Extracorporeal membrane oxygenation for general thoracic surgery: case series and narrative review.

Background and Objective: Extracorporeal membrane oxygenation (ECMO) has historically been utilized as a temporary life support option for patients with severe cardiac and pulmonary dysfunction. Recent advancements have enabled the safe application of ECMO in a wider variety of patients; we present a review of its use in patients undergoing general thoracic procedures supported by a case series at our institution. Methods: We review current literature focusing on ECMO applications in thoracic surgery outside of the traditional use. Additionally, we offer three cases of ECMO utilization to illustrate success stories and key lessons learned regarding the use of ECMO in general thoracic surgery. Key Content and Findings: Technologic advancements and enhanced safety profiles have enabled the safe application of ECMO in a wide array of patients far beyond the historic indications of cardiogenic shock and acute respiratory distress syndrome (ARDS). It is now feasible to consider ECMO for management of acute thoracic emergencies, as well as to better facilitate operative safety in complex general thoracic surgical procedures. Both venovenous and venoarterial ECMO can be utilized in carefully selected patients to provide cardiopulmonary support while enabling improved visualization and increased mobilization without concern for respiratory and/or cardiac compromise. Conclusions: Enthusiasm for the use of ECMO has increased in recent years. What was once considered a salvage therapy in cases of life-threatening cardiopulmonary decompensation now plays an increasingly important role in the safe conduct of complex thoracic surgery procedures, provides much needed time for organ recovery, and offers acute resuscitation options. This shift broadens our ability to deliver life-saving care to patients that previously would have otherwise had limited treatment options.

Evolving impact of the COVID-19 pandemic on lung transplant recipients: A single-center experience.

BACKGROUND: Lung transplant recipients (LTRs) are at increased risk of morbidity and mortality from coronavirus disease 2019 (COVID-19); however, the disease course has changed as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants have mutated. We compared COVID-19-related clinical outcomes in LTRs at different stages of the pandemic. We also identified risk factors for developing severe COVID-19 independent of the dominant SARS-CoV-2 variant. METHODS: This single-center, retrospective cohort study of LTRs with COVID-19 used Cox regression analyses and bootstrapping to identify factors affecting COVID-19 severity. RESULTS: Between March 2020 and August 2022, 195 LTRs were diagnosed with COVID-19, almost half (89 [45.6%]) during the Omicron period. A total of 113 (58.5%) LTRs were hospitalized and 47 (24.1%) died. Age >65 years increased the risk of hospitalization and death. Although infection with the Omicron variant was associated with a lower risk of hospitalization, the median length of hospital stay (10 days, [interquartile range, 5-19]) was similar between the variants. Intensive care unit (ICU) admission and death were more common with the Delta variant but comparable between the original, Alpha, and Omicron variants. Remdesivir and molnupiravir reduced the risk of hospitalization, and monoclonal antibody therapy reduced the risk of ICU admission, intubation, and death. Vaccination and pre-exposure prophylaxis (PrEP) with tixagevimab-cilgavimab did not significantly reduce COVID-19-related ICU admission, intubation, or mortality among LTRs. CONCLUSIONS: LTRs with COVID-19 continue to have high hospitalization rates and prolonged hospital stays, despite the reduced virulence of the Omicron variant. More effective PrEP and therapeutic interventions for COVID-19 among vulnerable patient groups are needed.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience.

PURPOSE: Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. METHODS: After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. RESULTS: During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality. CONCLUSION: The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

Surgical Complications of Lung Transplantation.

Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.

Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.

BACKGROUND: Lung transplantation is a life-saving treatment for patients with end-stage lung disease; however, it is infrequently considered for patients with acute respiratory distress syndrome (ARDS) attributable to infectious causes. We aimed to describe the course of disease and early post-transplantation outcomes in critically ill patients with COVID-19 who failed to show lung recovery despite optimal medical management and were deemed to be at imminent risk of dying due to pulmonary complications. METHODS: We established a multi-institutional case series that included the first consecutive transplants for severe COVID-19-associated ARDS known to us in the USA, Italy, Austria, and India. De-identified data from participating centres-including information relating to patient demographics and pre-COVID-19 characteristics, pretransplantation disease course, perioperative challenges, pathology of explanted lungs, and post-transplantation outcomes-were collected by Northwestern University (Chicago, IL, USA) and analysed. FINDINGS: Between May 1 and Sept 30, 2020, 12 patients with COVID-19-associated ARDS underwent bilateral lung transplantation at six high-volume transplant centres in the USA (eight recipients at three centres), Italy (two recipients at one centre), Austria (one recipient), and India (one recipient). The median age of recipients was 48 years (IQR 41-51); three of the 12 patients were female. Chest imaging before transplantation showed severe lung damage that did not improve despite prolonged mechanical ventilation and extracorporeal membrane oxygenation. The lung transplant procedure was technically challenging, with severe pleural adhesions, hilar lymphadenopathy, and increased intraoperative transfusion requirements. Pathology of the explanted lungs showed extensive, ongoing acute lung injury with features of lung fibrosis. There was no recurrence of SARS-CoV-2 in the allografts. All patients with COVID-19 could be weaned off extracorporeal support and showed short-term survival similar to that of transplant recipients without COVID-19. INTERPRETATION: The findings from our report show that lung transplantation is the only option for survival in some patients with severe, unresolving COVID-19-associated ARDS, and that the procedure can be done successfully, with good early post-transplantation outcomes, in carefully selected patients. FUNDING: National Institutes of Health. VIDEO ABSTRACT.

Peroral Endoscopic Myotomy for Achalasia.

Peroral endoscopic myotomy surgery is an incisionless, minimally invasive, natural orifice technique used to treat the symptoms of achalasia and other spastic disorders of the esophagus. Recent experience demonstrates that it can be performed safely by experienced esophageal surgeons and there are very good short-term outcomes comparable to laparoscopic myotomy. The rapid worldwide adoption of this technique demonstrates its potential to replace the current therapies available for achalasia. A cautionary note is important in that long-term outcomes are not yet available in terms of dysphagia and GERD symptoms.

Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training.

OBJECTIVE: Transitioning from medical school and general surgery training to cardiothoracic (CT) surgical training poses unique challenges for trainees and patient care. We hypothesized that participation in technology-enhanced simulation modules that provided early exposure to urgent/emergent CT patient problems would improve cognitive skills and readiness to manage common urgencies/emergencies. DESIGN: Traditional and integrated cardiothoracic residents at our institution participated in a technology-enhanced simulation curriculum. The course comprised of didactics, hands-on simulation, virtual models, and mock oral examinations. Residents also were given a validated pretest and post-test to evaluate knowledge retention and integration. Resident performance was graded using a previously validated objective structured clinical examination. Resident perception of course usefulness and relevance was determined through the completion of a perception survey. SETTING: This study occurred at the University of Pittsburgh School of Medicine with the Department of Cardiothoracic Surgery. The facility used was the Peter Winter Institute for Simulation, Education and Research. PARTICIPANTS: From 2013 to 2015, 25 traditional and integrated cardiothoracic residents participated in these training modules who have completed all portions of the simulation were used for analysis. RESULTS: For our participants, knowledge base significantly increased by 7.9% (pretest = 76.0% vs. post-test = 83.9%, p < 0.01). According to trained-rater evaluation, 93.6% of responses to the 11 objective structured clinical examination competencies were deemed adequate. Postcourse perception survey demonstrated 92% of participants scoring the sessions as important or very important toward development and confidence in managing the cardiothoracic scenarios. These findings were present despite historical assumption that these learners were prepared for complex patient care. CONCLUSIONS: After completing a technology-enhanced course combining didactics, simulation, and real-time assessment, residents demonstrated objective improvements in cognitive skills and readiness in managing CT patients. Resident postcourse feedback indicated enhanced confidence, suggesting increased preparedness transitioning to CT surgery. This has strong implications for improved patient safety during these potentially labile transition periods.

Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations.

IMPORTANCE: Aortic clamping technique has been implicated in stroke risk at the time of on-pump coronary artery bypass grafting (CABG) procedures. We hypothesized that partial aortic clamping (PAC) use in performing proximal coronary anastomosis does not increase risk of stroke. OBJECTIVE: To determine whether postoperative stroke incidence is influenced by single aortic clamping (SAC) or side-biting PAC use in performing proximal anastomosis during CABG procedures. DESIGN, SETTING, AND PARTICIPANTS: In a retrospective cohort study, we analyzed data from 1819 patients who underwent conventional, isolated, nonemergent, first-time, arrested-heart, on-pump CABG at a single US major academic, tertiary/quaternary medical center from January 1, 2005, to December 31, 2013. Postoperative stroke was defined according to Society of Thoracic Surgeons (STS) criteria as any confirmed neurological deficit of abrupt onset that did not resolve within 24 hours. Institutional STS data including STS predicted risk of postoperative stroke score were used to compare patients receiving proximal aortic anastomoses performed with either SAC (n = 1107) or combined PAC (n = 712) techniques. EXPOSURES: Use of SAC or PAC in performing proximal coronary anastomosis. MAIN OUTCOMES AND MEASURES: Thirty-day periprocedural postoperative stroke rates. RESULTS: There were no significant differences in preoperative risk or STS predicted risk of mortality between groups. Patients in the SAC group had longer myocardial ischemic time compared with those in the PAC group (mean [SD], 73.2 [22.8] vs 66.5 [22.8] minutes, respectively; P < .001) but shorter overall perfusion time (mean [SD], 96.6 [30.1] vs 102.2 [30.1] minutes, respectively; P < .001). The 30-day observed mortality rates between the SAC and PAC groups were equally low (21 of 1107 patients [1.9%] vs 13 of 712 patients [1.8%], respectively; P > .99) and congruent with STS predicted risk of mortality. Preoperative STS predicted risk of postoperative stroke scores were nearly identical between the SAC and PAC groups (mean [SD], 1.5% [1.4%] vs 1.6% [1.4%]; P = .95), and the 30-day actual observed postoperative stroke rates between the SAC and PAC groups were similar (17 of 1107 patients [1.5%] vs 10 of 712 patients [1.4%], respectively; P > .99). CONCLUSIONS AND RELEVANCE: In this contemporary study of on-pump CABG, we did not identify any significant differences in the incidence of postoperative stroke regardless of the clamping method used to perform proximal anastomosis.

Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review.

BACKGROUND: Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. DATA SOURCES: We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. CONCLUSIONS: Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.

Chordal relocation for repair of anterior mitral leaflet flail: a reproducible option.

Repair of anterior mitral leaflet (AML) flail is considered to be among the more technically challenging mitral procedures. While neochord reconstruction is an excellent technique, sizing challenges may limit wide reproducibility. Chordal relocation of secondary or tertiary AML chords can minimize sizing imprecision in open or minimally invasive repair while providing patients with a safe, durable and reproducible option. Native chords can be readily released and re-implanted from positions in the body of the leaflet to provide primary AML support, provided there is preservation of ipsilateral papillary muscle alignment. We illustrate the sole use of this reproducible method to repair AML flail.