Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio.

PURPOSE: To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure. MATERIALS AND METHODS: Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system. RESULTS: Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean = 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P = .0269). CONCLUSIONS: No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.

Esophagorespiratory Fistulas: Survival and Outcomes of Treatment.

GOAL: The purpose of this study was to characterize outcomes of esophagorespiratory fistulas (ERF) by etiology and initial treatment strategy. BACKGROUND: ERF is a morbid condition for which optimal treatment strategies and outcomes are still in evolution. STUDY: Medical records and images were reviewed for all patients diagnosed with ERF at Mayo Clinic in Rochester, MN, between September 1, 2001 and January 1, 2012. Fistulas were classified as malignant or benign. Treatment strategies were classified as surgical or nonsurgical (typically esophageal stent placement). Technical and clinical success, survival, and survival free of second intervention were assessed. RESULTS: A total of 123 patients with acquired ERF were identified, of whom 65 (53%) were malignant and 58 (47%) benign. Initial treatment strategy was nonsurgical in 88 (72%) patients and surgical in 35 (28%); lower Charlson comorbidity scores were associated with increased likelihood of surgery. Technical and clinical success was seen in a majority of patients treated both surgically and nonsurgically. Patients with malignant ERF treated surgically survived longer than patients undergoing nonsurgical treatment (hazard ratio=5.6, P=0.005). In contrast, those with benign ERF had similar overall survival regardless of whether they received initial surgical or nonsurgical treatment; reintervention was more common in those who underwent nonsurgical treatment (hazard ratio=2.3, P=0.03). CONCLUSIONS: We conclude that survival in malignant ERF is better with surgical intervention in selected patients. Surgical and nonsurgical techniques achieve similar survival in benign ERF, but reintervention is more common in those treated endoscopically.

A national analysis of the complications, cost, and mortality of percutaneous lung ablation.

PURPOSE: To perform a national analysis of the safety and cost of percutaneous image-guided lung malignancy ablation. MATERIALS AND METHODS: Using the National (Nationwide) Inpatient Sample, we evaluated complications, need for further intervention, in-hospital mortality, length of hospitalization, and hospital charges for patients undergoing inpatient percutaneous image-guided lung ablation in the United States during the period 2007-2011. Additionally, an analysis of the relationship between specific patient factors, procedural complications, and mortality was performed. RESULTS: The study group consisted of 3,344 patients, including 2,072 (61.9%) patients treated for primary lung carcinomas and 1,277 (38.1%) patients treated for pulmonary metastatic disease. In-hospital mortality occurred after 43 (1.3%) ablation procedures. A Charlson comorbidity index score ≥ 4 was associated with higher mortality (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.16-6.91). Pneumothorax was the most common complication (38.4%), followed by pneumonia (5.7%) and effusion (4.0%). Neither pneumothorax nor chest tube insertion was associated with higher in-hospital mortality rates (pneumothorax, OR, 1.10; 95% CI, 0.59-2.04, and chest tube insertion, OR, 1.45; 95% CI, 0.78-2.68). Surgical reintervention via thoracoscopy or thoracotomy occurred in 31 cases (0.9%). Median length of hospitalization was 1 day (interquartile range, 1-3 d), and median hospital charges were $22,320 (interquartile range, $13,705-$43,026). CONCLUSIONS: Percutaneous image-guided lung ablation of primary and metastatic disease has an acceptable safety profile, and surgical reintervention is rarely required. The most frequent complications of percutaneous lung ablation were not associated with increased in-hospital mortality.

Pulmonary metastasectomy: role of pulmonary metastasectomy and type of surgery.

OPINION STATEMENT: Patients with untreated metastatic disease have a less than 5 % to 10 % 5-year survival, and for the patient who has metastatic disease isolated to the lungs, pulmonary metastasectomy remains the best hope for cure. Pulmonary metastasectomy has been performed for decades. However, despite hundreds of studies spanning several decades, randomized control data in support of pulmonary metastasectomy is still lacking, and the evidence upon which we base this commonly accepted surgical practice is for the most part weak. While well-accepted surgical selection criteria exist, controversies related to pulmonary metastasectomy abound. Unanswered and clearly debatable are questions related to: optimal preoperative imaging, if mediastinal staging should be performed and if so when, is video-assisted thoracic surgery (VATS) equivalent to open thoracotomy, is finger palpation of the lung mandatory, is repeat pulmonary metastasectomy justified, and what is the interrelationship of pulmonary metastasectomy to other treatments. Current practice to the surgical approach to pulmonary metastasectomy remains quite variable.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes.

BACKGROUND: Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS: The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS: The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS: This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Sublobar Resection, Stereotactic Body Radiation Therapy, and Percutaneous Ablation Provide Comparable Outcomes for Lung Metastasis-Directed Therapy.

BACKGROUND: Prolonged survival of patients with metastatic disease has furthered interest in metastasis-directed therapy (MDT). RESEARCH QUESTION: There is a paucity of data comparing lung MDT modalities. Do outcomes among sublobar resection (SLR), stereotactic body radiation therapy (SBRT), and percutaneous ablation (PA) for lung metastases vary in terms of local control and survival? STUDY DESIGN AND METHODS: Medical records of patients undergoing lung MDT at a single cancer center between January 2015 and December 2020 were reviewed. Overall survival, local progression, and toxicity outcomes were collected. Patient and lesion characteristics were used to generate multivariable models with propensity weighted analysis. RESULTS: Lung MDT courses (644 total: 243 SLR, 274 SBRT, 127 PA) delivered to 511 patients were included with a median follow-up of 22 months. There were 47 local progression events in 45 patients, and 159 patients died. Two-year overall survival and local progression were 80.3% and 63.3%, 83.8% and 9.6%, and 4.1% and 11.7% for SLR, SBRT, and PA, respectively. Lesion size per 1 cm was associated with worse overall survival (hazard ratio, 1.24; P = .003) and LP (hazard ratio, 1.50; P < .001). There was no difference in overall survival by modality. Relative to SLR, there was no difference in risk of local progression with PA; however, SBRT was associated with a decreased risk (hazard ratio, 0.26; P = .023). Rates of severe toxicity were low (2.1%-2.6%) and not different among groups. INTERPRETATION: This study performs a propensity weighted analysis of SLR, SBRT, and PA and shows no impact of lung MDT modality on overall survival. Given excellent local control across MDT options, a multidisciplinary approach is beneficial for patient triage and longitudinal management.

Stent-associated esophagorespiratory fistulas: incidence and risk factors.

BACKGROUND: Esophageal self-expandable stents (SESs) effectively treat strictures and leaks but may be complicated by a stent-associated esophagorespiratory fistula (SERF). Little is known about SERFs. OBJECTIVE: To determine the incidence, morbidity, mortality, and risk factors for SERF. DESIGN: Retrospective case-control study. SETTING: Single referral center. PATIENTS: All adults undergoing esophageal SES placement during a 10-year period. INTERVENTION: Stent placement. MAIN OUTCOME MEASUREMENTS: Occurrence of SERF, morbidity, and mortality. RESULTS: A total of 16 of 397 (4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months) including 6 of 94 (6%), 10 of 71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, middle, and distal esophagus, respectively (overall P < .001). SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignant strictures, and none with other indications for SES placement (P = .27). The risk was highest (18%) in patients with benign anastomotic strictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio [OR] 1.47 for every 1-point increase; P = .04) and history of radiation therapy (OR 9.41; P = .03). Morbidity associated with SERF included need for lifelong feeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was 4.5 months (range 0.35-67), and 7 patients survived less than 30 days. LIMITATIONS: Retrospective design, limited statistical power. CONCLUSION: SERF is a morbid complication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERF are prior radiation therapy and comorbidity score.

Impact of FDG PET Standardized Uptake Value in Resected Clinical Stage IA Non-Small Cell Lung Cancer.

BACKGROUND: A significant proportion of patients with clinical stage IA non-small cell lung cancer (NSCLC) experience will recurrence and decreased survival after surgery. This study examined the impact of preoperative primary tumor positron emission tomography (PET) scan maximum standardized uptake value (SUVmax) on oncologic outcomes after surgery. METHODS: This was a retrospective review of 251 patients who underwent surgical treatment of clinical stage IA NSCLC at an academic medical center (2005-2014). Patients were classified according to PET SUVmax level (low vs high) for analysis of upstaging, tumor recurrence, and overall survival. RESULTS: Median SUVmax values were higher in squamous cell carcinoma than in adenocarcinoma (median 3.3 vs 7.2; P < .0001). There were 109 (43.4%) patients in the SUVmax low group and 142 (56.6%) in the SUVmax high group. Patients with SUVmax high had larger tumors. SUVmax high was associated with higher rates of nodal upstaging (16.2% vs 4.6% in SUVmax low; P = .004), particularly in N1 nodes. SUVmax high was independently associated with nodal upstaging (adjusted odds ratio, 3.95; 95% CI, 1.36-11.46; P = .011). SUVmax high was associated with time to recurrence (hazard ratio, 1.62; 95% CI, 1.03-2.54; P = .036), but this association was lost on multivariable analysis (hazard ratio, 1.52; 95% CI, 0.91-2.54; P = .106). SUVmax was not associated with overall survival. CONCLUSIONS: Preoperative PET SUVmax level is strongly associated with nodal upstaging, particularly in N1 nodes, in patients with clinical stage IA NSCLC who undergo resection. PET SUVmax should be regarded as a risk factor when considering candidacy for sublobar resections and in future trials involving patients with stage I NSCLC.

Determinants of Long-term Survival Decades After Esophagectomy for Esophageal Cancer.

BACKGROUND: Long-term survival in esophagectomy patients with esophageal cancer is low due to tumor-related characteristics, with few reports of modifiable variables influencing outcome. We identified determinants of overall survival, time to recurrence, and disease-free survival in this patient cohort. METHODS: Adult patients who underwent esophagectomy for primary esophageal cancer from January 5, 2000, through December 30, 2010, at our institution were identified. Univariate Cox models and multivariable logistic regression analyses were used to identify associations between modifiable and unmodifiable patient and clinical variables and outcome of survival for the total cohort and a subgroup with locally advanced disease. RESULTS: We identified 870 patients with esophageal cancer who underwent esophagectomy. The median follow-up time was 15 years, and the 15-year overall survival rate was 25.2%, survival free of recurrence was 57.96%, and disease-free survival was 24.21%. Decreased overall survival was associated with the following unmodifiable variables: older age, male sex, active smoking status, history of coronary artery disease, advanced clinical stage, and tumor location. Decreased overall survival was associated with the following modifiable variables: use of neoadjuvant therapy, advanced pathologic stage, resection margin positivity, surgical reintervention, and blood transfusion requirement. The overall survival probability 6 years after esophagectomy was 0.920 (95% CI, 0.895-0.947), and time-to-recurrence probability was 0.988 (95% CI, 0.976-1.000), with a total of 17 recurrences and 201 deaths. CONCLUSIONS: Once patients survive 5 years, recurrence is rare. Long-term survival can be achieved in high-volume centers adhering to National Comprehensive Cancer Network guidelines using multidisciplinary care teams that is double what has been previously reported in the literature from national databases.

Preoperative gabapentin for acute post-thoracotomy analgesia: a randomized, double-blinded, active placebo-controlled study.

BACKGROUND: The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients. METHODS: Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months. RESULTS: One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (P = 0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (P > 0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, P < 0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, P = 0.72). CONCLUSIONS: A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.

The Endangered State of Medicare Reimbursement for Cardiothoracic Surgery: A Call to Action.

Reimbursement for cardiothoracic surgery continues to be threatened with enormous financial cuts ranging from 5% to 10% in recent years. In this policy perspective, we describe the history of reimbursement for cardiothoracic surgery, highlight areas in need of urgent reform, propose possible solutions that Congress and the Executive Branch may enact, and call cardiothoracic surgeons to action on this critical issue. Meaningful engagement of members of The Society of Thoracic Surgeons with their elected representatives is the only way to prevent these cuts.

Does gastric resection have a role in the management of severe postfundoplication gastric dysfunction?

BACKGROUND: Bloating, flatulence, early satiety, and dysphagia resolve in more than 90% of patients early after fundoplication. Gastric dysfunction can persist, however, and a small number of patients develop severe gastric dysfunction (gastroparesis). Management of gastroparesis after antireflux procedures is generally conservative, but gastroparesis can become refractory to medical therapy. The aim of this study was to assess the role of gastric resection in the management of the unusual patient with severe postfundoplication gastric dysfunction. METHODS: From January 1990 to October 2010, a total of 5,129 gastric resections were performed at our institution. From this cohort, we identified nine patients with postfundoplication gastric dysfunction managed with gastric resection. Clinical records were reviewed retrospectively for preoperative evaluation, perioperative course, and long-term outcomes. RESULTS: Over 20 years, nine patients were treated with gastric resection for debilitating gastric dysfunction after antireflux surgery. Seven of the nine patients were female; the median preoperative body mass index was 25 kg/m(2) (18-31 kg/m(2)). Median follow-up was 23 months (1-97 months). Preoperatively, five patients required enteral feeding. Postoperatively, although there were no deaths, one patient required operative drainage of a subphrenic abscess, one developed temporary respiratory failure, and one was readmitted for partial small bowel obstruction. Six of the nine patients maintain their nutrition orally, but three are maintained with enteral nutrition. Only two patients are subjectively asymptomatic. CONCLUSIONS: Outcomes after gastric resection for postfundoplication gastric dysfunction are poor, with three of the nine patients requiring supplemental nutrition and seven of the nine having persistent symptoms.

The Man Behind the Clagett Procedure: Dr Oscar Theron "Jim" Clagett.

Dr O.T. "Jim" Clagett was a pioneer in surgery of the great vessels and thorax. The procedure that bears his name for treatment of postpneumonectomy empyema was only one of his many innovations in aortic, lung, and esophageal surgery. He performed over 35,000 operations and trained over 115 residents during his tenure at Mayo Clinic. His distinguished career highlights include: helping develop the field of cardiothoracic surgery during its infancy, starting the Thoracic Surgery Residency Program at Mayo Clinic, serving in numerous institutional and national leadership roles, and countless awards.

Autologous blood patch pleurodesis for prolonged postoperative air leaks.

BACKGROUND: A prolonged air leak (PAL) is the most frequent complication after pulmonary resection. This study aimed to assess the safety and efficacy of autologous blood patch pleurodesis (ABPP) to treat PAL. METHODS: A prospectively maintained database identified patients with a PAL after pulmonary resection for lung cancer between 2015-2019. In this observational cohort study, clinical data were collected to retrospectively compare patients undergoing ABPP to no ABPP in a propensity-matched analysis. Kaplan Meier estimates and Cox models accounting for inverse probability weighting (IPTW) were used to assess the association of ABPP with each outcome. RESULTS: Of the 740 patients undergoing lung resection, 110 (15%) were identified as having a PAL at postoperative day (POD) 5. There was no difference between baseline characteristics among those undergoing ABPP (n=34) versus no ABPP (n=76). Propensity-weighted analysis did not reveal a significant association of ABPP treatment with in-hospital complication (P=0.18), hospital length of stay (LOS) (P=0.13), or post-discharge complication (P=0.13). However, ABPP treatment was associated with a lower risk of hospital readmission [P=0.02, hazard ratio (HR) 0.16] and reoperation for air leak or empyema (P=0.05, HR 0.11). Although not statistically significant, the mean chest tube (CT) removal of 11 days for the ABPP group was less than the no ABPP group (16 days) (P=0.14, HR 1.5-2). Those treated with ABPP were less likely to be discharged with a CT (ABPP 7/34, 21% vs. no ABPP 40/76, 53%). There was no statistical difference in empyema development between groups (ABPP 0/34, 0% vs. no ABPP 4/76, 5%, P=0.39, HR 0.24). CONCLUSIONS: ABPP administration is safe compared to traditional PAL management. In a retrospective propensity-matched analysis, postoperative patients treated with ABPP required less readmission and reoperation for PAL. Larger powered randomized trials may demonstrate the magnitude of benefit from treatment with ABPP.

The prognostic importance of pathologically involved celiac node metastases in node-positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic.

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty-two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2-45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months-22 years) for N0 patients and 15.9 months (range, 0.03 months-14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months-15.7 years) for celiac node-positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98-3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long-term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.

Cardiac Surgery After Extraanatomic Esophageal Reconstruction: A Single Institution's Experience.

BACKGROUND: Extraanatomic retrosternal and presternal esophageal reconstruction performed after esophagectomy poses a significant technical challenge to those patients who require cardiac surgery. This study reviewed a single-center experience with cardiac surgical procedures in patients with extraanatomic esophageal conduits, to examine the relative advantages of median sternotomy and thoracotomy approaches. METHODS: This case series identified patients who underwent cardiac surgery after extraanatomic esophageal reconstruction between January 1, 1999 and October 1, 2019 at the Mayo Clinic in Rochester, Minnesota. Electronic medical records were reviewed for patient demographics, surgical indications, characteristics, and outcomes. Continuous variables were reported as the mean or as the median and range, as appropriate. RESULTS: Seven individual patients had 8 cardiac surgical procedures after extraanatomic esophageal reconstruction (5 retrosternal, 2 presternal). All were male, with a median age of 65.5 years (range, 51 to 71 years). Preoperative computed tomography was obtained in all but 1 patient. Median sternotomy was performed in 4 patients, left thoracotomy in 2, right thoracotomy in 1, and right anterior thoracotomy in 1. Median bypass time was 91 minutes (interquartile range, 113.5 minutes). The median cross-clamp time was 57.5 minutes (interquartile range, 27.0 minutes). There was 1 delayed injury to a retrosternal conduit after median sternotomy approach. There were no injuries to the blood supply of any conduit. In-hospital mortality was 0%. The median length of stay was 7.5 days (range, 5 to 34 days). CONCLUSIONS: Different cardiac surgical procedures can be performed safely in patients with extraanatomic esophageal reconstructions through median sternotomy or thoracotomy. Preoperative planning with computed tomography with intravenous contrast enhancement of the chest, abdomen, and pelvis is essential for individualization of the surgical approach.

Predictors of Patient-Reported Reflux After Esophagectomy.

BACKGROUND: Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. METHODS: A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). RESULTS: Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. CONCLUSIONS: The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.

Surgery for Mesothelioma After Radiation Therapy (SMART); A Single Institution Experience.

Background: The optimal treatment sequence for localized malignant pleural mesothelioma (MPM) is controversial. We aimed to assess outcomes and toxicities of treating localized MPM with neoadjuvant radiation therapy (RT) followed by extrapleural pneumonectomy (EPP). Methods: Patients were enrolled on an institutional protocol of surgery for mesothelioma after radiation therapy (SMART) between June 2016 and May 2017. Eligible patients were adults with MPM localized to the ipsilateral pleura. Patients underwent staging with PET/CT, pleuroscopy, bronchoscopy/EBUS, mediastinoscopy, and laparoscopy. Five fractions of RT were delivered using intensity modulated radiation therapy (IMRT), with 30 Gy delivered to gross disease and 25 Gy to the entire pleura. EPP was performed 4-10 days following completion of RT. Results: Five patients were treated on protocol. Median age was 62 years (range 36-66). Histology was epithelioid on initial biopsy in all patients, but one was found to have biphasic histology after surgery. Three patients had surgeon-assessed gross total resection, and two had gross residual disease. While all patients were clinically node negative by pretreatment staging, three had positive nodal disease at surgery. Patients were hospitalized for a median 24 days (range 5-69) following surgery. Two patients developed empyema, one of whom developed respiratory failure and subsequently renal failure requiring dialysis, while the other required multiple surgical debridements. Two patients developed atrial fibrillation with rapid ventricular response after surgery, one of whom developed acute respiratory distress requiring intubation and tracheostomy. At last follow-up, one patient died at 1.4 years after local and distant progression, two were alive with local and distant progression, and the remaining two were alive without evidence of disease at 0.1 and 2.7 years. Median time to progression was 9 months. Three patients received salvage chemotherapy. Conclusions: SMART provided promising oncologic outcomes at the cost of significant treatment related morbidity. Due to the significant treatment associated morbidity and favorable treatment alternatives, we have not broadly adopted SMART at our institution.