Intersurgeon variations in postoperative length of stay after video-assisted thoracoscopic surgery lobectomy.

Objectives: To identify factors associated with prolonged postoperative length of stay (LOS) after VATS lobectomy (VATS-L), explore potential intersurgeon variation in LOS and ascertain whether or not early discharge influences hospital readmission rates. Methods: We conducted a retrospective analysis of patients who underwent VATS-L at a single academic center between 2018 and 2021. Each VATS lobectomy procedure was performed by 1 of 7 experienced thoracic surgeons. The primary end point of interest was prolonged LOS, defined as an index LOS >3 days. Results: Among 1006 patients who underwent VATS lobectomy, 632 (63%) had a prolonged LOS. On multivariate analysis, the factors independently associated with prolonged LOS were: surgeon (P < .001), patient age (odds ratio [OR], 1.03; 95% CI, 1.02-1.06), operation time (OR, 1.01; 95% CI, 1.01-1.01), postoperative complication (OR, 3.60; 95% CI, 2.45-5.29), and prolonged air leak (OR, 8.95; 95% CI, 4.17-19.23). There was no significant association between LOS and gender, body mass index, coronary artery disease, prior atrial fibrillation, American Society of Anesthesiologists score >3, and prior ipsilateral thoracic surgery or sternotomy. There was no association between LOS ≤3 days and hospital readmission (20 [5.3%] vs 39 [5.9%]; OR, 0.88; 95% CI, 0.50-1.53). Conclusions: An intersurgeon variation in postoperative LOS after VATS-L exists and is independent of patient baseline characteristics or perioperative complications. This variation seems to be more closely related to differences in postoperative management and discharge practices rather than to surgical quality. Postoperative discharge within 3 days is safe and does not increase hospital readmissions.

Post-Operative Outcomes Associated With Open Versus Robotic Thymectomy: A Propensity Matched Analysis.

To compare post-operative outcomes associated with thymectomy performed using either open or robotic approaches. Retrospective cohort study from a single-center prospective registry consisting of patients undergoing thymectomy between 2000 and 2020. Patients were grouped according to surgical approach (open vs robotic). A propensity-score matching analysis was performed in a 2:1 open to robotic ratio, and surgical outcomes were evaluated. We analyzed 234 thymectomies (155 open; 79 robotic). Myasthenia gravis was present in 23.2% and 32.9% (P = 0.249) in the open and in the robotic group, respectively. All covariates were balanced in the matched groups (open n = 114; robotic n =5 9), except lesion size. The robotic approach was significantly associated with shorter surgical time (median 95 vs 65 minutes, P < 0.001), lesser clinical (21.1% vs 6.8%, P = 0.016) and surgical (11.4% vs 1.7%, P = 0.036) complications during the same hospitalization, less Clavien-Dindo grade 2 or higher complication rates (28.1 vs 15.3%, P = 0.048), chest tube duration (median: 3 vs 0 days, P < 0.001) and in-hospital length of stay (median: 5 vs 0 days, P < 0.001). Bleeding (P = 0.214), ICU length of stay (P = 0.167), reoperation rate (open, 1.8% vs robotic 0%), 90-day mortality (P = 0.341) and readmission rate post discharge (P = 0.277) were similar between the groups. In the matched population with primary thymic epithelial tumors, the completeness of resection rate was similar (open, 92.1% vs robotic 96.8%, P = 0.66.). Robotic thymectomy is associated with improved post-operative outcomes when compared to open thymectomy, without compromising the goals of oncologic surgery. Longer follow-up is needed to ensure oncologic equivalence.

Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System.

BACKGROUND: There is a literature gap for hospitals in single-payer health care systems quantifying the influence of hospital volume on outcomes after major lung cancer resection. We aimed to determine the effect of hospital volume on mortality and length of stay. METHODS: A retrospective cohort study using administrative, population-based data from a single-payer universal health care system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and postoperative mortality were compared using multivariable linear and nonlinear regression between hospital volume categories and continuously. Adjusted association between hospital volume and postoperative mortality was determined by multivariable logistic regression. RESULTS: In all, 10 831 lung resections were performed: 1237 pneumonectomies and 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median length of stay (6 vs 8 days, P = .001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter length of stay after lobectomy and overall resections (P ≤ .001), but not after pneumonectomy (P = .787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (odds ratio 0.607 [95% confidence interval, 0.399 to 0.925], and 0.632 [95% confidence interval, 0.441 to 0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (odds ratio 0.533 [95% confidence interval, 0.257 to 1.104], P = .090). CONCLUSIONS: Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital length of stay. The results support regionalized lung cancer care in a single-payer health care system.

Balloon Dilation for Endosonographic Staging in Esophageal Cancer: A Phase 1 Clinical Trial.

BACKGROUND: Dilation in patients with malignant esophageal strictures precluding the passage of the endoscopic ultrasonography (EUS) scope allows complete evaluation; however, it may be associated with complications. This study evaluates the safety and clinical value of balloon dilation to complete EUS in patients with stenotic esophageal cancers. METHODS: This study consists of a phase I clinical trial. One-hundred-and fifty patients were recruited. Endoscopic balloon dilation was performed before EUS in patients with high-grade stenosis. The analysis was focused on the ability to complete an endosonographic examination after dilation, 30-day morbidity, and change in the final stage or definitive management based on the completed endosonographic examination. RESULTS: Dilation was required in 55 patients (36.7%), with a complication rate of 10.9% (n = 6). Dilation allowed completion of EUS in 53 patients (96.4%), leading to a modification of the clinical stage for 18 patients (34%) and a deviation in the treatment plan in 7 patients (13.2%). No differences were found in these variables when compared with the group that did not require dilation (26.3% and 14.7%, P = .33 and P = .79, respectively). Dilation was associated with more advanced disease on final pathology among patients who underwent surgical resection (P = .006). CONCLUSIONS: High-grade malignant esophageal strictures that preclude the passage of the ultrasound probe are associated with advanced stage disease. Owing to the high risk of perforation and the limited benefit in staging, balloon dilation to complete the EUS staging should be avoided. (Clinicaltrials.gov identifier: NCT01950442.).

Lung Cryobiopsy Outside of the Operating Room: A Safe Alternative to Surgical Biopsy.

OBJECTIVE: Transbronchial lung cryobiopsy (TBLC) is a promising technique that can provide a histologic diagnosis in interstitial lung diseases (ILD) and is an alternative to surgical lung biopsy. The main concerns with the procedure are safety and diagnostic accuracy. The technique is applicable in patients unable to undergo surgical biopsy due to severe comorbidities or when patient transport to the operating room is dangerous. This study reports the initial experience with TBLC on a thoracic surgical service as a first attempt at diagnosis in patients with diffuse parenchymal lung diseases (DPLD). METHODS: Between May 2018 and July 2020, 32 patients underwent TBLC using bedside flexible bronchoscopy for suspected ILD on a thoracic surgical endoscopy service. Retrospective evaluation of the procedure details, complications, and diagnostic yield were analyzed and reported. RESULTS: A total of 89 pathological samples were obtained (mean 2.8 per patient). Pneumothorax and minor bleeding occurred in 25% and 16.7% of patients, respectively. Sixty-seven percent of complications occurred with use of the 2.4 mm cryoprobe (P = 0.036). Concordance between the histologic diagnosis and final clinical diagnosis was observed in 62.5% of patients and the pathology guided the final treatment in 71% (P = 0.027) with Kappa-concordance of 0.60 (P < 0.001). CONCLUSIONS: Cryobiopsy is becoming part of the diagnostic evaluation in patients with indeterminate DPLD or hypoxemic respiratory failure. TBLC is easy to perform and has a favorable safety profile. Thoracic specialists should consider adding TBLC to their procedural armamentarium as a first option for patients with indeterminate PLD.

Transvascular endosonographic-guided needle biopsy of intrathoracic lesions.

BACKGROUND: Endoscopic ultrasound-guided biopsy techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), are currently the standard of care for the assessment of mediastinal lymphadenopathy. Traditionally, passing the needle through and through vascular structures has been avoided owing to the risk of bleeding. In this study, we evaluated the safety and diagnostic accuracy of transvascular endosonographic-guided biopsies of mediastinal, hilar and lung lesions. Our hypothesis is that the approach is safe and adds to the endoscopic armamentarium, avoiding the need for surgical biopsy in specifically selected cases. METHODS: One hundred patients who underwent transvascular EBUS- or EUS-guided biopsy between 2012 and 2018 were identified from a prospective interventional endoscopy database. RESULTS: Biopsy was performed under EUS guidance in 65 patients and under EBUS guidance in 35 patients. The most frequent targets were the mediastinum (60 patients), lung (21 patients), and hilar lymph nodes (16 patients). The aorta was the vessel most commonly traversed (n = 57), followed by the pulmonary artery (n = 33). A median of 2 passes were performed per target (range, 1-5). The samples were adequate to make a diagnosis in 80 patients, and the endoscopic diagnosis was a malignancy in 62 patients. The overall sensitivity was 71.5%, and the accuracy was 74.5%. There were no observed intraoperative or immediate postoperative complications. A delayed complication, aortic pseudoaneurysm, was observed in 1 patient. Follow-up was completed in 84 patients, with a median duration of 12.3 ± 18 months. CONCLUSIONS: Transvascular endosonographic-guided biopsy is an important adjunct to conventional endoscopic techniques and allows the thoracic endoscopist to obtain biopsy specimens from intrathoracic lesions that are not accessible without vascular puncture.

Phase 1 Trial Evaluating Safety of Pulmonary Artery Sealing With Ultrasonic Energy in VATS Lobectomy.

BACKGROUND: Energy-sealing devices may be useful to divide small pulmonary arteries (PAs) during video-assisted thoracoscopic surgery (VATS) lobectomy. We evaluated the safety of PA branch sealing with an ultrasonic energy vessel-sealing device during VATS lobectomy. METHODS: The study consisted of a phase 1 trial. Patients planned to undergo VATS lobectomy were prospectively enrolled. Target sample size was 20 patients. Branches of 7 mm or less were sealed and cut with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative, in-hospital, and 30-day postoperative bleeding were prospectively recorded. RESULTS: Thirty-three patients were prospectively enrolled. Thirteen patients were not amenable to PA sealing with the vessel-sealing device because all PA branch diameters exceeded 7 mm (n = 10), conversion to thoracotomy (n = 2), and lobectomy not performed (n = 1). A minimum of one PA branch was sealed with the device in 20 patients. Fifty-eight PA branches were divided in 20 patients: 31 with ultrasonic device, 24 with endostaplers, 2 with clips, and 1 with sutures. The mean vessel diameter sealed with the device was 4 mm. Two patients were converted to thoracotomy (1 with PA injury during dissection, 1 with PA tumor invasion). No intraoperative or postoperative bleeding was related to ultrasonic PA branch sealing. No postoperative deaths occurred. CONCLUSIONS: PA branch sealing for vessels 7 mm or less was safely achieved using an ultrasonic energy vessel-sealing device in VATS lobectomy. Large-scale, prospective, multi-institutional studies are necessary before widespread clinical application of energy for PA branch sealing in VATS lobectomy.

Pulmonary artery sealing with ultrasonic energy in open lobectomy: A phase I clinical trial.

OBJECTIVE: Pulmonary artery branch sealing in video-assisted thoracoscopic surgical lobectomy is usually achieved with vascular endostaplers. Iatrogenic pulmonary artery injury may be caused by endostaplers. We evaluated the safety of pulmonary artery sealing with an ultrasonic energy vessel-sealing device in a phase I clinical trial evaluating in vivo safety of the device during open lobectomy. METHODS: Patients scheduled to undergo elective open (thoracotomy) pulmonary lobectomy were prospectively enrolled. Target sample size was 10 patients. Pulmonary artery diameter was measured intraoperatively. All branches ≤7 mm were divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative and postoperative bleeding were strictly recorded. RESULTS: Eighteen patients were prospectively enrolled. Eight patients were not amenable to pulmonary artery sealing with the device. In the 10 patients included in the analysis, a total of 14 pulmonary arteries were sealed with the ultrasonic device. The mean vessel diameter was 5 mm (range, 2-7 mm). One patient underwent reoperation for bronchial artery bleeding (vessel not sealed with device). There was no intra- or postoperative bleeding related to ultrasonic pulmonary artery sealing. There was no postoperative mortality. CONCLUSIONS: Pulmonary artery sealing for vessels with diameter ≤7 mm was safely achieved with an ultrasonic energy vessel-sealing device in open lobectomy. The use of ultrasonic energy vessel-sealing devices in video-assisted thoracoscopic surgical lobectomy may have the advantage of making small, short, pulmonary artery branch sealing safer than with vascular endostaplers. Further studies are necessary before widespread application in lobectomy, including video-assisted thoracoscopic surgical lobectomy.

Impact of pregabalin on the occurrence of postthoracotomy pain syndrome: a randomized trial.

BACKGROUND: Postthoracotomy pain syndrome (PTPS) is a frequent cause of chronic postoperative pain. Pregabalin might reduce the incidence of chronic postoperative pain. The goal of this study was to evaluate the impact of perioperative pregabalin on the occurrence of PTPS, defined as any surgical site pain 3 months after surgery. METHODS: We conducted a randomized, placebo-controlled, double-blind trial in patients undergoing elective thoracotomy. Patients received either pregabalin 150 mg orally twice a day initiated 1 hour before thoracotomy and continued until 4 days after thoracotomy (10 doses total) or a placebo using the same protocol. All patients received preincision thoracic epidural analgesia. Postthoracotomy pain syndrome was evaluated using the Brief Pain Inventory questionnaire through a telephone interview. Secondary outcomes included evaluation of neuropathic characteristics through the Leeds Assessment of Neuropathic Symptoms and Signs questionnaire, analgesic use 3 months after surgery, and evaluation of acute postoperative pain and opioid consumption. RESULTS: One hundred fourteen patients were randomized, and 99 patients completed the study (placebo, n = 49; pregabalin, n = 50). Postthoracotomy pain syndrome occurred in 49 (49.5%) of 99 patients and more frequently in the pregabalin group (31/50 [62%] vs 18/49 [37%] in the placebo group, P = 0.01). However, among patients with PTPS, those in the pregabalin group required significantly less analgesics, reported less moderate to severe average pain, and presented significantly less neuropathic characteristics than patients in the placebo group 3 months after surgery. CONCLUSIONS: Pregabalin did not reduce the incidence of PTPS in this study. Future research on PTPS should focus on the impact of regional analgesia on central sensitization.

Effects of emphysema and lung volume reduction surgery on transdiaphragmatic pressure and diaphragm length.

STUDY OBJECTIVES: To determine the effect of emphysema and lung volume reduction surgery (LVRS) on diaphragm length (Ldi) and its capacity to generate transdiaphragmatic pressure (Pdi). DESIGN: Prospective clinical trial with a parallel group design. SETTING: Laboratory investigations in normal volunteers recruited by advertisement and in emphysema outpatients being evaluated for elective LVRS. STUDY POPULATION: Thirteen normal subjects and 13 emphysema patients matched for age and sex. Six emphysema patients underwent LVRS. MEASUREMENTS: Ldi and maximal Pdi during static inspiratory efforts (PdiMax) were measured at three different lung volumes (LVs). Pdi during maximal bilateral phrenic nerve twitch stimulation (PdiTw) was measured at functional residual capacity (FRC). All measurements were repeated at 3, 6, and 12 months postoperatively. RESULTS: Ldi, PdiMax, and PdiTw were lower in emphysema patients than in normal subjects at their respective LVs. PdiMax and PdiTw at FRC returned within the normal range after LVRS in emphysema patients. The relationships between PdiMax and LV or Ldi were shifted respectively to higher LV and shorter Ldi in emphysema patients relative to normal subjects, both before and after LVRS. LVRS effected craniad displacement of the diaphragm but no change in rib cage dimensions. Improvements in dyspnea and quality of life after LVRS correlated with changes in LV and Ldi but not with changes in airway caliber. CONCLUSION: Adaptive mechanisms, consistent with sarcomere deletion, tend to restore diaphragm strength in emphysema patients at FRC, which are fully expressed after LVRS. Lung remodeling by LVRS may alter pleural surface pressure distribution, causing a sustained change in chest wall shape.

Oculopharyngeal muscular dystrophy: What's new?

The authors place autosomal dominant oculopharyngeal muscular dystrophy in a historical perspective, look at the genealogy involved, and review the genetic studies. In addition to summarizing what happens at the histopathological level, they examine the clinical characteristics of this late-onset dystrophy. Based on this knowledge, they try to present their rationale for the surgical treatment of the eyelid ptosis, taking into account that this disease is progressive and that treatment should be planned for the lifetime of the patient. Three representative cases are illustrated.

Pilot study of pulmonary arterial branch sealing using energy devices in an ex vivo model.

OBJECTIVE: Vascular endostaplers are bulky and can be dangerous when dividing small pulmonary arterial (PA) branch vessels during video-assisted thoracoscopic lobectomy. We aimed to evaluate and compare the immediate efficacy of modern energy sealing devices in an ex vivo PA sealing model. METHODS: Patients undergoing anatomical lung resection or lung transplantation were recruited for a prospective cohort pilot study. Four devices were evaluated: Harmonic Ace (Ethicon, Cincinnati, Ohio), Thunderbeat (Olympus, Tokyo, Japan), LigaSure (Covidien, Boulder, Colo), and Enseal (Ethicon; Cincinnati, Ohio). After anatomical lung resection, the PA branches were dissected in vitro. Sealing was then performed with 1 of the sealing devices, the vessel was slowly pressurized, and the bursting pressure was recorded. RESULTS: Forty-nine PA branches were sealed in 14 patients. The mean PA branch diameter was 7.4 mm (1.8-14.5 mm). Ten patients had normal PA pressure and 3 had PA hypertension. The mean bursting pressure in each was as follows: Harmonic Ace group, 415.5 mm Hg (137.1-1388.4 mm Hg), Thunderbeat group, 875 mm Hg (237.1-2871.3 mm Hg); LigaSure group, 214.7 mm Hg (0-579.6 mm Hg); Enseal group, 133.7 mm Hg (0-315.38 mm Hg). There were 2 complete sealing failures: LigaSure (diameter 6.78 mm) and Enseal (diameter 8.3 mm). CONCLUSIONS: In this pilot study to examine energy sealing of PA branches in a simulated ex vivo model, vascular sealing using energy was effective and was able to sustain high intraluminal bursting pressures. Further research is needed to determine the in vivo and long-term safety of PA branch energy sealing.

Gabapentin does not reduce post-thoracotomy shoulder pain: a randomized, double-blind placebo-controlled study.

PURPOSE: Despite adequate epidural analgesia, up to 97% of patients undergoing thoracotomy experience ipsilateral shoulder pain. In this setting, this study evaluated the safety and the efficacy of pre-emptive gabapentin. METHODS: A double-blind, placebo-controlled study was undertaken in 51 patients randomized into two groups. Two hours before surgery, 23 patients received gabapentin 1200 mg po (Group G), and 28 patients received placebo (Group P). Shoulder pain and postoperative pain, at the surgical site, were monitored every four hours for 24 hr, using a numerical rating scale. Subcutaneous hydromorphone was administered for rescue analgesia against shoulder pain. RESULTS: Forty-four patients complained of shoulder pain (prevalence of 86%). Demographic and surgical data were similar between the two groups. There were no significant differences in the total cumulative doses of hydromorphone administered at eight, 16, and 24 hr, nor were there differences in individual numerical rating scale scores for shoulder pain. The groups were similar with respect to the degree of pain at the surgical site. The frequency of side effects between groups at corresponding time intervals was also similar, with the exception of sedation. At four hours, the incidence of sedation scores > 1 was greater in Group G (21/23 patients), compared to Group P (18/28 patients; P = 0.025). In contrast, by 24 hr, 5/18 patients in Group P had sedation scores > 1, compared to 0/28 patients in Group G (P = 0.05). CONCLUSION: Pre-emptively administered gabapentin, 1200 mg, does not reduce the incidence, or the severity, of post-thoracotomy shoulder pain in patients receiving thoracic epidural analgesia.

Acetaminophen decreases early post-thoracotomy ipsilateral shoulder pain in patients with thoracic epidural analgesia: a double-blind placebo-controlled study.

OBJECTIVE: Despite effective epidural analgesia, up to 85% of post-thoracotomy patients complain of moderate-to-severe ipsilateral shoulder pain. This study assessed the efficacy of acetaminophen in decreasing postoperative shoulder pain after a thoracotomy. DESIGN: Double-blind randomized and placebo-controlled study. SETTING: University medical center. PARTICIPANTS: 65 patients. INTERVENTION: Patients were randomized into 2 groups; 31 patients received acetaminophen (group A), and 34 patients received a placebo (group P). After induction of anesthesia, patients received either a loading dose of acetaminophen, 1000 mg intrarectally, or a placebo suppository. Thereafter, acetaminophen, 650 mg, or a placebo, was administered intrarectally every 4 hours for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Postoperative pain at the surgical site and shoulder pain were assessed separately every 4 hours for 48 hours using a numerical rating scale (NRS). Rescue analgesia for severe shoulder pain (NRS > 7) consisted of subcutaneous hydromorphone. Sixty-three patients experienced shoulder pain (97% prevalence). Demographic and intraoperative data were similar between the 2 groups. Average NRS for shoulder pain was higher in group P compared with group A at 8, 12, and 16 hours postoperatively (3.1 +/- 2.9, 2.6 +/- 2.6, 2.3 +/- 2.4 vs 1.8 +/- 2.6, 1.2 +/- 1.5, 1.3 +/- 1.8; P < 0.05). The total dose of hydromorphone did not differ between the 2 groups at 16, 24, and 48 hours. CONCLUSION: Acetaminophen decreases post-thoracotomy ipsilateral shoulder pain when given preemptively and regularly during the first 48 hours postoperatively in patients who received thoracic epidural analgesia.

Balloon dilation and stent placement for esophageal lesions: indications, methods, and results.

Esophageal balloon dilation and expandable stent placement are safe, minimally invasive, effective treatments for esophageal strictures and fistulas. These procedures have brought the management of dysphagia due to esophageal strictures into the field of interventional radiology. Esophageal dilation is usually indicated for benign stenoses and is technically successful in more than 90% of cases. Most patients with esophageal carcinoma are not candidates for resection; thus, the main focus of treatment is palliation of malignant dysphagia and esophagorespiratory fistulas. Esophageal stent placement, which is approved only for malignant strictures, is one of the main therapeutic options in affected patients and relieves dysphagia in approximately 90% of cases. Dedicated commercially available devices continue to evolve, each with its own advantages and limitations. Stent placement is subject to technical pitfalls, and adverse events occur following esophageal procedures in a minority of cases. Although chest pain is common and self-limited, reflux esophagitis, stent migration, tracheal compression, and esophageal perforation and obstruction require specific interventions. In many cases, these complications can be recognized and treated by the interventional radiologist with minimally invasive techniques.