Are Routine Chest Radiographs After Chest Tube Removal in Thoracic Surgery Patients Necessary?

INTRODUCTION: The routine use of chest x-ray (CXR) to evaluate the pleural space after chest tube removal is a common practice driven primarily by surgeon preference and institutional protocol. The results of these postpull CXRs frequently lead to additional interventions that serve only to increase health care costs and resource utilization. We investigated the utility of these postpull CXRs in thoracic surgery patients and assessed their effectiveness in predicting the need for tube replacement. METHODS: Single-institution retrospective study comprising thoracic surgery patients requiring postoperative chest tube drainage over a 3-y period. Demographics and surgical characteristics, including surgical approach, procedure, and procedure type, were recorded. Outcomes included postpull CXR findings, interventions resulting from radiographic abnormalities, and the additional health resource utilization incurred by obtaining these studies on asymptomatic patients. RESULTS: The study included 433 patients. Postpull CXRs were performed in 87.1% of patients, with 33.2% demonstrating an abnormality compared with the prior study. Among these, 65.7% resulted only in repeat imaging and 25.7% resulted in discharge delay. Overall, a total of 13 patients (3%) required chest tube replacement, three during the index hospitalization and the other 10 requiring readmission. Among those requiring chest tube replacement, 75% had normal postpull imaging, and all were symptomatic. CONCLUSIONS: Recurrent pneumothorax after chest tube removal requiring immediate tube reinsertion is relatively rare and does not occur in the absence of symptoms. Our study suggests that routine postpull CXRs have limited clinical utility and can be safely omitted in asymptomatic patients with appropriate clinical observation.

Repair of iatrogenic tracheal injury in acute respiratory failure with veno-venous extracorporeal membrane oxygenation.

Iatrogenic tracheal injuries are rare but potentially serious complications of endotracheal intubation that frequently require lung isolation to repair. This is not tolerated in patients with severe respiratory failure. We describe a case in a patient with acute respiratory distress syndrome, repaired using veno-venous extracorporeal membrane oxygenation.

Effect of Body Mass Index on Outcomes in Left Ventricular Assist Device Recipients.

BACKGROUND AND AIM: Obesity is associated with higher mortality following heart transplantation, but there remains no consensus regarding outcomes in left ventricular assist device (LVAD) recipients. We sought to determine the impact of body mass index (BMI) on outcomes in patients undergoing LVAD implantation. METHODS: This was a single-institution retrospective review, including all patients who received a HeartMate II LVAD or HeartWare HVAD between March 2006 and June 2014. Patients were stratified into three groups based on normal (<25 kg/m(2) ), overweight (25-30 kg/m(2) ), and obese (>30 kg/m(2) ) BMI. RESULTS: Two hundred patients were included in the analysis. Mean BMI was 28.3 kg/m(2) , (27% normal, 36% overweight, and 36.5% obese). Obese patients were younger (51.9 years, p = 0.03) and had higher incidence of diabetes (58.9% vs. 24.1%; p < 0.001) and peripheral vascular disease (16.4% vs. 1.9%; p = 0.03). Normal BMI patients were more likely to undergo LVAD implantation as destination therapy compared to the overweight and obese groups (67% vs. 39% vs. 51%; p = 0.01) and had higher incidence of postoperative stroke/transient ischemic attack (22.2% vs. 6.9% vs. 12.3%; p = 0.04) and postoperative bleeding requiring reoperation (27.8% vs. 12.5% vs. 9.6%; p = 0.01). Survival at one, three, and five years was similar across all BMI groups. BMI was not an independent predictor of overall survival. CONCLUSIONS: Appropriately-selected patients at the extremes of BMI can safely undergo LVAD implantation with no difference in survival. BMI should not in itself be considered a contraindication to LVAD placement.

Outcomes after sublobar resection versus lobectomy in non-small cell carcinoma in situ.

OBJECTIVE: Guidelines for treatment of non-small cell lung cancer identify patients with tumors ≤2 cm and pure carcinoma in situ histology as candidates for sublobar resection. Although the merits of lobectomy, sublobar resection, and lymphoid (LN) sampling, have been investigated in early-stage non-small cell lung cancer, evaluation of these modalities in patients with IS disease can provide meaningful clinical information. This study aims to compare these operations and their relationship with regional LN sampling in this population. METHODS: The National Cancer Database was used to identify patients diagnosed with non-small cell lung cancer clinical Tis N0 M0 with a tumor size ≤2 cm from 2004 to 2017. The χ2 tests were used to examine subgroup differences by type of surgery. Kaplan-Meier method and Cox proportional hazard model were used to compare overall survival. RESULTS: Of 707 patients, 56.7% (401 out of 707) underwent sublobar resection and 43.3% (306 out of 707) underwent lobectomy. There was no difference in 5-year overall survival in the sublobar resection group (85.1%) compared with the lobectomy group (88.9%; P = .341). Multivariable survival analyses showed no difference in overall survival (hazard ratio, 1.044; P = .885) in the treatment groups. LN sampling was performed in 50.9% of patients treated with sublobar resection. In this group, LN sampling was not associated with improved survival (84.9% vs 85.0%; P = .741). CONCLUSIONS: We observed no difference in overall survival between sublobar resection and lobectomy in patients with cTis N0 M0 non-small cell lung cancer with tumors ≤2 cm. Sublobar resection may be an appropriate surgical option for this population. LN sampling was not associated with improved survival in patients treated with sublobar resection.

Esophagectomy vs Gastrectomy for Early Stage Adenocarcinoma of the Gastroesophageal Junction: What is the Optimal Oncologic Surgical Treatment?

Guidelines for the management of gastroesophageal junction (GEJ) adenocarcinoma recommend esophagectomy as the preferred surgical treatment. Gastrectomy has been proposed as an equivalent procedure. This study aims to compare the oncologic outcomes of these operations. The National Cancer Database was queried for patients with clinical T1N0M0 (all sizes) and T2N0M0 (≤2cm) GEJ adenocarcinoma from 2004-2017. Patients treated with surgery-only were included and were stratified by surgical treatment. Propensity-score matching (PSM) was used to create a balanced cohort. Multivariable logistic regression was performed to evaluate for factors predictive of treatment. Kaplan-Meier (KM) and Cox proportional hazards models were used to compare overall survival (OS). 2,446 patients were identified. 75.1% received esophagectomy, while 24.9% were treated with gastrectomy. Patients at high volume facilities were more likely to undergo esophagectomy (OR 1.750, P < 0.001). Factors associated with lower likelihood of undergoing esophagectomy included age ≥75 years (OR 0.588, P = 0.001), female sex (OR 0.706, P = 0.003), and non-White race (OR 0.430, P < 0.001), compared to age ≤50 years, male, and White race, respectively. In the unmatched cohort, gastrectomy was associated with a higher rate of positive margins (4.1% vs 2.3%, P = 0.022). PSM yielded 591 pairs. In the matched cohort, patients treated with esophagectomy had improved 5-year OS compared to gastrectomy (70.6% vs 66.5%, P = 0.030). Multivariable analysis showed improved OS in patients treated with esophagectomy compared to gastrectomy (HR 0.767, P = 0.010). Esophagectomy is associatedwith improved survival and a lower incidence of positive margins in patients with early-stage GEJ adenocarcinoma when compared to gastrectomy.

Residency selection: do the perceptions of US programme directors and applicants match?

OBJECTIVES: This study sought to evaluate the practices and perceptions of US residency programme directors (PDs) and residency applicants with reference to the use of social media and Internet resources in the resident doctor selection process. METHODS: A survey was distributed via e-mail (SurveyMonkey®) to 2592 PDs of programmes in 22 specialties accredited by the Accreditation Council for Graduate Medical Education. A separate survey was distributed to all residency candidates applying for postgraduate year 1 (PGY1) positions at the Saint Barnabas Medical Center, Livingston, New Jersey. RESULTS: A total of 1200 (46.3%) PDs completed the survey. Overall, 16.3% (n=196) of respondents reported visiting Internet resources to gain more information about applicants, 38.1% (74 of 194) of whom had ranked an applicant lower as a result. American medical graduates (AMGs), US international medical graduates (USIMGs) and non-USIMGs all felt that performance on Step 1 of the US Medical Licensing Examination (USMLE) was a critical aspect of a residency application. More AMGs than USIMGs and non-USIMGs believed that PDs made use of social media resources when evaluating applicants and that their online profiles might influence their rankings. CONCLUSIONS: Residency candidates universally understand the importance of USMLE Step 1 scores in maintaining a competitive application. However, significant differences exist among AMGs, USIMGs and non-USIMGs in their perceptions of the value of other applicant criteria, which may place some applicants at a disadvantage. A small but growing number of PDs currently use Internet resources to learn more about applicants and base their recruitment decisions in part on the information they encounter. At present, applicants are generally unaware of the implications their online activity may have on their selection for residency. Content guideline programmes that raise awareness of the possible impact of social media on the residency recruitment process are needed and should be delivered early in medical education.

Gastrointestinal cancer and brain metastasis: a rare and ominous sign.

Metastatic brain tumors represent 20% to 40% of all intracranial neoplasms and are found most frequently in association with lung cancer (50%) and breast cancer (12%). Although brain metastases occur in <4% of all tumors of the gastrointestinal (GI) tract, the incidence of GI brain metastasis is rising in part due to more effective systemic treatments and prolonged survival of patients with GI cancer. Data were collected from 25 studies (11 colorectal, 7 esophageal, 2 gastric, 1 pancreatic, 1 intestinal, 3 all-inclusive GI tract cancer) and 13 case reports (4 pancreatic, 4 gallbladder, and 5 small bowel cancer). Brain metastases are found in 1% of colorectal cancer, 1.2% of esophageal cancer, 0.62% of gastric cancer, and 0.33% of pancreatic cancer cases. Surgical resection with whole brain radiation therapy (WBRT) has been associated with the longest median survival (38.4-262 weeks) compared with surgery alone (16.4-70.8 weeks), stereotactic radiosurgery (20-38 weeks), WBRT alone (7.2-16 weeks), or steroids (4-7 weeks). Survival in patients with brain metastasis from GI cancer was found to be diminished compared with metastases arising from the breast, lung, or kidney. Prolonged survival and improvement in clinical symptoms has been found to be best achieved with surgical resection and WBRT. Although early treatment has been linked to prolonged survival and improved quality of life, brain metastases represent a late manifestation of GI cancers and remain an ominous sign.

Case report of a duplicated cystic duct: A unique challenge for the laparoscopic surgeon.

INTRODUCTION: Anatomical variants of the extrahepatic biliary tree are numerous, adding significantly to the risk of bile duct injury during cholecystectomy, especially when laparoscopic approach is employed. Duplicated cystic ducts draining a single gallbladder are extremely rare. PRESENTATION OF CASE: A 34-year-old female presented with signs and symptoms of acute cholecystitis which was confirmed on imaging. She was found to have an accessory cystic duct on laparoscopic cholecystectomy requiring conversion to open laparotomy with intraoperative cholangiogram to delineate the anatomy. DISCUSSION: In the English literature, there has been 20 reported cases of double cystic duct with a single gallbladder. Most of these cases were diagnosed intraoperatively despite the completion of a preoperative endoscopic retrograde cholangiopancreatography in a few of these patients. CONCLUSION: The limited success of preoperative biliary tract imaging in demonstrating anatomic aberrancies prior to cholecystectomy clearly highlights the importance of maintaining constant vigilance for even the slightest anatomic abnormality at operation. Any uncertainty or concern for ductal injury mandates immediate operative cholangiogram with cannulation of all structures in question.

Should Patients with Hepatic Fibrosis Undergo LVAD Implantation: A Comparative Analysis.

The purpose of our study was to evaluate outcomes in patients with hepatic fibrosis at the time of LVAD implantation. There were five (2.1%) patients with preoperative hepatic fibrosis with a mean age of 51.2 ± 16.8 years. Survival at 180 days was significantly reduced in patients with hepatic fibrosis, 40.0% vs. 88.0%; p = 0.001. Hepatic fibrosis was a significant independent predictor of mortality in multivariate analysis (hazard ratio [HR] 2.27, p = 0.036).

Outcomes on Continuous Flow Left Ventricular Assist Devices: A Single Institutional 9-Year Experience.

BACKGROUND: Continuous-flow left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure. The goal of this study was to review our 9-year institutional experience. METHODS: From March 2006 through May 2015, 231 patients underwent implantation of 240 CF LVADs, HeartMate II LVAD (Thoratec Corp., Pleasanton, CA; n = 205) or HVAD (HeartWare Inc., Framingham, MA; n = 35). Of these, 127 devices (52.9%) were implanted as bridge to transplantation (BTT) and 113 (47.1%) as destination therapy (DT). RESULTS: Mean age was 51.2 ± 11.9 years for BTT patients and 58.2 ± 11.4 years for DT patients (p < 0.001). There was a higher incidence of preoperative diabetes, renal insufficiency, peripheral vascular disease, and previous cardiac operation in DT patients (p < 0.05). Survival was higher for BTT patients, with 1-, 6-, 12-, and 24-month survivals of 91.0%, 90.0%, 88.5%, and 72.1%, respectively, versus 85.3%, 81.1%, 75.6%, and 59.0%, respectively, for DT patients (p = 0.038). Gastrointestinal bleeding was the most common complication (29.6%), followed by right ventricular failure (22.5%) and stroke (15.0%), with a similar incidence for BTT and DT patients. Preoperative liver biopsy (hazard ratio [HR] 2.27, p = 0.036), mechanical support (HR 1.82, p = 0.025), aspartate transaminase (HR 1.07, p = 0.001), and alanine aminotransferase (HR 0.95, p = 0.024) were severe independent predictors of survival in multivariate analysis. CONCLUSIONS: These data indicate excellent survival for BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become a plausible alternative to heart transplantation, we need to further decrease the incidence of postoperative complications.

Impact of Preoperative Atrial Fibrillation on Postoperative Thromboembolic Events After Left Ventricular Assist Device Implantation.

BACKGROUND: The incidence of atrial fibrillation (AF) among patients undergoing left ventricular assist device (LVAD) implantation is high. However, the impact of AF on clinical outcomes has not been clarified. We reviewed our 9-year experience of continuous flow (CF) LVADs to determine the impact of preoperative AF on stroke, device thrombosis, and survival. METHODS: Between March 2006 and May 2015, 231 patients underwent implantation of 240 CF LVADs, 127 (52.9%) as bridge to transplantation and 113 (47.1%) as destination therapy. Effect of AF on postoperative outcomes was assessed by using Kaplan-Meier survival and Cox proportional hazard regression. RESULTS: There were 78 patients (32.5%) with preoperative AF with a mean age of 55.7 ± 11.4 years. A similar incidence of stroke was found in patients with and without AF, 12.8% versus 16.0%, respectively (p = 0.803). Survival was similar, with 1-, 6-, 12-, and 24-month survivals of 96.2%, 91.7%, 84.5%, and 69.2%, respectively, for AF patients, versus 93.1%, 85.0%, 79.4%, and 74.1%, respectively, for non-AF patients (p = 0.424). Preoperative AF was not a significant independent predictor of survival with the use of Cox proportional hazard regression (hazard ratio 1.08, 95% confidence interval: 0.66 to 1.76). CONCLUSIONS: Preoperative AF was associated with a similar incidence of postoperative stroke, device thrombosis, and survival. On the basis of these data, it seems unnecessary to perform a left atrial appendage ligation or to alter postoperative anticoagulation in patients with AF undergoing LVAD implantation.

Effect of Preoperative Albumin Levels on Outcomes in Patients Undergoing Left Ventricular Device Implantation.

Hypoalbuminemia is a well-known predictor of morbidity and mortality in cardiac surgery. Our aim was to establish the impact of serum albumin on outcomes after left ventricular assist device (LVAD) implantation. This was a single-institution retrospective review, including all patients who underwent LVAD implantation between March 2006 and June 2014. Two hundred patients were included in the analysis. Mean serum albumin was 3.27 ± 0.47 g/dl, with 7% in the low albumin group (<2.5 mg/dl), 67.5% in the mid-range (2.5-3.5 mg/dl), and 25.5% in the normal albumin groups (> 3.5 mg/dl). Lower albumin was associated with a significant increase in postoperative renal failure (42.9 vs. 16.5 vs. 17.3%; p = 0.05) and prolonged hospitalization (median 28.5 vs. 16 vs. 15.5 days; p = 0.008). Six month, 1 year, and 5 year survival was 79%, 79%, and 49% with low, 84%, 78%, and 51% with mid-range, and 94%, 88%, and 60% with normal albumin, respectively (p = 0.22). Preoperative hypoalbuminemia is associated with postoperative acute renal failure (ARF) and prolonged hospitalization after LVAD implantation, with no effect on overall survival. Hypoalbuminemia is most likely a marker of advanced disease and should not, in itself, be considered a contraindication to LVAD candidacy.

An ERAS-based survey evaluating demographics, United States Medical Licensing Examination Performance, and research experience between American medical graduates and United States citizen international medical graduates: is the bar higher on the continent?

OBJECTIVE: To provide an assessment and comparison of the demographics, medical school academic performance, United States Medical Licensing Examination (USMLE) performance, and research experience between American Medical Graduate (AMG) and United States International Medical Graduate (USIMG) candidates who applied for and successfully matched into categorical general surgery residency programs. DESIGN: Data were obtained through the Electronic Residency Application Service (ERAS) and a post-match survey distributed to all applicants. SETTING: The study was conducted at a community-based, university-affiliated hospital. PARTICIPANTS: All United States citizen graduates of allopathic American medical schools or international medical schools, who were applying for a general surgery residency position at our institution. RESULTS: A total of 854 candidates applied, including 143 AMGs and 223 USIMGs. Seventy-two AMGs (50.3%) and 41 USIMGs (18.4%) were invited to interview (p < 0.0001). Mean USMLE step 1 scores were higher among USIMG applicants overall (USIMG: 212.1 ± 14.9 vs AMG: 206.9 ± 15.5; p < 0.0005) and among those invited to interview (USIMG: 227.8 ± 16.2 vs AMG: 215.5 ± 16.2; p < 0.0001). Seventy percent of AMGs matched into a categorical surgery residency compared with 31.6% of USIMGs (p < 0.001). Compared with AMGs, USIMGs applied to more programs (USIMG: 90.3 ± 42.8 vs AMG: 52.1 ± 26.4; p < 0.002), were offered fewer interviews (USIMG: 9.0 ± 6.9 vs AMG: 20.9 ± 13.7; p < 0.0001), and subsequently ranked fewer programs (USIMG: 7.5 ± 4.5 vs AMG: 12.5 ± 6.1; p < 0.0008). CONCLUSIONS: USIMGs require higher USMLE scores than their AMG counterparts to be considered for categorical general surgery residency positions. However, excellence on the USMLE neither ensures an invitation to interview nor categorical match success. A well-rounded application in conjunction with a practical application strategy is critical for USIMGs to achieve success in attaining a general surgery residency position.

Attitudes and practices of surgery residency program directors toward the use of social networking profiles to select residency candidates: a nationwide survey analysis.

OBJECTIVE: To determine whether residency program directors (PDs) of general surgery and surgical subspecialties review social networking (SN) websites during resident selection. DESIGN: A 16-question survey was distributed via e-mail (Survey Monkey, Palo Alto, California) to 641 PDs of general surgery and surgical subspecialty residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). SETTING: Institutions with ACGME-accredited general surgery and surgical subspecialty residency programs. PARTICIPANTS: PDs of ACGME-accredited general surgery and surgical subspecialty residency programs. RESULTS: Two hundred fifty (39%) PDs completed the survey. Seventeen percent (n = 43) of respondents reported visiting SN websites to gain more information about an applicant during the selection process, leading 14 PDs (33.3%) to rank an applicant lower after a review of their SN profile. PDs who use SN websites currently are likely to continue (69%), whereas those who do not use SN currently might do so in the future (yes 5.4%, undecided 44.6%). CONCLUSIONS: Online profiles displayed on SN websites provide surgery PDs with an additional avenue with which to evaluate highly competitive residency applicants. Applicants should be aware of the expansion of social media into the professional arena and the increasing use of these tools by PDs. SN profiles should reflect the professional standards to which physicians are held while highlighting an applicant's strengths and academic achievements.

Pediatric genital burns: a 15-year retrospective analysis of outcomes at a level 1 burn center.

BACKGROUND/PURPOSE: Burns involving the genitalia and perineum are commonly seen in the context of extensive total body surface area (TBSA) burns and rarely as isolated injuries because of protection provided by the thighs and the abdomen. Genital burns usually result in extended hospital stays and are accompanied by severe morbidity and increased mortality. METHODS: A retrospective analysis of consecutive pediatric (<18 years) patients with burns involving the genitalia admitted to the Saint Barnabas Medical Center Level 1 Burn Unit from January 1, 1995, to December 31, 2009, was performed. RESULTS: One hundred sixty pediatric patients (8.3%) had a genital burn, including 105 patients younger than 5 years (65.6%) and 55 patients between 5 and 18 years (34.4%). Overall mean TBSA was 13.8% ± 16.8%, mean TBSA (genitalia) was 0.84% ± 0.25%, mean length of stay (LOS) was 11.9 ± 11.9 days, and mean burn intensive care unit LOS was 4.9 ± 9.7 days. CONCLUSIONS: In patients younger than 5 years, a TBSA burn more than 10% with extensive genitalia involvement is almost always the result of a scald injury. Younger patients (<5 years) are more often the victims of abuse, and prolonged LOS is the norm (>2 weeks). Patients 5 years or older are more often male and usually have a TBSA burn more than 15%.

Elastofibroma dorsi: A soft tissue masquerade.

Elastofibroma dorsi (ED) is a soft tissue tumor found in the subscapular region. The pathogenesis of ED is unclear, but may involve a regenerative or reactive hyperproliferation due to mechanical microtrauma. Magnetic resonance imaging (MRI) is preferred to diagnose ED and complete excision is curative. When bilateral, subscapular masses are identified in the elderly patient and MRI characteristics are typical, biopsy and excision can be avoided. Symptomatic EDs should be excised, and recurrence is rare. Three hundred and thirty cases of ED have been reported since 1980. Fourteen case series and 43 isolated case reports involved 263 women and 67 men (F:M ratio = 3.9:1), with a mean age of 62 years (range 6-94 years). Bilateral ED was present in 164 patients and unilateral ED in 157. The reported prevalence in the elderly population ranges from a minimum of 2% to a maximum of 24%.