Lung Transplantation and the Routine Use of Cardiopulmonary Bypass and Median Sternotomy: Experience at the Ochsner Multi-Organ Transplant Institute.

BACKGROUND: From 1990-2005 at Ochsner Medical Center in New Orleans, LA, cardiopulmonary bypass (CPB) was used only when necessary during lung transplantation surgeries. Ochsner's lung transplant program was closed for more than 4 years after Hurricane Katrina, and since the program's reestablishment in 2010, the majority of lung transplantation surgeries have been performed with the patient on CPB and with a median sternotomy incision. The purpose of this study was to compare the outcomes of the CPB and non-CPB groups. METHODS: After institutional review board approval, we conducted a retrospective review of the entire program using the Ochsner lung transplant database to identify patients in the non-CPB group from 1990-2005 and in the CPB group from 2010-2014. We calculated 1- and 3-year survival rates for each patient and reviewed medical records for evidence of stroke, the need for operative reexploration, and venous stenosis. We also performed a subgroup analysis of the first 20 consecutive patients undergoing lung transplantation on CPB with median sternotomy from February 2010 through April 2011 to examine intraoperative blood product use, the quantity of blood products administered, CPB cannulation and pump complications, ischemic time, and primary graft dysfunction. RESULTS: Of the 208 patients in the non-CPB group, 74% had 1-year graft survival and 55% had 3-year survival following transplantation. After February 2010, 79 patients underwent lung transplantation on CPB with median sternotomy, and 90% of those patients had 1-year graft survival. Of the 46 patients available for 3-year follow-up, 59% were alive with functional grafts. The difference in 1-year survival rates between the 2 cohorts was statistically significant. Two deaths, 3 strokes, and 5 reexplorations of the chest for bleeding occurred during the perioperative time period in the CPB group, but no mortality was associated with these perioperative events. One patient who had perioperative complications died within the first year; the death was attributable to gastric perforation. CONCLUSION: Patients' early outcomes appear to have improved with the use of CPB and median sternotomy; however, 3-year survival is similar to the non-CPB group. Technical benefits of CPB with median sternotomy include decreased warm ischemia time during graft implantation, controlled hemodynamics and reperfusion, avoidance of single-lung ventilation of a freshly implanted graft, and the option to open the left atrium for implantation of a venous cuff without using a clamp. The surgical exposure facilitated by CPB with median sternotomy for lung transplantation appears to be a safe and feasible approach for lung transplantations.

Thoracoscopic Lobectomy for Non-small Cell Lung Cancer.

Lobectomy is the gold standard treatment in operable patients with surgically resectable non-small cell lung cancer. Thoracoscopic lobectomy has emerged as an option for surgeons facile with the technique. Video-assisted thoracoscopic surgery (VATS) is used for a variety of indications, but its efficacy as a reliable oncologic procedure makes it appealing in the treatment of non-small cell lung cancer. Fewer postoperative complications and decreased postoperative pain associated with VATS procedures can lead to shorter lengths of stay and lower overall costs. Thoracoscopic surgery continues to evolve, and uniportal, robot-assisted, and awake thoracoscopic procedures have all shown promising results.

Blunt cerebrovascular injury is poorly predicted by modeling with other injuries: analysis of NTDB data.

BACKGROUND: Traumatic blunt cerebrovascular injury (BCVI) may portend catastrophic complications if untreated. Who should be screened for BCVI is controversial. The purpose of this study was to develop and validate a prediction score (pBCVI) to identify those at sufficient risk to warrant dedicated screening. METHODS: We conducted a cohort study using data for years 2002-2007 from the National Trauma Data Bank. Blunt trauma patients aged 16 years and older were randomly divided into two groups for score creation and validation. Final prediction model included age, sex, Trauma Mortality Prediction Model p(death), traumatic intracranial hemorrhage, cerebellar/brain stem injury, malar/maxillary fracture, mandible fracture, cervical spine fracture, cervical spinal cord injury, thoracic spinal cord injury, and chest Abbreviated Injury Scale ≥3. pBCVI was evaluated using receiver operating characteristic curve area and the Hosmer-Lemeshow statistic. The Youden Index estimated an optimal cut-point (J) of the pBCVI. RESULTS: The cohort numbered 1,398,310 patients, including 2,125 with BCVI. The overall incidence of BCVI was 0.15%. Cervical spine fracture had the strongest association with BCVI (odds ratio 4.82, p < 0.001). The receiver operating characteristic curve for pBCVI was 0.93 and the Hosmer-Lemeshow statistic was 206.3, p < 0.01. The optimal cut-point (J) of pBCVI was 0.0013 (sensitivity 0.91, specificity 0.82) and would miss 186 (8.8%) injuries in our cohort. To identify all BCVI using this model, an unrealistic 96% of the cohort would require screening. CONCLUSIONS: A model based on a pattern of other injuries cannot be used as a stand-alone instrument to determine screening for BCVI. "Optimal" model cut-points are not ideal for all injuries. Clinical suspicion that integrates energy of mechanism and associated injuries remains essential to effectively screen for BCVI and minimize patient risk for a catastrophic missed injury.