Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression.

OBJECTIVES: We aimed to report efficacy, safety, and health-related quality of life (HRQoL) outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression among patients with thoracic outlet syndrome (TOS). BACKGROUND: TOS is a challenging condition where controversy remains in diagnosis and treatment, primarily given a lack of data exploring various treatment approaches and associated patient outcomes. METHODS: Patients who underwent unilateral, supraclavicular thoracic outlet decompression, or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and symptomatic improvement compared with baseline. RESULTS: Among 2869 patients evaluated (2007-2021), 1032 underwent surgery, including 864 (83.7%) supraclavicular decompressions and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes among surgical patients were neurogenic (75.4%) and venous TOS (23.4%). Most patients (92.9%) with nTOS underwent preoperative botulinum toxin injection; 56.3% reported symptomatic improvement. Before surgical consultation, few patients reported participation in physical therapy (10.9%). The median time from first evaluation to surgery was 136 days (interquartile range: 55, 258). Among 864 patients who underwent supraclavicular thoracic outlet decompression, complications occurred in 19.8%; the most common complication was chyle leak (8.3%). Four patients (0.4%) required revisional thoracic outlet decompression. At a median follow-up of 420 days (interquartile range: 150, 937) 93.3% reported symptomatic improvement. CONCLUSION: Based on low composite morbidity, need for very few revisional operations, and high rates of symptomatic improvement, a multidisciplinary treatment approach including primarily supraclavicular thoracic outlet decompression is safe and effective for patients with TOS.

Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

Sonographically guided botulinum toxin injections in patients with neurogenic thoracic outlet syndrome: correlation with surgical outcomes.

OBJECTIVE: We examined the role of botulinum toxin (BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in patients undergoing surgery for neurogenic thoracic outlet syndrome (NTOS). We hypothesized that symptomatic improvement from BTX injections correlates with favorable long-term response to surgery for NTOS. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act compliant study was approved by the institutional review board and prior informed consent requirement was waived. We retrospectively analyzed prospectively acquired data in NTOS patients who underwent sonographically guided chemodenervation of AS and PM using BTX type A followed by scalenectomy and first rib resection. Overall responses to BTX injections and surgery were recorded after each procedure. Statistical analyses were performed to determine correlation between responses to BTX injections and surgery. RESULTS: In 157 patients, 178 BTX injections followed by surgery were identified (114 females; mean age 38 ± 13 years). Responders and non-responders to BTX injections and surgery had similar preoperative symptom duration and age (P > 0.14). Better response to BTX injections correlated positively with better response to surgery (P = 0.003), persisting after adjustment for age, gender, and symptom duration (P = 0.03). A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specificity (90%). BTX injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%). CONCLUSION: Response to BTX injections correlates positively with long-term surgical outcome in subjects with NTOS, potentially playing an important role in patient management.

Safety and Efficacy of Catheter-Directed Therapies as a Supplement to Surgical Decompression in Venous Thoracic Outlet Syndrome.

OBJECTIVE: The purpose of this study is to evaluate the role of endovascular therapy in the management of venous thoracic outlet syndrome (TOS), with an emphasis on its role after surgical decompression. MATERIALS AND METHODS: This single-center retrospective review identified all patients who underwent conventional contrast-enhanced venography as a component of the imaging evaluation of clinically suspected venous TOS from January 2004 through September 2015. Eighty-one patients were identified, with a mean (± SD) age of 33 ± 12 years, of whom 59% (48/81) were women. After imaging confirmation of venous TOS, a standardized treatment protocol combining surgical and endovascular intervention was used for management. RESULTS: Of the 81 patients included in the study, 73 (90%) had angiographic evidence of venous TOS; 41 of these 73 patients (56%) underwent endovascular venous intervention (e.g., thrombolysis or angioplasty before surgical) decompression. A total of 67 patients (67/73; 92%) with venous TOS underwent surgical decompression, with 56 of these (56/73; 77%) undergoing postoperative venography. Of these 56 patients who underwent postoperative venography, 48 (86%) required venoplasty, four had normal-appearing subclavian veins (7%) and had no intervention, and four of 48 (8%) had chronic total venous occlusions that could not be recanalized. Only four of the 48 of the patients (8%) who underwent postdecompression venoplasty required subsequent repeat venography and intervention for management of persistent or recurrent symptoms, whereas all others (44/48; 92%) remained symptom free on clinical follow-up. No complications were identified that were related to the endovascular interventions. CONCLUSION: Combining venography and endovascular venous intervention with surgical decompression in managing patients with clinically suspected venous TOS is safe and effective. Postdecompression venoplasty appears to be highly effective, with a low rate of symptom recurrence.

Neoadjuvant irinotecan, cisplatin, and concurrent radiation therapy with celecoxib for patients with locally advanced esophageal cancer.

BACKGROUND: Patients with locally advanced esophageal cancer who are treated with trimodality therapy have a high recurrence rate. Preclinical evidence suggests that inhibition of cyclooxygenase 2 (COX2) increases the effectiveness of chemoradiation, and observational studies in humans suggest that COX-2 inhibition may reduce esophageal cancer risk. This trial tested the safety and efficacy of combining a COX2 inhibitor, celecoxib, with neoadjuvant irinotecan/cisplatin chemoradiation. METHODS: This single arm phase 2 trial combined irinotecan, cisplatin, and celecoxib with concurrent radiation therapy. Patients with stage IIA-IVA esophageal cancer received weekly cisplatin 30 mg/m(2) plus irinotecan 65 mg/m(2) on weeks 1, 2, 4, and 5 concurrently with 5040 cGy of radiation therapy. Celecoxib 400 mg was taken orally twice daily during chemoradiation, up to 1 week before surgery, and for 6 months following surgery. RESULTS: Forty patients were enrolled with stage IIa (30 %), stage IIb (20 %), stage III (22.5 %), and stage IVA (27.5 %) esophageal or gastroesophageal junction cancer (AJCC, 5th Edition). During chemoradiation, grade 3-4 treatment-related toxicity included dysphagia (20 %), anorexia (17.5 %), dehydration (17.5 %), nausea (15 %), neutropenia (12.5 %), diarrhea (10 %), fatigue (7.5 %), and febrile neutropenia (7.5 %). The pathological complete response rate was 32.5 %. The median progression free survival was 15.7 months and the median overall survival was 34.7 months. 15 % (n = 6) of patients treated on this study developed brain metastases. CONCLUSIONS: The addition of celecoxib to neoadjuvant cisplatin-irinotecan chemoradiation was tolerable; however, overall survival appeared comparable to prior studies using neoadjuvant cisplatin-irinotecan chemoradiation alone. Further studies adding celecoxib to neoadjuvant chemoradiation in esophageal cancer are not warranted. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00137852 , registered August 29, 2005.

Botulinum Toxin Injections in Musculoskeletal Disorders.

Botulinum toxin (BTX) is used for multiple clinical indications due to its ability to induce temporary chemodenervation and muscle paralysis. This property has supported its application in treating a variety of musculoskeletal conditions, especially those involving muscular hyperactivity and contractures such as cerebral palsy and dystonia. However, off-label use of BTX injection in other musculoskeletal disorders is gaining increased acceptance, such as in neurogenic thoracic outlet syndrome, epicondylitis, and shoulder pain after stroke. This review discusses the mechanism of action, best practices, and current indications of BTX injections in the musculoskeletal system. We also discuss the state of the science regarding BTX injections for musculoskeletal disorders and the available evidence supporting its use.

Use of Proteolytic Enzymes in the Treatment of Proteinaceous Esophageal Food Impaction.

BACKGROUND: Proteinaceous esophageal food impaction typically requires endoscopic intervention. An alternative approach is the use of proteolytic enzymes. Concerns regarding the use of proteolytic enzymes include the risk of perforation and aspiration pneumonitis. OBJECTIVE: We retrospectively reviewed our series of 69 patients treated with papain to determine the safety and efficacy of proteolytic enzymes. METHODS: Patients were retrospectively reviewed if treated for an esophageal food impaction from 1999 through 2008. RESULTS: Median age was 56 years (range 19-91 years), with 46 male and 23 female patients. In 27 patients (39%) this was their first presentation, in 14 (20%) it was the second, and 28 (41%) had multiple previous episodes. Meat was the cause in 49 (71%), chicken in 6 (9%), fish in 3 (4%), and unspecified in 11 (16%). All patients presented with dysphagia for solids, 56 (81%) could not tolerate liquids. Papain solution, 1 tsp in 8 oz of water, was given to patients in an unlimited quantity. Papain was successful in relieving the obstruction in 60 patients (87%). The remaining 9 patients (13%) underwent endoscopy with successful retrieval. No patient suffered a perforation, either with papain ingestion or endoscopy. There were no episodes of pneumonitis or pneumonia. CONCLUSIONS: We have used proteolytic enzymes with a high success rate and with minimal complication. Further, if proteolytic enzymes fail, endoscopy can be performed safely and effectively. We recommend the use of proteolytic enzymes as the initial management in all patients with proteinaceous food impaction of the esophagus.

Preoperative cetuximab, irinotecan, cisplatin, and radiation therapy for patients with locally advanced esophageal cancer.

PURPOSE: To determine the efficacy and toxicity of weekly neoadjuvant cetuximab combined with irinotecan, cisplatin, and radiation therapy in patients with locally advanced esophageal or gastroesophageal junction cancer. METHODS AND MATERIALS: Patients with stage IIA-IVA esophageal or gastroesophageal junction cancer were enrolled in a Simon's two-stage phase II study. Patients received weekly cetuximab on weeks 0-8 and irinotecan and cisplatin on weeks 1, 2, 4, and 5, with concurrent radiotherapy (50.4 Gy on weeks 1-6), followed by surgical resection. RESULTS: In the first stage, 17 patients were enrolled, 16 of whom had adenocarcinoma. Because of a low pathologic complete response (pCR) rate in this cohort, the trial was discontinued for patients with adenocarcinoma but squamous cell carcinoma patients continued to be enrolled; two additional patients were enrolled before the study was closed as a result of poor accrual. Of the 19 patients enrolled, 18 patients proceeded to surgery, and 16 patients underwent an R0 resection. Three patients (16%) had a pCR. The median progression-free survival interval was 10 months, and the median overall survival duration was 31 months. Severe neutropenia occurred in 47% of patients, and severe diarrhea occurred in 47% of patients. One patient died preoperatively from sepsis, and one patient died prior to hospital discharge following surgical resection. CONCLUSIONS: This schedule of cetuximab in combination with irinotecan, cisplatin, and radiation therapy was toxic and did not achieve a sufficient pCR rate in patients with localized esophageal adenocarcinoma to undergo further evaluation.

Evaluation of Patients with Neurogenic Thoracic Outlet Syndrome.

Neurogenic thoracic outlet syndrome (NTOS) results from the compression or irritation of the brachial plexus within the thoracic outlet. The associated symptoms result in significant disability and negative effects on patient health-related quality of life. The diagnosis of NTOS, despite being the most common type of TOS, remains challenging for surgeons, in part due to the nonspecific symptoms and lack of definitive diagnostic testing. In this article, we present the essential components of the evaluation of patients with NTOS including a thorough history and physical examination, stress maneuvers, diagnostic and therapeutic imaging, and assessment of disability using standardized patient-centered instruments.

Surgical Technique: Supraclavicular First Rib Resection.

Thoracic outlet syndrome is a condition of compression involving the brachial plexus and subclavian vessels. Although there are multiple surgical approaches to address thoracic outlet decompression, supraclavicular first rib resection with scalenectomy and brachial plexus neurolysis allow for complete exposure of the first rib, brachial plexus, and vasculature. This technique is described in detail. This approach is safe and can produce excellent outcomes in all variants of thoracic outlet syndrome.

Reoperation for Persistent or Recurrent Neurogenic Thoracic Outlet Syndrome.

Identifying the exact cause for persistent and recurrent neurogenic thoracic outlet syndrome (NTOS) is challenging even with high-resolution imaging of the thoracic outlet. Improvement can be achieved with redo first rib resection, although the posterior first rib remnant is one of several potential points of brachial plexus compression. In approaching reoperative surgery for NTOS, the aim is to provide complete thoracic outlet decompression as guided by the patient's history, physical examination, and adjunctive imaging. This may involve resection of the posterior first rib remnant, scar tissue encasing the brachial plexus, elongated C7 transverse process, cervical rib, and/or pectoralis minor tendon.

Supraclavicular Approach for Neurogenic Thoracic Outlet Syndrome: Description of a Learning Curve.

BACKGROUND: The supraclavicular exposure represents an alternative approach for thoracic outlet decompression in neurogenic thoracic outlet syndrome with unique access to neurovascular structures. We aimed to evaluate the learning curve for this approach and associated patient outcomes. METHODS: Patients undergoing first-time, unilateral, supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome were included. Cumulative-sum and linear-spline-regression analyses were used to determine the operative time learning curve. Patients were consecutively organized into early (learning phase) and late (competency) cohorts. Primary endpoints were the operative time learning curve operation number and association of this learning curve on differences in self-reported postoperative symptomatic improvement between early and late cohorts, adjusting for American Society of Anesthesiology classification, body mass index, previous treatment (opioid/neuropathic medication/botulinum-injection), and length of stay. RESULTS: Among 114 patients, learning curve analyses showed decreasing operative times, plateauing at the 51st operation (ß = -1.63, 95% confidence interval [-2.30, -0.95], P < .001). No periprocedural differences existed between early (operations 1-50) and late (operations 51-114) cohorts. Self-reported 90-day outcomes were similar in early and late cohorts (odds ratio [OR]: 1.60 [0.65, 3.95], P = .31). Mediators of poor self-reported outcomes included increasing American Society of Anesthesiology classification (OR 0.21 [0.08, 0.54], P = .001), failed preoperative botulinum injection (OR 0.15 [0.03, 0.65], P = .01), and increased length of stay (OR 0.40 [0.22, 0.73], P = .003). CONCLUSIONS: The learning curve for supraclavicular thoracic outlet decompression in neurogenic thoracic outlet syndrome occurred after 51 operations with a trend towards improved 90-day self-reported outcomes from the early to late phases. These findings, along with mediators of poorer outcomes, may aid surgeons in adopting a new approach and counseling patients on expected outcomes.

Botulinum toxin injection in neurogenic thoracic outlet syndrome: results and experience using a ultrasound-guided approach.

OBJECTIVE: The purpose of this study was to describe the technique, complications, and rate of symptom relief after ultrasound-guided botulinum toxin injection in subjects with suspected neurogenic thoracic outlet syndrome (NTOS). MATERIALS AND METHODS: This study was IRB-approved and followed HIPPA guidelines. Subjects investigated for NTOS were identified via retrospective review of medical records. Procedures included botulinum toxin injections of the anterior scalene, pectoralis minor, and subclavius muscles performed under real-time ultrasound guidance. Technical success was defined as satisfactory muscle identification, intramuscular needle placement, and intramuscular delivery of medication. Follow-up was performed to determine procedure-related complications and therapy response using a binary assessment and modified visual analogue scale (VAS). RESULTS: Forty-one subjects with suspected NTOS underwent a total of 92 injections (58 anterior scalene, 33 pectoralis minor, and 1 subclavius muscle). Technical success was achieved in all procedures. No complications occurred. Symptom improvement occurred after 69% of procedures. The VAS before and after the procedure changed from 7.1 to 2.8 (P < 0.0001) respectively. The mean time to symptom improvement and duration of symptom improvement were 12 and 31 days respectively. CONCLUSION: Botulinum toxin injection under ultrasound guidance is a safe and well-tolerated procedure with a satisfactory rate of temporary symptom relief in subjects with suspected NTOS.

High-frequency chest-wall compression during the 48 hours following thoracic surgery.

BACKGROUND: Postoperative pneumonia continues to be a leading cause of mortality and morbidity after thoracic surgery. High-frequency chest-wall compression (HFCWC) is an established therapeutic adjunct for patients with chronic pulmonary disorders that impair bronchopulmonary secretion clearance. We studied the feasibility of applying HFCWC following thoracic surgery. METHODS: Twenty-five consecutive adult patients who underwent a variety of thoracic operations received at least one HFCWC treatment in the first 2 postoperative days, along with routine postoperative care. HFCWC was applied at 12 Hz, for 10 min. Routine hemodynamic and pulse oximetry data were collected before, during, and after HFCWC. We also collected qualitative data on patient tolerance and preference for HFCWC versus percussive chest physiotherapy. RESULTS: No major adverse events were encountered. Hemodynamic and pulse oximetry values remained stable before, during, and after HFCWC. Eighty-four percent of the subjects reported little or no discomfort during therapy, and the subjects who expressed a preference preferred HFCWC to conventional chest physiotherapy by more than two to one. CONCLUSIONS: HFCWC is a safe, well-tolerated adjunct after thoracic surgery. The observation of hemodynamic stability is especially important, considering that the patients were studied in the early postoperative period, during epidural analgesia.

Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome.

OBJECTIVE: To describe the technique and complications of sonographically guided anesthetic injection of the anterior scalene muscle in patients being investigated for neurogenic thoracic outlet syndrome. MATERIAL AND METHODS: Subjects were identified via a retrospective review of medical records. For the procedure a 25-gauge needle was introduced into the anterior scalene muscle under real-time ultrasound guidance followed by injection of local anesthetic. The procedures were evaluated for technical success, which was defined as satisfactory identification of anterior scalene muscle, intramuscular needle placement, and intramuscular delivery of medication. There was a short-term follow-up to determine procedure-related complications and rate of unintended brachial plexus (BP) block, manifested by upper extremity paresthesias and/or weakness. RESULTS: Twenty-six subjects with suspected neurogenic thoracic outlet syndrome underwent 29 injections (three subjects received bilateral injections). Technical success was achieved in all procedures. The mean duration of the procedure was 30 min, and there were no cases of intravascular needle placement or neurogenic pain during the injection. No major complications occurred. Temporary symptoms of partial BP block occurred after nine injections (9/29, 31%), and a temporary complete BP block occurred after one injection (1/29, 3%). CONCLUSION: Sonographically guided anesthetic injection of the anterior scalene muscle is a safe and well-tolerated diagnostic test for patients being investigated for neurogenic thoracic outlet syndrome.

Pulmonary Artery Resection During Lung Resection for Malignancy.

BACKGROUND: Complete resection of central tumors invading the main pulmonary artery (PA) requires arterial reconstruction to avoid pneumonectomy. Oncologic equivalence with pneumonectomy has been suggested. We review clinical selection and outcome for these uncommon procedures in the context of candidacy for pneumonectomy. METHODS: From 2000 to 2018, 9 different surgeons performed 34 pulmonary arterial resections for primary or metastatic pulmonary malignancy, with independent determination of pneumonectomy candidacy and arterioplasty technique. Patients undergoing limited lateral stapled PA resection (n = 3) or resection for metastasis (n = 3) were excluded from survival analysis. RESULTS: The PA was resected as a sleeve with primary anastomosis (14.7%) or noncircumferentially with primary (61.8%), stapled (8.8%), or patch (14.7%) closure. Arterial resections represented between 2.5% and 43% of each surgeon's pneumonectomy volume. Sixteen (47%) patients were candidates for pneumonectomy. There was no operative mortality and 1 death at 47 days. Postoperative complications occurred in 21 (61.8%) patients. No patient required completion pneumonectomy. Overall 5-year survival was 33% (95% confidence interval [CI], 12-53). Compared with pulmonary arterioplasty alone, patients undergoing bronchial sleeve resection and pulmonary arterioplasty had better disease-free 5-year survival (50% [95% CI, 18-82] vs 19% [95% CI, 5-43]; P = .04), higher complete resection rate (100% [95% CI, 83-100] vs 80% [95% CI, 56-94]; P = .23) and lower disease recurrence (8% [n = 1 of 13] vs 47% [n = 7 of 15]; P = .04); 80% of disease recurrence was distant. CONCLUSIONS: Resection and reconstruction of the PA for malignant lung disease may be safely performed. In candidates for pneumonectomy, arterial resection offers low operative risk. Long-term survival is impaired by distant, not local, recurrence emphasizing the importance of systemic therapy.

Acute airway management.

Acute airway management has challenged clinicians for nearly four millennia. History underscores the discoveries of surgeons and anesthesiologists, whose advances in technology and surgical technique have transformed management algorithms from primarily surgical tracheostomy, to transoral endotracheal intubation under direct laryngoscopy. Despite this progress and a better understanding of airway anatomy, physiology and pathogenesis of disease, the acute airway, whether obstructed, traumatically disrupted, or externally compressed, remains a life-threatening challenge. The role of all clinicians in acute airway management is patient stability and emergent control of the airway to ensure patency as well as adequate oxygenation and ventilation. The standard of care remains transoral intubation under direct laryngoscopy with use of indirect laryngoscopy as a first adjunct. If unsuccessful, surgical intubation of the trachea via cricothyroidotomy with subsequent conversion to open tracheostomy is the procedure of choice. While there is growing support for the use of percutaneous tracheostomy as an alternative to surgical intubation of the trachea after failed transoral intubation, the potential for damage to critical neck structures and longer time-to-intubation must be considered. In this perspective, we provide a history of acute airway management, highlighting milestones in the fields of airway surgery and anesthesia. We present a review of current medical and surgical approaches to managing the acute airway, including the risks, benefits and appropriateness of each approach with respect to patient stability, available equipment, clinician training and patient outcomes. We conclude with an emphasis on the role of the thoracic surgeon in prevention and the critical nature of regular surveillance of patients with chronic, partial tracheal obstruction.

Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation.

OBJECTIVE: Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation. METHODS: Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. RESULTS: The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96). CONCLUSION: Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.

A Novel and Successful Repair of a Left Atriogastric Fistula After Esophagectomy.

Atriogastric fistulas remain a rare adverse event in patients who undergo esophagectomy with gastric pullthrough. The presentation of an atriogastric fistula ranges from self-limited gastrointestinal bleeding to life-threatening hemorrhage, end-organ dysfunction from septic emboli, or both. These fistulas are associated with significant mortality. Previous reports describe successful repairs of gastrocardiac fistulas with the use of cardiopulmonary bypass. This report describes a patient with a significant burden of cerebral embolic disease, which therefore required a unique approach to fistula repair.