Esophageal perforation secondary to malignant gastric outlet obstruction: a case report.

BACKGROUND: Esophageal perforation is a rare presenting sign of gastric cancer. To date, only nine case reports of this phenomenon have been previously published. CASE PRESENTATION: Esophageal perforation was diagnosed radiographically during workup for acute chest pain in a 67-year-old man. Emergent endoscopy confirmed esophageal perforation and biopsied a pre-pyloric mass confirmed to be adenocarcinoma. The perforation was managed with endoscopically placed transluminal pleural and mediastinal drains and esophageal stenting. The gastric outlet obstruction was temporized with a transpyloric stent. After the patient recovered from sepsis, distal gastrectomy was performed and he made a full recovery. CONCLUSIONS: Rarely, pre-pyloric gastric cancer can present with Boerhaave syndrome, spontaneous esophageal perforation associated with forceful vomiting. We present the tenth report in the literature of this phenomenon and the first to be initially treated with endoscopic stenting and transluminal thoracoscopic drainage. When endoscopic management is used to treat patients with Boerhaave syndrome, it may be beneficial to examine the entire stomach to evaluate for malignant etiology.

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery.

BACKGROUND: Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. METHODS: A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. RESULTS: Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. CONCLUSIONS: Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Robotic-Assisted Thoracoscopic Repair of Right-Sided Bochdalek Hernia in Adults: A Two-Case Series.

Bochdalek hernia is a congenital diaphragmatic hernia that presents rarely in adulthood. Because of the paucity of cases, no standard repair technique has been identified. Here we present two cases of robotic, thoracoscopic repair of this rare hernia defect. Two separate adult patients with right-sided abdominal pain presented to the emergency department for evaluation. Both patients were diagnosed with right-sided Bochdalek hernia and repair was undertaken with a robotic, transthoracic approach. Repair technique is described in detail, including port placement, dissection technique, and repair strategy. Advantages of the robotic, transthoracic approach are discussed in detail. A transthoracic minimally invasive approach using a robotic platform is noted to be both feasible and practical in the treatment of adult Bochdalek hernia.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy.

INTRODUCTION: Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection. OBJECTIVE: To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study. METHODS: NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort. RESULTS: The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24). CONCLUSION: In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study.

BACKGROUND: Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB). METHODS: NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing. RESULTS: Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages. CONCLUSION: ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02410837.

Thoracic Surgery Considerations in the Mentally Ill or Handicapped Patient.

Increasing prevalence of mentally ill and handicapped populations requiring surgical thoracic interventions has brought to light their worse associated morbidity and mortality. Baseline functional status, caretaker environment, and mental limitations in day to day life have an impact in the short and long term from these interventions. Aggressive perioperative care, multispecialty approach, technical aspects, palliative procedures, and ethical considerations all play a part in improving outcomes. In this article real cases are presented illustrating points of care and situations for discussion.

Feasibility and Safety of the Transbronchial Access Tool for Peripheral Pulmonary Nodule and Mass.

BACKGROUND: Navigational bronchoscopy and other imaging modalities have improved the ability to evaluate pulmonary nodules/mass. Many of these lesions are located outside the bronchial airway and are difficult to access even with these devices. The Transbronchial Access Tool (Medtronic, Minneapolis, MN) allows the bronchoscopist to create a pathway from the bronchial airway, across the lung parenchyma, and into the target lesion. We are reporting the feasibility and safety of this new device. METHODS: Patients with peripheral pulmonary nodules/mass with an absence of an air bronchogram on thoracic imaging underwent a navigational bronchoscopy in a hybrid operating room under general anesthesia. A navigational system located predetermined areas in the bronchial tree to deploy the Transbronchial Access Tool, and cone beam computed tomography confirmed that the target lesion was accessed. A standard protocol was developed and followed in the last 7 patients directing cone beam computed tomography use. The ability to enter the target lesion, diagnostic yield, radiation exposure, and procedural complications were recorded. RESULTS: The Transbronchial Access Tool was used in 14 patients who underwent an electromagnetic navigational bronchoscopy-guided biopsy from September 2015 to January 2016. The overall diagnostic yield was 71% (10 of 14) and 100% (7 of 7) when the standard protocol was instituted. Access was achieved in 75% (9 of 12) of the targeted lesions, with a diagnostic yield of 66% (8 of 12). One complication, a pneumothorax, occurred. The average radiation exposure during the procedure was 4.3 mSv (range, 3 to 5 mSv), and fluoroscopic time was 17 minutes (range, 2 to 44 minutes). CONCLUSIONS: The Transbronchial Access Tool is safe and permits access to pulmonary nodules/masses with navigational bronchoscopy.