Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules.

BACKGROUND: Localizing small or deep pulmonary nodules or subsolid ground-glass opacities often is difficult during video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). This can result in larger resections or conversion to thoracotomy. The goal of this study is to evaluate the role of electromagnetic navigational bronchoscopic localization (ENBL) as a safe and accurate intraoperative method to localize small, deep, or subsolid nodules. METHODS: This is a single-institution, single-surgeon retrospective study of all patients (51) who underwent combined ENBL and resection of 54 nodules between May 2013 and August 2015. Localization was performed by intraoperative ENBL-guided transbronchial injection of a liquid marker. The liquid marker used was methylene blue, either alone or in addition to indocyanine green and Isovue. A fiduciary also was added in 2 cases. Immediately after localization, the patients underwent VATS for evaluation before proceeding with RATS for anatomical sublobar resection. RESULTS: The mean preoperative largest nodule diameter on computed tomography scan was 13.3 mm (range, 4-44 mm). The mean distance from the surface of the lung to the middle of the nodule was 22 mm (range, 4-38 mm). Thirty-one nodules were solid (57.4%), whereas 23 were ground-glass opacities (42.6%). ENBL successfully localized the nodules for initial sublobar resection in 53 of 54 nodules (98.1%). Minimally invasive thoracoscopic surgery was performed successfully in 49 of 51 patients (96.1%), by RATS in 47 (92.2%), and VATS in 2 (3.9%). Two patients required conversion to thoracotomy secondary to extensive adhesions. Of the 54 nodules, final diagnosis was adenocarcinoma in 32 (59.2%), metastatic disease in 7 (13%), squamous cell carcinoma in 2 (3.7%), neuroendocrine tumor in 2 (3.7%), and benign in 11 (20.3%). There were no operative mortalities. Morbidities included acute renal insufficiency in 2 patients and prolonged air leak requiring a Heimlich valve in 3 patients. Mean length of stay was 3.9 days. CONCLUSIONS: ENBL is a safe and accurate intraoperative modality for targeted sublobar resection of pulmonary nodules that are deemed difficult to localize.

The impact of lungs from diabetic donors on lung transplant recipients†.

OBJECTIVES: We attempted to determine if transplants of lungs from diabetic donors (DDs) is associated with increased mortality of recipients in the modern era of the lung allocation score (LAS). METHODS: The United Network for Organ Sharing (UNOS) database was queried for all adult lung transplant recipients from 2006 to 2014. Patients receiving a lung from a DD were compared to those receiving a transplant from a non-DD. Multivariate Cox regression analysis using variables associated with mortality was used to examine survival. RESULTS: A total of 13 159 adult lung transplants were performed between January 2006 and June 2014: 4278 (32.5%) were single-lung transplants (SLT) and 8881 (67.5%) were double-lung transplants (DLT). The log-rank test demonstrated a lower median survival in the DD group (5.6 vs 5.0 years, P = 0.003). We performed additional analysis by dividing this initial cohort into two cohorts by transplant type. On multivariate analysis, receiving an SLT from a DD was associated with increased mortality (HR 1.28, 95% CI 1.07­1.54, P = 0.011). Interestingly, multivariate analysis demonstrated no difference in mortality rates for patients receiving a DLT from a DD (HR 1.12, 95% CI 0.97­1.30, P = 0.14). CONCLUSIONS: DLT with DDs can be performed safely without increased mortality, but SLT using DDs results in worse survival and post-transplant outcomes. Preference should be given to DLT when using lungs from donors with diabetes.

Venovenous Extracorporeal Membrane Oxygenation in Two Morbidly Obese Patients.

Case studies on the use of venovenous extracorporeal membrane oxygenation in the obese patient have been infrequently reported. We report the successful utilization of venovenous extracorporeal membrane oxygenation in two obese patients with acute respiratory distress syndrome. The first patient had a body mass index of 93 and developed acute respiratory distress syndrome in the setting of pneumonia and aspiration while the second patient had a body mass index of 47 and developed acute respiratory distress syndrome in the setting of gastrografin aspiration. Both were successfully managed with venovenous extracorporeal membrane oxygenation and discharged from the hospital.

Examining Mortality and Rejection in Combined Heart-Lung Transplantations.

Background There is a paucity of data on outcomes related to combined heart-lung transplantations (HLTs). Our objective was to identify variables associated with mortality and rejection in HLT. Methods The United Network for Organ Sharing database was reviewed for HLT performed between 1993 and 2008. Long-term survivors (survival > 5 years) were compared with short-term survivors (survival < 5 years). Factors associated with rejection were examined. Risk-adjusted multivariable Cox's proportional hazards regression analysis was performed to examine variables associated with mortality and rejection. Results Multivariable analysis revealed that recipient male gender was associated with mortality at 1 year (hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.11-2.54, p = 0.01) and 5 years (HR: 1.41, 95% CI: 1.05-1.89, p = 0.02). Preoperative extracorporeal membrane oxygenation (ECMO) was associated with mortality at 1 year (HR: 7.55, 95% CI: 2.55-22.30, p < 0.01) and 5 years (HR: 3.14, 95% CI: 1.19-8.32, p = 0.02). Preoperative mechanical ventilation (MV) was associated with mortality at 1 year (HR: 3.51, 95% CI: 1.77-6.98, p < 0.01) and at 5 years (HR: 2.70, 95% CI: 1.51-4.85, p < 0.01). Multivariable analysis showed that male gender (HR: 1.78, 95% CI: 1.03-3.09, p = 0.04) and cytomegalovirus (CMV) positivity in the recipient and donor (HR: 3.09, 95% CI: 1.59-6.01, p < 0.01) were associated with rejection. Clinical infection in the donor (HR: 2.05, 95% CI: 1.16-3.61, p = 0.01) was also associated with rejection. Conclusion Survival was affected by recipient male sex and need for preoperative ECMO or MV. Risk factors for rejection included male sex, CMV positivity in the donor and recipient, and donor with clinical infection.

Does socioeconomic status predict outcomes after cholecystectomy?

BACKGROUND: This study was performed to evaluate the effect of socioeconomic status (SES) on outcomes after cholecystectomy. METHODS: The National Inpatient Sample (NIS) database (2005 to 2011) was queried for patients undergoing cholecystectomy. Clinically relevant variables were used to examine clinical characteristics, postoperative complications, and mortality. SES was investigated by examining income quartile. RESULTS: More than 2 million patients underwent cholecystectomy during this period. They were divided into quartiles by SES. The lowest cohort was younger (50 years, P < .001) and had the lowest Charlson Comorbidity Index (2.08, P < .001). This cohort was more likely African American (15.8%, P < .001) and more likely to have Medicaid (19.2%, P < .001). Using split-sample validation and multivariate analysis, lower SES, Charlson comorbidity Index, and Medicaid recipients were associated with increased mortality. CONCLUSIONS: Patients with Medicaid and lower SES had poorer outcomes after cholecystectomy.

Current status of the implantable LVAD.

With the ongoing shortage of available organs for heart transplantation, mechanical circulatory support devices have been increasingly utilized for managing acute and chronic heart failure that is refractory to medical therapy. In particular, the introduction of the left ventricular assist devices (LVAD) has revolutionized the field. In this review, we will discuss a brief history of the LVAD, available devices, current indications, patient selection, complications, and outcomes. In addition, we will discuss recent outcomes and advancements in the field of noncardiac surgery in the LVAD patient. Finally, we will discuss several topics for surgical consideration during LVAD implantation.

Axillary Artery Access for Combined Endoaortic Balloon Occlusion and Perfusion During Robotic Mitral Valve Surgery.

We aimed to develop a method that provides an alternative cannulation site in robotic mitral valve surgery that allows simultaneous endo-occlusion and antegrade perfusion. A 71-year-old man with severe mitral regurgitation and history of coronary artery bypass grafting underwent totally endoscopic robotic mitral valve repair. A 23-mm endoreturn cannula was placed through a 10-mm graft that was sewn to the left axillary artery. An endoballoon was passed through the Dacron/cannula complex and into the ascending aorta. This complex was used for simultaneous antegrade perfusion, endoballoon occlusion, and antegrade cardioplegia. Completion transesophageal echocardiography showed no evidence of mitral regurgitation. The patient had an uneventful postoperative course and was doing well at his 2-month follow-up appointment. The left axillary artery is a viable option for simultaneous endoballoon occlusion, antegrade perfusion, and antegrade cardioplegia in robotic mitral valve surgery. This has the potential benefit of providing antegrade perfusion, which some studies have shown to be associated with a decreased risk of complications when compared with retrograde perfusion specifically in patients with severe peripheral vascular disease.

Detection of crossing vessels in pediatric ureteropelvic junction obstruction: Clinical patterns and imaging findings.

BACKGROUND: Pediatric ureteropelvic junction obstruction (UPJO) is caused by congenital intrinsic narrowing and/or a lower pole-crossing renal artery. When a crossing renal vessel (CRV) is missed at the time of pyeloplasty, a redo-pyeloplasty is often required. OBJECTIVES: The aims were to analyze clinical predictors for the presence of a CRV in UPJO and the utility of functional magnetic resonance urography (fMRU) in preoperative identification of a crossing vessel. METHODS: Using an Institutional Review Board approved registry database, we identified 166 patients from July of 2007 until January of 2014 who had undergone open, laparoscopic, or robotic assisted laparoscopic pyeloplasty at our institution. We abstracted data including age at surgery, preoperative symptoms, preoperative imaging findings, and whether or not a CRV was identified intraoperatively. Statistical analysis was performed on SPSS using the Mann-Whitney U test. RESULTS: Of the 166 patients identified, 78 were found to have a CRV at the time of surgery and 88 did not. The surgical approach was distributed as 104 robotic assisted laparoscopic, 51 open, and 11 pure laparoscopic. On univariate analysis, older age at presentation and pain at presentation predicted the presence of a CRV; antenatal hydronephrosis was a negative predictor, though 20 of 68 (25.6%) infants diagnosed with UPJO antenatally did have a CRV. Subgroup analysis of patients undergoing preoperative MRU showed a sensitivity of 88.2% and specificity of 91.7% for the detection of CRVs. DISCUSSION: This study confirmed the importance of looking for a crossing vessel in all cases, with the knowledge that increased age and pain at presentation were more likely to be associated with a crossing vessel. In addition, fMRU is a valuable source of information in the preoperative identification of the presence of a crossing vessel. The study has limitations including being retrospective in nature, and that the sensitivity of fMRU to identify CRVs was based on the read of an experienced uroradiologist who specializes in MRU, so may not correlate with the standard clinical read of an fMRU. CONCLUSION: This study confirms the need to maintain a high index of suspicion for the presence of a CRV when intervening in a clinically symptomatic older child, although 25% of infants with antenatally detected UPJO did have one too. Our subset analysis demonstrated that MRU is a reliable method of detecting crossing vessels.

Lobe-specific mediastinal nodal dissection is sufficient during lobectomy by video-assisted thoracic surgery or thoracotomy for early-stage lung cancer.

BACKGROUND: Lobectomy with complete mediastinal lymphadenectomy is considered standard for patients with early-stage non-small cell lung cancer (NSCLC). However, the benefits of complete lymphadenectomy are unproven. There is evidence suggesting a predictable pattern of mediastinal nodal drainage. This study analyzed the frequency and pattern of mediastinal nodal disease and its impact on outcome in patients with early-stage NSCLC. METHODS: Patients with clinical N0/N1 NSCLC staged with CT scans and PET scans were identified. Disease involvement of resected nodal stations was recorded. Patterns of recurrence in patients who underwent lobectomy with complete mediastinal systematic lymph node sampling (SLNS) were compared with those who underwent lobe-specific mediastinal SLNS. RESULTS: From July 2004 to April 2011, 370 patients were identified. Complete SLNS was performed in 282 patients. Fifteen patients (5.3%) in the group with complete SLNS were found to have N2 disease after pathologic evaluation. Patients with left-sided tumors were more likely to have pathologic N2 disease than were patients with right-sided tumors (P = .03). Only one patient (0.36%) had positive N2 disease in the distal mediastinum while skipping lobe-specific mediastinal nodes. In addition, patients with complete SLNS had a rate of recurrence similar to that of the group that had lobe-specific mediastinal evaluation (20.6% vs 18.2%, P = .68). CONCLUSIONS: Mediastinal N2 metastases follow predictable lobe-specific patterns in patients with negative preoperative CT scans and PET scans. Lobe-specific N2 nodal evaluation results in a recurrence rate similar to that of complete mediastinal evaluation. Lobe-specific mediastinal nodal evaluation appears acceptable in patients with early-stage NSCLC.