Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting.

BACKGROUND: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies. METHODS: Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies. RESULTS: Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48). CONCLUSIONS: Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions.

Assessment of Acute Kidney Injury in Neurologically Injured Patients Receiving Hypertonic Sodium Chloride: Does Chloride Load Matter?

Background: Increasing evidence suggests that large-volume infusions of 0.9% sodium chloride (NaCl) for resuscitation are associated with hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury (AKI). Patients with neurological injury may require hypertonic NaCl for therapeutic hypernatremia, treatment of cerebral salt wasting, hyponatremia, or elevated intracranial pressure. Consequently, this increased exposure to chloride may result in an increased risk for development of AKI. Objective: The primary aim of this study was to describe the risk for development of AKI in neurologically injured patients receiving large volumes of intravenous hypertonic NaCl. Methods: This single-center, retrospective study looked at neurologically injured patients who received hypertonic NaCl and sodium acetate. Data were collected to assess renal function, hyperchloremia, and acidemia. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive association between the amount of daily and overall chloride exposure and development of AKI. Results: A total of 301 patients were screened, and of those, 142 were included. Of the 142 patients included, 13% developed AKI, and 38% developed hyperchloremia. Additionally, 32% of patients were switched from NaCl to sodium acetate after an average of 3.4 ± 1.5 days of NaCl therapy. The ROC curve demonstrated that if patients received greater than 2055 mEq of chloride over 7 days, they were more likely to develop AKI (sensitivity 72%, specificity 70%; P = 0.002; area under the curve = 0.7). Conclusion and Relevance: Neurologically injured patients receiving hypertonic sodium therapy with a high chloride load are at risk of developing hyperchloremia and AKI.

Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures. METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed. RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE's occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed. CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.

Safety Comparison of Laryngeal Mask Use With Endotracheal Intubation in Patients Undergoing Dacryocystorhinostomy Surgery.

PURPOSE: This study will determine the safety of laryngeal mask airway (LMA) compared with endotracheal tube (ETT) in patients undergoing general anesthesia for dacryocystorhinostomy (DCR) surgery. METHODS: In this retrospective cohort study, intraoperative and postoperative outcomes of patients who underwent DCR at UAB Callahan Eye Hospital using either LMA or ETT were compared. RESULTS: Over a period of 52 months, 429 patients underwent external DCR surgery. An ETT was used in 37 patients and LMA in 392 patients. Baseline patient characteristics and anesthetic management were similar. No documented cases of blood or gastric aspiration occurred in the total cohort. Our study confirmed the findings of others that there is less cardiovascular lability on LMA placement than with ETT intubation. A 30% increase in heart rate from baseline after intubation (ETT 10.8%, LMA 1.8%; p = 0.010) and after incision (ETT 8.1%, LMA 1.8%; p = 0.047) occurred more frequently in the ETT group. Airway management with an LMA was also less difficult compared with an ETT (ETT 5.7%, LMA 0.5%; p = 0.035). CONCLUSIONS: The use of an LMA for airway control is safe and effective in patients undergoing general anesthesia for DCR surgery. No events of aspiration occurred with LMA use. Heart rate increase was significantly less in the LMA group. In our opinion, use of an LMA for airway control during DCR surgery is superior to use of an ETT. Airway protection, improved hemodynamics, and less difficulty in placement of the laryngeal airway device are all validated by this study.

Cost comparison of intrathecal morphine to intravenous patient-controlled analgesia for the first 24 h post cesarean delivery: a retrospective cohort study.

PURPOSE: Intrathecal morphine provides superior pain control for patients undergoing cesarean delivery when compared to intravenous opioid patient-controlled analgesia. However, no study has assessed the overall cost associated with each modality as a primary outcome. The aim of this study is to determine the overall cost of each modality for the first 24 h post cesarean delivery. METHODS: Charts of patients undergoing cesarean delivery at our institution from January 1, 2014 to December 31, 2014 were reviewed. Patients receiving intrathecal morphine were compared to patients undergoing general anesthesia and receiving intravenous opioid patient-controlled analgesia for post-procedure analgesia. The primary outcome measured was total cost of each modality for the first 24 h after delivery. Secondary outcomes included post-procedure pain scores, time to removal of the Foley catheter, need for rescue medications, and adverse events. RESULTS: There was a significant difference in total cost of intrathecal morphine when compared to intravenous opioid patient-controlled analgesia ($51.14 vs. $80.16, p < 0.001). Average pain scores between 0-1 h (0 vs. 5, p < 0.001) and 1-6 h (2.5 vs. 3.25, p < 0.001) were less in the intrathecal morphine group. The intrathecal morphine group received more ketorolac (p < 0.001) and required more rescue opioids (p = 0.042). There were no significant differences in documented adverse events. CONCLUSIONS: The use of intrathecal morphine for post-cesarean pain control leads to a significant cost savings for the first 24 h when compared to intravenous opioid patient-controlled analgesia. Patients also experienced less pain and were not at increased risk for adverse events.

Early Postoperative Albumin Administration Contributes to Morbidity After the Fontan Operation.

The Fontan operation has low mortality, but is associated with significant postoperative morbidity, including prolonged chest tube output (PCTO), which is associated with prolonged hospital length of stay (PLOS). We sought to identify variables present early in the clinical course that could predict patients at high risk for PCTO and PLOS. Retrospective data were collected on 84 Fontan (extracardiac conduit) operations from 1/2008 to 12/2013 at a single institution. PCTO was defined as ≥8 days (>75th percentile); PLOS was defined as ≥12 days postoperatively (>75th percentile). Multivariate regression was used to determine covariates associated with PCTO and PLOS. Median age was 3.5 years (IQR 3-5); weight was 14.5 kg (IQR 13-17). There was no mortality. LOS was 9 days (IQR 3-11), and duration of chest tube drainage 6 days (IQR 5-8) at 15 ml/kg/day (IQR 9-20). In univariate analysis, only systemic right ventricle, 24-h 5 % albumin administration, 24-h fluid balance, and 12-h inotrope score were associated with PCTO. In multivariate analysis, only 5 % albumin administration in first 24 h (p < 0.001) and PCTO were independently associated with PLOS. ROC curve analysis showed patients receiving >25 ml/kg of 5 % albumin in first 24-h predicted PLOS (94 % specificity, 93 % sensitivity, AUC = 0.95, p < 0.001). Increased colloid in the first 24-h post-CPB strongly predicts PCTO and PLOS after Fontan operation, potentially providing an early identification of a cohort with unfavorable Fontan physiology. A better understanding of the role of colloid resuscitation after Fontan is necessary, and efforts to reduce perioperative colloid administration could decrease hospital morbidity.

Outcomes of patients with gynecologic malignancies undergoing video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion.

OBJECTIVES: We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion. METHODS: After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes. RESULTS: Forty-two patients with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. Twenty-nine patients (69%) had ovarian cancer. Fifty-seven percent had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. Eight patients (19%) underwent perioperative VATS to improve pulmonary status. Seven patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1-53). Sixty-two percent had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300-4500), and the majority (88%) of patients had a talc pleurodesis performed. Seven patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS. One patient was readmitted with hospital-acquired pneumonia and died during readmission. Median time to death after VATS was 104 days (range 4-1062). Patients who underwent a perioperative VATS had the longest survival (845 days). CONCLUSION: Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.

A large single-center experience of EUS-guided FNA of the left and right adrenal glands: diagnostic utility and impact on patient management.

BACKGROUND: EUS-guided FNA of the left and right adrenals has been described, but data are very limited. OBJECTIVES: Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement. STUDY DESIGN: Observational study. SETTING: Tertiary referral center. PATIENTS: Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach. RESULTS: Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 x 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (> or =30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered. LIMITATIONS: Lack of surgical criterion standard; 1 experienced endosonographer. CONCLUSIONS: EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.

The management of chest tubes after pulmonary resection.

Most patients who undergo pulmonary resection can have one chest tube and have it removed by postoperative day 3. Air leaks are probably best treated with water seal (passive suction) for most patients with small leaks. If they develop a new or enlarging pneumothorax or subcutaneous emphysema, some suction (active suction) is needed and alternating suction at night with waters seal during the day may be best. Most patients with persistent air leaks can be discharged home safely on an outpatient device and have their tubes removed in 2 to 3 weeks even if they still have an air leak.

Effects of Intraoperative Ketamine on Post-Operative Recovery in Obstructive Sleep Apnea Patients: A Case-Control Study.

Objective To evaluate the post-operative outcomes of patients with obstructive sleep apnea (OSA) given intraoperative ketamine. Design: case-control study A total of 574 patients (287 received ketamine and 287 were matched controls) diagnosed with OSA and body mass index (BMI) > 30 who received general anesthesia were included in this study. Patients given intraoperative ketamine were matched (1:1) with those who did not receive ketamine for age, gender, BMI, ethnicity, anesthesia time, intraoperative fentanyl dose, ketamine dose, and surgery type. A sub-analysis was performed based on the dose of ketamine administered and also on the surgery type. Measured outcomes include post-operative pain scores, post-operative opioid requirements, respiratory status, oxygen use, and duration post-operatively. Results Intraoperative ketamine use did not decrease pain scores or post-operative opioid use when compared with the control (no intraoperative ketamine) group. Patients who received high-dose ketamine had significantly higher post-operative pain scores (p=0.048) while in the post-anesthesia care unit (PACU) and required supplemental oxygen for a longer period of time (p = 0.030), pain scores were not significant for patients who underwent orthopedic/spine procedures (p = 0.074), and high-dose ketamine group patients who underwent orthopedic/spine surgery required significantly more opioids in the PACU (p = 0.031). Among patients who received low-dose ketamine, those who underwent head, ear, nose, and throat surgery required significantly more opioids in PACU (p = 0.022). Conclusions Low-dose intraoperative ketamine did not decrease pain scores or post-operative opioid use significantly and did not improve standard respiratory recovery parameters for OSA patients after surgery. Neither low- nor high-dose ketamine demonstrated the anticipated benefits of low pain scores and reduced post-operative opioid use. These outcomes will differ depending on the surgery type and dose of ketamine used.

Cardiorespiratory Events Associated With Ophthalmic Surgery: A Single-Center, Retrospective Records Review of 130 775 Patients, 1999-2015.

Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases-9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event (P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that "the eye is the window to our overall health" seems to be correct.

Reactive species generated by heme impair alveolar epithelial sodium channel function in acute respiratory distress syndrome.

We previously reported that the highly reactive cell-free heme (CFH) is increased in the plasma of patients with chronic lung injury and causes pulmonary edema in animal model of acute respiratory distress syndrome (ARDS) post inhalation of halogen gas. However, the mechanisms by which CFH causes pulmonary edema are unclear. Herein we report for the first time that CFH and chlorinated lipids (formed by the interaction of halogen gas, Cl2, with plasmalogens) are increased in the plasma of patients exposed to Cl2 gas. Ex vivo incubation of red blood cells (RBC) with halogenated lipids caused oxidative damage to RBC cytoskeletal protein spectrin, resulting in hemolysis and release of CFH. Patch clamp and short circuit current measurements revealed that CFH inhibited the activity of amiloride-sensitive epithelial Na+ channel (ENaC) and cation sodium (Na+) channels in mouse alveolar cells and trans-epithelial Na+ transport across human airway cells with EC50 of 125 nM and 500 nM, respectively. Molecular modeling identified 22 putative heme-docking sites on ENaC (energy of binding range: 86-1563 kJ/mol) with at least 2 sites within its narrow transmembrane pore, potentially capable of blocking Na+ transport across the channel. A single intramuscular injection of the heme-scavenging protein, hemopexin (4 µg/kg body weight), one hour post halogen gas exposure, decreased plasma CFH and improved lung ENaC activity in mice. In conclusion, results suggested that CFH mediated inhibition of ENaC activity may be responsible for pulmonary edema post inhalation injury.

Ophthalmic Surgery in Patients with Left Ventricular Assist Devices.

The newer generation of left ventricular assist devices (LVADs) are commonly used as destination therapy; these devices have demonstrated improved outcomes and increased survival. Given the longer lifespan, it is not surprising that patients with LVADS are increasingly presenting with noncardiac, chronic diseases and interventions for their treatment. This includes ophthalmic procedures in patients with LVAD. There is a paucity of literature about the experiences and outcomes in this cohort of patients presenting for ophthalmologic surgery. Here we present a case series consisting of 7 patients with LVAD that underwent 10 ophthalmic surgeries. No adverse events including intraoperative hemodynamic instability or respiratory compromise occurred. All patients had an on-time discharge with no 30-day recidivism. Most patients underwent a phacoemulsification with intraocular lens implantation and received a topical with intracameral anesthetic. We attribute these successful outcomes to a standardized clinical workflow consisting of careful preoperative screening, communication and presence of VAD coordinator, continuation of antithrombotics, monitoring based on presence of pulsatile flow, and a plan for rapid transfer if needed.

Restaging after neo-adjuvant chemoradiotherapy for N2 non-small cell lung cancer.

Recent studies have shown that patients who are down-staged via neoadjuvant therapy and undergo resection have a significant increased 5-year survival rate (as high as 40%-50%) when compared with patients who have residual N2 disease. The identification of patients who are N2 negative after the completion of their neoadjuvant therapy is a critical component of proper patient selection for thoracotomy. Some may even argue that it is a necessary step before resection. In this article we review the best ways to restage patients with N2 disease after they have completed their neoadjuvant therapy.

The influence of preoperative risk stratification on fast-tracking patients after pulmonary resection.

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital length of stay and reduce costs; however, not all patients can be fast-tracked. Certain patient characteristics may put patients at increased risk to fail fast-tracking. Additionally some patients have multiple risk factors that have an additive effect that puts them at an even increased risk to fail fast-tracking, and more importantly, to significant morbidity. It is a mistake to force these protocols on all patients because it can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results via accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Once these characteristics are pinpointed, specific changes to the postoperative algorithm can be implemented, and these alterations can lead to improved outcomes. The authors have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high-patient satisfaction. We have also shown that the increased use of physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those who have low FEV1% and DLco%. Further studies are needed. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient, and cost-saving care via preset postoperative algorithms. When the typical daily events are convened each morning and the planned date of discharge is frequently communicated with the patient and family before surgery and each day in the hospital, most patients can be safely fast-tracked with high satisfaction and outstanding results.

Does minimally invasive thoracic surgery warrant fast tracking of thoracic surgical patients?

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital LOS and reduce costs for patients. who undergo both open and VATS procedures The ability to fast-track is not governed by the type of procedure (closed versus open), but rather by patient characteristics and the mindset of the operating surgeon and the postoperative care team. While use of protocols enhance the ability of many physicians to fast-track many different types of patients, it is a mistake to force these protocols on all patients because, if not modified, they can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results using accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Specific changes to the postoperative algorithms can be implemented and these alterations can lead to improved outcomes. For example, we have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high patient satisfaction. We have also shown that the use of increased physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those with low FEV1% and DLCO%. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient and cost-saving care by way of preset postoperative algorithms after VATS or thoracotomy procedures. When the typical daily events are communicated each morning and the planned date of discharge is reinforced with the patient and family before surgery and each day in the hospital on rounds, most patients can be safely fast-tracked with high satisfaction and outstanding results.

Differences in epidemiology, histology, and survival between cigarette smokers and never-smokers who develop non-small cell lung cancer.

BACKGROUND: The impact that smoking cigarettes has on the characteristics and survival of patients with non-small cell lung cancer (NSCLC) is disputed. METHODS: A retrospective cohort study using a prospective database of patients with NSCLC over a 6-year period. Clinical and histologic characteristics and survival rates were compared between smokers and never-smokers. RESULTS: There were 730 patients; 562 patients (77%) were smokers and 168 patients (23%) were never-smokers. The overall 5-year survival rate was greater in never-smokers (64%) compared to smokers (56%; p = 0.031). Never-smokers were more likely to be younger (p = 0.04), female (p = 0.01), symptomatic at the time of presentation (p < 0.001), have poorly differentiated tumors (p = 0.04), and have a higher maximum standardized uptake value (maxSUV) on positron emission tomography (PET) (p = 0.026) than smokers. The stage-specific 5-year survival rate was greater for never-smokers compared to smokers for stage I disease (62% vs 75%, respectively; p = 0.02), stage II disease (46% vs 53%, respectively; p = 0.09), and stage III disease (36% vs 41%, respectively; p = 0.13). The 5-year survival rate was significantly lower in patients who had a smoking history of > 20 pack-years. CONCLUSIONS: Never-smokers in whom NSCLC develops are more likely to be young, female, and have poorly differentiated tumors with higher maxSUV values on PET scans. Never-smokers with early-stage cancer have a significantly better survival rate than smokers. Patients with a smoking history of > or = 20 pack-years have worse survival. Thus, smoking not only causes lung cancer, but once NSCLC is diagnosed, the prognosis becomes worse. A biological, hormonal, and genetic explanation is currently lacking to explain these findings, and these data may help to improve treatment and surveillance.

The role of integrated positron emission tomography-computerized tomography in evaluating and staging patients with non-small cell lung cancer.

The stage of non-small cell lung cancer (NSCLC) determines that the treatment strategy and proper staging lead to improved survival. Integrated positron emission tomography/computerized tomography (CT) scan provides more accurate staging and better targets for biopsy than traditional methods such as CT scans of the chest and upper abdomen, bone scans, and magnetic resonance imaging scans. Integrated positron emission tomography/CT is the best initial test for an indeterminate pulmonary nodule that is 8 mm or greater; for the noninvasive staging of patients with NSCLC, it is the only test that produces a quantitative assessment of an NSCLC's virulence or biologic aggressiveness in a particular patient and is the best tool for restaging patients after radiation and and/or chemotherapy. Finally, its use as a tool for postoperative surveillance is under study.

Esophageal trauma.

Injury from blunt or penetrating trauma to the esophagus is relatively rare. Treatment strategy is contingent on the clinical status of the patient, associated injuries, and the degree of esophageal injury and the time of injury until diagnosis. Although nonoperative intervention may be acceptable in highly selected patients with contained injuries or those who are more than 24 hours removed from the injury and are clinically stable, operative intervention is the most conservative and safest approach. There are many potential surgical approaches but resection or diversion should be discouraged. Operative approaches include either side of the neck or chest, and an abdominal approach for selected injuries. Sometimes combined incisions are needed. The goal of any operation for a traumatic esophageal injury is removal of infected material, debridement of the esophagus, assessment of the distal and proximal extent of the injury, decortication of the lung if the injury soils the pleural space, primary closure of the esophageal defect if possible with buttressing of the closure with autologous pedicles tissue or muscle flaps, and to ensure distal patency without esophageal pathology.