Liposomal bupivacaine intercostal block placed under direct vision reduces morphine use in thoracic surgery.

Background: Thoracic epidural analgesia (TEA) and liposomal bupivacaine (LB) are two methods used for postoperative pain control after thoracic surgery. Some studies have compared LB to standard bupivacaine. However, data comparing the outcomes of LB to TEA after minimally invasive lung resection is limited. Therefore, the objective of our study was to compare postoperative pain, opioid usage, and outcomes between patients who received TEA vs. LB. Methods: We conducted a retrospective chart review of patients who underwent minimally invasive lung resections over an 8-month period. Intraoperatively, patients received either LB under direct vision or a TEA. Pain scores were obtained in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours postoperatively. Morphine milligram equivalents (MMEs) were calculated at 24 and 48 hours postoperatively. Postoperative outcomes were then compared between groups. Results: In total, 391 patients underwent minimally invasive lung resection: 236 (60%) wedge resections, 51 (13%) segmentectomies, and 104 (27%) lobectomies. Of these, 326 (83%) received LB intraoperatively. Fewer patients in the LB group experienced postoperative complications (18% vs. 34%, P=0.004). LB patients also had lower median pain scores at 24 (P=0.03) and 48 hours (P=0.001) postoperatively. There was no difference in MMEs at 24 hours (P=0.49). However, at 48 hours, patients who received LB required less narcotics (P=0.02). Median hospital length of stay (LOS) was significantly shorter in patients who received LB (2 vs. 4 days, P<0.001). On multivariable analysis, increasing age, postoperative complications, and use of TEA were independently associated with a longer hospital LOS. Conclusions: Compared to TEA, LB intercostal block placed under direct vision reduced morphine use 48 hours after thoracic surgery. It was also associated with fewer postoperative complications and shorter median hospital LOS. LB is a good alternative to TEA for pain management after minimally invasive lung resection.

Predicting outcomes in esophageal adenocarcinoma following neoadjuvant chemoradiation: Interactions between tumor response and survival.

OBJECTIVES: The prognostic value of tumor regression scores (TRS) in patients with esophageal adenocarcinoma (EAC) who underwent neoadjuvant chemoradiation remains unclear. We sought to investigate the prognostic value of pathologic and metabolic treatment response among EAC patients undergoing neoadjuvant chemoradiation. METHODS: Patients who underwent esophagectomy for EAC after neoadjuvant CROSS protocol between 2016 and 2020 were evaluated. TRS was grouped according to the modified Ryan score; metabolic response, according to the PERCIST criteria. Variables from endoscopic ultrasound, endoscopic biopsies, and positron emission tomography (primary and regional lymph node standardized uptake values [SUVs]) were collected. RESULTS: The study population comprised 277 patients. A TRS of 0 (complete response) was identified in 66 patients (23.8%). Seventy-eight patients (28.1%) had TRS 1 (partial response), 97 (35%) had TRS 2 (poor response), and 36 (13%) had TRS 3 (no response). On survival analysis for overall survival (OS), patients with TRS 0 had longer survival compared to those with TRS 1, 2, or 3 (P = .010, P < .001, and P = .005, respectively). On multivariable logistic regression, the presence of signet ring cell features on endoscopic biopsy (odds ratio [OR], 7.54; P = .012) and greater SUV uptake at regional lymph nodes (OR, 1.42; P = .007) were significantly associated with residual tumor at pathology (TRS 1, 2, or 3). On multivariate Cox regression for predictors of OS, higher SUVmax at the most metabolically active nodal station (hazard ratio [HR], 1.08; P = .005) was independently associated with decreased OS, whereas pathologic complete response (HR, 0.61; P = .021) was independently associated with higher OS. CONCLUSIONS: Patients with pathologic complete response had prolonged OS, whereas no difference in survival was detected among other TRS categories. At initial staging, the presence of signet ring cells and greater SUV uptake at regional lymph nodes predicted residual disease at pathology and shorter OS, suggesting the need for new treatment strategies for these patients.

Anatomy of mediastinal veins and nerves.

The mediastinum is the central compartment in the thoracic cavity that lies between the lungs. It extends from the thoracic inlet superiorly to the diaphragm inferiorly and sternum anteriorly to the vertebral column posteriorly. It is commonly divided into four compartments-superior, anterior, middle and posterior mediastinum. However, some have started to classify it into the more recent three compartments-anterior (prevascular), middle (visceral) and posterior (paravertebral). The mediastinum is of clinical significance because many vital structures, such as the heart, great vessels, esophagus, lymphatics, and trachea, lie within these compartments. Disease presentation can greatly vary depending on the structures involved, and the differential diagnosis can range widely. Therefore, knowledge of the anatomy and subdivisions of the mediastinum is vital for thoracic surgeons. Herein, we have provided a brief review of the mediastinal anatomy. Utilizing the four-compartment model, we detail the contents of each compartment of the mediastinum with special attention to its veins and nerves. There are also several venous junctions that are important for mediastinal surgery, such as the internal jugular-subclavian venous junction and the left-right brachiocephalic venous junction. We describe useful superficial landmarks, such as the sternocleidomastoid and manubrium, and how they relate to some of the key venous junctions.

Anastomotic Stricture After Minimally Invasive Esophagectomy.

BACKGROUND: Despite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America. METHODS: We performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models. RESULTS: Of 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001). CONCLUSIONS: After controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Validation of the Pictorial Fit-Frail Scale in a Thoracic Surgery Clinic.

OBJECTIVE: Examine feasibility and construct validity of Pictorial Fit-Frail scale (PFFS) for the first time in older surgical patients. BACKGROUND: The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics. METHODS: Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and Frailty Questionnaire (FRAIL) scale were obtained. To assess the validity of the PFFS in this population, the Spearman rank correlations (r spearman ) between PFFS trans and VES-13, FI-CGA, FRAIL were calculated. RESULTS: All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFS trans was 0.27 (interquartile range [IQR] 0.12-0.34), PFFS was 11 (IQR 5-14), and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFS trans and FI-CGA (r spearman = 0.81, P < 0.001) and a moderate correlation between PFFS trans and VES-13 and FRAIL score (r spearman = 0.68 and 0.64 respectively, P < 0.001). CONCLUSIONS: PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.

When a segmentectomy is not a segmentectomy: Quality assurance audit and evaluation of required elements for an anatomic segmentectomy.

OBJECTIVE: The advent of lung cancer screening and detection of smaller nodules amplifies the need to clarify the oncological quality of sublobar resections. Furthermore, studies comparing sublobar resections to lobectomies offer conflicting conclusions. We hypothesize that this is driven, in part, by inconsistency in reporting; that is, variable interpretation of what constitutes an operative segment. Without an established standard, 2 very different operations may be reported as segmental resections, leaving the data on sublobar approaches subject to interpretative variability. METHODS: A retrospective audit was performed on all segmental resections from May 2016 to December 2019 at Brigham and Women's Hospital. Pathology and operative reports were reviewed, with particular attention to the dissection of the component artery, vein, and bronchus. Resections with dissection and division of at least 1 major vascular structure (the segmental artery or vein), as well as the segmental bronchus, met operative criteria for anatomic segmentectomy. Surgical quality metrics were compared between the 2 groups. RESULTS: There were 271 segmental resections: 219 (80.8%) were anatomic segmentectomies and 52 (19.2%) were nonanatomic segmentectomies. For the entire cohort, nonanatomic segmentectomies had smaller margins (1.0 vs 1.5 cm; P = .02), fewer lymph nodes (2.0 vs 6.0; P < .001), and fewer mediastinal lymph node stations sampled (1.0 vs 2.0; P < .001). Similarly, there were smaller margins (1.5 vs 1.8 cm; P = .03), fewer lymph nodes (2.0 vs 6.0; P < .001), and fewer mediastinal lymph node stations sampled (1.0 vs 2.0; P < .001) in nonanatomic segmentectomies for non-small cell lung cancer. CONCLUSIONS: Nearly 20% of reported segmentectomies may not meet criteria for true segmental resection. Therefore, prior studies may need further scrutiny to clarify outcomes and results. Establishing a professional standard may help mitigate ambiguity in published data on this subject.

Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery.

BACKGROUND AND OBJECTIVES: We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients. METHODS: Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed. RESULTS: Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18). CONCLUSION: Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Manubrium Reconstruction.

To date, there is no standard approach for manubrial reconstruction. We had previously utilized mesh; however, this resulted in breakage, infection, and poor cosmesis. In this case series, we describe our transition to iliac wing autograft reconstruction. We examined 7 patients who underwent manubrial resection and reconstruction: 2 with mesh and methyl methacrylate and 5 with an iliac wing autograft. The outcomes of the autograft patients were overall favorable with no short-term complications or instances of breakage. We conclude that an iliac wing autograft for manubrial reconstruction is feasible and effective alternative to methyl methacrylate mesh.

Geographic differences in therapy for stage I non-small-cell lung cancer in older adults.

BACKGROUND: Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States. METHODS: Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed. RESULTS: Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05). CONCLUSIONS: Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Mandatory Nodal Evaluation During Resection of Clinical T1a Non-Small Cell Lung Cancers.

BACKGROUND: Recommendations for intraoperative lymph node evaluation are uniform regardless of whether a primary tumor is clinical T1a or T2a according to TNM 8th edition for stage I non-small cell lung cancer (NSCLC). We quantified nodal disease risk in patients with T1a disease (≤1 cm). METHODS: The National Cancer Database was queried for clinical T1a N0 M0 primary NSCLCs ≤1 cm undergoing lobectomy with mediastinal nodal evaluation from 2004-2014. Nodal disease risk was analyzed as a function of demographics and tumor characteristics. RESULTS: Among 2157 cases, 6.7% had occult nodal disease: 5.1% occult N1 and 1.6% N2. Adenocarcinoma (7.5%), large cell carcinoma (25%), and poor differentiation (11.8%) or undifferentiated/anaplastic (25.0%) had high rates of combined pN1 and N2 disease (P < .001). In univariable analysis, odds of pathologic N1, N2, or N1/N2 nodal disease with respect to N0 was greatest for large cell carcinoma (ref. adenocarcinoma odds ratio [OR] 4.31, 3.62, 4.12 respectively; all P < .05), and anaplastic grade (OR 10.71, 13.09, 11.55). Bronchoalveolar adenocarcinomas had the lowest odds (OR 0.41, 0.11, 0.32) and squamous cell carcinoma had lower odds for N2 (OR 0.29, all P < .05). In multivariable analysis only bronchoalveolar adenocarcinomas had lower odds of pathologic N2 and N1/N2 disease with respect to N0. Worsening grade remained significant for pathologic N1 and N1/N2 disease (both P < .05). CONCLUSIONS: A significant rate (6.7%) of occult nodal disease is present in primary NSCLCs ≤1 cm. Risk increases with certain histology and worsening grade. We recommend mandatory systematic hilar and mediastinal nodal evaluation for T1a NSCLC tumors for accurate staging and adjuvant therapy.

Routine Chest Roentgenogram After Chest Tube Removal Is Not Indicated for Minimally Invasive Lung Resection.

BACKGROUND: Chest roentgenograms after chest tube removal are common practice in postoperative thoracic surgery patients. Whether these roentgenograms change clinical management is debatable. We investigated prevalence and management of post-pull pneumothoraces after lung resection. METHODS: Patients undergoing minimally invasive wedge resections, segmentectomies, and lobectomies between March 2018 and September 2018 were retrospectively reviewed. Baseline factors, operative technique, chest tube management, and outcomes after post-pull chest roentgenograms, and factors associated with post-pull pneumothoraces were analyzed. RESULTS: The study analyzed 200 consecutive patients comprising 117 wedge resections (59%), 24 segmentectomies (12%), and 59 lobectomies (30%). Wedge resections compared with segmentectomy or lobectomy had lower rates of chest tube use, drain duration, air leaks, and need for a clamp trial, with Blake drains most often removed last compared with segmentectomy or lobectomy (all P < .001). Post-pull pneumothoraces, which were largely small/tiny/trace (96%), occurred in 110 patients (55%). Five patients experienced symptoms, and no patients required intervention. Resection type was associated with the pneumothorax rate, need for additional imaging, and discharge timing (all P < .05). Those with pneumothoraces compared with 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 < .05). Multivariable regression showed only clamp trial was associated with post-pull pneumothorax development (odds ratio, 2.48; 95% CI, 1.13-5.45; P = .024). CONCLUSIONS: Although routine use of post-pull chest roentgenograms 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.

Influence of Tasking During Vestibular Testing.

Purpose The purpose of this study was to investigate the effectiveness of different types of tasking on the measurement of peak slow phase velocity (SPV) for caloric testing and rotary chair testing. Method This study evaluated the peak SPV response for caloric testing and rotary chair across five conditions. Three verbal, one tactile, and one condition without tasking were used for both caloric testing and rotary chair. The subjects consisted of 20 young adults (age range: 22-33 years, M = 26.65, SD = 3.72; seven male, 13 female) with normal vestibular function and no history of ear surgery or vestibular disorder. Study participation consisted of two visits with 24 hr minimum between each, one for caloric testing and one for rotary chair testing. The test completed at each visit was counterbalanced. Caloric Testing: The caloric irrigations were performed 5 times, with the ears randomized and tasking conditions randomized. Rotary Chair Testing: Rotary chair sinusoidal harmonic acceleration testing was performed 5 times at 0.08 Hz with the tasking conditions randomized. Results Tasking of any kind resulted in significantly larger peak SPV responses when compared to the no tasking condition for rotary chair testing. When comparing each type of tasking, no significant differences were noted. No significant difference was noted when comparing the conditions with tasking to the no tasking condition for caloric testing. Conclusions Clinically, either mental or tactile tasking can be utilized as a method to reduce VOR suppression during rotary chair testing. As no difference was found when comparing different verbal tasks to each other, the type of tasking can be catered to the patient. If verbal tasking cannot be completed, the braiding tactile task is a valid substitution. Caloric results varied widely across subjects and did not reach statistical significance, so conclusions on the need for tasking cannot be drawn.