Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting.

BACKGROUND: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies. METHODS: Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies. RESULTS: Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48). CONCLUSIONS: Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions.

Effects of Intraoperative Ketamine on Post-Operative Recovery in Obstructive Sleep Apnea Patients: A Case-Control Study.

Objective To evaluate the post-operative outcomes of patients with obstructive sleep apnea (OSA) given intraoperative ketamine. Design: case-control study A total of 574 patients (287 received ketamine and 287 were matched controls) diagnosed with OSA and body mass index (BMI) > 30 who received general anesthesia were included in this study. Patients given intraoperative ketamine were matched (1:1) with those who did not receive ketamine for age, gender, BMI, ethnicity, anesthesia time, intraoperative fentanyl dose, ketamine dose, and surgery type. A sub-analysis was performed based on the dose of ketamine administered and also on the surgery type. Measured outcomes include post-operative pain scores, post-operative opioid requirements, respiratory status, oxygen use, and duration post-operatively. Results Intraoperative ketamine use did not decrease pain scores or post-operative opioid use when compared with the control (no intraoperative ketamine) group. Patients who received high-dose ketamine had significantly higher post-operative pain scores (p=0.048) while in the post-anesthesia care unit (PACU) and required supplemental oxygen for a longer period of time (p = 0.030), pain scores were not significant for patients who underwent orthopedic/spine procedures (p = 0.074), and high-dose ketamine group patients who underwent orthopedic/spine surgery required significantly more opioids in the PACU (p = 0.031). Among patients who received low-dose ketamine, those who underwent head, ear, nose, and throat surgery required significantly more opioids in PACU (p = 0.022). Conclusions Low-dose intraoperative ketamine did not decrease pain scores or post-operative opioid use significantly and did not improve standard respiratory recovery parameters for OSA patients after surgery. Neither low- nor high-dose ketamine demonstrated the anticipated benefits of low pain scores and reduced post-operative opioid use. These outcomes will differ depending on the surgery type and dose of ketamine used.

Reactive species generated by heme impair alveolar epithelial sodium channel function in acute respiratory distress syndrome.

We previously reported that the highly reactive cell-free heme (CFH) is increased in the plasma of patients with chronic lung injury and causes pulmonary edema in animal model of acute respiratory distress syndrome (ARDS) post inhalation of halogen gas. However, the mechanisms by which CFH causes pulmonary edema are unclear. Herein we report for the first time that CFH and chlorinated lipids (formed by the interaction of halogen gas, Cl2, with plasmalogens) are increased in the plasma of patients exposed to Cl2 gas. Ex vivo incubation of red blood cells (RBC) with halogenated lipids caused oxidative damage to RBC cytoskeletal protein spectrin, resulting in hemolysis and release of CFH. Patch clamp and short circuit current measurements revealed that CFH inhibited the activity of amiloride-sensitive epithelial Na+ channel (ENaC) and cation sodium (Na+) channels in mouse alveolar cells and trans-epithelial Na+ transport across human airway cells with EC50 of 125 nM and 500 nM, respectively. Molecular modeling identified 22 putative heme-docking sites on ENaC (energy of binding range: 86-1563 kJ/mol) with at least 2 sites within its narrow transmembrane pore, potentially capable of blocking Na+ transport across the channel. A single intramuscular injection of the heme-scavenging protein, hemopexin (4 µg/kg body weight), one hour post halogen gas exposure, decreased plasma CFH and improved lung ENaC activity in mice. In conclusion, results suggested that CFH mediated inhibition of ENaC activity may be responsible for pulmonary edema post inhalation injury.

Cardiorespiratory Events Associated With Ophthalmic Surgery: A Single-Center, Retrospective Records Review of 130 775 Patients, 1999-2015.

Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases-9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event (P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that "the eye is the window to our overall health" seems to be correct.

Assessment of Acute Kidney Injury in Neurologically Injured Patients Receiving Hypertonic Sodium Chloride: Does Chloride Load Matter?

Background: Increasing evidence suggests that large-volume infusions of 0.9% sodium chloride (NaCl) for resuscitation are associated with hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury (AKI). Patients with neurological injury may require hypertonic NaCl for therapeutic hypernatremia, treatment of cerebral salt wasting, hyponatremia, or elevated intracranial pressure. Consequently, this increased exposure to chloride may result in an increased risk for development of AKI. Objective: The primary aim of this study was to describe the risk for development of AKI in neurologically injured patients receiving large volumes of intravenous hypertonic NaCl. Methods: This single-center, retrospective study looked at neurologically injured patients who received hypertonic NaCl and sodium acetate. Data were collected to assess renal function, hyperchloremia, and acidemia. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive association between the amount of daily and overall chloride exposure and development of AKI. Results: A total of 301 patients were screened, and of those, 142 were included. Of the 142 patients included, 13% developed AKI, and 38% developed hyperchloremia. Additionally, 32% of patients were switched from NaCl to sodium acetate after an average of 3.4 ± 1.5 days of NaCl therapy. The ROC curve demonstrated that if patients received greater than 2055 mEq of chloride over 7 days, they were more likely to develop AKI (sensitivity 72%, specificity 70%; P = 0.002; area under the curve = 0.7). Conclusion and Relevance: Neurologically injured patients receiving hypertonic sodium therapy with a high chloride load are at risk of developing hyperchloremia and AKI.

Ophthalmic Surgery in Patients with Left Ventricular Assist Devices.

The newer generation of left ventricular assist devices (LVADs) are commonly used as destination therapy; these devices have demonstrated improved outcomes and increased survival. Given the longer lifespan, it is not surprising that patients with LVADS are increasingly presenting with noncardiac, chronic diseases and interventions for their treatment. This includes ophthalmic procedures in patients with LVAD. There is a paucity of literature about the experiences and outcomes in this cohort of patients presenting for ophthalmologic surgery. Here we present a case series consisting of 7 patients with LVAD that underwent 10 ophthalmic surgeries. No adverse events including intraoperative hemodynamic instability or respiratory compromise occurred. All patients had an on-time discharge with no 30-day recidivism. Most patients underwent a phacoemulsification with intraocular lens implantation and received a topical with intracameral anesthetic. We attribute these successful outcomes to a standardized clinical workflow consisting of careful preoperative screening, communication and presence of VAD coordinator, continuation of antithrombotics, monitoring based on presence of pulsatile flow, and a plan for rapid transfer if needed.

Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures. METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed. RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE's occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed. CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.

Safety Comparison of Laryngeal Mask Use With Endotracheal Intubation in Patients Undergoing Dacryocystorhinostomy Surgery.

PURPOSE: This study will determine the safety of laryngeal mask airway (LMA) compared with endotracheal tube (ETT) in patients undergoing general anesthesia for dacryocystorhinostomy (DCR) surgery. METHODS: In this retrospective cohort study, intraoperative and postoperative outcomes of patients who underwent DCR at UAB Callahan Eye Hospital using either LMA or ETT were compared. RESULTS: Over a period of 52 months, 429 patients underwent external DCR surgery. An ETT was used in 37 patients and LMA in 392 patients. Baseline patient characteristics and anesthetic management were similar. No documented cases of blood or gastric aspiration occurred in the total cohort. Our study confirmed the findings of others that there is less cardiovascular lability on LMA placement than with ETT intubation. A 30% increase in heart rate from baseline after intubation (ETT 10.8%, LMA 1.8%; p = 0.010) and after incision (ETT 8.1%, LMA 1.8%; p = 0.047) occurred more frequently in the ETT group. Airway management with an LMA was also less difficult compared with an ETT (ETT 5.7%, LMA 0.5%; p = 0.035). CONCLUSIONS: The use of an LMA for airway control is safe and effective in patients undergoing general anesthesia for DCR surgery. No events of aspiration occurred with LMA use. Heart rate increase was significantly less in the LMA group. In our opinion, use of an LMA for airway control during DCR surgery is superior to use of an ETT. Airway protection, improved hemodynamics, and less difficulty in placement of the laryngeal airway device are all validated by this study.

Outcomes of Patients Who Undergo Cardiac Surgical Procedures After Liver Transplantation.

BACKGROUND: There is a paucity of information available regarding the impact of cardiac surgical procedures on patients who have undergone previous liver transplantation. The primary purpose of this study was to ascertain the survival rate and predictors of death in this specific patient population. METHODS: This retrospective cohort study consisted of a consecutive series of patients with a functioning liver allograft who subsequently underwent cardiac surgical procedures between January 1991 and December 2012. The optimal Model for End-Stage Liver Disease (MELD) score for predicting late death was identified using receiver operating characteristic curve analysis. Risk of postoperative death was determined by parametric hazard analysis. RESULTS: Between January 1991 and December 2012, 43 patients (median age, 60 years) underwent cardiac surgical procedures after liver transplantation. The median interval between liver transplant and cardiac operation was 63 months (range, 1.1 to 217 months). Three operative deaths and 24 late deaths occurred. Receiver operating characteristic curve analysis identified the optimal preoperative and postoperative MELD score cut points for predicting late death as greater than 13.8 (area under the curve = 0.674) and greater than 17 (area under the curve = 0.633), respectively. Patients with a preoperative MELD score of 13.8 or less had significantly greater survival rates than those with a MELD score greater than 13.8 (p = 0.028); patients with a postoperative MELD score of 17 of less had significantly greater survival rates than those with a MELD score greater than 17 (p < 0.001). Multivariate parametric hazard analysis identified postoperative peak creatinine level as a statistically significant predictor of death (relative risk, 1.8; p = 0.01). The 1-, 5-, and 10-year Kaplan-Meier survival rates were 90%, 51%, and 35%, respectively; postoperative mortality rates followed a constant phase model with a hazard of death of 10% per year. CONCLUSIONS: Cardiac surgical procedures can be performed with acceptable short-term and long-term outcomes in liver transplant recipients. Elevated preoperative and postoperative MELD scores and postoperative peak creatinine level may portend death in this cohort. There is a constant hazard of death of 10% per year.

Cost comparison of intrathecal morphine to intravenous patient-controlled analgesia for the first 24 h post cesarean delivery: a retrospective cohort study.

PURPOSE: Intrathecal morphine provides superior pain control for patients undergoing cesarean delivery when compared to intravenous opioid patient-controlled analgesia. However, no study has assessed the overall cost associated with each modality as a primary outcome. The aim of this study is to determine the overall cost of each modality for the first 24 h post cesarean delivery. METHODS: Charts of patients undergoing cesarean delivery at our institution from January 1, 2014 to December 31, 2014 were reviewed. Patients receiving intrathecal morphine were compared to patients undergoing general anesthesia and receiving intravenous opioid patient-controlled analgesia for post-procedure analgesia. The primary outcome measured was total cost of each modality for the first 24 h after delivery. Secondary outcomes included post-procedure pain scores, time to removal of the Foley catheter, need for rescue medications, and adverse events. RESULTS: There was a significant difference in total cost of intrathecal morphine when compared to intravenous opioid patient-controlled analgesia ($51.14 vs. $80.16, p < 0.001). Average pain scores between 0-1 h (0 vs. 5, p < 0.001) and 1-6 h (2.5 vs. 3.25, p < 0.001) were less in the intrathecal morphine group. The intrathecal morphine group received more ketorolac (p < 0.001) and required more rescue opioids (p = 0.042). There were no significant differences in documented adverse events. CONCLUSIONS: The use of intrathecal morphine for post-cesarean pain control leads to a significant cost savings for the first 24 h when compared to intravenous opioid patient-controlled analgesia. Patients also experienced less pain and were not at increased risk for adverse events.

Late Left Ventricular Outflow Tract Obstruction Following the Rastelli Operation: Expectations Out to 20 Years.

BACKGROUND: Consensus is lacking regarding the optimal operation for transposition, ventricular septal defect, and pulmonary stenosis. METHODS: Between 1968 and 2012, a total of 76 patients underwent the Rastelli procedure, with 52 mid- or long-term survivors. A bracketing analysis was used to estimate the likelihood of late left ventricular outflow tract obstruction (LVOTO). RESULTS: Early mortality decreased over the period of study, with no hospital mortality since 2000. Among one year survivors, 10- and 20-year survival was 90% and 72%, respectively. Freedom from reoperation for LVOTO was 87% at 20 years, with no increase in risk among patients having the procedure before 5 years of age. Available late echocardiographic or catheterization data indicated mild or no LVOTO at a median of 14.3 years in a subset of 38 patients. Estimated freedom from major LVOTO at 20 years is bracketed between the estimate of 87% freedom from reoperation for LVOTO at 20 years and the 78% freedom from reoperation for LVOTO or cardiac death by 20 years. CONCLUSION: The Rastelli operation can be performed in the current era with an early mortality that approaches 0% and with 20-year survival that exceeds 70%. The late risk of important LVOTO appears to range from about 13% to 22% at 20 years, with no increase in risk among patients operated upon before the age of 5 years.

Early Postoperative Albumin Administration Contributes to Morbidity After the Fontan Operation.

The Fontan operation has low mortality, but is associated with significant postoperative morbidity, including prolonged chest tube output (PCTO), which is associated with prolonged hospital length of stay (PLOS). We sought to identify variables present early in the clinical course that could predict patients at high risk for PCTO and PLOS. Retrospective data were collected on 84 Fontan (extracardiac conduit) operations from 1/2008 to 12/2013 at a single institution. PCTO was defined as ≥8 days (>75th percentile); PLOS was defined as ≥12 days postoperatively (>75th percentile). Multivariate regression was used to determine covariates associated with PCTO and PLOS. Median age was 3.5 years (IQR 3-5); weight was 14.5 kg (IQR 13-17). There was no mortality. LOS was 9 days (IQR 3-11), and duration of chest tube drainage 6 days (IQR 5-8) at 15 ml/kg/day (IQR 9-20). In univariate analysis, only systemic right ventricle, 24-h 5 % albumin administration, 24-h fluid balance, and 12-h inotrope score were associated with PCTO. In multivariate analysis, only 5 % albumin administration in first 24 h (p < 0.001) and PCTO were independently associated with PLOS. ROC curve analysis showed patients receiving >25 ml/kg of 5 % albumin in first 24-h predicted PLOS (94 % specificity, 93 % sensitivity, AUC = 0.95, p < 0.001). Increased colloid in the first 24-h post-CPB strongly predicts PCTO and PLOS after Fontan operation, potentially providing an early identification of a cohort with unfavorable Fontan physiology. A better understanding of the role of colloid resuscitation after Fontan is necessary, and efforts to reduce perioperative colloid administration could decrease hospital morbidity.

Decreasing the Preincision Time for Pulmonary Lobectomy: The Process of Lean and Value Stream Mapping.

BACKGROUND: Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process). METHODS: After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated. RESULTS: One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p < 0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042). CONCLUSIONS: Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non-value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.

Health-Related Quality of Life in Adult Survivors After the Fontan Operation.

The primary objective of this study was to ascertain the long-term health-related quality of life (HRQOL) of adult patients who underwent a childhood Fontan operation for palliation of univentricular cardiac anomalies. The secondary objective was to compare the long-term HRQOL of Fontan survivors to that of pediatric heart transplant recipients. This cross-sectional study examined adult survivors (>19 years) who underwent a Fontan operation during childhood (Fontan group) or a pediatric heart transplant (HT group) between 1988 and 2011 (23-year span). HRQOL was assessed using the short form 36 survey. The study group consisted of 49 Fontan group patients and 13 HT group patients who responded to the survey. HRQOL scores of the Fontan group were similar to those of an age-controlled healthy US population in social and mental functioning, energy or vitality, and overall mental component score (P ≥ 0.2). However, Fontan scores in physical functioning, bodily pain, general health, and overall by physical component were significantly lower than those of the age-controlled US population (P < 0.05). No differences were identified between Fontan and HT patients. This favorable life-satisfaction period (average 18 years) should be considered when informing patients and families of expectations with the Fontan pathway vs certain higher-risk procedures.

Surgical and Anesthetic Management of a Mediastinal Fatty Tumor: Lipoblastoma.

Lipoblastoma is a rare fatty tumor that is diagnosed almost exclusively in children. Presentation often consists of respiratory symptoms; chest computed tomography shows a hypodense, low, attenuated mediastinal mass. Surgical approach and anesthetic management are dependent on the location of the tumor and the degree of airway compression; in most cases, a thoracotomy is performed, although a sternotomy is used in selected cases. Final diagnosis can be confirmed using molecular genetic analysis; a genetic hallmark of lipoblastoma is the rearrangement of chromosomal region 8q12 and the PLAG1 gene. Tumor recurrence is rare when a complete resection is performed.

Retention Rate of Electromagnetic Navigation Bronchoscopic Placed Fiducial Markers for Lung Radiosurgery.

BACKGROUND: Radiosurgery is becoming an increasingly used modality for the medically inoperable early stage lung cancer patient. The optimal fiducial marker with respect to retention rate has yet to be identified. METHODS: We retrospectively reviewed our experience with electromagnetic navigational bronchoscopic fiducial marker placement in preparation for stereotactic radiosurgery. RESULTS: Forty-eight patients, treated between 2010 and January 2013, were retrospectively reviewed. All patients had a diagnosis of early stage lung cancer. Comparison of initial fiducial placement procedure data with imaging at the time of treatment was accomplished for all patients in this data set. Fiducial retention rates were as follow: VortX coil fiducials were retained in 59 of 61 (96.7%) cases; two-band fiducials were retained in 24 of 33 (72.7%) of instances; and gold seed fiducials were retained in 23 of 33 (69.7%) of cases. Retention was statistically superior when comparing the VortX coil with the two-band fiducial or the gold seed (p = 0.004 and p = 0.0001). Anatomic location by lobe was analyzed, but no statistically significant differences were observed. CONCLUSIONS: The VortX coil fiducial marker showed a statistically significant increase in retention rate compared with gold seeds or two-band fiducials. This may translate to cost savings through placing fewer markers per patient as retention is high.

Left upper lobectomy after coronary artery bypass grafting.

OBJECTIVE: Left upper pulmonary lobectomy or segmentectomy after coronary artery bypass grafting (CABG) risks injury to the grafts. We reviewed our experience. METHODS: This is a retrospective review of a prospective database from 1 surgeon, of patients who underwent left upper lobectomy after having previous CABG. RESULTS: Between June 1998 and June 2014, a total of 2207 patients underwent lobectomy by 1 surgeon; 458 (21%) had a left upper lobectomy, and 28 (6.1%) had had a previous CABG. Twenty-seven patients (96.4%) had a left internal mammary artery (LIMA) used for the bypass. Twenty-six patients (96.2%) had significant adhesions between their lung and the bypass grafts. Of patients who had a LIMA graft, 25 (92.6%) had the left upper lobe completely dissected free from their grafts, whereas 2 patients (7.1%) had a sliver of their lung left on the grafts. No patient had a postoperative myocardial infarction, and 30-day and 90-day survival rates were both 100%. All patients had a curative resection, and all had complete thoracic lymphadenectomy. CONCLUSIONS: Left upper lobectomy after CABG, in patients with previous CABG and LIMA grafting, is safe. Usually the entire lung can be safely mobilized off the bypass grafts; if needed, a small sliver of lung can be left on the grafts. A curative resection is possible with minimal perioperative cardiac morbidity, and excellent 30- and 90-day mortality.

Prognostic nomogram to predict survival after surgery for synchronous multiple lung cancers in multiple lobes.

INTRODUCTION: In the absence of metastatic disease, surgery for synchronous non-small-cell lung cancers involving multiple lobes can be curative. However, there currently exists no reliable prognostic instrument for this patient population after surgery. We undertook an analysis to examine the prognostic significance of adenocarcinoma histology and developed a prognostic nomogram. METHODS: This study was a pooled analysis of six previously reported datasets. Patients without extra-thoracic metastasis who underwent surgical resection of synchronous lung cancers in multiple lobes were included. Those with small cell cancer, carcinoid tumor, or exclusively carcinoma in situ were excluded. A multivariable Cox proportional hazards regression model was fitted to identify independent survival predictors for nomogram development. RESULTS: Data from 467 patients were analyzed. Adenocarcinoma was a sole histology in 253 patients (54.2%). Those with exclusively adenocarcinoma histology had a better median survival than their counterparts: 67.4 versus 36.2 months, (p < 0.001). Multivariable analysis incorporating histology, sex, age, maximal T-size, highest N-stage, and laterality demonstrated that having exclusively adenocarcinoma histology independently predicted an improved survival: hazard ratio 0.61 (95% confidence interval: 0.48, 0.78). Other favorable survival predictors were N0, T-size less than or equal to 3 cm, bilateral cancers, age less than 70 years, and women sex. The developed nomogram was well calibrated and demonstrated a moderate to good discrimination with a bootstrap-corrected Harrell C-statistic of 0.70. CONCLUSION: Several unique features among patients with resected synchronous multiple lung cancers, including the presence of exclusively adenocarcinoma histology, are of prognostic significance. A simple nomogram incorporating these factors can be utilized to predict patient survival with acceptable accuracy.

The efficacy of restaging endobronchial ultrasound in patients with non-small cell lung cancer after preoperative therapy.

BACKGROUND: Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy. METHODS: This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy. RESULTS: There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively. CONCLUSIONS: Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.