Effect of Thoracic Surgery Regionalization on 1- and 3-Year Survival after Cancer Esophagectomy.

OBJECTIVE: The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the United States translated to longer-term survival benefit. BACKGROUND: Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival are mixed. METHODS: We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and chi-square tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality. RESULTS: Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% vs 73.9%, P = 0.02) but not 3-year survival (52.9% vs 58.2%, P = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.29-1.00], and only thoracic specialty at 3years (OR 0.62, 95% CI 0.38-0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model. CONCLUSIONS: Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.

Vertical rectus abdominis myocutaneous free flap repair of post-pneumonectomy bronchopleural fistula: a case report.

Background: Bronchopleural fistula (BPF) is a seldom encountered yet serious complication after thoracic surgery, and is often difficult to treat. Large BPFs usually require surgical intervention, and a variety of different surgical reconstruction options have been previously described. This case report presents the first description of a successful vertical rectus abdominis myocutaneous (VRAM) free flap repair of a BPF after pneumonectomy. Case Description: A 46-year-old male with a cough was found to have a right upper lobe lung mass with hilar involvement initially remarkable for epithelioid malignant mesothelioma on biopsy. After neoadjuvant chemotherapy, he underwent right extrapleural pneumonectomy and developed a late right mainstem BPF with associated empyema from adjuvant chemotherapy and COVID-19 pneumonia. He was treated with open Clagett window (OCW) to address the infection and then staged VRAM free flap coverage of the BPF. The patient recovered successfully and has since been able to pursue more demanding activities at home. Conclusions: This case presents the only successful VRAM free flap for a BPF involving the entire right mainstem bronchus at the carina. VRAM free flap repair offers a useful treatment option for BPFs, especially in patients with large pleural cavity defects.

Intercostal nerve blockade with liposomal bupivacaine reduces length of stay after video assisted thoracic surgery (VATS) lobectomy.

BACKGROUND: Intercostal nerve blockade (INB) for thoracic surgery analgesia has gained popularity in practice, but evidence demonstrating its efficacy remains sparse and inconsistent. We investigated the effect of INB with standard bupivacaine (SB) with epinephrine versus liposomal bupivacaine (LB) versus a mixed solution of the two on postoperative pain control and outcomes in video assisted thoracoscopic lobectomy patients. METHODS: Since 2014, our practice has shifted from using INBs with SB with epinephrine, to LB, to a mix of the two as the central component of multimodal analgesia after video assisted thoracoscopic surgery. The blocks are performed in a standardized fashion under thoracoscopic visualization consecutively from two rib spaces above to two below the outermost incisions. We retrospectively compared all minimally invasive lobectomies performed at our institution between January 2014 and July 2018 by type of local anesthetic used for INB. We examined median length of stay (LOS), opioid utilization, and subjective pain scores [0-10]. RESULTS: Out of 302 minimally invasive lobectomy patients, 34 received SB with epinephrine, 222 received LB alone, and 46 received the mixed solution. LOS was almost a full day shorter in the LB group than in the SB group (34.8 vs. 56.5 hours, P=0.01). There was nearly 25% lower median total morphine equivalent utilization in the mixed solution cohort compared to the LB cohort (-7.1 mg, P=0.02). Additionally, IV morphine equivalent utilization was over 50% lower in the mixed solution group than in the SB with epinephrine group (-10.0 mg, P=0.03). CONCLUSIONS: Our study is by far the largest (N=302) to compare types of local anesthetic used for INB within a uniform case population. The reductions in LOS and opiate utilization observed in our study among patients receiving LB-based formulations were both statistically and clinically significant.

Reduced opioid utilization and post-operative pain in Asian vs. Caucasian populations after video-assisted thoracoscopic surgery lobectomy with liposomal bupivacaine-based intercostal nerve blockade.

BACKGROUND: Regional analgesia, such as intercostal nerve blockade (INB), is a viable modality for postoperative pain control in thoracic surgery patients. Asian patients have historically been underrepresented in studies of pain responses and pain medication requirements based on race. In this study, we examined the postoperative opioid medications used by Asian and Caucasian patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy who received different bupivacaine-based INB. METHODS: We retrospectively reviewed patients undergoing VATS lobectomy who received standard bupivacaine (SB), liposomal bupivacaine (LB), or liposomal bupivacaine mixed with standard bupivacaine (MIX). Length of stay (LOS), postoperative pain scores, postoperative opioid use (in intravenous morphine equivalents) were evaluated. The Chi-square test was used to compare categorical variables; Student's t-test for normally distributed variables; and the Wilcoxon rank-sum test for non-normally distributed variables. Multivariable linear regression was used to assess opioid use in Asians compared to Caucasians. RESULTS: Of the 239 patients in the cohort, 212 received LB or MIX and 27 received SB. In the LB/MIX group, 48 (22.6%) were Asian and 164 (77.4%) were Caucasian. In the SB group, 7 (25.9%) were Asian and 20 (74.1%) were Caucasian. There were no differences in height, weight, and body mass index (BMI) between the SB and LB/MIX groups, but there was a significant difference in weight and BMI between Asian and Caucasian patients. The median LOS was comparable between the SB and LB/MIX groups. The average 24-hour postoperative pain score in the LB/MIX group was 2.5, and 2.0 and 2.7 in the Asian and Caucasian subgroups, respectively (P<0.01). The median opioid use in the LB/MIX group was 27.2 mg, and 16.9 and 31.1 mg in the Asian and Caucasian subgroups, respectively (P<0.01). On multivariable linear regression analysis adjusting for sex, age, BMI, and bupivacaine type, we found Asians used 25.5 mg less opioids compared to Caucasians (P<0.01). CONCLUSIONS: INB with LB or liposomal-standard bupivacaine mix resulted in statistically significant decreased postoperative pain scores and opioid use in Asians compared to Caucasians. There was no difference in LOS between the LB/MIX and SB groups.

Associations Between Medical Conditions and Alcohol Consumption Levels in an Adult Primary Care Population.

Importance: Excessive alcohol consumption is associated with increased incidence of several medical conditions, but few nonveteran, population-based studies have assessed levels of alcohol use across medical conditions. Objective: To examine associations between medical conditions and alcohol consumption levels in a population-based sample of primary care patients using electronic health record data. Design, Setting, and Participants: This cross-sectional study used separate multinomial logistic regression models to estimate adjusted associations between 26 medical conditions and alcohol consumption levels in a sample of 2 720 231 adult primary care patients screened for unhealthy drinking between January 1, 2014, and December 31, 2017, then only among those reporting alcohol use. The study was conducted at Kaiser Permanente Northern California, a large, integrated health care delivery system that incorporated alcohol screening into its adult primary care workflow. Data were analyzed from June 29, 2018, to February 7, 2020. Main Outcomes and Measures: The main outcome was level of alcohol use, classified as no reported use, low-risk use, exceeding daily limits only, exceeding weekly limits only, or exceeding daily and weekly limits, per National Institute on Alcohol Abuse and Alcoholism guidelines. Other measures included sociodemographic, body mass index, smoking, inpatient and emergency department use, and a dichotomous indicator for the presence of 26 medical conditions in the year prior to the alcohol screening identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes. Results: Among the 2 720 231 included patients, 1 439 361 (52.9%) were female, 1 308 659 (48.1%) were white, and 883 276 (32.5%) were aged 18 to 34 years. Patients with any of the conditions (except injury or poisoning) had lower odds of drinking at low-risk and unhealthy levels relative to no reported use compared with those without the condition. Among 861 427 patients reporting alcohol use, patients with diabetes (odds ratio [OR], 1.11; 95% CI, 1.08-1.15), hypertension (OR, 1.11; 95% CI, 1.09-1.13), chronic obstructive pulmonary disease (COPD; OR, 1.16; 95% CI, 1.10-1.22), or injury or poisoning (OR, 1.06; 95% CI, 1.04-1.07) had higher odds of exceeding daily limits only; those with atrial fibrillation (OR, 1.12; 95% CI, 1.06-1.18), cancer (OR, 1.06; 95% CI, 1.03-1.10), COPD (OR, 1.15; 95% CI, 1.09-1.20), or hypertension (OR, 1.37; 95% CI, 1.34-1.40) had higher odds of exceeding weekly limits only; and those with COPD (OR, 1.15; 95% CI, 1.07-1.23), chronic liver disease (OR, 1.42; 95% CI, 1.32-1.53), or hypertension (OR, 1.48; 95% CI, 1.44-1.52) had higher odds of exceeding both daily and weekly limits. Conclusions and Relevance: Findings suggest that patients with certain medical conditions are more likely to have elevated levels of alcohol use. Health systems and clinicians may want to consider approaches to help targeted patient subgroups limit unhealthy alcohol use and reduce health risks.