Extracorporeal membrane oxygenation for general thoracic surgery: case series and narrative review.

Background and Objective: Extracorporeal membrane oxygenation (ECMO) has historically been utilized as a temporary life support option for patients with severe cardiac and pulmonary dysfunction. Recent advancements have enabled the safe application of ECMO in a wider variety of patients; we present a review of its use in patients undergoing general thoracic procedures supported by a case series at our institution. Methods: We review current literature focusing on ECMO applications in thoracic surgery outside of the traditional use. Additionally, we offer three cases of ECMO utilization to illustrate success stories and key lessons learned regarding the use of ECMO in general thoracic surgery. Key Content and Findings: Technologic advancements and enhanced safety profiles have enabled the safe application of ECMO in a wide array of patients far beyond the historic indications of cardiogenic shock and acute respiratory distress syndrome (ARDS). It is now feasible to consider ECMO for management of acute thoracic emergencies, as well as to better facilitate operative safety in complex general thoracic surgical procedures. Both venovenous and venoarterial ECMO can be utilized in carefully selected patients to provide cardiopulmonary support while enabling improved visualization and increased mobilization without concern for respiratory and/or cardiac compromise. Conclusions: Enthusiasm for the use of ECMO has increased in recent years. What was once considered a salvage therapy in cases of life-threatening cardiopulmonary decompensation now plays an increasingly important role in the safe conduct of complex thoracic surgery procedures, provides much needed time for organ recovery, and offers acute resuscitation options. This shift broadens our ability to deliver life-saving care to patients that previously would have otherwise had limited treatment options.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience.

PURPOSE: Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. METHODS: After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. RESULTS: During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality. CONCLUSION: The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

Surgical Complications of Lung Transplantation.

Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.

Peroral Endoscopic Myotomy for Achalasia.

Peroral endoscopic myotomy surgery is an incisionless, minimally invasive, natural orifice technique used to treat the symptoms of achalasia and other spastic disorders of the esophagus. Recent experience demonstrates that it can be performed safely by experienced esophageal surgeons and there are very good short-term outcomes comparable to laparoscopic myotomy. The rapid worldwide adoption of this technique demonstrates its potential to replace the current therapies available for achalasia. A cautionary note is important in that long-term outcomes are not yet available in terms of dysphagia and GERD symptoms.

Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training.

OBJECTIVE: Transitioning from medical school and general surgery training to cardiothoracic (CT) surgical training poses unique challenges for trainees and patient care. We hypothesized that participation in technology-enhanced simulation modules that provided early exposure to urgent/emergent CT patient problems would improve cognitive skills and readiness to manage common urgencies/emergencies. DESIGN: Traditional and integrated cardiothoracic residents at our institution participated in a technology-enhanced simulation curriculum. The course comprised of didactics, hands-on simulation, virtual models, and mock oral examinations. Residents also were given a validated pretest and post-test to evaluate knowledge retention and integration. Resident performance was graded using a previously validated objective structured clinical examination. Resident perception of course usefulness and relevance was determined through the completion of a perception survey. SETTING: This study occurred at the University of Pittsburgh School of Medicine with the Department of Cardiothoracic Surgery. The facility used was the Peter Winter Institute for Simulation, Education and Research. PARTICIPANTS: From 2013 to 2015, 25 traditional and integrated cardiothoracic residents participated in these training modules who have completed all portions of the simulation were used for analysis. RESULTS: For our participants, knowledge base significantly increased by 7.9% (pretest = 76.0% vs. post-test = 83.9%, p < 0.01). According to trained-rater evaluation, 93.6% of responses to the 11 objective structured clinical examination competencies were deemed adequate. Postcourse perception survey demonstrated 92% of participants scoring the sessions as important or very important toward development and confidence in managing the cardiothoracic scenarios. These findings were present despite historical assumption that these learners were prepared for complex patient care. CONCLUSIONS: After completing a technology-enhanced course combining didactics, simulation, and real-time assessment, residents demonstrated objective improvements in cognitive skills and readiness in managing CT patients. Resident postcourse feedback indicated enhanced confidence, suggesting increased preparedness transitioning to CT surgery. This has strong implications for improved patient safety during these potentially labile transition periods.

Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations.

IMPORTANCE: Aortic clamping technique has been implicated in stroke risk at the time of on-pump coronary artery bypass grafting (CABG) procedures. We hypothesized that partial aortic clamping (PAC) use in performing proximal coronary anastomosis does not increase risk of stroke. OBJECTIVE: To determine whether postoperative stroke incidence is influenced by single aortic clamping (SAC) or side-biting PAC use in performing proximal anastomosis during CABG procedures. DESIGN, SETTING, AND PARTICIPANTS: In a retrospective cohort study, we analyzed data from 1819 patients who underwent conventional, isolated, nonemergent, first-time, arrested-heart, on-pump CABG at a single US major academic, tertiary/quaternary medical center from January 1, 2005, to December 31, 2013. Postoperative stroke was defined according to Society of Thoracic Surgeons (STS) criteria as any confirmed neurological deficit of abrupt onset that did not resolve within 24 hours. Institutional STS data including STS predicted risk of postoperative stroke score were used to compare patients receiving proximal aortic anastomoses performed with either SAC (n = 1107) or combined PAC (n = 712) techniques. EXPOSURES: Use of SAC or PAC in performing proximal coronary anastomosis. MAIN OUTCOMES AND MEASURES: Thirty-day periprocedural postoperative stroke rates. RESULTS: There were no significant differences in preoperative risk or STS predicted risk of mortality between groups. Patients in the SAC group had longer myocardial ischemic time compared with those in the PAC group (mean [SD], 73.2 [22.8] vs 66.5 [22.8] minutes, respectively; P < .001) but shorter overall perfusion time (mean [SD], 96.6 [30.1] vs 102.2 [30.1] minutes, respectively; P < .001). The 30-day observed mortality rates between the SAC and PAC groups were equally low (21 of 1107 patients [1.9%] vs 13 of 712 patients [1.8%], respectively; P > .99) and congruent with STS predicted risk of mortality. Preoperative STS predicted risk of postoperative stroke scores were nearly identical between the SAC and PAC groups (mean [SD], 1.5% [1.4%] vs 1.6% [1.4%]; P = .95), and the 30-day actual observed postoperative stroke rates between the SAC and PAC groups were similar (17 of 1107 patients [1.5%] vs 10 of 712 patients [1.4%], respectively; P > .99). CONCLUSIONS AND RELEVANCE: In this contemporary study of on-pump CABG, we did not identify any significant differences in the incidence of postoperative stroke regardless of the clamping method used to perform proximal anastomosis.

Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review.

BACKGROUND: Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. DATA SOURCES: We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. CONCLUSIONS: Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.

Chordal relocation for repair of anterior mitral leaflet flail: a reproducible option.

Repair of anterior mitral leaflet (AML) flail is considered to be among the more technically challenging mitral procedures. While neochord reconstruction is an excellent technique, sizing challenges may limit wide reproducibility. Chordal relocation of secondary or tertiary AML chords can minimize sizing imprecision in open or minimally invasive repair while providing patients with a safe, durable and reproducible option. Native chords can be readily released and re-implanted from positions in the body of the leaflet to provide primary AML support, provided there is preservation of ipsilateral papillary muscle alignment. We illustrate the sole use of this reproducible method to repair AML flail.

Lysosomal trafficking functions of mucolipin-1 in murine macrophages.

BACKGROUND: Mucolipidosis Type IV is currently characterized as a lysosomal storage disorder with defects that include corneal clouding, achlorhydria and psychomotor retardation. MCOLN1, the gene responsible for this disease, encodes the protein mucolipin-1 that belongs to the "Transient Receptor Potential" family of proteins and has been shown to function as a non-selective cation channel whose activity is modulated by pH. Two cell biological defects that have been described in MLIV fibroblasts are a hyperacidification of lysosomes and a delay in the exit of lipids from lysosomes. RESULTS: We show that mucolipin-1 localizes to lysosomal compartments in RAW264.7 mouse macrophages that show subcompartmental accumulations of endocytosed molecules. Using stable RNAi clones, we show that mucolipin-1 is required for the exit of lipids from these compartments, for the transport of endocytosed molecules to terminal lysosomes, and for the transport of the Major Histocompatibility Complex II to the plasma membrane. CONCLUSION: Mucolipin-1 functions in the efficient exit of molecules, destined for various cellular organelles, from lysosomal compartments.

The plasma membrane calcium ATPase MCA-3 is required for clathrin-mediated endocytosis in scavenger cells of Caenorhabditis elegans.

Plasma membrane Ca2+ ATPases (PMCAs) maintain proper intracellular Ca2+ levels by extruding Ca2+ from the cytosol. PMCA genes and splice forms are expressed in tissue-specific patterns in vertebrates, suggesting that these isoforms may regulate specific biological processes. However, knockout mutants die as embryos or undergo cell death; thus, it is unclear whether other cell processes utilize PMCAs or whether these pumps are largely committed to the control of toxic levels of calcium. Here, we analyze the role of the PMCA gene, mca-3, in Caenorhabditis elegans. We report that partial loss-of-function mutations disrupt clathrin-mediated endocytosis in a class of scavenger cells called coelomocytes. Moreover, components of early endocytic machinery are mislocalized in mca-3 mutants, including phosphatidylinositol-4,5-bisphosphate, clathrin and the Eps15 homology (EH) domain protein RME-1. This defect in endocytosis in the coelomocytes can be reversed by lowering calcium. Together, these data support a function for PMCAs in the regulation of endocytosis in the C. elegans coelomocytes. In addition, they suggest that endocytosis can be blocked by high calcium levels.

Suppression of the cup-5 mucolipidosis type IV-related lysosomal dysfunction by the inactivation of an ABC transporter in C. elegans.

Mutations in MCOLN1, which encodes the protein mucolipin 1, result in the lysosomal storage disease mucolipidosis Type IV. Studies on human mucolipin 1 and on CUP-5, the Caenorhabditis elegans ortholog of mucolipin 1, have shown that these proteins are required for lysosome biogenesis/function. Loss of CUP-5 results in a defect in lysosomal degradation, leading to embryonic lethality. We have identified a mutation in the ABC transporter MRP-4 that rescues the degradation defect and the corresponding lethality, owing to the absence of CUP-5. MRP-4 localizes to endocytic compartments and its levels are elevated in the absence of CUP-5. These results indicate that the lysosomal degradation defect is exacerbated in some cells because of the accumulation of MRP-4 in lysosomes rather than the loss of CUP-5 per se. We also show that under some conditions, loss of MRP-4 rescues the embryonic lethality caused by the loss of the cathepsin L protease, indicating that the accumulation of ABC transporters may be a more general mechanism whereby an initial lysosomal dysfunction is more severely compromised.