Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial.

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV1 from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV1 showed statistically significant improvements between the treatment and control groups-between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060-0.141) and 0.099 L (95% BCI, 0.048-0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

When the Gastrointestinal Conduit for Total Esophageal Reconstruction Is Not an Option: Review of the Role of Skin Flaps and Report of Salvage With a Single-Stage Tubed Anterolateral Thigh Flap.

This review adds to the limited body of literature describing the use of skin flaps for reconstruction of the esophagus and includes a report of a successful 1-stage, intrathoracic reconstruction of the cervical and thoracic esophagus after failed gastrointestinal conduit. Already widely used for reconstruction of the pharynx and cervical esophagus, the versatile anterolateral thigh flap can be considered an option for more extensive defects of the cervical and thoracic esophagus in this challenging patient population when gastric, jejunal, or colon conduits are not available. The authors believe the anterolateral thigh flap should be considered in 1-stage anatomic reconstruction of the cervical and thoracic esophagus in the absence of feasible gastrointestinal conduits.

Primary pulmonary leiomyosarcoma with invasion of the pulmonary vein-A case report.

INTRODUCTION: Primary pulmonary leiomyosacromas are a subset of the rare sarcomatous lung neoplasms, found to be less than 0.5% of the organ's primary malignant tumors (Attanoos et al., 1996). PRESENTATION OF CASE: We describe here a case of a 69-year-old woman who presented with heart palpitations, incidentally found to have a large lung mass abutting the left inferior pulmonary veins. Challenging tissue diagnosis led to invasive alternatives; attempted full neoplastic resection and pneumonectomy. DISCUSSION: The mainstay of treatment for these tumors is complete surgical resection. Chemotherapy and radiation can be helpful adjuncts as well. CONCLUSION: This case presents a unique invasion pattern of a primary leiomyosarcoma of the lung, our diagnostic process, and surgical intervention.

Roux-en-Y diversion for debilitating reflux after esophagectomy.

Two patients with debilitating reflux after esophagectomy are reported. Complete relief of symptoms after creation of a Roux-en-Y limb to the gastric conduit is described.

A novel approach to the management of tracheoinnominate artery fistula.

A 75-year-old gentleman with tracheoinnominate fistula is reported. The issues regarding the surgical approach to this problem are reviewed and a creation of an aorto-axillary bypass graft described.

First nationwide survey of US integrated 6-year cardiothoracic surgical residency program directors.

OBJECTIVE: The recently implemented integrated 6-year (I-6) format represents a significant change in cardiothoracic surgical residency training. We report the results of the first nationwide survey assessing I-6 program directors' impressions of this new format. METHODS: A 28-question web-based survey was distributed to program directors of all 24 Accreditation Council for Graduate Medical Education-accredited I-6 training programs in November 2013. The response rate was a robust 67%. RESULTS: Compared with graduates of traditional residencies, most I-6 program directors with enrolled residents believed that their graduates will be better trained (67%), be better prepared for new technological advances (67%), and have superior comprehension of cardiothoracic disease processes (83%). Just as with traditional program graduates, most respondents believed their I-6 graduates would be able to independently perform routine adult cardiac and general thoracic operations (75%) and were equivocal on whether additional specialty training (eg, minimally invasive, heart failure, aortic) was necessary. Most respondents did not believe that less general surgical training disadvantaged I-6 residents in terms of their career (83%); 67% of respondents would have chosen the I-6 format for themselves if given the choice. The greater challenges in training less mature and experienced trainees and vulnerability to attrition were noted as disadvantages of the I-6 format. Most respondents believed that I-6 programs represent a natural evolution toward improved residency training rather than a response to declining interest among medical school graduates. CONCLUSIONS: High satisfaction rates with the I-6 format were prevalent among I-6 program directors. However, concerns with respect to training relatively less experienced, mature trainees were evident.

Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin.

BACKGROUND: Thoracic residency program enrollment continues to decline. While job market and decreasing reimbursements are often cited as the main reasons, length of and format of training may also be significant. METHODS: The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program. RESULTS: Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional 2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees. CONCLUSIONS: Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.

Serratus anterior in vivo contractile force study.

BACKGROUND: A major limitation of functional muscle transfer for facial and intrinsic hand reanimation is the inability to predict the force that will be generated by the transplanted muscle. METHODS: The authors studied the contractile force of the slips of the serratus anterior in situ in 10 patients and tested the gracilis muscle in four subjects as a control. RESULTS: Mean contractile force generated by each serratus slip was 0.178 pound (range, 0.019 to 0.797 pound). This compares favorably with the maximum force generated by smiling (0.307 pound). Muscle strength correlated strongly with age (r = -0.805, p = 0.005). The lowest slip generated less force than those above it (0.133 pound versus 0.191 pound); this difference did not reach statistical significance. When the strength of the lowest slip is compared with the more superior slips as a percentage of total force generated by the slips (to compensate for the effect of age on muscle strength), the lowest slip was significantly weaker (18.6 percent of total force versus 25.5 percent of total force, p = 0.013). Mean contractile force generated by the gracilis was 0.963 pound, significantly different from that generated by a serratus anterior slip (p = 0.009). CONCLUSIONS: Each serratus slip could potentially be used to generate a separate force vector for facial reanimation. Further separation of the flap along preexisting fascial planes may allow generation of up to 10 independent force vectors, making the serratus anterior muscle flap an attractive option for facial reanimation and possibly intrinsic hand muscle reconstruction.