RESUMO
BACKGROUND: Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. METHODS: The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. RESULTS: A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. CONCLUSIONS: In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications.
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Pulmão/cirurgia , Ventilação Monopulmonar/métodos , Complicações Pós-Operatórias/epidemiologia , Volume de Ventilação Pulmonar/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Pulmonary masses occasionally occur after lung transplantation and vary in etiology, which includes malignant and benign conditions, such as infection. Here, we report a case of a patient presenting with a lung mass 3 years after lung transplant. To our knowledge, this is the first described case of pulmonary malakoplakia due to Rhodococcus equi infection in an allograft post-lung transplantation. This case outlines the challenges of differentiating benign from malignant masses after transplantation.
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Infecções por Actinomycetales/complicações , Pneumopatias/diagnóstico , Neoplasias Pulmonares/diagnóstico , Transplante de Pulmão/efeitos adversos , Malacoplasia/diagnóstico , Complicações Pós-Operatórias , Rhodococcus equi/isolamento & purificação , Infecções por Actinomycetales/epidemiologia , Infecções por Actinomycetales/microbiologia , Idoso , Diagnóstico Diferencial , Humanos , Pneumopatias/etiologia , Neoplasias Pulmonares/etiologia , Malacoplasia/etiologia , Masculino , PrognósticoRESUMO
BACKGROUND: Stenosis is the most frequent airway complication after lung transplantation. When complete obstruction is diagnosed without possibility of recanalization, options are generally limited to either resection or retransplantation, both associated with increased morbidity and mortality. We describe our experience with a novel technique using electromagnetic navigational bronchoscopy (ENB) to recanalize the occluded airway after lung transplantation. METHODS: Patients who underwent lung transplantation between 2010 and 2016 with subsequent development of complete airway obstruction and failed conventional recanalization attempts were included in this study. All patients underwent attempted recanalization using ENB. Primary outcomes included success of the technique and long-term patency. Secondary outcomes included procedure-related complications. RESULTS: Four patients met inclusion criteria and underwent attempted recanalization using the ENB platform. Location of the obstruction was the bronchus intermedius in two patients, the lingular bronchus in one patient, and the left basilar bronchus in one patient. Mean length of stenosis was 8.8 mm. Three patients (75%) were successfully recanalized and all airways remain patent at 1, 48, and 66 mo. There were no procedure-related complications. The one patient who was unable to be recanalized successfully underwent bilobectomy and died 7 mo later. CONCLUSIONS: ENB is a feasible method of airway recanalization in select patients with bronchial occlusion after lung transplantation. ENB recanalization spares lung parenchyma and avoids risks associated with surgical resection and retransplantation. This novel technique can be added to the armamentarium for thoracic surgeons who diagnose and treat this complicated problem.
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Broncopatias/cirurgia , Broncoscopia/métodos , Transplante de Pulmão , Complicações Pós-Operatórias/cirurgia , Radiografia Intervencionista/métodos , Adulto , Idoso , Broncopatias/diagnóstico por imagem , Constrição Patológica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagemRESUMO
As cardiothoracic surgeons, we face frequent challenges to our well-being and our ability to function as our best selves. Building personal resilience is an important way to help us manage these challenges. Here, the authors outline the scope of the problem, the consequences of burnout, and offer 4 strategies to train ourselves to be more resilient: (1) Pursuit of fulfillment, (2) Cultivation of community and belonging, (3) Mitigation of microstresses and avoiding feelings of overwhelm, and (4) Building a "resilience bank account."
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Esgotamento Profissional , Resiliência Psicológica , Humanos , Esgotamento Profissional/prevenção & controle , Cirurgia Torácica/educação , Cirurgia Torácica/organização & administração , Cirurgiões/psicologia , Cirurgiões/educaçãoRESUMO
Ventilation-perfusion SPECT with or without CT using technetium 99m (99mTc)-diethylenetriaminepentaacetic acid (DTPA) has been used to identify patterns typical of cardiopulmonary diseases, such as pulmonary embolism, pneumonia, heart failure, and obstructive lung disease. This case demonstrates the utility of a ventilation scan with SPECT/CT using 99mTc-DTPA for investigating the cause of a persistent complex pneumothorax in a patient with severe chronic obstructive pulmonary disease who recently underwent endobronchial valve placement. Keywords: CT-Spectral Imaging (Multienergy), SPECT/CT, Thorax, Lung Supplemental material is available for this article. © RSNA, 2024.
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Pneumotórax , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único , Pentetato de Tecnécio Tc 99m , Humanos , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único/métodos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Masculino , Compostos Radiofarmacêuticos , Doença Pulmonar Obstrutiva Crônica/complicações , IdosoRESUMO
BACKGROUND: In academic surgery publications, self-reporting of conflicts of interest (COI) has often proved to be inaccurate. Here, we review the accuracy of COI disclosures for studies related to the use of robotic technology in cardiothoracic surgery and evaluate factors associated with increased discrepancies. METHODS: A literature search identified robotic surgery-related studies with at least 1 American author published between January 2015 and December 2020 from 3 major American cardiothoracic surgery journals (The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and Annals of Cardiothoracic Surgery). Industry payments from Intuitive Surgical (Intuitive) were collected with use of the Centers for Medicare and Medicaid Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments found for the year of publication and the year prior (24-month period). RESULTS: A total of 144 studies (764 authors) were identified. At least 1 author of 112 studies (78%) had received payments from Intuitive. At least 1 author of 98 studies (68%) had received an undeclared payment from Intuitive. Authors who accurately disclosed payments received significantly higher median payments compared with authors who did not ($16,511 [interquartile range, $6389-$159,035] vs $1762 [interquartile range, $338-$7500]; P < .0001). Last authors were significantly more likely to have a COI discrepancy compared with middle and first authors (P = .018; P = .0015). CONCLUSIONS: Most studies investigating the use of robotic technology in cardiothoracic surgery did not accurately declare COI with Intuitive. This study highlights the need for improved accuracy of reporting industry sponsorship by publishing authors.
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Procedimentos Cirúrgicos Robóticos , Idoso , Humanos , Estados Unidos , Conflito de Interesses , Medicare , Revelação , IndústriasRESUMO
BACKGROUND: The utilization of post-operative clinical pathways leads to shorter hospital stays and decreased healthcare costs. This study evaluated patient outcomes after implementation of a 6-day discharge pathway after a pancreaticoduodenectomy. METHODS: A post-operative clinical pathway was developed and implemented for patients undergoing a pancreaticoduodenectomy at the present institution aimed at discharge by post-operative day six. Patient charts were retrospectively reviewed to determine the rates of adherence to the pathway at each step, readmission and post-operative complications. RESULTS: In total, 113 consecutive patients underwent a pancreaticoduodenectomy, receiving post-operative care under the clinical pathway guidelines. The median length of stay was 7 days (mode 6 days); 41% of patients were discharged by post-operative day six, 62% by day seven and 79% by day eight. In univariate analysis, delayed gastric emptying was associated with a delayed discharge after post-operative day six (P = 0.002). There were no post-operative deaths and 16% of patients required readmission within 30 days of discharge. In univariate analysis, obesity was the only variable associated with an increased rate of readmission (P < 0.001). DISCUSSION: Clinical pathway utilization after a pancreaticoduodenectomy allows a high percentage of patients to be discharged within a week and is associated with a low rate of readmission. Clinical pathway implementation allows for safe and efficient patient care.
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Procedimentos Clínicos , Pancreaticoduodenectomia , Idoso , Distribuição de Qui-Quadrado , Procedimentos Clínicos/normas , Estudos de Viabilidade , Feminino , Gastroparesia/etiologia , Gastroparesia/terapia , Fidelidade a Diretrizes , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/normas , Alta do Paciente , Readmissão do Paciente , Cuidados Pós-Operatórios , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: BACKGROUND. Surgical strategy for hilar cholangiocarcinoma often includes hepatectomy, but the role of portal vein resection (PVR) remains controversial. In this study, the authors sought to identify factors associated with outcome after surgical management of hilar cholangiocarcinoma and examined the impact of PVR on survival. METHODS: Three hundred five patients who underwent curative-intent surgery for hilar cholangiocarcinoma between 1984 and 2010 were identified from an international, multi-institutional database. Clinicopathologic data were evaluated using univariate and multivariate analyses. RESULTS: Most patients had hilar cholangiocarcinoma with tumors classified as T3/T4 (51.1%) and Bismuth-Corlette type II/III (60.9%). Resection involved extrahepatic bile duct resection (EHBR) alone (26.6%); or hepatectomy and EHBR without PVR (56.7%); or combined hepatectomy, EHBR, and PVR (16.7%). Negative resection (R0) margin status was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 64.2%; with PVR, 66.7%) versus EHBR alone (54.3%; P < .001). The median number of lymph nodes assessed was higher among the patients who underwent hepatectomy plus EHBR (without PVR, 6 lymph nodes; with PVR, 4 lymph nodes) versus EHBR alone (2 lymph nodes; P < .001). The 90-day mortality rate was lower for patients who underwent EHBR alone (1.2%) compared with the rate for patients who underwent hepatectomy plus EHBR (without PVR, 10.6%, with PVR, 17.6%; P < .001). The overall 5-year survival rate was 20.2%. Factors that were associated with an adverse prognosis included lymph node metastasis (hazard ratio [HR], 1.79; P = .002) and R1 margin status (HR, 1.81; P < .001). Microscopic vascular invasion did not influence survival (HR, 1.23; P = .19). Among the patients who underwent hepatectomy plus EHBR, PVR was not associated with a worse long-term outcome (P = .76). CONCLUSIONS: EHBR alone was associated with a greater risk of positive surgical margins and worse lymph node clearance. The current results indicated that hepatectomy should be considered the standard treatment for hilar cholangiocarcinoma, and PVR should be undertaken when necessary to extirpate all disease. Combined hepatectomy, EHBR, and PVR can offer long-term survival in some patients with advanced hilar cholangiocarcinoma.
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Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/cirurgia , Colangiocarcinoma/cirurgia , Hepatectomia , Veia Porta/patologia , Veia Porta/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Neoplasias dos Ductos Biliares/mortalidade , Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos/patologia , Quimioterapia Adjuvante , Colangiocarcinoma/mortalidade , Colangiocarcinoma/patologia , Estudos de Coortes , Feminino , Artéria Hepática/patologia , Artéria Hepática/cirurgia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Invasividade Neoplásica , Estadiamento de Neoplasias , Radioterapia Adjuvante , Fatores de Tempo , Resultado do Tratamento , Neoplasias Vasculares/secundário , Neoplasias Vasculares/cirurgiaRESUMO
INTRODUCTION: Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients. METHODS: We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms. RESULTS: Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001). DISCUSSION: Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.
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Linfonodos/cirurgia , Melanoma/cirurgia , Recidiva Local de Neoplasia/cirurgia , Neoplasias Cutâneas/cirurgia , Axila , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Melanoma/mortalidade , Melanoma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/secundário , Taxa de SobrevidaRESUMO
BACKGROUND: High-quality preoperative cross-sectional imaging is vital to accurately stage patients with pancreatic ductal adenocarcinoma (PDAC). We hypothesized that imaging performed at a high-volume pancreatic cancer center with pancreatic imaging protocols more accurately stages patients compared with pre-referral imaging. METHODS: We retrospectively reviewed data from all patients with PDAC who presented to the surgical oncology clinic at our institution between June 2005 and August 2009. Detailed preoperative imaging, staging, and operative data were collected for each patient. RESULTS: A total of 230 patients with PDAC were identified, of which 169 had pre-referral imaging. Patients were selectively reimaged at our institution based on the quality and timing of imaging at the outside facility: 108 (47%) patients were deemed resectable, 54 (23.5%) were deemed borderline-resectable, and 68 (29.5%) were deemed unresectable. Of the resectable patients, 99 opted for resection. Eighty-two of those 99 patients underwent preoperative imaging at our institution, and of these 27% had unresectable disease at the time of surgery compared with 47% of patients who only had pre-referral imaging (p = 0.14). Reimaging altered staging and changed management in 56% of patients. Among that group were 55 patients, categorized as resectable on pre-referral imaging, who on repeat imaging were deemed to be borderline resectable (n = 27) or unresectable (n = 28). CONCLUSIONS: Pancreas-protocol imaging at a high-volume center improves preoperative staging and alters management in a significant proportion of patients with PDAC who undergo pre-referral imaging. Thus, repeat imaging with pancreas protocols and dedicated radiologists is justified at high-volume centers.
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Adenocarcinoma/patologia , Carcinoma Ductal Pancreático/patologia , Imageamento por Ressonância Magnética , Neoplasias Pancreáticas/patologia , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/cirurgia , Idoso , Carcinoma Ductal Pancreático/diagnóstico por imagem , Carcinoma Ductal Pancreático/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Estadiamento de Neoplasias , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia , Padrões de Prática Médica , Cuidados Pré-Operatórios , Prognóstico , Radiografia , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Patients with borderline resectable pancreatic ductal adenocarcinoma (PDA) represent a high-risk group of patients due to tumor or patient-related characteristics. The optimal management of these patients has not been fully defined. MATERIALS AND METHODS: All patients undergoing evaluation for PDA between 2005 and 2008 were identified. Clinical, radiographic, and pathological data were retrospectively reviewed. Patients were staged as borderline resectable using the M.D. Anderson Cancer Center (MDACC) classification. RESULTS: A total of 170 patients with PDA were identified, 40 with borderline resectable disease. Of these, 34 borderline resectable patients (85%) completed neoadjuvant therapy and were restaged; pancreatic resection was completed in 16 patients (46%). Also, 8 patients completed 50 Gy of radiation in 28 fractions in 6 weeks, whereas 8 patients received 50 Gy in 20 fractions in 4 weeks plus chronomodulated capecitabine. An R0 resection was achieved in 12 of the 16 patients (75%). Also, 5 patients (63%) treated in 20 fractions had >90% pathologic response versus 1 (13%) treated in 28 fractions (P < .05). Borderline resectable patients completing surgery had similar survival to patients with resectable disease who underwent surgery. Patients receiving accelerated fractionation radiation had improved survival compared with patients treated with standard fractionation protocol. CONCLUSIONS: A neoadjuvant approach to borderline resectable PDA identifies patients who are most likely to benefit from pancreatic resection. Preoperative capecitabine-based chemoradiation is an effective, well-tolerated treatment for these patients. Neoadjuvant therapy for borderline resectable PDA warrants further investigation using treatment schedules that can safely intensify irradiation dose.
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Adenocarcinoma/terapia , Antimetabólitos Antineoplásicos/uso terapêutico , Carcinoma Ductal Pancreático/terapia , Desoxicitidina/análogos & derivados , Fluoruracila/análogos & derivados , Pancreatectomia , Neoplasias Pancreáticas/terapia , Idoso , Idoso de 80 Anos ou mais , Capecitabina , Quimioterapia Adjuvante , Terapia Combinada , Desoxicitidina/uso terapêutico , Feminino , Fluoruracila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Cuidados Pré-Operatórios , Estudos Prospectivos , Radioterapia Adjuvante , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Lung cancer remains the leading cause of cancer death worldwide and the search for modifiable risk factors to improve survival is ongoing. There is a growing appreciation for a biological relationship between opioids and lung cancer progression. Our goal was to evaluate the association between perioperative opioid use and long-term survival after lung cancer resection. METHODS: A retrospective analysis of 2006 to 2012 Surveillance, Epidemiology, and End Results Medicare datasets identified all patients undergoing pulmonary resection for non-small cell lung cancer stages I to III. Patients were stratified by filling opioid prescriptions only 30 days before or after surgery (standard group), filling opioid prescriptions greater than 30 days before surgery (chronic group), or filling opioid prescriptions greater than 90 days after surgery but not before surgery (prolonged group). Kaplan-Meier survival analysis compared each group; risk-adjusted survival analysis was performed using the Cox proportional hazards model. RESULTS: We identified 3273 patients, including 1385 in the standard group (42.3%), 1441 in the chronic group (44.0%), and 447 in the prolonged group (13.7%). Of previously opioid-naive patients, 447 of 1832 (24.4%) became new prolonged opioid users. Kaplan-Meier survival analysis illustrated lower overall and disease-specific survival in chronic and prolonged opioid groups (both P < .01). After risk adjustment, chronic (hazard ratio = 1.27; 95% confidence interval, 1.09-1.47; P < .01) and prolonged (hazard ratio = 1.42; 95% confidence interval, 1.17-1.73; P < .01) opioid use were independently associated with reduced long-term survival. CONCLUSIONS: Chronic and prolonged opioid use were independently associated with reduced long-term, disease-specific survival after lung cancer resection. These findings provide epidemiologic support for a biological relationship between opioid use and lung cancer progression.
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Analgésicos Opioides/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Duração da Terapia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/cirurgia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Initial staging of esophageal cancer relies on EUS in addition to FDG-PET/CT. It is our hypothesis that with the advancement of FDG-PET/CT staging, endoscopic ultrasound may not be required for initial staging in all cases. The purpose of this study is to analyze whether EUS affects initial treatment stratification in patients diagnosed with esophageal cancer. METHODS: A retrospective database at the University of Virginia was queried for patients diagnosed with esophageal squamous cell carcinoma and adenocarcinoma who underwent EGD with EUS and FDG-PET/CT at their initial evaluation from 10/2013 to 5/2017. Two thoracic surgeons were asked to determine appropriate management for each case. Options included surgical resection, neoadjuvant chemoradiotherapy followed by resection, definitive chemoradiotherapy, or chemotherapy with or without palliative radiation. Both surgeons received the FDG-PET/CT report along with the EGD report. For each case, one or both surgeons were randomly allocated to review EUS results in addition to the clinical information. The treatment decisions of each thoracic surgeon were compared to determine if EUS reports impacted clinical management. Simple and weighted correlation coefficients (kappa) were calculated to compare agreement of treatment choices between the two surgeons using McNemars test. Conditional logistic regression was used to assess the influence of EUS on the treatment recommendations. RESULTS: A total of 50 patients (44 male and 6 female) were enrolled and data was collected. The thoracic surgeons agreed on treatment decisions in 39 cases and disagreed on 11 cases. Agreement between surgeons was good despite lack of EUS information for one surgeon on each case (weighted Kappa =0.73, 95% CI: 0.57-0.89). Using conditional logistic regression, EUS did not have a statistically independent association with agreement on treatment plan (P for model =0.17). CONCLUSIONS: EUS did not have a statistically independent association with agreement on treatment plan for newly diagnosed esophageal cancer (P for model =0.17). Our findings suggest that EUS may not be necessary in the algorithm for the initial staging of every case of esophageal cancer. Selective, rather than mandatory use of EUS seems warranted.
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BACKGROUND: Lung transplantation outcomes are heavily scrutinized, given the high stakes of these operations, yet the Center for Medicare and Medicaid Services (CMS) method of using Scientific Registry of Transplant Recipients (SRTR) risk-adjusted outcomes to identify underperforming centers is controversial. We hypothesized that CMS flagging results in conservative behavior for recipient and organ selection, resulting in fewer patients added to the waitlist and fewer transplantations performed. METHODS: SRTR reports from July 2012 through July 2017 were included. Center characteristics were compared, stratified by number of flagging events. The impact of flagging for underperformance on risk aversion outcomes was analyzed using a mixed-effects regression model. RESULTS: A total of 72 centers had reported SRTR data during the study period. Of these, 21 centers (29%) met flagging criteria a median of 2 times (interquartile range, 1 to 4 times) for a total of 53 events. Flagging had no statistically significant impact on waitlist or transplantation volume and patient selection by mixed-effects modeling. Despite similar average expected 1-year survival (86.6% versus 87.7%, p = 0.27), centers that were flagged only once added more patients per year to the waitlist (16.3 patients versus 7.8 patients, p = 0.01) and performed more transplantations per year (28.4 transplantations versus 11.1 transplantations, p = 0.01). CONCLUSIONS: This analysis defines center-level trends in lung transplantation after CMS flagging. Contrary to our primary hypothesis, flagging did not result in temporal center-level changes. However, programs on prolonged probation demonstrated reduced activity, which likely indicates a shift to higher performing centers.
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Centers for Medicare and Medicaid Services, U.S./normas , Transplante de Pulmão/estatística & dados numéricos , Transplante de Pulmão/normas , Humanos , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP). METHODS: Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP. Oxygenation, pulmonary artery pressure, airway pressure, and compliance were measured hourly. Lung injury scores were assessed histologically after 4 hours of EVLP. RESULTS: After EVLP, all 3 groups met all the criteria for transplantation, except for 90-minute WIT lungs, which had a mean pulmonary artery pressure increase greater than 15%. There were no significant differences between groups as assessed by final oxygenation capacity, as well as changes in pulmonary artery pressure, airway pressure, or lung compliance. Histologic lung injury scores as well as lung wet-to-dry weight ratios did not significantly differ between groups. CONCLUSIONS: These results suggest that longer WIT alone (up to 120 minutes) does not predict worse lung function at the conclusion of EVLP. Expanding acceptable WIT after circulatory death may eventually allow for increased utilization of DCD lungs in procurement protocols.
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Foreign body ingestion is one of the many potential causes of esophageal perforation. In this case report we describe a man who presented with chest pain and was found to have an isolated hemorrhagic pericardial effusion secondary to occult ingestion and pericardial migration of a metallic foreign body. Surgical management was successful, and the patient has recovered well.
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Corpos Estranhos/complicações , Derrame Pericárdico/etiologia , Corpos Estranhos/cirurgia , Humanos , Masculino , Derrame Pericárdico/cirurgiaRESUMO
BACKGROUND: Obtaining National Institutes of Health (NIH) R01 funding remains extremely difficult. The utility of career development grants (K awards) for achieving the goal of R01 funding remains debated, particularly for surgeon-scientists. We examined the success rate for cardiothoracic and vascular (CTV) surgeons compared with other specialties in converting K-level grants into R01 equivalents. METHODS: All K (K08 and K23) grants awarded to surgeons by the NIH between 1992 and 2017 were identified through NIH Research Portfolio Online Report Tools (RePORTER), an online database combining funding, publications, and patents. Only grants awarded to CTV surgeons were included. Grants active within the past year were excluded. Mann-Whitney U tests and χ2 tests were used to compare groups. RESULTS: During this period, 62 K grants were awarded to CTV surgeons. The analysis excluded 16 grants that were still active within the last year. Twenty-two (48%) of the remaining K awardees successfully transitioned to an R01 or equivalent grant. Awardees with successful conversion published nine publications per K grant compared with four publications for those who did not convert successfully (p = 0.01). The median time for successful conversion to an R grant was 5.0 years after the K award start date. Importantly, the 10-year conversion rate to R01 was equal for CTV surgeons compared with other clinician-investigators (52.6% vs 42.5%). CONCLUSIONS: CTV surgeons have an equal 10-year conversion rate to the first R01 award compared with other clinicians. These data suggest that NIH achieves a good return on investment when funding CTV surgeon-scientists with K-level funding.
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Distinções e Prêmios , Organização do Financiamento/estatística & dados numéricos , National Institutes of Health (U.S.)/economia , Cirurgiões/economia , Cirurgia Torácica/economia , Procedimentos Cirúrgicos Vasculares/economia , Sucesso Acadêmico , Bases de Dados Factuais , Feminino , Organização do Financiamento/economia , Humanos , Masculino , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: To minimize the stress of operations, improve the patient experience, reduce variability, and optimize resource utilization, we implemented a thoracic enhanced recovery after surgery (ERAS) protocol and evaluated progress after 1 year. METHODS: Two protocols were developed: video-assisted thoracic surgery (ERAS-VATS) and thoracotomy (ERAS-T). Each incorporated preoperative patient education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, and early ambulation. Patient outcomes, length of stay, pain scores, opioid use, fluid administration, and cost for ERAS patients were compared with historic controls from the year before program initiation. RESULTS: Historic VATS (n = 162) were compared with 81 ERAS-VATS patients. Median postoperative morphine equivalents (86 versus 22 mg, p < 0.0001), total fluid balance (1279 versus 227 mL, p < 0.0001), and mean inflation adjusted hospital costs ($20,169 versus $14,870, p = 0.0003) all decreased significantly. Historic thoracotomy patients (n = 62) were compared with 58 ERAS-T patients. Median postoperative morphine equivalents (130 versus 54 mg, p < 0.0001), total fluid balance (788 versus -489 mL, p = 0.012), length of stay (6.0 versus 4.0 days, p = 0.009), and mean inflation adjusted hospital costs ($41,950 versus $26,089, p < 0.00001) all decreased significantly. CONCLUSIONS: Implementation of thoracic ERAS is a dynamic process with potential to improve outcomes in thoracic surgical procedures. In the first year we shortened length of stay, decreased opioid usage, minimized fluid overload, and decreased hospital costs.
Assuntos
Cirurgia Torácica Vídeoassistida , Toracotomia , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Cirurgia Torácica Vídeoassistida/métodos , Toracotomia/métodos , Fatores de TempoRESUMO
BACKGROUND: Development of curricula that appropriately progress a resident from medical school graduate to fully trained cardiothoracic surgeon is a key challenge for integrated cardiothoracic training programs. This study examined variability and perceived challenges in integrated curricula. METHODS: Responses to the 2016 TSDA/TSRA survey that accompanies the annual in-training exam taken by current cardiothoracic surgery residents were analyzed. Standard statistical methods were utilized to examine trends in participant responses. RESULTS: General surgery experience decreased with post-graduate year, whereas cardiac operative experience increased. Rotations in a wide variety of adjunct fields were common. The majority (87%) of respondents reported had dedicated cardiothoracic intensive care unit (ICU) rotations, and surgical ICU and cardiac care unit rotations were less common (68% and 42%, respectively). The most common surgical subspecialty rotations were vascular (94%) and acute care surgery (88%), with a wide range of clinical exposure (ie, 3-44 weeks for vascular). Importantly, 52% felt competition with general surgery residents for experience and 22.5% of general surgery rotations were at hospitals without general surgery residents. Perceived challenges included optimization of rotations (78%), faculty allowing residents to perform case components (60%), faculty teaching in the operating room (29%), and improving surgical experience on general surgery rotations (19%). CONCLUSIONS: Significant variation exists in integrated cardiothoracic surgery curricula. Optimization of rotations, access to surgical experience, and integration with general surgery appear to be the most significant perceived challenges. These data suggest that optimization of early clinical and surgical experience within institutions could improve trainee preparedness for senior cardiothoracic surgery training.
Assuntos
Currículo , Cirurgia Geral/educação , Internato e Residência , Cirurgia Torácica/educação , Inquéritos e Questionários , Estados UnidosRESUMO
Airway endoscopy has long been an important and useful tool in the management of thoracic diseases. As thoracic specialists have gained experience with both flexible and rigid bronchoscopic techniques, the technology has continued to evolve so that bronchoscopy is currently the foundation for diagnosis and treatment of many thoracic ailments. Airway endoscopy plays a significant role in the biopsy of tumors within the airways, mediastinum, and lung parenchyma. Endoscopic methods have been developed to treat benign and malignant airway stenoses and tracheomalacia. And more recently, techniques have been conceived to treat end-stage emphysema and prolonged air leaks in select patients. This review describes the abundant uses of airway endoscopy, as well as technical considerations and limitations of the current technologies.