Delayed Gastric Emptying Post-Esophagectomy: A Single-Institution Experience.

OBJECTIVE: Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy in patients with esophageal carcinoma. Management of DGE varies widely and it is unclear how comorbidities influence the postoperative course. This study sought to determine factors that influence postoperative DGE. METHODS: This retrospective study evaluates patients who underwent esophagectomy with gastric pull-up between 2007 and 2019. The cohort was stratified in various ways to determine if postoperative care and outcomes differed, including patient demographics, comorbidities, intraoperative and postoperative procedures. RESULTS: During the study period, 149 patients underwent esophagectomy and 37 had diabetes. Overall incidence of DGE, as defined in this study, was 76.5%. Surgery type was significantly different between DGE and normal emptying cohorts (P = 0.005). Comparing diabetic and nondiabetic patients, there was no significant difference noted in DGE (P = 0.25). Additionally, there was no difference in presence of DGE for patients who underwent any intraoperative pyloric procedure compared to those who did not (P = 0.36). Of significance, all 16 patients with chronic obstructive pulmonary disease had a delay in gastric emptying (P = 0.01). CONCLUSIONS: A higher proportion of patients with DGE post-esophagectomy were identified compared to the literature. There is little consensus on a true definition of DGE, but we believe this definition identifies patients suffering in the immediate postoperative period and in follow-up. There is no evidence to support a different postoperative course for patients with diabetes, but the link between chronic obstructive pulmonary disease and DGE warrants further investigation.

Electromagnetic Navigational Bronchoscopy Reduces the Time Required for Localization and Resection of Lung Nodules.

OBJECTIVE: The aims of the study were to evaluate electromagnetic navigational bronchoscopy (ENB) and computed tomography-guided placement as localization techniques for minimally invasive resection of small pulmonary nodules and determine whether electromagnetic navigational bronchoscopy is a safer and more effective method than computed tomography-guided localization. METHODS: We performed a retrospective review of our thoracic surgery database to identify patients who underwent minimally invasive resection for a pulmonary mass and used either electromagnetic navigational bronchoscopy or computed tomography-guided localization techniques between July 2011 and May 2015. RESULTS: Three hundred eighty-three patients had a minimally invasive resection during our study period, 117 of whom underwent electromagnetic navigational bronchoscopy or computed tomography localization (electromagnetic navigational bronchoscopy = 81; computed tomography = 36). There was no significant difference between computed tomography and electromagnetic navigational bronchoscopy patient groups with regard to age, sex, race, pathology, nodule size, or location. Both computed tomography and electromagnetic navigational bronchoscopy were 100% successful at localizing the mass, and there was no difference in the type of definitive surgical resection (wedge, segmentectomy, or lobectomy) (P = 0.320). Postoperative complications occurred in 36% of all patients, but there were no complications related to the localization procedures. In terms of localization time and surgical time, there was no difference between groups. However, the down/wait time between localization and resection was significant (computed tomography = 189 minutes; electromagnetic navigational bronchoscopy = 27 minutes); this explains why the difference in total time (sum of localization, down, and surgery) was significant (P < 0.001). CONCLUSIONS: We found electromagnetic navigational bronchoscopy to be as safe and effective as computed tomography-guided wire placement and to provide a significantly decreased down time between localization and surgical resection.

Atrial Esophageal Fistula Secondary to Ablation for Atrial Fibrillation: A Case Series and Review of the Literature.

This article describes 2 patients who presented to our institution with left atrial esophageal fistula after atrial fibrillation ablation; it also compares our experience with other atrial esophageal fistula cases reported in the literature. We performed a retrospective review of 2 patients who presented to our hospital between July 2015 and September 2015 with atrial esophageal fistula. Patient A, a 57-year-old man, presented 31 days postablation with a fever and right-sided weakness. A chest computed tomography showed gas in the left atrium and esophagus; an echocardiogram confirmed the diagnosis of atrial esophageal fistula. The patient subsequently underwent a left thoracotomy. Postoperative recovery was poor and included significant coagulopathy, sepsis, cardiogenic shock, and multisystem organ failure. The patient died on postoperative day 28. Patient B, a 77-year-old man, presented 21 days post-atrial fibrillation ablation with left-arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation. Because of positive cultures and worsening altered mental status, the patient underwent a head computed tomography, which showed pneumocephalus, leading to our suspicion of the atrial esophageal fistula. A follow-up chest computed tomography confirmed the atrial esophageal fistula. Treatment included an esophagectomy and repair of the atrium. Unfortunately, the atrial esophageal fistula closure dehisced, and the patient developed acute respiratory failure and cardiac tamponade, which led to cardiopulmonary arrest, and the patient died on postoperative day 10. Based on our experience, and the literature, we recommend that a chest computed tomography be immediately performed on patients presenting with the described symptoms after a recent atrial fibrillation ablation.

Reconstruction of a Long-Segment Tracheal Defect Using an AlloDerm Conduit.

This case describes successful reconstruction of a long-segment tracheal defect using AlloDerm as the conduit for reconstruction. A 38-year-old woman who had undergone a thyroid lobectomy in 2011 presented several months later unable to swallow. Chest computed tomography results revealed a tracheal/esophageal mass and a subsequent bronchoscopy, and esophagogastroduodenoscopy results revealed an upper esophageal/tracheal mass with two areas concerning for fistula. She underwent a bronchoscopy with a tracheal stent and percutaneous endoscopic gastrostomy placement. All biopsies were nondiagnostic for malignancy and the patient recovered well. After a repeat bronchoscopy and esophagogastroduodenoscopy a few months later, she underwent a diagnostic right video-assisted thoracoscopic surgery and thoracotomy. To obtain adequate tissue for diagnosis, the fistula was opened, resulting in a large defect in the esophagus and trachea, as portions of the trachea, esophagus, and right recurrent laryngeal nerve liquefied. A 7-cm portion of her esophagus, 8 cm of the posterior trachea, and 5 cm of the right trachea wall were removed. The pathology came back as Hodgkin lymphoma. Because of the size of the esophageal defect, reconstruction was not an option. Therefore, the remainder of the esophagus was resected, the stomach stapled off, and esophageal hiatus closed. The tracheal defect was also too large for patch repair and was reconstructed with a tube of AlloDerm (6 × 10 cm). Four years after reconstruction, the patient is disease free and living a normal life. This case demonstrates successful tracheal reconstruction with AlloDerm.

Electromagnetic Navigational Bronchoscopy: A Safe and Effective Method for Fiducial Marker Placement in Lung Cancer Patients.

The emergence of Electromagnetic Navigational Bronchoscopy (ENB) as a diagnostic tool for small peripheral lung nodules has introduced a new method for delivery of fiducial markers. This technique has not been well studied in the literature. The purpose of our study was to evaluate the safety and effectiveness of ENB when used in fiducial marker placement. We reviewed all patients undergoing ENB fiducial placement between June 2010 and February 2014 (n = 64). These 64 patients had 68 lung lesions, in which we placed a total of 190 markers. Primary end points were marker retention and postoperative complications. The retention rate for the study was 82 per cent (n = 156). Upper lobe lesions had a 78 per cent retention rate and the middle/lower lobe lesions had an 89 per cent retention rate; the difference was not significant (P = 0.126). Complications included hospital admissions, respiratory failure, and pneumothorax. The difference in complication rates between upper and middle/lower lobe markers was not significant. We found ENB to be a safe method for the placement of fiducial markers. We also found that placement of an average of three markers/lesion led to an adequate retention rate to allow for successful treatment of lung cancer in nonsurgical patients using lung-sparing stereotactic radiation.

The utility of electromagnetic navigational bronchoscopy as a localization tool for robotic resection of small pulmonary nodules.

BACKGROUND: Resection of small pulmonary nodules with minimally invasive techniques can be challenging when the lesions are not palpable. Localizing theses nodules by electromagnetic navigational bronchoscopy (ENB) techniques has not been well studied. METHODS: A review of our thoracic surgery database was performed for patients undergoing ENB localization of pulmonary nodules for robotic resection between August 2012 and April 2013. RESULTS: 19 patients were identified who underwent a combined localization with ENB and then da Vinci robotic lung resection. A transbronchial needle biopsy was performed in 14 patients followed by methylene blue dye marking on the pleural surface to localize the lesion. Five patients did not have a needle biopsy and underwent dye marking only. After dye marking, patients underwent robotic resection. Three patients who underwent transbronchial needle biopsy were found to have a diagnosis of malignancy and no diagnostic resection was needed. We proceeded directly to anatomic resection. Four patients had lesions too deep for a wedge resection, and a diagnostic segmentectomy was needed. The remaining 11 patients required a diagnostic wedge resection. The median time for the ENB portion of the procedure was 28 minutes. No adverse events were related to the placement of the dye marker, and no patients underwent conversion to an open procedure to localize the lesion. CONCLUSIONS: We found ENB to be a safe and effective technique for localization of small pulmonary nodules with the diagnostic needle biopsy, possibly altogether negating the need for a wedge resection without adding significant time to the procedure.

Initial multicenter community robotic lobectomy experience: comparisons to a national database.

BACKGROUND: In pulmonary lobectomy, video-assisted thoracoscopic surgery (VATS) offers advantages compared with open thoracotomy. However, various issues have limited its adoption, especially in community settings. Single surgeon studies suggest that completely portal robotic lobectomy (CPRL) may address such limitations. This multicenter study evaluates early CPRL experience in 6 community cardiothoracic surgeons' practices. METHODS: Perioperative data from each surgeon's initial 20, consecutive and unselected cases of CPRL were retrospectively gathered (total n = 120) and compared with the 2009 and 2010 Society of Thoracic Surgeons database for VATS (n = 4,612) and open (n = 5,913) lobectomy. The χ(2) and t test procedures were used and significance was defined at the 95% confidence level (p < 0.05). RESULTS: One hundred sixteen lobectomies (96.7%) were completed robotically with a conversion rate of 3.3%. Preoperative patient characteristics were comparable across the CPRL, VATS, and open groups. The CPRL was equivalent to VATS on all intraoperative and postoperative outcomes, and resulted in significantly lower postoperative blood transfusion rates (0.9% vs 7.8%; p = 0.002), air leaks greater than 5 days (5.2% vs 10.8%; p = 0.05), chest tube duration (3.2 days vs 4.8 days; p < 0.001), and length of stay (4.7 days vs 7.3 days; p < 0.001) when compared with open. For these outcomes, results trended favorably for CPRL over VATS. CONCLUSIONS: This early CPRL experience reveals a minimally invasive lobectomy technique that is safe and reproducible in varied practice settings. Outcomes were equivalent between CPRL and VATS, trending in favor of robotics. The CPRL was superior in several measures compared with open. The absence of patient selection and low conversion rates suggest a broad applicability of this technique.

Use of positron emission tomography in initial staging of nonsmall cell lung carcinoma: a regional teaching hospital experience.

The ability to accurately diagnose mediastinal lymph node involvement is significantly important in patients with nonsmall cell lung cancer (NSCLC). Positron emission tomography (PET) imaging has become a standard technique to assess lymph node involvement in patients with NSCLC. The purpose of this study is to evaluate the accuracy of PET scan imaging as a mediastinal staging tool in patients with NSCLC at our regional teaching institution. We performed a single-institution, retrospective review of patients diagnosed with NSCLC from January 1, 2006, through December 31, 2007. We included only those patients who underwent computed tomography (CT), PET, and pathologic assessment of mediastinal lymph nodes. Using pathologic assessment as the criterion standard, the overall accuracy, sensitivity, specificity, and positive and negative predictive values of CT and PET were calculated. One hundred seventeen patients were identified for inclusion in the study. The overall accuracy was 81.2 per cent for CT and 91.5 per cent for PET. Sensitivity was 42.1 per cent for CT and 52.6 per cent for PET. Specificity was 88.8 per cent for CT and 99.0 per cent for PET. Positive predictive values were 42.1 per cent for CT and 90.9 per cent for PET; negative predictive values were 88.8 per cent for CT and 91.5 per cent for PET. False-negative result rates were 9.4 per cent for CT and 7.7 per cent for PET; false-positive result rates were 9.4 per cent for CT and 0.9 per cent for PET. Our analysis confirms the use of PET scan imaging in the staging of patients with NSCLC at a regional teaching institution.

Lung cancer resection in octogenarians: a reasonable approach for our aging population.

Lung cancer is the third most common cancer but accounts for more deaths per year than breast, prostate, and colon cancer combined. Traditionally, age older than 80 years was a relative contraindication to pulmonary resection. Recently, multiple studies have validated the safety and efficacy of pulmonary resections in octogenarians. The purpose of this study was to review the authors' regional teaching hospital's experience with lung resections in octogenarians. A retrospective analysis of 20 octogenarians who underwent pulmonary resection for lung cancer from 1999 to 2004 was performed. Average age was 82.1 years. Ten patients (50%) were male. Seventeen patients (85%) had at least one comorbidity. Ten patients (50%) had stage I disease, with squamous cell being the most common histologic type (35%). Lobectomy, performed in 12 patients (60%), was the most common technique of resection. There was a 45 per cent overall complication rate and a 20 per cent major complication rate. The overall perioperative mortality rate was 10 per cent. Survival probability estimates show overall survival at 1 year to be 59 per cent and at 2 years to be 39 per cent. Overall median survival was 21.1 months. We conclude that octogenarians can undergo anatomic resections for lung cancer with acceptable morbidity and survival.

The utility and timing of surgical intervention for parapneumonic empyema in the era of video-assisted thoracoscopy.

Empyema, a pyogenic or suppurative infection of the pleural space, continues to cause significant morbidity and mortality in patients with pneumonia. The advent of video-assisted thoracoscopy has placed the treatment algorithm of empyema in flux. We retrospectively reviewed all patients who underwent surgical treatment for parapneumonic empyema from January 1, 1999, through December 31, 2003. Data collected included demographic information, preoperative CT scanning/ thoracostomy tube placement, morbidity/mortality, days from admission to surgery, and postoperative length of stay. We compared patients undergoing video-assisted thoracoscopy to those requiring conversion to open thoracotomy and those who had initial open thoracotomy. Morbidity and mortality rates were similar among all groups. Conversion rate to open thoracotomy was 21 per cent. We found patients operated on within 11 days of admission had a shorter postoperative length of stay with similar morbidity and mortality. Our data supports early aggressive surgery treatment for parapneumonic empyema.