the lower esophageal sphincter and vagus nerves, a potential advantage compared with other surgical alternatives to resection in this region.

Programmed Death Ligand 1: A Step Toward Immunoscore for Esophageal Cancer

BACKGROUND

This study sought to evaluate the effect of tumor-infiltrating lymphocyte (TIL) density and programmed death ligand 1 (PD-L1) expression on the prognosis of esophageal cancer.

METHODS

Banked tissue specimens from 53 patients who underwent esophagectomies for malignancy at a single institution over a 6-year period were stained for cluster of differentiation 3 (CD3), CD8, and PD-L1. Tumors were characterized as staining high or low density for CD3 and CD8, as well as positive or negative for PD-L1. TIL density and PD-L1 expression were analyzed in the context of survival, recurrence, and perioperative characteristics.

RESULTS

Median follow-up was 823 days, with 92.5% survival and 26.8% recurrence rates. All tumors were adenocarcinomas. Neoadjuvant chemotherapy was given in 56.6% of cases, and neoadjuvant radiotherapy was given in 37.7%. High CD3 density was found in 83%, whereas high CD8 density was found in 56.6%. A total of 18.9% of the tumors stained positive for PD-L1. Survival was significantly shorter in Kaplan-Meier analysis for patients with primary tumors staining positive for PD-L1 (log rank: p = 0.05). Multivariable analysis controlling for neoadjuvant therapy, TIL markers, PD-L1, age, and sex found no significant difference in recurrence or survival.

CONCLUSIONS

Positive staining for PD-L1 may be a prognostic marker for decreased survival in esophageal adenocarcinoma. Additional TIL cell types should be investigated for creation of an esophageal cancer Immunoscore. PD-L1 has potential as a therapeutic target.

Open window thoracostomy as an alternative approach to secondarily infected malignant pleural effusion and failure of intrapleural catheter drainage: a case report

Malignant pleural effusion (MPE) is a common and complex manifestation of advanced stage cancer. Treatment options have trended towards less invasive approaches such as intrapleural catheter drainage, however this technique is not without morbidity and not suitable for every patient. A troublesome scenario arises when an MPE is secondarily infected in the setting of an indwelling catheter, given both the high frequency of recurrence of such fluid and the presence of a foreign body. Further, quality literature surrounding this specific management issue is sparse and thus practice is heterogeneous. Herein we presented a case report of a 74-year-old gentleman with secondarily infected MPE and subsequent failure of indwelling pleural catheter (IPC) drainage. Given multiple failures of his catheter, we performed an open window thoracostomy (OWT) to provide a durable method of draining the pleural space and concomitantly achieving source control. OWT represents an infrequently described but invaluable alternative measure the surgeon may take when faced with failure of intrapleural catheter drainage and trapped lung.

Outpatient video-assisted thoracoscopic thymectomy in an octogenarian

Video-assisted thoracoscopic thymectomy has gained acceptance for the treatment of small thymomas. Appropriately selected elderly patients may benefit as much as younger patients from this procedure. Specific benefits of minimally invasive surgery include shorter hospital stays, decreased complications and improved oncologic outcomes. Outpatient thoracic surgery is an established model for some procedures. In this report, we present an 80-year-old patient with an enlarging 2.5 cm thymoma who successfully underwent an outpatient right video-assisted thoracoscopic thymectomy at our institution. The patient's postoperative course was uncomplicated. He continues to do well 3 years after his surgery. To our knowledge, this is the first reported outpatient video-assisted thoracoscopic thymectomy in an octogenarian.

Left video-assisted thoracic surgery thymectomy

Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.

"Just-In-Time" Simulation Training Using 3-D Printed Cardiac Models After Congenital Cardiac Surgery

BACKGROUND

High-fidelity simulation using patient-specific three-dimensional (3D) models may be effective in facilitating pediatric cardiac intensive care unit (PCICU) provider training for clinical management of congenital cardiac surgery patients.

METHODS

The 3D-printed heart models were rendered from preoperative cross-sectional cardiac imaging for 10 patients undergoing congenital cardiac surgery. Immediately following surgical repair, a congenital cardiac surgeon and an intensive care physician conducted a simulation training session regarding postoperative care utilizing the patient-specific 3D model for the PCICU team. After the simulation, Likert-type 0 to 10 scale questionnaire assessed participant perception of impact of the training session.

RESULTS

Seventy clinicians participated in training sessions, including 22 physicians, 38 nurses, and 10 ancillary care providers. Average response to whether 3D models were more helpful than standard hand off was 8.4 of 10. Questions regarding enhancement of understanding and clinical ability received average responses of 9.0 or greater, and 90% of participants scored 8 of 10 or higher. Nurses scored significantly higher than other clinicians on self-reported familiarity with the surgery (7.1 vs. 5.8; P = .04), clinical management ability (8.6 vs. 7.7; P = .02), and ability enhancement (9.5 vs. 8.7; P = .02). Compared to physicians, nurses and ancillary providers were more likely to consider 3D models more helpful than standard hand off (8.7 vs. 7.7; P = .05). Higher case complexity predicted greater enhancement of understanding of surgery (P = .04).

CONCLUSION

The 3D heart models can be used to enhance congenital cardiac critical care via simulation training of multidisciplinary intensive care teams. Benefit may be dependent on provider type and case complexity.