Left Thoracoscopic Robot-Assisted Excision of a Left Lower Paratracheal Parathyroid Adenoma for Cure of Primary Hyperparathyroidism.

We present a case of a 38-year-old male patient with symptomatic hypercalcemia secondary to primary hyperparathyroidism. After evaluation, the source of the excess parathyroid hormone was found to be an adenoma localized to the middle mediastinum. Specifically, it was located in the left paratracheal space along the lesser curve of the aortic arch. We discuss this case with a corresponding video to demonstrate the necessary equipment and setup as well as the 5 operative steps recommended to access this paratracheal subaortic location from a minimally invasive transthoracic approach. The pitfalls for this operation are also discussed. The purpose is to make this operation more reproducible for other surgeons.

Evaluating the accuracy of lung-RADS score extraction from radiology reports: Manual entry versus natural language processing.

INTRODUCTION: Radiology scoring systems are critical to the success of lung cancer screening (LCS) programs, impacting patient care, adherence to follow-up, data management and reporting, and program evaluation. LungCT ScreeningReporting and Data System (Lung-RADS) is a structured radiology scoring system that provides recommendations for LCS follow-up that are utilized (a) in clinical care and (b) by LCS programs monitoring rates of adherence to follow-up. Thus, accurate reporting and reliable collection of Lung-RADS scores are fundamental components of LCS program evaluation and improvement. Unfortunately, due to variability in radiology reports, extraction of Lung-RADS scores is non-trivial, and best practices do not exist. The purpose of this project is to compare mechanisms to extract Lung-RADS scores from free-text radiology reports. METHODS: We retrospectively analyzed reports of LCS low-dose computed tomography (LDCT) examinations performed at a multihospital integrated healthcare network in New York State between January 2016 and July 2023. We compared three methods of Lung-RADS score extraction: manual physician entry at time of report creation, manual LCS specialist entry after report creation, and an internally developed, rule-based natural language processing (NLP) algorithm. Accuracy, recall, precision, and completeness (i.e., the proportion of LCS exams to which a Lung-RADS score has been assigned) were compared between the three methods. RESULTS: The dataset includes 24,060 LCS examinations on 14,243 unique patients. The mean patient age was 65 years, and most patients were male (54 %) and white (75 %). Completeness rate was 65 %, 68 %, and 99 % for radiologists' manual entry, LCS specialists' entry, and NLP algorithm, respectively. Accuracy, recall, and precision were high across all extraction methods (>94 %), though the NLP-based approach was consistently higher than both manual entries in all metrics. DISCUSSION: An NLP-based method of LCS score determination is an efficient and more accurate means of extracting Lung-RADS scores than manual review and data entry. NLP-based methods should be considered best practice for extracting structured Lung-RADS scores from free-text radiology reports.

Ultralow-Dose Dynamic Expiratory CT and Repeated Imaging Enhance Evaluation for Tracheomalacia.

OBJECTIVE: This study aims to determine if a novel imaging protocol (ultralow-dose dynamic expiratory computed tomography [CT] with repeated imaging) identifies tracheomalacia (TM) more reliably than traditional dynamic tracheal CT. METHODS: We performed a retrospective evaluation of 184 consecutive ultralow-dose dynamic CTs for TM during 2017. The protocol obtains images during 1 inspiration and 2 forced expirations. Tracheal narrowing during both expirations (airway narrowing [percentage] during first dynamic expiration CT [DE1], airway narrowing [percentage] during second dynamic expiration CT [DE2]) was reported as a percentage of inspiratory area. We identified maximum narrowing of each patient's sequence (maximum narrowing [percentage] on either dynamic expiration CT [DEmax] = greatest narrowing of DE1 or DE2) and compared DE1, DE2, and DEmax in individual studies and between patients. Outcomes included frequency of TM, tracheal narrowing, and severity. Reliability was assessed by comparing tracheal area narrowing and TM grade. RESULTS: There was significantly more airway narrowing using 2 expiratory image acquisitions. Average DEmax tracheal area was 12% narrower than DE1 alone and 21% worse than DE2 alone (both P < 0.001). Using DEmax, TM was diagnosed 35% more often than DE1 alone and 31% more often than DE2 alone ( P < 0.001). DEmax identified more severe distribution of TM compared with DE1 or DE2 alone ( P < 0.001). Reliability between DE1 and DE2 was good for tracheal narrowing and moderate for TM grade. The mean effective radiation dose was 2.41 millisievert (mSv) for routine inspiration CT and 0.07 mSv for each dynamic expiration CT (total effective radiation, 2.55 mSv). CONCLUSIONS: Dynamic expiration CT with 2 expiratory image acquisitions enhanced evaluation of TM, minimally increased radiation dose, and should be considered as a noninvasive screening option.

Outcomes and Direct Cost of Isolated Nonemergent CABG in Patients With Low Ejection Fraction.

OBJECTIVE: Preoperative left ventricular ejection fraction (LVEF) is one of the main predictors of outcomes in cardiac surgery. We present current era outcomes and associated direct cost in nonemergent isolated coronary artery bypass surgery (CABG) patients with LVEF <20% over the past 6 years and compare it with higher EF subgroups. METHODS: Six-year data from 2016 to 2022 at hospitals sharing Society of Thoracic Surgeons and financial data with Biome Analytics were analyzed based on 3 EF subgroups (EF ≤20%, EF 21% to 35%, and EF >35%). Outcomes and costs were assessed. RESULTS: Overall 30-day mortality of 12,649 patients was 1.9%. The EF ≤20% (n = 248), EF 21% to 35% (n = 1,408), and EF >35 (n = 10,993) cohorts had mortality of 6.9%, 3.7%, and 1.6%, respectively. The EF ≤20% subgroup had higher use of cardiopulmonary bypass, blood products, and mechanical support. In addition, the EF ≤20% subgroup had higher complication rates in almost all measured categories. Also, the EF ≤20% cohort had significantly higher length of stay, intensive care unit (ICU) hours, ICU and hospital readmissions, and lowest discharge to home rate. The strongest factors associated with mortality were postoperative cardiac arrest, renal failure requiring dialysis, extracorporeal membrane oxygenation, sepsis, prolonged ventilation, and gastrointestinal event. The overall median direct cost of care was $37,387.79 ($27,605.18, $51,720.96), with a median direct cost of care in the EF ≤20%, EF 21% to 35%, and EF >35% subgroups of $52,500.17 ($34,103.52, $80,806.79), $44,108.32 ($31,597.58, $63,788.03), and $36,521.80 ($27,168.91, $50,019.31), respectively. CONCLUSIONS: In nonemergent isolated CABG surgery, low EF continues to have higher surgical risks and higher direct cost of care despite advances in cardiovascular care.

Long-term Outcomes After Lung Cancer Resection in Smokers: Analysis of the National Lung Screening Trial.

BACKGROUND: Smoking is a known risk factor for perioperative complications after lung resection; however, little data exists looking at the impact of smoking status (current versus former) on long-term oncologic outcomes after lung cancer surgery. We sought to compare overall survival (OS), progression-free survival (PFS), and cancer-specific mortality (CSM) in current and former smokers using data from the National Lung Screening Trial (NLST). Additionally, we performed subset analysis in current smokers in order to evaluate the effect of modern surgical techniques on long-term outcomes. METHODS: Patients with clinical stage IA or IB NSCLC who underwent upfront resection within 180 days of diagnosis were identified in the NLST database. Cox proportional hazard regression models were used to assess differences in patient and treatment characteristics with respect to OS and PFS, with a cause-specific hazard model used for CSM. RESULTS: A total of 593 patients were included in the study (269 former smokers, 324 current smokers). Lobar resection (LR) was performed more often than sublobar resection (SLR) (481 vs. 112), and thoracotomy was performed more often than thoracoscopy (482 vs. 86). Comparison of current versus former smokers showed no difference in OS or PFS after resection. Higher CSM was seen in current smokers (p = 0.049). Subset analysis of current smokers revealed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Although higher CSM was associated with thoracoscopy versus thoracotomy in this group, this finding was limited by a relatively small thoracoscopy sample size of 44 patients (p = 0.026). CONCLUSION: Our analysis of the NLST database shows no significant difference in OS and PFS when comparing current and former smokers undergoing resection for stage I NSCLC. Active smoking status was associated with higher CSM. Subset analysis of current smokers showed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Higher CSM was seen in current smokers who underwent thoracoscopy compared to thoracotomy; however, this finding was limited by a small sample size.

Impact of postoperative complications on long-term survival after esophagectomy in older adults: A SEER-Medicare analysis.

BACKGROUND: Esophagectomy is a complex procedure associated with a high rate of postoperative complications. It is not clear whether postoperative complications effect long-term survival. Most studies report the results from single institutions. METHODS: We examined the Surveillance, Epidemiology and End Results (SEER)-Medicare database to assess whether long-term overall and cancer-specific mortality of patients undergoing esophagectomy for cancer is impacted by postoperative complications. RESULTS: Nine hundred and forty patients underwent esophagectomy from 2007 to 2014, of which 50 died, resulting in a cohort of 890 patients. Majority were males (n = 764, 85.8%) with adenocarcinoma of the lower esophagus. Almost 60% of the group had no neoadjuvant therapy. Four hundred and fifty-five patients had no major complications (51.1%), while 285 (32.0%) and 150 (16.9%) patients had one, two, or more major complications, respectively. Overall survival at 90 days was 93.1%. Multivariate analysis of patients followed up for a minimum of 90 days demonstrated that the number of complications was significantly associated with decreased overall survival but no impact on cancer-specific survival. CONCLUSIONS: Our population-based analysis with its inherent limitations suggests that patients undergoing esophagectomy who experience complications have worse overall survival but not cancer-specific survival if they survive at least 90 days from the date of surgery.

Effect of On-Site Cardiac Surgery Program on General Thoracic Surgery Outcomes.

OBJECTIVE: Limited data exist exploring the relationship between multispecialty surgical collaboration and outcomes in general thoracic surgery. To address this, the Nationwide Inpatient Sample (NIS) was analyzed to determine whether the presence of an on-site cardiac surgery program is associated with improved general thoracic surgery outcomes. METHODS: The NIS (1999-2008) was utilized to identify 389,959 patients who had a lobectomy, pneumonectomy, or esophagectomy. Short-term outcomes of patients undergoing these procedures were compared between hospitals with and without an on-site cardiac surgery program. Univariate and multivariate analyses were performed to determine patient and hospital predictors of mortality and morbidity. RESULTS: During the study period, patients undergoing lobectomy (n = 314,130), pneumonectomy (n = 34,860), or esophagectomy (n = 40,969) were identified. Univariate analysis demonstrated lower mortality for lobectomy (P < 0.001) and esophagectomy (P < 0.001) but not pneumonectomy (P = 0.344) in hospitals with a cardiac surgery program. All-cause morbidity was significantly lower for all 3 procedures in hospitals with a cardiac surgery program. However, multivariate analysis demonstrated that a cardiac surgery program was not an independent predictor when adjusted for known confounders, particularly procedure volume and hospital academic teaching status. CONCLUSIONS: The presence of an on-site cardiac surgery program is not in and of itself associated with improved general thoracic surgery outcomes. The presence of a cardiac surgery program is likely a surrogate for other known predictors of improved outcomes such as hospital teaching status and procedure volume.

Morbidity and mortality after general surgery in heart and lung transplant patients.

BACKGROUND: Heart and lung transplant patients can develop conditions necessitating general surgery procedures. Their postoperative morbidity and mortality remain poorly characterized and limited to case series from select centers. METHODS: The National Inpatient Sample (1998-2015) was used to identify 6433 heart and 3015 lung transplant patient admissions for general surgery procedures. For a comparator group, we identified 23,764,164 nontransplant patient admissions for the same procedures. Patient morbidity and mortality after general surgery were compared between transplant patients and nontransplant patients. Data were analyzed with frequency tables, χ 2 analysis, and a mixed-effects multivariate regression. RESULTS: Overall mortality was higher and length of stay longer in the transplant group compared to the nontransplant group. Analysis revealed that hospital size and comorbidities were predictors of mortality for patients undergoing certain general surgery procedures. Transplant status alone did not predict mortality. CONCLUSION: Our findings demonstrate that heart and lung transplant patients, compared to nontransplant patients, have more complications and a higher length of stay after certain general surgery procedures.

Fibrosing Mediastinitis Requiring Multimodality Treatment to Maintain Pulmonary Vein Patency.

Fibrosing mediastinitis is a rare condition with limited epidemiologic data. We detail a case of a 43-year-old female with no past medical history, who presented with chest pain and dyspnea on exertion. Chest computed tomography revealed a large mediastinal mass that was invading into the anterior chest as well as encasing the pulmonary hilum. Surgical pathology returned as dense hyaline fibrosis tissue with focal histiocytic aggregates and giant cells consistent with fibrosing mediastinitis. Treatment with rituximab and steroids showed a reduction in the size of her mass.

A Comparative Analysis of Long-Term Survival of Robotic Versus Thoracoscopic Lobectomy.

BACKGROUND: Minimally invasive lobectomy can be performed robotically or thoracoscopically. Short-term outcomes between the 2 approaches are reported to be similar; however, the comparative oncological effectiveness is not known. We sought to compare long-term survival after robotic and thoracoscopic lobectomy. METHODS: We performed a propensity-matched analysis of SEER (Surveillance, Epidemiology and End Results)-Medicare patients with non-small cell lung cancer from 2008 to 2013 who underwent minimally invasive lobectomy using either a thoracoscopic (n = 3881) or a robotic-assisted (n = 426) approach. Patients in the 2 groups were propensity matched 1:1 based on demographics, comorbidities, treatment, and tumor characteristics. We compared the overall survival (OS) and cancer-specific mortality (CSM) between the 2 groups. RESULTS: Within the matched cohort (n = 409 per group), the median age at surgery was 73 (range, 65-91) years, with a median follow-up of 35 months postsurgery. There was no difference in OS or CSM between the thoracoscopic and robotic-assisted groups (OS: 71.4% vs 73.1% at 3 years, overall P = .366; CSM: 16.6% vs 14.9% at 3 years, overall P = .639). CONCLUSIONS: Our propensity-matched analysis demonstrates that patients undergoing robotic-assisted lobectomy have similar OS and CSM compared with those patients undergoing thoracoscopic lobectomy. Oncologic outcomes are similar between the 2 minimally invasive approaches. These results demonstrate that further investigation is needed in the form of a randomized control trial, its variations, or additional large-scale registry analyses to verify these results.

Disparities in utilization of services for racial and ethnic minorities with hepatocellular carcinoma associated with hepatitis C.

BACKGROUND: Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population. METHODS: We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics. RESULTS: In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality. CONCLUSION: We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies.

Disparities in Follow-Up After Low-Dose Lung Cancer Screening.

The National Lung Cancer Screening Trial (NLST) demonstrated an improvement in overall survival with lung cancer screening. Achieving follow-up for a positive screen is essential to impact early intervention for lung cancer. The objective of this study was to determine predictors of follow-up after a positive lung cancer screening test. The NLST database was queried for participants with a positive lung cancer screening exam. This cohort was then subdivided into patients who had follow-up and those who did not. Pairwise comparison was performed within different subgroups. A logistic regression model was then utilized to identify predictive factors associated with follow-up. Of the 53,454 patients who participated in the study, we identified 14,000 patients who had a positive lung cancer screening test. Of those patients, 12,503 followed up appropriately (89.3%). Women had a statistically higher follow-up rate compared to men (90% vs 88.8%, P ≤ 0.05). Patients reported as married or living as married also showed a higher rate of follow-up compared to patients reported as never married, divorced, separated, or widowed (90.2% vs 87.5%, P ≤ 0.05). The rate of follow-up among African-American patients was 82.8%, while those in white patients was 89.6%, this was statistically significant (P ≤ 0.05). Education level was not a significant factor in follow-up rates. Current smokers followed up at lower rates compared to former smokers (87.9 % vs 90.6%, P ≤ 0.05). Logistic regression determined gender, marital status, race, and smoking status to be predictors of follow-up. Follow-up rates after a positive lung cancer screening test were associated with a patient's gender, marital status, race, and smoking status.

Modified Blood Patch Used to Treat a High Output Chyle Leak After McKeown Esophagectomy.

Chyle leaks after esophagectomy are associated with significant morbidity and mortality. High-output fistulas are particularly difficult to manage, as the likelihood of spontaneous closure with conservative management is low. Leaks that fail to resolve with conservative management are referred for thoracic duct ligation or embolization. Some patients, however, are not candidates for these procedures or have persistent output despite intervention. We report a case of a post-McKeown esophagectomy patient with a high-output chyle leak despite intraoperative thoracic duct ligation. Treatment was successful with a modified blood patch through a neck drain.