A simple prediction score for postoperative mortality after decortication.

Background: Decortication of the lung, either by video-thoracoscopy or thoracotomy is potentially a morbid procedure and has significantly higher mortality compared with other major thoracic procedures. Much of this difference can be attributed to other significant comorbidities and to the non-elective nature of the surgery. Our primary goal was to recognize the preoperative unique characteristics of patients who had postoperative mortality within the first 30 days. Our secondary goal was to build a score system to calculate the odds of death after decortication. Methods: Patients who had undergone either partial or total pulmonary decortication were retrospectively identified from the 2015-2017 databases of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and were employed for this analysis. Multivariable regression models were used to evaluate the possible association of multiple risk factors with postoperative death. Factors that remained significant in the multivariable regression analysis were used to develop the Decortication Prognostic Score (DPS). Results: The final study population consisted of 2,315 patients. The overall observed mortality rate was 5.6%. The greatest independent risk factor for increased 30-day mortality in multivariable logistic regression analysis was disseminated cancer, followed by age ≥65 years, ventilator dependence, active hemodialysis, open wound or wound infection, partially or totally dependent preoperative functional status, preoperative systemic inflammatory response syndrome (SIRS), sepsis or septic shock, congestive heart failure (CHF), preoperative need for blood transfusion, dyspnea, and chronic obstructive pulmonary disease (COPD). Afterwards, we developed a prognostic score for calculating the odds of postoperative death. The total score was associated with a stepwise higher risk of postoperative death after decortication. Patients with a score of 1 had an associated mortality of 1.1% [odds ratio (OR): 2, 95% confidence interval (CI): 0.43-9.32, P=0.375], patients with scores 2-3 had an associated mortality of 6.6% (OR: 12.5, 95% CI: 3.04-51.36, P<0.001), and patients with scores ≥4 had an associated mortality of 27.1% (OR: 65.8, 95% CI: 15.86-273.2, P<0.001). Conclusions: Preoperative factors can predict postoperative mortality after decortication. DPS may help guide surgeons with bedside decision making and heighten awareness to patients most likely to be at risk for 30-day re-intubation, failure to wean from ventilator, surgical site infections, prolong length of stay and higher mortality after decortication.

New or enlarging hiatal hernias after thoracic surgery for early lung cancer.

Objective: The study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia. Methods: Preoperative and postoperative computed tomography imaging from 373 patients from the International Early Lung Cancer Action Program and the Initiative for Early Lung Cancer Research on Treatment were compared at a median of 31.1 months of follow-up after resection of clinical early-stage non-small cell lung cancer. Incidence of new hiatal hernia or changes to preexisting hernias were recorded and evaluated by patient demographics, surgical approach, extent of resection, and resection site. Results: New hiatal hernias were seen in 9.6% of patients after lung resection (5.6% after wedge or segmentectomy and 12.4% after lobectomy; P = .047). The median size of new hernias was 21 mm, and the most commonly associated resection site was the left lower lobe (24.2%; P = .04). In patients with preexisting hernias, 53.5% demonstrated a small but significant increase in size from 21 to 22 mm (P < .0001). All hernias persisted through the latest postoperative computed tomography scan. When 110 surgical patients without preexisting hernia were matched by sex, age, and smoking to nonoperative controls, the incidence of new hernia at follow-up was significantly higher among those who underwent surgery (17.3% vs 2.7%, P = .0003). Conclusions: Both open and minimally invasive lung resection for clinical early-stage lung cancer are associated with new or enlarging postoperative hiatal hernia, especially after resections involving the left lower lobe.

Taken Together: Effective Multimodal Approaches for Malignant Pleural Mesothelioma.

Malignant pleural mesothelioma is an aggressive, deadly cancer often requiring input from multiple medical disciplines. Treatment has evolved over the last several decades with increasing evidence and ongoing advances in chemotherapy, radiation, and immunotherapy; however, no standard treatment regimen has yet been defined. Regardless of the overall strategy, surgery remains the foundation of treatment to remove macroscopic disease, and preservation of lung parenchyma via extended pleurectomy/decortication may be preferable to extrapleural pneumonectomy.

Transdiaphragmatic Migration of a Spinal Fixation Rod into the Lung.

Adolescent idiopathic scoliosis may require surgical treatment for extreme curvature of the spine or loss of pulmonary function. We present a report of a 31-year-old woman with a history of scoliosis and anterolateral spinal fusion who developed chest pain and hemoptysis. Imaging revealed that a fixation rod had migrated cephalad, penetrating the diaphragm into the left lower lobe of the lung. The hardware was removed and lung repaired with good results. This is the first reported case of cranial spinal rod migration over a decade after initial implantation.

Transfusion begets anemia: the effect of aged blood on hematopoiesis.

BACKGROUND: Following trauma, transfusion of aged stored blood is often necessary yet associated with increased morbidity and mortality. Despite blood replacement, many patients have a prolonged anemia requiring further transfusions. The effects of aged blood on bone marrow (BM) hematopoiesis have not been studied, and we hypothesized that stored blood suppresses BM function. METHODS: Blood from Sprague-Dawley rats was stored for 1, 14, or 28 days with the industry preservative citrate-phosphate-dextrose-adenine-1 (CPDA-1). For in vitro studies, 5% supernatant was incubated with normal rat BM and cultured for erythroid (CFU-E) and granulocyte-macrophage (CFU-GM) colony-forming units. Data were compared with cultures of BM alone, 5% control plasma (negative control), and 12% CPDA-1. For in vivo studies, rats were transfused with stored supernatants (5% estimated blood volume (EBV) over 30 minutes). BM from each recipient was cultured for CFU-E and CFU-GM at 3 hours after transfusion. Data were compared with cultures of BM alone. Difference between groups determined by analysis of variance and Tukey's multiple comparison test. RESULTS: In vitro exposure to CPDA-1, control plasma, or 1-day supernatant (D1) had no effect on BM growth compared with BM alone. In vitro exposure to 14-day (D14) and 28-day (D28) supernatant significantly suppressed CFU-E by 60% and CFU-GM growth by 71% (both p < 0.05) compared with D1 or medial alone. There were no differences between D14 and D28. In vivo exposure to D14 reduced BM CFU-E and CFU-GM growth by 55% (both p < 0.05) compared with D1 supernatant. CONCLUSION: Plasma from aged blood adversely affects CFU-E and CFU-GM growth in rats. The effect is not mediated by CPDA-1. Transfusion of aged stored blood may contribute to BM dysfunction in critically ill patients, resulting in persistent anemia and the need for further transfusion. This BM dysfunction may also partly explain the observed increased susceptibility to infection.

Functional outcomes after limb-salvage surgery and endoprosthetic reconstruction with an expandable prosthesis: a report of 4 cases.

OBJECTIVE: To determine the functional outcomes of skeletally immature patients after replacement of the femur and tibia performed by using noninvasive expandable endoprostheses. DESIGN: Case series. SETTING: A hospital-based ambulatory care center. PARTICIPANTS: Pediatric patients (N=4) with primary bone tumors of the distal femur and proximal tibia who underwent surgical replacement performed by using the Repiphysis noninvasive expandable endoprosthesis (Wright Medical Technology, Memphis, TN). INTERVENTIONS: Wide resection of bone sarcoma and placement of expandable endoprosthesis. MAIN OUTCOME MEASURES: Musculoskeletal Tumor Society (MSTS) scores were assessed at the beginning of the study and at each follow-up visit. Medical Outcomes Study 36-Item Short-Form Health Survey, Version 2 (SF-36); gait; sit-to-stand transition; and range of motion (ROM) were assessed at an average follow-up of 31.5 months. RESULTS: At an average of 31.5 months postoperative, the SF-36 physical component summary scores lagged behind the national mean, whereas the mental component summary scores were satisfactory. MSTS scores indicated low levels of pain and supports use with high emotional acceptance and walking ability but persisting difficulties with function and gait. Patients also showed altered patterns of sit-to-stand transition including decreased peak vertical force in the operated limb and increased center of mass momentum in a shorter amount of time. Parts of gait functioning were found to be decreased, including gait velocity, stride length, and cadence. Some patients displayed alternate weight-bearing strategies that accompanied increased double-limb support and stance phase during walking. ROM and strength were diminished at both the hip and knee joints in the operated limb and in the nonoperated limb. CONCLUSIONS: Reconstruction with a noninvasive expandable endoprosthesis produces satisfactory functional outcomes in pediatric patients with primary tumors of the bone. Patients in our study displayed some persisting physical difficulties including decreased ROM and strength and altered gait and sit-to-stand patterns, yet they maintained high levels of emotional acceptance and coping.