Preoperative nutritional counselling in patients undergoing oesophagectomy.

BACKGROUND: Patients undergoing surgery for oesophageal cancer are at high risk of malnutrition due to pathology and neoadjuvent therapy. This study sought to determine if oesophageal cancer patients undergoing oesophagectomy achieve superior clinical outcomes when preoperative nutritional counselling is performed. METHODS: Oesophageal cancer patients undergoing oesophagectomy were retrospectively divided into cohorts based on those who received (n = 48) and did not receive (n = 58) preoperative nutritional counselling. We compared weight loss, length of stay, 30-day readmission related to nutrition or feeding tube problems, and 90-day mortality. RESULTS: Per cent weight loss was less in patients who received preoperative nutritional counselling. There was a trend toward decreased mean length of stay and there were fewer readmissions for feeding tube-related complications in patients who received counselling. CONCLUSIONS: Nutritional counselling before surgery may lead to decreased weight loss and reduced readmissions for feeding tube-related complications in patients with oesophageal cancer undergoing oesophagectomy.

Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: A National Cancer Database propensity-matched study.

OBJECTIVES: Endoscopic resection has been rapidly adopted in the treatment of early-stage esophageal tumors. We compared the outcomes after esophagectomy or endoscopic resection for stage T1a adenocarcinoma. METHODS: We queried the National Cancer Database for patients with T1a esophageal adenocarcinoma who underwent esophagectomy or endoscopic resection and generated a balanced cohort with 735 matched pairs using propensity-score matching. We then performed a multivariable Cox regression analysis on the matched and unmatched cohorts. RESULTS: We identified 2173 patients; 1317 (60.6%) underwent esophagectomy, and 856 (39.4%) underwent endoscopic resection. In the unmatched cohort, patients who underwent esophagectomy were younger, more often not treated in academic settings, and more likely to have comorbidities (30.4% vs 22.5%, P = .002). They had longer hospital stays and more readmissions than patients who underwent endoscopic resection. Factors positively affecting overall survival were younger age, resection at an academic medical center, and lower Charlson-Deyo comorbidity score. In the matched cohort, patients who underwent esophagectomy had longer hospital stays and were more likely to be readmitted within 30 days (7.0% vs 0.6%, P < .001). When a time period-specific partition was applied, endoscopic resection had a lower death hazard 0 to 90 days after resection (hazard ratio, 0.15; P = .003), but this was reversed for survival greater than 90 days (hazard ratio, 1.34; P = .02). CONCLUSIONS: In patients with early-stage esophageal adenocarcinoma, survival appears equivalent after endoscopic resection or esophagectomy, but endoscopic resection is associated with shorter hospital stays, fewer readmissions, and less 90-day mortality. In patients surviving more than 90 days, esophagectomy may provide better overall survival.

Esophagectomy After Weight-Reduction Surgery.

Obesity is now epidemic worldwide, and an increasing number of patients have undergone a weight-loss procedure. Although obesity is a risk factor for esophageal cancer, there are few reports on esophagectomy after bariatric procedures. Careful understanding of the patient's gastroesophageal anatomy as a result of the bariatric procedure and attention to the creation of the esophageal replacement conduit are fundamental for the success of esophagectomy after bariatric surgery.

Operating on Patients Who Smoke: A Survey of Thoracic Surgeons in the United States.

BACKGROUND: Although preoperative smoking is associated with increased postoperative complications in patients who undergo major thoracic surgical procedures, there are no national guidelines that address the patient's preoperative tobacco use. This study examined the typical preoperative management of thoracic surgical patients who are smokers. METHODS: The link to an anonymous survey was emailed to cardiothoracic surgeons in the United States. The survey included questions regarding the likelihood of a surgeon to offer surgery and strategies used to assist patients in quitting smoking before surgery. RESULTS: The majority of the 158 surgeons who responded to the survey were general thoracic surgeons (68%, 107 of 158), in an academic practice (57%, 90 of 158), with more than 15 years of experience (51%, 81 of 158). An overwhelming majority of respondents (98.1%, 155 of 158) considered smoking preoperatively a risk factor for postoperative complications. The most common cessation strategy offered to smokers was pharmacologic intervention (77%, 122 of 158). Nearly half of the surgeons (47%, 74 of 156) would not perform certain operations in a patient who was a current smoker, but only 14% (10 of 74) tested patients preoperatively for smoking. Thoracic surgeons (odds ratio 2.1, p = 0.0379) and surgeons in academic practice (odds ratio 1.9, p = 0.057) were more likely to deny certain surgeries to current smokers. Two thirds of the surgeons (66%, 48 of 74) thought that the ideal wait time from smoking cessation to surgery was 2 to 4 weeks. CONCLUSIONS: There is significant disagreement in the cardiothoracic surgical community regarding how to treat patients who smoke, especially when deciding to deny or postpone surgery. Prospective studies and guidelines are needed.

Electromagnetic Navigation Bronchoscopy for Identifying Lung Nodules for Thoracoscopic Resection.

BACKGROUND: Pulmonary nodules smaller than 1 cm can be difficult to identify during minimally invasive resection, necessitating conversion to thoracotomy. We hypothesized that localizing nodules with electromagnetic navigation bronchoscopy and marking them with methylene blue would allow minimally invasive resection and reduce conversion to thoracotomy. METHODS: We retrospectively identified all patients who underwent electromagnetic navigation bronchoscopy followed by minimally invasive resection of a pulmonary nodule from 2011 to 2014. Lung nodules smaller than 10 mm and nodules smaller than 20 mm that were also located more than 10 mm from the pleural surface were localized and marked with methylene blue. Immediately after marking, all patients underwent resection. RESULTS: Seventy patients underwent electromagnetic navigation bronchoscopy marking followed by minimally invasive resection. The majority of patients (68/70, 97%) had one nodule localized; 2 patients (2/70, 3%) had two nodules localized. The median nodule size was 8 mm (range, 4-17 mm; interquartile range, 5 mm). The median distance from the pleural surface was 6 mm (range, 1-19 mm; interquartile range, 6 mm). There were no conversions to thoracotomy. Nodule marking was successful in 70 of 72 attempts (97.2%); two nodules were identified by palpation. The nodules were most commonly metastases from other sites (31/70, 44.3%). There were no adverse events related to electromagnetic navigation bronchoscopy-guided marking or wedge resection, and minimal adverse events after resections that were more extensive. CONCLUSIONS: Localizing and marking small pulmonary nodules using electromagnetic navigation bronchoscopy is safe and effective for nodule identification before minimally invasive resection.

Surgical management of complicated pancreatic pseudocysts after acute pancreatitis.

BACKGROUND: Management of pancreatic pseudocysts (PP) is unclear when located in areas outside the lesser sac, infected, or when portal venous (PV) occlusion is present. METHODS: Patients having internal drainage of PP. Management and outcome were assessed relative to location, presence of infection, and/or PV occlusion. RESULTS: No patient required transfusion, and there were no readmissions in 9 patients with PV occlusion. Eleven patients had infected PP including 5 extending outside the lesser sac. Six had postoperative imaging, 4 readmission, and 3 required adjunct postoperative percutaneous drainage. All but 2 with PP beyond the lesser sac had Roux-en-Y cystjejunostomy including 4 with 2 anastomoses. Nine, 4, and 5 required reimaging, readmission, and postoperative therapeutic intervention, respectively. CONCLUSIONS: (1) Open PP drainage in the face of PV occlusion confers a low risk of bleeding and a minimal need for reimaging or readmission; (2) internal drainage of infected PP is a viable option to external drainage; and (3) PP extending beyond the lesser sac can most often be managed successfully by Roux-en-Y drainage but may require additional intervention.

Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience.

BACKGROUND: For more than a decade, operative decisions (resection plus anastomosis vs diversion) for colon injuries, at our institution, have followed a defined management algorithm based on established risk factors (pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or presence of significant comorbid diseases). However, this management algorithm was originally developed for patients managed with a single laparotomy. The purpose of this study was to evaluate the applicability of this algorithm to destructive colon injuries after abbreviated laparotomy (AL) and to determine whether additional risk factors should be considered. STUDY DESIGN: Consecutive patients over a 17-year period with colon injuries after AL were identified. Nondestructive injuries were managed with primary repair. Destructive wounds were resected at the initial laparotomy followed by either a staged diversion (SD) or a delayed anastomosis (DA) at the subsequent exploration. Outcomes were evaluated to identify additional risk factors in the setting of AL. RESULTS: We identified 149 patients: 33 (22%) patients underwent primary repair at initial exploration, 42 (28%) underwent DA, and 72 (49%) had SD. Two (1%) patients died before re-exploration. Of those undergoing DA, 23 (55%) patients were managed according to the algorithm and 19 (45%) were not. Adherence to the algorithm resulted in lower rates of suture line failure (4% vs 32%, p = 0.03) and colon-related morbidity (22% vs 58%, p = 0.03) for patients undergoing DA. No additional specific risk factors for suture line failure after DA were identified. CONCLUSIONS: Adherence to an established algorithm, originally defined for destructive colon injuries after single laparotomy, is likewise efficacious for the management of these injuries in the setting of AL.