Racial and Ethnic Variations in Patients Undergoing Mitral and Tricuspid Valve Surgery.

INTRODUCTION: Prior investigations assessing the impact of race/ethnicity on outcomes after mitral valve (MV) surgery have reported conflicting findings. This analysis aimed to examine the association between race/ethnicity and operative presentation and outcomes of patients undergoing MV and tricuspid valve (TV) surgery. METHODS: We retrospectively analyzed 5984 patients (2730 female, median age 63 y) who underwent MV (n = 4,534, 76%), TV (n = 474, 8%) or both MV and TV (n = 976, 16%) surgery in a statewide collaborative from 2012 to 2021. The influence of race/ethnicity on preoperative characteristics, MV and TV repair rates, and postoperative outcomes was assessed for White (n = 4,244, 71%), Black (n = 1,271, 21%), Hispanic (n = 144, 2%), Asian (n = 171, 3%), and mixed/other race (n = 154, 3%) patients. RESULTS: Black patients, compared to White patients, had higher Society of Thoracic Surgeons predicted risk of morbidity/mortality (24.5% versus 13.1%; P < 0.001) and more comorbid conditions. Compared to White patients, Black and Hispanic patients were less likely to undergo an elective procedure (White 71%, Black 55%, Hispanic 58%; P < 0.001). Degenerative MV disease was more prevalent in White patients (White 62%, Black 41%, Hispanic 43%, Asian 51%, mixed/other 45%; P < 0.05), while rheumatic disease was more prevalent in non-White patients (Asian 28%, Hispanic 26%, mixed/other 25%, Black 17%, White 10%;P < 0.05). After multivariable adjustment, repair rates and adverse postoperative outcomes, including mortality, did not differ by racial/ethnic group. CONCLUSIONS: Patient race/ethnicity is associated with a higher burden of comorbidities at operative presentation and MV disease etiology. Strategies to improve early detection of valvular heart disease and timely referral for surgery may improve outcomes.

Transected thin melanoma: Implications for sentinel lymph node staging.

BACKGROUND AND OBJECTIVES: Indications for sentinel lymph node (SLN) biopsy in patients with thin melanoma (≤1 mm thick) are controversial. We asked whether deep margin (DM) positivity at initial biopsy of thin melanoma is associated with SLN positivity. METHODS: Cases were identified using prospectively maintained databases at two melanoma centers. Patients who had undergone SLN biopsy for melanoma ≤1 mm were included. DM status was assessed for association with SLN metastasis in univariate and multivariate analyses. RESULTS: 1413 cases were identified, but only 1129 with known DM status were included. 39% of patients had a positive DM on original biopsy. DM-positive and DM-negative patients did not differ significantly in primary thickness, ulceration, or mitotic activity. DM-positive and DM-negative patients had similar incidence of SLN metastasis (5.7% vs 3.5%; P = 0.07). Positive DM was not associated with SLN metastasis on univariate analysis (OR 1.69, 95% CI: 0.95-3.00, P = 0.07) or on multivariate analysis adjusted for Breslow depth, Clark level, mitotic rate, and ulceration (OR = 1.59, 95% CI: 0.89-2.85; P = 0.12). CONCLUSIONS: For patients with thin melanoma, a positive DM on initial biopsy is not associated with risk of SLN metastasis, so DM positivity should not be considered an indication for SLN staging in an otherwise low-risk patient.

Comparing International and United States Undergraduate Medical Education and Surgical Outcomes Using a Refined Balance Matching Methodology.

OBJECTIVE: The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs). SUMMARY OF BACKGROUND DATA: IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined. METHODS: Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008-2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance. RESULTS: We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ±â€Š5.1 vs 57.8 ±â€Š8.4, P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent. CONCLUSION: Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat.

Predictors of false negative sentinel lymph node biopsy in trunk and extremity melanoma.

BACKGROUND: Nodal recurrence following negative sentinel lymph node biopsy (SLNB) for melanoma is known as false-negative (FN) SLNB. Risk factors for FN SLNB among patients with trunk and extremity melanoma have not been well-defined. METHODS: After retrospective review, SLNB procedures were classified FN, true positive (TP; positive SLNB), or true negative (TN; negative SLNB without recurrence). Factors associated with high false negative rate (FNR) and low negative predictive value (NPV) were identified by comparing FNs to TPs and TNs, respectively. Survival was evaluated using Kaplan-Meier methods. RESULTS: Of 1728 patients, 234 were TP and 37 were FN for overall FNR of 14% and NPV of 97.5%. Age ≥65 years was independently associated with high FNR (FNR 20% in this group). Breslow thickness >1 mm and ulceration were independently associated with low NPV. Among patients with ulcerated tumors >4 mm, NPV was 88%. Median time to recurrence for FNs was 13 months. Among patients with primary melanomas ≤2 mm in depth, overall and distant disease-free survival were significantly shorter with FN SLNB than TP SLNB. CONCLUSIONS: Older age is associated with increased FNR; patients with thick, ulcerated lesions should be considered for increased nodal surveillance after negative SLNB given low NPV in this group.

Racial Disparities in Initial Presentation of Benign Thyroid Disease for Resection.

BACKGROUND: Racial disparities exist in thyroidectomy outcomes. One contributing factor may be the disease state upon presentation to a surgeon. Minorities with thyroid cancer present at a later disease stage and with larger tumors. This relationship has not been examined for benign thyroid disease. We sought to examine the association between race, referral patterns, and disease severity for benign thyroid conditions. METHODS: We analyzed all patients receiving a thyroidectomy for benign disease in our institutional endocrine surgery registry. Patient demographics, disease history, disease severity, and postoperative outcomes were investigated. Univariate analysis compared black and white patients. Multivariable linear regression examined the relationship between race and time to surgical referral. RESULTS: Of the 1189 patients studied, the majority (86.0 %) were white. Black and white patients differed in median income and reason for referral. When compared with white patients, black patients more commonly presented with compressive symptoms (black: 45.0 % vs. white: 21.2 %, p < .01) and dysphagia (19.0 % vs. 10.1 %, p < .01), and after a longer disease duration [black: median 0 years (interquartile ratio, IQR, 0-5) vs. white: 0 years (IQR, 0-2)]. Blacks also had larger glands than white [median 71 grams (IQR, 33.5-155.3) vs. 24.3 grams (IQR, 15.0-50.2)]. With the exception of reintubation rate, there were no differences in postoperative outcomes. CONCLUSIONS: Black patients with benign thyroid conditions have a longer time to surgical referral and present for surgical evaluation with more severe disease than white patients. Identification of these disparities is the first step in eliminating differences in patient care.

Role of adrenal vein sampling in primary aldosteronism: Impact of imaging, localization, and age.

BACKGROUND: The role of adrenal vein sampling (AVS) has been debated, with some authorities advocating selective use in younger patients (≤40 years), and those localized by preoperative imaging. We examined our experience to determine the impact of AVS in patients who routinely underwent AVS with a high success rate. METHODS: A retrospective cohort study was performed using a prospectively maintained database of patients referred for evaluation of PA (1997-2013). Patients were classified as localized (L) if a unilateral mass was identified on imaging, and non-localized (NL) otherwise. RESULTS: Of 367 patients, 94% (n = 345) underwent successful AVS. Seventy-two percent (n = 265) were L; AVS was lateralizing 58% (n = 214). AVS changed management in 43% of patients (n = 158). In patients ≤40 years, AVS changed management in 30% (n = 15). In patients ≤40 years with a ≥1 cm adrenal mass, 12% (n = 3) would have undergone unnecessary surgery based on imaging results alone; in patients >40 years with a ≥1 cm adrenal mass, 3% (n = 5) would have undergone wrong-side surgery, and 30% (n = 50) would have undergone unnecessary surgery based on imaging. CONCLUSION: AVS changed management in a significant minority of patients regardless of age and imaging findings. AVS should be routinely recommended in all patients with PA, to direct operative therapy. J. Surg. Oncol. 2016;113:532-537. © 2016 Wiley Periodicals, Inc.

Preoperative Metyrosine Improves Cardiovascular Outcomes for Patients Undergoing Surgery for Pheochromocytoma and Paraganglioma.

BACKGROUND: The goal of preoperative pharmacotherapy for pheochromocytoma (PCC) and paraganglioma (PGL) resection is to minimize intraoperative hemodynamic instability and perioperative cardiovascular complications, but no standard preoperative regimen exists. Historically, treatment used metyrosine and phenoxybenzamine (MP). The recent metyrosine shortage required that phenoxybenzamine alone (PA) be used for treatment. The authors examined their experience to determine the impact of preoperative metyrosine treatment on patient outcomes. METHODS: A retrospective cohort study investigated patients who underwent initial PCC/PGL resection (2000-2014). The primary outcome was intraoperative hemodynamics, measured by heart rate (HR) and systolic blood pressure (SBP). The secondary outcomes included perioperative complications and cardiovascular-specific complications (CVC). Univariate analysis was performed, and adjusted risk differences were estimated after confounding was taken into account. RESULTS: Of 174 patients, 142 (81.6 %) were in the MP group. The MP and PA patients had comparable intraoperative use of antihypertensives (83.9 vs 78.1 %; p = 0.443), vasopressors (74.6 vs 87.5 %; p = 0.120), and fluid resuscitation (mean, 24.4 vs 24.8 ml/min; p = 0.761). Although the perioperative complication rate did not differ significantly between the MP and PA groups (respectively 23.4 vs 34.4 %; p = 0.198), the PA patients had a 15.8 % higher rate of CVC even after controlling for confounders (p = 0.034). Compared with the MP patients, the PA patients had significantly more hemodynamic instability intraoperatively, with a greater range in HR (7.4 bpm; p = 0.034) and SBP (14.8 mmHg; p = 0.020). CONCLUSIONS: In this study, preoperative metyrosine improved intraoperative hemodynamic stability and decreased CVC rates in patients undergoing PCC/PGLresection. These data suggest that the addition of preoperative metyrosine may improve operative outcomes.

Robot-assisted thoracoscopic repair of tracheal gunshot wound.

A 23-year-old man suffered two gunshot wounds and upon arrival to the emergency room was found on imaging to have a large pneumothorax with considerable subcutaneous emphysema. Intubation and placement of bilateral chest tubes did not improve the patient's oxygenation; bronchoscopy revealed a 1 cm tracheal defect in the membranous wall 4 cm proximal to the carina. The patient underwent robot-assisted primary repair of the tracheal injury with a #3-0 PDS Stratafix barbed suture buttressed with an intercostal muscle flap. The patient was discharged in good condition on post-operative day 17, with follow-up bronchoscopy showing complete healing of the trachea.

Unusual presentation and delayed diagnosis of cardiac angiosarcoma.

BACKGROUND: Primary cardiac angiosarcomas are very rare and present aggressively with high rates of metastasis. Given the poor prognosis, particularly once disease has spread, early diagnosis and multidisciplinary treatment is essential. CASE PRESENTATION: We present the case of a 46-year-old male who presented with chest pain, intermittent fevers, and dyspnea. Workup with computed tomography scan and transesophageal echocardiography demonstrated a right atrial pseudoaneurysm. Given the concern for rupture, the patient was taken to the operating room, where resection of the pseudoaneurysm and repair using a bovine pericardial patch was performed. Histopathology report initially demonstrated perivascular lymphocyte infiltrate. Six weeks later, the patient represented with chest pain and new word finding difficulty. Workup revealed multiple solid lung, pericardial, brain, and bone nodules. Eventual biopsy of a cardiophrenic nodule demonstrated angiosarcoma, and rereview of the original pathology slides confirmed the diagnosis of primary cardiac angiosarcoma. CONCLUSIONS: Primary cardiac angiosarcomas are often misdiagnosed given the rarity of these tumors, but early diagnosis and initiation of treatment is essential. The unique presentation of our case demonstrates that clinical suspicion for cardiac angiosarcoma should be maintained for spontaneous pseudoaneurysm originating from the right atrium.

Surgery for metastatic neuroendocrine tumors with occult primaries.

INTRODUCTION: Neuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively. MATERIALS AND METHODS: Patients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared. RESULTS: Sixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively. CONCLUSION: The primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.

How To Do It: Mitral Valve Translocation.

Mitral valve translocation (MVT) is a novel procedure that was developed to treat patients with severe, symptomatic, secondary mitral regurgitation (MR). MVT enhances leaflet coaptation by insertion of an autologous pericardial patch interposed between the mitral annulus and the native mitral leaflets. The patch substantially increases total leaflet surface area and creates supranormal coaptation. In addition, it relieves leaflet tethering by transposing the native valve deeper into the ventricle and decreases the circumference of the annulus. The enhanced coaptation produced by MVT may protect against recurrent MR in patients with continued adverse left ventricular remodeling. The procedural steps include detachment of the intact native mitral valve at the annulus, placement of interrupted pledgeted sutures around the annulus to secure the proximal aspect of the patch, and attachment of the native valve to the distal aspect of the patch using running suture. Follow-up of patients who have undergoing MVT is ongoing, with satisfactory short-term results, including sustained MR grades of ≤mild and 14 mm coaptation at 12 months.

Ascending aorta thoracic endovascular aortic repair for infected pseudoaneurysm.

A 70-year-old woman with a bioprosthetic aortic valve replacement for aortic valve endocarditis complicated by recurrent endocarditis and requiring homograft aortic root replacement 10 years earlier had presented at 1 month after her admission for pseudomonal bacteremia with right-sided chest pain. An aortic pseudoaneurysm, identified on computed tomography, was treated with an ascending aorta thoracic endovascular aortic repair using two overlapping abdominal aortic stent grafts in the ascending aorta. Postoperative and follow-up imaging demonstrated exclusion of the pseudoaneurysm with stable positioning of the stent grafts. Ascending aorta thoracic endovascular aortic repair can be performed safely with good short-term results in patients presenting with infected pseudoaneurysms of the ascending aorta.

Double adenoma as a cause of primary hyperparathyroidism: Asymmetric hyperplasia or a distinct pathologic entity?

BACKGROUND: Primary hyperparathyroidism (PHPT) caused by double adenoma may carry a higher risk of failure to cure. We compared outcomes in single adenoma (SA), double adenoma (DA) and four-gland hyperplasia (HP). METHODS: Patients undergoing initial parathyroidectomy for PHPT were categorized by diagnosis. The primary outcome was persistent/recurrent disease postoperatively. RESULTS: Of 3408 patients, 81.3% had SA, 9.5% had DA, and 9.3% had HP. Rates of persistence/recurrence were 2.9%, 5.3%, and 4.5% in SA, DA, and HP, respectively (p = 0.281). Patients with persistence/recurrence had higher preoperative calcium (11.0 vs 10.7 mg/dl, p = 0.028) and PTH (96 vs 77 pg/ml, p = 0.015), and lower rates of IOPTH normalization (77% vs 96%, p < 0.001). On multivariable analysis, DA was associated with increased risk of persistent/recurrent disease (OR 3.0, p = 0.017). CONCLUSIONS: Most patients with DA are cured with removal of two glands, but approximately 5% experience disease persistence/recurrence. Low-normal final IOPTH was associated with lower risk of persistent/recurrent disease.

Sarcina Organisms in the Upper Gastrointestinal Tract: A Report of 3 Cases With Varying Presentations.

Sarcina species are anaerobic gram-positive cocci rarely seen in the upper gastrointestinal tract and associated with delayed gastric emptying. We present 3 cases of Sarcina infection with varying clinical presentations including the first reported case of Sarcina in a patient with eosinophilic esophagitis. Although the pathogenesis of Sarcina is unclear, awareness of the bacteria is important as they can usually only be detected on histopathologic examination of upper gastrointestinal biopsies. Treatment in symptomatic patients may prevent severe complications such as emphysematous gastritis and gastric perforation.

Pulmonary Mucormycosis Treated With Lobectomy.

A 57 year old man was referred from an outside facility for an unresolving pneumonia. Imaging of the chest demonstrated a right lung mass with a consolidation in the middle lobe, pleural effusion, and mediastinal lymphadenopathy. Cytologic examination of cultures from the bronchoscopy and thoracentesis did not yield a definitive diagnosis. Video-assisted thoracoscopic surgery (VATS) was performed because of a retained hemothorax and a suggestive lesion. Biopsy specimens obtained during VATS were consistent with mucormycosis. The patient underwent a middle lobectomy and pleurectomy without any adverse event. When bronchoscopy and thoracentesis cannot provide a diagnosis, thoracoscopic pleural biopsy can be the next step in the diagnosis of mucormycosis.

Treatment for sternoclavicular joint infections: a multi-institutional study.

BACKGROUND: Sternoclavicular joint (SCJ) infections are rare and difficult to manage. Surgery is necessary for treatment. METHODS: A retrospective chart review of the university hospital and Veterans Administration (VA) hospitals of all patients treated for SCJ infections since 2001 was conducted. Fifteen [15] patients were identified and evaluated for the types of infections, risk factors, treatments and survival. RESULTS: All 15 patients were symptomatic including: pain [13], erythema [9], purulent drainage [3], fever greater than 38.3 °C [2], and leukocytosis [9]. The associated medical problems included: diabetes mellitus (DM), hypertension (HTN) and renal failure. All patients underwent intraoperative joint resection. Sixty-seven percent (67%) of intraoperative wound cultures grew staphylococcus aureus. Fourteen patients were discharged on intravenous antibiotics. The follow-up ranged between 1 week-11 months. Thirteen patients are currently alive without infection. Two patients died: 1 of sepsis and 1 of unknown causes after discharge. CONCLUSIONS: Symptomatic SCJ infections require surgical intervention. The most common organism was staphylococcus aureus.

Tracheal Chondrosarcoma: Systematic Review of Tumor Characteristics, Diagnosis, and Treatment Outcomes with Case Report.

To our knowledge this is the first systematic review of tracheal chondrosarcoma treatment outcomes. Management insights are thoroughly discussed. Men constitute 93.8% of cases, and most of these occur in the distal trachea. The most common symptom, dyspnea, occurs in virtually all patients. Extratracheal extension had occurred in 78.6% of patients. Definitive treatment with tracheal resection showed no recurrences in 10 patients with mean follow-up of 3.1 years. Adjuvant radiotherapy may be utilized for improving local control when open complete resection cannot be performed, but only after endoscopic excision of gross tumor.

The use of thrombolytics in the management of complex pleural fluid collections.

BACKGROUND: To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. METHODS: We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). RESULTS: One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. CONCLUSIONS: Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.