Effect of Thoracic Surgery Regionalization on 1- and 3-Year Survival after Cancer Esophagectomy.

OBJECTIVE: The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the United States translated to longer-term survival benefit. BACKGROUND: Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival are mixed. METHODS: We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and chi-square tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality. RESULTS: Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% vs 73.9%, P = 0.02) but not 3-year survival (52.9% vs 58.2%, P = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.29-1.00], and only thoracic specialty at 3years (OR 0.62, 95% CI 0.38-0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model. CONCLUSIONS: Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.

Association of Surgical Timing with Outcomes in Early Stage Lung Cancer.

BACKGROUND: Optimal time to surgery for lung cancer is not well established. We aimed to assess whether time to surgery correlates with outcomes. METHODS: We assessed patients 18-84 years old who were diagnosed with stage I/II lung cancer at our integrated healthcare system from 2009 to 2019. Time to surgery was defined to start with disease confirmation (imaging or biopsy) prior to the surgery scheduling date. Outcomes of unplanned return to care within 30 days of lung cancer surgery, all-cause mortality, and disease recurrence were compared based on time to surgery before and after 2, 4, and 12 weeks. RESULTS: Of 2861 included patients, 70% were over 65 years old and 61% were female. Time to surgery occurred in 1-2 weeks for 6%, 3-4 weeks for 31%, 5-12 weeks for 58%, and 13-26 weeks for 5% of patients. Patients with time to surgery > 4 (vs. ≤ 4) weeks had greater risk of both death (hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.00-1.39) and recurrence (HR 1.33, 95% CI 1.10-1.62). Associations were not statistically significant when dichotomizing time to surgery at 2 or 12 weeks for death (2 week HR 1.23, 95% CI 0.93-1.64; 12 week HR 1.35, 95% CI 0.97-1.88) and recurrence (2 week HR 1.54, 95% CI 0.85-2.80; 12 week HR 2.28, 95% CI 0.80-6.46). CONCLUSIONS: Early stage lung cancer patients with time to surgery within 4 weeks experienced lower rates of recurrence. Optimal time to surgical resection may be shorter than previously reported.

Differences in outcomes by race/ethnicity after thoracic surgery in a large integrated health system.

Background: Disparities exist throughout surgery. We aimed to assess for racial/ethnic disparities among outcomes in a large thoracic surgery patient population. Methods: We reviewed all thoracic surgery patients treated at our integrated health system from January 1, 2016-December 31, 2020. Post-operative outcomes including length of stay (LOS), 30-day return to the emergency department (30d-ED), 30-day readmission, 30- and 90-day outpatient appointments, and 30- and 90-day mortality were compared by race/ethnicity. Bivariate analyses and multivariable logistic regression were performed. Our multivariable models adjusted for age, sex, body mass index, Charlson Comorbidity Index, surgery type, neighborhood deprivation index, insurance, and home region. Results: Of 2730 included patients, 59.4 % were non-Hispanic White, 15.0 % were Asian, 11.9 % were Hispanic, 9.6 % were Black, and 4.1 % were Other. Median (Q1-Q3) LOS (in hours) was shortest among non-Hispanic White (37.3 (29.2-76.1)) and Other (36.5 (29.3-75.4)) patients followed by Hispanic (46.8 (29.9-78.1)) patients with Asian (51.3 (30.7-81.9)) and Black (53.7 (30.6-101.6)) patients experiencing the longest LOS (p < 0.01). 30d-ED rates were highest among Hispanic patients (21.3 %), followed by Black (19.2 %), non-Hispanic White (18.1 %), Asian (13.4 %), and Other (8.0 %) patients (p < 0.01). On multivariable analysis, Hispanic ethnicity (Odds Ratio (OR) 1.43 (95 % CI 1.03-1.97)) and Medicaid insurance (OR 2.37 (95 % CI 1.48-3.81)) were associated with higher 30d-ED rates. No racial/ethnic disparities were found among other outcomes. Conclusions: Despite parity across multiple surgical outcomes, disparities remain related to patient encounters within our system. Health systems must track such disparities in addition to standard clinical outcomes. Key message: While our large integrated health system has been able to demonstrate parity across many major surgical outcomes among our thoracic surgery patients, race/ethnicity disparities persist including in the number of post-operative return trips to the emergency department. Tracking outcome disparities to a granular level such as return visits to the emergency department and number of follow up appointments is critical as health systems strive to achieve equitable care.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes.

Importance: With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies. Objective: To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies. Design, Setting, and Participants: This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons. Exposures: Robotic-assisted or video-assisted lung lobectomy. Main Outcomes and Measures: The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator. Results: The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process. Conclusions and Relevance: In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

Efficacy of varenicline versus bupropion for smoking cessation: A systematic review and meta-analysis of randomized controlled trials.

According to the Global Burden of Disease (GBD) Study conducted in 2019, smoking tobacco leads to over 8 million deaths each year. Hence, it is crucial to identify optimal smoking cessation therapy. To compare the efficacy of varenicline versus bupropion for smoking cessation by performing a meta-analysis of randomized controlled trials (RCTs). Protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The Patient intervention comparison outcome time (PICOT) format is used in the study. Patients having nicotine use disorder treated with varenicline or bupropion were included, and the continuous abstinence rate (CAR) was assessed at 12, 24, and 52 weeks. The PubMed and Google Scholar databases were systematically searched, and after the screening, RCTs involving a comparison of varenicline and bupropion in smoking cessation were included. We performed a meta-analysis of three RCTs (10110 patients) by RevMan 5.4.1 statistical software to determine the efficacy of varenicline compared with bupropion in smoking cessation. The CAR at 9- to 12-week follow-up of varenicline is superior to bupropion (OR = 1.79, CI range: 1.59-2.02, P < 0.001). Similarly, the CAR of varenicline is superior to bupropion for weeks 9-24 (1.51, 1.32 to 1.72) and weeks 9-52 (1.60, 1.22 to 2.12), suggesting the absolute advantage of varenicline over bupropion for smoking cessation in terms of efficacy. Both varenicline and bupropion are efficacious therapies for smoking cessation. Compared with bupropion, varenicline can significantly improve the CAR at the end of treatment, at 24 weeks, and at 52 weeks of follow-up.

A refined procedure for esophageal resection using a full minimally invasive approach.

OBJECTIVE: Newer minimally invasive approaches to esophagectomy have brought substantial benefits to esophageal-cancer patients and continue to improve. We report here our experience with a streamlined procedure as part of a comprehensive perioperative-care program that provides additional advances in the continued evolution of this procedure. METHODS: All patients with primary esophageal cancer referred for resection to the Oakland Medical Center of the Kaiser-Permanente Northern California health plan who underwent this approach between January 2013 and August 2018 were included. Operative and clinical outcome variables were extracted from the electronic medical record, operating-room files, and manual chart review. RESULTS: 142 patients underwent the new procedure and care program; 121 (85.2%) were men with mean age of 64.5 years. 127 (89.4%) were adenocarcinoma; 117 (82.4%) were clinical stage III or IVA. 115 (81.0%) required no jejunostomy. Median hospital length-of-stay was 3 days and 8 (5.6%) patients required admission to the intensive care unit. Postoperative complications occurred in 22 (15.5%) patients within 30 days of the procedure. There were no inpatient deaths; one patient (0.7%) died within 30 days following discharge and three additional deaths (2.1%) occurred through 90 days of follow-up. CONCLUSIONS: This approach resulted in excellent clinical outcomes, including short hospital stays with limited need for the intensive care unit, few perioperative complications, and relatively few patients requiring feeding tubes on discharge. This comprehensive approach to esophagectomy is feasible and provides another clinically meaningful advance in the progress of minimally invasive esophagectomy. Further development and dissemination of this method is warranted.

Comparison of Survival by Multimodal Treatment Regimen Among Malignant Pleural Mesothelioma Patients in an Integrated Health System.

BACKGROUND: Optimal therapy for malignant pleural mesothelioma (MPM) remains unclear. We compared overall survival in patients with MPM after various multimodal treatment regimens including combinations of immunotherapy, chemotherapy, and surgery. PATIENTS AND METHODS: We examined MPM patients treated within our integrated health system from January 1, 2009 to December 31, 2020. Patients were grouped based on treatment regimen: chemotherapy alone (CT), immunotherapy with or without chemotherapy (iCT), surgery with chemotherapy (sCT), and surgery with immunotherapy and chemotherapy (siCT). We analyzed baseline characteristics and overall patient survival among these groups and several subgroups. RESULTS: One hundred seventy-nine patients were included. Among the study groups, there was no difference in age, sex, race/ethnicity, Charlson Comorbidity Index, or Eastern Cooperative Oncology Group performance status. Patients treated with CT (N = 109), iCT (N = 35), sCT (N = 26), and siCT (N = 9) had median (95% confidence interval) survivals of 11.7 (9.9-16.3), 18.2 (14.5-29.8), 20.7 (11.6-37.2), and 22.6 (19.7-37.8) months, respectively (P < .001). Median survival among patients with and without immunotherapy was 19.7 (17.4-29.8) and 12.3 (10.6-17.3) months, respectively (P = .023). Median survival among patients with and without surgery was 21.7 (17.6-34.8) and 13.6 (11.5-17.3) months, respectively (P = .007). Patients with biphasic/sarcomatoid subtypes who received immunotherapy experienced 76.2% (55.8%-100.0%) 12 month survival vs. 13.6% (4.8%-39.0%) among those who did not (P < .001). CONCLUSION: MPM patients receiving surgery and immunotherapy as part of multimodal treatment regimens experienced the longest survival. Surgery and immunotherapy are each associated with survival. Further investigations are warranted to assess the benefit of immunotherapy within multimodal treatment regimens for MPM.

Effect of thoracic surgery regionalization on long-term survival after lung cancer resection.

OBJECTIVE: Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit. METHODS: We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ2 or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors. RESULTS: Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality. CONCLUSIONS: We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.

Intercostal nerve blockade with liposomal bupivacaine reduces length of stay after video assisted thoracic surgery (VATS) lobectomy.

BACKGROUND: Intercostal nerve blockade (INB) for thoracic surgery analgesia has gained popularity in practice, but evidence demonstrating its efficacy remains sparse and inconsistent. We investigated the effect of INB with standard bupivacaine (SB) with epinephrine versus liposomal bupivacaine (LB) versus a mixed solution of the two on postoperative pain control and outcomes in video assisted thoracoscopic lobectomy patients. METHODS: Since 2014, our practice has shifted from using INBs with SB with epinephrine, to LB, to a mix of the two as the central component of multimodal analgesia after video assisted thoracoscopic surgery. The blocks are performed in a standardized fashion under thoracoscopic visualization consecutively from two rib spaces above to two below the outermost incisions. We retrospectively compared all minimally invasive lobectomies performed at our institution between January 2014 and July 2018 by type of local anesthetic used for INB. We examined median length of stay (LOS), opioid utilization, and subjective pain scores [0-10]. RESULTS: Out of 302 minimally invasive lobectomy patients, 34 received SB with epinephrine, 222 received LB alone, and 46 received the mixed solution. LOS was almost a full day shorter in the LB group than in the SB group (34.8 vs. 56.5 hours, P=0.01). There was nearly 25% lower median total morphine equivalent utilization in the mixed solution cohort compared to the LB cohort (-7.1 mg, P=0.02). Additionally, IV morphine equivalent utilization was over 50% lower in the mixed solution group than in the SB with epinephrine group (-10.0 mg, P=0.03). CONCLUSIONS: Our study is by far the largest (N=302) to compare types of local anesthetic used for INB within a uniform case population. The reductions in LOS and opiate utilization observed in our study among patients receiving LB-based formulations were both statistically and clinically significant.

Outcomes of Anastomotic Evaluation Using Indocyanine Green Fluorescence during Minimally Invasive Esophagectomy.

BACKGROUND: Limited evidence exists assessing whether anastomotic evaluation using indocyanine green fluorescence (IGF) during minimally invasive esophagectomy (MIE) predicts or improves outcomes. We hypothesized that IGF helps surgeons predict anastomotic complications and reduces anastomotic leaks after MIE. METHODS: In September 2019, our institution began routinely using IGF for intraoperative evaluation of anastomoses during MIE. Data were collected from patients undergoing MIE in the two years before and after this technology began being routinely used. Baseline characteristics and outcomes, including anastomotic leak, in patients who underwent indocyanine green fluorescence evaluation (ICG) and those who did not (nICG) were compared. Outcomes were also compared between ICG patients with normal versus abnormal fluorescence. RESULTS: Overall, 181 patients were included. Baseline demographic and clinical characteristics did not differ between the ICG and nICG groups. ICG patients experienced higher rates of anastomotic leak (10.2% vs. 1.6%, P = .015) and 90-day mortality (8.5% vs. 1.6%, P = .04) compared to nICG patients. Due to lack of equipment availability, 19 nICG patients underwent MIE after the use of IGF became routine, and none developed leaks. ICG patients with abnormal fluorescence had higher rates of anastomotic leak (71.4% vs 1.9%, P < .001) and 30-day mortality (28.6% vs 0%, P = .012) compared to those with normal fluorescence. DISCUSSION: Abnormal intraoperative IGF was associated with increased rate of anastomotic leak, suggesting predictive potential of IGF. However, its use was associated with an increased leak rate and higher mortality. Further studies are warranted to assess possible physiologic effects of indocyanine green on the esophageal anastomosis.

Reduced opioid utilization and post-operative pain in Asian vs. Caucasian populations after video-assisted thoracoscopic surgery lobectomy with liposomal bupivacaine-based intercostal nerve blockade.

BACKGROUND: Regional analgesia, such as intercostal nerve blockade (INB), is a viable modality for postoperative pain control in thoracic surgery patients. Asian patients have historically been underrepresented in studies of pain responses and pain medication requirements based on race. In this study, we examined the postoperative opioid medications used by Asian and Caucasian patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy who received different bupivacaine-based INB. METHODS: We retrospectively reviewed patients undergoing VATS lobectomy who received standard bupivacaine (SB), liposomal bupivacaine (LB), or liposomal bupivacaine mixed with standard bupivacaine (MIX). Length of stay (LOS), postoperative pain scores, postoperative opioid use (in intravenous morphine equivalents) were evaluated. The Chi-square test was used to compare categorical variables; Student's t-test for normally distributed variables; and the Wilcoxon rank-sum test for non-normally distributed variables. Multivariable linear regression was used to assess opioid use in Asians compared to Caucasians. RESULTS: Of the 239 patients in the cohort, 212 received LB or MIX and 27 received SB. In the LB/MIX group, 48 (22.6%) were Asian and 164 (77.4%) were Caucasian. In the SB group, 7 (25.9%) were Asian and 20 (74.1%) were Caucasian. There were no differences in height, weight, and body mass index (BMI) between the SB and LB/MIX groups, but there was a significant difference in weight and BMI between Asian and Caucasian patients. The median LOS was comparable between the SB and LB/MIX groups. The average 24-hour postoperative pain score in the LB/MIX group was 2.5, and 2.0 and 2.7 in the Asian and Caucasian subgroups, respectively (P<0.01). The median opioid use in the LB/MIX group was 27.2 mg, and 16.9 and 31.1 mg in the Asian and Caucasian subgroups, respectively (P<0.01). On multivariable linear regression analysis adjusting for sex, age, BMI, and bupivacaine type, we found Asians used 25.5 mg less opioids compared to Caucasians (P<0.01). CONCLUSIONS: INB with LB or liposomal-standard bupivacaine mix resulted in statistically significant decreased postoperative pain scores and opioid use in Asians compared to Caucasians. There was no difference in LOS between the LB/MIX and SB groups.

Regionalization of Lung Cancer Surgery Improves Outcomes in an Integrated Health Care System.

BACKGROUND: Current literature favors a volume-outcome relationship in pulmonary lobectomy that prompted centralization of these operations abroad, in national, single-payer health care settings. This study examined the impact of regionalization on outcomes after lung cancer resection within a US integrated health care system. METHODS: This study retrospectively reviewed major pulmonary resections (lobectomy, bilobectomy, pneumonectomy) for lung cancer that were performed before (2011 to 2013; n = 782) and after (2015 to 2017; n = 845) thoracic surgery regionalization during 2014. RESULTS: Case migration from 16 regionwide sites to 5 designated centers was complete by 2016. Facility volume increased from 17.4 to 48.3 cases/y (P = .002), and surgeon volume increased from 12.5 to 19.9 cases/y (P = .001). The postregionalization era was characterized by increased video-assisted thoracoscopic surgery (86% from 57%; P < .001), as well as decreased intensive care unit use (-1.0 days; P < .001) and hospital length of stay (-3.0 days; P < .001). Postregionalization patients experienced fewer total (26.2% from 38.6%; P < .001) and major (9.6% from 13.6%; P = .01) complications. The association between regionalization and decreased length of stay and morbidity was independent of surgical approach and case volume in mixed multivariate models. CONCLUSIONS: After the successful implementation of thoracic surgery regionalization in our US health care network, pulmonary resection volume increased, and practice shifted to majority video-assisted thoracoscopic surgery and minimum intensive care unit utilization. Regionalization was independently associated with significant reductions in length of stay and morbidity.

Progel Use is Not Associated with Decreased Incidence of Postoperative Air Leak after Nonanatomic Lung Surgery.

CONTEXT: Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported. OBJECTIVE: To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel. DESIGN: Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%). MAIN OUTCOME MEASURE: Presence of postoperative lung air leak. RESULTS: No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414). CONCLUSION: Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.

Cardiac autotransplantation for malignant or complex primary left-heart tumors.

Malignant or complex benign tumors of the left heart can present a formidable challenge for complete resection, due to anatomic inaccessibility. Cardiac autotransplantation (cardiac explantation, ex-vivo tumor resection, reconstruction, and reimplantation) was introduced for complex benign primary left-heart cardiac tumors by Cooley and for malignant left-heart tumors by Reardon. Herein, we update our previously reported experience.From April 1998 through July 2008, 20 patients underwent 21 cardiac autotransplantations for complex left-sided cardiac tumors that were nonresectable by traditional means. Demographics, tumor histology, operative data, and mortality rates were analyzed. Follow-up was complete in all patients.Of the 20 patients, 17 had malignant lesions, and 3 had benign disease. Two patients had left ventricular lesions and the rest had left atrial lesions. Histology showed 7 malignant fibrous histiocytomas, 5 undifferentiated sarcomas, 3 leiomyosarcomas, 1 malignant osteosarcoma, 1 myxoid sarcoma, 2 paragangliomas, and 1 myxoma. Fourteen patients had previous resection of their cardiac tumors, and 1 patient had repeat autotransplantation for recurrent disease. There were no operative deaths in patients undergoing autotransplantation alone (0/15), and 3 operative deaths in patients undergoing combined cardiac autotransplantation and pneumonectomy (3/6, 50%). All 3 patients with benign disease survived surgery and are alive without recurrent disease. Local recurrence occurred in 3/18 patients with malignant disease: 1 underwent successful repeat autotransplantation and 2 are receiving chemotherapy. The mean survival for all patients with sarcoma is 22 months.Cardiac autotransplantation enables complete resection and accurate reconstruction in many primary malignant and complex benign left-heart tumors.

Treatment of Tracheoinnominate Fistula with Ligation of the Innominate Artery: A Case Report.

INTRODUCTION: Tracheoinnominate fistula, a rare complication of tracheostomy, carries high mortality regardless of treatment; therefore prevention and quick diagnosis is pertinent to survival. CASE PRESENTATION: A 76-year-old man who underwent emergent tracheostomy placement presented on postoperative day 10 with massive hemorrhage concerning for tracheoinnominate fistula and was treated with median sternotomy and ligation of the innominate artery. DISCUSSION: This presentation describes a concise diagnosis and treatment plan for a rare event. The key to good outcomes is quick diagnosis and urgent surgical intervention.

Acteylcholinesterase inhibitor rivastigmine enhances cellular defenses in neuronal and macrophage-like cell lines.

Neuroprotection mediated by the cellular heat shock response offers 1 clinical strategy to prevent, stabilize, and possibly reverse neurodegenerative processes. Although damaged proteins are thought to be the primary stimulus for the heat shock response, several studies indicate that pharmaceutical agents can either directly induce the heat shock transcription factor (Hsf1) or enhance its activation during different forms of cellular stress. Because Hsf1 is now known to combat the proteotoxicity of aging and has a central role in modulating amyloid aggregation, pharmacologic interventions to strengthen Hsf1 action may have important implications for preventing neurodegeneration linked to altered and damaged proteins such as observed in Alzheimer's disease. Given reports that some agents for the treatment of Alzheimer's disease have neuroprotective properties, this project investigated whether rivastigmine, which is an acetyl and butaryl cholinesterase inhibitor, mediates the neuroprotection of the neuronal-like cell line SH-SY5Y. The cells were exposed to various concentrations of rivastigmine to determine whether the drug protected cells from toxic injury and induced the 1st phase of the cellular heat shock response. In all, 100-micromol/L rivastigmine decreases cell death by 40% compared with untreated cells. This concentration enhances Hsf1 activation by strengthening both its multimerization and its phosphorylation, which leads to increased messenger RNA (mRNA) for hsp70. Therefore, one of the putative neuroprotective mechanisms of rivastigmine seems to be mediated through the heat shock response. These results also are observed in cultured macrophage-like cells, which suggests a future clinical tool for monitoring pharmacologically improved stress responses in peripheral blood mononuclear cells during treatment of Alzheimer disease.