Obstruction of the Inferior Vena Cava Following Coronary Artery Bypass Grafting.

Obstruction of the inferior vena cava (IVC) following coronary artery bypass grafting (CABG) is a rare complication. We describe a case of IVC outflow obstruction secondary to inferior cavoatrial junction injury during CABG. The diagnostic and management approaches used to care for this patient are discussed. (Level of Difficulty: Intermediate.).

Establishment of a per oral endoscopic myotomy program at a rural tertiary care center.

BACKGROUND: This study's purpose is to determine the application and effectiveness of a POEM program in the rural healthcare setting. Achalasia has a substantial impact on the lives of afflicted patients. Traditionally, a Heller myotomy with fundoplication has been the standard of care for treatment. In 2008, the first per oral endoscopic myotomy (POEM) was performed in Japan. Since 2017, our rural healthcare institution has performed approximately 60 POEMs. METHODS: An IRB approved, single-institution retrospective review of patient outcomes after POEM was performed along with prospective analysis of post-operative surveys. An institutional cost analysis was also performed. Demographic and qualitative variables were measured and included PPI use, a Likert scale of 0-5 for progressively worsening symptoms of heartburn, dysphagia, and regurgitation. In addition, we included a Dysphagia Outcome and Severity Scale. RESULTS: The number of myotomy operations increased from 4.5 per year to 28.8 per year after initiation of the POEM program. Mean Likert scale scores were 0.91, 0.73, and 1 for heartburn, dysphagia, and regurgitation, respectively. 72.5% percent of patients were satisfied with their present condition. 87.5% of patients reported minimal or no dysphagia on the Dysphagia Severity Scale. Intraoperative costs were $2477 for laparoscopic myotomy and $1650 for POEM. The capital expense of the equipment required to perform POEM was $110,232. Average contribution margin per case was $6024. The procedure pays off capital outlay upon completion of the 19th case. CONCLUSIONS: This study shows that patients have excellent symptom control after POEM. When compared to the institution's laparoscopic myotomy volume, POEM far surpasses in terms of operative volume and monetary benefit. Examination of these data shows that a rural hospital can successfully employ a state-of-the-art intervention when there is a population in need and an infrastructure in place.

Combined surgical treatment of symptomatic carotid, coronary and mesenteric occlusive disease.

The surgical management of advanced symptomatic atherosclerotic disease in multiple distributions including the coronary circulation presents unique challenges due to the high risk of perioperative ischemic complications in the setting of coronary artery bypass grafting. We present a novel case of the combined surgical management of symptomatic carotid, coronary and mesenteric ischemic disease. The patient underwent carotid endarterectomy followed by combined coronary and mesenteric revascularization using cardiopulmonary bypass during the same hospital admission. He had an uncomplicated post-operative course and was discharged to home on post-operative day 7 after the combined procedure. Ninety-day follow-up was also unremarkable with the patient having no recurrent symptoms of ischemia. This case demonstrates the feasibility and safety of our approach for this rare clinical presentation.

Introduction of Minimally Invasive Esophagectomy in a Community Teaching Hospital.

BACKGROUND AND OBJECTIVES: The safety of minimally invasive esophagectomy (MIE) outside of high-volume centers has not been studied. Therefore, we evaluated our experience with the introduction of MIE in the setting of a community teaching hospital. METHODS: A retrospective cohort of all elective esophagectomy patients treated in a community hospital from 2008 through 2015 was evaluated (n = 57; open = 31 vs MIE = 26). Clavien-Dindo complication grades were recorded prospectively. RESULTS: Mean age was 63 ± 11 years (range, 30-83), mean Charlson comorbidity index was 4.5 ± 1.7 and proportion of ASA score ≥3 was 87%. The groups did not differ in age, gender distribution, or comorbidity indices. There were 108 complications observed, including 2 deaths (3.5%, both coronary events). Postoperative complication rate was 77.1% and serious complication rate (grades 3 and 4) was 50.8% in the entire cohort. The rate of serious complications was similar (58% for open vs 42% for MIE group; 2-sided P = .089). MIE operations were longer (342 ± 109 vs 425 ± 74 minutes; P = .001). Length of stay trended toward not being significantly shorter among MIE cases (15 ± 13 vs 12 ± 12 days; P = .071). Logistic regression models including MIE status were not predictive of complications. CONCLUSIONS: Introduction of MIE esophagectomy in our community hospital was associated with prolonged operative time, but no detectable adverse outcomes. Length of stay was nonsignificantly shortened by the use of MIS esophagectomy.