Thymic en-bloc resection with veins: case demonstrations and review of the literature.

Locally invasive thymic neoplasms are challenging clinical scenarios and typically require a multidisciplinary approach. The involvement of major mediastinal veins such as the superior vena cava (SVC) used to be a contraindication to surgery, but with improved surgical technique and outcomes, this paradigm has shifted. In some situations, complex resections and reconstructions may be indicated and required to improve the long-term outcome of these patients. We report two of our cases along with a current review of literature. We also describe the preoperative workup, operative techniques, postoperative management, complications, and outcomes of patients with invasive thymic neoplasms that involve the mediastinal veins. Our first case describes a patient who was diagnosed with a thymoma extending from the diaphragm to the base of the neck that was also encasing major vascular structures including the SVC and left innominate vein. Our second case describes a patient who was also diagnosed with a large anterior mediastinal mass encasing the great veins and invading the chest wall. We describe the management of these patients and then delve deeper into operative techniques including SVC resection and reconstruction. We describe the types of conduits that can be used and complications to be mindful of when clamping the great veins, such as the SVC. Improvements in conduit materials and neoadjuvant and adjuvant therapies over the years have made it more feasible for patients with invasive thymic neoplasms to undergo surgery.

Gender trends in cardiothoracic surgery authorship.

OBJECTIVE: In recent years, the historically low proportion of women cardiothoracic surgeons and trainees has been a subject of intense focus. Publications remain a key metric of academic success and career advancement. We sought to identify trends in the gender of first and last author publications in cardiothoracic surgery. METHODS: We searched for publications between 2011 and 2020 in 2 US cardiothoracic surgery journals, identifying those with Medical Subject Heading publication types of clinical trials, observational studies, meta-analyses, commentary, reviews, and case reports. A commercially available, validated software (Gender-API) was used to associate gender with author names. Association of American Medical Colleges Physician Specialty Data Reports were used to identify concurrent changes in the proportion of active women in cardiothoracic surgery. RESULTS: We identified 6934 (57.1%) pieces of commentary; 3694 (30.4%) case reports; 1030 (8.5%) reviews, systematic analyses, meta-analyses, or observational studies; and 484 (4%) clinical trials. In total, 15,189 total names were included in analysis. Over the 10-year study period, first authorship by women rose from 8.5% to 16% (0.42% per year, on average), whereas the percentage of active US women cardiothoracic physicians rose from 4.6% to 8% (0.42% per year). Last authorship was generally flat over the decade, going from 8.9% in 2011% to 7.8% in 2020 and on average, increased at just 0.06% per year (P = .79). CONCLUSIONS: Over the past decade, authorship by women has steadily increased, more so at the first author position. Author-volunteered gender identification at the time of manuscript acceptance may be useful to more accurately follow trends in publication.

Extended Resections for Lung Cancer.

This article briefly reviews the literature supporting the practice of extended pulmonary resection followed by a comprehensive description of the indications, workup, and technique commonly used for patients requiring extended pulmonary resections for advance lung cancers. The article also provides up-to-date advances in the field that have aided in the safe and effective practice of extended pulmonary resections.

Gender trends of military general surgery residency applicants.

BACKGROUND: Despite the fact that women comprise half of medical school graduates, women remain under-represented in General Surgery. We aimed to identify the trend in military general surgery applicants based on gender. METHODS: A retrospective review of the Medical Operational Data System (MODS) applicants from 2014 to 2019 was performed. Demographic data included age, gender, average board scores, applied and matched specialty. RESULTS: 204 students applied and 167 applicants matched into Army General Surgery programs from 2014 to 2019. The percentage of all students applying to General Surgery was statistically higher in females (13.4% vs 9.0%, p = 0.04), with females matching at a statistically higher rate (77% vs 57%, p = 0.02). Over the last 6 years, 55% of residents in training are men and 45% are women. CONCLUSION: Army General Surgery programs have increased the amount of women in training over the last six years. We believe that this will ultimately translate to more female surgeons contributing to military medicine.

Thoracoscopic Radial Diaphragm Plication.

In appropriately selected patients diaphragm plication improves quality of life by alleviating dyspnea and allowing patients to return to their routine activities. Many plication techniques exist, but the optimal surgical approach remains unclear. We report our experience with a minimally invasive radial diaphragm plication technique. It offers 2 distinct advantages: (1) suture placement avoids the phrenic nerve fibers, allowing for potential nerve recovery, and (2) the interrupted radial sutures improve the distribution of tension along the flaccid muscle and may achieve a more durable repair.

Gender Differences in Medical Specialty Decision Making: The Importance of Mentorship.

INTRODUCTION: While there have been many studies reviewing factors considered by medical students in deciding on a specialty, there is a relative paucity of data in how these factors differ between males and females. The aim of this study was to determine if there are differences in how male and female medical students' value various factors in choosing a career path in medicine. METHODS: A survey of basic demographic information and a Likert-based questionnaire addressing various factors in specialty choice was sent to all military medical students in the class of 2019. RESULTS: The survey response rate was 30%. Amongst the students that completed the survey, 72% were male and 28% were female. The majority of students were less than 27 years old (52%) and Caucasian (76%). Female medical students placed more importance in exposure to third year clerkships (P = 0.004) and gender diversity within the specialty (P = 0.03) than their male counterparts. There was no statistical difference in opinions of significant others or family members, desire to have a family, or having a well-balanced life between female, and male medical students. CONCLUSION: Female medical students valued exposure to third year clerkships and gender diversity more than their male colleagues when choosing a future specialty. These findings suggest that a strategic focus should be placed on mentoring female medical students in order to promote a diverse medical workforce.

Panniculectomy after bariatric surgical weight loss: Analysis of complications and modifiable risk factors.

INTRODUCTION: Bariatric surgery results in massive weight loss, leaving many patients with redundant skin that can cause significant physical and psychosocial limitations. We sought to identify variables associated with postoperative complications and adjuncts associated with the mitigation of postoperative complications. METHODS: A retrospective review was performed of all post-bariatric surgery patients who underwent panniculectomy over a 10-year period. RESULTS: Total 706 patients included. Overall complication rate was 56%: dehiscence (24%), surgical site infection (22%), seroma (18%), and post-operative bleeding (5%). Return to operating room rate was 12%. Significant factors were: BMI >26 (p < 0.01), fleur-de-lis panniculectomy (p < 0.01), concomitant hernia repair (p < 0.01). Multivariate regression analysis demonstrated ASA class >2 (OR 1.97, p < 0.05) and incision type (OR 1.64, p < 0.05) to be independent predictors of morbidity. CONCLUSION: High morbidity for post-bariatric panniculectomy is primarily local wound complications. Potentially modifiable factors that increase the complication risk profile include higher BMI, higher ASA class, and the use of fleur-de-lis incision.

Assessing serum hemoglobin levels without venipuncture: accuracy and reliability of Pronto-7 noninvasive spot-check device.

BACKGROUND: Hemoglobin is a frequently obtained test in hospital settings. We analyzed accuracy of a noninvasive device compared to standard laboratory analyzers in a variety of settings. METHODS: A noninvasive hemoglobin monitoring device was analyzed for reliability, correlation, precision, and bias. Hemoglobin levels were obtained from standard laboratory and point-of-care hemoglobin analyzers and compared to noninvasive hemoglobin in inpatient and military field environments. RESULTS: Ninety-seven patients were enrolled. Overall, the noninvasive hemoglobin device had high correlation compared to invasive laboratory values. Stratified by location, the device had high correlation in hospital and low correlation in austere environment. The highest variation in accuracy was seen in the austere environment. CONCLUSIONS: Overall, the noninvasive spot-check hemoglobin device is reliable and highly correlates to standard hemoglobin analysis. Use in an austere setting requires further study.

Reliability of Continuous Non-Invasive Assessment of Hemoglobin and Fluid Responsiveness: Impact of Obesity and Abdominal Insufflation Pressures.

BACKGROUND: During surgery, proper fluid resuscitation and hemostatic control is critical. Pleth variability index (PVI) is advocated as a reliable way of optimizing intraoperative fluid resuscitation. PVI is a measure of dynamic change in perfusion index during a complete respiratory cycle. Non-invasive monitoring of total hemoglobin could provide a reliable means to determine need for transfusion. We analyzed the impact of insufflation and obesity on non-invasive measurements of hemoglobin and PVI in laparoscopic procedures to validate reliability of fluid responsiveness and hemoglobin levels. METHODS: A non-invasive hemoglobin and PVI monitoring device was prospectively analyzed in patients undergoing abdominal operations. Patients were stratified by open and laparoscopic approach and obesity (body mass index (BMI) ≥35). PVI and hemoglobin values were assessed before, during, and after insufflation and compared to control patients undergoing open surgery. RESULTS: Sixty-three patients were enrolled (mean age 42 years; 71 % male; mean BMI 36) with 24 patients laparoscopic non-obese (LNO), 20 laparoscopic obese (LO), and 19 undergoing open operations. There was no significant blood loss. Hemoglobin did not change significantly before or after insufflation. There was false elevation of PVI with insufflation and more pronounced in obese patients. CONCLUSIONS: Insufflation or obesity was not associated with significant variations in hemoglobin. Non-invasive monitoring of hemoglobin is useful in laparoscopic procedures in obese and non-obese patients. PVI values should be used cautiously during laparoscopic procedures, particularly in obese patients.

Standard laparoscopic trocars for the treatment of tension pneumothorax: a superior alternative to needle decompression.

BACKGROUND: Needle thoracostomy (NT) is a commonly taught intervention for tension pneumothorax (tPTX) but has a high failure rate. We hypothesize that standard 5-mm laparoscopic trocars may be a safe and more effective alternative. METHODS: Thirty episodes of tPTX and 27 episodes of tension-induced pulseless electrical activity (PEA) were induced in five adult swine using thoracic CO2 insufflation via balloon trocar. Tension was defined as a 50% decrease in cardiac output. Chest decompression was performed with 5-mm laparoscopic trocars for the treatment of both tPTX with hemodynamic compromise and tension-induced PEA. The lungs and heart were inspected and graded at necropsy for trocar-related injury. Results were also compared with success rates with NT in the same model. RESULTS: The placement of a 5-mm trocar rapidly and immediately relieved tension physiology in 100% of the cases. Mean arterial pressure, cardiac output, central venous pressure, and pulmonary capillary wedge pressure all returned to baseline within 1 minute of trocar placement. Adequate perfusion was restored in 100% of tension-induced PEA cases within 30 seconds of trocar placement. There was no evidence of trocar-related heart or lung damage in any of the experimental animals at necropsy (mean injury scores, 0 for both). Five-millimeter trocars significantly outperformed standard NT for both tPTX and tension-induced PEA arrest. CONCLUSION: tPTX and tension-induced PEA can be safely and effectively treated with chest decompression using 5-mm laparoscopic trocars. This technique may serve as a more rapid and reliable alternative to needle decompression.

Acute coagulopathy in a porcine venous hemorrhage and ischemia reperfusion model.

BACKGROUND: Injury-related coagulopathy is a complex process. We analyzed coagulation in a swine model of shock using rotational thromboelastometry (ROTEM). METHODS: Forty-eight swine underwent laparotomy, 35% hemorrhage, supraceliac aortic cross-clamp, then reperfusion and resuscitation. ROTEM measurements and standard labs were taken at baseline and 6 hours into resuscitation. RESULTS: Clot formation time (98 vs 53 seconds, P = .001) and international normalized ratio (1.67 vs 1.01, P < .001) were prolonged after resuscitation. Maximum clot firmness (61 vs 72 mm, P < .001) and fibrinogen levels (94 vs 165, P < .001) declined significantly during resuscitation. Despite decreased fibrinogen levels, there was no significant increase in fibrinolysis as measured by maximum lysis (3.9% vs 3.8%, P = .99). CONCLUSIONS: ROTEM demonstrated the development of an acute coagulopathy. The most significant impacts on coagulopathy were seen with clot initiation and fibrin polymerization. Clot strength decreased over time, although there was little impact on clot breakdown because of fibrinolysis.

Tranexamic acid corrects fibrinolysis in the presence of acidemia in a swine model of severe ischemic reperfusion.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic with anti-inflammatory properties associated with improved outcomes when administered to trauma patients at risk for bleeding; however, its efficacy is unknown in acidemia. We evaluated the efficacy of TXA on hyperfibrinolysis using an established porcine traumatic hemorrhage ischemic shock model. METHODS: Ten Yorkshire swine underwent a controlled hemorrhage followed by supraceliac aortic cross-clamping. During standard resuscitation, control animals received recombinant tissue plasminogen activator (rtPA) after cross-clamp removal, and experimental animals received rtPA followed by TXA. Rotational thromboelastometry analysis was performed at baseline, 5 minutes and 15 minutes after rtPA dosing, and 4 hours after cross-clamp removal. RESULTS: Control and experimental animals had similar hemodynamics and routine laboratory values at baseline and throughout resuscitation. At the time of TXA administration, average pH was 7.2. Clot formation time was prolonged from baseline and all resuscitation time points in both groups, with no difference at any time point. Maximum clot firmness decreased from baseline at all resuscitation time points in both groups. Maximum lysis increased from baseline (9% control vs. 9% TXA) after tissue plasminogen activator administration in both groups (100% control vs. 99% TXA). In experimental animals, maximum lysis returned to baseline 10 minutes after TXA administration (92% vs. 9%, p < 0.001). CONCLUSION: TXA rapidly and fully reverses hyperfibrinolysis despite severe acidemia in a porcine trauma model. TXA is a promising adjunct to trauma resuscitation that is easily administered in austere or prehospital settings.

Outcome comparison following colorectal cancer surgery in an equal access system.

BACKGROUND: Previous reports suggest outcome differences following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to compare community and tertiary centers in an equal access system. MATERIALS AND METHODS: Patients treated for CRC at Department of Defense medical facilities were stratified by care at tertiary (MEDCEN) versus community (MEDDAC) medical centers. Disease-free and overall survival outcomes were calculated, including Cox multivariate analysis. RESULTS: A total of 6438 patients met inclusion criteria. Overall, 3347 operations were performed at MEDCENs and 3091 operations at MEDDACs. By stage, 25.6% were stage 1, 27.1% stage 2, 29.1% stage 3, and 18.2% stage 4. Mean number of lymph nodes harvested were 11.3 ± 10.2, with no difference between facilities. Disease-free survival at 5 y was similar between the two cohorts (mean 88.1%). Overall 5-y survival was 52.7% (MEDDAC) versus 46.8% (MEDCEN), P < 0.001, due to significant differences in stage 2 patients. Cox regression and logistic regression analysis identified stage 2 patients as independently associated with significantly increased 5-y mortality risk at MEDCEN. CONCLUSION: Outcomes following surgery for CRC in an equal access system are improved in stage 2 patients treated at MEDDACs compared to high-volume, specialist-centered MEDCENs. Further evaluation into factors impacting improved overall survival at MEDDACs, including adjuvant therapy utilization, is warranted to optimize outcomes.

Colorectal cancer screening in an equal access healthcare system.

INTRODUCTION: The military health system (MHS) a unique setting to analyze implementation programs as well as outcomes for colorectal cancer (CRC). Here we look at the efficacy of different CRC screening methods, attributes and results within the MHS, and current barriers to increase compliance. MATERIALS AND METHODS: A literature search was conducted utilizing PubMed and the Cochrane library. Key-word combinations included colorectal cancer screening, racial disparity, risk factors, colorectal cancer, screening modalities, and randomized control trials. Directed searches were also performed of embedded references. RESULTS: Despite screening guidelines from several national organizations, extensive barriers to widespread screening remain, especially for minority populations. These barriers are diverse, ranging from education and access problems to personal beliefs. Screening rates in MHS have been reported to be generally higher at 71% compared to national averages of 50-65%. CONCLUSION: CRC screening can be highly effective at improving detection of both pre-malignant and early cancers. Improved patient education and directed efforts are needed to improve CRC screening both nationally and within the MHS.

Perioperative protocols in colorectal surgery.

The reduction in health-care expenditures and more efficient use of medical resources are now overriding health policy priorities with the two-pronged goal of improving patient outcomes while decreasing overall cost. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. To combat this, Kehlet and colleagues introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to decrease surgical stress, enhance postoperative recovery, and reduce length of stay. The benefits, safety, and cost-effectiveness of fast-track protocols are validated in multiple randomized controlled trials. In this review, the authors focus on the evidence regarding fast-track pathways, use of minimally invasive surgery and its role in fast-track pathways, newer perioperative interventions, and future directions.

Hypertension-linked decrease in the expression of brain gamma-adducin.

Gene profiling data coupled with adducin polymorphism studies led us to hypothesize that decreased expression of this cytosolic protein in the brain could be a key event in the central control of hypertension. Thus, our objectives in the present study were to (1) determine which adducin subunit gene demonstrates altered expression in the hypothalamus and brainstem (two cardioregulatory-relevant brain areas) in two genetic strains of hypertensive rats and (2) analyze the role of adducins in neurotransmission at the cellular level. All three adducin subunits (alpha, beta, and gamma) were present in the hypothalamus and brainstem of Wistar Kyoto (WKY) and spontaneously hypertensive (SH) rats. However, only the gamma-adducin subunit expression was 40% to 60% lower in the SH rat compared with WKY rat. A similar decrease in gamma-adducin expression was observed in the hypothalamus and brainstem of the renin transgenic rat compared with its normotensive control. Losartan treatment of the SH rat failed to normalize gamma-adducin gene expression. A hypertension-linked decrease of gamma-adducin was confirmed by demonstrating a decrease in gamma-adducin expression in hypothalamic/brainstem neuronal cultures from prehypertensive SH rats. Neuronal firing rate was evaluated to analyze the role of this protein in neurotransmission. Perfusion of a gamma-adducin-specific antibody caused a 2-fold increase in the neuronal firing rate, an effect similar to that observed with angiotensin II. Finally, we observed that preincubation of neuronal cultures for 8 hours with 100 nmol/L angiotensin II caused a 60% decrease in endogenous gamma-adducin and was associated with a 2-fold increase in basal firing rate. These observations support our hypothesis that a decrease in gamma-adducin expression in cardioregulatory-relevant brain areas is linked to hypertension possibly by regulating the release of neurotransmitters.