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BACKGROUND: Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States. RESULTS: A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States. CONCLUSIONS: In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.
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Neoplasias Pulmonares/cirurgia , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/etnologia , Idoso , População Negra , Feminino , Disparidades em Assistência à Saúde , Hispânico ou Latino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de PropensãoAssuntos
Medicina Baseada em Evidências/métodos , Hidrotórax/terapia , Cirrose Hepática/terapia , Equipe de Assistência ao Paciente , Terapia Combinada/métodos , Gastroenterologia/métodos , Humanos , Hidrotórax/diagnóstico , Hidrotórax/etiologia , Hidrotórax/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Pneumologia/métodos , Radiologia Intervencionista/métodos , Especialidades Cirúrgicas/métodos , Análise de Sobrevida , Resultado do TratamentoRESUMO
Background: Data on perioperative outcomes of emergent versus elective resection in esophageal cancer patients requiring esophagectomy are lacking. We investigated whether emergent resection was associated with increased risks of morbidity and mortality. Methods: Data on patients with esophageal malignancy who underwent esophagectomy from 2005 to 2020 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day complication and mortality rates were compared between emergent esophagectomy (EE) and non-emergent esophagectomy. Logistic regression assessed factors associated with complications and mortality. Results: Of 10,067 patients with malignancy who underwent esophagectomy, 181 (1.8%) had EE, 64% had preoperative systemic inflammatory response syndrome, sepsis, or septic shock, and 44% had bleeding requiring transfusion. The EE group had higher American Society of Anesthesiologists (ASA) class and functional dependency. More transhiatal esophagectomies and diversions were performed in the EE group. After EE, the rates of 30-day mortality (6.1% vs. 2.8%), overall complications (65.2% vs. 44.2%), bleeding, pneumonia, prolonged intubation, and positive margin (17.7% vs. 7.4%) were higher, while that of anastomotic leak was similar. On adjusted logistic regression, older age, lower albumin, higher ASA class, and fragility were associated with increased complications and mortality. McKeown esophagectomy and esophageal diversion were associated with a higher risk of postoperative complications. EE was associated with 30-day postoperative complications (odds ratio, 2.39; 95% confidence interval, 1.66-3.43; p<0.0001). Conclusion: EE was associated with a more than 2-fold increase in complications compared to elective procedures, but no independent increase in short-term mortality. These findings may help guide data-driven critical decision-making for surgery in select cases of complicated esophageal malignancy.
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Background: While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists. Methods: A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration. Results: A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03). Conclusions: Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.
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Lung cancer is the third most common cancer with Black/AA men showing higher risk and poorer outcomes than NHW men. Lung cancer disparities are multifactorial, driven by tobacco exposure, inequities in care access, upstream health determinants, and molecular determinants including biological and genetic factors. Elevated expressions of protein arginine methyltransferases (PRMTs) correlating with poorer prognosis have been observed in many cancers. Most importantly, our study shows that PRMT6 displays higher expression in lung cancer tissues of Black/AA men compared to NHW men. In this study, we investigated the underlying mechanism of PRMT6 and its cooperation with PRMT1 to form a heteromer as a driver of lung cancer. Disrupting PRMT1/PRMT6 heteromer by a competitive peptide reduced proliferation in non-small cell lung cancer cell lines and patient-derived organoids, therefore, giving rise to a more strategic approach in the treatment of Black/AA men with lung cancer and to eliminate cancer health disparities.
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Background: Anastomotic leak is a major contributor to comorbidity and mortality following esophagectomy. We sought to assess rate and predictors of leak after esophagectomy and compare outcomes of chest versus neck anastomotic leaks. Methods: A retrospective review was performed utilizing National-Surgical-Quality-Improvement-Program data from 2016-2019 for patients undergoing esophagectomy for malignancy. Preoperative characteristics and postoperative outcomes were compared. Patients were classified into two groups: Ivor Lewis esophagectomy [ILE, chest leak (CL)] and transhiatal esophagectomy (THE)/McKeown esophagectomy [ME, neck leak (NL)]. Multivariable regression models were constructed to determine predictors of each type of leak and postoperative complications. Results: A total of 1,665 patients underwent esophagectomy with 14.1% reported post-operative leak, 61% of patients underwent ILE while 39% underwent THE or ME. Of patients who underwent ILE, 13.8% had CL with complications including significantly higher length of stay and mortality compared to patients without leak. Independent predictors of CL included: diabetes, hypertension, advanced disease stage, chronic steroid use, and operative time. Ninety-five patients (14.6%) who underwent either THE or ME had NL with similar complications. Diabetes, pre-operative white blood cell (WBC), and operative time were independent predictors for NL. On multivariable regression, CL was associated with greater odds of requiring intervention compared with NL. Conclusions: Post-esophagectomy CL and NL are associated with higher morbidity and mortality. Diabetes and operative time were independent predictors for both leaks while steroid use, hypertension, and advanced disease stage predicted CL. CL was associated with greater odds of needing an intervention, but contrary to conventional wisdom, was not associated with higher morbidity or mortality.
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Bochdalek hernias are the most common congenital diaphragmatic hernias and are usually diagnosed during childhood. They can present in adulthood and, in uncommon circumstances, result in gastric herniation with strangulation. We present a case of an adult Bochdalek hernia resulting in total gastric necrosis necessitating Roux-en-Y esophagojejunostomy in an otherwise healthy 39-year-old man. This case highlights the potential morbidity associated with unrepaired congenital diaphragmatic hernias and the need for appropriate referral.
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Esofagoplastia , Hérnias Diafragmáticas Congênitas , Gastropatias , Adulto , Anastomose em-Y de Roux , Hérnia , Hérnias Diafragmáticas Congênitas/complicações , Humanos , Masculino , Necrose/complicaçõesRESUMO
OBJECTIVE: Adoption of thoracoscopic lobectomy has been increasing in the US; however, open lobectomy (OL) is still performed in half of the cases. Postoperative care and enhanced recovery after surgery (ERAS) pathways have evolved and improved outcomes. The study aims to evaluate postoperative outcomes of OL over the last 15 years. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2019 were identified in the National Surgical Quality Improvement Program and divided into three groups; pre-ERAS (2005-2011), transitional period (2012-2015), and wider ERAS implementation (2016-2019). Preoperative characteristics and postoperative outcomes were compared and multivariable regression analysis was constructed to assess independent predictors of outcomes. RESULTS: OL was comprised of 40% of lobectomies for lung cancer. 10,021 patients met inclusion criteria. 49% were males and mean age was 67. Patients who belonged to the (2016-2019) period group had significantly higher comorbidities and ASA classification. General surgeons performed < 10% of OL in 2016-2019 compared to over 30% during 2005-2011. Patients in the 2016-2019 period were less likely to experience unplanned intubation, surgical site infections, and sepsis. Mortality was also significantly lower than the previous groups (1.9% vs 2.0% and 2.8%, p = 0.05). The rate of discharge to facility as well as length of hospital stays improved over the years. The surgeon specialty served as an independent predictor for length of stay, unplanned intubation, and home discharge. CONCLUSION: The outcomes of OL are improving over the years. Increasing number of these surgeries being performed by dedicated thoracic surgeons and ERAS pathways are likely helping improve outcomes.
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Neoplasias Pulmonares , Pneumonectomia , Idoso , Estudos de Coortes , Humanos , Tempo de Internação , Neoplasias Pulmonares/cirurgia , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Cirurgia Torácica VídeoassistidaRESUMO
Objective: The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database. Methods: Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes. Results: There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005). Conclusions: The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.
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Background: Pulmonary lobectomy is the standard of care for the treatment of early-stage non-small cell lung cancer. This study investigated the rate of utilization of supplemental anesthesia in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy using a national database and assessed the effect of regional block (RB) on postoperative outcomes. Methods: Patients who underwent lobectomy for lung cancer between 2014-2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The patients' primary mode of anesthesia and supplemental anesthesia were recorded. Preoperative characteristics and postoperative outcomes were compared between 2 surgical groups: those who underwent general anesthesia (GA) alone versus GA with RB. Multivariable regression analyses were performed on the outcomes of interest. Results: In total, 13,578 patients met the study criteria, with 87% undergoing GA and the remaining 13% receiving GA and RB. The use of neuraxial anesthesia decreased over the years, while RB use increased up to 20% in 2019. Age, body mass index, and preoperative comorbidities were comparable between groups. Patients who underwent VATS were more likely to receive RB than those who underwent thoracotomy. RB was most often utilized by thoracic surgeons. An adjusted analysis showed that RB use was associated with shorter hospital stays and a reduced likelihood of prolonged length of stay, but a higher rate of surgical site infections (SSIs). Conclusion: In a large surgical database, there was underutilization of supplemental anesthesia in patients undergoing lobectomy for lung cancer. RB utilization was associated with a shorter length of hospital stay and an increase in SSI incidence.
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Malignant pleural mesothelioma (MPM) is a cancer of the mesothelial lining of the pleura that has traditionally been associated with asbestos exposure in an industrial setting. Asbestos usage has fortunately been banned or phased out in most industrialized countries resulting in its decline in countries such as the United States. Despite this, MPM continues to place significant burden on its affected patients resulting in overall poor prognosis and survival. Questions arise as to what factors, especially what health disparities, contribute to the disease's dismal prognosis. This article will present a narrative review of recent literature that identifies the impact age, sex, race, access to medical centers, and economics have on the diagnosis, treatment, and prognosis of MPM. As will be discussed, research has shown that factors including younger age, female sex, non-white race, private insurance, Medicare, and higher income have been associated with better survival in MPM. Whereas older age, male sex, white race, lack of insurance, and lower income are associated with worse survival. The identification of these and other health disparities related to MPM may allow for future research, clinical guidelines, and policies to be implemented to decrease the burden health disparities create in the diagnosis, treatment, and prognosis of patients with MPM.
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Deglutition syncope is a rare, neurally mediated reflex syncope associated with swallowing. It is typically associated with pharyngoesophageal disorders with secondary abnormal vagal reflex causing atrioventricular cardiac block and cerebral hypoperfusion. Diagnosis can be delayed and challenging. Various treatment options have been reported, including withholding cardiac blocker agents, diet modifications, and pacemaker placement. We present a case of persistent deglutition syncope secondary to esophagogastric junction outflow obstruction that failed medical therapy and was managed successfully with peroral endoscopic myotomy with excellent long-term outcome.
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Deglutição , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural , Síncope/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Boca , Síncope/etiologiaRESUMO
OBJECTIVE: Segmentectomy for lung tumors has been performed with either video-assisted thoracoscopic surgery (VATS) or thoracotomy; however, there is a lack of contemporary, multicenter study that compares both approaches. The aim of this study was to compare the 30-day surgical outcomes of VATS versus thoracotomy for segmentectomy using a large national database. METHODS: We performed a retrospective analysis of prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent segmentectomy for benign or malignant tumors between 2013 and 2017 were included and divided into 2 groups based on whether they received a thoracotomy or VATS approach. All VATS patients were then into 2 subgroups: early (2013 to 2015) and late (2016 to 2017). Propensity-matched analysis was conducted, and the perioperative variables and outcomes were compared. RESULTS: A total of 1,785 patients met the inclusion criteria. VATS segmentectomy was associated with shorter hospital stays (3.9 vs 5.8 days, P < 0.001) and higher rates of home discharge (94% vs 89%, P = 0.002) compared to thoracotomy segmentectomy. VATS was also associated with less postoperative pneumonia (2.8% vs 5.8%, P = 0.007), unplanned intubation (1.5% vs 3.5%, P = 0.016), prolonged intubation (0.6% vs 2.7%, P = 0.001), transfusion requirement (1.7% vs 5.8%, P < 0.001), and deep venous thrombosis (0.1% vs 1.1%, P = 0.03). Compared to the earlier VATS group, the late group was associated with less cardiac arrests (0% vs 0.8%, P = 0.025) and shorter hospital stays (3.3 vs 4.2 days, P < 0.001). CONCLUSIONS: When compared with thoracotomy, VATS segmentectomy is associated with less postoperative complications and shorter hospital length of stay. VATS segmentectomy has been used more frequently and with improved outcomes.
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Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida , Toracotomia , Idoso , Análise de Variância , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Toracotomia/efeitos adversosRESUMO
BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are routinely inserted in the surgical intensive care unit (SICU). Poor tissue healing or technical issues after tube insertion can lead to peritonitis requiring a laparotomy. This study aimed to identify risk factors leading to peritonitis. METHODS: A retrospective study reviewed of PEG tubes inserted in SICU patients from 2003 to 2006. Age, sex, body mass index (BMI), organ dysfunction, vasopressor use, fluid balance, steroid use for medical reasons, and nutritional status of the patients were noted. The patients with acute spinal cord injury who received high-dose steroids were excluded from the study. Mortality and peritonitis requiring laparotomy were the outcomes. Logistic regression performed with SAS version 9.1 (Cary, NC) was used for analysis. RESULTS: Of 322 patients, 16 (5%) required a laparotomy for peritonitis, and 74 (23%) died during the hospital stay. The major predictors of the need for a laparotomy were higher BMI (p = 0.0005) and a serum albumin level lower than 2.5 gm/dL (p = 0.0008). Patients with both a BMI exceeding 30 kg/m(2) and an albumin level lower than 2.5 gm/dL were 25 times more likely to need a laparotomy (95% confidence interval [CI], 7.74-83.3). The mean time from tube placement to laparotomy was 11 days. Of the 16 patients who required laparotomy, 9 died during the hospitalization. Patients requiring a laparotomy were five times more likely to die during the hospitalization than patients not requiring a laparotomy (p = 0.004; 95% CI, 1.68-13.07). The mean time from laparotomy to death was 23 days. Signs of sepsis and worsening abdominal examination developed in all 16 laparotomy patients. Dislodged tube with gastric wall not opposed to the abdominal wall was the most common finding at laparotomy. CONCLUSION: Approximately 5% of patients undergoing PEG insertion in the SICU require laparotomy for peritonitis and are more likely to die during the hospitalization. Higher BMI and a lower serum albumin level, by contributing to poor healing, increase the risk of peritonitis.
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Gastrostomia/efeitos adversos , Gastrostomia/instrumentação , Laparotomia/mortalidade , Peritonite/etiologia , Peritonite/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Cuidados Críticos/métodos , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/instrumentação , Laparotomia/efeitos adversos , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Peritonite/cirurgia , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Technical advances in the application of laparoscopic and robotic surgical systems have improved platform usability. The authors hypothesized that using two monitors instead of one would lead to faster performance with fewer errors. METHODS: All tasks were performed using a surgical robot in a training box. One of the monitors was a standard camera with two preset zoom levels (zoomed in and zoomed out, single-monitor condition). The second monitor provided a static panoramic view of the whole surgical field. The standard camera was static at the zoomed-in level for the dual-monitor condition of the study. The study had two groups of participants: 4 surgeons proficient in both robotic and advanced laparoscopic skills and 10 lay persons (nonsurgeons) who were given adequate time to train and familiarize themselves with the equipment. Running a 50-cm rope was the basic task. Advanced tasks included running a suture through predetermined points and intracorporeal knot tying with 3-0 silk. Trial completion times and errors, categorized into three groups (orientation, precision, and task), were recorded. RESULTS: The trial completion times for all the tasks, basic and advanced, in the two groups were not significantly different. Fewer orientation errors occurred in the nonsurgeon group during knot tying (p=0.03) and in both groups during suturing (p=0.0002) in the dual-monitor arm of the study. Differences in precision and task error were not significant. CONCLUSIONS: Using two camera views helps both surgeons and lay persons perform complex tasks with fewer errors. These results may be due to better awareness of the surgical field with regard to the location of the instruments, leading to better field orientation. This display setup has potential for use in complex minimally invasive surgeries such as esophagectomy and gastric bypass. This technique also would be applicable to open microsurgery.
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Terminais de Computador/normas , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Monitorização Intraoperatória/instrumentação , Robótica/instrumentação , Técnicas de Sutura/instrumentação , Desenho de Equipamento , HumanosRESUMO
Eosinophilic esophagitis (EoE) is a rare disease of the esophagus that is characterized by eosinophilic infiltrate within the esophageal mucosa resulting in chronic inflammation and stenosis. It typically presents with symptoms of esophageal dysfunction with dysphagia and food impaction being the most common presenting complaints. Herein we describe a rare case presentation of a young patient with spontaneous esophageal perforation in the setting of undiagnosed EoE. We suggest that the placement of a covered esophageal stent can provide full closure of the perforation and restoration of the integrity of the GI tract without the need for more invasive open repair. The patient had a short recovery time with no reported postoperative complications upon 30 months follow up. We believe that it's important to consider and rule out EoE in patients with a history of dysphagia and esophageal perforation.
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A gastrointestinal stromal tumor is an infrequent tumor of the gastrointestinal tract with very rare involvement of the esophagus. We present a case of a patient with dysphagia and a 4 cm submucosal mass. The patient underwent thoracoscopic enucleation with complete resection of the mass. We present case details and operative video highlighting the important surgical steps of exposure and retraction. We believe that the Endoloop is a very useful tool in providing countertraction needed during minimally invasive resection of such lesions.