Clinical T2 N0 M0 Esophageal Cancer: Identifying Predictive Factors of Upstaging.

BACKGROUND: Inaccuracy of clinical staging renders management of clinical T2 N0 M0 (cT2 N0 M0) esophageal cancer difficult. When an underlying advanced-stage disease is understaged to cT2 N0 M0, patients miss the opportunity to gain the potential benefits of neoadjuvant therapy. This study aimed to identify preoperative factors that predict underlying advanced-stage esophageal cancer. METHODS: From 2000 to 2020, 1579 patients with esophageal cancer underwent esophagectomy. Sixty patients who underwent upfront surgery for cT2 N0 M0 esophageal cancer were included in this study. The median age was 62.5 years, and 78% (n = 47) of these patients were male. Radiologic, clinical, and endoscopic factors were evaluated as preoperative markers. The Fisher exact and the Wilcoxon rank sum tests were used for categoric and continuous variables, respectively. Random forest classification was used to identify preoperative factors for predicting upstaging and downstaging. RESULTS: Of the 60 patients, 8 (13%) were found to have pathologic T2 N0 M0 esophageal cancer. Sixteen (27%) patients had cancer that was pathologically downstaged, and 36 (60%) had upstaged disease. Seven (19%) patients had upstaged cancer on the basis of the pathologic T stage, 14 (39%) had upstaging on the basis of the pathologic N stage, and 15 (42%) had upstaging on the basis of both T and N stages. Dysphagia (P = .003) and tumor maximum standardized uptake value (P = .048) were predictors of upstaging, with a combined predictive value of up to 75%. CONCLUSIONS: The presence of dysphagia and of high maximum standardized uptake value (≥5) of the tumor is predictive of more advanced underlying disease for patients with cT2 N0 M0 esophageal cancer, and these patients should be considered for neoadjuvant therapy.

Are adult thoracic patient education materials designed with patients in mind?

OBJECTIVE: Patients are increasingly using the internet to obtain health care information. US News and World Report Best Hospital rankings received more than 103 million views in 2021. Considering 21% of thoracic surgery patients are minorities, 27.9% are in the bottom quartile of household income, and 70% have Medicare/Medicaid or no insurance, online patient educational materials (PEMs) should be accessible and written at a level easily understood by majority of patients. We performed a comprehensive analysis of readability of websites containing patient-centered resources across all adult thoracic surgery areas. METHODS: Online PEMs on thoracic surgical procedures were collected from top 50 hospitals for pulmonology and lung surgery ranked by US News and World Report Best Hospital as of December 1, 2021. Text pertaining to thoracic surgical procedures was collected and divided into 4 procedural genres: esophageal, lung, transplant procedures, and other. Texts were analyzed using OleanderSoftware's Readability Suite through the Raygor readability test. RESULTS: Three hundred seventy-two articles met criteria for analysis. Websites were difficult to read; mean (standard deviation) readability score for all content required a 13.9 (3.6) grade level for comprehension. The mean (standard deviation) readability for esophageal, lung, lung transplant, and other surgeries were 14.5 (3.6), 13.1 (3.6), 11.5 (3.9), and 13.4 (3.7), respectively. CONCLUSIONS: Online PEMs required at least a college reading level to comprehend, well exceeding the sixth-grade level recommended by the American Medical Association. As digital health becomes increasingly relevant, improving the readability of online PEMs in adult cardiac surgery will facilitate equitable access to high-quality care.

Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report.

Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

Development and validation of a universal esophageal patient-reported outcome measure: The Cleveland Clinic Esophageal Questionnaire (CEQ).

OBJECTIVE: Currently, there is no validated patient-reported outcome measure (PROM) applicable to all esophageal diseases. Our objective was to create a psychometrically robust, validated universal esophageal PROM that can also objectively assess patients' quality of life (QoL). METHODS: The pilot PROM constructed based on expert opinions, literature review, and previous unpublished institutional research had 27 items covering 8 domains. It was completed by 30 patients in the outpatient clinic followed by a structured debriefing interview, which allowed for refining the PROM. The final PROM: Cleveland Clinic Esophageal Questionnaire (CEQ) included 34 items across 6 domains (Dysphagia, Eating, Pain, Reflux & Regurgitation, Dyspepsia, Dumping), each accompanied by a corresponding QoL component. Further psychometric assessment of the PROM was conducted by evaluating (1) acceptability, (2) construct validity, (3) reliability, and (4) responsiveness. RESULTS: Five hundred forty-six unique patients (median 63.7 years [54.3-71.7], 53% male [287], 86% White) completed CEQ at >90% completion within 5 minutes. Construct validity was demonstrated by differentiating scores across esophageal cancer (n = 146), achalasia (n = 170), hiatal hernia (n = 160), and other diagnoses (n = 70). Internal reliability (Cronbach alpha 0.83-0.89), and test-retest reliability (intraclass correlation coefficients 0.63-0.85) were strong. Responsiveness was demonstrated through CEQ domains improving for 53 patients who underwent surgery for achalasia or hiatal hernia (Cohen d 0.86-2.59). CONCLUSIONS: We have constructed a psychometrically robust, universal esophageal PROM that allows concise, consistent, objective quantification of symptoms and their effect on the patient. The CEQ is valuable in prognostication and tracking of longitudinal outcomes in both benign and malignant esophageal diseases.

Preoperative predictors of spread through air spaces in lung cancer.

OBJECTIVE: Spread through air spaces (STAS) is a new histologic feature of invasion of non-small cell lung cancer that lacks sensitivity and specificity on frozen sections and is associated with higher recurrence and worse survival with sublobar resections. Our objective is to identify preoperative characteristics that are predictive of STAS to guide operative decisions. METHODS: From January 2018 through December 2021, 439 cT1-3N0 M0 patients with non-small cell lung cancer and a median age of 68 years, 255 (58%) women, who underwent primary surgery at our institution were included. Patients who received neoadjuvant therapy and whose STAS status was not documented were excluded. Age, sex, smoking status, tumor size, ground-glass opacities, maximum standardized uptake values, and molecular markers on preoperative biopsy were evaluated as preoperative markers. Comparisons between groups were conducted using standardized mean differences and random forest classification was used for prediction modeling. RESULTS: Of the 439 patients, 177 had at least 1 STAS-positive tumor, and 262 had no STAS-positive tumors. Overall, 179 STAS tumors and 293 non-STAS tumors were evaluated. Younger age (50 years or younger), solid tumor, size ≥2 cm, and maximum standardized uptake value ≥2.5 were independently predictive of STAS with prediction probabilities of 50%, 40%, 38%, and 40%, respectively. STAS tumors were more likely to harbor KRAS mutations and be PD-L1 negative. CONCLUSIONS: Young age (50 years or younger), larger (≥2 cm) solid tumors, high maximum standardized uptake values, and presence of KRAS mutation, are risk factors for STAS and can be considered for lobectomy. Smoking status and gender are still controversial risk factors for STAS.

Thoracoabdominal approach for traumatic diaphragmatic hernia in a hemodynamically unstable patient.

Background: Diaphragmatic hernias with strangulated contents are a surgical challenge. Thoracoabdominal incisions are commonly used for a variety of thoracic and vascular cases, although rarely used for diaphragmatic hernias, which are typically repaired with laparotomy, thoracotomy, or minimally invasive approaches. Case report: We present the unique case of a 60-year-old, critically ill unstable patient with severe heart failure with a reduced ejection fraction (15-25%) and severe valve disease presenting with a left-sided diaphragmatic hernia containing strangulated small intestine and requiring urgent surgical exploration. This was safely and efficiently repaired via a thoracoabdominal approach at the index surgery, with intestines left in discontinuity and placement of temporary chest and abdominal closure. At the second planned operation, good continuity was successfully restored. Results: The patient had early extubation, gradual diet advancement with full recovery, and discharge home on postoperative day 17. Conclusion: A thoracoabdominal incision can safely be used in large strangulated diaphragmatic hernias, including in critically unstable patients. This approach provides rapid access to both the chest and abdomen with excellent, speedy, and safe exposure, which can save a life in extreme conditions.

Non-iatrogenic esophageal trauma: a narrative review.

Background and Objective: Non-iatrogenic esophageal trauma is a rare entity that has a high morbidity and mortality. The diagnosis can often be quite challenging, however is critical to perform in a timely manner. The workup and management of non-iatrogenic trauma continues to evolve, with new innovative approaches available for both diagnosis and treatment. The aim of this narrative review is to comprehensively describe the incidence, presentation, workup, treatment approaches and outcomes of non-iatrogenic esophageal trauma. Methods: A thorough literature review was performed using full length articles available in English via PubMed between January 1, 1960 to September 30, 2021, focusing on the epidemiology, workup and treatment of non-iatrogenic esophageal trauma, including current surgical techniques. Key Content and Findings: Injuries to the cervical esophagus are more common than injuries to the thoracic esophagus, occurring more in young males, with significant racial disparity. Penetrating trauma via gunshot wounds are the most common forms of injury, followed by stab wounds and blunt trauma. Workup is multimodal and involves a combination of plain radiographs, computed tomography (CT) scans, endoscopy and fluoroscopy depending of the stability of the patient and associated injuries. Conclusions: Workup and management of non-iatrogenic esophageal trauma depends on the location and extent of esophageal injury, and can include observation, debridement and drainage, esophageal diversion, endoscopic approaches or esophagectomy, with indications, techniques and outcomes described in further detail in this review.

Select octogenarians with stage IIIa non-small cell lung cancer can benefit from trimodality therapy.

Objectives: Currently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non-small cell lung cancer (NSCLC) in patients 80 years of age or older. Methods: The National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson-Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan-Meier survival analyses were performed. Results: From the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group. Conclusions: Selected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.

Modified Ravitch Procedure for Pectus Excavatum Combined With Complex Cardiac Surgery.

Pectus excavatum is common in patients with connective tissue disorders or congenital heart disease undergoing cardiac surgery, and is occasionally severe enough to warrant repair. The optimal surgical strategy is currently debated. We report our experience with simultaneous repair. From January 2012 to January 2020, 11 patients (median age of 35 ± 18 years, range 12-74) underwent a modified Ravitch procedure for severe pectus excavatum performed by a single thoracic surgeon at the time of simultaneous complex cardiac surgery. Eight patients (73%) had a confirmed connective tissue disorder and 2 patients (18%) had recurrent pectus excavatum following a failed Nuss procedure in adolescence. The mean Haller index was 7.3 ± 3.2 (range 3.8-13). The most common concomitant cardiac procedures were valve-preserving aortic root replacement (n=7, 64%) and mitral valve repair (n = 4, 36%). Patients are presented as a case series with descriptive analysis. The median total operative and cardiopulmonary bypass times were 400 minutes (±109 minutes) and 168 minutes (± 43 minutes), respectively. No deaths occurred in-hospital or during follow-up. There were no reoperations for bleeding, tamponade or other indications. No deep or superficial sternal wound infections occurred. Postoperative analgesia regimens were multimodal to facilitate early mobilization and pulmonary hygiene. None of the patients required prolonged ventilation or reintubation for respiratory failure. The mean stay in the intensive care unit was 82 hours (±56 hours) and the mean hospital stay was 9.1 days (2.4 days). Concurrent pectus excavatum repair at the time of cardiac surgery using a modified Ravitch technique can be safely performed by a multi-disciplinary team and should be considered for patients with multiple indications for operation.

Comparison of mechanical cardiopulmonary support strategies during lung transplantation.

INTRODUCTION: Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy. AREAS COVERED: This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation. EXPERT OPINION: The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.

Global Alliance against Chronic Respiratory Diseases symposium on air pollution: overview and highlights.

A 1-day symposium before the annual meeting of the Global Alliance against Chronic Respiratory Diseases, gathered authorities and researchers from around the world to discuss the impact of air pollution on human and planetary health. Air quality is a high priority for Global Alliance against Chronic Respiratory Diseases and China, the host country. This article presents a summary, commentary, and amplification of the 17 presentations. Air pollution is closely linked with global warming and harms most body systems even at levels below international standards. Information about the genetic, cellular, and metabolic effects of exposure to air pollution is important for better understanding of individual responses and even potential therapeutic mediation. Reducing air pollution at its source leads to prompt and important benefits and should be the first priority for political and public action.

The health effects of ultrafine particles.

Ultrafine particles (PM0.1), which are present in the air in large numbers, pose a health risk. They generally enter the body through the lungs but translocate to essentially all organs. Compared to fine particles (PM2.5), they cause more pulmonary inflammation and are retained longer in the lung. Their toxicity is increased with smaller size, larger surface area, adsorbed surface material, and the physical characteristics of the particles. Exposure to PM0.1 induces cough and worsens asthma. Metal fume fever is a systemic disease of lung inflammation most likely caused by PM0.1. The disease is manifested by systemic symptoms hours after exposure to metal fumes, usually through welding. PM0.1 cause systemic inflammation, endothelial dysfunction, and coagulation changes that predispose individuals to ischemic cardiovascular disease and hypertension. PM0.1 are also linked to diabetes and cancer. PM0.1 can travel up the olfactory nerves to the brain and cause cerebral and autonomic dysfunction. Moreover, in utero exposure increases the risk of low birthweight. Although exposure is commonly attributed to traffic exhaust, monitored students in Ghana showed the highest exposures in a home near a trash burning site, in a bedroom with burning coils employed to abate mosquitos, in a home of an adult smoker, and in home kitchens during domestic cooking. The high point-source production and rapid redistribution make incidental exposure common, confound general population studies and are compounded by the lack of global standards and national reporting. The potential for PM0.1 to cause harm to health is great, but their precise role in many illnesses is still unknown and calls for more research.

Helsinki by nature: The Nature Step to Respiratory Health.

BACKGROUND: The Nature Step to Respiratory Health was the overarching theme of the 12th General Meeting of the Global Alliance against Chronic Respiratory Diseases (GARD) in Helsinki, August 2018. New approaches are needed to improve respiratory health and reduce premature mortality of chronic diseases by 30% till 2030 (UN Sustainable Development Goals, SDGs). Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends. Planetary health and human health are interconnected, and both need to be considered by individuals and governments while addressing several SDGs. RESULTS: The concept of the Nature Step has evolved from innovative research indicating, how changed lifestyle in urban surroundings reduces contact with biodiverse environments, impoverishes microbiota, affects immune regulation and increases risk of NCDs. The Nature Step calls for strengthening connections to nature. Physical activity in natural environments should be promoted, use of fresh vegetables, fruits and water increased, and consumption of sugary drinks, tobacco and alcohol restricted. Nature relatedness should be part of everyday life and especially emphasized in the care of children and the elderly. Taking "nature" to modern cities in a controlled way is possible but a challenge for urban planning, nature conservation, housing, traffic arrangements, energy production, and importantly for supplying and distributing food. Actions against the well-known respiratory risk factors, air pollution and smoking, should be taken simultaneously. CONCLUSIONS: In Finland and elsewhere in Europe, successful programmes have been implemented to reduce the burden of respiratory disorders and other NCDs. Unhealthy behaviour can be changed by well-coordinated actions involving all stakeholders. The growing public health concern caused by NCDs in urban surroundings cannot be solved by health care alone; a multidisciplinary approach is mandatory.

Capillary Proliferation in Systemic-Sclerosis-Related Pulmonary Fibrosis: Association with Pulmonary Hypertension.

OBJECTIVE: We sought to determine if any histopathologic component of the pulmonary microcirculation can distinguish systemic sclerosis (SSc)-related pulmonary fibrosis (PF) with and without pulmonary hypertension (PH). METHODS: Two pulmonary pathologists blindly evaluated 360 histologic slides from lungs of 31 SSc-PF explants or autopsies with (n = 22) and without (n = 9) PH. The presence of abnormal small arteries, veins, and capillaries (pulmonary microcirculation) was semiquantitatively assessed in areas of preserved lung architecture. Capillary proliferation (CP) within the alveolar walls was measured by its distribution, extent (CP % involvement), and maximum number of layers (maximum CP). These measures were then evaluated to determine the strength of their association with right heart catheterization-proven PH. RESULTS: Using consensus measures, all measures of CP were significantly associated with PH. Maximum CP had the strongest association with PH (P = 0.013; C statistic 0.869). Maximum CP 2 or more layers and CP % involvement 10% or greater were the optimal thresholds that predicted PH, both with a sensitivity of 56% and specificity of 91%. The CP was typically multifocal rather than focal or diffuse and was associated with a background pattern of usual interstitial pneumonia. There was a significant but weaker relationship between the presence of abnormal small arteries and veins and PH. CONCLUSION: In the setting of advanced SSc-PF, the histopathologic feature of the pulmonary microcirculation best associated with PH was capillary proliferation in architecturally preserved lung areas.

Health Benefits of Air Pollution Reduction.

Air pollution is a grave risk to human health that affects nearly everyone in the world and nearly every organ in the body. Fortunately, it is largely a preventable risk. Reducing pollution at its source can have a rapid and substantial impact on health. Within a few weeks, respiratory and irritation symptoms, such as shortness of breath, cough, phlegm, and sore throat, disappear; school absenteeism, clinic visits, hospitalizations, premature births, cardiovascular illness and death, and all-cause mortality decrease significantly. The interventions are cost-effective. Reducing factors causing air pollution and climate change have strong cobenefits. Although regions with high air pollution have the greatest potential for health benefits, health improvements continue to be associated with pollution decreases even below international standards. The large response to and short time needed for benefits of these interventions emphasize the urgency of improving global air quality and the importance of increasing efforts to reduce pollution at local levels.

Value of perioperative inhaled epoprostenol with low tidal volume ventilation for complex endocarditis surgery.

BACKGROUND AND AIM: To compare outcomes of patients treated with inhaled epoprostenol and low tidal volume ventilation during cardiopulmonary bypass with those who did not receive this medication in the operating room at all, and those who received it as a rescue therapy at the end of the case. METHODS: Retrospective chart review between 2014 and 2017, follow-up included the entire hospital stay. RESULTS: Seventy-one patients were included, and mean age was 54 years. 78.9% of the patients were male. Procedures included 96% (n = 68) aortic valve replacement, 28% (n = 20) reconstruction of the intravalvular fibrosa, and 13% (n = 9) repair of an endocarditis-related intracardiac fistula. Patients who received epoprostenol (iEpo) (treatment and rescue groups), when compared with the control group had more intra-aortic balloon pump placement (23% vs 2.5%, P = .018), open chest after surgery (32% vs 7.5%, P = .012), and duration of mechanical ventilation (8.3 ± 2.7 vs. 2.4 ± 0.4 days, P = 0.01). There was no significant difference between the two groups in terms of extracorporeal circulatory support (6.5% vs 2.5%, P = .577) and hospital death (13% vs 10%, P = .72). In a subanalysis, hospital death and duration of mechanical ventilation were higher in the recue group when compared with the treatment group (P = .004 and .056, respectively). CONCLUSIONS: Prophylactic application of iEpo with low tidal volume ventilation for an anticipated complex endocarditis operation may contribute to favorable outcome when compared with postoperative epoprostenol rescue.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae.

INTRODUCTION: Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED: This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY: Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.