Determining optimal air leak resolution criteria when using digital pleural drainage device after lung resection.

Objective: There is limited clinical evidence to support any specific parenchymal air leak resolution criteria when using digital pleural drainage devices following lung resection. The aim of this study is to determine an optimal air leak resolution criteria, where duration of chest tube drainage is minimized while avoiding complications from premature chest tube removal. Methods: Airflow data averaged at 10-minute intervals was collected prospectively using a digital pleural drainage device (Thopaz; Medela) in 400 patients from 2015 to 2019. All permutations of air leak resolution criteria from <10 to 100 mL/minute for 4 to 12 hours were applied retrospectively to the pleural drainage data to determine air leak duration, and air leak recurrence frequency and volume. Air leak recurrence indicates potential for rather than occurrence of adverse events. Descriptive statistics were used to identify the optimal criteria based on patient safety (low frequency and volume of air leak recurrences), and efficiency (shortest initial air leak duration). Results: The majority of the 400 patients underwent lobectomy (57% [227 out of 400]), wedge resections (29% [115 out of 400]), or segmentectomies (8% [32 out of 400]) for lung cancer (90% [360 out of 400]). An airflow threshold <50 mL/minute resulted in longer air leak duration before meeting the criteria for air leak resolution (P < .0001). Air leak recurrence frequency and volume were greater in patients with a monitoring period <8 consecutive hours (P < .0001). Conclusions: When using a digital pleural drainage device, a postoperative air leak resolution criteria <50 mL/minute for 8 consecutive hours was associated with the best safety and efficiency profile.

A Case Report of an Isolated Cardiac Metastasis in a Patient with Esophageal Carcinoma.

A 76-year-old Caucasian male presented with syncope, intermittent melena, anemia, and unexplained weight loss. Esophagogastroduodenoscopy revealed a friable non-obstructing esophageal tumor that appeared thickened on computed tomography (CT). Biopsies confirmed a poorly differentiated carcinoma. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (F-18 FDG PET/CT) showed intense FDG avidity with a maximum standardized uptake value (SUVmax) of 23. Although CT did not identify any lymphadenopathy or distant metastases, a mildly enhancing lobulated circumscribed mass with no internal calcification was incidentally identified in the left atrium. Cardiac magnetic resonance imaging (MRI) favored myxoma over thrombus given the signal characteristics and mild enhancement; however, F-18 FDG PET/CT showed an SUVmax of 18, more consistent with a metastasis. The cardiac mass was resected and shown to be a metastatic focus of poorly differentiated carcinoma, histologically identical to the esophageal mass. He received a single 8 Gray (Gy) fraction of urgent hemostatic radiotherapy for his primary tumor followed by palliative chemotherapy with cisplatin, capecitabine, and pembrolizumab. He was readmitted for transfusion due to recurrent bleeding from his primary tumor and given a second urgent hemostatic fraction of 8 Gy for stabilization. Systemic therapy was eventually discontinued due to declining performance status. He received consolidative palliative radiotherapy (20Gy in five fractions) but continued to deteriorate over the next three months and died in hospice, ten months from the time of his initial presentation.

Impact of surgical approach on perioperative and long-term outcomes following esophagectomy for esophageal cancer.

BACKGROUND: Surgical resection remains a critical component of esophageal cancer treatment with curative-intent. The aim of this study was to compare open (OE) to minimally invasive Ivor Lewis esophagectomy (MIE) with respect to perioperative and oncologic outcomes. METHODS: Retrospective single-institution review of MIE and OE patients operated between 2001 and 2015 was conducted. Univariable and multivariable models were created using Cox regression. The Kaplan-Meier method was used to compare oncologic outcomes. Propensity score matching was used to compare oncological outcomes in MIE and OE patients. RESULTS: Of 210 esophageal resection patients, 47% had OE (137/291) and 25% had MIE (73/291). The MIE and OE groups were comparable with respect to patient factors and operative details. Fewer OE patients received neoadjuvant chemoradiation. MIE was associated with improved lymph node yield, (MIE = 30 [IQR:22-39]; OE = 14 [IQR:7-19], p < 0.001), less intraoperative blood loss (MIE = 312 mL [100-400]; OE = 657 mL [350-700], p < 0.001), and shorter median length of stay (MIE = 10 days [IQR = 8-14]; OE = 14 days [IQR = 11-22] p < 0.01). The OE group had significantly more adverse events resulting in reoperation or intensive care unit admission (MIE = 21%; OE = 34%; p < 0.01). On multivariable analysis, age and positive resection margins were associated with decreased odds of survival. The number of lymph nodes retrieved, positive resection margins, and pathologic stage were significant predictors of disease-free survival. Analysis of 69 matched pairs showed equivalent median overall survival (MIE = 49 months [18-67]; OE = 29 months [17-69]; p = 0.26) and disease-free survival (MIE = 9 [6-22]; OE = 13 [6-22]; p = 0.45) between the two groups. CONCLUSIONS: Although long-term oncologic outcomes appear to be similar, MIE is associated with significantly less intraoperative blood loss, improved lymph node yield, less risk of severe postoperative adverse events, and shorter length of stay.

Identifying Patients at Higher Risk of Prolonged Air Leak After Lung Resection.

BACKGROUND: Predictive models of prolonged air leak have relied on information not always available preoperatively (eg, extent of resection, pleural adhesions). Our objective was to construct a model to identify patients at increased risk of prolonged air leak using preoperative factors exclusively. METHODS: From 2012 to 2014, data on consecutive patients undergoing pulmonary resection were collected prospectively. Prolonged air leak was defined as lasting longer than 7 days and requiring hospitalization. Factors associated with the primary outcome (p < 0.2) were included in a multivariate model. Regression coefficients were used to develop a weighted risk score for prolonged air leak. RESULTS: Of 225 patients, 8% (18/225) experienced a prolonged air leak. Male gender (p = 0.08), smoking history (p = 0.03), body mass index (BMI) 25 or below (p < 0.01), Medical Research Council (MRC) dyspnea score above 1 (p = 0.06), and diffusion capacity for carbon monoxide below 80% (Dlco) (p = 0.01) were selected for inclusion in the final model. Weighted scores were male gender (1 point), BMI 25 or below (0.5 point), smoker (2 points), Dlco% below 80% (2 points), and MRC dyspnea score above 1 (1 point). The area under the receiver operating characteristic curve was 0.8 (95% confidence interval [CI] = 0.7 to 0.9]. An air leak score above 4 points offered the best combination of sensitivity (83% [95% CI = 58 to 96]) and specificity (65% [95% CI = 58 to 71]). CONCLUSIONS: A subgroup of lung resection patients at higher risk for a prolonged air leak can be effectively identified with the use of widely available, preoperative factors. The proposed scoring system is simple, is clinically relevant to the informed consent, and allows preoperative patient selection for interventions to reduce the risk of prolonged air leak.

Surgical team turnover and operative time: An evaluation of operating room efficiency during pulmonary resection.

OBJECTIVE: Health care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. METHODS: We performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. RESULTS: A total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). CONCLUSIONS: Active management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection.

Randomized trial of digital versus analog pleural drainage in patients with or without a pulmonary air leak after lung resection.

OBJECTIVE: An unclear aspect of digital pleural drainage technology is whether it can benefit all lung resection patients or only those who have a postoperative air leak. The aim of this study was to evaluate the impact of digital pleural drainage on time to chest tube removal and length of hospitalization, taking into consideration postoperative air leak status. METHODS: A single-center, randomized, controlled, open-label, parallel-group trial was conducted. On postoperative day 1, stratification according to air leak status was performed by 2 independent, blinded observers. Patients were randomized to a water-sealed, pleural drainage device (analog) or to a digital device (digital). RESULTS: In both air leak groups (no air leak = 87; air leak = 85), patient factors and operative details were comparable. In the no air leak group, the difference in median chest tube drainage between analog and digital randomization arms was not statistically significant (3 days vs 2.9 days; P = .05). Median length of stay was also comparable in that group (analog = 4.3 days; digital = 4 days; P = .09). In patients with an air leak, similar findings were observed for chest tube duration (analog = 5.6 days; digital = 4.9 days; P = .11) and length of stay (analog = 6.2 days; digital = 6.2 days; P = .36). Chest tube clamping trials were significantly reduced in the digital arm of the air leak absent (0% vs 16%; P = .01) and air leak present groups (23% vs 50%; P = .01). CONCLUSIONS: Although digital devices decreased tube clamping trials, the impact on duration of chest tube drainage and hospital stay was not statistically significant, even after stratifying by postoperative air leak status.

Digital versus analogue pleural drainage phase 1: prospective evaluation of interobserver reliability in the assessment of pulmonary air leaks.

OBJECTIVES: The ability to accurately characterize a pulmonary air leak is an essential skill in chest medicine and surgery. The objective was to evaluate interobserver variability in air leak assessments using analogue and digital pleural drainage systems. METHODS: Air leak severity in lung resection patients with a pulmonary air leak was prospectively evaluated by at least one thoracic surgeon, one surgical resident and one to two nurses using a standardized questionnaire. The first assessment was performed with pleural drains connected to an analogue system. Subsequently, patients were re-assessed after changing from the analogue to a digital drainage system. The thoracic surgeon's evaluation was considered the reference standard for comparison. Agreement between observers was quantified using the kappa (κ) statistic. RESULTS: A total of 128 air leak evaluations were completed in 30 patients (thoracic surgeon = 30; nurses = 56; resident = 30; physiotherapists = 12). The mean time between analogue and digital assessment was 2.16 (±1.66) h. The level of observer agreement regarding air leak severity significantly increased from very slight to substantial when using the digital drainage system [analogue κ = 0.03; confidence interval (CI): 0.04-0.11; P = 0.40) (digital κ = 0.61; CI: 0.49-0.73; P < 0.01]. Similar improvements were observed in subgroups of health-care professionals using digital technology. CONCLUSIONS: Digital pleural drainage technology improves the agreement level between members of the health-care team when assessing the severity of a pulmonary air leak after lung resection.

Prognostic significance of a positive radial margin after esophageal cancer resection.

OBJECTIVE: The prognostic significance of an incomplete esophageal cancer resection due to a positive microscopic radial margin remains unclear. The aim of this study is to examine the relationship between radial margin status and oncologic outcomes. METHODS: We performed a retrospective review of esophageal cancer resections between 2004 and 2012. Radial margin status was defined according to the College of American Pathologists. Exclusion criteria were complete pathologic response (n = 12), positive proximal or distal margin (n = 11), R2 resection (n = 5), and carcinoma in situ (n = 2). RESULTS: Of 154 patients, 30 (19%) had a positive radial margin (RM+) and 124 (81%) had a complete resection (R0). The 2 groups were similar with respect to age, gender, proportion of squamous tumors, middle thoracic tumor location, rate of neoadjuvant chemoradiation and adjuvant radiation, transhiatal approach, number of examined lymph nodes, and length of proximal and distal margins. In patients with stage III, the locoregional recurrence-free interval was similar between groups; however, RM+ was associated with a 17-month decrease in the median time to distant recurrence (RM+ = 7 months [95% confidence interval, 4-14]; R0 = 24 months [median not reached]; P < .01). The median survival was also significantly decreased by 12 months in the RM+ group (RM+ = 13 months [95% confidence interval, 7-26]; R0 = 25 months [95% confidence interval, 20-30]; P = .04). CONCLUSIONS: An isolated, positive microscopic radial margin was associated with a greater risk for distant recurrence. There was no impact on locoregional disease control. The role of adjuvant, systemic therapy in patients with an isolated, microscopically RM+ merits further evaluation.

Carinal sleeve resection for persistent bronchopleural fistula after completion right pneumonectomy.

Sleeve bronchoplasty is an uncommon surgical option for the management of bronchopleural fistulae. We present the management of an individual who developed T1N0M0 non-small cell lung cancer involving the right upper lobe 20 years after right lower lobe cancer. Following completion right pneumonectomy, this patient developed a bronchial stump leak. Primary repair of the stump was performed, but failed leading to empyema and necessitated creation of a Clagett window. The size of the stump defect became sufficiently large to render the patient dyspneic and aphonic. A carinal sleeve resection was successful in managing the massive bronchopleural fistula.

Risk of pneumonectomy after induction therapy for locally advanced non-small cell lung cancer.

BACKGROUND: Recent data from prospective multimodality trials have documented an unacceptable early mortality with pneumonectomy after induction chemotherapy. This finding has raised skepticism toward pneumonectomy as a surgical option for patients with regionally advanced nonsmall-cell lung cancer. In the current study, perioperative outcomes after pneumonectomy with or without neoadjuvant therapy are compared to determine the impact of induction therapy on perioperative mortality in this setting. Variables associated with increased perioperative risk are identified. METHODS: A review of 315 nonsmall-cell lung cancer patients (196 male [62%]) undergoing pneumonectomy over a 15-year period was undertaken. Patients were well matched for clinical variables other than receiving induction chemotherapy. Complications and operative mortality were analyzed for associations with laterality and induction chemotherapy. RESULTS: Median age was 64 years, (range, 25 to 82). Age was predictive of mortality in 13 of 86 patients (15%) more than 70 years old, compared with 16 of 229 patients (7%) less than 70 years old (hazard ratio = 1.77, p = 0.046). Overall operative mortality was 9.2% (29 of 315). There were 115 left-sided (37%) and 200 right-sided (63%) pneumonectomies. Sixty-eight patients (22% [left = 31, right = 37]) received induction chemotherapy. Surgery alone was performed in 247 patients. Mortality among patients undergoing induction chemotherapy was 21% (odds ratio = 4.01; p = 0.0007). After induction chemotherapy, postoperative bronchopleural fistula associated with respiratory failure was predictive of operative mortality (hazard ratio = 148, p = 0.0001). Left-side pneumonectomy did appear to a have a greater incidence of postoperative arrhythmia. CONCLUSIONS: Morbidity and mortality after pneumonectomy is substantial. Patients greater than 70 years old appear to be at increased risk. Induction chemotherapy also increases the risk of operative mortality after pneumonectomy. Patients should be advised of this increased operative risk, and the multidisciplinary team must consider this when pneumonectomy appears necessary after induction therapy for locally advanced nonsmall-cell lung cancer.

Continuous multi-parameter heart rate variability analysis heralds onset of sepsis in adults.

BACKGROUND: Early diagnosis of sepsis enables timely resuscitation and antibiotics and prevents subsequent morbidity and mortality. Clinical approaches relying on point-in-time analysis of vital signs or lab values are often insensitive, non-specific and late diagnostic markers of sepsis. Exploring otherwise hidden information within intervals-in-time, heart rate variability (HRV) has been documented to be both altered in the presence of sepsis, and correlated with its severity. We hypothesized that by continuously tracking individual patient HRV over time in patients as they develop sepsis, we would demonstrate reduced HRV in association with the onset of sepsis. METHODOLOGY/PRINCIPAL FINDINGS: We monitored heart rate continuously in adult bone marrow transplant (BMT) patients (n = 21) beginning a day before their BMT and continuing until recovery or withdrawal (12+/-4 days). We characterized HRV continuously over time with a panel of time, frequency, complexity, and scale-invariant domain techniques. We defined baseline HRV as mean variability for the first 24 h of monitoring and studied individual and population average percentage change (from baseline) over time in diverse HRV metrics, in comparison with the time of clinical diagnosis and treatment of sepsis (defined as systemic inflammatory response syndrome along with clinically suspected infection requiring treatment). Of the 21 patients enrolled, 4 patients withdrew, leaving 17 patients who completed the study. Fourteen patients developed sepsis requiring antibiotic therapy, whereas 3 did not. On average, for 12 out of 14 infected patients, a significant (25%) reduction prior to the clinical diagnosis and treatment of sepsis was observed in standard deviation, root mean square successive difference, sample and multiscale entropy, fast Fourier transform, detrended fluctuation analysis, and wavelet variability metrics. For infected patients (n = 14), wavelet HRV demonstrated a 25% drop from baseline 35 h prior to sepsis on average. For 3 out of 3 non-infected patients, all measures, except root mean square successive difference and entropy, showed no significant reduction. Significant correlation was present amongst these HRV metrics for the entire population. CONCLUSIONS/SIGNIFICANCE: Continuous HRV monitoring is feasible in ambulatory patients, demonstrates significant HRV alteration in individual patients in association with, and prior to clinical diagnosis and treatment of sepsis, and merits further investigation as a means of providing early warning of sepsis.

Fourier-transform infrared spectroscopic study of characteristic molecular structure in cancer cells of esophagus: an exploratory study.

OBJECTIVE: To investigate the structural changes at the molecular level and to assess the usefulness of Fourier-transform infrared (FTIR) spectroscopy in the diagnosis of esophageal cancer. METHODS: A pilot study was established of 10 consecutive patients with adenocarcinoma of the esophagus. Tissue samples from the diseased and normal sites of the resected specimens were analyzed and compared using FTIR spectroscopy and histopathology. RESULTS: Specific changes were observed in the FTIR spectral features of esophageal cancer and thus spectral criteria were established for the detection of malignancy in esophagus tissues by FTIR spectroscopy. The spectral changes in cancer were the results of characteristic structural alterations at the molecular level in the esophageal cancer specimens. These alternations included an increase in the nuclei-to-cytoplasm ratio, an increase in the relative amount of DNA while a decrease in the relative amount of RNA, an enhancement in the phosphorylation of proteins, a decrease in the glycogen level, a loss of hydrogen bonding of the COH groups in the amino acid residues of proteins, a tighter intermolecular packing and a stronger intermolecular interaction among the DNA molecules, an increase in the distribution of protein segments with the conformation of beta-sheet and unordered turns and a tighter packing of the alpha-helical segments in overall tissue proteins, a decrease in the overall CH(3)-to-CH(2) ratio and an accumulation of triglycerides. CONCLUSIONS: FTIR is an automated method that has shown promise in differentiating cancer in the esophagus and may play a role in surveillance programs in premalignant conditions.

Desmoid tumor of the chest wall with pleural involvement.

Although there have been reports of desmoid tumors of the chest wall, pleural extension, as well as overall size greater than 20 cm, is rare. We present the case of a large desmoid tumor involving the left anterior chest wall, upper abdomen, and diaphragm, which impinged on the left lung and displaced the liver. Wide surgical excision, reconstruction, and differential diagnosis from fibrosarcoma are essential elements in the treatment of these rare tumors.