Lobar versus sublobar resection for atypical lung carcinoid: An analysis from the National Cancer Database.

BACKGROUND: There is a knowledge gap regarding lobar versus sublobar resection for atypical carcinoid (AC) of the lung. As such, the authors sought to understand and analyze the outcomes of sublobar resection versus lobectomy in this patient population. METHODS: A retrospective analysis using the National Cancer Database was performed to compare overall survival (OS) between patients treated with lobectomy and patients treated with sublobar resection for AC of the lung between the years 2004 and 2016. Patient characteristics were compared with χ2 tests. The Kaplan-Meier method was used to estimate OS distributions, and the log-rank test was used to compare distributions by treatment strategy. A multivariable Cox regression model was used to assess associations between the treatment strategy and OS. A propensity score matching method was also implemented to further eliminate treatment selection bias in the study sample. RESULTS: The database identified 669 patients with T1-T4 and N0-N3 lung ACs that were surgically resected. Unadjusted Kaplan-Meier survival curves did not demonstrate an OS difference between lobectomy and sublobar resection (p = .094). After propensity score matching, curves demonstrated a numerical improvement in OS with lobectomy; however, it was not statistically significant (p = .5). In a subgroup analysis, lobectomy and node-negative disease were associated with the best OS, whereas sublobar resection and node-positive disease were associated with the worst OS (p < .0001). Nodal involvement was associated with worse survival, regardless of surgical treatment (p < .0001). CONCLUSIONS: In patients with T1-T4 and N0-N3 ACs of the lung, lobectomy was not associated with an improvement in OS in comparison with sublobar resection.

First Use of a Novel Extracorporeal Life Support System: Successful Application in Tracheoesophageal Fistula Repair.

Extracorporeal life support, commonly referred to as extracorporeal membrane oxygenation (ECMO), is indicated when conventional medical and surgical measures fail to support a patient during cardiac or respiratory failure. Increased use of ECMO in recent years has led to innovation that has improved safety in appropriate candidates. This has resulted in the application of novel approaches to complex surgical problems. Herein, we describe a simple, novel, and new-to-market ECMO circuit used for successful perioperative veno-venous ECMO support of a patient undergoing complex repair of a tracheoesophageal fistula. We believe that this circuit and its use for intra-and post-operative extracorporeal support provides a framework for safe and simple ECMO support in the future, including perioperative support for patients undergoing complicated and challenging thoracic procedures.

A Simple Method to Improve Intraoperative Localization of Fiducial Markers during Lung Resections.

Background Lung cancer screening programs have increased the detection of early-stage lung cancer. High-resolution computed tomography can detect small, low-density pulmonary nodules, or ground-glass opacities. Obtaining a tissue diagnosis can be challenging, often necessitating surgical diagnosis. Preoperative localization and intraoperative fluoroscopy are valuable tools to guide resections for small pulmonary nodules. Case Description We present three cases using intraoperative fluoroscopy and Faxitron Bioptics that enhanced our certainty of resection of nonpalpable nodules. Conclusion We support the use of intraoperative fluoroscopy with the unique addition of Faxitron BioVision as safe and reliable methods to enhance the certainty of resection.

Anterior Thoracic Diskectomy and Fusion: Surgical Technique and Anatomic Considerations.

Ossification of the posterior longitudinal ligament (OPLL) is a rare condition that can lead to progressive spinal cord compression.1 Currently, surgical decompression remains the optimal treatment in symptomatic patients.2,3 In cases with significant thoracic stenosis and concern for ventral erosion of the dura, an anterior approach may be necessary for direct decompression.4 In Video 1, we demonstrate the successful application of a multidisciplinary approach for surgical resection of a large OPLL lesion located at the T2-3 disk space. A 37-year-old female with medical history significant for rickets presented a year after a fall with bilateral lower extremity paraparesis and saddle anesthesia. Exposure consisted of a manubrial window, followed by thoracic diskectomy and fusion with drilling of the calcified posterior longitudinal ligament. Major steps within this video include 1) a summary of the patient presentation and preoperative imaging, 2) exposure of thoracic vertebrae via a manubrial window approach, 3) thoracic diskectomy and fusion with take-down of calcified posterior longitudinal ligament, and 4) a review of the postoperative imaging. The patient tolerated the procedure well with immediate relief of symptoms and was subsequently discharged on postoperative day 1 with no complications. This operative video illustrates the technical steps and capabilities of an anterior approach, achieving near-complete gross total resection of an OPLL lesion using a multidisciplinary approach. The patient consented to this procedure.

Sex Differences in Objective Measures of Adult Patients Presenting for Pectus Excavatum Repair.

BACKGROUND: Women have a reported incidence of pectus deformities four to five times less than men. Sex differences have not been well studied. METHODS: A retrospective review was performed of adult patients (aged 18 years or more) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010, to December 31, 2019). RESULTS: In total, 776 adults underwent pectus repair, with 30% being women. Women presented older (mean age 35 vs 32 years, P = .007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher maximum oxygen consumption and oxygen pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, P < .001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between men and women, with the majority occurring in patients 30 years of age or more (11.5% for age 30 or more, 1.7% for age less than 30; total 7%). Women were also less likely to require three bars for repair (12% vs 42%, P < .001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively, women reported a greater daily intensity of pain, but only on the initial postoperative day did they use significantly more opioids than men. Cardiopulmonary exercise testing of 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both sexes. CONCLUSIONS: Women presented for pectus excavatum repair at an older age and with greater symptoms and more severe symptoms. Despite this, women required fewer bars, and there were no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both women and men.

Surgical treatment of displaced pediatric lateral condyle fractures of the humerus by the posterior approach.

The surgical approach for open reduction and internal fixation of lateral condyle fractures in children is controversial. Some authors recommend the lateral approach to the elbow over the posterior approach because of theoretical concern for injury to the vascular supply of the distal humerus and potential avascular necrosis (AVN). The purpose of this retrospective case series study is to report the outcomes of open reduction and internal fixation of displaced lateral condyle fractures of the humerus by the posterior approach. Fifteen consecutive cases were reviewed and the posterior approach resulted in minimal postoperative loss of motion, no angular deformity, cosmetic scars, and no AVN. We support that AVN occurs because of stripping of soft tissues from the lateral condyle fragment and not the approach used. Stripping of soft tissues is not required when using the posterior approach because of excellent visualization of the fracture reduction.

Increasing Body Mass Index Is Inversely Related to Groin Hernias.

Few studies describe the relationship between obesity and groin hernias. Our objective was to investigate the correlation between body mass index (BMI) and groin hernias in a large population. Patients with the diagnosis of inguinal or femoral hernia with and without incarceration or strangulation were identified using the Kaiser Permanente Southern California regional database including 14 hospitals over a 7-year period. Patients were stratified by BMI. There were 47,950 patients with a diagnosis of a groin hernia--a prevalence of 2.28 per cent. Relative to normal BMI (20-24.9 kg/m(2)), lower BMI was associated with an increased risk for hernia diagnosis. With increasing BMI, the risk of incarceration or strangulation increased. Additionally, increasing age, male gender, white race, history of hernia, tobacco use history, alcohol use, and higher comorbidity index increased the chance of a groin hernia diagnosis. Complications were higher for women, patients with comorbidities, black race, and alcohol users. Our study is the largest to date correlating obesity and groin hernias in a diverse United States population. Obesity (BMI ≥ 30 kg/m(2)) is associated with a lower risk of groin hernia diagnosis, but an increased risk of complications. This inverse relationship may be due to limitations of physical exam in obese patients.