Utilization of Supplemental Regional Anesthesia in Lobectomy for Lung Cancer in the United States: A Retrospective Study.

Background: Pulmonary lobectomy is the standard of care for the treatment of early-stage non-small cell lung cancer. This study investigated the rate of utilization of supplemental anesthesia in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy using a national database and assessed the effect of regional block (RB) on postoperative outcomes. Methods: Patients who underwent lobectomy for lung cancer between 2014-2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The patients' primary mode of anesthesia and supplemental anesthesia were recorded. Preoperative characteristics and postoperative outcomes were compared between 2 surgical groups: those who underwent general anesthesia (GA) alone versus GA with RB. Multivariable regression analyses were performed on the outcomes of interest. Results: In total, 13,578 patients met the study criteria, with 87% undergoing GA and the remaining 13% receiving GA and RB. The use of neuraxial anesthesia decreased over the years, while RB use increased up to 20% in 2019. Age, body mass index, and preoperative comorbidities were comparable between groups. Patients who underwent VATS were more likely to receive RB than those who underwent thoracotomy. RB was most often utilized by thoracic surgeons. An adjusted analysis showed that RB use was associated with shorter hospital stays and a reduced likelihood of prolonged length of stay, but a higher rate of surgical site infections (SSIs). Conclusion: In a large surgical database, there was underutilization of supplemental anesthesia in patients undergoing lobectomy for lung cancer. RB utilization was associated with a shorter length of hospital stay and an increase in SSI incidence.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes.

PURPOSE: Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. METHOD: We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. RESULTS: Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. CONCLUSION: Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Trends in open lobectomy outcomes for lung cancer over the last 15 years: national cohort.

OBJECTIVE: Adoption of thoracoscopic lobectomy has been increasing in the US; however, open lobectomy (OL) is still performed in half of the cases. Postoperative care and enhanced recovery after surgery (ERAS) pathways have evolved and improved outcomes. The study aims to evaluate postoperative outcomes of OL over the last 15 years. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2019 were identified in the National Surgical Quality Improvement Program and divided into three groups; pre-ERAS (2005-2011), transitional period (2012-2015), and wider ERAS implementation (2016-2019). Preoperative characteristics and postoperative outcomes were compared and multivariable regression analysis was constructed to assess independent predictors of outcomes. RESULTS: OL was comprised of 40% of lobectomies for lung cancer. 10,021 patients met inclusion criteria. 49% were males and mean age was 67. Patients who belonged to the (2016-2019) period group had significantly higher comorbidities and ASA classification. General surgeons performed < 10% of OL in 2016-2019 compared to over 30% during 2005-2011. Patients in the 2016-2019 period were less likely to experience unplanned intubation, surgical site infections, and sepsis. Mortality was also significantly lower than the previous groups (1.9% vs 2.0% and 2.8%, p = 0.05). The rate of discharge to facility as well as length of hospital stays improved over the years. The surgeon specialty served as an independent predictor for length of stay, unplanned intubation, and home discharge. CONCLUSION: The outcomes of OL are improving over the years. Increasing number of these surgeries being performed by dedicated thoracic surgeons and ERAS pathways are likely helping improve outcomes.

Common femoral vein obstruction secondary to femoral sheath lipoma.

Common femoral vein obstruction secondary to femoral sheath lipomas are rare. We describe the case of a 49 year-old male that presented to the clinic with a 3 month history of progressive right lower extremity pain, edema and discoloration. Venous duplex imaging was consistent with proximal venous obstruction and led to Computerized Tomographic Venography (CTV) which demonstrated a large mass obstructing the external iliac vein (EIV) and common femoral vein (CFV) consistent with a femoral sheath lipoma. Surgical exploration revealed a large well encapsulated lipoma in the right femoral sheath posterior to the CFV and external iliac vein causing near occlusion. We present an overview of the diagnosis and surgical management of symptomatic femoral vein obstruction caused by a large femoral sheath lipoma.

Analysis of a Novel Inpatient Acute Limb Ischemia Alert System.

OBJECTIVES: Acute limb ischemia (ALI) is a surgical emergency that generally develops in the outpatient setting. Hospitalized patients are also at risk for acute limb ischemia, but their presentation may be atypical or altered by medical therapy. Our institution developed an alert system to facilitate the prompt recognition and treatment of ALI that occurs in the inpatient population. We aimed to evaluate the usage of the system after the first 2 years of operation. METHODS: All ALI alerts from October 2017 to December 2019 were collected from paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours) or delayed (after 8 hr). Time and location data were evaluated to determine patterns of usage and true-positive rate of the system. RESULTS: From October 2017 to December 2019, there were 237 ALI alerts obtained from paging records containing time and location information for the alert. More alerts originated from ICUs relative to non-ICU floors (68% vs. 33%, P< 0.001), however a greater proportion of non-ICU floor alerts required intervention compared to ICU alerts (32.0% vs. 5.1%, P < .0001). The highest number of ALI alerts were from the Medical ICU (MRICU) (45.9%) and medical/surgical floors (33.3%), followed by Surgical ICU (20.2%). Alerts were more common within 3 hr of morning and evening nursing shift changes (47.3%, P < 0.001). From the 237 total alerts, the patient was able to be identified retrospectively in 186 cases, and of these 27 resulted in operative interventions (14.5%, positive predictive value), with 11 patients (40.7%) requiring urgent intervention with a median time to intervention of 3.5 hr (range 2.2-4.8), and 16 (59%) alerts undergoing a delayed intervention at a mean of 3 days (range 2-4). A total of 73 (39.2%) alert patients died during their admission, of which 65 (89.0%) were in an ICU, and no deaths were directly related to ALI. The median time to death was 2 days (range 0-95 days), and in 22 cases death occurred <24 hr from time of alert. CONCLUSION: Our novel hospital-wide ALI alert system demonstrates a 14.5% positive predictive value for ischemia that resulted in an intervention. Alerts were more likely to originate from the ICU setting and during nursing shift changes. Alerts originating from non-ICU floors were 5 times more likely to undergo surgical intervention for ALI. Further analysis is required to assess the effect of this system on patient safety, outcome, and allocation of institutional resources.

Does Race or Ethnicity Impact Complications After Pulmonary Lobectomy for Patients With Lung Cancer?

BACKGROUND: Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States. RESULTS: A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States. CONCLUSIONS: In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

Omental infarction with liquefied necrosis after Roux Y gastric bypass: case report and literature review.

Omental infarction is a rare phenomenon that can be idiopathic or secondary to a surgical intervention. Greater omentum division has been advocated to decrease tension at the gastro-jejunal anastomosis during laparoscopic Roux-en-Y gastric bypass (RYGB). We report a case of omental infraction complicated by liquefied infected necrosis presenting 3 weeks after antecolic antegastric RYGB. The patient underwent laparotomy and subtotal omentectomy with a protracted hospital course due to intra-abdominal abscesses, acute kidney injury and small bowel obstruction that were successfully managed non-operatively. We reviewed the available literature on omental infarction after RYGB, focusing on associated symptoms, possible etiology, timing of presentation, management and propose an alternative technique without omental division.

Massive megarectum secondary to constipation in institutionalized patient.

Chronic constipation is a common cause of morbidity in the elderly and institutionalized population. It can be associated with significant morbidity and socioeconomical burden. Chronic resistance constipation can rarely be associated with megarectum. Herein, we present the case of a patient with physical and mental disability that presented with refractory constipation associated with extreme stool burden and a massive megarectum. We discuss chronic constipation in the elderly population, its etiologies and diagnostic work-up including surgical options. The management of chronic constipation with megarectum should be on a case-by-case basis.

Prevalence and Characteristics of Low Back Pain in a Rural Ghana Primary Care Clinic Population.

INTRODUCTION: Low back pain (LBP) is the leading cause of disability in the developed world. Less is known about the impact of LBP in the developing world, and particularly the rural developing world. In 2015, the World Health Organization (WHO) issued an urgent call for additional research into the prevalence and effect of LBP on developing world populations. OBJECTIVE: To calculate the prevalence of LBP in a rural Ghana primary care clinic population. DESIGN: Survey of LBP prevalence and severity. SETTING: Primary care mission clinic in rural Southeastern Ghana. PARTICIPANTS: Six hundred eighty-four adult patients. METHODS: All adult patients were screened for LBP using the definition "any pain occurring within the region between the lower margin of the 12th ribs and the gluteal folds." The Oswestry Disability Index (ODI) was used to further characterize LBP in those screening positive. Chi-square test was used to assess statistical significance of difference in prevalence between groups, and ordinary least squares regression was used to assess the relationship between LBP severity and gender and age. MAIN OUTCOME MEASUREMENTS: LBP prevalence and LBP severity as assessed using the ODI. RESULTS: Overall LBP prevalence was 15.7%, with no statistically significant differences observed by age or gender. The activities of standing, traveling, and walking were most severely affected. Of those with LBP, 10.3% were considered "crippled" based on ODI responses, whereas a further 31.8% were "severely disabled." No statistically significant relationship between LBP severity and age or gender was found. CONCLUSIONS: LBP is a cause of significant disability within this region of rural Ghana; however, prevalence appears to be lower than in the developed world and parts of the urbanized developing world. Increased attention to screening and treatment of LBP represents an opportunity to improve the health of rural Africans. LEVEL OF EVIDENCE: IV.

Dual specificity phosphatase 5 regulates perfusion recovery in experimental peripheral artery disease.

Peripheral artery disease (PAD) is caused by atherosclerotic occlusions of vessels outside the heart, particularly those of the lower extremities. Angiogenesis is one critical physiological response to vessel occlusion in PAD, but our understanding of the molecular mechanisms involved in angiogenesis is incomplete. Dual specificity phosphatase 5 (DUSP5) has been shown to play a key role in embryonic vascular development, but its role in post-ischemic angiogenesis is not known. We induced hind limb ischemia in mice and found robust upregulation of Dusp5 expression in ischemic hind limbs. Moreover, in vivo knockdown of Dusp5 resulted in impaired perfusion recovery in ischemic limbs and was associated with increased limb necrosis. In vitro studies showed upregulation of DUSP5 in human endothelial cells exposed to ischemia, and knockdown of DUSP5 in these ischemic endothelial cells resulted in impaired endothelial cell proliferation and angiogenesis, but did not alter apoptosis. Finally, we show that these effects of DUSP5 on post-ischemic angiogenesis are a result of DUSP5-dependent decrease in ERK1/2 phosphorylation and p21 protein expression. Thus, we have identified a role of DUSP5 in post-ischemic angiogenesis and implicated a DUSP5-ERK-p21 pathway that may serve as a therapeutic target for the modulation of post-ischemic angiogenesis in PAD.

Modulation of miR29a improves impaired post-ischemic angiogenesis in hyperglycemia.

Individuals with diabetes mellitus suffer from impaired angiogenesis and this contributes to poorer peripheral arterial disease outcomes. In experimental peripheral arterial disease, angiogenesis and perfusion recovery are impaired in mice with diabetes. We recently showed that a disintegrin and metalloproteinase domain-containing protein 12 (ADAM12) is upregulated in ischemic endothelial cells and plays a key role in post-ischemic angiogenesis and perfusion recovery following experimental peripheral arterial disease. Here we investigated the role of miR29a in the regulation of endothelial cell ADAM12 expression in ischemia and how hyperglycemia negatively affects this regulation. We also explored whether modulating miR29a can improve impaired post-ischemic angiogenesis associated with hyperglycemia. Additionally, we tested whether miR29a modulation could improve post ischemic angiogenesis in the setting of impaired vascular endothelial growth factor signaling. We forced miR29a expression in ischemic endothelial cells and assessed ADAM12 expression. We also evaluated whether hyperglycemia in vivo and in vitro impair ischemia-induced ADAM12 upregulation and miR29a downregulation. Lastly, we determined whether modulating endothelial cell miR29a expression in ischemia and hyperglycemia could improve impaired endothelial cell functions. We found under ischemic conditions where ADAM12 is upregulated in endothelial cells, miR29a is downregulated. Forced expression of miR29a in ischemic endothelial cell prevented ADAM12 upregulation . In ischemic hind limbs of mice with type 1 diabetes and in endothelial cells exposed to simulated ischemia plus hyperglycemia, ADAM12 upregulation and miR29a downregulation were blunted while angiogenesis was impaired. Knocking down miR29a with an miR29a inhibitor was sufficient to improve ADAM12 upregulation and angiogenesis in simulated ischemia plus hyperglycemia. It was also sufficient to improve perfusion recovery in type 1 diabetes mellitus mice in vivo and angiogenesis in vitro even when vascular endothelial growth factor signaling was impaired with blocking antibodies. In conclusion, MiR29a regulates endothelial cell ADAM12 upregulation in ischemia and this is impaired in hyperglycemia. Modulating miR29a improves impaired post-ischemic angiogenesis associated with hyperglycemia. Impact statement Individuals with diabetes are more likely to develop peripheral arterial disease (PAD), and when PAD is present, in those with diabetes, it is more severe and there is currently no effective medical treatment for impaired blood flow which occurs in diabetics with PAD. The current work advances the field by providing an understanding of a molecular mechanism involved in impaired post ischemic angiogenesis in diabetes. It shows for the first time that failure to downregulate miR29a in ischemic diabetic tissues is a major contributing factor to poor perfusion recovery in experimental PAD, and miR29a is elevated in skeletal muscle samples from human diabetics compared with levels in those without diabetes. Knocking down the elevated miR29a in ischemic diabetic mouse hind limbs improved perfusion recovery following experimental PAD. This shows miR29a modulation as a novel therapeutic target for improving blood flow in diabetics with PAD.