Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy.

INTRODUCTION: Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. METHODS: This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. RESULTS: Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak. CONCLUSIONS: Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma.

OBJECTIVE: Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision. METHODS: A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma. RESULTS: There was no association between tumor type and age group (P = .183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P < .001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P < .001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma. CONCLUSIONS: Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

A brief overview of thoracic surgery in the United States.

The 331 million people of the United States are served by a complex and expensive healthcare system that accounts for nearly 18% of the country's gross domestic product. Over 90% of patients are insured by private or government-funded plans, but despite high coverage and unusually high healthcare spending, vast disparities exist within the United States population based on demographics in terms of diagnosis, treatment, and outcomes of disease. Thoracic surgeons in the United States are trained to treat patients with diseases of the chest in the operative and perioperative settings, and can accomplish this training through multiple highly competitive pathways. Thoracic surgeons perform an average of 135 operations each per year which address diseases of the lungs, trachea, esophagus, chest wall, mediastinum, and diaphragm. Video assisted thoracoscopic surgeries are the most commonly performed procedures, which are primarily completed to treat lung cancer. Lung cancer is the deadliest and second most prevalent malignancy in the United States, with over 200,000 new cases expected this year. In addition to encouragement of smoking cessation and more attention to air pollutants, increased access to lung cancer screening has significantly expedited diagnosis and reduced mortality from lung cancer in the last several years. Thoracic surgeons in the United States are tasked with treating common yet highly morbid diseases of the chest in a patient population that is diverse in terms of race, socioeconomic status, and healthcare insurance coverage. As the population ages and a shortage of thoracic surgeons looms, the importance of early diagnosis, skillful surgical management, and attention to the disparities that exist in our system cannot be overstated.

Applications of Three-Dimensional Printing in Surgical Oncology.

A variety of three-dimensional (3D) printing techniques and materials facilitate the creation of customized models that promise to improve surgical procedures and patient outcomes. Three-dimensional-printed models allow patients, trainees, and experienced surgeons to explore anatomy through direct visualization and tactile feedback. Although 3D-printed models serve a range of purposes including preoperative planning, education, skills refinement, patient-specific intraprocedural guides, and implants, much work remains to decrease the turnaround time and cost of printing models, collect long-term effectiveness data, and refine regulatory oversight of 3D printing in medicine.

Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries.

OBJECTIVES: The purposes of this study were to evaluate the relationship between body mass index (BMI) and postoperative complications and to determine the incidence of reoperation after surgical treatment of pelvic ring injuries. SETTING: Three Level I trauma centers. PATIENTS/PARTICIPANTS: A retrospective review of 184 consecutive surgically treated pelvic ring injuries (Orthopaedic Trauma Association 61) was performed. Two patients died in the initial postoperative period, and the remaining 182 patients were followed for a minimum of 3 months. MAIN OUTCOME MEASUREMENTS: Complications that were evaluated included wound infection and dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis, pneumonia, and the development of decubitus ulcers. Body mass index was calculated for each patient, and a BMI greater than 30 kg/m considered to be obese as defined by the National Institutes of Health. RESULTS: There were 132 males and 50 females with an average age of 36.4 years (range, 14-83 years). There were 48 (26%) patients with a BMI over 30 kg/m. Complications occurred in 46 of 182 patients (25.3%) with 26 occurring in the 48 patients with BMI greater than 30 kg/m (54.2% complication rate) and 20 occurring in the 134 patients with BMI less than 30 kg/m (14.9% complication rate). Complications included 20 infections (four superficial wound dehiscence and 16 deep), 23 losses of reduction, five deep vein thromboses, three pulmonary embolus, three pneumonia, two decubitus ulcers, and three iatrogenic nerve injuries. Reoperation was required in 29 of 182 (15.9%) patients with 16 (8.8%) irrigation and débridement, and 17 (9.3%) refixation procedures. All wound complications occurred after open exposures. Open exposures were performed for the anterior pelvic ring in 143 of 182 (78.6%) patients, the posterior pelvic ring in 64 of 182 (35.2%) patients, and percutaneous treatment of the posterior pelvic ring was performed in 80 of 182 (44.0%) patients. Logistic regression modeling analyzing BMI as a continuous variable found a relationship between increasing BMI and complication rate (P < 0.0001) and need for reoperation (P = 0.0013). Odds ratios analysis revealed that obese patients (BMI greater than 30 kg/m) were 6.87 (95% confidence interval, 3.25-14.49) times more likely to have a complication and 4.68 (95% confidence interval, 2.03-10.76) times more likely to undergo reoperation than patients with BMI less than 30 kg/m. CONCLUSIONS: Body mass index correlates with an increased rate of complications and reoperation after operative treatment of pelvic ring injuries.