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BACKGROUND: The significance of lymphovascular invasion (LVI) in esophageal adenocarcinoma (EAC) has not yet been described. Potential utility as an adjunct to current staging guidelines remains unknown. METHODS: The National Cancer Database was queried from 2006 to 2020. Univariate and multivariable models, Kaplan Meier method, and log-rank test were used. Subgroup analyses by pN stage were conducted. RESULTS: Of 9,689 patients, 23.2% had LVI. LVI was an independent prognostic factor (hazard ratio [HR] 1.401, 95% confidence interval [CI] 1.307-1.502, p < 0.0001) with reduction in median survival to 20.0 months (95% CI 18.9-21.4) from 39.7 months (95% CI 37.8-42.3, p < 0.0001). Multivariable survival analysis adjusted on pN and pT stage found that patients with LVI had decreased survival in a given pN stage (p < 0.001). pN0/LVI+ patients had a similar prognosis to the higher staged pN1/LVI- (28.6 months), although pN1/LVI- patients did slightly worse (p = 0.0135). Additionally, patients with pN1/LVI+ had equivalent survival compared with pN2/LVI- (p = 0.178) as did pN2/LVI+ patients compared with pN3/LVI- (p = 0.995). CONCLUSIONS: In these data, LVI is an independent negative prognostic factor in EAC. LVI was associated with a survival reduction similar to an upstaged nodal status irrespective of T stage. Patients with LVI may be better classified at a higher pN stage.
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BACKGROUND AND AIMS: Transcatheter aortic valve replacement (TAVR) has become the primary treatment for severe symptomatic aortic stenosis in patients >65 years with volumes exceeding surgical aortic valve replacements (SAVR) since 2019. As a less invasive procedure with lower complication rates, TAVR is preferable in most patient populations, particularly those with increased surgical risk. One such population is patients who have undergone solid organ transplant (SOT). We aimed to evaluate periprocedural outcomes and complication rates following TAVR in SOT recipients as compared to the general TAVR population. METHODS: The 2016-2018 National Inpatient Sample (NIS) was queried by ICD-10 PCS codes to identify TAVR cases; hospitalizations were subsequently stratified by SOT history. Multivariate analyses were completed to evaluate complication rates, length of stay (LOS), and cost of stay (COS). RESULTS: No significant difference was observed in mortality rates or post-procedural complications between SOT recipients (n = 223) and those without transplant history undergoing TAVR (n = 29,448) except for increased thromboembolic events captured in transplant patients (p < .001). There was no significant variation in LOS or COS between the two populations; female sex and Black or Hispanic race were predictors of increased inpatient time. CONCLUSIONS: SOT recipients have no increased risk of mortality or periprocedural complications when undergoing TAVR. Though the rate of thromboembolic events was higher in SOT recipients, observation size was small (n = 27 TAVR, n = 4 TAVR + SOT) thus external validity is limited. Based on these data, transplant recipients experience no difference in outcomes following TAVR as compared to patients without a history of organ transplant.
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Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Transplante de Órgãos , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Transplantados , Resultado do TratamentoRESUMO
As technology in mechanical circulatory support continues to advance, so does the utilization of durable left ventricular assist devices (LVADs). We present the first reported case of HeartMate 3 (HM3) LVAD bend relief disconnection causing laceration of the outflow graft. Our patient is a 34 year old male with end-stage heart failure status post-HM3 implantation with recent debridement of a driveline infection who presented with weakness and sanguineous drainage 5 days after an episode of heavy lifting associated with a palpable substernal pop. During the initial evaluation, he experienced sudden massive decompression of a left chest hematoma through a thoracotomy incision with exsanguinating hemorrhage and an abrupt drop in LVAD flow. An emergent anterolateral thoracotomy was performed where it was discovered that the bend relief was disconnected and had lacerated the outflow graft. The graft was repaired and the ring was removed using a diamond blade rotary saw. He was discharged home and made a full recovery. Mechanical device malfunction has been documented in several prior versions of durable LVADS. Although there have been reported cases in the Heartmate 2, this is the first reported case of a HM3 bend relief disconnection and resultant laceration of the outflow graft.
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Background and Objective: Extracorporeal membrane oxygenation (ECMO) has historically been utilized as a temporary life support option for patients with severe cardiac and pulmonary dysfunction. Recent advancements have enabled the safe application of ECMO in a wider variety of patients; we present a review of its use in patients undergoing general thoracic procedures supported by a case series at our institution. Methods: We review current literature focusing on ECMO applications in thoracic surgery outside of the traditional use. Additionally, we offer three cases of ECMO utilization to illustrate success stories and key lessons learned regarding the use of ECMO in general thoracic surgery. Key Content and Findings: Technologic advancements and enhanced safety profiles have enabled the safe application of ECMO in a wide array of patients far beyond the historic indications of cardiogenic shock and acute respiratory distress syndrome (ARDS). It is now feasible to consider ECMO for management of acute thoracic emergencies, as well as to better facilitate operative safety in complex general thoracic surgical procedures. Both venovenous and venoarterial ECMO can be utilized in carefully selected patients to provide cardiopulmonary support while enabling improved visualization and increased mobilization without concern for respiratory and/or cardiac compromise. Conclusions: Enthusiasm for the use of ECMO has increased in recent years. What was once considered a salvage therapy in cases of life-threatening cardiopulmonary decompensation now plays an increasingly important role in the safe conduct of complex thoracic surgery procedures, provides much needed time for organ recovery, and offers acute resuscitation options. This shift broadens our ability to deliver life-saving care to patients that previously would have otherwise had limited treatment options.
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The safety and efficacy of hyperthermic intrathoracic chemotherapy (HITHOC) as an adjunct to cytoreductive surgery (CRS) in pleural malignancies has been well demonstrated. This is most often described in cases of mesothelioma, thymoma, or other secondary pleural metastases. The utilization of a direct cytotoxic agent with increased penetration secondary to a hyperthermic environment is especially beneficial in pleural malignancy as a microscopic resection remains immensely challenging. Despite favorable outcomes with a limited associated risk profile, there persists a variety in utilization and technique of HITHOC described in current literature. National Comprehensive Cancer Network (NCCN) guidelines state that though intraoperative adjuvant therapies such as HITHOC have been studied, they remain of unclear benefit and definitive recommendations do not currently exist. This ambiguity limits the standardization of HITHOC, thus hindering its further application in a patient population with exceedingly poor outcomes within current guideline-based therapy. As the prevalence of pleural malignancies necessitating CRS with adjuvant HITHOC remains quite low, we believe a task force initiative to further investigate the role of HITHOC in surgical management of pleural malignancies would enable wider utility of this promising technique. Additionally, we propose that the creation of a pleural cancer index could aid in standardization of HITHOC in those with pleural malignancy.
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Objective: Traditionally, critically ill patients requiring prolonged mechanical ventilation benefit from a long-term airway, thus necessitating tracheostomy. The widespread application of extracorporeal membrane oxygenation (ECMO) has exponentially increased in recent years, creating a new subset of patients necessitating tracheostomy with significantly increased bleeding risk. We present a hybrid dilational tracheostomy technique utilizing a Rummel tourniquet developed at our institution to mitigate bleeding risk in patients on ECMO necessitating long-term airway. Methods: A total of 24 patients on ECMO underwent bedside hybrid dilational tracheostomy with utilization of a Rummel tourniquet from 06/2020 to 01/2022 at our institution. These patients were followed longitudinally and evaluated for postoperative bleeding. Particular attention was paid to anticoagulation regimens pre- and post-operatively. Results: The primary outcome of the study, postoperative bleeding, was observed in four of the 24 study participants (16.67 %). Each of these complications were managed with tightening of the Rummel tourniquet and application of hemostatic packing agents; no operative interventions were required. Anticoagulation was held for a mean time of 4.33 h preoperatively and 5.2 h postoperatively. Conclusions: Our data support this hybrid tracheostomy technique with the addition of a Rummel tourniquet to be a safe and effective adjunct for perioperative hemostasis in high-risk patients necessitating tracheostomy while on ECMO. While this technique was initially developed for critically ill COVID-19 patients, we believe it can be applied to all patients on ECMO to help mitigate perioperative bleeding risk.
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Objective: Lobar torsion is a rare occurrence in which a portion of the lung is twisted on its bronchovascular pedicle. The vast majority are observed in the acute postoperative period often following right upper lobectomy. Spontaneous middle lobe torsion independent of pulmonary resection is exceptionally rarer; fewer than 15 cases have been recorded. We present an institutional case series of 2 patients postorthotopic liver transplantation who developed spontaneous middle lobe torsion due to large pleural effusions. Methods: We provide the medical course as well as intraoperative techniques for our 2 patients along with a review of the literature. Results: Both patients in this case series underwent orthotopic liver transplant complicated postoperatively by a large pulmonary effusion. Patient one developed an abdominal hematoma requiring evacuation and repair, after which he developed progressive shortness of breath. Bronchoscopy revealed a right middle lobe obstruction; upon thoracotomy, 180-degree torsion with widespread necrosis was evident and the middle lobe was removed. He is doing well to date. Patient 2 experienced postoperative pleural effusion and mucus plugging; computed tomography revealed abrupt middle lobe arterial occlusion prompting urgent operative intervention. Again, the middle lobe was grossly ischemic and dissection revealed a 360-degree torsion around the pedicle. It was resected. He is doing well to date. Conclusions: As the result of its rarity, radiographic and clinical diagnosis of spontaneous pulmonary lobar torsion is challenging; a high index of suspicion for spontaneous middle lobe torsion must be maintained to avoid delays in diagnosis. Prompt surgical intervention is essential to improve patient outcomes.
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Doege Potter syndrome is a rare condition causing non-islet cell paraneoplastic hypoglycaemia associated with fibrous tumours, which can be both benign and malignant. The vast majority are solitary and located within the chest. Non-islet cell tumour-induced hypoglycaemia, as in Doege Potter syndrome, is quite rare and occurs around 4 times less often than islet cell-associated paraneoplastic hypoglycaemia. We present a case of Doege Potter syndrome with severe hypoglycaemia in conjunction with multiple recurrent fibrous tumours of the lung and pleura.